In a new review article published in JAMA, researchers offer updated guidance on classification, diagnostic strategies, and treatment options for uveitis. They emphasize evidence-based approaches that are tailored by disease subtype, etiology, and severity.

Uveitis Epidemiology and Classification

Uveitis affects between 38 and 714 per 100,000 people globally and is responsible for 3% to 10% of vision impairment in high-income countries. It is also a contributing factor in up to 25% of blindness in low- and middle-income countries. The disease primarily affects individuals aged 20 to 50 years and is slightly more common in females.

Anatomically, uveitis is classified as:

• Anterior (41% to 60%)
• Posterior (17% to 23%)
• Intermediate (9% to 15%)
• Panuveitis (7% to 32%)

Anterior uveitis is often unilateral, while intermediate, posterior, and panuveitis are usually bilateral.

Etiologies and Systemic Associations

Uveitis has a broad range of causes. Noninfectious causes account for 52% to 79% of cases and are often linked to systemic autoimmune conditions such as axial spondyloarthritis and sarcoidosis.

Infectious causes (11% to 50%) include toxoplasmosis, herpes viruses, tuberculosis, HIV, and syphilis. Geographic variations affect prevalence; for instance, tuberculosis is more common in lower-income countries, while HLA-B27–associated anterior uveitis is more predominate in high-income countries.

In 27% to 51% of cases, the cause remains idiopathic despite full workup.

Diagnostic Evaluation

Initial assessment requires ophthalmologic referral. Key diagnostic tools include:

• Slit lamp examination for anterior chamber cells and keratic precipitates.
• Indirect ophthalmoscopy for intermediate and posterior involvement.
• Imaging and laboratory workup based on clinical signs and geographic risk factors.

The researchers provide a diagnostic algorithm and diagram of clinical features in this review to support clinicians in uveitis assessments.

Treatment Strategies by Subtype

In noninfectious anterior uveitis, first-line treatment focuses on topical corticosteroids (eg, 1% prednisolone acetate or rimexolone) with tapering regimens. Second-line treatments include local corticosteroid injections or systemic corticosteroids.

For noninfectious posterior uveitis and panuveitis, systemic corticosteroids with or without disease-modifying antirheumatic drugs (DMARDs; eg, methotrexate, mycophenolate mofetil) are used as first-line treatment. In previous studies, methotrexate achieved inflammation control in 52.1% to 74.9% of patients, depending on uveitis location, and mycophenolate mofetil had a 70.9% success rate for posterior/panuveitis, the review authors noted.

For second-line treatment, biologics (eg, adalimumab) are recommended if inflammation is refractory to DMARDs. In studies, adalimumab extended time to treatment failure from 13 weeks (placebo) to 24 weeks and reduced treatment failure rates from 78.5% to 54.5% (P<.001).

For management of infectious uveitis, treatment targets the underlying infection, often in combination with corticosteroids:

• Tuberculosis: WHO-recommended 6-month regimen achieves 85% success, according to previous research.
• Syphilis: In line with WHO and CDC guidelines, studies have shown high cure rates with IV penicillin, and adjunct corticosteroids improved outcomes to 95%.
• Herpesvirus-related uveitis: Patients are treated with antivirals (eg, acyclovir or valacyclovir) and topical steroids. Experts advise against using topical steroids alone, the review authors noted. They added that antiviral and anti-inflammatory treatments can be used as preventive therapy to reduce future recurrences, which are experienced by almost half of patients within 10 years, but prophylaxis should be individualized based on disease severity and recurrence history.  
• Toxoplasmosis: Systemic antibiotics reduced recurrence from 18.9% to 4.5% in 3 randomized, controlled trials.

Prognosis and Complications

Common complications from severe and chronic uveitis include cataracts (18% to 49%), glaucoma (7% to 56%), and macular edema (8% to 10%). Long-term studies (eg, MUST and VISUAL III) show declining visual acuity in chronic uveitis, though treatments like adalimumab have significantly increased inflammation control rates from 34% to 85% over 3 years.

Complications from prolonged topical, periocular, intravitreal implant, and systemic corticosteroid use also include glaucoma, cataracts, and ocular hypertension, the review authors noted. Specifically, “up to 18% to 24% of patients treated with steroids may require cataract or glaucoma surgery,” they added.

A full list of author disclosures can be found in the original publication