Uveitis / Eye Inflammation

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The pigmented layer of the eye (made up of the Iris/Choroid) is called the Uvea and when this is inflamed (Itis = Inflammation) it is called Uveitis.

When the inflammation only affects the Iris it is called Iritis (see separate Iritis information), Uveitis can affect patients of all ages but most will be aged 25-45.

What are the symptoms of Uveitis?

Because there is inflammation inside the eye, symptoms and signs such as discomfort, redness, watering, blurred vision, light sensitivity and floaters can occur. Many of these symptoms are seen in other eye conditions as well so it is important that an Ophthalmologist examine your eye under magnification (slit-lamp).

How is Uveitis treated?

There are over 50 different types of uveitis and despite thorough investigations it is not uncommon to find no obvious cause. It is likely that some form of infection sets off the immune system. Part of this response then 'reacts' with other parts of the body such as the eye or joints (flu can give joint aches). Sometimes the inflammation in the eye can be potentially dangerous to the vision and so medication is required to reduce the risk of damage.

Some cases of Uveitis go as quickly as they come but there are other forms that will run a chronic course and so the need for medication may be prolonged, sometimes even for several years. Control of the inflammation is usually obtained by taking steroid medication (see Steroid Information) in eye drop, slow release injection and tablet form, but if too high a dose of Steroid is required for too long a period then the use of 'steroid sparing' medication will be discussed. In order to help find out what type of Uveitis a patient is suffering from some blood tests, chest X-ray or CT scan may be required.

Uveitis is usually well controlled although there may be grumbling 'low-grade' persistent inflammation in the eye that just needs regular review. Uveitis is not contagious unless it is due to an infection such as Tuberculosis. Very rarely does Uveitis run in families and this reflects the genetic predisposition of an individual when exposed to an infection.

Increasingly there are more complex therapies for Uveitis and cases that are previously being looked after by a general Ophthalmologist are now referred earlier to someone specialising in Uveitis.

Read more about:

• Ankylosing Spondylitis
• Iritis
• HLA B27 and Iritis
• Intermediate Uveitis
• Behcets Disease and Uveitis
• Cataract and Uveitis
• Glaucoma and Uveitis
• Treatment with Steroids
• Intravitreal Steroid Injection
• Treatment with Azathioprine
• Toxoplasmosis
• Sarcoidosis
• Scleritis
• Vasculitis
• Shingles

Ankylosing Spondylitis

Ankylosing Spondylitis strongly relates to HLA B27 part of your genetic make-up, which predisposes a patient to joint inflammation, arthritis, Iritis and Uveitis.

 Ankylosing Spondylitis (AS) is different from Rheumatoid Arthritis but may be understood as arthritis of the spine. It strongly relates to an HLA B27 genetic make-up, which predisposes to joint inflammation following some type of immune stimulus such as an infection.

Ankylosing Spondylitis affects about 1 in 200 men and 1 in 500 women and starts in the late teens or early twenties. Men are more severely affected however the degree that the disease shows itself can vary.

The discomfort is usually in the lower spine. There are several types of arthritis that can also cause inflammation in the eye which is called Iritis / Uveitis.

Recently a new group of drugs called anti-Tumour Necrosis Factor therapy have been used in patients with Ankylosing Spondylitis and have produced very good results. The two most commonly used are Entanercept and Infliximab.  This therapy has the potential to modify the clinical outcome of the disease rather than just managing the discomfort. Tumour Necrosis Factor should be thought of as one of the keystones in the immune reaction. By switching off the Tumour Necrosis Factor immune response, the side effect of inflammation is dramatically reduced.

It is necessary to repeat the anti-Tumour Necrosing Factor injections at regular intervals depending on how you respond to the treatment.

This treatment has been described as the greatest breakthrough in the treatment of Ankylosing Spondylitis since the condition was first described three thousand years ago.

The decision to use this medication will be made by your Rheumatologist.

Iritis

What is Iritis?

Iritis is inflammation at the front of the eye. Iritis, Iridocyclitis and Anterior Uveitis all mean the same thing - you have inflammation at the front of your eye (Iris = coloured part of the eye, Itis = Inflammation).

Because the sensitive seeing parts of the eye are at the back, the diagnosis of Iritis is therefore usually not sight threatening.

What are the symptoms of Iritis?

Inflammation of the eye can cause Discomfort, Redness, Blurred Vision, Watering and Sensitivity to light. Iritis can sometimes be subtle and so is best diagnosed following a detailed examination of the eye under magnification (slit-lamp) by an Ophthalmologist (eye doctor).

How is Iritis treated?

Over 90% of people with Iritis have no obvious cause and the problem will go on its own but eye drops make this quicker and reduce possible complications such as a rise in pressure within the eye (glaucoma). Certain features of the inflammation and possible associated symptoms (e.g.: stiff lower back) may make the doctor send off some investigations and prompt a referral to another specialty such as Rheumatology. It is surprising how many joint and eye conditions go together. Usually patients will need steroid and dilating (making the pupil big) eye drops to control the inflammation and ease the discomfort. The dilating eye drops will further make the vision blurred and the effect of these drops can last for several days after having been stopped.

Iritis often recurs and so should make you contact your GP / Optometrist on a semi-urgent basis to get your eyes rechecked. You should NOT self-prescribe steroid eye drops as this can cause long-term problems itself.

HLA B27 and Iritis

HLA B27 is a name given to part of your genetic make up and is found in 7% of the UK population. It is still unknown how this genetic make up can predispose you to inflammation conditions such as Iritis but it probably is involved in the way your immune system deals with infections.

Iritis and HLA B27

This type of Iritis can be of sudden onset and can be quite aggressive. It is therefore important that if you feel discomfort in the eye associated with redness and a possible worsening of discomfort in bright light that an Ophthalmologist sees you soon.

Is Iritis associated with any conditions?

Certain medical conditions such as Psoriasis (a skin condition); Irritable bowel disorder; Ankylosing Spondylitis (an arthritis of the lower spine) and Reactive Arthritis (joint pain following an infection) are more frequent if you are HLA B27 positive. It is therefore important that you let your doctor know if you or anyone in your family has these conditions or symptoms such as a sore lower back even if they are mild. The importance for this is that early diagnosis can help prevent later possible problems such as a longstanding stiff back and neck.

How is HLA B27 treated?

Usually patients will need steroid and dilating (making the pupil big) eye drops to control the inflammation and ease the discomfort. The dilating eye drops will further make the vision blurred and the effect of these drops can last for several days after having been stopped. Warm compressions with a flannel soaked in cooled boiled water can also ease discomfort and help to dilate the pupil. Steroid eye drops may be given every hour for the first few days. Sometimes it may be necessary to give a small injection of anti-inflammation medicine beside the eye. This is so a high dose can be given to where it is needed to try and gain control of the inflammation, which can be quite aggressive.

The Iritis will usually resolve on its own in 6-8 weeks but the drops can make this quicker and with less discomfort.

Frequently asked questions about Iritis

Will my vision get better?

It is rare for this type of Iritis to cause permanent vision loss. Problems can occur if Steroid medication is used without proper close follow-up by an Ophthalmologist.

How can I prevent involvement of the other eye?

Unfortunately there is little you can do to prevent recurrences in either eye. The best thing is to recognise that it can recur and so get the inflammation treated quickly with eye drops.

Intermediate Uveitis

Uveitis is a term used to describe a variety of inflammations inside the eye. There are many different forms of uveitis, but even so, uveitis is not a common problem.

Intermediate Uveitis is one form accounting for approximately 5% of uveitis types. It often first comes to notice in teenage or young adult years but can be in any age including children. Many patients may have had it for many years before seeing the Ophthalmologist.

Inflammation affecting the front of the eye usually causes it to be red and painful. If affecting the back of the eye it often causes visual loss. Intermediate uveitis affects a band around the inside of the eye between the front and back parts. It does not usually cause pain and redness and often does not cause blurred vision. Mostly both eyes are affected with one eye being worse than the other.

Intermediate uveitis causes clumps of cells to appear in the vitreous (clear jelly of the inside of the eye). These may be described as 'floaters', 'spiders' or 'tadpoles' which are black spots of all shapes and sizes floating around in the vision. They are more obvious if you 'looks for them', on bright days or against a white background such as a wall or book.

Anterior uveitis:

Some eyes become inflamed at the front of the eye (anterior uveitis). In this case the eyes may become red and sore, and bright lights may cause discomfort. This will need to be treated with steroid/anti-inflammation eye drops, and some patients will need these long-term in order to control the inflammation.

Cataract:

Many different forms of uveitis, particularly those that go on for long periods of time, can lead to a cataract and an operation may be needed to remove it.

Macular Oedema:

The macular is the part of the back of the eye that is used for seeing fine detail such as reading. In Intermediate uveitis the macula may become 'waterlogged' - this is referred to as macular oedema.

Floaters:

Sometimes, especially in young people, the black floaters become so dense that they actually begin to obstruct vision.

Glaucoma:

Any type of uveitis can cause the pressure inside the eye to be too high which can damage vision (glaucoma).

Behcets Disease and Uveitis

Behcets disease (BD) is a form of inflammation which can affect many different parts of the body and whose cause is not fully known but a genetic predisposition is understood.

Diagnosing Behcets Disease

BD is a complex disease that can show itself in different ways in different patients. Sometimes it is very difficult to diagnose and there is no 'test' to confirm the diagnosis. 

Uveitis in Behcets Disease

The uveitis in BD can be very characteristic. It may affect the front of the eye, the back of the eye or both together. If the front of the eye becomes inflamed there is often redness and pain and the eye may be sensitive to light. The vision may be blurred. If the back of the eye is affected there is no pain but, because blood vessels may become blocked, there can be marked reduction in vision. Both types of attack can arise rapidly, within a day or two. Either one or both eyes may be affected during an attack.

Treating Bechets Disease

It may be necessary to see more than one type of doctor as BD affects more than one part of the body. In the Uveitis clinic it will be possible to give general advice about the disease and the effects elsewhere in the body but, if necessary, a referral will be made to other doctors who are more expert in dealing with problems in their own field. At any one time it is important that one of these doctors is 'controlling' the treatment. As the uveitis can be severe, the Ophthalmologist is often in this position to 'control' treatment.

Cataract and Uveitis

The lens inside the human eye is transparent and, due to the ability of it to change shape, allows fine focusing to take place. When it turns cloudy, this is called a cataract. Cataract is extremely common in the elderly although it can occur at any age.

Uveitis is a name given to a large group of disorders causing inflammation inside the eye. This inflammation can cause a cataract to form that may produce blurred vision. When this becomes a problem an operation to remove the cataract can be considered. Laser cannot remove a cataract.

Cataract surgery

Removing a cataract is the most common operation performed by eye surgeons and happens thousands of times each year at this hospital. Modern techniques have made the operation extremely reliable.

Cataract operations can be performed under local anaesthetic (drops / injection to 'numb' the eye). The operation usually takes under 20 minutes. During the operation a small incision is made at the upper edge of the cornea, underneath the upper eyelid. The cataract is removed and a synthetic lens put in place of it. This helps the eye to focus after the operation and stays in the eye for life. This artificial lens can not change shape so glasses will be needed after the operation to achieve the change of focus at various distances (eg. distance to reading). The eyes are tested for glasses after a few weeks. Eye drops are required after the operation to help control any inflammation from the surgery.

Cataract surgery in patients with Uveitis

If your cataract has arisen as a complication of uveitis, an operation to remove it is less straightforward. This will vary from patient to patient and the issues will be discussed with you in the clinic before any decision is made.

The operation

The operation can be technically more difficult due to the scarring inside the eye from the uveitis and so the operation can take longer.

The lens implant

The best way to get good vision following a cataract operation is to put a synthetic lens into the eye.

After the operation

Frequent outpatient attendance is required in the first few weeks after the operation to keep a close watch on the eye. A combination of frequent drops will be prescribed and it is very important that you take them as directed.

Reading glasses

It is normal, usually sometime after the age of 40, to need reading glasses as the lens inside the eye looses its ability to alter focal distance. As many people with cataract due to uveitis are under the age of 40, they will experience a need for glasses in order to acquire the best vision possible in their eye following cataract surgery.

Glaucoma and Uveitis

Production and drainage of fluid inside the eye keeps the eye at a particular pressure and shape. The circulation and drainage of this fluid can be disturbed by inflammation inside the eye. If the pressure slowly increases over a long period of time it can cause painless damage to vision. This condition is called chronic glaucoma.

Diagosis

Measuring the pressure inside the eye is a routine part of an eye examination and will be performed at most visits. For this reason glaucoma is usually detected early in patients with uveitis before it has caused significant damage.

Prevention

In uveitis, the inflammation and scarring caused by the uveitis is the usual cause of glaucoma. Keeping the inflammation down to a minimum is therefore a priority and severe inflammation must be treated vigorously with either eye drops or other treatments.

Uveitis has a particular tendency to cause the iris (coloured part of the eye) to stick to the lens behind it.

Treatment

Treatment includes eye drops, which work by reducing the amount of fluid being made by the eye and are, used mostly twice a day. Tablets may be needed to help control the eye pressure. Common side effects are tingling fingers, tiredness and loss of appetite. Its use is usually temporary. In some circumstances laser treatment is the best method to control the pressure but is only undertaken if medical treatment is not adequate. If pressure control is poor, surgery may be advised.

Treatment with Steroids

Prednisolone is a steroid tablet. It is similar to one of your own naturally occurring hormones and has a powerful effect against inflammation.

 It is commonly used by people who have severe arthritis and asthma, but is also used in many other inflammations such as uveitis (inflammation in the eye).

Steroids only suppress the inflammation and do not 'cure' it. Some types of uveitis only last for a short time (a few weeks or more) then disappear by themselves. However, even in this short time, they may cause considerable damage to vision. Some forms of uveitis get 'switched on' by unknown causes and, for some reason, the body can not 'switch off' the inflammation. In this way, uveitis can last for many years and, during this time, damage to vision often occurs. In this circumstance, Prednisolone may be prescribed to try and minimise this damage but, because the inflammation does not go away, Prednisolone needs to be taken for long periods of time.

Prednisolone is often started at a high dose in order to 'gain control' of the inflammation. Once it has begun to take effect the dose will be reduced. Your eyes will be followed closely during this period to see what dose of Prednisolone is required. Some patients need to continue with a high dose in order to minimise damage to vision.

Every attempt will be made to reduce the dose of Prednisolone, but sometimes it is necessary to combine treatment with other 'steroid sparing' drugs such as Azathioprine, so that the dose of Prednisolone can be reduced further. This is usually necessary only for severe forms of uveitis.

If Prednisolone is to be prescribed for your eye inflammation, you will need to know about potential problems associated with it. The most important of these include: Psychological changes, stomach irritation, weight gain, diabetes, high blood pressure and increased chance of infection.

Intravitreal Steroid Injection

Steroid injections are used for inflammation in the eye when other treatments have not been successful.

To control inflammation inside the eye you may need anti-inflammatory steroids. This type of treatment is used for Uveitis when other treatments to control the inflammation have not been successful.

Steroid treatment is often used for Cystoid Macular Oedema (water logging of the macula - the part of the retina that sees fine detail).

The injection is done under local anaesthetic as a day case procedure. After your treatment you will be able to go home. You may notice some increased floaters and blurred vision, which is due to the medication inside the eye. This should clear with time. Your next appointment will be in one week's time in the Out Patient Department.

What are the side effects?

Approximately 80% of eyes will develop a cataract over a two-year period. Cataract surgery has a very high success rate and can be managed later. 40% of eyes can develop high pressure inside the eye, which can be controlled with anti-pressure eye drops and tablets (Diamox), but in a small percentage of cases an operation may be neccessary.

Treatment with Azathioprine

Azathioprine is a drug used to suppress the immune system. The immune system is responsible for fighting infections, but there may be circumstances where it is necessary to suppress its action.

For instance, Azathioprine is given to patients with a kidney transplant to try and stop their body's immune system from rejecting the kidney.  Azathioprine is taken by mouth in the form of tablets. The dose is around 50mg three times a day. It works by preventing some cells from dividing and reproducing so quickly and therefore reduces the ability of these cells to cause inflammation.

It is usually given to reduce the dose of prednisolone in order to reduce side effects. If Azathioprine is to be prescribed for your eye inflammation, you will need to know about potential side effects of the drug, and the regular tests that will be performed in order to minimise problems.

• The bone marrow and blood cells. Azathioprine acts by preventing some white blood cells from causing inflammation. In a few patients there is a more generalised reduction in the number of white blood cells, which is undesirable. Rarely the red blood and clotting cells are also affected and this is also undesirable. There will be blood tests every few weeks and then every 3 months when stable.

• Stomach irritation. A few patients feel slightly sick when starting to take Azathioprine. This is not usually a major problem, and is minimised by taking the tablets after a meal.

• Infection. Azathioprine alone, taken in small to moderate doses (as for the treatment of uveitis) is unlikely to lead to an increased infection risk.

• Others. If you are a woman, it is important you do not become pregnant when using Azathioprine, as there is a small risk of damage to a baby. In a few people, hair loss can occur.

Toxoplasmosis

Toxoplasmosis is a type of infection that can be caught from eating under cooked meat such as lamb and pork, drinking contaminated water: and also touching soil that has been contaminated with cat faeces.

What is Toxoplasmosis?

Toxoplasmosis is a type of infection, which is found all over the world. Many people have antibodies against Toxoplasmosis meaning that they have been exposed to it at some point in the past but only a very few actually develop symptoms. It is mainly caught from raw / undercooked meat (especially pork and lamb), contaminated water and soil that has been in contact with cat faeces.

What are the symptoms of Toxoplasmosis?

Some people develop blurred vision and floaters. A small minority may feel flu like symptoms, but this is uncommon.

How is Toxoplasmosis treated?

Eye Toxoplasmosis is a clinical diagnosis. There is a blood test to detect antibodies to Toxoplasma but if it is positive it just means that your eye inflammation may be due to it - remember a large percentage of the population have already been exposed to Toxoplasma and have no symptoms and therefore they will be positive for the antibody test. Conversely if the test is negative it means that it is unlikely to be the cause of the eye problem.

The inflammation inside the eye will resolve on its own but floaters can persist for many months and treatment may be advised if they are particularly bad, or if the inflammation is close to an important part of the eye. The most common treatment is a combination of an antibiotic and steroids as this offers the best protection by softening the inflammation, which is potentially damaging to the eye. Unfortunately, it is common for the infection to recur (approximately 5-7 times in a lifetime) and further treatment could be required dependent on the severity.

Sarcoidosis

Sarcoidosis is a condition of unknown cause that can produce inflammation in any part of the body.

It can show itself in many different ways. Some people feel lethargic, weak and may loose weight. Others can have a cough with shortness of breath. Some can have night sweats and fevers. Others may develop swollen glands or a skin rash. One in 5 people with sarcoidosis will present with an eye problem first and so the condition may be diagnosed after seeing an ophthalmologist.

Over 20% of people with sarcoidosis develop eye involvement. Uveitis is inflammation inside the eye, which can cause a variety of problems. The treatment of uveitis depends on which part off the eye is affected. Many patients will only need steroid eye drops to control the inflammation. Other eye drops may also be necessary. If severe inflammation at the back of the eye is in danger of damaging the vision, it will be necessary to use a steroid tablet Prednisolone.

If sarcoidosis is suspected, blood tests and a chest X-ray may help confirm the diagnosis. Lung involvement is common in sarcoidosis. Inflammation here may not cause symptoms, or may cause breathlessness or cough. If such inflammation goes untreated, it can lead to permanent changes.

Scleritis

What is Scleritis?

The Sclera is the white part of the eye. When it becomes inflamed it is called Scleritis (Itis = inflammation). When only the outer part of the Sclera is inflamed it is called Episcleritis. This is a condition that often goes on its own without the need for treatment and does not disturb the vision. Patients with Scleritis are more commonly female and the greatest incidence is between the ages of 40-60 years.

What are the symptoms?

In 35-50% of cases Scleritis affects both eyes. The eye appears red and is painful. Sometimes the inflammation is only apparent at the back of the eye and this can reduce the vision in an eye that is not red - this is called Posterior Scleritis.

Scleritis is caused by an immune response to something such as an infection, trauma or a virus, which then 'cross-reacts' with the eye. While we want our immune system to fight infection we do not like the 'side-effect' of this process, which can cause conditions such as Scleritis and Arthritis (joint inflammation). It is surprising how many Rheumatological and eye conditions go together. Some of the patterns of this type of inflammation have recognised signs and symptoms, examples being Rheumatoid arthritis and Wegners Granulomatosis (blood vessel inflammation - see Vasculitis section). Because Scleritis therefore can be part of a more generalised inflammation disorder it is important that the problem is correctly identified.

How is it treated?

Getting to the correct diagnosis involves sending of blood, X-ray, Ultrasound and occasionally eye / brain scanning investigations. The treatment options depend on the severity of the Scleritis. If mild it can be controlled on eye drop or tablet Non-steroidal anti-inflammatory drugs (NSAIDS). If more aggressive then steroid tablets are needed (see Treatment with Steroids section). If the dose of steroid is too high for too long a period then steroid-sparing medication will be discussed.

Sometimes Scleritis can run a severe course despite medical treatment but usually the inflammation can be brought under control and the vision remains good.

Vasculitis

What is Vasculitis? Vasculitis means inflammation of the blood vessels. Vasculitis inside the eye is often part of a general inflammation process that can affect other parts of the body.

The eye can respond to ischaemia by growing new blood vessels. While this sounds a sensible idea these new vessels are thin and can leak causing a sudden loss of vision due to a bleed inside the eye. They can also cause a form of glaucoma, which can result in a painful eye. Laser therapy can reduce the risk of getting this type of glaucoma but is only needed when there has been a lot of ischaemic change in the eye.

How is Vasculitis treated?

There are over 20 different types of vasculitis. Yorkshire Eye Hospital uses a slit-lamp microscope to view inside the eye to see if it is predominantly the arteries or veins that are affected and also observe associated inflammation areas. Certain clusters of signs and symptoms, supported with investigations such as blood tests and X-rays, can help identify the type of vasculitis. This is important as it then gives the clinician the chance to explain the possible future of how the inflammation may behave and direct appropriate anti-inflammation medication. An example of this is the inflammation of the veins and not the arteries of the retina in conditions such as Sarcoidosis (see Sarcoidosis information).

Other vasculitis conditions such as Wegners Granulomatosis and Behcets (see Behcets information) can affect the arteries and veins while Systemic Lupus Erythematosus affects the small arteries. As Vasculitis can be part of a more generalised inflammation disorder it is important that the problem is correctly identified. Some Ophthalmologists have a special interest in these disorders and have a dedicated Inflammation (Uveitis) clinic.

Some cases of Vasculitis resolve quickly but there are other forms that will run a chronic course and so the need for medication may be prolonged, sometimes even for several years. Control of the inflammation is usually obtained by taking steroid medication (see treatment with Steroids) in slow release injection or tablet form, but if too high a dose of steroid is required for too long a period then the use of 'steroid sparing' medication will be discussed.

Do let your doctor know of other symptoms such as aching joints, new headaches, mouth ulcers, skin rashes, genital ulcers, shortness of breath and diarrhoea which can all be connected with the eye inflammation.

Shingles

Chicken Pox and Shingles is the same virus. Shingles is a reactivation of the Chicken Pox virus that remains hidden and dormant in the nerve.

The resulting rash causes pain along the nerve route and can be very uncomfortable. Sometimes the virus can be in the nerve, which supplies sensation to the skin around the eye.

If your eye becomes red or sore or you have reduced vision, it is important that you see an Ophthalmologist who will be able to determine if there is any inflammation on the surface of the eye (keratitis) or inside the eye (uveitis). This is usually well controlled with medication such as artificial teardrops, anti-viral ointment (Acyclovir) and steroid eye drops. The skin rash can be treated with anti-viral tablets and cream. After the rash has subsided the skin discomfort can take several months to subside.