The distance from the surface of the eye to the optic nerve is only about 2.5 cm, but within that short distance, an incredible diversity of tissue resides and almost any portion of that tissue could become inflamed. A rheumatologist should have a working knowledge of uveitis, keratitis, scleritis, episcleritis, conjunctivitis, optic neuritis, anterior ischemic optic neuropathy, dry eye, and orbital inflammation because rheumatologic diseases can be associated with inflammation in each of these areas and because managing a patient with one of these problems may require systemic immunosuppression, a form of treatment that is outside the expertise of the vast majority of ophthalmologists.
- Divided into anterior, intermediate, and posterior forms. Different disease entities are associated with different forms of uveitis.
- Panuveitis, the occurrence of anterior, intermediate, and posterior uveitis in the same patient, is particularly characteristic of Behçet disease and sarcoidosis.
- Management strategies vary according to whether the uveitis is anterior, intermediate, or posterior.
The uvea—the middle layer of the eye—includes the iris, ciliary body, and choroid. Anatomic subsets of uveitis can be defined: anterior uveitis (or iritis); iridocyclitis, when the ciliary body is inflamed along with the iris; intermediate uveitis (inflammation in the vitreous humor); posterior uveitis (involvement of the choroid or retina); and panuveitis, when the iris, vitreous, and retina all show evidence of inflammation. Uveitis can also be classified by etiology (Tables 67–1 and 67–2). A rheumatologist is usually essential in treating inflammation that is confined to the uveal tract or part of a systemic disease involving the uveal tract.
Table 67–1. Causes of Uveitis. ||Download (.pdf)
Table 67–1. Causes of Uveitis.
- Infections such as herpes simplex, herpes zoster, or toxoplasmosis
- Syndromes confined to the eye such as pars planitis, sympathetic ophthalmia, or birdshot retinochoroidopathy
- Masquerade syndromes such as lymphoma, leukemia, or retinal degeneration
- Systemic immunologic disease as listed in Table 67–2
Table 67–2. Systemic Immunologic Diseases Commonly Associated with Uveitis. ||Download (.pdf)
Table 67–2. Systemic Immunologic Diseases Commonly Associated with Uveitis.
- Ankylosing spondylitis
- Behçet disease
- Drug reactions (eg, rifabutin)
- Familial granulomatous synovitis with uveitis
- Inflammatory bowel disease
- Interstitial nephritis
- Juvenile idiopathic arthritis
- Multiple sclerosis
- Neonatal-onset multisystem inflammatory disease
- Psoriatic arthritis
- Reactive arthritis
- Relapsing polychondritis
- Systemic lupus erythematosus
- Vasculitis, especially Kawasaki syndrome and Cogan syndrome
- Vogt-Koyanagi-Harada syndrome
Uveitis has a variety of complications including cataract, glaucoma, posterior synechiae, macular edema, and retinal vasculitis. In an unpublished series, retinal vasculitis (Plate 51) was detected in one of every seven patients with uveitis, but retinal vasculitis does not have the same therapeutic implication as systemic vasculitis and patients with retinal vasculitis rarely have a systemic disease.
Many patients with uveal ...