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UVEITIS

Anatomy/Background
The iris regulates the amount of light that enters the eye, the ciliary body produces aqueous humor and supports the lens, and the choroid provides oxygen and nourishment for the retina.

Definition (Mayoclinic.com)
Uveitis is inflammation of the uvea, the middle layer of the eye. The uvea consists of the iris, choroid and ciliary body. The choroid is sandwiched between the retina and the white of the eye (sclera), and it provides blood flow to the deep layers of the retina. The most common type of uveitis is an inflammation of the iris called iritis (anterior uveitis).

Classifications (Brunner & Suddarth pg1790, Lippincott pg596, Medscape.com)

By Location: Anterior uveitis inflammation of the iris (iritis) and ciliary body (iridocyclitis) IS THE MOST COMMON Intermediate uveitis inflammation of the structures posterior to the lens (pars plantis or peripheral uveitis) Posterior uveitis inflammation of the choroid (choroiditis), retina (retinitis), or vitreous near the optic nerve and macula After anatomical classification, uveitis is further described by the following: Onset (sudden or non-granulomatous) vs. (insidious or granulomatous) Duration (limited less than 3 months in duration, or persistent greater than 3 months in duration) Course (acute, recurrent, or chronic) Laterality (unilateral vs. bilateral)

Incidence (Medscape.com)
1. United States - The estimated annual incidence is approximately 12 cases per 100,000 persons. 2. International - Uveitis is more common in Finland, where the annual incidence is approximately 23 cases per 100,000 persons. This is probably because of high frequency of the gene HLA-B27 in the population. 3. Mortality/Morbidity

No deaths due to iritis or uveitis have been reported. Morbidity results from posterior synechiae formation (adhesions between the iris and the lens) that may lead to high intraocular pressure and subsequent optic nerve loss.

2 4. The majority of patients are aged 20-50 years.

Etiology ((Brunner & Suddarth pg1790, Lippincott pg596, Medscape.com + Mayoclinic.com)

Sometimes, the specific cause of uveitis isn't clear (idiopathic/unknown). However, in some people, uveitis is associated with: (1)Inflammatory (2) Traumatic (3) Infections (4) Drug induced (5) Genetic Possible risk factors for uveitis include: A genetic predisposition - people with changes in certain genes may be more likely to develop uveitis. Having an infection - a number of infections, such as toxoplasmosis, cat-scratch fever, tuberculosis, herpes, syphilis and West Nile virus, can increase the risk of uveitis. Having an autoimmune or inflammatory disorder such as ankylosing spondylitis, sarcoidosis, Behcet's disease, ankylosing spondylitis, sarcoidosis, psoriatic arthritis, Crohn's disease and ulcerative colitis. A history of eye injury - trauma to the eye can cause uveitis. It's even possible for uveitis to develop in the eye that wasn't injured. Certain cancers, such as lymphoma, that can directly or indirectly affect the eye Drugs such as : rifabutin, cidofovir, sulfonamides, pamidronate

Pathophysiology
Will depend on the cause 1. The mechanism for trauma is believed to be a combination of microbial contamination and accumulation of necrotic products at the site of injury, thereby stimulating proinflammatory processes. For infectious etiologies of uveitis, it is postulated that the immune reaction directed against foreign molecules or antigens may injure the uveal tract vessels and cells. 2. When uveitis is found in association with autoimmune disorders, the mechanism may be a hypersensitivity reaction involving immune complex deposition within the uveal tract.

Clinical Manifestations/Signs & Symptoms

Diseases that predispose a patient to uveitis and are likely to present to the emergency department include inflammatory bowel disease, rheumatoid arthritis, systemic lupus erythematosus (SLE), sarcoidosis, tuberculosis, syphilis, and AIDS.

Complications (Mayoclinic.com)
If left untreated, uveitis can cause the following complications: Abnormally high pressure inside the eye (glaucoma) Damage to the optic nerve Clouding of the lens (cataract) or cornea Retinal problems, such as fluid within the retina or retinal detachment Vision loss

Diagnostic Evaluation

If the uveitis is recurrent, a careful history should be initiated to discover any underlying causes.

This evaluation should include a complete history, physical examination, and diagnostic tests, including a complete blood cell count, erythrocyte sedimentation rate, antinuclear antibodies, and Venereal Disease Research Laboratory (VDRL) and Lyme disease titers

Nursing Assessment

((Brunner & Suddarth pg1790, Lippincott pg596, Medscape.com + Mayoclinic.com)

Hx Taking Questions to be asked When did you first begin experiencing symptoms? Have your symptoms been continuous or occasional? How severe are your symptoms? Have they gotten worse? Does anything seem to improve your symptoms? What, if anything, appears to worsen your symptoms? Have you ever had uveitis before? Do you have any other medical problems? Do you have arthritis? Do you have back problems? Have you had any recent skin rashes? Have you had any ulcerated sores in your mouth or on your genitalia? Have you had a recent upper respiratory infection or cold symptoms?

Medical Management
1. Wear dark glasses outdoors to help manage photophobia 2. Ciliary spasms and synechia are managed by mydriasis cyclopentolate (Cyclogyl) and atropine are used 3. Anti-inflammatory medication. Your doctor may prescribe anti-inflammatory medication, such as a corticosteroid, to treat your uveitis. This medication may be given as eye drops. Or, you may be given corticosteroid pills or an injection into the eye.
a. Local corticosteroid drops, such as Pred Forte 1% and Flarex 0.1%, instilled four to six times a day are also used to decrease inflammation. In very severe cases, systemic corticosteroids, as well as intravitreal corticosteroids, may be used. b. For people with difficult-to-treat posterior uveitis, a device that's implanted in your eye may be an option. This device slowly releases corticosteroid medication into your eye for about 2 1/2 years.

4. Antibiotic or antiviral medication. If uveitis is caused by an infection, antibiotics, antiviral medications or other medicines may be given with or without corticosteroids to bring the infection under control. 5. Immunosuppressive or cell-destroying (cytotoxic) medication. Immunosuppressive or cytotoxic agents may be necessary if your uveitis doesn't respond well to corticosteroids or becomes severe enough to threaten your vision. 6. Surgery. Vitrectomy surgery to remove some of the jelly-like material in your eye (vitreous) may be necessary both for diagnosis and management of your uveitis. A small sample of the vitreous can help identify a specific cause of eye inflammation, such as a virus, bacterium or lymphoma. The procedure may also be used to remove developing scar tissue in the vitreous.

Nursing Diagnosis, Interventions, and Expected Outcome

Family Education and Health Maintenance Discharge Planning