UVEITIS

The Essentials : Things you should know

Arief Mustaram MD

Susi Heryati MD

Angga Fajriansyah MD

Patriotika Muslima MD

Elfa Ali Idrus MD

External Eye Disease, Infection and Immunology Unit

Cicendo National Eye Hospital
 What is uveitis?

Inflammation of the uveal tract

Uveitis is a sight-threatening inflammatory ocular disease
and includes multiple heterogeneous clinical entities.
Epidemiolo
gy

• Uveitis is responsible for 10% of all blindness in the US, 25%

worldwide
• Prevalence 58 – 131 per 100.000 in the US, 1070 per 100.000
worldwide
• Anterior uveitis is the most common (70-80% of cases)
• Uveitis incidence peaks between 20 – 60 years of age
• Developing countries have higher rates of infectious uveitis
• The prevalence of various types of uveitis depends upon
multiple factors, such as age, sex, race, geographic
distribution, environmental influence, genetics,
Diagnostic Considerations and
in Uveitis. Uveitis and social
Ocular Inflammation. American Academy

habits.
Of Ophthalmology
Duplechain et al. Uveitis StatPearls
Cicendo Eye Hospital Bandung 2019
209 new cases
Classifications

Based On :
Anatomy
Duration
Etiology
Histopathology
 • Uvea consists of the iris, ciliary
body, and choroid

• Function :
- Vascular
- Light control
- Accomodation
- Aqueous production

• May also involve adjacent

Image from Kanski’s Clinical Ophthalmology, 2011 tissues including sclera, cornea,

vitreous humor, retina, and optic

Barisani-Asenbauer T, et al. Orphanet J Rare Dis. 2012;7:57;
nerve Jantzi et al, Seidenberg Protzko Eye Associates
Anatomy Classification
Primary site of
inflammation
Includes
• Iritis (iris)
Anterior • Anterior chamber • Iridocyclitis (iris &
ciliary body)

• Pars planitis (pars

Intermediate • Vitreous humor
plana)

• Focal, multifocal, or
diffuse choroiditis
Posterior • Retina and/or choroid • Chorioretinitis
• Retinitis
• Neuroretinitis
• Anterior chamber,
vitreous humor,
Panuveitis
retina, and/or
choroid
Jabs DA, et al. Am J Ophthalmol 2005;140:509–16;
Muchatuta MN. Iritis and Uveitis.
Acute uveitis
• sudden onset uveitis which resolves within 3
months.
Chronic uveitis
• persistent uveitis with relapse less than 3
months after discontinuation of treatment.
Recurrent uveitis
• repeated episodes of uveitis spaced with
inactive untreated periods > 3 months.

Trusko, et al. (2013). The standardization of uveitis nomenclature (sun) project. Methods of information in
medicine, 52(03), 259-265.
Etiology
Non - Masquera
Infectious Trauma
Infectious de
“Great mimicker of
Known uveitis”
Bacterial systemic
associations Neoplasti
Fungal No known c
systemic
associations Non-
Viral neoplasti
c

Parasitic

Agrawal RV, et al. Indian J Ophthalmol 2010;58:11–9

Histopatholo
gy

Granulomatous
• e.g Tb, Sarcoidosis, Syphilis, Multiple Sclerosis,
Symphatetic Ophthalmia

Non-granulomatous
• e.g HLA B-27 associated, Juvenile RA, Fuchs
iridocyclitis

Agrawal RV, et al. Indian J Ophthalmol 2010;58:11–9

Impact of Uveitis on Quality
of Life
 The burden of disease is high, as 70–90% of people affected are 16–60 years
old (working age)
Distribution of anatomic subtypes of uveitis according to patient age

Anterior uveitis (n=209) Posterior uveitis (n=101)

100
85.5
80.9
77.2
80
) %( s tnei taP

65.6

60

40 32.3
19.8
20 7.7 10.1 11.5
3 2.1 4.3
0
<16 16–60 >60
Patient age (years)

Larson T, et al. Expert Opin Emerg Drugs 2011;16:309–22;

Soheilian M, et al. Ocul Immunol Inflamm 2004;12:297–310
• Major vision loss is reported in 20–70% of patients treated in uveitis
referral centers or academic ophthalmology clinics
• Up to 40% of patients with uveitis will lose 25% of their vision and
5–20% will become blind
• Posterior uveitis and panuveitis are more likely to be sight-
threatening leading to blindness.
• Chronic uveitis is generally associated with a greater degree of
structural damage and is responsible for a greater percentage of
visual loss than acute forms

Dick AD, et al. Ophthalmology 2016;123:655–62;

Durrani OM, et al. Br J Ophthalmol 2004;88:1159–62;
Vavvas D, Foster CS. Int Ophthalmol Clin 2004;44:187–2
Soheilian M, et al. Ocul Immunol Inflamm 2004;12:297–31
• Patients with uveitis have poorer visual functioning and a lower
general health status compared with healthy subjects
• Uveitis associated with systemic disease is are associated with
depression
• Patients being currently treated for uveitis tend to be more worried and
frustrated by their eyesight and need more help because of their vision
• Patients with a longer follow-up time have worse QoL

Schiffman RM, et al. Arch Ophthalmol 2001;119:

841–9;
Naik RK, et al. JAMA Ophthalmol 2013;131:
219–25;
Hoeksema L, Los L. PLoS ONE 2016;11:
e0146956;
Dick AD, et al. Ophthalmology 2016;123:
655–62;
Consequences of Delayed Diagnosis and Treatment of Uveitis
• Increased frequency of ocular surgery for uveitis-related complications
• Loss of independence

• Vision loss associated with uveitis has an impact on QoL and

activities of daily living

• Vision loss in uveitis is usually a result of long-term, persistent

inflammation, and resulting ocular complications such as cataracts,
secondary glaucoma, retinal detachment, CME
Schiffman RM, et al. Arch Ophthalmol 2001;119:841–9;
Naik RK, et al. JAMA Ophthalmol 2013;131:219–25;
Hoeksema L, Los L. PLoS ONE 2016;11:e0146956;
Dick AD, et al. Ophthalmology 2016;123:655–62;
 Diagnosing Uveitis

Diagnosis is not the end, but the beginning of practice.

- Martin Fischer-

History taking
Extraocular findings
Ophthalmology examination “Signs and Symptoms”
Additional investigations
Patient
history

“Listen to the patient, he is telling you the

diagnosis”
- Sir William Osler -

;
History taking

Traumatic
Iritis

S.R Rathinam and M.Babu. Algorithmic approach in the diagnosis of uveitis. Indian J Ophthalmology.2013 Jun; 61(6): 255–262
• Extraocular findings

“Look at the patients”

S.R Rathinam and M.Babu. Algorithmic approach in the diagnosis of uveitis. Indian J Ophthalmology.2013 Jun;
61(6): 255–262
DermNet New Zealand
S.R Rathinam and M.Babu. Algorithmic approach in the diagnosis of uveitis. Indian J
Ophthalmology.2013 Jun; 61(6): 255–262
S.R Rathinam and M.Babu. Algorithmic approach in the diagnosis of uveitis. Indian J Ophthalmology.2013
Jun; 61(6): 255–262
Ocular
examination
Always check both anterior and posterior segment of the eye !!!
- Best Corrected Visual Acuity (BCVA)
- Intraocular Pressure (IOP)

Funduscopy
examination

Slit-lamp Images from Google

examination images
Cicendo Eye Hospital
Clinical presentation : Anterior uveitis
Acute :
• Pain Chronic :
• Primarily blurred vision and mild redness
• Redness
• Patients have little pain or photophobia except when having
• Photophobia
• Blurred vision an acute episode
• Increased
lacrimation

Ciliary injection

Keratic Precipitates (KPs)

Muchatuta MN. Iritis and

Uveitis.
wwww.aao.org
Clinical presentation : Anterior uveitis

Iris nodules Hypopyon

Synechiae

American Journal Of Ohthalmology

Clinical presentation : Intermediate uveitis
• Painless floaters and decreased vision (similar to
posterior uveitis)
• Minimal photophobia or external inflammation

Snowbanking
Vitreous Cells Snowballs

Wenkel, H. “Intermediate Uveitis, Snowballs”

Eyerounds.org
Muchatuta MN. Iritis and Uveitis.
Clinical presentation : Posterior uveitis
• Blurred vision and floaters
• Absence of symptoms of anterior uveitis (ie pain, redness, and
photophobia)

Retinal
vasculitis Retinitis Choroiditis

Gross, J and Raouf, S. 2016

Whitcup, S. M., Fenton, R. M., Pluda, J. M., De Smet, M. D., Nussenblatt, R. B., & Chan, C. C.,
1992
Muchatuta MN. Iritis and Uveitis.
Clinical presentation : Panuveitis
Any or all of the symptoms of anterior, posterior, or
intermediate uveitis

Vasculitis and BRVO due to Behcet’s Disease

“Sunset glow appearance” on VKH

Baltmr et al. Vogt–Koyanagi–Harada syndrome – current perspectives

Hamid Ahmadieh MD. Retina Image Bank
Masquerade Syndrome

Choroidal Melanoma
Masquerade Syndrome
John J. Huang and Anthony J.
Correnti
 Additional
investigations
• Principle Exclude infective causes first !!!
Chest X- Ray
• Tb, Sarcoidosis

Serologic Test
• Syphilis, SLE

Human Leukocyte Antigen (HLA)

• HLA B-27 associated (AS, Reiter syndr, IBD, PA), Behcet’s disease

HIV screening

MRI
• MS

PCR
• Viral

ANA
• autoimmune
Albert Vitale MD. Uveitis Diagnostic
Approach
Managing Uveitis

Ocular therapy
Underlying disease
Surgical management
Treatment goals :
• Managing inflammation
• Prevent further complications
• Prevent visual loss

Treatment depends on severity

Initial treatment : corticosteroids, cycloplegics, earlier
immunomodulator therapy if uveitis affecting choroid and retina

Infectious uveitis -> direct to the microorganism

Kempen et al. Factorspredicting VA outcome in IU, PU, panuveitis; the MUST trial.
AJO. 2015;160
 Corticosteroi
ds
• Corticosteroids may be given via the following routes
• Topical
• Local injections
• Implants
• Systemic

• Chronic use of corticosteroids is associated with adverse ocular and

systemic side effects
• Therapy should be started with a high dose of corticosteroids and
tapered according to the clinical response as the inflammation
subsides

Pan J, et al. Curr Allergy Asthma Rep 2014;14:4

Foster CS, et al. Surv Ophthalmol 2016;61:1–17
Non-Corticosteroid Immunomodulator Therapy
• When to start?: • Non-corticosteroid
• Active uveitis not immunomodulator therapy
controlled by used in non-infectious uveitis
corticosteroids (greater includes:
than 3 months) – Antimetabolites, eg MTX,
• Contraindication for AZA
corticosteroid use (DM, – Calcineurin inhibitors, eg
GERD, peptic ulcer, etc) CyA
Biologics agents (i.e Infliximab,
• Rapidly recurrent or – Alkylating agents, eg
chronic uveitis to Adalimumab)
cyclophosphamide
decrease the dosage of are recombinant proteins or antibodies that
Jabs DA, et al. Am J Ophthalmol 2000;130:
corticosteroids necessary target specific molecules or cytokines
492–513; involved
Kim EC, et al. Int Ophthalmolo Clin 2006;46:
to control the disease: in the inflammatory cascade 141–64;
Airody A, et al. Drugs 2016;76:27–39
increasingly being used in cases of refractory
• Treatment of the underlying diseases
• Refer to
• Internist, Rheumatologist
• Otolaryngologist
• Dermato-venerologist
• Neurologist
Surgical management of uveitis
• Reasons for surgical management:
• Visual rehabilitation, eg removal of cataract
• Management of high IOP, glaucoma surgery
• Diagnostic, eg aqueous tap, biopsy

• Surgical timing and inflammatory control both pre- and post-operatively !

!!

Murthy SI, et al. Indian J Ophthalmol

2013; 61:284–90
 Take home message
• Uveitis is a sight threatening condition -> causing blindness -> reduce
QoL
• Uveitis cause may vary
• Diagnosing uveitis requires detailed history taking, systemic condition,
ophthalmology examination, laboratory evaluation
• Management of uveitis needs close collaboration
• Informed Consent -> treat the patient not the disease
thank you

Reda Gomah. Facts about Phacoemulsification in Uveitic Patients