Panuveitis: Symptoms, Types, Causes and Treatment

Panuveitis is a complex and sight-threatening inflammatory eye disease that affects all layers of the uveal tract as well as neighboring structures like the retina and vitreous. It is a diverse clinical entity with multiple causes, presentations, and management strategies. Whether you’re a patient, clinician, or simply curious about eye health, understanding panuveitis is crucial for timely recognition and treatment. This article will guide you through its symptoms, the different types, underlying causes, and evidence-based treatment options.

Symptoms of Panuveitis

Panuveitis presents with a constellation of symptoms that may overlap with other forms of uveitis but are typically more widespread and severe due to the diffuse inflammation. Early recognition of these symptoms can be vision-saving, as prompt diagnosis and treatment are crucial.

Symptom	Description	Severity/Onset	Source(s)
Eye Pain	Aching or throbbing discomfort	Acute/subacute	1 12
Redness	Diffuse redness, not just periphery	Acute	12
Photophobia	Sensitivity to light	Acute/chronic	1 12
Blurred Vision	Reduced sharpness or clarity	Sudden/progressive	1 4 7 12
Floaters	Perceived spots, threads in vision	Insidious	1 4 7
Decreased Vision	Marked visual loss	Severe	7 12
Tearing	Excessive tear production	Variable	3
Headache	Associated in multisystemic syndromes	Systemic phase	2 5

Table 1: Key Symptoms

Eye Discomfort and Redness

• Pain and photophobia are common, resulting from inflammation of the uveal tissues.
• Redness is typically diffuse, not limited to one area, reflecting the panocular involvement 1 12.

Visual Disturbances

• Blurred vision and decreased vision are hallmark features, often progressing if untreated.
• Floaters—caused by inflammatory cells in the vitreous—can be an early sign, especially when associated with other symptoms 4 7.

Systemic and Associated Symptoms

• Headache and neurologic complaints may be present in cases linked to syndromes like Vogt–Koyanagi–Harada (VKH) disease 2 5.
• Tearing and conjunctivitis can occur, particularly if infectious agents like Zika virus are involved 3.

Severity and Prognosis

• The severity of symptoms ranges from mild discomfort to profound vision loss.
• Early intervention can improve outcomes, but chronic or relapsing cases may lead to complications such as cataracts, glaucoma, or retinal detachment 7 12.

Types of Panuveitis

Panuveitis is not a single disease but a grouping based on the distribution of inflammation. It’s important to distinguish its various clinical patterns, as they influence both prognosis and management.

Type	Main Features	Typical Etiologies	Source(s)
Idiopathic	Unknown cause, bilateral/unilateral	Immune-mediated, undetermined	1 7 12
Infectious	May be acute or chronic, variable	Toxoplasma, Herpetic, Zika, TB	3 4 6 7 12
Non-infectious	Often bilateral, chronic	Autoimmune (VKH, Behçet, sarcoidosis, sympathetic ophthalmia)	2 4 5 7 8 12
Granulomatous	Nodules, keratic precipitates	TB, sarcoid, VKH, sympathetic ophthalmia	2 5 8 12
Nongranulomatous	Diffuse infiltrates, no nodules	Idiopathic, some autoimmune	2 5

Table 2: Clinical Types of Panuveitis

Idiopathic Panuveitis

• Many cases remain idiopathic, with no clear underlying cause even after thorough workup.
• These cases may be immune-mediated and can present unilaterally or bilaterally 1 7 12.

Infectious Panuveitis

• Toxoplasma, herpetic viruses, Zika virus, and tuberculosis are notable infectious causes 3 4 6 7 12.
• These may present acutely or with chronic relapsing inflammation.

Non-Infectious (Autoimmune) Panuveitis

• Vogt-Koyanagi-Harada (VKH) disease, Behçet disease, sarcoidosis, and sympathetic ophthalmia are leading non-infectious causes 2 4 5 7 8 12.
• These types are often bilateral and associated with systemic features.

Granulomatous vs Nongranulomatous

• Granulomatous panuveitis is characterized by large keratic precipitates and nodular infiltrates seen in TB, sarcoidosis, and VKH 2 5 8 12.
• Nongranulomatous forms lack these features and may be more diffuse 2 5.

Special Syndromes

• Multifocal choroiditis and panuveitis is a unique syndrome, often in young women, with multiple chorioretinal lesions and risk of vision loss 10.
• Diffuse panuveitis can also be seen in animal models (like dogs) and provides insight into human disease mechanisms 1.

Causes of Panuveitis

The causes of panuveitis are diverse, ranging from infections and autoimmune conditions to idiopathic (unknown) origins. Identifying the underlying cause is essential for optimal management.

Cause	Examples	Frequency/Prevalence	Source(s)
Autoimmune	VKH, Behçet, sarcoidosis, SO	Common in tertiary centers	2 4 5 7 8 12
Infectious	Toxoplasma, TB, herpes, Zika, fungi	Common in endemic regions	3 4 6 7 12
Idiopathic	No identified cause	Up to 30%+ cases	1 7 12
Post-surgical/Trauma	Sympathetic ophthalmia, phacoanaphylactic	Less common	2 7 12
Neoplastic	Lymphoma	Rare	1

Table 3: Major Causes of Panuveitis

Autoimmune and Systemic Diseases

• Vogt-Koyanagi-Harada (VKH) disease is a multisystem autoimmune disorder targeting melanocytes, leading to bilateral panuveitis with neurologic and skin findings 2 4 5.
• Behçet disease is a major cause in certain populations, especially in the Middle East and Mediterranean, presenting with recurrent, severe inflammation 4.
• Sarcoidosis is characterized by granulomatous inflammation, often with systemic involvement 7 8.
• Sympathetic ophthalmia occurs after ocular trauma or surgery, causing bilateral granulomatous panuveitis 2 7 12.

Infectious Causes

• Toxoplasma gondii is a protozoan parasite, often causing focal or diffuse panuveitis, especially in immunocompromised or pediatric patients 4 6 7.
• Herpetic viruses (HSV, VZV, CMV) can cause acute or chronic panuveitis, sometimes with necrotizing retinitis 4 7 12.
• Tuberculosis can cause granulomatous panuveitis, particularly in high-prevalence regions 4 12.
• Zika virus has been identified as a cause of panuveitis with shedding of virus in tears and involvement of various ocular tissues 3.

Idiopathic Panuveitis

• In many cases, no underlying etiology is found despite extensive investigation; these are labeled as idiopathic 1 7 12.

Post-surgical/Traumatic

• Sympathetic ophthalmia and phacoanaphylactic uveitis are rare but important causes, generally following eye injury or surgery 2 7 12.

Neoplastic

• Lymphoma involving the eye can mimic panuveitis, though it is rare 1.

Treatment of Panuveitis

Effective management of panuveitis depends on identifying the cause and promptly controlling inflammation to prevent vision loss and complications. Treatment is often multidisciplinary and tailored to individual patient needs.

Treatment	Indication	Outcomes/Notes	Source(s)
Corticosteroids	Acute inflammation, first-line	Rapid control, systemic/ocular routes	1 7 8 10 11 12
Immunosuppressive agents	Steroid-resistant, chronic, autoimmune	Methotrexate, azathioprine, biologics; reduced flares	5 8 9 10 12
Biologics (e.g., adalimumab)	Refractory noninfectious panuveitis	Improved control, reduced steroid use	9 12
Intravitreal therapies (e.g., Ozurdex)	Macular edema, local inflammation	Improved vision, risk of cataract/IOP rise	11
Antimicrobial therapy	Infectious causes	Pathogen-directed, essential for cure	3 4 6 7 12
Surgery (e.g., vitrectomy)	Complications, diagnosis, therapy	For persistent inflammation or complications	12

Table 4: Mainstay Treatments for Panuveitis

Corticosteroids

• Systemic and local corticosteroids remain the cornerstone for rapid suppression of intraocular inflammation 1 7 8 10 11 12.
• These can be given orally, intravenously, as eye drops, periocular injections, or intravitreal implants (e.g., Ozurdex) 11.

Immunosuppressive Agents

• Methotrexate, azathioprine, mycophenolate, cyclosporine are used for chronic, steroid-resistant, or autoimmune panuveitis 5 8 10 12.
• Methotrexate has shown efficacy in sarcoid-associated panuveitis, reducing both inflammation and steroid dependence 8.

Biologic Therapies

• Biologics (e.g., adalimumab, infliximab) target specific immune pathways and are used in refractory noninfectious cases 9 12.
• Studies show these agents reduce flares and allow for lower steroid doses, with adalimumab offering lower relapse rates than some alternatives 9.

Intravitreal Implants

• Dexamethasone intravitreal implants (Ozurdex) are effective for posterior segment inflammation and macular edema, improving vision in many patients 11.
• Risks include elevated intraocular pressure and cataract formation, so close monitoring is needed 11.

Antimicrobial Therapy

• For infectious panuveitis, pathogen-specific treatments (antibiotics, antivirals, antiparasitics) are mandatory and should be initiated promptly 3 4 6 7 12.

Surgery

• Vitrectomy may be performed for diagnostic purposes, persistent inflammation, or to manage complications such as retinal detachment 12.

Monitoring and Outcomes

• Chronic therapy can have significant side effects, including glaucoma and cataracts, necessitating careful long-term follow-up 7 11 12.
• Visual prognosis varies: with prompt and appropriate therapy, many patients retain or regain vision, but chronic, relapsing cases are at risk for permanent vision loss 1 7 10.

Conclusion

Panuveitis is a severe, multifaceted inflammatory disease of the eye, demanding precise diagnosis and tailored management. Here are the main takeaways:

• Symptoms include pain, redness, blurred vision, floaters, and sometimes systemic features.
• Types range from idiopathic and infectious to noninfectious autoimmune entities, each with unique presentations.
• Causes are diverse: autoimmune syndromes, infections, idiopathic cases, and rare post-traumatic or neoplastic origins.
• Treatment hinges on corticosteroids, immunosuppressive agents, biologics, local therapies, and surgery—selected based on cause and disease severity.

Key Points:

• Early recognition and intervention are crucial to preserve vision.
• Identifying the underlying cause guides therapy and prognosis.
• Advances in immunomodulatory and biologic treatments offer hope in refractory cases.
• Long-term monitoring is essential for managing side effects and preventing relapse.

If you or someone you know is experiencing symptoms suggestive of panuveitis, seek prompt ophthalmic evaluation. With modern therapies and collaborative care, outcomes have improved, but vigilance remains vital.