Rheumatological disease and uveitis

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Uveitis describes inflammation within the eye, commonly classified by its predominant anatomical site. Anterior uveitis involves the iris and anterior ciliary region; disease behind the lens may affect the vitreous, retina or choroid. The distribution matters because a treatment reaching the front of the eye may be inadequate for posterior disease. Systemic associations provide clues, but do not replace an ocular diagnosis.

The relationship with rheumatological disease runs in both directions. An ophthalmologist may uncover previously unrecognised inflammatory back pain, while a rheumatology service may identify a patient needing urgent eye care or childhood screening. Cooperation is particularly important when immunosuppression is already prescribed: active inflammation, infection and medicine-related complications can coexist, and the same red-eye label can conceal very different treatment needs.

Key points

Uveitis may be the first clue to systemic inflammatory disease, but many episodes lack an identified systemic cause.
Ask about inflammatory back pain, joint symptoms, psoriasis, bowel inflammation and recurrent oral or genital ulcers.
Describe which ocular structures are inflamed; anterior, intermediate, posterior and panuveitic disease require different assessment and treatment.
NICE recommends same-day ophthalmological assessment for symptoms of acute anterior uveitis.
A negative HLA-B27 result alone does not exclude spondyloarthritis when the clinical picture remains suggestive.
Childhood JIA-associated inflammation can remain silent, making scheduled slit-lamp examinations essential.
Treat the ocular inflammation and monitor treatment harms while the rheumatological team addresses the associated systemic disease.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Spondyloarthritis-associated inflammation

Acute anterior uveitis can accompany axial or peripheral spondyloarthritis, including psoriatic and inflammatory-bowel-disease-associated patterns. The eye episode may precede a formal joint diagnosis, making a targeted musculoskeletal history clinically useful.

Childhood inflammatory arthritis

Juvenile idiopathic arthritis is associated with ocular inflammation that may develop without conspicuous pain or redness. Risk varies with the child's disease characteristics, and routine visual behaviour cannot replace specialist screening.

Other inflammatory associations

Sarcoidosis and Behçet's disease can involve intraocular structures, sometimes with posterior or widespread disease. Symptoms outside the eye help direct investigation, although absence of a familiar systemic syndrome does not exclude uveitis.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Breakdown of intraocular barriers
Inflammation permits cells and protein to enter normally clear intraocular spaces. Slit-lamp examination can reveal anterior chamber cells and flare, while vitreous inflammatory material may produce floaters or obscure the posterior view.
2
Adhesion and pressure disturbance
Inflamed iris tissue may adhere to the lens, altering pupil shape and aqueous movement. Pressure can rise through inflammatory outflow obstruction, adhesions or a corticosteroid response, while severe inflammation can also impair aqueous production.
3
Posterior functional injury
Inflammation affecting retinal vessels, the macula or other posterior structures can impair vision through leakage, ischaemia or structural damage. Central acuity and anterior chamber findings do not fully describe the extent of posterior disease.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Recognise an acute anterior episode

Ask about photophobia, aching pain, blurred vision and onset in one or both eyes. Look for redness concentrated around the cornea and an abnormal pupil, but do not expect every sign. Record acuity and arrange urgent assessment before attributing the complaint to a routine inflammatory flare.

Use the eye episode for targeted case finding

Ask whether joint pain has led to a GP consultation and whether back pain began before age forty-five and persisted for more than three months. Enquire about psoriasis or suggestive skin lesions. These questions support the NICE ophthalmology pathway for identifying possible spondyloarthritis.

Look beyond the musculoskeletal history

Recurrent oral and genital ulcers, bowel symptoms, skin lesions and respiratory or other systemic features can direct specialist investigation. Record the timing of systemic symptoms relative to eye episodes. A single laboratory association should not replace a coherent clinical assessment.

Recognise the silent childhood presentation

A child may continue reading and playing normally despite anterior inflammation. Ask whether the planned slit-lamp checks are occurring and whether an appointment was missed. Parents need to understand that the purpose is detecting inflammation before it produces noticeable visual loss.

Red flags requiring action

A painful red eye with light intolerance or reduced vision needs same-day ophthalmic assessment.
Sudden visual loss or new floaters in Behçet's disease requires emergency assessment for sight-threatening ocular involvement.
An immunosuppressed person with ocular inflammation needs consideration of infection before treatment is intensified.
A child with juvenile idiopathic arthritis still needs scheduled eye screening when vision seems normal and the eyes look white.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Slit-lamp examination with pressure assessmentFirst step
Why
Confirm anterior inflammation and assess associated structural or pressure complications.
Interpretation and limitations
Cells, flare, corneal findings and synechiae guide classification and treatment. Pressure elevation may reflect active inflammation, a steroid response or both; one mechanism should not be assumed from the prescription history alone.
02
Dilated posterior assessment and targeted OCT
Why
Identify inflammation behind the lens and explain reduced central function.
Interpretation and limitations
Posterior examination and imaging help detect vitreous involvement, macular oedema or retinal pathology. A central OCT alone cannot exclude all posterior inflammatory or infectious lesions.
03
Directed rheumatological assessment
Why
Investigate systemic clues rather than ordering an indiscriminate autoimmune panel.
Interpretation and limitations
NICE's acute-anterior-uveitis case-finding pathway uses joint or qualifying back symptoms, assessment for psoriasis and HLA-B27 testing in the relevant subgroup. Neither a negative HLA-B27 result nor normal inflammatory markers alone rules out spondyloarthritis.
04
Infectious and treatment-safety investigations when indicated
Why
Exclude important mimics and prepare safely for systemic treatment.
Interpretation and limitations
The ophthalmic pattern, exposure history and proposed immunosuppressant determine targeted infection tests and baseline monitoring. An undirected negative panel does not establish non-infectious disease, and tests should not delay emergency assessment of a threatened eye.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Microbial keratitis or intraocular infection

Corneal infection and infectious uveitis require cause-specific treatment. Immunosuppression, an epithelial defect, a focal infiltrate or an unusual course should prompt diagnostic reconsideration before additional corticosteroid exposure.

Scleritis and ocular surface disease

Inflammatory systemic disorders can affect the sclera or tear-producing apparatus as well as intraocular tissues. The examination localises the painful or irritated structure so that a rheumatological history does not lead automatically to a uveitis diagnosis.

Other painful red-eye emergencies

Acute angle closure and recent surgical complications can cause pain, redness and blurred vision. Pressure, chamber depth, corneal findings and the history of surgery help identify the correct emergency pathway.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01Acute symptomsEstablish the ocular diagnosis todayFirst stepPain, redness, photophobia or blurred vision suggests acute anterior uveitis.

1Arrange same-day ophthalmological assessment, stating visual change, immune treatment and relevant systemic disease.
2EscalationDocument available visual findings and medication exposure while avoiding empirical escalation of steroid for an undiagnosed red eye.
3After diagnosis, provide the prescribed ocular plan, early review date and a clear instruction for worsening symptoms.

02Systemic clues after anterior uveitisConnect the eye and rheumatology pathwaysAn ophthalmologist identifies joint symptoms or qualifying persistent back pain during acute anterior uveitis assessment.

1Assess for psoriasis or suggestive skin findings and refer for spondyloarthritis assessment when present.
2If psoriasis is absent in this NICE case-finding group, obtain HLA-B27 and refer when positive.
3If clinical suspicion persists despite negative tests, seek appropriate rheumatological advice rather than treating a single negative result as exclusion.

03Recurrent or persistent diseaseControl inflammation with a sustainable shared planOcular inflammation recurs, persists or cannot be controlled with an acceptable local treatment burden.

1Reassess anatomical distribution, infection risk and treatment delivery before labelling the disease resistant.
2Coordinate ocular treatment and any systemic immunomodulation between ophthalmology and the relevant rheumatology or paediatric service.
3Specify the monitoring owner, medicine review, blood-test responsibilities and urgent contact route, including care outside specialist clinic days.

Key medicines and prescribing safety1 treatment · regimens, roles and cautions

Provides local corticosteroid treatment when the ocular diagnosis and exclusion of relevant infection justify it. Shake the suspension and compress the lacrimal sac at the inner canthus for one minute after administration to reduce systemic absorption. This adult schedule is not a paediatric prescribing instruction.

Pred Forte 1% prednisolone acetate suspension for specialist-confirmed inflammation

The adult UK product regimen is one or two drops in the affected eye two to four times daily; during the first 24–48 hours, two drops every hour may be prescribed. The ophthalmologist determines subsequent frequency, taper and stop point from inflammation control.

Do not use for an undiagnosed red eye, untreated purulent infection, superficial herpes simplex keratitis, relevant viral corneal or conjunctival disease, fungal eye disease or ocular tuberculosis. Treatment beyond ten days requires strict ophthalmic supervision and regular pressure checks. Review corneal thinning and delayed healing. During pregnancy use cautiously only when benefit outweighs fetal risk; the product is not recommended during breastfeeding. Review systemic steroid interactions, particularly CYP3A inhibitors such as cobicistat, and monitor systemic effects if combined treatment is justified.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Synechiae and secondary glaucoma

Persistent adhesions and outflow disturbance can leave ongoing pressure problems after inflammation settles. Monitoring must assess the drainage consequences and optic nerve, not only the number of inflammatory cells.

Macular oedema and visual damage

Inflammatory fluid or retinal injury can reduce reading vision and cause lasting impairment. An apparently quiet anterior chamber does not establish that all sight-threatening disease is controlled.

Treatment-related harm

Cataract, raised pressure and infection can complicate corticosteroid treatment, while systemic immunomodulation introduces additional monitoring needs. The benefits and harms of therapy must be reviewed together rather than treating either as an isolated problem.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Follow anterior chamber activity, symptoms and acuity while also reviewing pressure, pupil adhesions and any posterior involvement.
Ensure children continue the screening or disease-monitoring schedule chosen by their ophthalmic team, even when arthritis symptoms and visual behaviour seem reassuring.
After a steroid change, assess both inflammatory response and pressure; a lower pressure is not a satisfactory result if sight-threatening inflammation has returned.
Reconcile systemic and topical medicines at every transfer of care and confirm responsibility for laboratory monitoring when systemic immunomodulation is used.
Investigate new or worsening visual loss during apparent remission rather than assuming that discomfort alone measures disease activity.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

A rheumatological label is not an ocular diagnosis

One person can have dry-eye symptoms, scleritis, uveitis or an unrelated eye disorder at different times. Describe the tissue involved and supporting findings in each episode. This prevents a previous diagnosis from turning every future red eye into an automatic repeat prescription.

Childhood screening and active monitoring differ

Screening looks for inflammation in a child without recognised eye disease; once uveitis is present, review assesses activity and treatment consequences. The interval is individual and may change. A hospital leaflet's usual three-month screening schedule should not be substituted for a closer active-disease plan.

Immunosuppression does not exclude infection

A patient already receiving anti-inflammatory therapy can develop infectious ocular disease, and additional immunosuppression may worsen it. New focal lesions, atypical inflammation or unexpected deterioration should lead to reassessment of the diagnosis and targeted microbiological investigation where appropriate.

Rheumatological and ocular activity can diverge

Comfortable joints and improved systemic markers do not prove that the eye is quiet. Likewise, a controlled eye episode does not settle the wider diagnosis. Shared records should identify the actual ocular findings and treatment goal so that one service does not infer stability from the other's outcome.

Reducing treatment requires an agreed endpoint

Patients may stop drops when redness disappears or continue them indefinitely because they fear recurrence. Explain how examination guides the taper and who can change it. Ensure that a missed appointment leads to prompt contact with the responsible team rather than an unsupervised treatment experiment.

11Common pitfallsFrequent interpretation and management errors.

01
Delaying a symptomatic uveitis assessment while waiting for rheumatology blood-test results.
02
Using HLA-B27 negativity as the sole reason to dismiss convincing inflammatory back and eye symptoms.
03
Stopping JIA eye screening because the child has normal acuity and no visible redness.
04
Increasing corticosteroids before reconsidering infection in an immunosuppressed person with atypical ocular deterioration.
05
Measuring treatment success only by symptom relief without checking pressure and relevant posterior findings.