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Chronic Uveitis: Symptoms, Causes, and Treatments

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Chronic uveitis is when inflammation of the uvea in the eye lasts for six weeks or longer, or it comes back within three months of being treated. Chronic uveitis is diagnosed through eye exams. Often, additional testing is used, as it can be related to another health issue.

Treatments continue to advance as science and technology do. There are many successful ways to manage the condition.

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What Is Chronic Uveitis?

The middle layer of your eye is called the uvea. It contains three main parts: the anterior (front), ciliary body or intermediate (middle), and choroid and retina in the posterior (back). Uveitis is an inflammation in one of these layers of the eye. In the case of panuveitis, all three layers are impacted.

Chronic uveitis is when the condition persists for a period of six weeks or longer. It can also be recurring, which means it goes away with treatment and then comes back within three months.

Uveitis can be very uncomfortable, and it can significantly impact your vision. Without treatment, it can lead to vision loss.

Chronic vs. Acute Uveitis

Uveitis is either acute, recurrent, or chronic.

DurationCommon CauseCommon TypePotential Complication
Acute UveitisFew weeks to monthsInfection or eye injuryAnterior uveitisVaries
Recurrent UveitisFlares up repeatedlyVariable based on individual casesVariesVaries
Chronic Uveitis6 weeks or longerUnderlying inflammatory disease or autoimmune disorderIntermediate and posterior uveitisGlaucoma, cataracts, macular edema, potentially leading to vision loss

Anterior uveitis is the most common form of uveitis. It is generally acute and not chronic, although when it is related to an autoimmune disorder, it can be chronic as well. Intermediate and posterior forms of uveitis are regularly chronic.

Chronic uveitis is commonly related to an underlying condition or disease, such as an inflammatory disease or autoimmune disorder. Acute uveitis is often the result of an infection or eye injury.

Chronic uveitis can lead to complications, such as glaucoma, cataracts, and macular edema. These can all lead to vision loss.

Symptoms of Chronic Uveitis

While acute uveitis often presents with sudden and intense symptoms, chronic uveitis can sometimes be more subtle, leading patients to delay seeking medical attention. However, over time, if left untreated, chronic uveitis can cause severe damage and complications. Symptoms specific to chronic uveitis include:

  • Persistent eye redness: Unlike the acute form, which may cause sudden and severe redness, chronic uveitis can lead to sustained mild to moderate redness in the affected eye.
  • Blurred vision: Vision can become progressively blurred, often slowly worsening over weeks to months.
  • Gradual increase in light sensitivity: A person with chronic uveitis may find themselves increasingly bothered by bright lights or may have difficulty transitioning from darker to brighter environments.
  • Low-grade eye pain or discomfort: Rather than intense pain, someone with chronic uveitis might experience a constant dull ache or a sensation of pressure in the eye.
  • Floaters: These can become more numerous and noticeable. They may appear as tiny specks, clouds, or cobweb-like structures drifting across the visual field.
  • Occasional vision loss: Episodes of decreased vision can occur, especially during flare-ups.
  • Chronic inflammation: Even if the symptoms are mild or intermittent, chronic inflammation can be ongoing and detected during an eye examination.
  • Potential for complications: Over time, chronic uveitis can lead to cataracts, glaucoma, and retinal damage.

Any individual experiencing these symptoms should seek a comprehensive eye examination. Chronic uveitis requires ongoing monitoring by an ophthalmologist to manage the condition and prevent potential complications.

Diagnosing Chronic Uveitis

Uveitis can be infectious or noninfectious. It can also be related to an autoimmune disorder or inflammatory disease.

Your doctor will need to take a thorough medical history and perform an exam to determine what could be causing your chronic uveitis. Lab and imaging tests can also be helpful in either ruling out or diagnosing the root cause of uveitis.

A complete eye exam to screen for uveitis includes:

  • Visual acuity or eye chart test to see if your vision has changed or decreased.
  • Testing of ocular pressure.
  • Funduscopic exam to carefully look at the back of the eye.
  • Slit lamp exam, with or without dye, to fully inspect the entire eye in a noninvasive manner.

Chronic uveitis is ongoing. It is diagnosed if acute uveitis either does not respond to treatment, continues for six weeks or more, or keeps coming back.

Causes of Uveitis

Uveitis is an inflammatory response in the eye.

Inflammation is the body’s natural response to some sort of trauma, which can include injury, exposure to toxins or infection, and disease. White blood cells flood the eye, causing heat and swelling and often tissue damage. The body’s immune system tries to fight off whatever is causing the problem.

Uveitis can therefore be caused by many different things, including:

  • Injury to the eye.
  • Infection.
  • Toxin exposure.
  • Immune system attack, which can be caused by disease anywhere in the body or an autoimmune disorder.

Diseases and disorders, such as HIV/AIDS, tuberculosis, rheumatoid arthritis, herpes, syphilis, lupus, inflammatory bowel disease, Lyme disease, simplex virus, shingles virus, sarcoidosis, Behcet’s syndrome, and multiple sclerosis, can all be associated with chronic uveitis.

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Treatment Options

Treatment for chronic uveitis mainly depends on the cause of the condition. Infectious uveitis, for instance, is treated by targeting the pathogens, while non-infectious uveitis treatments strive to control inflammation by addressing the root cause.

Chronic uveitis is treated with:

Treatment OptionDescriptionSide EffectsConditions Best Treated
Topical and Local CorticosteroidsStandard treatment designed to reduce inflammation, administered as eye drops or injections into the eye.ye pressure, cataractsIncreased eye pressure, cataracts.Non-infectious uveitis, not suitable for systemic diseases.
Systemic CorticosteroidsAdministered for underlying issues causing inflammation, taken orally in pill form..Hypertension, weight gain, diabetes, osteoporosis.Chronic uveitis with underlying systemic causes.
Corticosteroid Implants (e.g., Retisert)Implanted into the eye to treat non-infectious posterior uveitis, releasing medication over a period of 30 monthsIncreased eye pressure, cataracts, glaucoma, infection from surgical procedure.Non-infectious posterior uveitis, not suitable for systemic causes.
Immunosuppressive Agents (e.g., MethotrexateMedications that act systemically to reduce inflammation at its cause, often preferred for long-term treatment.Delayed onset of effectiveness.Non-infectious chronic uveitis related to disease or an autoimmune disorder.
VitrectomyA surgical procedure to remove the vitreous fluid at the back of the eye, usually a last-resort treatment for severe and resistant conditions.Risks associated with surgery.Severe and resistant cases of chronic posterior uveitis.

Topical and local corticosteroids

The standard and front-line treatment for uveitis is corticosteroids, which are designed to reduce inflammation. These can be administered as eye drops locally or through injections into the eye. Local corticosteroid administration is usually the first treatment option for non-infectious uveitis.

Corticosteroids work quickly and can be very effective at reducing inflammation. They can also lead to complications, such as increased eye pressure and cataracts. If there is a systemic disease or medical issue going on, then corticosteroids applied locally are not going to address the underlying problem.

Systemic corticosteroids

When there is an underlying issue, disorder, or disease causing the inflammation, systemic corticosteroids can be administered. These will also help to treat chronic uveitis as well as whatever is causing the inflammation. Medications like prednisone are taken orally in pill form. Systemic corticosteroids will need to be tapered down over time, and long-term use should be carefully considered.

Typically, doctors will prescribe the lowest maintenance dose possible to keep chronic uveitis under control. This is to minimize side effects, which can include hypertension, weight gain, diabetes, and osteoporosis. Systemic corticosteroids can be very effective at controlling chronic uveitis, but there are many health concerns related to the potential side effects of long-term use.

Corticosteroid implants

Long-acting corticosteroid implants, such as Retisert (fluocinolone), can be implanted into the eye to treat non-infectious posterior uveitis. This medication can be very effective in lowering inflammation and controlling uveitis symptoms for up to three years. It releases medication in a time-release fashion over a period of 30 months. Retisert implantation is a surgical procedure that can carry a risk of infection.

The implant will need to be replaced if the uveitis returns after the 30-month period. It increases the risk for increased eye pressure, cataracts, and glaucoma. The implant can cause more eye problems than traditional methods of steroid administration, but it can also decrease eye inflammation faster and to a higher degree. This also improves vision. Corticosteroid implants can treat uveitis locally, but they will not impact other possible causes of inflammation or diseases in the body.

Immunosuppressive agents

Medications that act as immunosuppressive agents target the whole body and therefore work on a systemic level to reduce inflammation at its cause. They target the source of the problem and not just the chronic uveitis. These medications are often preferred for long-term treatment of non-infectious chronic uveitis related to disease or an autoimmune disorder.

Methotrexate is an immunosuppressive agent that has few side effects of long-term use. It is a good treatment for managing chronic uveitis for years. It does have a long onset, however, which can mean that it takes a while for your body to build up to it. If your uveitis is progressing quickly, you may benefit from a course of steroids and then the immunosuppressive agent as a follow-up treatment.

Vitrectomy

This is usually considered a last-resort treatment for chronic posterior uveitis. It is only used if the condition is severe and resistant to other forms of treatment. A vitrectomy can be done to remove the vitreous fluid at the back of the eye. It is replaced with a temporary substitute that is either fluid-based or a bubble of gas, giving your eyes time to replace it with aqueous humor. Your doctor will often send a sample of your vitreous fluid to a lab to test for infection or other issues.

Advancement in Treatments

Treatments for uveitis continue to advance as technology and scientific knowledge improves. Since chronic uveitis can be related to so many issues within the entire body, it is important for doctors to find out what is causing the inflammation in order to know what to treat.

Advancements in medicine have gone beyond treating chronic uveitis with steroids, for example, as much of the time it is related to an autoimmune disorder that can respond better to a systemic approach, including immunosuppressive agents. New delivery methods for medications are also being researched for their effectiveness.

New medications, such as anti-TNF (tumor necrosis factor) drugs, fall into the biologic agent treatment category. They are being investigated for their use in treating chronic uveitis when corticosteroids and immunosuppressant medications are not working.

These medications are often administered as subcutaneous injections. They have been used to treat systemic inflammatory conditions, such as rheumatoid arthritis. These options are showing promise with reducing inflammation and minimizing the recurrence of uveitis.

References

  1. Uveitis Symptoms and Causes. (2017). Ocular Immunology and Uveitis Foundation.
  2. What Is Uveitis? (August 2019). American Academy of Ophthalmology (AAO).
  3. Uveitis Symptoms. (August 2019). American Academy of Ophthalmology (AAO).
  4. Uveitis. (July 2019). National Eye Institute (NEI).
  5. Uveitis. (2019). National Institute of Blind People (RNIB).
  6. A Look at Emerging Treatments for Uveitis. (January 2018). Review of Ophthalmology.
  7. Recent Advances in Managing and Understanding Uveitis. (2017). F1000 Research.
  8. Retisert. U.S. Food and Drug Administration (FDA).
  9. The Latest Treatment Approaches for Uveitis. (August 2017). Review of Ophthalmology.
  10. Biologic Agents: TNF-alpha Inhibition. (2020). American Academy of Ophthalmology (AAO).

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