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ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 9-14

Pattern of uveitis in general Ophthalmology practice


1 Department of Ophthalmology, Shri Dharmasthala Manjunatheshwara University, Shri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital, Dharwad, Karnataka, India
2 Department of Vitreo-Retina, LV Prasad Eye Institute, Hyderabad, Telangana, India

Date of Submission07-Jan-2020
Date of Decision29-Apr-2021
Date of Acceptance17-May-2021
Date of Web Publication3-Feb-2022

Correspondence Address:
Charushila V Gajapati
81, Rajaji Nagar, Sattur, Dharwad-580 009, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_5_21

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  Abstract 


Aim: The aim of this study is to describe the pattern of uveitis in a General Ophthalmology Clinic in North Karnataka. Materials and Methods: Case records of uveitis seen from June 2015 to December 2019 were reviewed retrospectively. Data regarding the patients' age, sex, anatomical location of the disease, and etiology were analyzed. Results: A total of 119 records were reviewed. The mean age at the presentation was 40.4 years with a male preponderance. The majority of unilateral cases had anterior uveitis. We could establish a specific diagnosis in 63.9% of cases. The most common noninfectious etiology was spondyloarthropathy causing anterior uveitis (19.3%) and tuberculosis causing posterior uveitis is the most common form of infective etiology (12.9%). Conclusion: Our study revealed that anterior uveitis of noninfectious etiology is more frequently encountered by general/comprehensive ophthalmologists. In our region, the most common cause of anterior uveitis was spondyloarthropathy, whereas infectious etiology must be considered in posterior uveitis, and the most common etiology in our region was tuberculosis.

Keywords: Endophthalmitis, general ophthalmology, general practice, panuveitis, pattern, spondyloarthropathy


How to cite this article:
Gajapati CV, Shetty AB, Pooja K V. Pattern of uveitis in general Ophthalmology practice. J Clin Ophthalmol Res 2022;10:9-14

How to cite this URL:
Gajapati CV, Shetty AB, Pooja K V. Pattern of uveitis in general Ophthalmology practice. J Clin Ophthalmol Res [serial online] 2022 [cited 2022 Aug 11];10:9-14. Available from: https://www.jcor.in/text.asp?2022/10/1/9/337194



Uveitis is a potentially sight-threatening condition affecting the worldwide population. It is an inflammation of uveal tissue along with surrounding structures such as the vitreous, retina, and optic nerve. Uveitis is responsible for almost 5%–10% of the visual impairments worldwide.[1] The diagnosis of uveitis is challenging as a variety of both ocular and systemic signs and symptoms are vast. Despite advanced diagnostic tests, a large number of cases remains idiopathic. The pattern of uveitis keeps changing due to multiple factors including geographic, ethnicity, genetic predisposition, environment, and demographic factors.[2]

The literature provides many reports globally on epidemiology and pattern of uveitis. Understanding the demographic and clinical patterns of uveitis in different geographic areas will prevent unnecessary laboratory investigations and wastage of valuable and limited resources as well as an economic burden on the patient. This also would help the treating ophthalmologist in better tailoring the set of investigations in that particular region. Most of the literature provides reports from referral centers or tertiary eye care centers, and therefore, they cannot reflect the true nature of distribution in the population.[3],[4] The pattern of etiology of any disease keeps changing in a given population; can be an important health indication.[5] Therefore, knowledge of epidemiology is important to help the clinicians in narrowing down the various possibilities of differential diagnosis and investigations.[6]

We planned a retrospective analysis of cases of uveitis seen in the general ophthalmology clinic of a teaching hospital. We aim to describe the epidemiological pattern of uveitis and the associated systemic conditions encountered in the general ophthalmology practice.


  Materials and Methods Top


A retrospective analysis of the clinical records of patients diagnosed with uveitis in our general ophthalmology outpatient department from June 2015 to December 2019 was done. The institutional ethics board approved data collection and study complied with the tenets of the declaration of Helsinki. Demographic data and clinical history of all the patients were reviewed.

Patients who did not have adequate records to classify anatomically or etiologically, patients of postoperative uveitis, postoperative endophthalmitis, pan ophthalmitis, and corneal graft rejection and scleritis have been excluded from the study.

Diagnosis of uveitis was based on comprehensive and extensive systemic examination including ocular and systemic history. Complete ophthalmic examination findings were noted in all cases, including best-corrected Snellen visual acuity, slit-lamp examination, applanation tonometry, and dilated fundus examination with 78D lens and indirect ophthalmoscopy wherever possible. Cases of uveitis were classified according to standardized uveitis nomenclature criteria based on anatomic site of inflammation, namely anterior uveitis, intermediate uveitis, posterior uveitis, and panuveitis.[7]

Fluorescein angiography, visual field testing, and ocular ultrasonography were undertaken in the patients with posterior segment involvement where indicated. A primary set of investigations ordered keeping differential diagnosis in mind and included complete blood count, erythrocyte sedimentation rate, chest and sacroiliac joint X-ray, Mantoux test, C-reactive proteins, and urine routine analysis was done in every patient. Other relevant investigations were done based on symptoms, like antinuclear antibody, RA factor (rheumatoid arthritis), c-ANCA, p-ANCA (anti-neutrophil cytoplasmic antibodies), human leukocyte antigen B27 (HLA B27), computerized tomography of the chest, QuantiFERON TB gold test for tuberculosis for Mantoux positive patients, venereal disease laboratory test for syphilis, enzyme-linked immunosorbent assay for toxoplasma (immunoglobulin IgG and IgM), human immunodeficiency virus, serum angiotensin-converting enzyme, serum calcium, and polymerase chain reaction of aqueous humor for tuberculosis.

After pursuing all specific investigations, patients were referred to a rheumatologist, hematologist, and pulmonologist depending on the requirements. The cases, in which no specific diagnosis could be arrived at, despite all the possible investigations and cross-reference, were labeled as idiopathic.


  Results Top


Medical records of 123 patients were analyzed retrospectively. The total number of patients who attended the ophthalmology department of our hospital during the study period was 109,122. We excluded 4 patients, out of which 2 had posterior synechiae (1 male and 1 female) and two patients with vitreous hemorrhage (30/M and 19/M with no other systemic comorbidities). No documents could be traced to confirm the type and etiology of uveitis in these patients.

We picked up 119 patients with uveitis among them which 67 (56.9%) were male and the rest 52 (43.1%) were female. The male-to-female ratio was 1.3:1. The mean age at presentation was 40.46 years, ranging from 13 to 76 years. The commonly affected age group was 20–65 years – 97 cases (81.5%). Cases <20 years of age were 9 (7.6%) and more than 60 years of age were 13 (10.9%).

The unilateral presentation was seen in 81 (67.2%) cases. Anterior uveitis was seen in 45 (38.8%) cases from this group. The bilateral presentation was seen in 38 (32.7%) cases mainly of posterior uveitis followed by pan and intermediate uveitis [Table 1].
Table 1: Demographic details of the study population

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Anatomically, anterior uveitis was seen, most commonly in 62 (52.1%) cases, followed by posterior uveitis in 34 (28.6%), panuveitis in 19 (15.9%), and intermediate uveitis in 4 (3.4%) cases. In anterior uveitis, the specific diagnosis could be achieved in 35 patients (56.5%), whereas 27 (43.5%) turned out to be idiopathic. The most common cause of anterior uveitis was spondyloarthropathy (11 cases; 17.7%). Six cases (9.8%) had HLA B27 association, followed by trauma-related anterior uveitis in 5 (8.1%) patients [Table 2]. Infectious anterior uveitis was seen infrequently. Out of 6 cases, the most common cause was tuberculosis (3 cases) followed by herpetic uveitis (2 cases).
Table 2: Etiology of uveitis according to the location of five diseases

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Among 34 cases (28.6%) of posterior uveitis, the specific diagnosis could be achieved in 27 cases (79.4%), tuberculosis being the most common cause detected in 10 (29.4%) cases. They presented either as multifocal choroiditis or retinal vasculitis, four had toxoplasmosis and four were postviral etiology. We detected posterior uveitis in two cases of typhoid who presented after 1 week of being Widal-positive and one case of dengue-positive.

Panuveitis was seen in 19 (15.9%) cases, most of which were idiopathic 8 (42.1%) and the rest had infectious etiology like endophthalmitis (endogenous in two and traumatic in two cases). Intermediate uveitis was seen in four cases, out of which 2 were idiopathic, one was a case of juvenile rheumatoid arthritis, and one was tuberculosis. In our series of 119 patients, 87 (73.1%) were due to a noninfectious etiology, among whom 43 (36.1%) were idiopathic. Infectious etiology could be revealed in 32 (26.9%) cases, the most common cause being tuberculosis (11.7%) followed by viral, predominantly herpes virus, and toxoplasmosis [Table 3].
Table 3: Etiology of uveitis and diseases associated with uveitis

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  Discussion Top


Uveitis is a complex, sight-threatening disease if left untreated. The diagnosis of uveitis is still an enigma.[2] Most of the reports in the literature are from tertiary eye care centers, they might bear referral bias.[3],[4]

Tertiary care centers and exclusive uvea clinics are usually located in urban and metro cities. The patients here are usually referred from every corner of the country.[4] Therefore, the incidence and prevalence of uveitis patterns in these centers do not represent that geographic region. Majority of the Indian population resides in the semi-urban and rural regions devoid of tertiary uvea clinics compelling the patients to approach general ophthalmology clinics where ophthalmologists follow tertiary uvea clinic data to order the set of investigations. Hence, it is very important to have region-specific uveitis pattern data to help the treating ophthalmologists of that region to order judiciously optimized investigations to patients with limited resources.

Since our hospital is multispecialty, we had the unique opportunity to seek expert opinion from the departments such as rheumatology, hematology, and pulmonology. This helped us to identify specific etiology in a good number of cases (63.7%) reducing the number of cases ascribed to the “idiopathic” group (36.1%).

In our study, the mean age at presentation was 40.4 years and the most affected age group was 20–50 years[2],[5],[6] and M: F ratio was 1.3:1. Studies from developed countries show marginal female preponderance,[8],[9] whereas Indian studies have reported slight male preponderance.[10] According to Consul et al., men tend to seek medical attention more often than women in agricultural societies and the prevailing social practice in India might have reflected in our trend.[11]

The incidence of unilateral cases is higher than bilateral cases in our study which is similar to other reports.[10],[12] Unilateral involvement was the highest in anterior uveitis, whereas bilateral involvement was seen mostly in posterior and panuveitis.[2],[8],[9]

According to Lee et al., noninfectious and milder forms of uveitis are more commonly seen in general practice than referral.[13]

In the present study, anterior uveitis (52.1%) was the most common form of uveitis, followed by posterior uveitis (28.6%), panuveitis (15.9%), and intermediate uveitis (3.4%).[5],[6],[12] Reports from Central India and Western India show the highest number of cases of panuveitis (21.2%) and intermediate uveitis (31.9%), respectively, followed by anterior uveitis.[10],[14] Developed countries such as the USA show the highest number of cases of posterior uveitis, whereas studies from Singapore, Iran, and Japan reported panuveitis cases as the highest in number.[3],[4],[8],[15]

We found four cases of intermediate uveitis. Asymptomatic nature of the disease which causes delayed presentation might be the cause of pars planitis commonly detected in referral clinics.[3]

Among anterior uveitis subjects, a cause could be identified in 56.5%. Comparable proportion was reported in various studies such as Singapore – 50.4%, North Africa – 35.5%, Western India – 53.7%, Central India – 37.4%, and North India – 41.5% [Table 4].[4],[9],[11],[14],[16] Out of 9.7% infectious causes of anterior uveitis, majority of patients had tuberculosis (4.8%) and herpetic infection (3.2%). Studies from Singapore, North Africa, and Japan have reported that herpetic iridocyclitis is the most common observation.[4],[9],[15]
Table 4: Etiologic pattern of uveitis in different regions of India

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Specific etiology of posterior uveitis could be sought in 79.4% of cases. In our series, the most common cause was tuberculosis (29.4%) presented as multifocal choroiditis or retinal vasculitis. Singh et al. reported a common presentation of tuberculosis as serpiginous choroiditis (25.1%).[16] Other reported causes were leptospirosis, toxoplasmosis, and retroviral disease.[2],[5],[14]

We encountered one case of dengue fever presenting after 3 days of fever with the blurring of vision showing due to retinal vasculitis and the other case presented as panuveitis. Yudhishdran et al. reported a case of dengue in a South Asian young woman with serous retinopathy and retinal hemorrhages at the posterior pole.[17] We saw two cases of typhoid fever presenting with vitritis, macular edema, following 1 week of Widal positivity. One case had chorioretinitis and vasculitis noted in the other case. A similar case has been reported by Levinson et al.[18] We need to consider these two in the differential diagnosis in a case of intraocular inflammation followed by fever.

The cause could be identified in 57.9% of panuveitis cases. The most common cause was endophthalmitis. Out of 19 (16.4%) cases of panuveitis, four had endophthalmitis (two endogenous and two trauma related). Reports from South Korea, Japan, and Myanmar are suggestive of endophthalmitis as the most common form of panuveitis.[13],[15],[19]

The majority of infective causes found in the posterior (29.4%) and panuveitis (10.5%) were tuberculosis. We found two cases of leprosy one presenting as anterior uveitis and one as panuveitis. Studies from Central and Western India too found cases of leprosy.[11],[14]

The most common etiology was of noninfectious type in (44/119; 36.9%) related to various conditions such as spondyloarthropathy (ankylosing spondylitis, sacroiliitis, HLA B27, and inflammatory bowel disease) in 17 cases (38.6%). Some of these cases had two conditions together like HLA B27 and ulcerative colitis or ankylosing spondylitis. One case of tuberculosis was positive for HLA B27. Juvenile rheumatoid arthritis (3.2%) presented as anterior uveitis and one case each posterior and intermediate uveitis. Spondyloarthropathy is most prevailing cause of uveitis in Indian sub-continent and few Western countries [Table 4].[3],[5],[6],[10],[14],[16],[19],[20],[21]

Other reported noninfectious cause of anterior uveitis was Fuch's hetero chromic uveitis.[2],[12] Panuveitis caused by Vogt-Koyanagi-Harada's disease, Behcet's disease, and sarcoidosis too reported in the literature, these causes found very infrequently in our participants.[8],[9],[14]

The limitation of our study is retrospective nature and hospital-based design which cannot represent the entire population.


  Conclusion Top


The incidence of unilateral anterior uveitis is more in general ophthalmology practice. Spondyloarthropathy is the most common noninfective cause of uveitis. It needs extensive systemic workup and immunomodulation therapy. Hence, HLA B27 typing and rheumatologist opinion are important. Typhoid and dengue are the emerging infections causing posterior uveitis and they deserve more attention.

Acknowledgment

We sincerely thank Dr. R D Kulkarni, HOD Microbiology, SDM medical college Dharwad, for the constant support and suggestions offered throughout this work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



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



 

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