Uveitis, scleritis and ocular inflammatory problems: detailed information for patients

 

Uveitis, scleritis and other inflammatory problems of the eye can be a source of vision problems and/or pain and discomfort, sometimes over prolonged periods. There are multiple conditions which may cause inflammatory eye diseases, including infections, immune disorders, and rarely even cancer.

 

The medical approach to these problems includes several levels:
 

1. An attempts to define the extent and severity of the eye problem

2. An attempt to find a cause and look for other health problems which may underlie the eye problem

3. A decision whether treatment is required, and what treatment to use
    

Typically, patients with ocular inflammation undergo a clinical assessment (describing their symptoms and answering relevant medical history questions). This is followed by examination of the eyes and, when relevant, a general medical physical examination. In many, but not all cases, further workup is required including laboratory and imaging tests. The need for such tests is determined by the specialist based on his/her clinical impression. 

 

After conducting a medical assessment and laboratory workup, the specialist may arrive at one of the following conclusions:

1. The condition is limited to the eye and is the result of a specific, treatable problem (for instance, an infection with toxoplasma or herpes virus).

2. The condition is limited to the eye and is the result of an immune disorder of an unknown cause (for instance, retinal vasculitis, Fuchs' uveitis syndrome).

3. The condition is part of a systemic problem (involving other organs than the eye), and is the result of a specific, treatable problem (e.g. an infection with tuberculosis).

4. The condition is part of a systemic immune disorder of unknown cause (for instance, lupus, sarcoidosis, ankylosing spondilitis). While many of these conditions have specific medical names, there is no clear understanding why they occur, and they are treated using similar general principles and similar drugs. However, given their potential effect on other organs, there is often a need for a team of doctors to be involved, most commonly an ophthalmologist and a rheumatologist.

 

How is uveitis treated?

 

This is a very broad question and the answer depends on the type of uveitis, and the cause, if known. Each patient has different problems and needs, and the treatment is decided on based on the individual circumstances.

 

Treatment may include:

 

• Local anti inflammatory treatment to the eye/s in the form of eye drops.

• Local anti inflammatory treatment to the eye/s in the form of injections to the vicinity of the eye or to the eye.

• Oral medications, including corticosteroids (cortisone type drugs) antibiotics, antiviral tablets, and/or drugs which suppress the immune system.

• Local medical and surgical treatment of possible eye complications of uveitis, such as cataract, glaucoma or epiretinal membrane. 

 

Commonly Asked Questions:

 

Q: What can I do to avoid “flare ups” of my condition?

A: This is one of the most commonly asked questions, and the answer is far from satisfying. It would be fair to say that, for most of these conditions, there is no understanding of the reason they occur at a given time to a given person. There is therefore not a lot one can do to reduce the chance of a recurrent disease. Changing diet, exercise patterns, environment, stress levels etc are not proven to make a difference.

 

Q: Will I go blind from uveitis?

A: In the vast majority of cases, the answer is NO. Uveitis may inflict considerable damage on the eye/s and may rarely cause blindness. However, if diagnosed correctly and treated in a timely manner, many of its blinding complications can be avoided or treated and controlled. There is an ever increasing arsenal of drugs and techniques to battle complications of uveitis, such as macular oedema, cataract or glaucoma. Like with any disease, there is a range of severity, and most patients with uveitis do not have a vision threatening condition. Similarly, in a small minority of patients, the condition is very severe, and even aggressive therapy cannot prevent loss of vision.

Luckily, most patients at this day and age manage to lead a normal lifestyle, work, study and drive, despite suffering from uveitis.

 

Q: Will it ever go away?

A: It certainly may, but in a very unpredictable manner. Some patients have a disease which comes and goes in short-lived episodes (“flare ups”). Others have a chronic disease which is active for many months or years. In both instances, the disease may “run its course” eventually, and become inactive, not requiring any more treatment.

 

 

What is scleritis?

 

Scleritis is an inflammatory process affecting the white of the eye, or sclera. This tissue is tough and forms the “external wall” of the eyeball. The muscle which move the eyes attach to the sclera.

Typical symptoms of scleritis include red eye/s, severe pain in the eye, which may occur at night and wake the patient from sleep, pain when moving the eyes, or trying to read, and sometimes pain in the light or reduction in vision. Eyes with scleritis are often tender to touch.

 

Underlying reasons for scleritis: In many patients with scleritis, no cause is found for their eye disease and they have no other inflammatory diseases. However, various inflammatory (auto-immune) diseases may cause scleritis and in some patients scleritis is their first sign. Common examples are rheumatoid arthritis, lupus, relapsing polychondritis and Wegener’s granulomatosis (also called granulomatosis with polyangeitis). Infections may also cause scleritis, especially after injuries or surgeries on the sclera.
A less serious, commoner, and often under recognised condition associated with recurrent scleritis is acne rosacea, a treatable skin condition affecting the facial skin and, sometimes, the eyes.

 

Severe scleritis may create permanent damage and thinning of the sclera and cornea. When this occurs, we use the term “necrotising scleritis”. These cases tend to occur more in patients with underlying immune diseases, and an effort is made to identify such conditions which may require treatment. Necrotising scleritis also has a higher potential for causing permanent visual damage.

 

 

 

Treatment of scleritis:

 

The principles of treatment are similar to those described above for uveitis. Mild scleritis often responds well to oral anti inflammatory medications such as indomethacin, ibuprofen and diclofenac. Steroid (cortisone derived) eye drops may also help the symptoms in some patients. Long term oral antibiotics may help patients with acne rosacea.

More severe cases require oral treatment with oral or intravenous cortisone type medications (e.g. prednisolone) and sometimes systemic drugs which suppress the immune system, as described above.
 

In many cases, injection of steroids to the inflamed area has a rapid effect in stopping the pain and redness, although recurrences may occur once the medication has absorbed and disappeared from the eye (usually after months). This treatment may avoid the need for systemic treatment and its potential side effects. However, like any other local steroid treatment to the eye, it has a risk of causing high pressure in the eye (glaucoma) and cataract.