Uveitis and Glaucoma
Chat Highlights
July 16, 2008

On Wednesday, July 16, 2008, Dr. Sunir Garg, a retina specialist at Wills, and the glaucoma chat group discussed "Uveitis and Glaucoma".

Moderator: This evening our topic is Uveitis and our special guest is Dr. Sunir Garg. Before we chat about the topic, doctor, can you briefly tell us about yourself?

Dr. Sunir Garg: I am a retina surgeon at Wills, and I also do a lot of uveitis or eye inflammation work at Wills.

Moderator: Did you train at Wills?

Dr. Sunir Garg: I did my retina training at Wills, and for 12 yrs before that I was at the U of Michigan.

Moderator: Thank you doctor. OK, let’s start! First question, Dr Garg. What is uveitis?

Dr. Sunir Garg: It is inflammation of the eye. Much like people get arthritis, they can can get inflammation (or arthritis) of any part of the eye.

P: Is it painful?

Dr. Sunir Garg: Often people will have redness, pain, sensitivity to light or decreased vision. but sometimes only floaters without pain.

P: How many types of uveitis are there?

Dr. Sunir Garg: Well over 100, but only 10 or so are common.

Moderator: Wow, that is very many! What are the symptoms?

Dr. Sunir Garg: 'RSVP' is the easiest way to remember it: Redness, Sensitivity to light, Vision changes and Pain.

P: Is it the same thing as blepheritis?

Dr. Sunir Garg: No. Blepharitis is inflammation of the eyelids, but isn't part of uveitis.

P: Is it easy to diagnose uveitis?

Dr. Sunir Garg: It's easy to see the uveitis (if you are used to it) but coming up with the right disease and treatment plan for that particular patient and their form of uveitis can be hard.

P: It sounds like the doctor must rule out other causes and then say it must be uveitis? Is that right?

Dr. Sunir Garg: Not really; I can see the uveitis. In cases when I can't, like glaucomatocyclitic crisis (Posner Scholssman) or in certain cases of herpes virus, the presentation is so characteristic that the diagnosis isn't hard to make.

P: How is it diagnosed?

Dr. Sunir Garg: Often I can diagnose it just by talking to someone, but there are many things on examination that can lead you to the most likely cause. Some laboratory tests can help too.

P: What kind of lab tests?

Dr. Sunir Garg: Chest x-rays, and tests looking for genetic markers such as HLA-B27, and for other infections can be helpful, but they aren't always needed.

P: Is there an age range in which uveitis is most prevalent?

Dr. Sunir Garg: It becomes more common with age, most people are between 20 and 60, but I have kids as young as three and as old as 85.

P: Is uveitis genetic?

Dr. Sunir Garg: There can be a genetic component but often it's not. Just like lupus can be more common in certain families, so too can uveiits

P: Are there risk factors?

Dr. Sunir Garg: Age is a big one, and underlying diseases such as lupus, rheumatoid arthritis, and sarcoidoisis can increase risk.

Moderator: Are there any other risk factors, Dr. Garg?

Dr. Sunir Garg: A history of infections, and diseases like HIV can also be risk factors.

P: What causes the inflammation?

Dr. Sunir Garg: We don't know. Uveitis is an autoimmune process, in which the body attacks itself. We think that certain viruses and bacteria can trigger it.

P: What portion of the population is effected with uveitis?

Dr. Sunir Garg: Anywhere from one to five percent of the population will get it at some point, but if you have other autoimmune diseases, the chance goes up.

P: How does uveitis relate to glaucoma?

Dr. Sunir Garg: Uveitis can cause inflammation of the trabecular meshwork which can damage it, making it harder for fluid to leave the eye. The steroids we use to treat the uveitis can also cause the intraocular pressure to go up.

P: I've done very little reading about uveitis, but I'm surprised to hear that it's by definition an autoimmune disease. In other words, any irritation inflammation of the uveal tract that's not autoimmune in origin is not, by definition, uveitis?

Dr. Sunir Garg: Thanks for the chance to clarify. Any inflammation of the eyeball is uveitis, both autoimmune and infectious.

P: What is the uveal tract?

Dr. Sunir Garg: It's the inner lining of the eyeball, including the iris, ciliary body, and choroid. Uva means grape in Latin, so uveitis is inflammation of the eye ball, not just the uveal tract.

P: How do we differ between autoimmune uveitis and that caused by infection or something else?

Dr. Sunir Garg: Mostly based on a person's history, some clinical findings, and confirmatory blood work.

P: When uveitis causes glaucoma, is the glaucoma treated any differently any other type? Does blindness occur more or less often? Do medications work better?

Dr. Sunir Garg: Treating uveitic glaucoma can be challenging. The drops may not work as well, laser procedures can make the inflammation worse sometimes, and the surgery may not work as well or for as long. Controlling the inflammation can reduce glaucoma risk and improves treatment success.

P: Does glaucoma make one more prone to uveitis?

Dr. Sunir Garg: No, not really.

P: What causes vision loss from uveitis? Is it caused by the inflammation?

Dr. Sunir Garg: The inflammation can cause cataracts, glaucoma, retina swelling, retinal scar tissue formation, corneal scarring and dense debris or floaters - all of which can affect vision.

P: How is uveitis treated?

Dr. Sunir Garg: Mild to moderate cases can be treated with topical steroid drops. Some need steroid shots, steroid implants, and others need strong systemic drugs. Infections need antibiotics or antiviral medications.

P: Does vision loss occur quickly?

Dr. Sunir Garg: Not usually. People often have smoldering disease, but some very severe cases have had profound vision loss over hours to days; but this is uncommon.

P: Can uveitis lead to ulcers?

Dr. Sunir Garg: Uveitis can be associated with ulcerative colitis (bowel ulcers) and ulcers in the mouth or on the genetalia, and sometimes the cornea, but not commonly.

P: Can retinal scar tissue formation lead to Age-related Macular Degeneration (AMD)?

Dr. Sunir Garg: No; AMD is a different disease and uveitis isn't related. Inflammation plays a role in AMD, but it's a completely different disorder.

P: Don't the prostaglandin analogs work by promoting a kind of inflammation in the ciliary muscle? To the extent that they do, do they exacerbate inflammation generally in the eye?

Dr. Sunir Garg: If patients have uveitis, prostaglandin analogs are not usually used as first line treatment. We try to use other drugs, but it's not a hard and fast rule.

P: Does the treatment of children, and pregnant or breastfeeding women, differ from that of the general population?

Dr. Sunir Garg: Often uveitis gets better during pregnancy. We are less aggressive with systemic drugs out of concern for the baby if the mother is pregnant or breast feeding. Children are treated aggressively to prevent lazy eye formation and cataracts.

P: I know someone who has chronic eye pain, inflamed bowels, and inflamed gums. Is it likely uveitis is the cause of the eye pain, because it is not high pressure?

Dr. Sunir Garg: Very likely, but high eye pressure, if the pressure goes up gradually, may have no pain. It is possible she has uveitis (or dry eye, another manifestation of some systemic autoimmune diseases).

P: Can uveuitis occur with just the pain in the eye and no other symptoms?

Dr. Sunir Garg: Yes. Inflammation can irritate the iris, which is very sensitive, and there can be pain only.

P: As long as you use prostalgandins and its analogues for treatment of glaucoma, do you have a greater chance of getting uveitis? I used Travatan and Travatan Z for sometime and my eyes were blood- shot.

Dr. Sunir Garg: Redness occurs in a certain percentage of folks, but uveitis developing due to prostaglandin is really uncommon. I do have patients in that category, but for all the people using prostaglandins, only a few ever develop uveitis from it, and if they do, the uveitis goes away when the drug is stopped.

P: Would simple rinsing with saline solution help?

Dr. Sunir Garg: No.

P: Is there any promising research being done at this time?

Dr. Sunir Garg: We have good drugs, an available steroid implant, and another new drug we are studying at Wills. Finding the underlying causes is harder, but good progress is being made.

P: What are some of the more common types of drugs in use?

Dr. Sunir Garg: Many of the drugs I use are the ones used to treat rheumatoid arthritis like methotrexate, remacaide, and humira. Oral steroids are important as well.

P: Is inflammation of the sclera or conjuntiva also uveitis?

Dr. Sunir Garg: Yes, scleritis is a form of uveitis, as is conjunctivitis. But allergies and pink eye we usually don't consider as uveitis.

P: Do the treatments usually work quickly or do they take time to be effective?

Dr. Sunir Garg: They take time. I'd rather start with something I think has a good chance of working and become more aggressive, rather than jumping to the strongest drug (maybe with more side effects). But I can usually stop it quickly if needed.

P: Is IOP elevated in your uveitis patients? Do you see a clear trend? Do you use the Goldman tonometer on your patients?

Dr. Sunir Garg: IOP is usually low in most of my uveitis patient initially. If they develop glaucoma, I'll ask my glaucoma colleagues to help out. In our office we'll use tono pen.

Moderator: Doctor, in what cases of glaucoma can the retina be related?

Dr. Sunir Garg: Conditions like herpes infection are common. Long-standing uveitis can damage the trabecular meshwork and that can lead to glaucoma. Often if the inflammation is aggressively controlled from the start we can reduce the risk of getting glaucoma.

P: So is uveitis curable? I mean can it be completely cured, in distinction from glaucoma that can only be slowed down?

Dr. Sunir Garg: It can't be cured like pneumonia can be cured; it can be treated like cholesterol or diabetes can be treated, as a chronic disease.

P: Does the probability increase for a second episode if someone has experienced uveitis once?

Dr. Sunir Garg: Yes, but people are allowed to have one episode (assuming it goes away) without getting too worried. The risk is higher than a person with no history, but still low.

P: Can one who has glaucoma use Restasis? Is dry eye also a frequent manifestation of uveitis?

Dr. Sunir Garg: Dry eye isn't all that common with uveitis, but it's not unknown with some types, such as rheumatoid arthritis. Some of the glaucoma drops can worsen dry eyes. As far as I know, Restasis should be OK.

P: Sorry, I made a mistake. I wanted to ask is there any effect of Restasis on uveitis (not glaucoma).

Dr. Sunir Garg: No, while cyclosporine is useful in uveitis, Restasis doesn't do much.

Moderator: That was the last question for the evening. Dr Garg, thank you so much for being here with us this evening. It was a very informative chat and we so much appreciate your time.

Dr. Sunir Garg: Thank you and have a good night.

On August 6, Dr. Pro discussed "Incisional Surgery Risks" in the Chat room. Click here for highlights of that meeting.

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