Changing patterns of intraocular inflammatory disease in Japan

Demographic and Clinical Characteristics of Uveitis for Adult Patients Attending Mansoura Ophthalmic Center

AIM

The aim of this research is to evaluate the demographic attributes and clinical manifestations of uveitis in adult patients frequenting the Mansoura Ophthalmic Center.

METHODS

Utilizing a cross-sectional, prospective, analytical study design, this research engaged adult patients visiting the outpatient uveitis clinic at the Mansoura Ophthalmic Center. Comprehensive case evaluations involved collecting detailed patient histories, examining ophthalmic records, and conducting thorough ocular examinations. These examinations encompassed the assessment of visual acuity, slit-lamp examination, and fundus examination. Furthermore, selected cases underwent optical coherence tomography (OCT) and fundus fluorescein angiography (FFA).

RESULTS

The Study involved an examination of 411 eyes belonging to 254 uveitic patients. In the Egyptian context, anterior uveitis surfaced as the most prevalent form of uveitis. The average Best-Corrected Visual Acuity (BCVA) among the cases studied was 0.797 ± 0.77 LogMAR, with the majority of cases demonstrating vision superior to 0.3 LogMAR. Notably, the principal causes of vision loss were generally reversible. Macular edema was identified as the leading cause of vision loss, representing 20.7% of cases as evidenced by OCT. The ratio of non-infectious to infectious uveitis stood at 92.2% to 7.8%. The most commonly observed etiologies of non-infectious uveitis included Behçet's disease (33.3%), Vogt-Koyanagi-Harada (VKH) syndrome (19.7%), idiopathic causes (19.2%), and ankylosing spondylitis (AS) (11.9%). Conversely, the most frequent infectious etiologies were trematode-induced uveitis (2.9%), herpetic uveitis (1.7%), toxoplasmosis (1.5%), tuberculosis (TB) (1.5%), and brucellosis (0.2%).

CONCLUSIONS

This study conclusively indicates that anterior uveitis is the predominant anatomical type of uveitis in Egypt. Further, etiological diagnoses of uveitis should particularly emphasize Behçet's disease, VKH syndrome, and ankylosing spondylitis.

A Comparison of Adult and Juvenile Behcet Patients and a Look at Clinical Trends: Retrospective Data from a Turkish Follow-Up Cohort Study

BACKGROUND

Previous reports indicate that juvenile Behçet's disease (BD) may have a different course than adult BD. However, as a direct comparison with adult Behçet patients has only been made in a limited number of studies, the issue is still controversial.

OBJECTIVES

The primary aim of our study was to compare clinical manifestations in a large cohort of juvenile and adult Behçet patients registered in a single centre. The secondary aim of our study was to compare the data of newly diagnosed patients registered between 1998 and 2020 with the data of those registered between 1976 and 1997.

METHODS

Data were collected retrospectively from medical records of patients registered between 1998 and 2020. Juvenile BD was defined as fulfilment of International Criteria for Behçet's Disease at or before 16 years of age.

RESULTS

A similar course of disease was noted in juvenile and adult Behçet patients with no significant difference in the frequency of mucocutaneous findings, major organ involvement, and positivity of the pathergy test. A comparison of the periods, 1976-1997 and 1998-2020, revealed no significant difference in the prevalence of mucocutaneous lesions and major organ involvement.

CONCLUSIONS

Our results indicate that juvenile and adult Behçet patients have a similar course with a similar frequency of clinical manifestations. Contrary to reports suggesting an overall tendency to milder disease over time, no decrease in the risk of major organ involvements was observed. A significant trend towards a decline in pathergy test positivity was noted.

The large Hellenic Study of Uveitis: epidemiology, etiologic factors and classification

PURPOSE

To analyse the demography, etiology, and classification of uveitis at a tertiary academic referral center.

METHODS

An observational study was conducted on the archives of uveitic patients at the Ocular Inflammation Service of the Department of Ophthalmology at the University Hospital of Ioannina (Greece) from 1991 to 2020. This study aimed to investigate the epidemiological profile of patients, including their demographics and the main etiologic factors of uveitis.

RESULTS

Out of 6191 cases with uveitis, 1925 were infectious, 4125 were non-infectious, and an overall of 141 masquerade syndromes were recorded. Among these cases, 5950 patients were adults, with a slight female predominance, while 241 were children (< 18 years old). Interestingly, 24.2% of cases (1500 patients) were associated with 4 specific microorganisms. Herpetic uveitis (HSV-1 and VZV/HZV) was the most common cause of infectious uveitis (14.87%), followed by toxoplasmosis (6.6%) and tuberculosis (2.74%). In 49.2% of non-infectious uveitis cases, no systematic correlation was found. The most frequent causes of non-infectious uveitis included sarcoidosis, white dot syndromes, ankylosing spondylitis, lens-induced uveitis, Adamantiades-Behçet disease, and idiopathic juvenile arthritis. Infectious uveitis was more common in the rural population, whereas non-infectious uveitis was more frequently recorded in the urban population CONCLUSIONS: Although our study was conducted on a predominantly white Caucasian population, it also reflects the effect of increasing immigration, improvements of diagnostic techniques, changes in referral patterns, and various actual changes in disease incidence.

A COVID-19 perspective of Vogt-Koyanagi-Harada disease

Vogt-Koyanagi-Harada (VKH) disease, a bilateral granulomatous panuveitis associated with multisystem involvement, is a T-cell-mediated autoimmune disorder in which cytotoxic T-cell target melanocytes in genetically susceptible individuals. Recently, there has been an increase in literature on the new onset of uveitis and reactivation of previously diagnosed cases of uveitis following Covid-19 vaccinations. It has been postulated that Covid-19 vaccines can lead to an immunomodulatory change resulting in an autoimmune phenomenon in the recipients. VKH following COVID-19 infection was reported in four patients and a total of 46 patients developing VKH or VKH-like disease following COVID-19 vaccinations. There are reports of four patients who had been recovering or recovered from VKH after receiving the first dosage of the vaccine and developed worsening of ocular inflammation after receiving the second dose of the vaccine.

Diagnosis of tuberculous uveitis by the macrogenome of intraocular fluid: A case report and review of the literature

BACKGROUND

Tuberculous uveitis caused by tuberculosis infection factors is common, but tuberculous uveitis caused by Mycobacterium tuberculosis found in the intraocular fluid is rare. This report describes the use of intraocular fluid in the diagnosis of tuberculous uveitis in a patient and reviews the relevant literature.

CASE SUMMARY

A 24-year-old woman who was 31-wk pregnant visited Hebei Chest Hospital due to intermittent chest pain, fever, and decreased vision for 3 mo. The hydrothorax test suggested “tuberculous pleurisy”, and yellow effusion was extracted from the chest tube twice resulting in a total volume of approximately 800 mL. The patient chose to continue the pregnancy without treatment, and was hospitalized again due to high fever. Following 2 mo of anti-tuberculosis treatment, a healthy boy was delivered by cesarean section. Tuberculous uveitis was diagnosed using tuberculosis Xpert, and intraocular infection was detected by second-generation gene sequencing. Following systemic treatment, the patient gradually improved, and the corrected visual acuity of the left eye gradually increased from 0.08 to 1.0.

CONCLUSION

The etiology of uveitis is complex, and it is necessary to assess the patient’s general condition and apply molecular biology methods to determine the pathogenesis and guide precise treatment, to improve clinicians’ awareness and standardize treatment of the disease.

Polymerase chain reaction confirmed mycobacterium tuberculosis intermediate uveitis - analysis of 22 eyes of 14 cases from a tertiary care centre in South India: a retrospective study

Background

To report the role of Polymerase Chain Reaction in confirming the diagnosis of presumed Mycobacterium Tuberculosis (MTB) Intermediate Uveitis.

Method

Retrospective analysis of 22 eyes of 14 cases of presumed tubercular intermediate uveitis wherein intraocular fluid was tested for MTB DNA by Nested & Real-time PCR, based on clinical suspicion of tubercular aetiology. QuantiFERON TB gold test and High-Resolution CT Chest were done. Patients were treated with anti-tubercular therapy with oral steroids & immunomodulators. In the study, eleven were male (79%) and three female (21%). The median age was 34 years. Nested PCR for both IS 6110 & MPB 64 was positive in 64% of the cases, IS 6110 positive in 23% and MPB 64 positive in 15%. Real-time PCR was positive in 48% of the cases. Vision improved in 33% of cases, maintained in 57%, and worsened in 10% of cases.

Conclusion

Presumed Tubercular intermediate uveitis can be confirmed by PCR of intraocular fluids. Anti-tubercular therapy with immunosuppression can improve vision and prevent recurrences in such cases.

The Historical Evolution of Ocular Tuberculosis: Past, Present, and Future

Ocular involvement is a rare manifestation of tuberculosis. Four key issues historically faced by clinicians when diagnosing and treating ocular tuberculosis - diagnostic uncertainty, naturally heterogeneous presentations, limitations of existing laboratory diagnostic tools, and non-uniform treatment guidelines - continue to test today's physicians. Unparalleled scientific and clinical developments over the past century have greatly expanded the knowledge surrounding this challenging ophthalmic condition. Experience with large volumes of cases at tuberculosis-endemic centres has led to recent growth in knowledge and physician experience, perhaps more so in developing countries. Looking forward, the role of diverse new technologies, including artificial intelligence and proteomics, will advance ocular tuberculosis research. Efforts have been made to address the lack of standardized nomenclature, diagnostic uncertainty, and unvalidated, geographically variable treatment guidelines.

LV Prasad Eye Institute EyeSmart electronic medical record-based analytics of big data: LEAD-Uveitis Report 1: Demographics and clinical features of uveitis in a multi-tier hospital based network in Southern India

Purpose

To describe the demographics and epidemiology of uveitis presenting to a multi-tier ophthalmology hospital network in Southern India.

Methods

Cross-sectional hospital-based study of 19,352 patients with uveitis presenting between March 2012 and August 2018.

Results

In total, 1,734,272 new patients were seen across the secondary and tertiary centers of our multi-tier ophthalmology hospital network during the study period. Among them, 25,353 eyes of 19,352 patients were diagnosed with uveitis and were included in the study. Uveitis constituted 1.11% of all cases. The majority of patients were male (60.33%) and had unilateral (68.09%) affliction. The most common age group was 21-50 years with 12,204 (63.06%) patients. The most common type of uveitis was anterior uveitis, which was seen in 7380 (38.14%) patients, followed by posterior uveitis in 5397 (23.89%) patients. Among the infectious causes, tuberculosis was the most common etiology (2551 patients, 13%) followed by toxoplasmosis (1147 patients, 6%).

Conclusion

Uveitis constituted 1.11% of all cases presenting to our clinics. It was more common in the age group of 21-50 and was predominantly unilateral. Anterior uveitis was the most common subtype seen in 38%.

Sympathetic Ophthalmia: Where Do We Currently Stand on Treatment Strategies?

Sympathetic ophthalmia is a rare bilateral diffuse granulomatous panuveitis that usually results from surgical or penetrating trauma to one eye. The symptoms range from impaired near vision to pain, photophobia, and loss of visual acuity. Anterior segment manifestations include bilateral acute uveitis with mutton-fat keratic precipitates and posterior segment findings include vitritis, multifocal neurosensory retinal detachment, choroiditis, optic nerve edema, and Dalen-Fuchs nodules. The diagnosis is clinical. Ancillary investigations include fundus fluorescein angiography, indocyanine green angiography, optical coherence tomography (OCT), ultrasound B scan, and autofluorescence imaging. The management options include corticosteroids (topical and systemic) as the first line along with immunomodulatory therapy started at the presentation of the disease. Recent advances include imaging with OCT-angiography, enhanced depth imaging-OCT (EDI-OCT, choroidal vascular index/CVI), targeting IL-23/IL-17 pathway, and use of biologics for the management of this rare entity. Recent advances in early diagnosis and prompt treatment has led to improved final visual outcomes in both the sympathizing and exciting eye. This review is aimed at giving a comprehensive overview of sympathetic ophthalmia along with a special emphasis on current treatment strategies and recent advances.

The Efficacy of Adalimumab as an Initial Treatment in Patients with Behçet's Retinal Vasculitis

Background: No study has evaluated the effectiveness of Adalimumab (ADA) as first-line in treatment-naïve patients with retinal vasculitis due to Behçet’s Uveitis (BU).

Objective: To compare the efficacy of ADA plus conventional therapy and conventional therapy alone as initial treatments in naïve BU patients characterized by retinal vasculitis.

Methods: Medical records of BU patients characterized by retinal vasculitis treated with conventional therapy (CT, refers to glucocorticoid and immunosuppressive agents) alone or ADA plus conventional therapy with at least 6 months of follow-up between February 2015 and June 2020 were analyzed. Only patients who were first diagnosed with BU without previous systemic treatment were reviewed. The retinal vasculitis score based on fluorescein angiography (FA), best-corrected visual acuity, glucocorticoid-sparing effect, the number of relapses and ocular complications were evaluated.

Results: A total of 45 patients (87 eyes) were included. Twenty-four patients (55.33%) in the CT group were treated with conventional therapy and 21 patients (46.67%) in the ADA group were treated with ADA plus conventional therapy. The inflammatory parameters improved in both groups. FA scores showed significantly greater improvement in ADA group than CT group (p < 0.001). The median number of relapses was significantly lower, and the duration of remission was longer in ADA group than CT group (p < 0.001). At the last visit, a significantly better BCVA improvement (p = 0.024), better inflammation control (anterior chamber inflammation p = 0.017 and vitritis p < 0.001) and lower daily glucocorticoid dosage (p = 0.005) were identified in patients received ADA therapy. In CT group, 1 patient suffered hepatitis B and tuberculosis, 1 had growth retardation, 1 patient had with osteoporosis, then followed by other mild AEs (mostly respiratory upper tract infections); while in ADA group, 1 patient experienced a mild pneumonia (n = 1) while milder AEs were represented mostly by respiratory upper tract infections followed by gastrointestinal discomfort.

Conclusion: ADA plus conventional therapy achieved superiority over conventional therapy as initial treatment in naïve BU patients with retinal vasculitis.

Oral Health and Its Aetiological Role in Behçet's Disease

Behçet's disease (BD) is a chronic multi-systemic inflammatory disorder characterised by oro-genital ulcers, cutaneous manifestations, ocular, vascular, neurologic and gastrointestinal involvement. Complex interactions operating on the genetic background e.g.(HLA51), of infectious and other environmental agents, together with immune dysregulation impacts on the pathogenesis of BD. This suggests that the environmental factors triggering immune responses may activate clinical manifestations in genetically susceptible individuals. Since oral health forms the basis of all general health both dental and systemic, it is an important component of both Dentistry and Medicine. Oral ulcers are the most common clinical manifestation of oral mucosal health. Changes in the oral environment consequently acts as an infective and immune trigger. In this review, complex interactions between the oral ulcers, the oral microbiome and immune responses together with the course of oral and systemic disease manifestations in BD are discussed in the context of the aetiologic role of oral health.

Rational laboratory testing in uveitis: A Bayesian analysis

Uveitis encompasses a heterogeneous group of clinical entities with the common feature of intraocular inflammation. In addition to patient history and examination, a focused set of laboratory investigations is frequently necessary to establish a specific diagnosis. There is limited consensus among uveitis specialists regarding appropriate laboratory evaluation for many distinct patient presentations. The appropriateness of a laboratory test for a given case of uveitis will depend on patient-specific as well as epidemiologic factors. Bayesian analysis is a widely used framework for the interpretation of laboratory testing, but is seldom adhered to in clinical practice. Bayes theorem states that the predictive value of a particular laboratory test depends on the sensitivity and specificity of that test, as well as the prevalence of disease in the population being tested. In this review we will summarize the performance of commonly-utilized laboratory tests for uveitis, as well as the prevalence of uveitic diagnoses in different geographic practice settings. We will propose a logical framework for effective laboratory testing in uveitic disease through rigorous application of Bayesian analysis. Finally, we will demonstrate that while many highly sensitive laboratory tests offer an effective means to rule out associated systemic disease, limited test specificity and low pretest probability often preclude the diagnosis of systemic disease association with any high degree of certainty, even in the face of positive testing.

Tuberculous Scleritis and Multidrug Resistance

Purpose: To present a case of necrotizing sclerokeratitis in a patient with multidrug-resistant tuberculosis and study the challenges in diagnosis and management of anterior tuberculous scleritis.Methods: Retrospective observational case report and review of anterior tuberculous scleritis.Results: A 28-year-old woman, previously diagnosed as presumed tubercular panuveitis, presented with necrotizing sclerokeratitis and progressed to develop panophthalmitis. Laboratory investigations revealed multidrug-resistant Mycobacterium tuberculosis as the etiological agent. We reviewed cases of anterior tuberculous scleritis published in the literature, with regards to clinical features, microbiological investigations, treatment, and outcomes. Treatment includes standard antitubercular therapy, with or without systemic corticosteroids. Poor response to treatment is seen either due to delayed diagnosis or drug resistance, and the significance of the same is highlighted in our case.Conclusion: Diagnosis of tuberculous scleritis is a challenge. Therapeutic failure must alert the clinician for drug resistance which is diagnosed early, can prevent the devastating outcomes.

Pattern of Uveitis in Iran: A Systematic Review

PURPOSE

Uveitis is the third leading cause of blindness worldwide. This study aimed to summarize the pattern of uveitis in Iran through a systematic review.

METHODS

This review was conducted according to the guidelines for systematic reviews in the following four steps: literature search, study selection and assessment, inclusion and exclusion criteria, and statistical analysis.

RESULTS

One hundred and fifteen articles were identified by an encyclopedic literature search, and three independent investigators examined them according to the defined inclusion and exclusion criteria. Eventually, 109 manuscripts were retrieved and six cross-sectional studies covering 3,567 patients were included and reviewed. According to the results, the mean age of patients was 40 years, and sex was not a statistically significant predisposing factor. The most common anatomical pattern of involvement was anterior uveitis, and the prevalence of the other three types of uveitis, including middle, posterior, and pan-uveitis, were almost equal. Overall, the most common etiologies of uveitis in the Iranian population were idiopathic uveitis, toxoplasmosis, Behcet's syndrome, and Fuchs heterochromic iridocyclitis.

CONCLUSION

This study depicted the pattern of uveitis in the Iranian society; this can help physicians in the diagnostic approach, management, and treatment of patients.

The Collaborative Ocular Tuberculosis Study (COTS)-1: A Multinational Descriptive Review of Tubercular Uveitis in Paediatric Population

PURPOSE

To examine disease profile of tubercular uveitis (TBU) in Paediatric population.

METHODS

Among 945 patients of the retrospective multinational study by the Collaborative Ocular Tuberculosis Study (COTS)-1, 29 Paediatric patients diagnosed with TBU were analyzed.

RESULTS

Mean age of disease presentation was 12.8 (range 4-18 years), with predominance of males (n = 14/20; 70.0%) and Asian ethnicity (n = 25/29; 86.2%). Posterior uveitis (n = 14/28; 50%) was the most frequent uveitis phenotype, with choroidal involvement occurring in 64.7% (n = 11/17). Incidence of optic disc edema and macular edema was higher in children (n = 8/18; 44.4% and n = 5/18; 27.8%, respectively) than in adults (n = 160/942; 16.9% and n = 135/942; 14.3%, respectively). Comparison of optic disc edema between subgroups showed a significant difference (P =.006). All patients received oral corticosteroids, most of them with antitubercular therapy. Treatment failure developed in 4.8% (n = 1/21).

CONCLUSIONS

Children have a more severe inflammatory response to the disease, and an intensive anti-inflammatory therapeutic regimen is required to achieve a positive treatment outcome.

Analysis of new cases of uveitis at academic and community settings

PURPOSE

Describe the demographics of new patients with uveitis presenting to an urban, academic centre and affiliated, suburban satellite clinics to assess if changes in infrastructure were needed for clinical care. Secondarily, examine the frequency of infectious uveitides.

METHODS

A retrospective chart review of single academic centre of 436 consecutive, new patients with uveitis (686 eyes) and 3 affiliated, satellite clinics seen by 8 uveitis specialists from 1 July 2013 to 31 March 2017. Demographics recorded included patient age, race, associated systemic disease, uveitis chronicity, and anatomic location. The main outcome measure was comparing frequencies of patient demographics, immunosuppressive agent use, and infectious uveitis between locations.

RESULTS

366 patients (587 eyes) were evaluated at the academic clinic and 70 (99 eyes) at the satellite locations. Anterior uveitis was the most common anatomic location; more acute, unilateral cases were seen at satellites (p=0.007; p=0.002, respectively). A larger percentage of posterior and panuveitis cases presented to the academic centre (p<0.0001). There was no difference in systemic disease association (p=0.925) or infectious uveitis cases (p=0.956). The use of non-corticosteroid immunosuppressive medications was higher at the academic clinic (p<0.001).

CONCLUSIONS

Anterior uveitis comprised the majority of cases in both clinics. Non-corticosteroid immunosuppressive agents were used more frequently at the academic clinic, reflecting more cases of chronic posterior and panuveitis. Compounded intravitreal injections, specialised ophthalmic imaging studies and high-risk medication monitoring can be centralised in the academic clinic. Infectious uveitis cases were seen at both locations, with an increase in syphilis diagnoses at the academic centre.

Ocular tuberculosis epidemiology, clinic features and diagnosis: A brief review

The spread of tuberculosis is directly related to the processes of globalization and migration. Tuberculosis has also been the main cause of fatality associated with antimicrobial resistance and also the main cause of death in people who have HIV infection. Additionally, tuberculosis smites the lungs in 80% of patients, and in the remaining 20% of patients the tuberculosis may smites other organs, such as the vision/eye. Ocular tuberculosis is a specific infectious disease of bacterial etiology with a chronic and persistent course, the prognosis of which is extremely doubtful. Even effective chemotherapy can be accompanied by a decrease in visual acuity, and clinical recovery is not always persistent. Ocular tuberculosis often leads to permanent disability and, as a result, the quality of life of patients decreases. A statistical reporting of this disease does not always reflect the true picture, since ocular tuberculosis sometimes develops against the background of an existing specific lesion in the lung tissue. Currently, ocular tuberculosis remains substantially a conjectural clinical diagnosis. This review paper presents an analytical review of the literature on the epidemiology, clinical features, and diagnosis methods of ocular tuberculosis. The results of recent studies that focused on the modern clinical manifestations of this pathology, its diagnosis, and complex therapy are systematized. The development of new rational regimens and pathogenetic treatment methods are also highlighted in this review.

Clinical utility of aqueous humor polymerase chain reaction and serologic testing for suspected infectious uveitis: a single-center retrospective study in South Korea

Background

This study aimed to assess and compare the clinical value of aqueous humor polymerase chain reaction (PCR) and serologic tests in patients diagnosed with suspected infectious uveitis.

Methods

In this retrospective observational study, data of 358 patients who were diagnosed with suspected infectious uveitis and who underwent aqueous humor PCR testing were analyzed. PCR and serologic test results were compared with the clinical features.

Results

The rates of initial diagnoses for infectious uveitis were higher with PCR (99 patients, 28%) compared to those with serologic tests (38 pateints, 11%). The diagnostic positivity of PCR was 29% for anterior uveitis, 0% for intermediate uveitis, 5% for posterior uveitis, and 30% for panuveitis. In particular, PCR was useful in confirming the diagnosis of cytomegalovirus and varicella-zoster virus infections and Toxoplasma gondii-associated uveitis. For PCR test, the sensitivity was 0.431, specificity was 0.985, and the negative and positive predictive values were 0.506 and 0.980, respectively. For IgM test, the sensitivity was 0.151, specificity was 0.970, and the negative and positive predictive values were 0.403 and 0.895, respectively.

Conclusion

Aqueous humor PCR can be a valuable diagnostic tool for confirming the infectious etiology in patients clinically diagnosed with uveitis. PCR had good predictive and diagnostic value for anterior uveitis and panuveitis compared with that for intermediate and posterior uveitis.

Pattern of uveitis in a tertiary eye care center of central India: Results of a prospective patient database over a period of two years

Purpose

To identify the pattern of uveitis at a tertiary eye center in the central India and to compare with other reported studies.

Methods

This prospective observational study was undertaken with all new uveitis cases attending the uvea clinic between January 2016 and September 2017. A standard clinical protocol and detailed investigations were done to find out the specific cause of uveitis.

Results

A total of 210 patients with uveitis were evaluated. Anterior uveitis (47.1%) followed by intermediate uveitis (31.90%) were the most common type of uveitis in this study. Specific etiology of uveitis could be established in a majority of cases of uveitis (51.91%), except in intermediate uveitis group where the cause was mostly idiopathic (77.61%).

Conclusion

Tuberculosis (46.29%) and viral etiology (38.88%) were the most common forms of infective uveitis (25.71%), whereas spondyloarthropathy (27.27%) and traumatic cause (14.54%) were the most common in the noninfective group of uveitis (26.19%).

Macular edema associated with non-infectious uveitis: pathophysiology, etiology, prevalence, impact and management challenges

Macular edema (ME) is the most common sight-threatening complication in uveitis. The diagnostic and therapeutic management of the uveitic macular edema (UME) might be challenging due to the complex diagnostic workup and the difficulties physicians face to find the underlying cause, and due to its usually recurrent nature and the fact that it can be refractory to conventional treatment. Some of the mild cases can be treated with topical steroids, which can be combined with non-steroid anti-inflammatory drugs. However, immunomodulators such as methotrexate, tacrolimus, azathioprine, cyclosporine and mycophenolate mofetil together with anti-tumor necrosis factor-α (anti-TNF alpha) monoclonal antibodies such as adalimumab and infliximab, may be required to control the inflammation and the associated ME in refractory cases, or when an underlying disease is present. This review of the literature will focus mostly on the non-infectious UME.

Clinical Profile and Treatment Response of Patients with Ocular Inflammation due to Presumed Ocular Tuberculosis: A Retrospective Study

Objectives:

Ocular tuberculosis is an extrapulmonary tuberculous infection and has varying manifestations which pose a huge challenge to diagnosis and treatment. The purpose of this study is to describe the various clinical manifestations of ocular inflammations due to tuberculosis and to assess the response to treatment following antituberculous therapy (ATT) and corticosteroids in these patients.

Materials and Methods:

We performed a retrospective analysis of 29 patients with presumed ocular tuberculosis who were started on ATT and completed follow-up of at least 6 months after ATT was initiated. The data collected were: age at presentation, sex, laterality, presence or absence of pulmonary/extrapulmonary tuberculosis, history of exposure to tuberculosis, site of ocular involvement and duration of illness, visual acuity at presentation and at 6-month follow-up, and response to treatment.

Results:

Most of the patients were of economically productive age, between 21-60 years. This most common presentation in our study population was unilateral nongranulomatous anterior uveitis. In spite of the delay between symptom onset and start of therapy, favorable response was noted in 79.3% of patients at completion of 6 months of ATT. The various reasons for the delay in start of therapy were also evaluated.

Conclusion:

In this case series, we presented the various ocular manifestations and the difficulties faced in the diagnosis of presumed ocular tuberculosis. Outcomes of ATT were favorable in most of our patients. Thus, the clinician should exercise a very high degree of suspicion and should not withhold a trial of ATT.

Triggering agents and microbiome as environmental factors on Behçet's syndrome

Environmental and other triggering factors are suggested to cause the onset and the clinical relapses of Behçet's syndrome (BS), a multi-systemic inflammatory disorder. In this review, environmental factors are discussed according to their interactions with etiopathogenesis, immune response and disease activity. Stress is a common self-triggering factor for most BS patients. Stimuli such as some foods can activate oral ulcers, and may be linked to the histamine content of the food. Oral/skin trauma and menstruation associated with hormonal factors aggravate, whereas allergy/atopy seem to alleviate the symptoms of BS. Infections are associated with BS, and microbial stimuli can activate inflammation in mucosal surfaces with increased Th1/Th17 responses. Fecal and oral microbiome patterns change in diversity and composition in BS. Better oral hygiene applications and anti-microbial interventions might be helpful to suppress oral ulcers in BS.

Noninfectious uveitis in the Asia-Pacific region

Uveitis is a sight-threatening disease. Up to 35% of patients may have impaired vision. Inflammation of the uvea tissue has more than 60 etiologies. Previous reports have shown that 20-40% of uveitis cases were noninfectious. Some of them may be associated with systemic rheumatological and autoimmune diseases but some may affect the eyes only. The epidemiology and clinical situations of some specific uveitis entities vary worldwide because they are influenced by genetic, ethnic, environmental, and socioeconomic factors. The Asia-Pacific region comprises more than 30 countries. Epidemiology and patterns of uveitis vary greatly in this region. However, some uveitis entities, such as Behcet's disease, sarcoidosis, and Vogt-Koyanagi-Harada disease, are more common in this region. Many studies on the epidemiology, risk factors, and immune pathogenesis of this disease have been conducted. In this article, we review the epidemiology of noninfectious uveitis and special situations of these three uveitis entities in the Asia-Pacific region.

Musculoskeletal manifestations of tuberculosis: An observational study

Background:

Data of musculoskeletal manifestations of tuberculosis (TB) are limited to case reports, series, or retrospective studies. Therefore, we conducted this study to create awareness among doctors about musculoskeletal manifestations of TB.

Materials and Methods:

This was a prospective observational study conducted at a referral TB Hospital in North India in September and October 2016. The aim of our study was to study musculoskeletal manifestations of TB. We included patients who had active TB as per the World Health Organization 2010 criteria. Patients with other chronic illnesses were excluded. A detailed history, examination, and appropriate investigations (blood, urine, serological, and radiological) of the 100 consecutive patients fulfilling the inclusion criteria were recorded.

Results:

The mean age of patients was 32.16 ± 12.93 years. Male-to-female ratio was 43:57. The mean duration of disease was 6.85 ± 8.83 months. Of the 100 patients, 60 (60%) had pulmonary TB. The mean duration of antitubercular therapy was 1.79 ± 1.34 months. Fibromyalgia was classified in 21 (21%) patients, polyarthralgia was seen in 9 (9%), Pott's spine in 7 (7%), osteomyelitis in 4 (4%), and scleritis in 2 (2%) patients. Uveitis, tenosynovitis, erythema induratum, subcutaneous abscess, and dactylitis were seen in 1 (1%) patient each. In 21 patients who had fibromyalgia, 11 developed fibromyalgia with the second episode of TB amounting to 60.75% patients.

Conclusion:

This is the first prospective study to look at the musculoskeletal manifestations of TB. Patients with active TB were found to have various rheumatological manifestations.

Patterns of uveitis in patients with proven systemic (pulmonary and extrapulmonary) tuberculosis

PURPOSE

To report patterns of uveitis in patients with systemic tuberculosis.

METHODS

Records of patients presenting at uvea clinic of a tertiary eye care centre were evaluated retrospectively, and 47 cases with proven systemic tuberculosis were analyzed for patterns of uveitis. Tuberculosis had been proven with a combination of radio imaging and detection of acid fast bacilli in body fluids. All patients had been reviewed by a specialist as applicable before diagnosing tuberculosis. These patients had undergone a thorough ocular workup. Pattern of uveitis was the primary outcome measure.

RESULTS

Mean age was 35.34 ± 15.56 years. Lung was the commonest systemic focus, seen in nearly 75% of the cases. Anterior uveitis was the most common presentation (48.9%), followed by posterior (25.5%), panuveitis (10.6%) and intermediate uveitis (10.6%). Multifocal serpiginoid choroidopathy (MSC) was seen in only one patient, while granulomatous choroiditis was the commonest type of posterior uveitis.

CONCLUSIONS

Anterior uveitis is the most frequent type of uveitis seen in patients with proven systemic tuberculosis. Rarity of MSC in such patients indicates possibility of etiologies other than tuberculosis in causing MSC.

Review of Epidemiology of Uveitis in Asia: Pattern of Uveitis in a Tertiary Hospital in the Philippines

PURPOSE

To describe the pattern of uveitis in patients seen at the uveitis clinic of the East Avenue Medical Center, Philippines.

METHODS

Clinical records of patients seen from January 2010 to June 2015 were reviewed. Data collected included demographics, clinical presentation, associated systemic disease, work-up, and diagnosis.

RESULTS

A total of 595 records were reviewed. The mean age at presentation was 38 ± 18.4 years. The majority of the cases were unilateral and chronic. Anterior uveitis was the most common, followed by panuveitis, posterior uveitis, and intermediate uveitis. Uveitis was idiopathic in 54.1%, while specific diagnosis was found in 45.9%. Infectious cause of uveitis was found in 25.6% with tuberculosis (TB) being the most common followed by toxoplasmosis. Vogt-Koyanagi-Harada (VKH) was the most common cause of non-infectious uveitis followed by Fuchs' heterochromic iridocyclitis (FHI).

CONCLUSIONS

In a tertiary hospital in the Philippines, the most common causes of uveitis were TB, VKH, toxoplasmosis, FHI, and sympathetic ophthalmia.

Pediatric Uveitis

Pediatric uveitis differs from adult-onset uveitis and is a topic of special interest because of its diagnostic and therapeutic challenges. Children with uveitis are often asymptomatic and the uveitis is often chronic, persistent, recurrent, and resistant to conventional treatment. Anterior uveitis is the most common type of uveitis in children; the prevalence of intermediate, posterior, and panuveitis varies geographically and among ethnic groups. Regarding etiology, most cases of pediatric uveitis are idiopathic but can be due to systemic inflammatory disorders, infections, or a manifestation of masquerade syndrome. Ocular complications include cataracts, hypotony or glaucoma, band keratopathy, synechiae formation, macular edema, optic disc edema, choroidal neovascular membranes, and retinal detachment. These complications are often severe, leading to irreversible structural damage and significant visual disability due to delayed presentation and diagnosis, persistent chronic inflammation from suboptimal treatment, topical and systemic corticosteroid dependence, and delayed initiation of systemic disease‒modifying agents. Treatment for noninfectious uveitis is a stepwise approach starting with corticosteroids. Immunomodulatory therapy should be initiated in cases where quiescence cannot be achieved without steroid dependence. Patients should be monitored regularly for complications of uveitis along with systemic and ocular adverse effects from treatments. The goals are to achieve steroid-free durable remission, to reduce the risk of sight-threatening complications from the uncontrolled ocular inflammation, and to avoid the impact of lifelong burden of visual loss on the child and their family. Multidisciplinary management will ensure holistic care of affected children and improve the support for their families.

Epidemiology of uveitis in a US population-based study

Background

The purpose of this study is to assess the relationship between self-reported uveitis and purported demographic and clinical risk factors, using an American adult population extracted from the National Health and Nutrition Examination Survey (NHANES) for the years 2009 and 2010. This is a cross-sectional, population-based study using a sample of 5106 subjects between 20 and 69 years old. The main outcome for our study was the self-report of a diagnosis of uveitis. The demographic analysis included age, gender, and ethnicity. Potential predictors were having a diagnosis of ankylosing spondylitis (AS), ulcerative colitis (UC), or Crohn’s disease (CD); a history of cigarette smoking; vitamin D deficiency; and different mental health measures. Univariate and multivariate analyses were conducted using RStudio.

Results

Of the 5106 participants, 27 had reported a diagnosis of uveitis, showing an adjusted prevalence of 5.4 per 1000 subjects (95% CI 3.4–8.5/1000). Increased age was associated with higher uveitis prevalence in the multivariate analysis (odds ratio [OR] = 1.04, 95% CI 1.01–1.07; p = 0.02). Positive smoking history was reported in 59.2% of patients. Multivariate analysis comparing smoking with the presence of uveitis showed an OR of 3.18 (95% CI 1.59–6.37; p = 0.003), adjusting for age and gender. Moreover, 11.1% of the participants from the uveitis group self-reported a diagnosis of AS and 11.7% informed a diagnosis of UC and 7.1% of CD. The ORs were of 16.64 (95% CI 3.64-76.09; p = 0.001), 11.34 (95% CI 2.69-47.88; p = 0.003), and 22.16 (95% CI 2.64-186.17; p = 0.007), respectively when compared with the non-uveitis group in the multivariate analysis.

Conclusions

Age, cigarette smoking, AS, UC, and CD are positively associated with self-reported uveitis. There is previous evidence that smoking and female gender are positive risk factors for uveitis, as well as evidence that HLA-B27-positive spondyloarthritides have the highest association with non-infectious uveitis in the adult population in North America and Europe. However, there are no prior studies that have utilized a representative US population-based sample to validate these findings. The present study supports smoking as a risk factor, which has clinical relevance since this is a modifiable habit.

Patterns of Uveitis at a Tertiary Referral Center in Northeastern Iran

Purpose

To describe the demographic and clinical patterns of patients with uveitis referred to a tertiary center in northeastern Iran.

Methods

This cross-sectional retrospective study included 235 patients with uveitis who had been referred to the uveitis clinic of Khatam-Al-Anbia eye hospital, affiliated to Mashhad University of Medical Sciences, from February 2013 to March 2014. Data regarding patient age, sex, anatomical location of the disease, and etiologic and clinical features were analyzed.

Results

Mean patient age at the onset of uveitis was 35.75 ± 16.3 (range: 3-82) years. The ratio of females to males was 1.5 to 1. Sixty-four percent had bilateral involvement. The predominant type of inflammation was non-granulomatous (76%). Panuveitis (46.8%, 110 cases) was the most common form of uveitis followed by anterior (37%, 87 cases), intermediate (11.9%, 28 cases), and posterior uveitis (4.25%, 10 cases). The most common diagnoses were "idiopathic" in anterior and intermediate uveitis cases, toxoplasmosis in posterior uveitis group, and Behçet and Vogt-Koyanagi-Harada diseases in panuveitis cases. Overall, noninfectious causes (80.42%) of uveitis were more frequent than infectious causes (19.57%). The proportion of noninfectious uveitis was 82.75% in anterior uveitis, 78.18% in panuveitis, 92.85% in intermediate uveitis, and 50% in posterior uveitis. The most common associated systemic disease was Behçet disease.

Conclusion

In contrast to most epidemiologic studies of uveitis, the clinical and etiologic patterns of uveitis were different in a tertiary referral center in northeastern Iran. Panuveitis was the most common clinical pattern in this study, and the most common associated systemic disease was Behçet disease.

MTBDRplus for the rapid diagnosis of ocular tuberculosis and screening of drug resistance

PurposeTimely diagnosis of intraocular tuberculosis (IOTB) along with detection of drug resistance can save many eyes from visual impairment. With the growing incidence of IOTB and rising drug resistance, a reliable diagnostic platform for simultaneous detection of the agent and mutated gene is urgently needed. The MTBDRplus assay was evaluated directly on vitreous fluid samples for the same.Patients and methodsIn a prospective study, The MTBDRplus assay was performed on 127 vitreous fluid samples (77 'study group' comprising cases of presumed ocular tuberculosis and 50 'control group' cases of disease controls (n=25) and non-uveitic controls (n=25)). All samples positive by MTBDRplus assay were subjected to gene sequencing to confirm the mutations for rifampicin and isoniazid resistance.ResultsThe MTBDRplus assay produced a sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 36.36%, 100%, 100%, and 50.50%, respectively, for the detection of IOTB. Among the 28 cases from study group that were positive by MTBDRplus assay, rifampicin resistance was reported in six and isoniazid resistance in two cases. On sequencing of rpoB and katG gene, one case of false rifampicin-resistant by MTBDRplus was found. The other resistant isolates showed concordant mutations between MTBDRplus assay and sequencing.ConclusionThe MTBDRplus assay is an effective tool for the rapid diagnosis of IOTB along with detection of drug resistance, thereby improving the outcome in IOTB.

Development and evaluation of multiplex real-time PCR for diagnosis of HSV-1, VZV, CMV, and Toxoplasma gondii in patients with infectious uveitis

Infectious uveitis is a vision threatening inflammatory ocular disease wherein early diagnosis may prevent the loss of vision. The purpose of this study was to develop a multiplex real-time PCR for the diagnosis of Herpes simplex virus-1, Varicella zoster virus, cytomegalovirus and Toxoplasma gondii in patients with suspected infectious uveitis. A total of 126 intraocular samples (aqueous and vitreous humor) were collected and subjected to multiplex real-time PCR. Overall 26.2% (33/126) patients were found to be positive for one or more of the pathogens tested. The overall positivity for VZV, HSV, CMV and T. gondii was found to be 16 (12.7%), 7 (5.6%), 5 (3.9%), and 9 (7.1%); with mean pathogen load of 5.07×10⁵, 9.5×10⁴, 1.08×10⁴ and 394 (copies/μl) respectively. The development of highly sensitive and specific assay for early differentiation of pathogens is important for the early initiation of treatment thereby preventing irreversible damage to the ocular structures.

Clinical spectrum and management options in Vogt-Koyanagi-Harada disease

Purpose

The aim of this study was to describe the clinical features, treatment options, and visual outcome of Vogt–Koyanagi–Harada (VKH) disease patients over a 9-year period.

Method

A retrospective chart analysis of 32 patients with VKH, from January 2007 to December 2015, at a tertiary care government medical college eye hospital in South India.

Results

A total of 32 patients were diagnosed with VKH. The mean age at diagnosis was 32.03±8.8 years. There were 24 patients (42 eyes) with acute VKH and eight patients (16 eyes) with recurrent/chronic VKH. The mean baseline best-corrected visual acuity on presentation in the acute VKH group was 5/60 (1.114±0.565) and at last follow-up it was 6/9 (0.225±0.157). Intravenous methyl prednisolone (IVMP) was administered for 3 days to all patients with acute and recurrent VKH, followed by posterior subtenon triamcinolone (40 mg/mL) and oral azathioprine.

Conclusion

VKH-related uveitis is more common in the female gender in this South Indian population. Posterior uveitis is the most common initial manifestation. Initial aggressive treatment with IVMP, peribulbar long-acting corticosteroids, and immunosuppressives, avoiding side effects of systemic steroids, gives a good visual outcome without recurrences. Cases of unilateral VKH, seen in six patients, are the initial manifestations in the natural course of the disease, which if managed aggressively at the acute stage prevents recurrence in the other eye.

Intermediate uveitis: pattern of etiology, complications, treatment and outcome in a tertiary academic center

Background

Patients with intermediate uveitis (IU) represent a heterogenous group characterized by a wide spectrum of etiologies and regional differences. Aim of the study was to analyze the characteristics of patients with IU examined in an academic center in Germany.

Methods

We conducted a retrospective analysis of the clinical records of all patients with intermediate uveitis referred to the Eye Center, University of Freiburg from 2007 to 2014. Diagnosis followed the Standardization in Uveitis Nomenclature (SUN) criteria. Data analysis included: etiology of IU, demographics, complications, treatment and visual acuity.

Results

We identified 159 patients with intermediate uveitis during that period. Mean age at diagnosis was 35 years. Most are female (64%), and the mean duration of IU was 6.1 years (range 1 month – 35 years). Etiology of IU was idiopathic in 59%. Multiple sclerosis (MS) (20%) and sarcoidosis (10%) were frequent systemic causes of IU. Other etiologies including infectious diseases (tuberculosis, borreliosis) or immune-mediated conditions (eg, after vaccination) were present in 11%. The pattern of complications included macular edema (CME) (36%), cataract (24%), secondary glaucoma (7%), and epiretinal membrane formation (19%). Periphlebitis and optic neuritis were more frequent in conjunction with MS. Treatment comprised local and systemic steroids, immunosuppressive agents, biologics, and surgery. Best corrected visual acuity was better than 20/25 in 60% of the eyes after more than 10 years of follow-up.

Conclusions

In our German academic center, most IU cases were idiopathic or associated with MS or sarcoidosis. In contrast to other countries, infectious cases were rare. Patients’ overall visual prognosis is favorable even when the duration of IU has been long and and despite numerous complications.

Association of Vogt Koyanagi Harada Syndrome and Seronegative Rheumatoid Arthritis

BACKGROUND

Vogt Koyanagi Harada (VKH) Syndrome is a rarely-seen multi-systemic, autoimmune and inflammatory disease. It observed frequently with neurologic, auditory and skin manifestations and characterized with bilateral, chronic and diffused granulomatous panuveitis. It generally affects women in young-adult period.

CASE

A 57 year-old female patient applied to a special center one year ago with a complaint of decrease in the sight acuity of the right eye. The right eye was operated on with cataract diagnosis. Uveitis was developed firstly in the right eye and then in the left eye after the operation. Having complaints about uveitis, tinnitus and hear loss, the patient was diagnosed with VKH syndrome. The pains started to be felt in small hand joints and both of the two ankles. The pains were increasing especially in the mornings and during rest. The duration of morning stiffness was two hours in hand and foot joints. The patient had had lumbar pain with mechanic characteristic for five years.

CONCLUSION

Being diagnosed with seronegative rheumatoid arthritis (RA), our case is presented because VKH syndrome is rarely seen in Turkey, and the joint findings are at the forefront.

Ocular Autoimmune Systemic Inflammatory Infectious Study (OASIS) - Report 1: Epidemiology and Classification

PURPOSE

To report the epidemiology and classification of ocular inflammation at a tertiary eye care center in Singapore.

METHODS

Retrospective cohort study of the clinical records of consecutive new cases from the Ocular Autoimmune Systemic Inflammatory Infectious Study (OASIS) database from 2004-2015.

RESULTS

A total of 2200 patients were studied from the OASIS database. The most common anatomic diagnosis was anterior uveitis (55.9%), posterior uveitis (17.5%), panuveitis (9.6%), and intermediate uveitis (4.7%). In addition, scleritis (6.1%), keratouveitis (2.8%), retinal vasculitis (2.2%), and episcleritis (1.2%) were observed. Etiology was established in 65.1%, with 35.2% of patients associated with non-infectious etiologies. The most common etiologies found were presumed tuberculosis (7.2%), followed by cytomegalovirus infection (6.9%), herpetic infection (6.3%), HLA-B27-associated anterior uveitis (4.2%), and ankylosing spondylitis (3.8%).

CONCLUSIONS

The pattern of ocular inflammation in Singapore has similarities with both Western and Asian populations. Anterior uveitis was the most common, with non-infectious etiologies being slightly more common than infectious etiologies.

Epidemiology and Clinical Features of Uveitis from Urban Populations in South India

PURPOSE

To report the epidemiology of uveitis in two urban centers in South India.

METHODS

Case records seen between January 2014 and December 2014 at two tertiary eye centers in South India were retrospectively reviewed.

RESULTS

A total of 1123 patients in the study population had uveitis. Anterior uveitis was seen in 48.9%, posterior in 20.5%, intermediate in 17.3%, and panuveitis in 13.3%. Of these cases, 68.4% were acute uveitis. Pediatric uveitis constituted 6.9% patients. Tuberculosis was the commonest infectious etiology.

CONCLUSIONS

Idiopathic uveitis was highest in non-infectious and tuberculosis in infectious etiology. Toxoplasmosis was seen in the pediatric age group.

Continuous evolution of clinical phenotype in 578 Japanese patients with Behçet's disease: a retrospective observational study

Background

It has been suggested that the phenotypes of Behçet’s disease (BD) in Japan are changing. To ask whether the evolution of BD holds true in recent-onset cases in Japan, we performed a retrospective study.

Methods

We reviewed the records of 578 patients with BD who met the 1987 revised diagnostic criteria of the Behçet’s disease research committee of Japan. The patients were divided into three groups based on the date of disease onset. We compared the demography, clinical features, and treatments among them with or without adjustment for the observation period. Patients having oral ulcers, genital ulcers, regional skin involvement, and uveitis are categorized as having complete-type BD, and the associated factors were determined by univariate and multivariate logistic regression analyses.

Results

Male patients had a higher propensity for uveitis and central nervous system (CNS) involvement, whereas female patients had higher rates of genital ulcers and arthritis. We found a significant trend in reduction of complete-type, genital ulcer, HLA-B51 carriers, and increment of gastrointestinal BD over time. Multiple regression analysis identified HLA-B51 positivity, earlier date of disease onset, and younger age of onset as independently associated with complete-type BD. Although treatments had been also chronologically changed, the causative relationship between therapeutic agents and phenotypical changes was not determined from the study.

Conclusion

The present study revealed that phenotypical evolution was characterized by decreased incidence of the complete type and increment of gastrointestinal involvement in Japanese patients with BD during the last 30 years.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-016-1115-x) contains supplementary material, which is available to authorized users.

Pattern of Uveitis in a Tertiary Ophthalmology Center in Thailand

PURPOSE

To study the etiology and pattern of uveitis in a tertiary ophthalmology center in Thailand.

METHODS

A cross-sectional study was conducted on uveitis patients presenting to a uveitis clinic at Ramathibodi Hospital, Thailand, between February 2014 and January 2015.

RESULTS

A total of 758 uveitis patients were enrolled into this study. The most common identified cause was herpetic uveitis (17.2%), followed by Vogt-Koyanagi-Harada disease (13.5%), cytomegalovirus uveitis (12.7%), and HLA-B27/spondyloarthropathy-associated uveitis (12.4%).

CONCLUSIONS

Herpetic uveitis was the commonest form of infectious uveitis, whereas Vogt-Koyanagi-Harada disease was most frequently seen as the non-infectious cause of uveitis in Thailand.