Clinical Consultations: Uveitis

Uveitis

C. Stephen Foster MD

Uveitis is inflammation inside the eye, specifically affecting one or more of the three parts of the eye that make up the uvea: the iris (the colored part of the eye), the ciliary body (behind the iris, responsible for manufacturing the fluid inside the eye) and the choroid (the vascular lining tissue underneath the retina). Problems associated with uveitis are relatively under-appreciated by the general population and ophthalmologists alike. Few people realize, for example, that the third leading cause of blindness in this country is uveitis.

Approximately sixty different things can cause uveitis, and the "detective work" involved in trying to discover what a particular patient’s cause for their uveitis is may be extremely tedious and costly. This "detective work" is much more like diagnostic work involved in internal medicine than like the typical work involved in the practice of ophthalmology. Primarily for this reason, few ophthalmologists choose to specialize in uveitis. Additionally, the care of some forms of uveitis requires the use of systemic medications (nonsteroidal anti-inflammatory drugs, steroids, and/or immunomodulators, "chemotherapy.") This too, dissuades many ophthalmologists from the practical care of patients with uveitis. There are, however, several centers around the United States specializing in the care with patients with this potential blinding problem. Additionally, increasing numbers of younger ophthalmologists are spending time, after completing their training in ophthalmology, getting specialty training so that they may care for patients with uveitis.

Both infectious and non-infectious as well as malignant causes for uveitis are represented in the spectrum of patients cared for at the specialized centers. Clearly, then, "getting to the bottom of it," and definitively identifying the cause of the uveitis is quite critical, since proper choice of treatment is so dependent on the underlying cause; the proper treatment for one cause would in many instances frankly be deleterious in the care of patients with uveitis from another cause.

Uveitis on the basis of autoimmunity (see last month’s educational section) is the most common form of uveitis. This uveitis tends to be recurrent. We employ a "stepladder" approach to the care of our patients with autoimmune uveitis, generally beginning with steroid drops, advancing to steroid injections and/or pills, adding an oral non-steroidal anti-inflammatory medication, and culminating in the use of an immunomodulatory, chemotherapeutic drug if the patient’s uveitis continues or continues to recur each time the steroid medications are tapered and stopped. The reason for our philosophy on this point of a limit of total amount of steroid used stems from the fact that so many potentially avoidable complications occur with open ended use of steroids. Additionally, we have a philosophy of a complete intolerance to continued recurrences or the continuance of "low grade" inflammation in the eye. This philosophy is born of twenty-one years of experience here in seeing the consequences of allowing such recurrences or of allowing such "low grade" inflammation to persist: slow but inevitable damage to the eye such that vision is progressively lost.

We believe that, as more physicians recognize the lack of progress in reducing blindness secondary to uveitis over the past forty years, they will increasingly abandon the old attitudes of treating this disorder and will embrace a new philosophy of a zero tolerance model for inflammation and will employ a step ladder algorithm in their treatment approach to patients with uveitis.