Uveitis

About uveitis

In this section, you or a loved one can find out more about prescription medication used to treat uveitis. We also provide practical advice on living with uveitis and offer tips on how to tap into your support network. Read on and you’ll find answers to some of your questions as well as links to resources for more information. Being informed is an important first step towards becoming an active decision-maker in managing your uveitis.

What is uveitis?

Uveitis is due to inflammation inside the eye. Inflammation is the body’s way of responding to tissue damage, germs, or toxins. It leads to swelling, redness and the eye may feel hot.

In uveitis, the inflammation occurs in the central part of the eye or uveal tract (also called uvea). Quite a few of the blood vessels that nourish the eye are found in the uvea.

The uveal tract is made up of three parts: iris, ciliary body and choroid:

Iris: coloured portion of the eye that controls the amount of light entering.
Ciliary body: forms a clear liquid filling the front of the eye; provides nutrients to the eye.
Choroid: supplies blood to the eye.

Uveitis is not one disease – rather it is a group of conditions all characterized by irritation and swelling in the uveal tract.

Early diagnosis and treatment of uveitis are important. Uveitis can be serious and may lead to permanent vision loss.

The type of uveitis depends on the location in the uveal tract where the swelling and irritation occur.

Anterior uveitis (also called iritis): the most common type of uveitis, occurs in front of the uveal tract affecting the iris, the ciliary body or both.
Posterior uveitis (also called cyclitis or retinitis): affects the choroid and retina at the back of the eye.
Intermediate uveitis (also called choroiditis): affects a clear gel within the eye called the vitreous humour
Panuveitis: is uveitis of all parts of the uveal tract.

In any of these conditions, the jelly-like material in the center of your eye may be inflamed.

Uveitis can also be described in terms of its duration. Acute uveitis lasts from weeks to months and then gets better; chronic uveitis may last from months to years and may or may not completely disappear.

Finding out you have uveitis can leave you feeling worried about your eyes and vision, so it's crucial to reach out for help and information from people who are close to you and to your healthcare team. Along with obtaining the best possible medical support and treatment, it is important to prioritize your emotional and physical wellbeing, to ask for help and support when you need it, and to nurture relationships with compassionate people who enrich your life. You don't have to do it alone – there are many ways to manage your daily life with your healthcare team, family and friends, as you will see in the following sections.

What causes uveitis?

Possible causes of uveitis include:

Eye injury (for example due to getting a chemical in the eye)
Associated with eye surgery
Autoimmune disorder, for example, sarcoidosis, ankylosing spondylitis, Reiter syndrome, multiple sclerosis, juvenile rheumatoid arthritis and Crohn’s disease
Inflammatory disorder
Infections, such as cat-scratch disease, herpes zoster, syphilis, toxoplasmosis, tuberculosis, Lyme disease or West Nile virus
Cancer affecting the eye, such as lymphoma
Certain drugs, such as rifabutin, a type of antibiotic

People who have relatives with uveitis may be more likely to develop it themselves. A study showed that cigarette smoking may be associated with uveitis.

In about half of all cases, the specific cause of uveitis is unknown.

Uveitis is swelling and irritation in the central part of the eye which is called the uvea or uveal tract.¹
Possible causes of uveitis include infection, injury, or an autoimmune or inflammatory disease. Many times a cause can't be identified.²
It is estimated that approximately 200 out of every 10,000 people are diagnosed with uveitis each year.¹
Uveitis is the most common cause of vision loss in young adults.¹
Uveitis causes 20% of all legal blindness (20/200 vision).^1,3

In developed countries, uveitis is the 5^th most common cause of vision loss amongst persons aged 20 to 60 years.¹

References:

What are the effects of uveitis

Uveitis can be different in different people. Some people, particularly children and young adults, may not experience any symptoms at all. Other people may experience severe symptoms.

A patient’s experience with uveitis may be affected by the cause, location and duration of the disease, as well as their overall state of health.

The signs and symptoms of uveitis may occur suddenly and quickly worsen, although in some cases, they develop gradually. They may affect one or both eyes.

Common signs and symptoms of uveitis include:

Aching eye pain
Redness in the eye
Sensitivity to light
Tearing
Blurry, hazy vision
Moving dark spots called floaters
Flashing lights
Narrowing of the pupil

Are there other associated conditions?

Without treatment, uveitis may cause complications, including:

Glaucoma
Cataracts
Optic nerve damage
Retinal detachment
Permanent vision loss

Uveitis can also be associated with many conditions, such as:

Aids
Ankylosing spondylitis
Behcet’s syndrome
CMV retinitis
Herpes zoster infection
Histoplasmosis
Kawasaki disease
Multiple sclerosis
Psoriasis
Reactive arthritis
Rheumatoid arthritis
Sarcoidosis
Syphilis
Toxoplasmosis
Tuberculosis
Ulcerative colitis
Vogt Koyanagi Harada’s disease

Support means everything

No man is an island: in other words, it is not helpful to try to live with uveitis all by yourself. It is normal for anyone living with a disease to feel isolated sometimes – especially when you have to adapt your routine to your symptoms or their effect on your daily life; when you have to see doctors more often than other people do, or learn a lot of new medical information. It may seem difficult at first, but if you or a loved one has uveitis, it’s essential to discuss the symptoms with a medical professional.

Over time, there can be challenges for a person with uveitis such as vision problems, but friends and family can help, along with your team of health care professionals. Speak up and ask your doctors and nurses whatever you want to know – their expertise can be a great help. Always keep in mind that although the people on your team are all professionals, they are also human beings so it’s important to build a good relationship with them with open, honest communication.

Other sources of support are people who have gone through what you’re going through. These people understand how you feel, they can tell you what to expect, how they coped, and give you hope for the future. You can get in touch with people in your situation through organized support programs. If you’re interested in an organized support program, ask your doctor or other member of your healthcare team for more information or consult these suggested resources.

When you have uveitis, it’s essential to keep the lines of communication open – with your family, friends and even trusted coworkers. You can help them understand what it’s like to live with uveitis and what can help you feel better and live life more fully. Strive to talk openly about it – especially with the people you like, and who make you feel you can safely be yourself.

Here are some tips and helpful insights we’ve learned from patients:

Ask those closest to you to learn about your condition. This will help them understand your symptoms better and how you feel about them. It may give them new ideas about how to make things easier for you in day-to-day life, and the awareness alone will make you all more comfortable dealing with uveitis. Mutual understanding often arises from education – friends and relatives can read this or other Web sites, look up reliable sources of information in libraries, or go with you to some of your appointments. Consulting the Canadian Uveitis Society website is another option.
Let them know you need their support. This could be just some welcome empathy when you need to talk – even about things not directly related to uveitis. Nourish your important personal relationships – share how you are feeling physically and emotionally. There will be times when you experience more symptoms and limitations, and are frustrated. But at other times you’ll feel so good you won’t be thinking about uveitis at all.
Always be open and honest about your uveitis. It’s the only way people can help you. Search out proper medical support and try not to let your uveitis dictate your life. And if you’ve ever concluded that your doctor or loved ones aren’t doing enough because “They don’t know what it’s like”, perhaps that’s because you haven’t fully told them. Help them to help you by letting them know what you’re experiencing and what you want and need from them. Here are some examples of what you may ask of your friends and family:
- Reading to you
- Driving you to appoitments or activities
- Helping you administer your eye drops

When we stop doing the things we love, our mood drops, symptoms seem worse, and it becomes even harder to get motivated. Keeping fun in your life is absolutely essential – make it a top priority. It boosts your mood, your relationships, and your energy level. Doing harmless things you enjoy “just because” is good for your health. Find one activity you love – even a simple or small one that takes little time – that without fail you can make part of each week, and another you can do every day. This might be something you do alone, like cooking a favourite recipe or a short walk to a friend’s house. Or something you do with others, like a yoga class or a special interest club. Cultivate special things you really enjoy. Once these become routine, you’ll start feeling better and will want to add new ones to your schedule.

Uveitis can be different in every person. The key is to closely follow your health care team’s instructions for the steps and medications to take. Be persistent in following your treatment, and be patient: it can take a while for some medications to work. Keep notes and communicate regularly with your doctor about your progress and the effects of your treatment. If you feel there’s a problem with your regimen, or are experiencing any side effects, talk to your doctor right away about trying something else. Don’t hold back from asking questions. Be pro-active and involved in the decision-making about your health – there are many things to try, so don’t be discouraged if one treatment isn’t working – another one might work better.

Here are some tips on how to get the most out of your appointment with people on your healthcare team:

Write down any questions you have and bring the list with you
Take notes
Ask who you should call if something happens between scheduled appointments
Try not to become hostile or angry during your appointment, this can affect how your healthcare team communicates with you

Lifestyle options

For most people, regardless of having an eye disease or not, taking care of your eyes, quitting smoking, exercise, healthy eating and good sleep habits are recommended. A healthy lifestyle generally increases quality of life. Before making any lifestyle changes, talk to your doctor.

Tips for eye health:

When watching TV, sit at a distance from the screen of at least 5 times the width of your TV screen
Eat eye healthy foods such as those containing Vitamin C (papayas, red bell peppers, kiwi, strawberries, oranges) or antioxidants such as lutein and beta-carotene (carrots, sweet potatoes, squash, spinach, kale, broccoli)
When using a computer for work or play, follow the 20/20/20 rule: take a 20 second break from your computer screen every 20 minutes; when taking the break focus your eyes on something at least 20 feet away
Wear proper protective eyewear when doing any indoor or outdoor work that could affect your eyes; wear sunglasses outside even if the sun isn’t shining – keep in mind that UV rays are harmful to your eyes all year round
If you experience eye irritation from allergies, inflammation, infection or injury, see your optometrist, family physician or eye specialist (ophthalmologist)

Generally, a rheumatologist will assess your uveitis and prescribe medication. An eye specialist (ophthalmologist) will monitor your uveitis. Ask your ophthalmologist if you should also continue to consult an optometrist for regular comprehensive eye examinations (see recommended frequency below). If you don’t have an optometrist visit www.doctorsofoptometry.ca to find an optometrist near you.

Comprehensive eye exams: recommended frequency

Infants and Toddlers (Birth to 24 months)	Infants and toddlers should undergo their first eye examination between the ages of 6 and 9 months
Preschool Children (2 to 5 years)	Preschool Children should undergo at least one eye examination between the ages of 2 and 5 years
School Age Children (6 to 19 years)	School children aged 6 to 19 years should undergo an eye examination annually
Adults (20 to 39 years)	Adults aged 20 to 39 years should undergo an eye examination every 2 to 3 years
Adults (40 to 64 years)	Adults aged 40 to 64 years should undergo an eye examination every 2 years
Adults (65 years or older)	Adults aged 65 years or older should undergo an eye examination annually

Adapted from the Canadian Association of Optometrists.

While most people know that smoking has a negative effect on overall health, often there is less awareness of the impact of smoking on vision and the eyes. A recent study showed a significant association between uveitis and cigarette smoking.

Here are a few reasons why to quit smoking:

Quitting smoking:

Is the single best thing you can do to improve your health and your life
Immediately starts to reduce your risk of developing heart disease, cancer and breathing problems
Provides health benefits to anyone who has smoked: both men and women, young and old

“Remember, quitting is not one big challenge – it is a series of small ones. Take it one minute, one hour and one day at a time.” – Health Canada

Health Canada recommends that you speak to a health care professional when you are planning to quit. Doctors, nurses and other healthcare professionals can provide you with useful advice on nicotine replacement therapies, stop smoking medications, and can also refer you to other sources of support.

For more information visit Health Canada Quit Smoking.

According to a study published in the Canadian Journal of Optometry, most smokers are not aware that their tobacco use can cause blindness.

Like most parts of our body, our eyes need good blood circulation and oxygen. Both of these are stimulated by regular exercise. Regular exercise also helps us maintain a healthy weight, which reduces the risk of diabetes and diabetes-related eye disease.

Make sure to discuss any plans for new activities with your doctor. If you experience shortness of breath of severe pain while exercising, be sure to seek medical attention.

Benefits of exercise:

For all adults, being active for approximately two and a half hours per week (for example, 20 minutes per day) can lead to improved:

Fitness
Strength
Mental health

Other benefits of exercise include reducing the risk of premature death, heart disease, stroke, high blood pressure, certain types of cancer, type 2 diabetes, osteoporosis and becoming overweight and obesity.

For older adults aged 65 years and above, being active for approximately two and a half hours per week (for example, 20 minutes per day) can also help:

Maintain independence
Maintain mobility
Maintain bone health

Recommended elements of exercise:

Aerobic activities (may also be called “endurance”) – examples are brisk walking, cycling (this includes using a stationary bicycle) and water aerobics
- Intensity is important: moderate intensity means you’ll sweat a little and breathe harder than usual; vigorous intensity means you shouldn’t be able to say more than a few words without pausing for a breath.
Activities that increase muscular and bone strength (at least 2 days a week) – examples include lifting weights and heavy gardening involving digging or shoveling

For older adults, balance is also important. Activities that improve balance; examples include Tai Chi and yoga.

For most people, healthy eating means having a balanced diet that includes lots of fruit, vegetables and whole grains plus drinking water and other fluids. For people with uveitis, good nutrition can help you attain and maintain a healthy weight and energy level. Check out Canada’s Food Guide for more information.

Examples of eye healthy foods:

Foods rich in lutein, zeaxanthin, and vitamin C, such as orange peppers
Kiwi is a good fruit source of vitamin C. Other excellent fruit sources of vitamin C include raspberries, papayas, red, white and black currants and litchis
Turkey breast and lean beef (contain large amounts of zinc and vitamin E)
Fish with a lot of omega-3 fatty acids
Nuts and seeds

Tip:

Mix 1 tablespoon of ground flax seed or wheat germ into your daily diet for a boost of eye nutrients.

As we sleep, our eyes benefit from continuous lubrication. During our sleep, the eyes clear out irritants such as dust, allergens, or smoke that may have accumulated during the day.

Some studies have suggested that light-sensitive cells in the eye are important to our ability to regulate our waking and sleeping cycles. This light sensitivity may become more important as we age, when more people have problems sleeping.

While we know we need to protect our eyes from over-exposure to UV light, our eyes also need exposure to some natural light every day to help maintain normal sleep-wake cycles.

Practice good sleep!

Go to bed only when you’re sleepy; try to establish a relaxing bedtime routine (for example, soaking in a bath)
Establish a good sleep environment with few distractions (minimum noise, light and comfortable temperature)
Avoid any foods, drinks and medications that may contain stimulants
Avoid alcohol and nicotine before going to bed
Reduce or eliminate your intake of caffeine
Exercise regularly, but not before bed
Try physical and mental relaxation techniques such as yoga
Avoid taking naps in late afternoon and evening
Avoid heavy meals before bedtime
Use the bed only for sleep and intimacy (no eating, reading, computer/tablet or watching TV in bed!)
Establish regular wake times

Complimetary therapy options

For some people with uveitis, complementary and alternative therapies – treatments that fall outside the scope of traditional western medicine – may help. Ask your health care professional about alternative therapies.

Uveitis needs medical treatment prescribed and monitored by a doctor. Relying on complementary and alternative therapies alone to treat uveitis is not advised.

Make sure to let you doctor know about any herbs or supplements you use or plan to use.

In addition to a healthy diet rich in eye healthy foods, these supplements may also help your eyes:

A daily multivitamin containing the antioxidant vitamins A, C, E, the B vitamins as well as trace minerals, such as magnesium, calcium, zinc, and selenium
- A small study has suggested that vitamin C and E may help reduce symptoms of anterior uveitis; the patients in the study took vitamin C (500 mg twice a day) and vitamin E (100 mg twice a day) along with their standard medical treatment. When considering these results, it’s important to keep in mind that Vitamin C supplements may interact with other medications, including chemotherapy drugs, estrogen, warfarin, and others. Vitamin E may interact with a number of medications, including blood thinners
Omega-3 fatty acids, such as fish oil, may help reduce inflammation and boost the immune system. You should avoid taking omega-3 fatty acids before surgery for uveitis as they may increase the risk of bleeding. Before taking omega-3 fatty acid supplements, be sure to let your doctor know if you also take blood thinning medications, such as aspirin, warfarin, or clopidogrel
Lutein is an antioxidant important for eye health

Medical treatments

The goals when treating uveitis are to prevent vision loss, to provide pain relief and to reduce or prevent new and harmful changes in the eye.

Specialists (ophthalmologist or rheumatologist) work with patients to find the best possible treatment options for that particular patient.

The decision of whether or not to treat uveitis and how to do so is made in consideration of the following factors:

Eye structures affected by uveitis
Whether or not the uveitis may be reversible
Extent to which vision is affected
If one or both eyes are affected
Patient age and overall health

How uveitis medications are administered:

Drops
Pills
Injections (into the eye)

The most commonly used medications to treat uveitis are: cycloplegic medications, corticosteroids, immunosuppressive agents and non-steroidal anti-inflammatory drugs. There are also other medications, such as antibiotics and antiviral medications, which are only used for specific causes of uveitis.

You may need to visit your doctor for follow-up appointments and blood tests every 1 to 3 months.

Cycloplegic medications are one of the most common treatments for uveitis. These medications are administered as drops and can help reduce some of the symptoms experienced in uveitis, such as sensitivity to light. Cycloplegic medications can also help to prevent complications to uveitis.

Commonly used cycloplegic medications include: homatropine, atropine, cyclopentolate and tropicamide.

Side effects:

Homatropine and atropine: clumsiness, unsteadiness, confusion, unusual behavior, dry skin, rapid or irregular heartbeat, fever, flushing, seeing, hearing, or feeling things that are not there (hallucinations), skin rash, slurring of speech, swollen stomach (in infants), thirst, unusual dryness of mouth, unusual tiredness, drowsiness, or weakness.
Cyclopentolate: eye irritation (for example, mild stinging), enlarged pupil, blurred vision, difficulty focusing and rarely, dry mouth, flushing, dry skin, constipation, difficulty urinating, and rapid heartbeat.
Tropicamide: eye irritation (for example, mild stinging, and sensitivity to light), blurred vision, feeling faint or dizzy, headache, feeling sick (nausea).

Corticosteroids are the most commonly used medication for uveitis. These medications are effective at reducing the irritation and swelling that occurs in uveitis. Corticosteroids have been used for decades and play an important role in uveitis therapy.

It is important to be aware that corticosteroids do have potentially harmful side effects. The dosage, strength, duration of usage and route of medication are all factors in whether or not side-effects develop.

Examples of commonly prescribed corticosteroids are: prednisolone acetate, prednisolone phosphate and rimexolone. The most common oral (by mouth) steroid is prednisone.

Side effects of corticosteroids drops include: cataract, glaucoma, and droopy eyelid (ptosis).

Side effects of corticosteroids pills are: muscle weakness, osteoporosis, nausea, increased appetite, stomach ulcers, poor wound healing, tendency to bruise, increased sweating, headaches, moodiness, menstrual irregularities, diabetes, weight gain, blood clot formation, hirsutism as well as serious eye complications such as cataracts and glaucoma.

Immunosuppressive medications help reduce the irritation and swelling associated with uveitis. These agents have been used to treat uveitis many years and are particularly important for patients who are unable to tolerate corticosteroid treatment.

There are a wide range of different immunosuppressive medications and ophthalmologists recommend those that are best suited to a specific patient. They are usually taken orally (by mouth).

Commonly prescribed immunosuppressive medications include:

Azathioprine
Methotrexate
Cyclophosphamide
Cyclosporine
Mycophenolate
Tumour necrosis factor (TNF) alpha antagonists
Other biologic agents

Although they can be very effective, immunosuppressive medications can also cause side-effects. These may include: reduced number of blood cells, infection, scarring of lungs, kidney problems, liver problems, visual disturbances, birth defects, cancer, nausea, vomiting and diarrhea.

Understanding biologic and biosimilar medications

Most people are familiar with conventional medications such as pain relievers. These medications are made from chemicals (chemically synthesized).

Some of you may also have heard about biological or “biologic” medications which are used to treat serious illnesses, such as cancer, inflammatory bowel disease, psoriasis and rheumatoid arthritis. Biologics are special medications created using the biologic processes within living cells.

Conventional medicines and biologic medicines have important differences.

Conventional medicines	Biologic medicines
Made from chemicals	Created in living cells
Generally small molecules	Complex large molecules

Some history on biologics…

In the 1970s and 1980s, scientists started inserting selected genes into living cells to make specific proteins, or “biologics” that could be used as treatments for people.
The first biologic was human insulin, used to treat diabetes.

It is common knowledge that when the patent expires on a conventional medication, other companies are allowed to make copies called generics. Although the active ingredient in a generic is exactly the same as the active ingredient in the original conventional medication, non-medicinal ingredients, like fillers and colouring, may be different.

When the patent on a biologic medication expires, other companies are allowed to make copies. However, since it is impossible to make exact copies of biologic medications because of the way they are made, the copies are not called generics or even biogenerics. The correct term is biosimilar since it can only be similar and not identical to the original. In Canada, the official term for a biosimilar medication is Subsequent Entry Biologic or SEB.

Is a biosimilar a generic version of the original biologic drug?

No, biosimilars are similar to, but not identical to the original biologic drug. This is because the group of cells used to produce the drugs (the cell line), the actual drug molecule and the manufacturing process are different.

In Canada, manufacturers of biosimilars are required to show Health Canada that their product is similar to the original biologic and that the benefits of their product outweigh the risks. SEBs must have a label that is different from the original biologic medication.

Does the difference between a biosimilar and the original biologic matter to me and my care?

Yes, original biologics and biosimilars may act differently in your body and could have different side effects.

Since original biologics and the biosimilar versions are not identical, it’s important that you review your prescription with your doctor so you know which one is being prescribed.

Health Canada does not support automatic substitution of a biosimilar for an original biologic at the pharmacy.

For more information about biosimilar medicines, visit:

Health Canada www.canada.ca/en/health-canada/services/drugs-health-products/biologics-radiopharmaceuticals-genetic-therapies/applications-submissions/guidance-documents/fact-sheet-biosimilars.html

Alliance for Safe Biologic Medicines (USA) www.safebiologics.org

NSAIDs are a group of medications used frequently in different areas of medicine. NSAIDs help to reduce the irritation and swelling within the eye that is characteristic of uveitis.

NSAIDs may not be as effective as corticosteroids; however, the NSAID side effects are less severe than those associated with corticosteroids.

Side effects of NSAIDs may include: nausea, vomiting, diarrhea, constipation, decreased appetite, dizziness and headaches.

Commonly used NSAIDs (in Canada) are:

Drops:

Diclofenac
Nepafenac

Oral (pills taken by mouth):

Celecoxib
Naproxen
Indomethacin

At times, uveitis treatment may also require antibiotic or antiviral medications if the uveitis is caused by an infection. It’s important to take antibiotics exactly as prescribed by your doctor since taking antibiotics improperly or irregularly can lead to antibiotic resistance.

When there is physical damage caused to structures within the eye that can only be corrected surgically, surgery is an option. Although eye surgery can be risky, advancements in technology have made it easier and safer to operate in various parts of the eye.

Disclaimer

Please note that the information on this Web site should not be used as a substitute for seeking medical advice or treatment from a physician. You should not use this information to diagnose or treat a medical condition or health problem. Speak to your health care provider if you have any questions about your medical condition, symptoms or treatment options.

The Canadian Uveitis Society

The Canadian Uveitis Society exists to help organize Canada’s uveitis practitioners and researchers. It also seeks to educate patients and promote the importance of uveitis care. This website is intended to help researchers and practitioners and the general public. This web site does not participate in the coordination of individual medical care.