Uveitis is a general concept denoting inflammation of various parts of the vascular membrane of the eye (iris, ciliary body, choroid). Uveitis is characterized by redness, irritation and soreness of the eyes, increased photosensitivity, blurred vision, lacrimation, the appearance of floating spots in front of the eyes. Ophthalmological diagnostics of uveitis includes visometry and perimetry, biomicroscopy, ophthalmoscopy, measurement of intraocular pressure, retinography, ultrasound of the eye, optical coherence tomography, electroretinography. Treatment of uveitis is carried out taking into account the etiology; The general principles are the appointment of local (in the form of eye ointments and drops, injections) and systemic drug therapy, surgical treatment of complications of uveitis.
ICD 10
H20 Iridocyclite
General information
Uveitis or inflammation of the uveal tract occurs in ophthalmology in 30-57% of cases of inflammatory lesions of the eye. The uveal (vascular) membrane of the eye is anatomically represented by the iris (iris), the ciliary or ciliary body (corpus ciliare) and the chorioidea (chorioidea) – the actual vascular membrane lying under the retina. Hence, the main forms are iritis, cyclitis, iridocyclitis, chorioiditis, chorioretinitis, etc. In 25-30% of cases, disease leads to poor vision or blindness.
The high prevalence is associated with an extensive vascular network of the eye and slow blood flow in the uveal pathways. This feature contributes to a certain extent to the retention of various microorganisms in the vascular membrane, which under certain conditions can cause inflammatory processes. Another fundamentally important feature of the uveal tract is the separate blood supply to its anterior part, represented by the iris and ciliary body, and the posterior part – the choroid. The structures of the anterior part are supplied with blood by the posterior long and anterior ciliary arteries, and the choroid is supplied by the posterior short ciliary arteries. Due to this, the defeat of the anterior and posterior parts of the uveal tract in most cases occurs separately. The innervation of the departments of the vascular membrane of the eye is also different: the iris and the ciliary body are abundantly innervated by the ciliary fibers of the first branch of the trigeminal nerve; the choroid has no sensitive innervation. These features affect the occurrence and development of uveitis.
Classification
According to the anatomical principle, uveitis is divided into anterior, median, posterior and generalized. Anterior uveitis is represented by iritis, anterior cyclitis, iridocyclitis; median (intermediate) – pars-planitis, posterior cyclitis, peripheral uveitis; posterior – choroiditis, retinitis, chorioretinitis, neuroveitis.
The anterior uveitis involves the iris and the ciliary body – this localization of the disease occurs most often. With median uveitis, the ciliary body and choroid, vitreous body and retina are affected. Posterior uveitis occurs with the involvement of the choroid, retina and optic nerve. With the involvement of all parts of the vascular membrane, panuveitis develops – a generalized form.
The nature of the inflammatory process in uveitis can be serous, fibrinous-lamellar, purulent, hemorrhagic, mixed.
Depending on the etiology, uveitis can be primary and secondary, exogenous or endogenous. Primary uveitis is associated with general diseases of the body, secondary – directly with the pathology of the organ of vision.
According to the peculiarities of the clinical course, uveitis is classified into acute, chronic and chronic recurrent; taking into account the morphological picture, granulomatous (focal metastatic) and non-granulomatous (diffuse toxic-allergic).
Causes
The causal and triggering factors are infections, allergic reactions, systemic and syndromic diseases, injuries, metabolic disorders and hormonal regulation.
The largest group consists of infectious uveitis – they occur in 43.5% of cases. Infectious agents in uveitis are most often Mycobacterium tuberculosis, streptococci, toxoplasma, pale treponema, cytomegalovirus, herpesvirus, fungi. Such uveitis is usually associated with infection entering the vascular bed from any infectious focus and develops in tuberculosis, syphilis, viral diseases, sinusitis, tonsillitis, dental caries, sepsis, etc.
In the development of allergic uveitis, an increased specific sensitivity to environmental factors plays a role – drug and food allergies, hay fever, etc. Often, with the introduction of various serums and vaccines, serum uveitis develops.
Uveitis can be etiologically associated with systemic and syndromic diseases: rheumatism, rheumatoid arthritis, spondyloarthritis, psoriasis, sarcoidosis, glomerulonephritis, autoimmune thyroiditis, multiple sclerosis, ulcerative colitis, Reiter syndrome, Vogt-Koyanagi-Harada syndrome (uveomeningoencephalitis), etc.
Uveitis of post-traumatic genesis occurs after eye burns, due to penetrating or contusion damage to the eyeball, foreign bodies entering the eyes.
The development of uveitis can contribute to metabolic disorders and hormonal dysfunction (diabetes mellitus, menopause, etc.), diseases of the blood system, diseases of the visual organ (retinal detachment, keratitis, conjunctivitis, blepharitis, scleritis, perforation of corneal ulcers) and other pathological conditions of the body.
Symptoms
Manifestations of uveitis may vary depending on the localization of inflammation, pathogenicity of microflora and general reactivity of the body.
In the acute form, anterior uveitis occurs with pain, redness and irritation of the eyeballs, lacrimation, photophobia, pupil constriction, vision impairment. Pericorneal injection turns purple, intraocular pressure often increases. With chronic anterior uveitis, the course is often asymptomatic or with weakly expressed signs – slight redness of the eyes, “floating” dots in front of the eyes.
Corneal precipitates (accumulation of cells on the corneal endothelium) and cellular reaction in the moisture of the anterior chamber, detected during biomicroscopy, serve as an indicator of the activity of anterior uveitis. Complications of anterior uveitis may be posterior synechiae (fusion between the iris and the lens capsule), glaucoma, cataract, keratopathy, macular edema, inflammatory membranes of the eyeball.
With peripheral uveitis, there is a lesion of both eyes, floating opacities in front of the eyes, a decrease in central vision. Posterior uveitis is manifested by a feeling of blurred vision, distortion of objects and “floating” dots in front of the eyes, decreased visual acuity. With posterior uveitis, macular edema, macular ischemia, retinal vascular occlusion, retinal detachment, optical neuropathy may occur.
The most severe form of the disease is widespread iridocyclochorioiditis. As a rule, this form of uveitis occurs against the background of sepsis and is often accompanied by the development of endophthalmitis or panophthalmitis.
With uveitis associated with Vogt-Koyanagi-Harada syndrome, headaches, sensorineural hearing loss, psychosis, vitiligo, alopecia are observed. With sarcoidosis, in addition to ocular manifestations, as a rule, there is an increase in lymph nodes, lacrimal and salivary glands, shortness of breath, cough. The connection of uveitis with systemic diseases may be indicated by nodular erythema, vasculitis, skin rash, arthritis.
Diagnosis
Ophthalmological examination for uveitis includes an external examination of the eyes (the condition of the skin of the eyelids, conjunctiva), visometry, perimetry, examination of the pupillary reaction. Since uveitis can occur with hypo- or hypertension, it is necessary to measure intraocular pressure (tonometry).
With the help of biomicroscopy, areas of ribbon-like dystrophy, precipitates, cellular reaction, posterior synechiae, posterior capsular cataract, etc. are detected. Gonioscopy with this disease allows you to identify exudate, anterior synechiae, neovascularization of the iris and the angle of the anterior chamber of the eye.
During ophthalmoscopy, the presence of focal changes in the fundus, retinal edema and OND, retinal detachment is established. If it is impossible to perform ophthalmoscopy (in case of opacity of optical media), as well as to assess the area of retinal detachment, an ultrasound of the eye is used.
For differential diagnosis of posterior uveitis, determination of neovascularization of the choroid and retina, retinal edema and OND, retinal vascular angiography, optical coherence tomography of the macula and OND, laser scanning tomography of the retina is indicated.
Rheoophthalmography, electroretinography can provide important diagnostic information for uveitis of various localization. Clarifying instrumental diagnostics includes anterior chamber paracentesis, vitreal and chorioretinal biopsy.
Additionally, with uveitis of various etiologies, a consultation of a phthisiologist with lung radiography and Mantoux reaction may be required; consultation of a neurologist, CT or MRI of the brain, lumbar puncture; consultation of a rheumatologist, radiography of the spine and joints; consultation of an allergist-immunologist with tests, etc.
From laboratory studies with uveitis, according to indications, an RPR test is performed, the determination of antibodies to mycoplasma, ureaplasma, chlamydia, toxoplasma, cytomegalovirus, herpes, etc., the determination of CEC, C-reactive protein, rheumatoid factor, etc.
Treatment
Treatment of uveitis is carried out by an ophthalmologist with the participation of other specialists. This disease requires early differential diagnosis, timely etiotropic and pathogenetic treatment, corrective and replacement immunotherapy. Uveitis therapy is aimed at preventing complications that can lead to vision loss. At the same time, treatment of the disease that caused the development is required.
The basis for the treatment is the appointment of mydriatics, steroids, systemic immunosuppressive drugs; for uveitis of infectious etiology – antimicrobial and antiviral agents, for systemic diseases – NSAIDs, cytostatics, for allergic lesions – antihistamines.
Instillations of mydriatics (tropicamide, cyclopentolate, phenylephrine, atropine) can eliminate spasm of the ciliary muscle, prevent the formation of posterior synechiae or break already formed adhesions.
The main link in the treatment is the use of steroids topically (in the form of instillations into the conjunctival sac, laying ointments, subconjunctival, parabulbar, subtenon and intravitreal injections), as well as systemically. Prednisone, betamethasone, dexamethasone are used for uveitis. In the absence of a therapeutic effect from steroid therapy, the appointment of immunosuppressive drugs is indicated.
With increased iOP, appropriate eye drops are used, and hirudotherapy is performed. As the severity of uveitis subsides, electrophoresis or phonophoresis with enzymes is prescribed.
In case of an unfavorable outcome and the development of complications, dissection of the anterior and posterior synechiae of the iris, surgical treatment of vitreous opacities, glaucoma, cataracts, retinal detachment may be required. With iridocyclochorioiditis, vitreoectomy is often resorted to, and if it is impossible to save the eye, evisceration of the eyeball.
Prognosis and prevention
Comprehensive and timely treatment of acute anterior uveitis, as a rule, leads to recovery in 3-6 weeks. Chronic disease is prone to relapses due to the exacerbation of the leading disease. The complicated course can lead to the formation of posterior synechiae, the development of angle-closure glaucoma, cataracts, retinal dystrophy and infarction, OND edema, retinal detachment. Due to central chorioretinitis or atrophic changes in the retina, visual acuity is significantly reduced.
Prevention requires timely treatment of eye diseases and general diseases, exclusion of intraoperative and household eye injuries, allergization of the body, etc.