Rheumatic uveitis is an autoimmune lesion of the structures of the uveal tract of the eyeball. Common symptoms for all forms are hyperemia, conjunctival injection, pain, photophobia and lacrimation. Diagnosis of rheumatic uveitis includes external examination, visometry, tonometry, biomicroscopy, ophthalmoscopy, gonioscopy. With anterior uveitis, local use of mydriatics, NSAIDs, glucocorticosteroids (GC) is indicated. The second-line drugs are derivatives of aminosalicylic acid. When the posterior parts are affected, systemic GC and immunosuppressors are used. Anti-TNF therapy is recommended in the absence of the effect of basic therapy.
Rheumatic uveitis is an acute or chronic disease in ophthalmology characterized by inflammation of the uveal tract in patients with a history of active autoimmune process. In 20% of cases, uveitis develops at the age of 25-35 years on the background of rheumatism. In children, pathology is often diagnosed after the age of 3, while serous plastic uveitis develops more often in early and preschool age. Mostly female patients suffer. The disease is characterized by a recurrent course. Relapses occur in the spring and autumn period. Rheumatic uveitis is an important medical and social problem, because it affects the young able-bodied population and in 30% of cases leads to a decrease in visual acuity with subsequent disability.
The cause of rheumatic uveitis is an immuno-inflammatory lesion of the vessels of the eyeball of streptococcal genesis. The disease occurs more often against the background of chronic, less often acute course of Sokolovsky-Buyo disease. In this case, the anterior parts of the uveal tract, the ciliary body or the vascular membrane are affected. Simultaneous involvement of all the above structures in the pathological process is possible. The risk of developing this pathology is increased by a decrease in reactivity and resistance of the body, hypothermia. Frequent angina can be the provoking factors of relapses of the disease. The nodular form of rheumatic uveitis, as a rule, occurs in patients with arthritis of autoimmune origin. Also, this pathology can be one of the manifestations of such systemic diseases as seronegative spondyloarthritis, juvenile chronic arthritis, Behcet’s disease.
Depending on the lesion of one or another part of the eyeball, anterior, posterior, peripheral uveitis and panuveitis are distinguished. Rheumatic uveitis is acute or chronic. As a rule, the inflammatory process is characterized by the predominance of exudative or transudative type of secretion. Rheumatic plastic uveitis develops acutely, often preceded by conjunctivitis. The patient complains about the sensation of a foreign body in the eye, burning, increased separation of serous contents, mydriasis. After 3-4 days, a ciliary injection is added. At the same time, the dilation of the pupils is replaced by their narrowing. 2-3 days after the development of the first symptoms, pain in the eye socket, lacrimation and photophobia increase. Patients note changes in the color of the iris, which is caused by edema, hyperemia and secretion of exudate. As a result of the formation of synechiae, there is a high risk of developing secondary cataracts or glaucoma.
Clinical manifestations of serous-plastic anterior rheumatic uveitis persist for a long time, but this form is characterized by a lighter course. Patients note minor soreness and photophobia, less often injection of vessels at the edge of the iris. The most common complication is vitreous detachment. In the serous variant, the disease has a latent course without external manifestations of the inflammatory process. As a rule, chronic serous uveitis transforms into serous plastic and is complicated by secondary glaucoma or cataract. A feature of the hemorrhagic form of rheumatic uveitis is the predominance of the exudative type of secretion over the transudate. At the same time, an admixture of blood is observed in the exudate. In turn, with panuveitis, the vascular membrane is also involved in the pathological process. Clinical symptoms of peripheral rheumatic uveitis are represented by the appearance of “fog” or “flies” in front of the eyes.
Diagnosis of rheumatic uveitis is based on anamnestic data, results of external examination, visometry, tonometry, biomicroscopy, ophthalmoscopy, gonioscopy. External examination of a patient with rheumatic plastic uveitis determines redness and injection of conjunctival vessels, slight pupil dilation, swelling of the eyelids. By biomicroscopy, pigmented and cone-shaped synechiae along the edge of the pupil, corneal edema and striation of its posterior part are visualized. A specific symptom is the “lattice” formed by the folds of the descemet shell. Dilated vessels are detected in the anterior parts of the iris. With the help of a slit lamp, it is possible to detect a narrowing of the space behind the lens, a pronounced Tyndall phenomenon. In the serous-plastic form of rheumatic uveitis, small rounded precipitates of gray color are visualized. A long-term course is indicated by a change in their contour from smooth to scalloped.
Gonioscopy determines the opalescent moisture of the anterior chamber of the eye, yellow-gray exudate. Ophthalmoscopy indicates a slight hyperemia in the area of the optic disc. Macroscopic examination of the optical slice reveals the accumulation of pathological suspensions in the retrolental space and vitreal detachments. In the nodular form of rheumatic uveitis, pink-gray nodules with a diameter of 1-3 mm can be diagnosed by biomicroscopy. After their disappearance, areas of atrophy form on the pupil belt of the iris, which are replaced by posterior synechiae.
In the hemorrhagic form of rheumatic uveitis, clusters of dark red exudate are detected by gonioscopy. Fluid also accumulates in the corner of the anterior chamber, in the area of the iris and pupil. After resorption of the exudate, posterior synechiae are visualized during biomicroscopy. Foci of opacity when the vascular membrane is involved in the pathological process are determined during ophthalmoscopy. They are yellowish formations with an indistinct contour. Old foci have a white color. This method allows you to detect hyperemia of the optic disc. In peripheral rheumatic uveitis, during biomicroscopy, inflammatory suspensions in the vitreous body and ciliary detachment can be detected. Additional research methods are visometry, which allows to determine the degree of visual acuity reduction, and tonometry, performed to measure IOP in patients with suspected secondary glaucoma.
The tactics of treatment of rheumatic uveitis depends on the severity of clinical manifestations and localization of the pathological process. The main method of conservative therapy of acute anterior rheumatic uveitis is the local use of glucocorticoids in drops and injections with cycloplegic agents. Also, with this form, the instillation of mydriatics is shown. With a recurrent course (more than 3 relapses per year or 2 in the last 3 months), it is recommended to prescribe medications from the group of aminosalicylic acid derivatives.
Local application of glucocorticosteroids in the form of drops in posterior rheumatic uveitis and panuveitis is ineffective. With a monocular lesion, hormonal agents should be administered in the form of retro- or parabulbar injections. This method of administration provides a sufficient concentration of the drug in the area of inflammation. With binocular rheumatic uveitis of the posterior parts, systemic therapy with immunosuppressants, cytostatics and glucocorticoids is carried out. Anti-TNF therapy is indicated in the absence of the effect of all of the above treatment methods. The drugs used are biological agents that act on tumor necrosis factor α (TNF α).
Prognosis and prevention
Specific measures for the prevention of rheumatic uveitis have not been developed. Non-specific preventive measures are reduced to timely treatment of systemic autoimmune diseases in the anamnesis, normalization of sleep and wakefulness, correction of diet. All patients should be examined by an ophthalmologist 2 times a year with mandatory tonometry, visometry and biomicroscopy. The prognosis for life and work capacity with timely diagnosis and treatment is favorable. The progression of rheumatic uveitis, the formation of a large number of synechiae and the development of secondary complications (cataract, glaucoma) can lead to complete loss of vision and further disability of the patient.