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Overview |
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Definition |
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Uveitis is characterized by inflammation of one or all parts of the uveal
tract (iris, ciliary body, choroids). The most common form is anterior uveitis
(iritis, iridocyclitis); posterior uveitis (choroiditis, chorioretinitis) is
uncommon and found mostly in persons with AIDS who have cytomegalovirus (CMV)
infection. Uveitis occurs in acute (<6 weeks) and chronic forms. The cause is
often unknown but may result from either ocular trauma (e.g., chemical exposure)
or an underlying systemic disease; the latter accounts for 40% of all cases (see
section entitled Etiology for more details). Rate of incidence in both
the U.S. and worldwide is 8 to 15 cases per 100,000. Uveitis occurs in men and
women of all ages, with most patients presenting between 20 and 50 years of age;
peak incidence is during the third decade of life. |
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Etiology |
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- Infection, including viral, bacterial, spirochetal, parasitic, and
fungal infections (e.g., syphilis, tuberculosis, CMV, Lyme disease,
histoplasmosis); toxoplasmosis is common cause of congenital posterior uveitis
- Masquerade syndromes (syndromes that simulate uveitis) include
leukemia, lymphoma, retinitis pigmentosa, retinoblastoma, and malignant melanoma
of the choroid
- Systemic disease, including suspected immune-mediated disorders (e.g.,
Behcet's and Crohn's disease, juvenile rheumatoid arthritis, multiple sclerosis,
Reiter's syndrome, sarcoidosis); HLA-B27 genotype on chromosome 6 is present in
some patients with acute anterior uveitis associated with ankylosing
spondylitis, Reiter's syndrome, inflammatory bowel disease, psoriatic arthritis,
and recurrent anterior uveitis
- Ocular trauma
- Idiopathic and/or confined to the eye, as in the case of acute retinal
necrosis, birdshot choroidopathy, multifocal choroiditis, pars planitis, and
Fuchs' heterochromic iridocyclitis
- Some drugs may cause uveitis; rifabutin, for example, has been
identified in at least 113 cases by the FDA. Other drugs associated with uveitis
include cidofovir, pamidronic acid, and sulfonamides.
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Risk Factors |
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Forms of uveitis are geographically endemic (e.g., histoplasmosis in Ohio and
Mississippi Valleys and Lyme disease in the northeastern, north central, and
western U.S.). Uveitis due to toxoplasmosis is sometimes associated with pets.
General risk factors include the following:
- History of autoimmune disease
- Infections
- Other eye diseases
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Signs and Symptoms |
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- Painful eye(s)
- Conjunctival redness
- Photophobia
- Blurred or decreased vision
- Tearing
- Redness
- Floaters (posterior)
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Differential
Diagnosis |
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- Corneal abrasion or ulceration
- Ulcerative or ultraviolet keratitis
- Glaucoma
- Scleritis
- Conjunctivitis
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Diagnosis |
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Physical Examination |
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Complete history and physical exam are required to identify possible
underlying systemic disease. Signs of systemic disease include joint deformities
(arthritis), oral or genital lesions (Reiter's and Behcet's syndromes), low back
pain (ankylosing spondylitis), breathing problems (sarcoidosis), rash, and nail
pitting (psoriasis). An ophthalmologic examination may reveal the following:
Anterior:
- Pupil contraction
- Inflammatory cells visible via slit-lamp examination
- Keratic precipitates on posterior corneal surfaces
Posterior:
- Inflammatory cells
- Fuzzy white retinal lesions
- Retinal and/or choroid inflammation (may be localized, diffuse, or
multifocal)
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Laboratory Tests |
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Laboratory tests should be tailored toward specific signs and symptoms when
an underlying etiology is suspected.
- Angiotensin-converting enzyme (sarcoidosis)
- Antinuclear antibody testing (autoimmune diseases)
- Complete blood count (bacterial or viral etiology)
- Enzyme-linked immunosorbent assay (Lyme disease)
- Erythrocyte sedimentation rate (systemic disease)
- Human leukocyte antigen-B27 (HLA-B27)
- Syphilis serology; RPR and VDRL may also be associated with
granulomatous uveitis; FTA-ABS and microhemagglutination assay for antibodies to
Treponema pallidum are more specific for syphilis
- Purified-protein derivative skin test (tuberculosis)
- Skin test for anergy
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Pathology/Pathophysiology |
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Although specific pathophysiology is unknown, the most common cause is an
immune reaction against foreign molecules or antigens, which may also cause
direct injury to uveal vessels and cells. In the case of autoimmune disorders,
immune complexes may deposit in the uveal tract. Findings may include the
following:
- Inflammation of ocular structures
- Small, white (not mutton-fat) keratic precipitates without iris
nodules (nongranulomatous anterior uveitis)
- Large mutton-fat keratic precipitates and iris nodules (granulomatous
anterior uveitis)
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Imaging |
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- Chest X ray (tuberculosis and sarcoidosis)
- Joint X rays (juvenile rheumatoid arthritis and ankylosing
spondylitis)
- Fluorescein angiography (may reveal late hyperfluorescence associated
with cystoid macular edema)
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Other Diagnostic
Procedures |
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- Slit-lamp examination helps confirm diagnosis by revealing leukocytes
and increased protein (flare) in aqueous humor
- Gonioscopy determines the presence of progressive peripheral anterior
synechia
- Tonometry measured intraocular pressure
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Treatment Options |
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Treatment Strategy |
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Prompt treatment is required to preserve vision. Conventional practitioners
recommend warm compresses to help relieve symptoms; naturopathic doctors may
recommend the addition of herbs, such as eyebright, goldenseal, or marigold
(Calendula officinalis) to the water used to make the compress.
Sunglasses can protect for light sensitivity. In posterior uveitis, the goals
are to determine and treat the systemic cause of the
inflammation. |
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Drug Therapies |
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- Corticosteroids (topical or systemic) (e.g., prednisone, 0.125% to 1%;
fluorometholone; 0.1% to 0.25%) to reduce inflammation and pain, stabilize cell
membranes, inhibit release of lysozyme by granulocytes, and suppress lymphocyte
circulation; oral prednisone or intraocular injections may be used in
recalcitrant cases; contraindicated in patients with viral, fungal, and
tubercular infections; can lead to increased intraocular pressure; posterior
subcapsular cataracts associated with chronic topical use
- Cyclopegics (e.g., cyclopentolate, 0.5% to 2%; homatropine, 2% to 5%)
block neurotransmission to the ciliary muscle, reduce pain, prevent adhesion of
the iris to anterior lens capsule, stabilize blood-aqueous barrier, and help
prevent continued protein leakage (flare); contraindicated in patients with
narrow-angle glaucoma; toxic anticholinergic side effects are rare and occur
most often in children; side effects include loss of accommodation (difficulty
reading closeup)
- Antimicrobials
- Anti-inflammatories
- Oral immunosuppressants require close monitoring of side effects
- Humanized anti-Tac monoclonal antibody (daclizumab; approved now for
immunosuppression in the case of kidney
transplantation)—phase I/II clinical trial conducted by
the National Eye Institute (NEI) of the NIH suggests that this treatment, given
IV one time per month, controlled uveitis as effectively as standard treatment
with a marked decrease in side effects for the small group of patients studied;
the next phase of research for daclizumab is to test the treatment on patients
with Behcet's disease followed by a large, multicenter trial
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Surgical Procedures |
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Surgery is used to repair ocular damage, such as glaucoma, cataracts, or
detached retina. |
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Complementary and Alternative
Therapies |
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CAM therapies may be beneficial in reducing the severity of systemic diseases
whose sequelae include uveitis. Reducing free radical damage with herbs and
nutrients may prevent or slow the progression of uveitis. |
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Nutrition |
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Flavonoids are highly concentrated in the eye. They inhibit neutrophil
respiratory burst and superoxide production, both of which can create free
radical damage in ocular tissues. In one study, the flavonoid, quercetin,
decreased intraocular inflammation, reduced hemorrhagic changes, and minimized
choroidal thickening in rats with S-antigen-induced uveoretinitis (Romero et al.
1989). High concentrations of flavonoids are found in red grapes, blueberries,
cherries, and onions. Quercetin, 200-400 mg tid with meals, may also be taken as
a supplement, often with bromelain to enhance function. Carotenoids are also
thought to have antioxidant activity, particularly in the eye. Orange, yellow,
and dark green vegetables contain a lot of dietary carotenoids. Supplement forms
include mixed natural carotenoids (50,000 IU/day) and the carotenoid lutein (5
mg/day); the latter is considered to have a particular affinity for the eyes.
Food to avoid that may be pro-inflammatory include saturated fats, fried foods,
dairy products, and refined foods; anti-inflammatory foods include flaxseed,
fatty fish, and other forms of essential fatty acids.
A randomized, double-blind, placebo-controlled trial evaluated the effects of
vitamins C (1,000 mg/day) and E (200 IU/day) in patients with a first or
recurrent episode of acute anterior uveitis. A total of 130 patients completed
the study. Patients were evaluated for changes in anterior segment inflammation,
measured by a laser cell flare meter. Clinical assessments included
best-corrected visual acuity (VA), scores on the Hogan-Kimura scale for uveitis,
and the number of drops of prednisolone and mydriatic administered (van Rooij et
al. 1999).
Upon completion of the study, no significant differences in laser flare and
cell measurements were detected between the vitamin and placebo groups, possibly
because all patients were also treated with steroids. However, average visual
acuity was better on all points in the vitamin group as compared to the placebo
group. The investigators suggest that oral vitamins C and E protect
photoreceptors from free radical damage and, in this manner, help preserve
visual acuity. In addition, vitamin E may play a role in protecting against
cystoid macular edema. CME can lead to loss of visual acuity in uveitis patients
(van Rooij et al. 1999). |
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Herbs |
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Curcumin, the primary active substance in turmeric, has been reported to have
anti-inflammatory effects including inhibition of prostaglandin synthesis and
stabilization of lysosomal membranes. Specific application for uveitis is not
definitive but results of a recent preliminary study are intriguing. In a
three-year study following 32 patients with chronic anterior uveitis,
researchers report that curcumin (Curcuma longa) showed effects
comparable to those of corticosteroid therapy but had none of the adverse
effects associated with steroid use. Patients received curcumin, along with
topical mydriatics and warm compresses for spasm and pain relief. Antitubercular
drugs were added to the regimen if the person had a strongly positive PPD
(Purified Protein Derivative, a substance used to measure reactivity to
tuberculosis). Curcumin 375 mg po tid was administered to patients for 12 weeks.
Antitubercular therapy was continued for one year. Although patients in both
groups had recurrences of anterior uveitis (55% in those receiving curcumin
alone and 36% in those with the addition of anti-TB drugs), each group showed
noticeable improvement. In addition, according to the authors, the rates of both
recurrence and complications secondary to the uveitis for all 32 patients on
curcumin, with or without anti-TB medications, were similar to these figures for
patients taking corticosteroids to treat uveitis. Finally, none of the
participants complained of side effects from the curcumin (i.e., any side
effects experienced were in the anti-TB drug group and were attributable to
those medications) (Lal et al. 1999).
Similar to particular foods (see Nutrition section), herbs with
concentrated amounts of flavonoids, such as ginkgo (Ginkgo biloba) and
bilberry (Vaccinium myrtillus), have a long tradition of use in treating
diseases of the eye. However, their use in the treatment of uveitis specifically
has not yet been validated by scientific studies (Blumenthal et al.
2000). |
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Homeopathy |
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Homeopathic treatment can address both constitutional and acute
aspects of disease in general. In homeopathic terminology, the constitutional
state reflects a pattern of underlying vulnerability or weakness that is unique
to the individual and persists throughout that person's life. Symptoms tend to
alternate over time and treatment consists of selecting the appropriate remedy
specific for the patient's constitutional type. By contrast, in acute conditions
a remedy can be administered without reference to any particular constitutional
state (Ullman 1995). Although there are no known scientific studies evaluating
the utility of specific homeopathic remedies for treating uveitis, acute
homeopathic remedies may be beneficial in providing symptomatic
relief. |
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Acupuncture |
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Acupuncture has been shown to be effective in the treatment of other ocular
diseases (see Macular Degeneration monograph, for example) but has not
been fully assessed in the treatment of uveitis. |
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Massage |
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N/A |
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Patient Monitoring |
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Slit-lamp and intraocular pressure measurements every 1 to 7 days in acute
phase, with follow up every 1 to 6 months. |
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Other
Considerations |
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Prevention |
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There are no known preventive measures for uveitis. However, regular eye
exams can screen for chronic asymptomatic uveitis. Treatment of causative
disorders may help prevent onset. |
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Complications/Sequelae |
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- Glaucoma
- Cataracts due to neovascularization
- Permanent partial vision loss
- Retinal detachment
- Band keratopathy
- Cystoid macular edema
- Macula scarring impairs central vision
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Prognosis |
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- Prognosis is good with early diagnosis and treatment; anterior uveitis
tends to respond to treatment in days to weeks
- Outcome may be dependent on underlying condition
- Chronic uveitis (defined as presence of inflammation >6 weeks) may
require long-term low-dose topical steroid use and can lead to ocular scarring
and vision loss
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Pregnancy |
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Safety of topical steroid use in pregnant women has not been
established. |
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References |
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Alexander KL, Dul MW, Lalle PA, Magnus DE, Onofrey B. Optometric Clinical
Practice Guideline: Care of the Patient with Anterior Uveitis. 2nd edition.
American Optometric Association; 1997. Accessed at: www.aoanet.org/cpg-7-au.html
on February 8, 2000.
Berkow R, Fletcher AJ, Beers MH, eds. The Merck Manual. Rahway, NJ:
Merck & Co.; 1992:2380-2382.
Blumenthal M, Goldberg A, Brinckmann J, eds. Herbal Medicine: Expanded
Commission E Monographs. Newton, Mass: Integrative Medicine Communications;
2000:18, 165-166.
Dunn JP, Nozik RA. Uveitis: role of the physician in treating systemic
causes. Geriatrics. 1994;49(8):27-32.
Fraunfelder FW, Rosenbaum JT. Drug-induced uveitis. Incidence, prevention and
treatment. Drug Saf. 1997;17(3):197-207.
Gordon K III. Iritis and uveitis. In: Adler J, Brenner B, Dronen S, et al.
Emergency medicine: An On-line Medical Reference. Accessed at
http://emedicine.com/cgi-bin/foxweb.exe/showsection@d:/em/ga?book=emerg&topicid=276
on August 17, 2000.
Lal B, Kapoor AK, Asthana OP, et al. Efficacy of curcumin in the management
of chronic anterior uveitis. Phytother Res. 1999;13(4):318-322.
No author listed. Drug-induced uveitis can usually be easily managed.
Drugs Ther Perspect. 1998;11(10):11-14.
Nussenblatt RB, Fortin E, Schiffman R, et al. Treatment of noninfectious
intermediate and posterior uveitis with the humanized anti-Tac mAb: a phase I/II
clinical trial. Proc Natl Acad Sci USA 1999;96(13):7462-7466.
Romero J, Marak GE Jr, Rao NA. Pharmacologic modulation of acute ocular
inflammation with quercetin. Ophthalmic Res. 1989;21(2):112-117.
Sowka JW, Gurwood AS, Kabat AG. Anterior Uveitis. In: Handbook of Ocular
Disease Management. Review of Optometry Online. Accessed at
www.revoptom.com/handbook/sect4e.htm on February 8, 2000.
Ullman D. The Consumer's Guide to Homeopathy. New York, NY:
Tarcher/Putnam; 1995.
van Rooij J, Schwartzenberg SG, Mulder PG, Baarsma SG. Oral vitamins C and E
as additional treatment in patients with acute anterior uveitis: a randomised
double masked study in 145 patients. Br J Ophthalmol.
1999;83(11):1277-1282. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |