Frequently Asked Questions
Written by Prof. Susan Lightman, of Moorfields Eye Hospital, London,
this section has answers to commonly asked questions that are asked
either at clinics or are asked of the UIG. 

What is Uveitis?
The term uveitis really means that you have inflammation inside the eye.
There are lots of different types of uveitis with many causes so the
term itself does not say anything about this. It is not one disorder.

Why Me?
We do not know why most people get uveitis. There is an association with
some infections (eg toxoplasmosis) and with certain diseases (such as
sarcoidosis and Behcet’sdisease) in some patients and some patients
have an increased likelihood due to the genes they carry (eg some types
of uveitis are associated with certain gene types such as HLA B27 and
HLA A29). But in many patients, we do not find a cause.. We think that
uveitis falls into the group of diseases known as autoimmune in which
the body reacts against itself. The trigger for this is unknown but
might be infection in susceptible individuals. Treating for infection
even if we knew what is was, is unlikely to help as the immune system is
already activated and causes the damage.

What types of Uveitis are there?
Uveitis is divided initially into anterior in which only the front part
of the eye is involved (this is also sometimes called iritis and
iridocylitis), posterior in which the back of the eye is involved and
panuveitis in which the front and the back of the eye are both involved.
Within each type, there are several subtypes. Anterior uveitis can be
subdivided into acute disease which lasts a few weeks and chronic
disease which is defined as lasting more than 3 months and can last many
years. Posterior uveitis is usually chronic and can last a long time
except in patients with toxoplasmosis when it may settle in a few weeks.
It is important to know which type of uveitis you have as this
determines the type of investigations and treatment you need and well as
the complications.

Can it be cured?
No it cannot and the treatment only suppresses the inflammation until
the disease process burns itself out. The treatment needs to be
continued as long as the inflammation is active. In any patient, it is
not possible to know how long the disease will last and when it will go
away. There is nothing we know that you can do to really influence it
either.

Is it caused by stress? 
A lot of patients tell us that stress can bring on an attack or cause a
relapse. There is a relationship between stress and the immune system
but it not an easy one to understand. Unfortunately removing stress does
not guarantee the disease will go away but luckily not all patients find
stressful events have any effect on the disease either.

Why do I have to use drops? 
Inflammation at the front of the eye (anterior uveitis) can be treated
with drops as the drugs in them penetrate well into the front of the
eye. Steroid drops come in a variety of types and strengths and are
given to suppress the inflammation until it goes away. The more intense
the inflammation you have, the stronger the steroid drops and the more
frequently you have to put them in. As the inflammation is brought under
control, the frequency and strength of the steroid drops can be reduced.
Steroid can also be given as an ointment used at night – this
releases steroid into the eye keeping it “marinaded” in steroid
overnight Dilating drops are given to stop the iris (the coloured part
of the eye), which becomes sticky when it is inflamed, sticking to the
lens which is right behind it. If it sticks a lot, there is increased
likelyhood of cataract and other complications in the long term. Again
there are a variety of types of dilating drops which last different
lengths of time –atropine can last several weeks, cyclopentolate most
of a day and tropicamide a few hours. Often the pain of acute
inflammation is helped by dilating the pupil as spasm of the iris can
contribute to the discomfort.

Are steroid drops dangerous - do they cause cataracts?
It is true that steroid drops can cause cataract but uncontrolled
inflammation can also cause it and will do more harm to the eye. It is
therefore best to get the inflammation under control with the lowest
amount of steroid required.

Will I have to take tablets?
Patients who have inflammation at the back of the eye which is causing
trouble cannot use drops to control it as the drops do not get to the
back of the eye. Sometimes steroids can be given by injection under the
eye in a depot slow release form an this is useful if only one is
involved. Most patients who have both eyes involved take steroid tablets
to control the inflammation. As we all know steroids have lots of side
effects which are mainly dose dependent but in this day and age it is
unnecessary for someone to have to stay on high doses of steroids in the
long term. Other drugs such as cyclosporin, azathioprine and
mycophenolate can work with the steroids enabling them to be effective
at a lower dose, although they do have side effects of their own. The
tablets don’t cure the disease either and have to be taken for as
long as the disease is active.

How will I know the uveitis is over?
Treatment can bring the inflammation under control and it is only
possible to know whether the treatment is still required when you start
to withdraw it. If all remains quiet, the uveitis is in remission but
may relapse later. If the disease activity increases as the treatment is
reduced, the disease process is still active and treatment needs to be
continued.

Will I go blind?
If by going blind you mean will you wake up in darkness, no you
won’t. Most patients with acute uveitis do not lose vision and
treatment is aimed to control the inflammation to prevent it causing
visual loss. The main causes of visual loss in patients with chronic
uveitis are cataract (which can be removed), glaucoma or damage to the
back of the eye from high pressure inside the eye, and macular oedema or
'waterlogging' of the retina due to the chronic inflammation. Control of
the inflammation on the lowest dose of drugs possible and ensuring the
intraocular pressure is not raised are key to reducing the chance of
permanent visual loss.

Should I worry if a cause cannot be found for my uveitis?
In many people, no obvious cause is found for their uveitis. In many
diseases associated with inflammation, no underlying cause can be found
either – the most common example being rheumatoid arthritis. In some
patients , inflammation can be detected elsewhere such as in the lung
and the disease process may be called sarcoidosis, but we do not know
the cause of that either. In some patients infection is the cause such
as that associated with toxoplasma or toxocara but these have very
distinct clinical appearances allowing them to be easily detected on eye
examination.  Current theories of why people get these autoimmune
diseases such as rheumatoid arthritis, insulin dependent diabetes in
young people, thyroid disease and uveitis include certain infections in
which the immune system responds by producing cells to fight the
infecting which also react incidentally with self tissue. This would not
happen in everyone but only in patients with a certain genetic make-up
which would form these cross-reactive cells. By the time the uveitis
occurs, there is no place for treatment of the infection as it has long
gone-it is the immune response which causes the damage and this is what
is treated.

How will my uveitis and the medication used to treat it affect my
pregnancy/breastfeeding?  
Drops are the most frequent type of therapy used to treat uveitis and
are not a threat as only very low doses get into the bloodstream if any
does.  Drugs taken by mouth include steroids, azathioprine, cyclosporin,
methotrexate, mycophenolate, tacrolimus and Diamox amongst others used
less commonly. Of these Diamox is definitely contraindicated in
pregnancy but the others are less clear cut. There is a risk with any
drugs you take in pregnancy and although the risk is small, it is not
zero. It is better not to be pregnant or breastfeeding on anything.
However, this is not always realistic and most of the experience comes
from patients who have had kidney transplants, are on similar
medications and have had successful normal pregnancies. If you are
contemplating getting pregnant or become pregnant while taking these
type of drugs, it is very important that you discuss the situation with
your ophthalmologist as quickly as possible. In this way, everything can
be discussed and a plan that is best for you sorted out.

Published by Uveitis Information Group in August 2006
Further information can be obtained from:

Uveitis Information Group
South House,
Sweening
Vidlin
Shetland Isles ZE2 9QE
Tel: 0845 6045660
email: info@uveitis.net
website: www.uveitis.net