Uveitis: acute, recurrent or chronic

Uveitis is classified as acute, recurrent or chronic according to the following factors: cause, severity and duration of inflammatory episodes. Making these distinctions is important because the course of the disease and its corresponding management will be different for each patient.

Uveitis is not a hereditary, transmissible or contagious disease. Many cases have a good prognosis, but some have an aggressive and degenerative course. The factors that determine the visual prognosis of uveitis cases are: its cause, how soon it is diagnosed, how well it is managed, the patient's age, the effectiveness of treatment, the severity of symptoms and the occurrence of complications. On the other hand, the reactivation of inflammatory episodes will depend mainly on: the cause of the uveitis and the effectiveness of the treatment. The visual and general prognosis of uveitis cases cannot be predetermined with certainty because the reactivation of inflammatory episodes is unpredictable. Like all chronic diseases, chronic uveitis impacts four main aspects of patients' lives: their health, finances, personal life, studies and/or jobs. The management of these cases may extend over months or years, but they are usually brought under control with proper treatment and the natural course of time. There are no established criteria for determining the chronicity of uveitis cases, but the following factors may help predetermine the course of the disease:

Cause

There are certain diseases associated with uveitis that are recognized for their chronic course. They are diseases that require long-term treatment, may cause significant visual impairment and impact the quality of life of patients. These diseases are: Birdshot chorioretinopathy, serpiginous choroiditis, multifocal choroiditis and panuveitis, Vogt-Koyanagi-Harada syndrome and Behçet's disease.

Patient’s age

The age of the patients is another important factor that determines the prognosis of uveitis cases. The pediatric population is especially susceptible to developing more ocular complications than the adult population, even when the cause of ocular inflammation is the same. For example uveitis caused by arthritis in children is more aggressive than uveitis in adults that is also caused by arthritis. This is an extremely delicate population that is at higher risk for the development of complications and vision loss.

Localization of inflammation

Uveitis is a medical emergency regardless of its location: anterior, intermediate, posterior or panuveitis. However, anterior uveitis is associated with a lower risk of visual impairment than intermediate or posterior uveitis, in the absence of other ocular complications. Intermediate or posterior uveitis are associated with a more complex course that may become chronic over time, because they affect ocular structures that are essential for vision.

Severity, duration and recurrence of inflammatory episodes

The severity, duration and recurrence of uveitis is both variable and unpredictable. The severity of uveitis episodes will depend on the ocular structures affected and the intensity of the inflammation. If it is very intense, there may be considerable loss of vision, eye pain, photophobia, headache, among other symptoms and complications. The severity with which the inflammation affects the eyes may determine how well patients recover under treatment. Recurrence of inflammatory episodes determines the prognosis of the case and the duration of treatment. Recurrences not only compromise patients' vision, but also affect many other aspects of their lives and require lifestyle adjustments. Although physicians cannot predict them with certainty, the following general criteria could be considered when determining the chronicity of non-infectious uveitis cases based strictly on recurrences:

1. Three or more episodes occur per year.

2. Uveitis fails to be controlled under treatment with systemic corticosteroids for a period of three

months.

3. Uveitis recurs in less than six months after being treated with ocular injections. It also presents other complications such as inflammation of the macula or optic nerve

4. Uveitis is not controlled under systemic treatment and recurs even while patients are under such treatments. This includes corticosteroids and/or immunomodulators.

5. Patient has presented recurrences throughout the implementation of a “stepladder approach”. In other words, the treatments have been ineffective.

Complications

The complications that may arise also influence the chronicity of the cases. These primarily occur because of postponement of the visit to a specialist or because of the side effects of the treatments. The side effects of treatments can be prevented or even remedied, but it is still important to recognize the risks associated with them. In contrast, complications resulting from inflammation, specifically when it goes undiagnosed and unmanaged in a timely manner, can result in irreversible vision loss. Complications associated with uveitis include: cataract, glaucoma, retinal vascularization, cystic macular edema (CME), optic nerve inflammation and/or atrophy, retinal detachment, among others.

Visual impairment

Decrease in vision, whether progressive or sudden, is an indicator of the chronicity of cases. It is the main factor compromising patients' quality of life, but not the only one. Chronic inflammation and its consequent sequelae or complications result in progressive vision loss, especially when it does not respond to treatment. Once sufficient irremediable vision loss occurs to prevent patients from normal functioning or major activities, assistive measures should start to be implemented so that quality of life is not impaired. The main purpose of this is for patients and the people around them to acquire the appropriate skills to create an environment that allows for the healthy integration of patients according to their needs. Ocular inflammation can heal under appropriate treatment but, because the eyes are very delicate organs, it often leaves sequelae that affect the quality of the patient's vision. The progressive accumulation of these sequelae results in deterioration of vision. That is why the main goal of uveitis management is to eradicate even minimal ocular inflammation and prevent its reactivation. Prompt diagnosis and management of ocular inflammation is essential to prevent vision loss and maintain good ocular health.

Differences between acute uveitis and chronic uveitis

Optimal chronic disease management involves more than just the primary treatment and extends far beyond the doctor's office. It requires active participation of patients in the management of their health. In addition to compliance with treatment, implementing certain measures that can improve the patient's quality of life and health would be of great benefit. Through education about their disease, patients can begin to make better decisions about their health.

A chronic disease is a very particular stressor because it cannot be completely escaped or remedied: one can only learn to live with the disease. This can induce a feeling of helplessness and uncertainty. Recognizing the aspects that are under the patient's control and those that are not can help establish a care plan that also provides a sense of empowerment. The uncertainty of this type of disease is one of the most difficult emotional aspects to cope with. Here are some aspects that can be controlled and others that cannot.

Factors that can be controlled

Attend medical appointments

Complying with treatments

Educating yourself about your disease: education is power

Adopt new measures to help promote good health

Seek a second opinion, if desired

Factors to improve the quality of life

Adequate rest

Implement measures that help prevent complications

Adopting holistic measures to help manage symptoms and side effects of treatments

Implement changes in the work and/or academic environment to meet their new needs

Communicate effectively to the corresponding institutions or personnel

Establishing good interpersonal relationships

Attending support groups or individual therapy

Factors that CANNOT be controlled

Reactivation of uveitis episodes cannot be predicted

The decrease or loss of vision cannot be predicted

You cannot decide how your body will recover or how long it will take. You have to listen to the symptoms and adjust yourself to them

Accelerate recovery time

Prevent or correct irreparable damage to ocular tissues