Diagnosis and treatment of uveitis; not restricted to the ophthalmologist
Uveitis is associated with a wide range of underlying causes. Familiarity with its clinical manifestations, referral indications, and treatment strategies are required for the optimal use of current therapeutic options. Uveitis can be caused by infectious and non-infectious factors, resulting in differing prognoses and treatments. The treatment of chronic, non-infectious uveitis has profoundly changed in the last years due to the advent of biologicals, but also of intraocular therapies. In severe uveitis, treatment of the underlying cause, whether ocular or systemic, is required to prevent severe loss of vision. For these purposes, a multidisciplinary clinical approach is important, which is addressed in this review.
Relevance for patients: A broad understanding of the different causes of uveitis and the implementation of disease-tailored, multidisciplinary management of uveitis is expected to improve treatment outcomes for patients with different types of uveitis.
[1] Jabs DA, Nussenblatt RB, Rosenbaum JT. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol 2005; 140: 509-516.
[2] Gritz DC, Wong IG. Incidence and prevalence of uveitis in Northern California; the Northern California Epidemiology of Uveitis Study. Ophthalmology 2004; 111: 491-500.
[3] Lardenoye CW, van KB, Rothova A. Impact of macular edema on visual acuity in uveitis. Ophthalmology 2006; 113: 1446-1449.
[4] Durrani OM, Tehrani NN, Marr JE, Moradi P, Stavrou P, Murray PI. Degree, duration, and causes of visual loss in uveitis. Br J Ophthalmol 2004; 88: 1159-1162.
[5] Westeneng AC, Rothova A, de Boer JH, de Groot-Mijnes JD. Infectious uveitis in immunocompromised patients and the diagnostic value of polymerase chain reaction and GoldmannWitmer coefficient in aqueous analysis. Am J Ophthalmol 2007; 144: 781-785.
[6] de Groot-Mijnes JD, Rothova A, Van Loon AM, Schuller M, Ten Dam-Van Loon NH, de Boer JH, Schuurman R, Weersink AJ. Polymerase chain reaction and Goldmann-Witmer coefficient analysis are complimentary for the diagnosis of infectious uveitis. Am J Ophthalmol 2006; 141: 313-318.
[7] Wensing B, de Groot-Mijnes JD, Rothova A. Necrotizing and nonnecrotizing variants of herpetic uveitis with posterior segment involvement. Arch Ophthalmol 2011; 129: 403-408.
[8] Chee SP, Bacsal K, Jap A, Se-Thoe SY, Cheng CL, Tan BH. Clinical features of cytomegalovirus anterior uveitis in immunocompetent patients. Am J Ophthalmol 2008; 145: 834-840.
[9] Sudharshan S, Ganesh SK, Balu G, Mahalakshmi B, Therese LK, Madhavan HN, Biswas J. Utility of QuantiFERON(R)-TB Gold test in diagnosis and management of suspected tubercular uveitis in India. Int Ophthalmol 2012; 32: 217-223.
[10] La Distia NR, van Velthoven ME, Ten Dam-Van Loon NH, Misotten T, Bakker M, van Hagen MP, Rothova A. Clinical manifestations of patients with intraocular inflammation and positive QuantiFERON-TB gold in-tube test in a country nonendemic for tuberculosis. Am J Ophthalmol 2014; 157: 754-761.
[11] van Daele PL, Bakker M, van Hagen PM, Baarsma GS, Kuijpers RW. TB or not TB: treat to see. Med J Aust 2006; 185: 178-179.
[12] Gupta A, Bansal R, Gupta V, Sharma A, Bambery P. Ocular signs predictive of tubercular uveitis. Am J Ophthalmol 2010; 149: 562- 570.
[13] Sanghvi C, Bell C, Woodhead M, Hardy C, Jones N. Presumed tuberculous uveitis: diagnosis, management, and outcome. Eye (Lond) 2011; 25: 475-480.
[14] Wensing B, Relvas LM, Caspers LE, Valentincic NV, Stunf S, de Groot-Mijnes JD, Rothova A. Comparison of rubella virus- and herpes virus-associated anterior uveitis: clinical manifestations and visual prognosis. Ophthalmology 2011; 118: 1905-1910.
[15] Birnbaum AD, Tessler HH, Schultz KL, Farber MD, Gao W, Lin P, Oh F, Goldstein DA. Epidemiologic relationship between fuchs heterochromic iridocyclitis and the United States rubella vaccination program. Am J Ophthalmol 2007; 144: 424-428.
[16] de la Torre A, Stanford M, Curi A, Jaffe GJ, Gomez-Marin JE. Therapy for ocular toxoplasmosis. Ocul Immunol Inflamm 2011; 19: 314-320.
[17] Wong RW, Jumper JM, McDonald HR, Johnson RN, Fu A, Lujan BJ, Cunningham ET, Jr.. Emerging concepts in the management of acute retinal necrosis. Br J Ophthalmol 2013; 97: 545-552.
[18] Aslanides IM, De SS, Wong DT, Giavedoni LR, Altomare F, Detorakis ET, Kymionis GD, Pallikaris IG. Oral valacyclovir in the treatment of acute retinal necrosis syndrome. Retina 2002; 22: 352- 354.
[19] Messenger W, Hildebrandt L, Mackensen F, Suhler E, Becker M, Rosenbaum JT. Characterisation of uveitis in association with multiple sclerosis. Br J Ophthalmol 2015; 99: 205-209.
[20] Marrie RA, Reider N, Cohen J, Stuve O, Sorensen PS, Cutter G, Reingold SC, Trojano M. A systematic review of the incidence and prevalence of autoimmune disease in multiple sclerosis. Mult Scler 2015; 21: 282-293.
[21] Le SJ, Seve P, Renoux C, Broussolle C, Confavreux C, Vukusic S. Uveitis associated with multiple sclerosis. Mult Scler 2008; 14: 415-417.
[22] Lee FF, Foster CS. Pharmacotherapy of uveitis. Expert Opin Pharmacother 2010; 11: 1135-1146.
[23] Heo J, Sepah YJ, Yohannan J, Renner M, Akhtar A, Gregory A, Shulman M, Do DV, Nguyen QD. The role of biologic agents in the management of non-infectious uveitis. Expert Opin Biol Ther 2012; 12: 995-1008.
[24] van Laar JA, Jamnitski A, Baarsma GS, van Daele PL, van Hagen PM. [Behcet's disease and the possibilities of modern tumour necrosis factor inhibiting medication]. Ned Tijdschr Geneeskd 2006; 150: 705-709.
[25] Lindstedt EW, Baarsma GS, Kuijpers RW, van Hagen PM. Anti-TNF-alpha therapy for sight threatening uveitis. Br J Ophthalmol 2005; 89: 533-536.
[26] Smith JR, Levinson RD, Holland GN, Jabs DA, Robinson MR, Whitcup SM, Rosenbaum JT. Differential efficacy of tumor necrosis factor inhibition in the management of inflammatory eye disease and associated rheumatic disease. Arthritis Rheum 2001; 45: 252-257.
[27] Kempen JH, Altaweel MM, Holbrook JT, Jabs DA, Louis TA, Sugar EA, Thorne JE. Randomized comparison of systemic antiinflammatory therapy versus fluocinolone acetonide implant for intermediate, posterior, and panuveitis: the multicenter uveitis steroid treatment trial. Ophthalmology 2011;118:1916-1926.
[28] Tomkins-Netzer O, Taylor SR, Bar A, Lula A, Yaganti S, Talat L, Lightman S. Treatment with repeat dexamethasone implants results in long-term disease control in eyes with noninfectious uveitis. Ophthalmology 2014;121:1649-1654.
[29] Nederlands Oogheelkundig Gezelschap. Richtlijn voor diagnostiek en behandeling uveïtis. NOG, 2007.