Year : 2004 | Volume
: 52 | Issue : 2 | Page : 121--5
Pattern of Uveitis in a Referral Eye Clinic in North India
R Singh, V Gupta, A Gupta
Department of Ophthalmology, Postgraduate Institute of Medical Eudcation and Research, Chandigarh, India
Department of Ophthalmology, Postgraduate Institute of Medical Eudcation and Research, Chandigarh
Purpose: To report the pattern of uveitis in a north Indian tertiary eye center.
Methods: A retrospective study was done to identify the pattern of uveitis in a uveitis clinic population of a major referral center in north India from January 1996 to June 2001. A standard clinical protocol, the źDQ╗naming and meshingźDQ╗ approach with tailored laboratory investigations, was used for the final diagnosis.
Results: 1233 patients were included in the study; 641 (51.98%) were males and 592 (48.01%) females ranging in age from 1.5 to 75 years. The anterior uveitis was seen in 607 patients (49.23%) followed by posterior uveitis (247 patients, 20.23%), intermediate uveitis (198 patients, 16.06%) and panuveitis (181 patients, 14.68%). A specific diagnosis could be established in 602 patients (48.82%). The infective aetiology was seen in 179 patients, of which tuberculosis was the commonest cause in 125 patients followed by toxoplasmosis (21 patients, 11.7%). Non-infectious aetiology was seen in 423 patients, of which ankylosing spondylitis was the commonest cause in 80 patients followed by sepigionous choroidopathy (62 patients, 14.65%) .
Conclusion: Tuberculosis and toxoplasmosis were the commonest form of infective uveitis, while ankylosing spondylitis and serpiginous choroidopathy were commonly seen as the non-infective causes of uveitis in North India.
|How to cite this article:|
Singh R, Gupta V, Gupta A. Pattern of Uveitis in a Referral Eye Clinic in North India.Indian J Ophthalmol 2004;52:121-5
|How to cite this URL:|
Singh R, Gupta V, Gupta A. Pattern of Uveitis in a Referral Eye Clinic in North India. Indian J Ophthalmol [serial online] 2004 [cited 2020 Jun 4 ];52:121-5
Available from: http://www.ijo.in/text.asp?2004/52/2/121/14611
The term "uveitis" includes a large group of intraocular inflammatory diseases of diverse aetiology. The correct diagnosis of uveitis is often challenging as these patients present with a plethora of ocular as well as systemic signs and symptoms. Despite improved understanding of the aetiopathogenesis and evolution of advanced diagnostic techniques, the aetiology of uveitis still remains elusive in a significant number of cases.
Differential diagnosis of uveitis is extensive and the pattern of uveitis keeps changing with time with the emergence of new uveitic entities. Various genetic, ethnic, demographic and envoirmental factors influence the patterns. The literature includes many reports from the Western world describing the epidemiology of uveitis in Caucasians. ,,,,, Biswas et al have reported the pattern of uveitis from a tertiary eye center in the south India. We performed this retrospective study in a tertiary eye center in north India with the objective of determining the causes of uveitis, the associated systemic conditions and to compare the pattern in north India with that seen elsewhere in the world. ,,,,,,
Materials and Methods
The clinical records of all patients with uveitis seen at our uveitis clinic between January 1996 and June 2001 were analysed retrospectively. Information regarding age, gender, race, details of ocular examination, investigations, diagnosis and systemic disease association, if any were recorded for all patients. Patients diagnosed with infective endophthalmitis, Eales' disease, uveitis following trauma or surgery, and lens-induced uveitis were excluded.
The diagnosis for specific ocular uveitic entities or systemic disease association was based on a detailed clinical history, ophthalmological examination, general physical examination, laboratory and ancillary tests. Ocular examination included external examination, slitlamp biomicroscopy including applanation tonometery, fundus examination with 90D/3-mirror Goldman contact lens and indirect ophthalmoscopy with scleral depression after full dilatation. Ancillary tests including ultrasonography and fundus flourescein angiography were carried out when needed.
The anatomical classification of uveitis was based on the International Uveitis Study Group classification system and a short differential diagnosis was made in each case. Subsequently, a tailored laboratory approach was adopted as described by Nozik. The laboratory investigations included complete blood counts, erythrocyte sedimentation rate, Mantoux skin test, Treponema pallidum hemoagglutition test (TPHA), serum Angiotensin converting enzyme (ACE) levels , Enzyme linked immunosorbent assay (ELISA) for Toxoplasma, Toxocara, Human Immunodeficiency virus (HIV) and Human leukocyte antigen (HLA) typing. Radiological investigations included x-rays of the chest, sacroiliac joints and knee joints. Aqueous and vitreous tap was done wherever deemed necessary, for cytological examination and polymerase chain reaction (PCR). Consultations were sought with internist, rheumatologist or pulmonlogist whenever required to reach the final aetiological diagnosis.
The diagnosis of intraocular tuberculosis was made, if the patient fulfilled the criteria A with B or C (vide infra).
(A) Clinical suspicion of disease where any two of the following features were present: i) Granulomatous anterior uveitis, ii) Active periphelebitis, iii) Neuroretinitis, iv) Retinochorioditis, v) Subretinal granuloma/ abscess.
(B) Corroborative evidence of disease (any of the two): i)Mantoux × 20mm/ Necrosis ii) Positive x-ray chest
iii) Aqueous or vitreous tap positive for Mycobacterium tuberculosis by (PCR iv) Sputum positive for acid-fast-bacilli on smear, culture or both v) Histopathological evidence of tuberculosis from cervical or parahilar lymph nodes.
(C) Response to the antitubercular treatment.
The term 'idiopathic' was used whenever the intraocular inflammation could not be attributed to a specific ocular cause or any underlying systemic disease.
The records of 1233 patients who fulfilled the above criteria were analysed. There were 641 (51.98%) males and 592 (48.01%) females. The mean age at presentation was 34.4 years in males and 31.7 years in females (Range of 1.5 to 75 years).
Anatomically, anterior uveitis was the most common type of uveitis, seen in 607 patients (49.23%) followed by posterior uveitis (247 patients, 20.23%), intermediate uveitis (198 patients, 16.06%) and panuveitis (181 patients, 14.68%).
In anterior uveitis, a specific diagnosis could be established in 235 patients (38.7%). The most common specific diagnosis for anterior uveitis was ankylosing spondylitis in 80 patients (13.2% of anterior uveitis patients) followed by tuberculosis (48 patients, 7.9% of anterior uveitis patients). [Table 1]
In posterior uveitis, the specific diagnosis could be established in 186 cases (75.3%). The serpiginous choroidopathy (62 patients, 25.1%) was the most common specific diagnosis in posterior uveitis; followed by multifocal chorioditis (51 patients, 20.7%).
In intermediate uveitis, the specific diagnosis could be established in 17 patients (8.6%), of which tuberculosis and sarcoidosis were the most common underlying cause, seen in 8 patients (4%) each. In the remaining 181 patients (91.4%), no specific cause could be found; these were labeled idiopathic pars planitis. [Table 1]
In the panuveitis group, 164 patients (90.6%) had a specific aetiology. The most common specific diagnosis in this group was tuberculosis seen in 47 patients (26%), followed by Vogt-Koyanagi-Harada syndrome (44 patients, 24.3%). In 17 patients (9.4%), the aetiology could not be determined. [Table 1]
Out of 1233 patients, 602 patients (48.82%) had a specific aetiology. Of the 602 patients with specific aetiology, 179 ( 29.73% ) were infectious aetiology, of which tuberculosis was the commonest infection (125 patients; 69.8%); followed by toxoplasmosis (21 patients, 11.7%); herpes simplex virus (9 patients, 5.01%) and HIV retinopathy (8 patients, 4.4%). Among the specific aetiology of non-infectious origin (423 patients, 70.06%), ankylosing spondylitis was the commonest (80 patients, 18.91%), followed by serpiginous choroidopathy (62 patients, 14.65%); multifocal chorioditis (51 patients, 12.05%); and Vogt- Koyanagi- Harada's (VKH) disease (44 patients, 10.4%).
The variation in the spectrum of uveitis is largely due to complex geographic, ecological, racial, nutritional and socioeconomic differences . Our uveitis study population had fairly homogenous background; all patients were Asian Indians and majority of patients belonged to north India.
In this series, the aetiology could be established in 48.82%. In 51.18% patients, the aetiology could not be established, despite all possible laboratory investigative procedures and ancillary tests. There were fewer idiopathic cases in our study compared to south Indian study but more compared to those reported elsewhere in the world. ,,
Anterior uveitis (49.23%) was the most common anatomical type of uveitis in the study. This was similar to several series.,, In contrast, in the study by Henderly et al posterior uveitis was most common form of uveitis (38.4%) in the USA. [Table 2]
The most common underlying cause for non infective anterior uveitis was ankylosing spondylitis (80 patients, 18.91%), similar trends were observed in India and elsewhere previously. ,,, Amongst the infective aetiologies of anterior uveitis, tuberculosis constituted 7.9% of anterior uveitis patients. A somewhat similar incidence has been reported in a study from Italy where 6.31% of the anterior uveitis patients had a tubercular origin [Table 3].
Serpiginous choroidopathy was the leading cause (62 patients, 25.1%) of posterior uveitis. In other studies toxoplasma was the most common cause of posterior uveitis,,, [Table 3]. Tuberculosis was seen in 8.95% of our posterior uveitis patients. Similar trends were seen in a study from Italy (9.9% of posterior uveitis patients). The number of patients with acute posterior multifocal pigment epitheliopathy (APMPPE), sarcoidosis, Behcet's disease, acute retinal necrosis, cytomegalovirus retinitis and cysticercosis; were comparable to other studies. ,,, HIV retinopathy comprised of 0.6% of total cases, which was less compared to reported incidence in other study by Biswas et al.
Intermediate uveitis is most often idiopathic. However, specific systemic disorders recently have been associated with this form. In our study, the associated systemic disease tuberculosis and saroidosis (4.04% of intermediate uveitis patients). Tuberculosis and sarcoidosis have been previously reported to cause intermediate uveitis. Henderly et al reported all cases intermediate uveitis (pars planitis, classical form or variant form) as idiopathic [Table 3]. Multiple sclerosis, Lyme disease, systemic lupus erythromatoses and Juvenile rheumatoid arthritis have been reported as a cause of intermediate uveitis in many studies,, but were not seen in our series.
Tuberculosis was the most common cause of panuveitis (26.0% of panuveitis patients) [Table 3]. This was significantly higher than in previous studies carried out by Biswas et al (2.16% of panuveitis patients), Rodriguez et al (2.0% of panuveitis patients) and Mercanti et al (5.8% of panuveitis patients). Vogt-Koyanagi-Harada's (VKH) disease was the second most common cause of panuveitis (24.3% of panuveitis patients), which was similar to studies by Biswas et al (21.08% of panuveitis patients), and Henderly et al (33.3% of panuveitis patients ). Sympathetic ophthalmia (2.1% of total patients) was seen more frequently, compared to other studies.,, Similar high prevalence was seen in a study by Weiner et al from Israel (2.2% of total uveitis cases). Sarcoidosis as aetiology of panuveitis was seen infrequently in our series as well as in south India (Biswas et al, 1.6%) compared to studies from the USA.,
In our series, the incidence of intraocular tuberculosis was quite high. Similar high prevalence has been reported in an Italian population. The reason for the high prevalence in our study could be due to use of PCR for Mycobacterium tuberculosis as a diagnostic criteria in our clinic. ,,,
We have noted a high prevalence of serpiginous choriodopathy in our population and reported one of the largest series in such patients. We have also suggested tuberculin hypersensitivity as a possible mechanism in serpiginous choroidopathy. The possible reason for the high prevalence of both serpiginous and ocular tuberculosis in our population merits further studies to establish etiological reason, if any.
It is important to mention that leptospira, onchocerciasis, Lyme disease, birdshot retinochoroido-pathy, diffuse unilateral subacute neuroretinitis and presumed ocular histoplasmosis syndrome were not diagnosed in our series.
|1||Rodriguez A, Calonge M, Pedroza-Seres, Akova YA, Messmer EM, D'Amico DJ, Foster CS. Referral patterns of uveitis in a tertiary eye care center. Arch Ophthalmol . 1996;114:593-99.|
|2||Henderly DE, Genstler AJ, Smith RE, Rao NA . Changing patterns of uveitis. Am J Ophthalmol 1987;103:131-36.|
|3||Mercanti A, Parolini B, Bonora A, Lequaglie Q, Tomazzali. Epidemiology of endogenous uveitis in North -Eastern Italy. Analysis of 655 new cases. Acta Ophthalmol Scand. 2001;79:64-68.|
|4||Smit RLMJ, Baarsma GS, de Vries J. Classification of 750 consecutive uveitis patients in the Rotterdam eye hospital. Intern Ophthalmol 1993;17:71-75.|
|5||Latanza L, Damiano C, DeRosa C. Three years experience at the uveitis clinic of the eye department of Cararelli hospital, Naples. Recent Advances in Uveitis . Amsterdam/New York: Kreger Publications, 1993.pp.175-78.|
|6||Weiner A, BenEzra D. Clinical patterns and associated conditions in chronic uveitis. Am J Ophthalmol 1991; 112:151-58.|
|7||Biswas J, Narain S, Das D, Ganesh SK. Pattern of uveitis in a referral uveitis clinic in India. Int Ophthalomol 1996-97; 20:223-28.|
|8||Bloch-Michel E, Nussenblatt RB. International Uveitis study group recommendations for the evaluation of intraocular inflammatory disease. Am J Ophthalmol .1987; 103:234- 35|
|9||Smith RE, Nozik RA. Uveitis : A Clinical Approach to Diagnosis and Management , 2nd ed. Baltimore: Williams and Wilkins, 1989: pp23-26. |
|10||Gupta V, Arora S, Gupta A, Ram J, Bambery P, Sehgal S. Management of presumed intraocular tuberculosis: possible role of polymerase chain reaction. Acta Ophthalmol Scand 1998;76:679-82.|
|11||Gupta A, Gupta V, Arora A, Dogra MR, Bambery P. PCR-positive tubercular retinal vasculitis: clinical characteristics and management. Retina 2001; 21 :435-44.|
|12||Arora SK, Gupta V, Gupta A, Bambery P, Kapoor GS, Sehgal S. Diagnostic efficacy of polymerase chain reaction in granulomatous uveitis. Tuber Lung Dis 1999; 79:229-33.|
|13||Gupta V, Aggarwal A, Gupta A, Bambery P, Narang S. Clinical characteristics of serpiginous choroidopathy in North India. Am J Ophthalmol 2002; 134:47-56.|
|14||Gupta V, Gupta A, Arora SK, Bambery P, Dogra MR, Aggarwal A. Presumed Tubercular Serpiginous Chorioditis. Ophthalomolgy 2003;110:1747-52.|