By Guada Respicio, MD, MS, FACP, FACR, CCD
“My eye doctor said that I have uveitis. He advised that I see a rheumatologist.”
What is uveitis?
You may be asked to see a rheumatologist if your ophthalmologist finds that you have uveitis. What is uveitis? Uveitis is an uncommon condition characterized by inflammation ofthe uvea, which is the middle portion of the eye. The anterior (front) portion of the uvea consists of the iris and the ciliarybody; inflammation of this area is described as anterior uveitis or iritis (they are synonymous). If the inflammation extends tothe ciliary body, it is then called iridocyclitis. Symptoms mayinclude red eye, eye pain, being very uncomfortable looking at bright lights, a small pupil, or blurred vision. The posterior (back) portion of the uvea includes the choroid; inflammation of this area is called posterior uveitis. Patients may present with blurred vision or floaters (tiny, dark spots that move across one’s line of sight). Anterior uveitis is about four times more common than posterior uveitis.
What are the causes of uveitis?
There are multiple causes of uveitis. The main reason patients are referred to a rheumatologist is to be evaluated for a potential systemic autoimmune condition. Uveitis causes are categorized into different subsets: infection vs. autoimmune conditions (systemic autoimmune condition or other immunerelated conditions) vs. syndromes isolated strictly to the eye. About 40 percent of patients may have uveitis related to an autoimmune condition. Interestingly, in about 30 percent of patients, there is no identifiable cause. These cases are classified as idiopathic uveitis.
There are numerous infectious causes of uveitis, including bacterial and spirochetal diseases (such as tuberculosis and syphilis), viral diseases (including herpes virus, cytomegalovirus “CMV” and West Nile virus), fungal infections, and parasitic infections (for instance, toxoplasmosis). Blood samples must be obtained to evaluate for exposure to these organisms.
Uveitis can be the first extra-articular (outside the joint or aside from joint involvement) manifestation of many systemic inflammatory conditions, including the spondyloarthritis family of disorders (ankylosing spondylitis, psoriatic arthritis and reactive arthritis); sarcoidosis; other systemic rheumatic diseases, such as Behcet’s disease, juvenile idiopathic arthritis, relapsing polychondritis, Sjögren’s syndrome, systemic lupus erythematosus; and other systemic disorders, such as inflammatory bowel disease (Crohn’s colitis and ulcerative colitis). It is rare to see uveitis result from a reaction to a medication.
Spondyloarthritis is a family of joint disorders that may include ankylosing spondylitis, psoriatic arthritis and reactive arthritis. These conditions are the most common systemic immune disorders associated with uveitis in North America and Europe. In certain conditions, there is a genetic predisposition to the development of uveitis. For instance, acute anterior uveitis is associated with the human leucocyte antigen HLAB27. About 20-40 percent of patients with either any one of these HLA-B27-related disorders develop the sudden onset of anterior uveitis. Most patients may have an incomplete or evolving spondyloarthropathy by the time they present with uveitis symptoms so they need to be closely monitored by their rheumatologist for evolution into these systemic autoimmune conditions. Sarcoidosis is another inflammatory condition that accounts for a significant percentage of patients who present with uveitis. In fact, approximately 20 percent of patients develop eye disease as their initial presentation of sarcoidosis. Juvenile idiopathic arthritis (JIA) may be associated with uveitis, especially in patients with the oligoarticular pattern (limited joint involvement) and those whose laboratory tests show positive for antinuclear antibody (ANA).