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  • Review Article
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The management of adult and paediatric uveitis for rheumatologists

Nature Reviews Rheumatology volume 20, pages 795–808 (2024)Cite this article

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Abstract

Uveitis encompasses multiple different conditions that are all characterized by intra-ocular inflammation. Uveitis occurs in the context of many different rheumatological conditions and carries a substantial risk to vision. Uveitis can develop both at the early stages of rheumatic diseases, sometimes even preceding other clinical features, and at later stages of disease. Uveitis can also occur as either a direct or an indirect complication of therapies used to treat patients with rheumatic disease. Conversely, patients with uveitis of non-rheumatic aetiology sometimes require immunosuppression, a treatment option that is not readily accessible to ophthalmologists. Thus, collaborative working between rheumatologists and ophthalmologists is critical for optimal management of patients with uveitis. This Review is written with rheumatologists in mind, to assist in the care of patients with uveitis. We collate and summarize the latest evidence and best practice in the diagnosis, management and prognostication of uveitis, including future trends and research priorities.

Key points

  • Uveitis accounts for up to 10% of visual impairment globally, highlighting the need for prompt recognition and management.

  • TNF inhibitors have significantly improved outcomes in both adult and paediatric uveitis, with the strongest evidence for adalimumab. An exception is etanercept, which worsens uveitis.

  • The second-line biologic option for uveitis is IL-6 inhibitors, with intravenous tocilizumab having the most substantial supporting evidence.

  • Collaborative work between rheumatologists and ophthalmologists is critical for optimal management of uveitis.

  • More trials are needed in uveitis, as there is a wide array of novel molecules available for systemic rheumatic diseases that should be explored for therapeutic use in uveitis.

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Fig. 1: Clinical presentation in uveitis.
Fig. 2: Pathogenesis of uveitis and therapeutic targets.

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Author notes

  1. These authors contributed equally: Sarah L. N. Clarke, Panagiotis Maghsoudlou.

Authors and Affiliations

  1. Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK

    Sarah L. N. Clarke & Athimalaipet V. Ramanan

  2. Department of Paediatrics, Royal United Hospital Bath, Bath, UK

    Sarah L. N. Clarke

  3. MRC Integrative Epidemiology Unit and School of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK

    Sarah L. N. Clarke

  4. Regional Ocular Inflammatory Service, Bristol Eye Hospital, Bristol, UK

    Panagiotis Maghsoudlou, Catherine M. Guly & Andrew D. Dick

  5. Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK

    Panagiotis Maghsoudlou, Andrew D. Dick & Athimalaipet V. Ramanan

  6. Institute of Ophthalmology, University College London, London, UK

    Andrew D. Dick

  7. NIHR Biomedical Research Centre of Ophthalmology, Moorfields Eye Hospital, London, UK

    Andrew D. Dick

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Glossary

Anterior uveitis

Inflammation of the front part of the eye, which includes the iris and surrounding tissue, and causes redness, pain, photophobia and blurred vision.

Band keratopathy

A condition in which calcium deposits form on the cornea, the clear front part of the eye, causing a band-like appearance and potentially affecting vision.

Flare

The presence of proteins in the aqueous humour, the clear fluid in the front part of the eye, indicates inflammation, which can cause the fluid to appear cloudy.

Glaucoma

A group of eye conditions that damage the optic nerve, often owing to high pressure inside the eye; glaucoma can lead to vision loss or blindness if untreated.

Intermediate uveitis

Inflammation that affects the middle part of the eye, including the vitreous humour (the gel-like substance filling the eye), symptoms of intermediate uveitis can include floaters and blurred vision.

logMAR

A logarithmic notation used to express visual acuity (clarity of vision) in which lower scores correspond to better vision; logMAR is a more precise way of measuring visual acuity than the traditional Snellen chart.

Macular oedema

Swelling or fluid build-up in the macula, the central part of the retina, responsible for detailed vision, that can cause distorted or blurred vision.

Panuveitis

Inflammation affecting all parts of the uvea (the middle layer of the eye), including the iris, ciliary body, and choroid, that can cause widespread vision problems.

Posterior synechiae

Adhesions between the iris and the lens of the eye, often as a result of inflammation, that can lead to irregular pupil shape and other vision issues.

Posterior uveitis

Inflammation of the back part of the eye, including the retina and choroid; symptoms of posterior uveitis can include blurred vision, floaters and sometimes pain.

Standardization of Uveitis Nomenclature

(SUN). Standardized guidelines developed by SUN Working Group to classify and describe uveitis for consistent diagnosis and treatment.

Visual acuity

A measure of the clarity or sharpness of vision, often assessed using an eye chart (see logMAR), that indicates how well a person can see details at a specific distance.

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Clarke, S.L.N., Maghsoudlou, P., Guly, C.M. et al. The management of adult and paediatric uveitis for rheumatologists. Nat Rev Rheumatol 20, 795–808 (2024). https://doi.org/10.1038/s41584-024-01181-x

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