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BRIEF REPORT
Year : 2003  |  Volume : 51  |  Issue : 1  |  Page : 77-79

Recurrent anterior uveitis and healed retinal vasculitis associated with multiple sclerosis.


Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, India

Correspondence Address:
Kannan M Narayana
Medical and Vision Research Foundations, Sankara Nethralaya, Chennai
India
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Source of Support: None, Conflict of Interest: None


PMID: 12701867

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  Abstract 

We describe the occurrence of anterior uveitis with healed retinal vasculitis in an Asian-Indian woman. She had features of anterior uveitis and healed retinal vasculitis. This rare disease in India may be associated with intraocular inflammation.

Keywords: Multiple sclerosis, anterior uveitis, retinal vasculitis


How to cite this article:
Narayana KM, Agrawal R, Biswas J, Arjundas D. Recurrent anterior uveitis and healed retinal vasculitis associated with multiple sclerosis. Indian J Ophthalmol 2003;51:77-9

How to cite this URL:
Narayana KM, Agrawal R, Biswas J, Arjundas D. Recurrent anterior uveitis and healed retinal vasculitis associated with multiple sclerosis. Indian J Ophthalmol [serial online] 2003 [cited 2020 Aug 10];51:77-9. Available from: http://www.ijo.in/text.asp?2003/51/1/77/14733

Multiple sclerosis is suspected to be of autoimmune origin. It predominantly involves the white matter of the central nervous system. It is more common among the Caucasian population. Several authors have observed the association of uveitis with multiple sclerosis.[1],[2],[3] Common intraocular associated inflammations include retinal periphlebitis (10-20%), [1] peripheral uveitis (15-27%)[3] and iridocyclitis (4.3-5.5%).[2] Multiple sclerosis, though relatively uncommon in the Indian population, has been reported in the Indian literature.[4] However, to our knowledge (Medline search), uveitis with multiple sclerosis has not been reported so far in Indian subjects. We report a case of recurrent anterior uveitis and healed retinal vasculitis in a patient with multiple sclerosis.


  Case report Top


A 46-year-old lady presented with history suggestive of recurrent anterior uveitis in her left eye for the past 7 years. She had a history of left-sided lower motor neuron type facial palsy 20 years ago and left hemi-paresis 8 years ago. She had recovered from both conditions spontaneously. Magnetic resonance imaging (MRI) of brain, done 8 years ago, showed a large hyperintense lesion in the posterior limb of the right internal capsule and corona radiata suggestive of demyelination [Figure - 1]. The magnetic resonance angiogram had confirmed the non-vascular nature of the lesion. The pattern VEP (Visually Evoked Potentials), auditory evoked potentials, and somatosensory evoked potentials were normal. A follow-up MRI 10 days later showed partial resolution of the lesion. No fresh lesions were seen. A diagnosis of demyelinating disease, possibly multiple sclerosis, was made by the neurologist. As the lesion was spontaneously regressing, the patient was not advised any treatment. She had recently seen an ophthalmologist and was diagnosed with chronic anterior uveitis.

She had also undergone investigations for uveitis, including: total leukocyte count (6700 cells/mm[3], neutrophils-61%, lymphocytes-37%, eosinophils-1%), ESR-11mm at first hour, normal lipid profile, normal renal function parameters, negative enzyme linked immunosorbent assay (ELISA) for toxoplasmosis, normal serum angiotensin converting enzyme (ACE), negative antinuclear antibody negative and negative anti-ds-DNA antibody. The patient was negative for human immunodeficiency virus (HIV) infection and the chest X-ray showed no abnormalities. The patient was using 1% prednisolone acetate eye drops 4 times a day and 0.5% timolol maleate eye drops twice a day in the left eye.

The best corrected vision was 6/6,N6 in both eyes. Ocular motility was normal. Slitlamp examination of anterior segment in the right eye was normal. The left eye had 2+ flare, 2+ cells in the anterior chamber, old and fresh, medium-sized keratic precipitates, large posterior synechiae [Figure - 2]a and early posterior subcapsular cataract. Intraocular pressure (IOP) by applanation tonometry was 12 mm of Hg in the right eye and 26 mm of Hg in the left eye. Gonioscopy showed 360 open angles in both the eyes and peripheral anterior synechiae in the left eye. Indirect ophthalmoscopy showed no abnormalities in the right eye fundus. Left eye showed glaucomatous cupping of the optic disc with cup-disc ratio of 0.8. There was an area of perivascular sheathing in the inferior periphery, without any overlying vitritis, suggestive of healed perivasculitis [Figure - 2]b. The patient was asked to continue prednisolone acetate and timolol eye drops; 0.2% brimonidine 3 times a day and 2% Homatropine twice a day in the left eye were added. She was instructed to return for regular follow-ups.


  Discussion Top


Multiple sclerosis is a demyelinating disorder in which there is normal formation of myelin, which is subsequently damaged by an as yet unrecognised mechanism. The disease principally affects young adults in all countries and is slightly more common in women. Nearly two-thirds of patients experience symptoms between 20 and 40 years of age. Epidemiologically three frequency zones have been identified:[4] (1) high risk zone which includes United Kingdom, Western Europe, the northern United States and southern Canada (prevalence rate 30-80/100,000), (2) medium risk zone (prevalence after 5-15/100,000) which includes southern Europe, the southern United States and Australia and (3) low risk zone (prevalence below 5/1,00,000) which includes Asia and Africa. Association with HLA-A3, B7, B12 have been found in various studies. The most common presentations include limb weakness (50%), and visual disturbances such as blurred vision, blindness due to optic nerve involvement, and diplopia (30%). The signs and symptoms remit, but relapses occur at varying intervals. Despite remissions patients are usually left with residual neurological deficits.

The aetiopathogenesis of multiple sclerosis remains uncertain. Autoimmune mechanism is the most commonly accepted explanation. Ohguro et al found a high rate of positive serum antibodies reactive with

β -arrestin and arrestin in patients with multiple sclerosis.[5] They also suggested that the course of disease progression might be related to the presence of these antibodies. We believe that uveitis is a part of the autoimmune disease process of multiple sclerosis.

Many authors have described an association between multiple sclerosis and uveitis. [1],[2],[3] In these reports presence of granulomatous anterior uveitis, retinal periphlebitis or intermediate uveitis are reported. To our knowledge (Medline search), multiple sclerosis associated with recurrent uveitis has not been reported in Indian subjects. Anterior uveitis with retinal periphlebitis has been described in systemic lupus erythomatosis, Behcet's disease, and polyarteritis nodosa. Sometimes sarcoidosis patients can also present initially with non-granulomatous uveitis. Our patient did not have any history, systemic features or investigations suggestive of any of these disorders. We excluded other disorders by detailed history, examination and relevant investigations.

Multiple sclerosis has been reported to occur in the Indian subcontinent. However, Asia and Africa are designated as low-risk zones (with prevalence rate below 5/100,000).[4]

Our case indicates that it might be prudent to elicit any neurological symptoms in all patients with recurrent uveitis to rule out multiple sclerosis. A detailed fundus examination is required to rule out peripheral retinal periphlebitis. Neurological consultation with MRI may be needed in patients with a history of neurological deficits with recurrent uveitis or active or healed retinal vasculitis.

 
  References Top

1.
Arnold AC, Usaf MC, Pepose JS, Helper RS, Froos RY. Retinal periphlebitis and retinitis in multiple sclerosis. Ophthalmology 1984;91:255-62.  Back to cited text no. 1
    
2.
Breger BC, Leopod IH. The incidence of uveitis in multiple sclerosis. Am J Ophthalmol 1966;62:540-45.  Back to cited text no. 2
    
3.
Lim JI, Tessler HH, Goodwin JA. Anterior granulomatous uveitis in patients with multiple sclerosis. Ophthalmology 1991;98:142-45.  Back to cited text no. 3
    
4.
Singhal BS. Demyelinating and dysmyelinating disorders. In Chopra JS, Arjundas G, Prabhakar S, editors. Textbook of Neurology . New Delhi, B I Churchill Livingstone, 2001. pp 339-54.  Back to cited text no. 4
    
5.
Ohguro H,Chiba S,Igarashi Y, Matsumoto H, Akino T, Palezewski K. β -arrestin and arrestin are recognized by autoantibodies in sera from multiple sclerosis patients. Proc Natl Acad Sci USA 1993;90:3241-45.  Back to cited text no. 5
    


    Figures

  [Figure - 1], [Figure - 2]


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