Year : 1995 | Volume
: 43 | Issue : 3 | Page : 117--121
Pattern of uveitis in a referral uveitis clinic in India
Debashis Das, Jyotirmay Biswas, Sudha K Ganesh
From Medical Research Foundation, Madras, India
From Medical Research Foundation, Madras
The pattern of uveitis changes over time with the emergence or identification of new uveitic entities. The aim of this prospective study was to obtain a correct incidence pattern and aetiology of uveitis cases seen in a uveitis clinic. We studied all new uveitic cases seen in a-one year period. A standard clinical protocol was followed for each case. Of the 465 new uveitic cases, anterior uveitis was most commonly encountered (170 cases, 36.5%), followed by posterior uveitis (132 cases, 28.4%), intermediate uveitis (92 cases, 19.8%) and panuveitis (71 cases, 15.3%). The aetiology remained undetermined in majority of the cases (58.7%): anterior uveitis (48.8%), posterior uveitis (45.45%), panuveitis (53.52%). The most common cause was collagen disease (29.4%) in anterior uveitis; toxoplasmosis (30.3%) in posterior uveitis; and Vogt-Koyanagi Harada«SQ»s disease (25.35%) in panuveitis.
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Das D, Biswas J, Ganesh SK. Pattern of uveitis in a referral uveitis clinic in India.Indian J Ophthalmol 1995;43:117-121
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Das D, Biswas J, Ganesh SK. Pattern of uveitis in a referral uveitis clinic in India. Indian J Ophthalmol [serial online] 1995 [cited 2022 Jan 22 ];43:117-121
Available from: https://www.ijo.in/text.asp?1995/43/3/117/25283
The pattern of uveitis is influenced by several demographic and ethnic factors. It further changes over time with the emergence or identification of new uveitic entities. Till date, there is no report in the literature on the pattern of uveitis in India.
To identify the pattern of uveitis in a referral uveitis clinic, we undertook a prospective study of all cases of uveitis seen at our institute between January and December 1992, using a standard protocol and compared the results with the pattern of uveitis in other countries.
The aims of our study was fourfold, namely, to obtain a correct incidence pattern of uveitis; (2) to understand the aetiology of the pathological process; (3) to identify different causes and syndromes causing uveitis; (4) to compare the pattern of uveitis in India with that of others.
MATERIALS AND METHODS
Four hundred sixty-five new cases of uveitis were included in this prospective study conducted in our uveitis clinic between January and December 1992. Patients with endophthalmitis and Eales' disease were excluded from the study. A standard clinical proforma was filled in all cases for analytical study which included salient points in history, clinical findings, ancillary tests (e.g., ultrasonography and fluorescein fundus angiography (FFA), tailored laboratory investigations, anatomic type of uveitis, stage of the disease and the final aetiology. All patients underwent indirect ophthalmoscopy with scleral depression after dilatation. All patients were examined by one of us (JB).
An anatomical diagnosis of uveitis was made in all cases as follows:
Anterior uveitis group: Patients with iritis or iridocyclitis without involvement of the vitreous body.
Intermediate uveitis group: Patients with predominant inflammation of the vitreous humour involving the pars plana region.
Posterior uveitis group: Patients with choroiditis or chorioretinitis. Further classification was made according to the location and other characteristic features.
Panuveitis group: Patients with inflammatory findings in both anterior and posterior segments including inflammation of the vitreous body.
A short differential diagnosis was made in each case. Subsequently, a tailored laboratory investigation was carried out as per the scheme outlined by Smith and Nozik. Investigations included total and differential counts, erythrocyte sedimentation rate, urine and stool examination, Mantoux test, serum angiotensin converting enzyme, serum lysozyme, serum calcium and phosphorus, enzyme-linked immunosorbent assay (ELISA) for toxoplasmosis, toxocariasis and human immunodeficiency virus (HIV). ELISA for HIV was done in 12 selected cases of choroiditis and retinitis. Human leucocyte antigen assay (HLA B27, HLA B5, HLA B7, HLA B51, HLA A25) was done to support the diagnosis: HLA B27 in 123 cases of anterior uveitis; HLA B5 in 5 cases of retinal vasculitis; HLA A25 in 3 cases, and HLA B7 in one case of presumed ocular histoplasmosis; and HLA B51 in one case of Behcet's disease. Anterior chamber tap was done in cases of hypopyon uveitis or recalcitrant anterior uveitis to rule out endophthalmitis. Radiological investigations included skigram of chest (sarcoidosis and tuberculosis); lumbosacral joint (ankylosing spondylitis); and knee joints (juvenile rheumatoid arthritis). Consultation was done with medical specialist as well as specialist in rheumatology and pulmonary diseases, whenever needed. Tubercular uveitis was diagnosed only when anterior chamber tap showed acid-fast bacilli on direct examination or on culture. The diagnosis of tuberculoma was based on evidence of pulmonary tuberculosis and characteristic clinical picture.
A diagnosis of intraocular lens (IOL)-induced uveitis was considered in those cases where inflammation persisted despite 2 weeks of standard postoperative regimen with topical steroids and mydriatic-cycloplegic drops. All of these cases had signs of extensive anterior segment inflammation, e.g., multiple keratic precipitates, exudates in the anterior chamber, extensive posterior synechiae or multiple pigment deposits on the IOL surface. In all cases of retinal vasculitis, Eales' disease was carefully ruled out by careful ophthalmoscopy. All cases of retinal vasculitis underwent laboratory investigations to rule out sarcoidosis, Behcet's disease, syphilis, tuberculosis and collagen diseases. The final aetiological diagnosis was made based on the clinical features, laboratory investigations and systemic evaluation by medical specialists.
Four hundred sixty-five new cases of uveitis were seen in 1992 amounting to 1.8% of all new ophthalmic patients examined in this period in this institute. Anterior uveitis was the most common anatomic type of uveitis encountered (170 cases, 36.5%), followed by posterior uveitis (132 cases, 28.4%), intermediate uveitis (92 cases, 19.8%), and panuveitis (71 cases, 15.3%).
Uveitis was seen most commonly in the 30 to 39 year old age group. It was less common in children below 10 years (2.36%) and in patients over 60 years of age (7.74%). Males (299 cases, 64%) were predominantly affected in the present study in comparison to females (166 cases, 36%).
The tailored laboratory investigations enable d specific diagnosis in 192 cases (41.3%). Specific diagnosis was possible more in posterior uveitis (54.5%) than in other anatomic types of uveitis.
In anterior uveitis, specific diagnosis was arrived at in 87 cases (51.2%). Collagen disorder was found to be the most common association of anterior uveitis (29.4%) [Table:1]. HLA B27 positivity was seen in 14.5% of idiopathic anterior uveitis. The underlying collagen disease was identified as systemic lupus erythematosus in 11 cases, juvenile rheumatoid arthritis in 7 cases, ankylosing spondylitis in 5 cases and nonspecific collagen disorder in 25 cases.
In posterior uveitis, specific diagnosis was made in 72 cases (54.5%), the remaining 60 cases being idiopathic choroiditis (43.9%) and idiopathic vasculitis (1.51%) [Table:2]. Eales' disease was ruled out in cases of idiopathic vasculitis. The most commonly diagnosed cause of posterior uveitis was toxoplasmosis (40 cases, 30.3%).
Of all the different types of choroiditis, active or healed, the most common variety of choroiditis was multifocal type (30 cases, 52-63%), followed by central choroiditis (16 cases, 28.07%) and single focal choroiditis (4 cases, 7.02%).
In panuveitis, specific diagnosis was made in 33 cases (45.8%), and the remaining 38 cases were idiopathic. The most common cause of panuveitis was Vogt-Koyanagi-Harada disease (18 cases, 25.4%). Sympathetic ophthalmia, lens-induced panuveitis and Behcet's syndrome were found to be rare in our series [Table:3].
Prospective epidemiologic studies are extremely difficult to organise as it is not easy to make valid comparisons between uveitis statistics from different countries. In each community, the pattern of uveitis is dependent upon multifactorial aspects of life and, the demographic and ethnic factors prevalent during that period. These determine a definite geographical distribution of the pattern of uveitis. Our study results were compared with the United States and Italian studies. The details of these comparisons are shown in [Table:4] to [Table:7].
As Perkins and Folk have observed, there is limitation of making valid comparisons between uveitis statistics of different countries, due to different diagnostic criterion and concept of aetiopathogenesis. It is well known that certain forms of uveitis have a definite geographical distribution. Studies on the incidence of uveitis in a country are important to enable rational investigation and management. Male preponderance (64%) and higher incidence of anterior uveitis (36.5%) was striking in our study. This was contrary to reports from Japan and Argentina.
Although intermediate uveitis (19.8%) was one of the commonly diagnosed forms of uveitis in our study, the majority of these entities eluded any specific aetiological diagnosis. Our results are close to Henderly et al (intermediate uveitis, 15.4%) and not as low as that reported by Perkins and Folk (4.6%), Schlaegel (4.6%) and Palmares et al (4.0%).
The most commonly diagnosed cause of posterior uveitis was toxoplasmosis. This is in concordance with other epidemiologic studies as depicted in our comparative analysis.,,
VKH disease is the most commonly diagnosed cause of panuveitis. VKH disease is also the leading cause of panuveitis in both the US-based and Argentina-based studies. Japan- and Mediterranean region-based studies, however, have Behcet's syndrome as the commonest cause of panuveitis.
In majority of the uveitis cases, the aetiology remained undetermined despite modern laboratory investigations and ancillary tests like ultrasonography and fundus fluorescein angiography. In our study, specific diagnosis was arrived at in only 192 cases (41.3%). In a similar study in north Portugal and Japan specific diagnosis could not be arrived in 48.5% and 49% cases, respectively.
The aetiological pattern of uveitis keeps changing over time. It was tuberculosis in the forties, autoimmune activities (Behcet's disease, sympathetic ophthalmia, juvenile rheumatoid arthritis) in the late sixties and specific infections (Yersinia and Borrelia) in the eighties.
Intraocular lens implantation has become popular in the last two decades. Mild intraocular inflammation is common following IOL implantation. In our series this entity accounted for 3.9% of all uveitic cases and 10.6% of all cases of anterior uveitis. This inflammation is often related to surgical manipulations and occurs as a result of transient breakdown of blood-ocular barrier. Majority of cases respond to the routine postoperative regimen of topical steroids and do not cause any significant problem. However, sometimes complications related to excessive surgical manipulations or hypersensitivity to lens protein following extracapsular cataract extraction or mechanical damage caused by the IOL can induce a recalcitrant uveitis. This new form of uveitis has emerged in the last decade due to switching over from intracapsular to extracapsular cataract extraction and IOL implantation.
Apart from intraocular lens-induced uveitis, newer uveitic entities have also emerged over the last decade. They are better called as 'subentities' with the names - Birdshot, APMPPE, MEWDS, ARN, etc., but the aetiopathogenesis remains obscure in most of them. Our study revealed one case each of birdshot retinochoroidopathy and acute retinal necrosis, respectively.
The patient of birdshot retinochoroidopathy presented with bilateral progressive visual impairment and floaters. Indirect ophthalmoscopy revealed multiple depigmented oval to round shaped lesions, at the level of the retinal pigment epithelium and choroid [Figure:1]. The lesions were less than a quarter of a disc diameter. There was no reactive hyperpigmentation.
Acute retinal necrosis (ARN) was seen in a 50-year-old woman who presented with pain and redness in the right eye of 20 days' duration. Visual acuity in the affected eye was counting fingers at 2 meters. Slit-lamp examination revealed fine to medium pigmented keratic precipitates with aqueous flare. Indirect ophthalmoscopy revealed mild vitreous haze, pallor of the optic disc with blurring of the margin, and patchy areas of necrotising retinitis [Figure:2]. Anti-CMV antibody was detected in the serum of this patient.
In such studies limitations are bound to exist. The study institute being a tertiary referral centre, more patients with posterior uveitis and panuveitis could have been referred and hence the total incidence quoted may not truly reflect the actual incidence in the population. Though majority of these patients (80%) were referred from various other states of the country, a very large segment came from eastern India. Despite these limitations, our results still convey, to a large extent, the general uveitis pattern in India.
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