Uveitis
Uveitis is an inflammation of the uvea (iris, ciliary body and/or choroid).
We distinguish: Anterior uveitis which can affect the iris: iritis, the ciliary body: cyclitis, or both: iridocyclitis.
Intermediate uveitis corresponds to an inflammation of the vitreous: hyalitis
Posterior uveitis affecting the choroid is choroiditis, or chorioretinitis,
Panuveitis or total uveitis affects all the structures of the uvea.
The current trend is to classify uveitis into anterior, intermediate and posterior, acute or chronic.
As uveitis is a potentially serious condition, management by the Ophthalmologist must be rapid.
The examination will include, in addition to the interview, a measurement of refraction and bilateral visual acuity, distance and close, a slit lamp examination with measurement of intraocular pressure, and an examination of the fundus, with a 3-mirror glass.
It will be necessary to associate a more general examination (parotids, lacrimal glands, skin condition, etc.) depending on the case in search of a causal disease.
1 – Anterior uveitis: iritis, cyclitis, iridocyclitis:
- Symptoms:
Variable decrease in visual acuity, absent or moderate in the case of anterior uveitis.
Variable eye pain often with a heaviness type.
Tearing, blepharospasm, discomfort in light (photophobia).
- During the examination, the ophthalmologist found characteristic signs:
– Red eye with perikeratic circle (dilation of the vessels of ciliary origin)
– Tight pupil, no purulent secretions and especially at the slit lamp, presence of a Tyndall presenting as “dust grains in a ray of sunlight”, or even hypopyon creating a lower whitish level as well as retro deposits behind the cornea.
– We can still find irido-crystalline synechiae, fixing the pupil on the anterior surface of the lens:
Systematic FO in the face of any anterior uveitis looks for an associated posterior lesion, then indicating panuveitis.
2 – Posterior uveitis:
Any posterior uveitis may be associated with anterior uveitis, and present with the symptoms described above.
- Symptoms:
– Decreased visual acuity linked to vitreous disorder (hyalite) or to the macular location of a focus.
– Scotoma (part of the visual field not seen or whose perception is altered), which reflects the chorioretinal focus.
– Vision of “floating flies” (Myodesopsias).
– Luminous phenomena (Photopsias) by vitreoretinal traction.
– Metamorphopsias sometimes: visual deformations.
Pain is rarer.
- The examination by the Ophthalmologist reveals localized or diffuse vitreous disorder (hyalite) with sometimes lower condensations associated or not with a chorioretinitis in a variable location and number.
Given this diagnosis, it is important to undertake an assessment to find the cause of this uveitis. It is based on questioning and on possible additional examinations.
1 – Questioning:
Family, personal, ophthalmological history, lifestyle and risk factors, associated cutaneous, rheumatological, ENT, genitourinary signs, etc., date and mode of onset, progression, notion of recurrence, treatment, assessment, etc. Contraception? Serological status (toxoplasmosis? rubella? HIV?)…
2 – Assessment:
In the event of a first episode of moderate anterior uveitis, and in the absence of warning signs in favor of an etiology, treatment is undertaken without additional etiological assessment.
On the other hand, in the event of any episode of posterior uveitis, recurrent or severe anterior uveitis, an assessment guided by questioning and clinical examination is undertaken, without this delaying treatment.
3 – The causes of uveitis are numerous and varied:
– Local causes:
Post-surgical, eye tumor, old retinal detachment, foreign body, Fuchs heterochromia: iris heterochromia, cataract, uveitis.
– Locoregional causes:
Neighborhood ENT or dental infection,
Sympathetic ophthalmia (after involvement of the other eye) extremely rare.
– Infectious causes:
– Tuberculosis, Syphilis, Brucellosis, Leptospirosis, Rickettsiosis, Leprosy, Candidiasis, Histoplasmosis (USA),
– Herpes, Zona, CMV (AIDS),
– Toxoplasmosis, Toxocariasis: posterior uveitis with chorioretinitis.
– Rheumatic causes:
Rheumatic pelvispondylitis with HLA B27+ causes anterior uveitis. The search for HLA B27 is systematic in cases of anterior uveitis in young people.
Fiessinger-Leroy-Reiter syndrome: with urethritis, reactive arthritis.
Still's disease or juvenile arthritis.
– General causes:
Diabetes to be looked for in any uveitis,
Sarcoidosis,
Behçet's disease,
Multiple sclerosis sometimes causes anterior uveitis,
Lymphoma sometimes found in cases of posterior uveitis in the elderly.
Evolution
Under treatment, uveitis heals readily without after-effects.
But recurrences are frequent, and the repetition of episodes promotes complications. Corticosteroid dependence is sometimes observed.
Any “cured” chorioretinal focus does so at the cost of an atrophic retinal scar, which is serious if its location is macular.
Uveitis can be complicated by cataracts, hypertonia, retinal detachment, permanent iridocrystalline synechiae, glaucoma, and optic atrophy.
Complications of corticosteroid therapy are not exceptional.
Treatment is adapted, depending on the cause of the uveitis:
Treatment of anterior uveitis:
Corticosteroid therapy in Mydriatic eye drops (eye drops that dilate the pupil and temporarily blur near vision) to prevent the formation of synechiae.
Treatment of posterior uveitis:
Local and general corticosteroid therapy.
Sometimes, long-term immunosuppressants are used in severe cases (Behçet's disease).
The patient must be informed of the nature and progression of his disease, and he must come for a consultation in the event of a recurrence. He must also be informed, as well as his doctor, of the risks of excessive local corticosteroid therapy.
A special case, ocular toxoplasmosis:
Toxoplasmic chorioretinitis is a relatively common condition and a cause of posterior uveitis to be investigated.
In the vast majority of cases (except in AIDS patients) it is the reactivation of a focus of congenital toxoplasmosis (present at birth, linked to a maternal infection), and unrecognized; and not an acquired toxoplasmosis.
The patient, generally an adolescent or young adult, consults for a decrease in acuity with scotoma, floaters, sometimes luminous phenomena, metamorphopsias (distorted vision of straight lines).
On examination, the ophthalmologist observes signs of associated anterior uveitis (Tyndall).
On FO, a focal lesion is observed with a vitreous reaction opposite.
The discovery of chorioretinal scars on an eye has a diagnostic orientation value in favor of toxoplasmosis.
The positive diagnosis is based on the interview, repeated blood serologies, and the dosage of antibodies and the aqueous humor sample by anterior chamber puncture.
Fluorescein angiography will provide arguments for the positive diagnosis, but above all, will make it possible to judge the evolution and healing of the lesions.
General treatment will be undertaken, in the absence of contraindications, and by informing the patient of the potential risks and the course of action to take if necessary.
It typically combines pyrimethamine, sulfadiazine, folic acid, and sometimes general corticosteroid therapy.
Weekly clinical and biological monitoring is necessary.
The progression is towards healing of the toxoplasmic chorioretinal focus, but the risk of recurrence and reactivation from the edge of the focus is always possible.
Source / to find out more: uveitis by Dr Florian TCHAPLYGUINE, Pr Philippe GAIN