Uvéites : que doivent savoir le rhumatologue et l’interniste ?

Abstract

Rheumatologists and internists may need to establish the etiological diagnosis and handle the therapeutic management of adults with uveitis. A prospective study named ULISSE (Uveitis: clinical and medicoeconomic evaluation of a standardized strategy for etiological diagnosis) has shown that a standardized strategy for the etiological diagnosis of uveitis was neither inferior nor superior to an open strategy. Subsequent analysis showed that only a few diagnostic tests were useful for the etiological assessment of uveitis. These tests were often inexpensive, simple, usually guided by clinical findings, and allowed an etiological diagnosis to be made for many patients. Three systemic diseases are particularly prevalent in patients referred to internists or rheumatologists: HLA-B27- and spondyloarthritis-associated uveitis, Behçet's disease, and sarcoidosis. Uveitis associated with spondyloarthritis follows a « rule of 90 »: around 90 of cases are unilateral, anterior, and acute. Among patients with uveitis and spondyloarthritis, about two thirds are diagnosed with joint disease during a uveitis assessment. Patients with inflammatory or noninflammatory low back pain should be routinely evaluated for spondyloarthritis, which is the leading cause of uveitis in western countries. The risk of blindness is extremely low, and the main complication is recurrent uveitis, seen in 50 to 60 % of cases. Sulfasalazine decreases the frequency, duration, and severity of uveitis and can be used prophylactically. Sarcoidosis is an underestimated cause of uveitis, which occurs in 15 % of cases, with a predilection for middle-aged women. The treatment of sarcoid uveitis largely follows the general principles of idiopathic uveitis. Behçet's disease uveitis affects young people of both sexes and of all origins and usually presents as panuveitis and retinal vasculitis. The treatment of Behçet's uveitis aims at a complete disappearance of the ocular inflammation. The prognosis of the severe and refractory forms has been dramatically changed by the introduction of TNF-α antagonists.