|
|
|
Newsletter no. 8 Feb 2002 |
Introduction and News Introduction
Welcome to the first newsletter of the year. The content ,as usual, tries to respond to the questions and comments that I hear from people who contact the group. A lot of contact is now being made with people abroad, from as far as Pakistan to Argentina. Whilst culture and health care systems vary enormously in different countries, it is clear that human nature is the same the world over and someone from Chile will tend to have the same sorts of questions and concerns as someone from the UK. Interestingly the other thing that comes across is that where good treatment is available, it seems to be remarkably similar the world over.
In this newsletter, there is a section explaining some terms that crop up a lot in peoples’ letters, e-mails etc. and probably are heard often in the eye clinics. They will be added to our ‘uveitis glossary’ which appeared in a past newsletter and is on the web site. If anyone would like a printed copy then please get in touch with us.
The other article aims to tackle the
confusion over whether treatment is directed toward active uveitis or complications of the uveitis or its treatment. If we can understand that a little better than it can go a long way in following the reasons for certain types of treatments.
News
Address Exchange
The list is now getting quite long. An updated contact list is enclosed for those who requested inclusion. It is still probably the simplest way to put people in touch with each other .
Junior / Family exchange.
We now have a list of families with children affected by uveitis. Any parents who have not added their names but wish to do so could contact us and we will explain what is involved.
Newsletters on the Internet
These newsletters are posted on the group’s website. If you would prefer to receive an e-mail notification of this instead of receiving a printed newsletter then just let us know (preferably by e-mail so that we can confirm an up to date e-mail address). The internet newsletter has some advantages It may contain useful links etc. It also, of course, saves considerably on printing and postage.
Uveitis in National News
An article appeared recently in the Daily Mail, about a trial of drug implants for uveitis and other eye conditions. Six Hospitals are running trials on a small number of patients. The principle is to surgically implant a supply of slowly released drug just behind the eye to target the drug to the site thus increasing effectiveness and reducing or removing systemic side effects. This and other new forms of treatment will be followed closely here but whilst there are some very promising new potential treatments on the horizon, they inevitably take quite a while to be used more widely.
- Public meeting
There has been little response to calls for a public meeting but would remain an aim to arrange a get together with leading specialists. Moorfields have offered to host one. Please get in touch so we can gauge interest. (contact UIG)
The Main Complications of Uveitis,
This article attempts to explain:
some of the vision threatening complications of uveitis.
the difference between the direct effects of active uveitis and the effects of complications of the condition.
The inflammation caused by uveitis can directly damage our vision, be it temporary or permanent. However, many patients find that their uveitis may be under good control (or ‘quiet’) but there seem to be ongoing problems requiring all sorts of treatment. This situation causes confusion and comes up time and time again when people contact the UIG. It is well worth trying to understand the difference between active uveitis (frequently referred to as ‘flare ups’) and complications of uveitis.
The inflammation inside the eye in uveitis, can potentially lead to various other problems in the eye, such as glaucoma and cataract. These are examples of complications.
They may become the only thing troubling a patient, long after the uveitis has ceased to be a major problem.Specialists in uveitis now assess a patient carefully to look for the signs of early complications.
The treatment we receive is also planned in a way to prevent or minimise any potentially sight threatening complications.
Primarily, the doctors are interested in protecting the patient’s vision. They are more concerned with preventing and treating potential vision robbing effects of the condition, than categorising the exact type and cause of the uveitis, (although this is obviously important as well).
I think that it is true to say that many patients spend a great deal of time trying to:
pin down a cause for their uveitis.
work out whether their uveitis is active or ‘flaring up’ or not.
This is perfectly understandable and, of course, it is essential not to tolerate any active inflammation, but it may be useful to consider the indirect effects of uveitis or complications because they can be the dominant factor in many cases.
The main complications most usually seen in the eye clinics are dealt with below, but not necessarily all of them are covered here.
It would be simplest to divide them into those seen in anterior and posterior uveitis.
1, Complications of Anterior uveitis
a) Blurring of vision
This can be a result of the inflammation but also can be a temporary problem whilst using drops to enlarge the pupil (mydriatic or dilating drops).
b) Floaters
Debris from inflammatory blood cells can be seen in the visual field as wispy dots or streaks. They can be of nuisance value or can sometimes significantly reduce vision.
c) Persistent pain and redness
This may be a problem even after a ‘flare up’ has been treated and no inflammation is present.
d) Cataracts
Cataracts are very common in the whole population as we grow older and is one of the most common indications for treatment in eye clinics today. Uveitis sufferers are, however, more likely to develop cataracts and at a younger age. This is a problem which can be dealt with but may be more complicated in people with uveitis. The main priority is for the inflammation to be totally under control before and after removal of the cataract.
e) Rise in intraocular pressure (IOP)
The normal eye has a pressure maintained by the flow of fluid through it. If the pressure is raised this can potentially cause glaucoma and is usually controlled with drops. The pressure is easily measured and uveitis sufferers will always have their eye pressure carefully monitored.
Some people’s IOP rises as a result of taking steroid drops (steroid responders). (there is a separate fact sheet uveitis and glaucoma).
f) Synechiae
Sometimes due to the inflammation, the iris becomes ‘sticky’ and it sticks to the lens which sits close behind it. (posterior synechiae). This can distort the shape of the iris and sometimes can influence the IOP (see above).
2. Complications of Posterior Uveitis
a) Macular Oedema (also cystoid macular oedema)
This can be acute (short term) or chronic(long term).
The macula is a very small area of the retina which is responsible for our detailed or ‘central vision’. Fluid may build up in the retina at this area which may affect the central vision.
Chronic macula oedema can persist in the absence of active uveitis and may be treated with steroid therapy or with immunosuppressants.
b) Vitritis
Inflammation in uveitis may affect the vitreous gel, the clear jelly behind the lens filling the eye to cause vitritis. The result of this can be floaters or a more substantial obstruction of vision if a lot of debris is present.
c) Neovascularisation
Sometimes, as a result of inflammation small, new blood vessels grow at the back of the eye. These vessels are produced as part of the body’s own healing response to injury, but they are unwelcome because they are weak and prone to leak and break down. They can be managed by laser treatment.
Sometimes these new blood vessels form a Sub retinal neovascular membrane, a membrane just behind the retina, which can be treated by laser or may even be surgically removed in a few cases.
d) Loss of Visual field.
Inflammation may result in damaged areas of the retina to produce ‘blind spots’ or scotoma. These may be in the peripheral vision and hardly noticeable but if near the macula, the central vision can be significantly affected.
This ‘list’ of complications should not be a cause of great concern. Much as it can be off putting reading the side effects section of a leaflet that comes with any drug we take nowadays, most people will suffer none or only one or two of all the possible problems.
The aim here has been to emphasise that it is not always the uveitis directly that dictates our current treatment. Sometimes a complication such as glaucoma can ‘take over’ as the main problem.
This is another reason why there is so much variation in the way individual patients will be managed.
Each type of complication has not been covered in great detail. The UIG has more detailed information about these complications on request. It is hoped that this will make it easier to discuss and question your doctors.
Cells, flare, and some other terms explained.
When we are in the eye clinic, we will often hear the doctors using various terms that we may not understand. This will be inevitable, especially when 2 doctors are discussing your condition.
Some of these terms may not be necessarily useful to know about but curiosity normally gets the better of us and we spend the next half an hour wondering what things like flare or KP’s are. So to help understand what is going on at our appointments and to satisfy the curiosity, some of these terms are explained below.
In anterior uveitis,
the inflammation in the eye, both past and present needs to be assessed and this is done in different ways. Some of the terms used in these assessments are outlined below.
Flare
Flare is usually measured as 0 to 4 or by + to ++++, the higher the number the worse the flare. So what is flare? Have a look at the diagram (page 5) and find the anterior chamber (AC). This is where flare occurs.
The fluid in the anterior chamber is normally crystal clear. It needs to be to allow good vision. Uveitis is an inflammation and when inflamed, blood vessels in the region of the iris or ciliary body become “leaky”. This results in protein in the blood entering the anterior chamber and making the fluid in it slightly opaque or cloudy.
This can be observed in the clinic when a light is shone into the eye, (a bit like shining headlights into mist). This flare is just one of various signs that your doctor is looking for to see whether there is active inflammation.‘Cells’
In a similar way to how flare is caused, another effect of the inflammation is that blood cells may escape from the vessels into the anterior chamber (AC). The number of white blood cells that appear can be estimated and this again provides a guide to the severity of the active uveitis. The “scoring system” used normally describes 0 to 5 or uses + signs. 0 describe less than five cells in the field and would denote no inflammation (‘quiet’)
Keratic precipitates (KP’s)
These may occur commonly in anterior uveitis. They are accumulations of inflammatory cells that “stick” to the inside of the cornea. They are a useful aid in diagnosing past and present uveitis, and will vary according to the type of uveitis.
As the inflammation affects further back in the eye, we will come across different terms. The following terms apply more to intermediate or posterior uveitis
Vitreous Opacification
When inflammation affects the more posterior parts of the eye then the ‘by products’ of inflammation, such as cells, cell debris and protein may leak out into the vitreous which is the clear, jelly like fluid filling the area behind the lens. These opacities may be bad enough to decrease the vision. As before, an assessment of this is made in the clinic and scored from 0 (completely clear) to 5 (back of eye completely obscured).
One main difference in the vitreous is that the number of cells and opacity isn’t always a sign of active inflammation, it can also show past episodes of inflammation as the debris may remain in the vitreous for a long time. An active inflammation affecting the vitreous is called a vitritis.
There are different terms that describe some different types of vitreous opacification:
Floaters
These are seen by the patient as small black objects, “floating” across the front of the eye, usually as dots or wispy lines. They are caused by cells and debris, getting into the vitreous.
Haze
Haze is basically similar to flare. It is caused by a leaking of protein into the vitreous, instead of the anterior chamber, causing ‘cloudiness’. The terms haze and flare both seem to get used when referring to this effect in the vitreous.
If vitreous opacification becomes a severe enough problem, then the jelly –like contents of the vitreous can be removed surgically in a process called a vitrectomy (the subject of a separate fact sheet).
Hopefully this has proved useful, or at least interesting, and if you are still puzzling over any terms or abbreviations you keep hearing in the clinic , then you are more than welcome to ‘request’ an explanation.
