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ORIGINAL ARTICLE
Year : 2003  |  Volume : 51  |  Issue : 2  |  Page : 129-132
 

Patterns of uveitis in children presenting at a tertiary eye care centre in south India


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

Correspondence Address:
Kannan M Narayana
Medical and Vision Research Foundation, Sankara Nethralaya, Chennai
India
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PMID: 12831142

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   Abstract 

Purpose: To study the patterns of uveitis in the paediatric age group in a referral eye care centre in south India. Materials and Methods: Thirty-one patients 15 years or younger with uveitis, examined in the year 2000, were included in this study. The uveitis was classified according to the anatomical site of ocular involvement and the most probable aetiological factor. The final diagnosis was based on clinical manifestations and results of specific laboratory investigations. Results: A total 31 (6.29%) paediatric uveitis cases were seen among the 493 uveitic cases in the year 2000. The male: female ratio was 17:14. Anterior (9 cases), intermediate (9 cases) and posterior uveitis (9 cases) were seen in equal number. Four patients had panuveitis. Twenty-seven patients had visual acuity of 6/36 or better at presentation. Approximately 25% (8 of 31) patients had cataract secondary to inflammation. Immunosuppressives were administered in 4 patients and one patient required cataract surgery. Conclusion: Uveitis in children comprises approximately 6% of uveitis cases in a referral practice in south India. Anterior, intermediate and posterior uveitis are seen in equal numbers. We recommend that intermediate uveitis be ruled out in all cases of anterior uveitis by careful clinical evaluation including examination under anesthesia (EUA) when required.


Keywords: Uveitis, children, toxoplasmosis, intermediate uveitis


How to cite this article:
Narayana KM, Bora A, Biswas J. Patterns of uveitis in children presenting at a tertiary eye care centre in south India. Indian J Ophthalmol 2003;51:129-32

How to cite this URL:
Narayana KM, Bora A, Biswas J. Patterns of uveitis in children presenting at a tertiary eye care centre in south India. Indian J Ophthalmol [serial online] 2003 [cited 2014 Jul 30];51:129-32. Available from: http://www.ijo.in/text.asp?2003/51/2/129/14716


Uveitis is more common among adults than children. Several studies[1],[2],[3],[4],[5],[6],[7],[8] have shown that children constitute about 5-10% of all new uveitis patients. In paediatric uveitis, anterior uveitis accounts for 30-40%, posterior uveitis 40-50%, intermediate uveitis 10-20% and panuveitis 5-10%.[1],[2],[3],[4],[5],[6],[7],[8] The unique problems in detection of intraocular inflammation in the paediatric age group may arise due to inability of children to clearly articulate their ocular complaints, the absence of symptoms in certain diseases, e.g., anterior uveitis associated with juvenile rheumatoid arthritis (JRA), and the development of amblyopia if the vision is impaired. Various authors have studied patterns of inflammation in childhood in their respective geographic locations.[1],[2],[3],[4],[5],[6],[7],[8] Endogenous uveitis in Indian children has been described earlier.[9] In our study of patterns of uveitis in India, 3% of uveitis patients were in the paediatric age group.[10] In order to further classify the pattern of uveitis in children below 15 years, we retrospectively reviewed case records of 31 children seen in one year (2000) in Sankara Nethralaya, a tertiary care referral eye institute in south India.


   Materials and Methods Top


This consecutive series was drawn from the total population of new uveitis cases in the year 2000 seen by the uveitis service of the institute. Medical records of 31 patients with the onset of uveitis at 15 years or below were reviewed. The collected data included details of ocular examination performed at each visit including those examined under anaesthesia (EUA). This included best-corrected visual acuity (not for children examined under anaesthesia), ocular motility, slitlamp bimicroscopy, tonometry and indirect ophthalmoscopy. The systemic disease details and laboratory workups were collected and analysed. The routine laboratory workup included complete white blood cell count with a differential count, erythrocyte sedimentation rate, and urinalysis. Other investigations had been ordered depending on the differential diagnoses. For example, in the case of anterior uveitis with a history suggestive of arthritis, antinuclear antibodies, rheumatoid factor, erythrocyte sedimentation rate (ESR) and rhematologist consultation were obtained. In the case of granulomatous anterior uveitis and intermediate uveitis, chest X-ray, Manoux test and serum angiotensin converting enzyme were obtained to rule out tuberculosis and sarcoidosis. Uveitis was classified using the International Uveitis Study Group (IUSG) classification system.[11]

The final diagnosis was based on chronological history, clinical manifestations and the results of specific laboratory investigations. The diagnosis of ocular toxoplasmosis was made mainly on clinical grounds.[12] In short, this included a patch of retinochoroiditis adjacent to a healed chorioretinal atrophic scar or a primary unifocal intensely white retinitis or yellow-white retinochoroiditis, with overlying vitreous reaction, with or without dense vitreous reaction. SerumELISA for IgG and IGM antibodies was obtained as a supportive measure.

Management in these patients included a consultation with paediatrician or rheumatologist when systemic disease associations were present or suspected, and use of immunosuppressive or corticosteroid therapy administered in consultation with the internist, when required. Laboratory parameters including total leukocyte count and platelet count. The liver function tests were monitored every 1-2 weeks in all patients on immunosuppressive agents. Patients were specifically questioned for the presence of any side effects with the immunosuppressive and oral corticosteroid at each visit.


   Results Top


There were 17 male and 14 female children. They comprised 6.29% (31 of 493) of new uveitis patients. The uveitis was bilateral in 9 cases (29.03%) and unilateral in 22 cases (70.96%). Anatomical types of uveitis are given in [Table - 1]. The specific diagnosis of these cases is given in [Table - 2]. Two children were diagnosed as having intermediate uveitis after EUA. A majority of the patients had visual acuity of 6/36 or better at presentation (27 eyes). Thirteen eyes had visual acuity of 6/60 or worse. Eight patients had cataractous lens changes. Complica-tions seen are given in [Table - 3]. Treatment for these patients was based on the type of uveitis and associated systemic disease. Four patients had received an immunosuppressive agent. All four patients with juvenile rheumatoid arthritis received methotrexate. Cataract surgery was performed on one child.


   Discussion Top


Our study showed that 6.29 % of all the new uveitis subjects in a referral practice were in the paediatric age group. In comparison with previous series[2],[3],[4],[9] our study showed two remarkable features [Table - 4]. The disease was bilateral in 50-70% patients in the previous series, while it was unilateral in 70% of patients in our series.

Secondly, intermediate uveitis (pars planits) was the most common type of uveitis by aetiological diagnosis in our series. This was nearly twice as common as in the other series. The diagnosis of intermediate uveitis in cases presenting with anterior uveitis may be missed in the absence of careful evaluation of the peripheral fundus by indirect ophthalmoscopic evaluation with scleral depression. EUA is needed in younger children to carry out detailed fundus evaluation with scleral depression in cases of suspected posterior segment involvement in any case of intraocular inflammation. This is also very important in cases of intermediate uveitis to visualize the snowball opacities and snowbanking in the peripheral fundus. We had to perform EUA to make the diagnosis in 2 children. The natural course of anterior uveitis and pars planits are quite different. Pars planits is known to be associated with more frequent complications like cataract and cystoid macular oedema. The importance of recognizing pars planits increases further as recent reports indicate that pars planits in children may proceed more aggressively.[13] Sarcoidosis associated uveitis accounts for 0.8-3.9% of cases of paediatric uveitis.[5],[8] In the earlier report by Sen (1977) tuberculosis was the common cause and sarcoidosis was not detected.[9] In our study tuberculosis was not seen. A changing pattern of uveitis in children is not uncommon.[4] However, we need a larger sample to comment on changing patterns of uveitis in Indian children.

Juvenile rheumatoid arthritis (JRA) was found in 4 (12%) children in the current study. JRA is reported up to 41% in paediatric patients.[6] This group of patients may need aggressive therapy with systemic corticosteroids and immunosuppressive agents for the intraocular inflammation as well as for the systemic disease. Whenever the oral corticosteroid had to be continued for more than 3 months, its effects on growth and development had to be addressed. In such recalcitrant cases of uveitis it is prudent to add immunosuppressive agents. The duration of such therapy depends upon the severity of the inflammation and its response to therapy, but in general it may be required for 3-6 months. Careful clinical and laboratory monitoring every 2 weeks is essential in these patients to detect any side effects.

In our study, anterior, intermediate and posterior uveitis were seen in equal numbers. Idiopathic was the most common type of anterior and intermediate uveitis. Toxoplasmosis was the most common cause of posterior uveitis and all infectious uveitis. We believe that better understanding of the epidemiological data of paediatric uveitis by ophthalmologists in their respective geographic locations may help improve management of uveitis in paediatric subjects. We recommend that intermediate uveitis be ruled out in all cases of anterior uveitis by careful clinical evaluation including examination under anaesthesia (EUA) when required[Figure - 1].

 
   References Top

1.Cunningham ET Jr. Uveitis in Children. Ocular Immunology and Inflammation 2000;8:251-61.   Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Ben Ezra D, Cohen E, Maftzir G. Patterns of intraocular inflammation in children. Bull Soc Belge Ophthalmol 2001;25-38.   Back to cited text no. 2    
3.Perkins ES. Pattern of uveitis in children. Br J Ophthalmol 1966;50:169-85.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Tugal-Tutkun I, Havrlikova K, Power WJ, Foster CS. Changing patterns of uveitis in childhood. Ophthalmology 1996;103:375-83.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Giles CL. Uveitis in childhood-Part I Anterior. Ann Ophthalmol 1989;21:13-19.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Giles CL. Uveitis in childhood-Part II Intermediate. Ann Ophthalmol 1989;21:20-22.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Giles CL. Uveitis in childhood-Part III Posterior. Ann Ophthalmol 1989;21:23-28.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Kanski JJ, Shun Shin GA. Systemic uveitis syndromes in childhood: An analysis of 340 cases. Ophthalmology 1984;91:1247- 52.  Back to cited text no. 8    
9.Sen DK. Endogenous uveitis in Indian children: Analysis of 94 cases. J Pediatr Ophthalmol 1977;14:25-32.   Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Das D, Biswas J, Ganesh SK. Pattern of uveitis in a referral uveitis clinic in India. Indian J Ophthalmol 1995; 43:117-21.   Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Bloch-Michel E, Nussenblatt RB, International Uveitis Study Group recommendations for the evaluation of intraocular inflammatory disease. Am J Ophthalmol 1987;103:234-35.  Back to cited text no. 11    
12.Holland GN, O' connor GR, Berfort R, Remington JS. Toxoplasmosis. In: Pepose JS, Holland GN, Wilhelmus KR, editors. Ocular Infection and Immunity . Missouri, USA: Mosby Year Book, 1996.pp 1183-1223.   Back to cited text no. 12    
13.Guest S, Funkhouser E, Lightman S Pars planitis: A comparison of childhood onset and adult onset disease. Clin Experiment Ophthalmol 2001;29:81-84.  Back to cited text no. 13    


    Figures

[Figure - 1]

    Tables

[Table - 1], [Table - 2], [Table - 3], [Table - 4]


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