Uveitis in Multiple Sclerosis, What To Do

uveitis in multiple sclerosis

Uveitis is an infrequent but serious eye problem that can develop in individuals who have multiple sclerosis. What should you know about uveitis and what steps can you take to manage it?

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The occurrence of uveitis in multiple sclerosis patients is about ten times that seen in the general population. If you have MS, you should become familiar with this eye disease, what to look for, and what you can do about it.

What is uveitis?
Uveitis is an eye disease characterized by irritation and swelling of the middle layer of the eye (uvea). The uvea contains much of the blood vessels in the eye. It is instrumental in providing blood to the retina, which is located at the back of the inner eye where it transforms images that enter the eye’s lens and sends them to the brain through the optic nerve.

Symptoms of uveitis depend on the type of inflammation. However, generally the symptoms include blurry vision, floaters (dark spots in your vision), eye pain, red eyes, and hypersensitivity to light. If you have multiple sclerosis and experience any of these or other changes in your vision, it’s time to see an ophthalmologist.

Uveitis can present in a variety of forms, with the most common one being anterior uveitis. In this form, the inflammation usually affects only the front part of the eye, or the iris, which is why it is often called iritis. Along with the iris, the uvea also consists of the ciliary body (which helps with focusing) and choroid (blood vessels that provide nutrients to the retina).

Uveitis and multiple sclerosis
Among people with multiple sclerosis, the most common type of uveitis is a more severe form called intermediate uveitis. This form of uveitis is characterized by inflammation in the fluid-filled area inside the eye. A subtype of intermediate uveitis, called pars planitis, commonly occurs. In pars planitis, white blood cells and other substances invade the vitreous chamber and cause streaks or floaters that can make vision difficult.

In a new study published in British Journal of Ophthalmology, 113 individuals with multiple sclerosis and uveitis were evaluated. Here are the findings:

  • Most (80%) of the patients had intermediate uveitis
  • 24 (15%) had anterior uveitis
  • The remaining patients had one of the other less common types, either posterior or pan-uveitis.

According to the authors, “the visual prognosis is generally favourable.” This latter point is especially important and is contingent largely on getting an accurate diagnosis and choosing proper treatment. These are discussed below.

Although the exact cause of uveitis is not known, it appears to be related to various disease or problems that occur either in the eye or is associated with inflammatory conditions elsewhere in the body. Multiple sclerosis falls into the latter category.

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In fact, one of the popular beliefs about multiple sclerosis and uveitis is that like the damage to the myelin in multiple sclerosis, a similar process occurs in individuals who have uveitis associated with MS. Although this may be true in some cases, some types of inflammation seen in patients with multiple sclerosis and uveitis appears where there is no myelin. This fact thickens the plot!

Treatment of uveitis in MS
Before you can embark on effective treatment of uveitis, you need to get a definitive diagnosis. People with multiple sclerosis may experience other visual problems, such as optic neuritis and macular edema (which can be a complication of uveitis and is seen in diabetes), among others. To ensure the right treatment path is followed, an accurate diagnosis is essential, which means it is best to find an ophthalmologist who is familiar with multiple sclerosis if at all possible.

According to the authors of a recent article on multiple sclerosis-associated uveitis, treatment is dependent on the severity and location of the inflammation. In fact, intermediate uveitis may not require treatment if patients do not have macular edema.

Treating uveitis in people who have multiple sclerosis should be done with caution because it’s not known whether early intervention in individuals who are not experiencing vision problems may have a negative impact on the course of multiple sclerosis. That concern is raised because typical treatment of uveitis involves corticosteroids and immunosuppressive therapy, whose risks may outweigh the benefits.

Other treatment options for uveitis in multiple sclerosis patients include:

  • Interferons, whose use has not been proven effective although there is evidence that interferon beta can be helpful in patients with macular edema associated with uveitis
  • Cryotherapy, which may be helpful when steroids have not been therapeutic
  • Laser photocoagulation in individuals who have pars planitis. However, both of these latter two approaches may cause more inflammation and an increased risk of retinal detachment.
  • Some research has suggested that daclizumab, natalizumab, and fingolimod may have some promise in managing uveitis in multiple sclerosis. However, it should be noted that a small percentage (0.5%) of patients in one study developed macular edema while they took fingolimod. The problem disappeared in most patients once they stopped the medication.
  • Other potential treatment options, which have not been backed by studies, include calcineurin inhibitors, alkylating agents, and anti-metabolites
  • Use of anti-tumor-necrotizing factors such as adalimumab and infliximab should be avoided since they may exacerbate multiple sclerosis

Read about a new MS drug that may reverse damage

Uveitis is an uncommon yet possible vision problem associated with multiple sclerosis. If you have multiple sclerosis and are experiencing vision problems, you should talk to your doctor and possibly an ophthalmologist to uncover the cause of your eyesight challenges.

SOURCES
American Academy of Ophthalmology
Biousse V et al. Multiple sclerosis associated with uveitis in two large clinic-based series. Neurology 1999; 52(1): 179-81
Bonfioli AA et al. Intermediate uveitis. Semin Ophthalmology 2005; 20(3): 147-54
Hildebrandt AL, Mackensen F. Uveitis in multiple sclerosis: overview and perspectives. Ophthalmologe 2014 Aug; 111(8): 733-39
Jain N et al. Fingolimod-associated macular edema: incidence detection, and management. Neurology 2012; 78(9): 672-80
Messenger W et al. Characterisation of uveitis in association with multiple sclerosis. The British Journal of Ophthalmology 2014 Aug 28. Epub ahead of print
Mohan N et al. Demyelination occurring during anti-TNF-alpha therapy for inflammatory arthritides. Arthritis & Rheumatism 2001; 44(12): 2862-69
Park SE et al. 2 peripheral scatter photocoagulation for neovascularization associated with pars planitis. Archives of Ophthalmology 1995; 113(10): 1277-80
Smith JR, Rosenbaum JT. Neurological concomitants of uveitis. The British Journal of Ophthalmology 2004; 88(12): 1498-99
Wiendl H, Hohlfeld R. Therapeutic approaches in multiple sclerosis: lessons from failed and interrupted treatment trials. BioDrugs 2002; 16(3): 183-200
Zein G et al. Multiple sclerosis-associated uveitis. Ocular Immunology and Inflammation 2004 Jun; 12(2): 137-42

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