UVEITIS BLUES Claes Feinbaum M.Sc. Ph.D. Vision4You UVEITIS BLUES Claes Feinbaum M.Sc. Ph.D. Professor Emeritus OPHTHALMOLOGY & OPTOMETRY BEN GURION UNIVERSITY OF THE NEGEV, ISRAEL

uveitis blues?? My good gal's trying to make a fool out of me Lord my gal's trying to make a fool out of me Trying to make me believe I ain't got that old TB I've got the UVEITIS blues Jimmy Rodgers world famous blues singer, with chronic uveitis

What is UVEITIS? Uveitis is swelling of the middle layer of the eye, which is called the uvea. It may occur from both infectious and non-infectious causes. The uvea supplies blood to the retina. The condition usually isn’t serious. Severe cases of uveitis can cause vision loss if not treated early.

Symptoms of Uveitis The following symptoms may occur in one or both eyes: severe redness in the eye pain floaters, which are dark floating spots in your vision light sensitivity blurred vision

What Causes Uveitis? The cause of uveitis is often unknown and frequently occurs in otherwise healthy people. It can sometimes be associated with another illness such as an autoimmune disorder or an infection from a virus or bacteria.

Autoimmune disease Occurs when the immune system attacks a part of the body. These conditions include: rheumatoid arthritis ankylosing spondylitis psoriasis arthritis ulcerative colitis Kawasaki disease Crohn’s disease sarcoidosis

Infections are another cause of uveitis AIDS, which is caused by a virus Herpes, which is caused by a virus CMV retinitis, which is a viral infection of the eye West Nile, which is caused by a virus Syphilis, which is caused by sexually transmitted bacteria Toxoplasmosis, which is caused by a parasite Tuberculosis, which is caused by a bacteria Histoplasmosis, which is caused by a fungus

Other potential causes of uveitis include exposure to a toxin that penetrates the eye bruising injury trauma

DIAGNOSIS 1. Examine the interior of the eye. 2. Uveitis is often connected with other diseases or conditions, some tests may be needed: a. a physical exam, b. blood or skin tests, c. examination of eye fluids, and d. imaging tests, such as X-rays.

Types of Uveitis There are many types of uveitis. Each type is classified by where the inflammation occurs in the eye.

Anterior Uveitis Anterior uveitis is often referred to as “iritis” because it affects the iris. Iritis is the most common type of uveitis Generally occurs in healthy people Affect one eye, or it may affect both eyes at once Iritis is usually the least serious type of uveitis

Anterior Uveitis cont. Unilateral or bilateral Granulomatous, mutton-fat keratic precipitates Iris nodules may be present near pupillary border or on iris surface Broad-based posterior synechiae Hypopyon may be observed Often accompanied by vitritis

Treatment for anterior uveitis, or iritis Dark glasses, Eye drops to dilate the pupil and reduce pain and Steroid eye drops to reduce inflammation or irritation.

Intermediate Uveitis Also called iridocyclitis The word “intermediate” in the name refers to the location of the inflammation and not the severity of the inflammation. Includes the pars plana This type of uveitis may occur in otherwise healthy people It has been linked to some autoimmune diseases such as multiple sclerosis

IRIDOCYCLITIS DEFINITION Inflammation occurs in the ciliary body and iris

IRIDOCYCLITIS IN CHILDREN This condition afflicts children who have been diagnosed with Rheumatoid arthritis Anteriorpart of the uvea becomes inflamed Can affect the focusing capability of the eyes Arthritis affects not only the joints and tissues but also the eyes, which gets irritated and swells up However, a recent study has stated that the presence of high antinuclear antibodies might give rise to this disease instead of Juvenile Arthritis.

TYPES OF IRIDOCYCLITIS Acute Iridocyclitis: This type occurs all of a sudden and lasts for a maximum period of around 6 weeks. It is accompanied by a number of symptoms. Chronic Iridocyclitis: Chronic types have a prolonged existence and last for more than 6 weeks. They are usually asymptomatic. Systemic disorders like inflammatory bowel disease, syphilis, ankylosing spondylitis and Reiter’s syndrome are often linked with these types. Exogenous Iridocyclitis: This one is basically related to uveal injury caused from the outside. It has also been linked with the external microbes. Endogenous Iridocyclitis: This type of the disease is the result of internal microbes. Granulomatous Iridocyclitis: It comes along with voluminous cellular or keratic deposits. Non-granulomatous Iridocyclitis: This form is usually associated with small cellular deposits.

IRIDOCYCLITIS TREATMENT The treatment of the disease mainly considers the usage of steroidal eye drops, pain-relieving pupil-dilating eye drops and other medications. For light sensitivity, dark glasses can be worn. Steroids or tropane alkaloids. For easing inflammation, steroids can be applied topically. Dexamethasone and prednisolone are some of the effective topical steroids for this purpose. Atropine and Scopolamine are some of the effective medications which help in managing pain. Concentration of these tropane alkaloids can be 1% (Atropine) and .25% (Scopolamine). If these remedies do not work, and patient suffering from severe Iridocyclitis, administer subconjunctival steroid injection. Steroids are avoided if a patient is found to have corneal ulcer or infection in the eye.

Iridocyclitis Image

Posterior Uveitis Posterior uveitis may also be referred to as choroiditis because it affects the choroid. The tissue and blood vessels of the choroid are important because they deliver blood to the posterior of the eye. This type of uveitis usually occurs in people with an infection from a virus, parasite, or fungus. It can also occur in people with an autoimmune disease. Posterior uveitis tends to be more serious than anterior uveitis because it can cause scarring in the retina. Posterior uveitis is the least common form of uveitis.

Posterior Uveitis cont. Unilateral or bilateral 3 funduscopic patterns: Solitary tubercle Miliary choroidal tubercles Tuberculoma (single large lesion that may mimic tumor) Usually complication of untreated tubercule

Serpiginous-like choroiditis (SLC) Multifocal lesions that progress in a serpiginoid pattern and coalesce Individual lesions heal centrally and show centrifugal spread in amoeboid fashion Usually bilateral, noncontiguous to optic disc and associated with mild vitreous inflammation 2 distinct patterns: Multifocal, discrete choroidal lesions that are initially noncontiguous and later progress to form diffuse lesions with an active edge resembling serpiginous choroiditis Solitary, diffuse plaque-like lesion with an amoeboid extension

Choroidal Tubercles Most recognized lesions in intraocular TB Yellowish lesions with poorly defined borders and typically elevated centrally Commonly situated in posterior pole Solitary and few in number Inflammatory cells and subretinal fluid may be present Tubercles near or at macula present with diminished visual acuity (otherwise, may be asymptomatic)

Immune recovery uveitis (IRU) Can occur among patients with concurrent HIV and TB infection during antiretroviral therapy Has also been reported among patients with HIV and concurrent TB, cytomegalovirus retinitis, and varicella zoster ocular infection.

Treatment for posterior uveitis Steroids taken orally Visits to additional specialists to treat the infection or autoimmune disease. A body-wide infection is usually treated with antibiotics

Pan-Uveitis When the inflammation affects all major parts of the eye, it’s called pan-uveitis. It often involves a combination of features and symptoms from all three types of uveitis.

Pan Uveitis cont. A serious inflammation of the uveal tract of the eye. The uveal tract includes the iris, the ciliary body, and the choroid. Panuveitis also typically involves the retina and the vitreous humor. Panuveitis can be caused by infections, chronic inflammatory diseases, or its cause may be unknown.

More

FDA Clears Adalimumab (Humira) for Uveitis

Adalimumab is the first and only FDA-approved noncorticosteroid therapy for adults with noninfectious intermediate uveitis, posterior uveitis, and panuveitis The FDA approval is based on results from two phase 3 studies, which showed that adults with active and controlled noninfectious intermediate and posterior uveitis and panuveitis treated with adalimumab every other week had a significantly lower risk for treatment failure (a combination of uveitic flare and decrease in visual acuity) compared with placebo. No new safety risks were identified in this patient population. The European Commission recently approved adalimumab in the European Union for noninfectious intermediate and posterior uveitis and panuveitis in adult patients who do not respond adequately to corticosteroids, in patients who need corticosteroid-sparing, or patients in whom corticosteroid treatment is inappropriate.

VISUAL-I and VISUAL-II clinical trials Randomized 1:1 Patients treated with HUMIRA received an 80 mg baseline loading dose Followed by 40 mg given by subcutaneous injection at week 1 Followed by 40 mg every other week for up to 80 weeks.

Conclusions In patients with active, non-infectious intermediate, posterior, or pan uveitis despite the use of corticosteroids, ADA significantly lowered the risk for uveitic flare or BCVA loss. The safety profile was consistent with the known safety profile across approved ADA indications.