HLA-B27-associated acute anterior uveitis in the University Referral Centre in North Thailand: clinical presentation and visual prognosis

The Presence of Pigmentation on Central Anterior Lens Capsule in the Human Leukocyte Antigen B27-Associated Anterior Uveitis and Its Value in Clinical Diagnosis

PURPOSE

To report on the value of presence of pigmentation on central anterior lens capsule (PioLe) in HLA B27- associated anterior uveitis (HLA B27-AU).

METHODS

268 patients (320 eyes) with AU were reviewed. Two diagnostic models to predict probability of HLA-B27-AU were developed. The first model included 6 variables (age, gender, unilaterality, presence of non-granulomatous keratic precipitates, hypopyon, and intraocular pressure (IOP). The second model was developed to investigate the added value of PioLe into the first model.

RESULTS

     Unilaterality, presence of hypopyon, IOP <21 mmHg and PioLe were characteristic for HLA-B27 positive patients (P≤0.003 for all). All of 6 variables had area under receiver operating characteristic curves (AuROC) ≤ 60, but PioLe reached even higher value (65.5). Diagnostic model I and II had AuROC 76.3% (95%CI, 68.4%-84.2%) and 80.0% (95%CI, 72.6%-87.5%), respectively.

CONCLUSIONS

Unilaterality, hypopyon, IOP <21 mmHg and presence of PioLe are clinical signs suggesting HLA B27- AU.

Clinical Profile of HLA-B27-Associated Uveitis in an Egyptian Cohort

PURPOSE

To describe the clinical profile of patients with HLA-B27-associated uveitis at 2 Egyptian tertiary eye centers.

METHODS

A retrospective study reviewing the medical records of all patients with HLA-B27-associated uveitis served at 2 uveitis referral clinics in Egypt between January 2010 and June 2018.

RESULTS

The study included a total of 554 patients. Anterior uveitis was the most common type. Ankylosing spondylitis was an important systemic comorbidity in the present study, affecting 27.4% of our patients. Cataract was the most frequent ocular complication. By the conclusion of the study, 6.1% of the affected eyes had a BSCVA poorer than 20/200.

CONCLUSION

The clinical profile of HLA-B27-associated uveitis in our cohort of Egyptian patients is similar to that reported from other regions of the world. In our study, a relatively high rate of cataract was observed.

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 of HLA B-27-Associated Uveitis Patients in a Tertiary Care Eye Hospital in Eastern India

Purpose: To analyse clinical profile of the patients with HLA B 27- associated uveitis in a tertiary care eye hospital in Eastern India Method: Retrospective analysis of 61 eyes of 43 patients with HLA B27- associated uveitis between 2015 and 2016. Result: We observed a male predominance (67%), and more unilateral involvement (58%) in our patients. The mean age of presentation was 44.7 ±11.7 years. Significant vitritis and macular edema were noted in 14 and 7 eyes respectively. In addition to topical therapy, oral steroid was required in 49% patients and 58% patients were treated with methotrexate. Five patients (12%) required biologicals. There was improvement in BCVA at final follow-up (p<0.001). Conclusion: Compared to the existing literature, the current study observed relatively high age of presentation and frequent posterior segment involvement with less systemic association.

Clinical features of HLA-B27-positive acute anterior uveitis with or without ankylosing spondylitis in a Chinese cohort

AIMS

To characterise the clinical features of human leucocyte antigen (HLA)-B27⁺acute anterior uveitis (AAU) patients with or without ankylosing spondylitis (AS) and investigate the retinal vascular involvement in these patients.

METHODS

A total of 1056 HLA-B27⁺ AAU patients (1525 eyes) were retrospectively studied from April 2008 to February 2016. Patients were divided into human leucocyte antigen (HLA)-B27⁺AS⁺ and HLA-B27⁺AS^- group. Clinical features including the onset of uveitis, laterality, the age at first attack, clinical examinations, best corrected visual acuity (BCVA), abnormalities in fundus fluorescence angiography (FFA) and complications were determined and compared between these two groups.

RESULTS

There were 581 (55.0%) and 475 (45.0%) patients respectively classified into HLA-B27⁺AS⁺ and HLA-B27⁺AS^- group. Males had a higher prevalence than females in the HLA-B27⁺AS⁺ group (75.2%) as compared with the HLA-B27⁺AS^- group (51.8%, p<0.001). The HLA-B27⁺AS⁺ patients showed a higher percentage of bilateral/alternating involvement (47.3%) as compared with the HLA-B27⁺AS^- group (36.6%, p=0.001). A higher percentage of fibrinous exudation, synechiae as well as complications including complicated cataract and secondary glaucoma were found in the HLA-B27⁺AS⁺ group as compared with the HLA-B27⁺AS^- group. Worse visual outcome as indicated by a higher percentage of patients with BCVA <0.5 and with BCVA <0.05 was noted in the HLA-B27⁺AS⁺ group as compared with the HLA-B27⁺AS^- group both before and after treatment. FFA showed mild capillary fluorescence leakage in the late phase with indistinctly defined margins on the peripheral retina in 39.3% of HLA-B27⁺ AAU patients. There was no difference concerning the retinal vascular involvement between these two groups.

CONCLUSIONS

Our study confirmed that HLA-B27⁺AS⁺ patients show a higher percentage of males, more common bilateral involvement, a higher frequency of fibrinous exudates, synechiae and secondary glaucoma as compared with HLA-B27⁺AS^- patients. Visual outcome was poorer, possibly due to the higher prevalence of complicated cataract in HLA-B27⁺AS⁺ patients. Retinal vascular involvement was not uncommon in HLA-B27⁺ AAU patients.

Potential Predictors of Poor Visual Outcome in Human Leukocyte Antigen-B27-Associated Uveitis

PURPOSE

To identify potential predictors of permanent vision loss in patients with human leukocyte antigen (HLA)-B27-associated uveitis in a tertiary referral center.

DESIGN

Retrospective case-control study.

METHODS

The charts of 212 patients (338 eyes) with HLA-B27-associated uveitis that visited the University Medical Center Utrecht with a follow-up of at least 6 months were retrospectively studied. Clinical features at presentation and during follow-up were compared to final visual outcome in quiescent state. Eyes with (sub-) normal vision (>20/50) were compared with visually impaired (≤20/50) and blind (≤5/50, or a visual field of <10 degrees) eyes, using survival analysis. A multivariate Cox proportional hazards analysis was performed to analyze potential predictors for permanent vision loss.

RESULTS

Median follow-up was 10.4 years (range, 0.5-44.7 years). During follow-up 226 eyes (66%) experienced vision loss up to 20/50, but most recovered. Twenty patients (9%) became permanently visually impaired or blind in at least 1 eye because of uveitis, after a median of 9.7 years (range, 0-20.9 years). The main cause was secondary glaucoma or related to glaucoma surgery (12/22 eyes, 55%). Survival analysis showed, after adjustment for age and sex, an ocular pressure of >21 mm Hg, hypotony, and panuveitis to be potential predictors at presentation, and the development of secondary glaucoma or hypotony to be predictors of blindness or visual impairment during follow-up.

CONCLUSIONS

The long-term visual prognosis of HLA-B27-associated uveitis is relatively good, but the true incidence of permanent vision loss is probably still underestimated. Our findings highlight the importance of proper control of intraocular pressure.

Risk of relapse in primary acute anterior uveitis

PURPOSE

To evaluate the risk of and risk factors for a second episode (relapse) among patients with remitted primary anterior uveitis.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients with primary anterior uveitis presenting to 1 of 4 academic ocular inflammation subspecialty practices achieving remission of the primary episode within 90 days of initial uveitis diagnosis.

METHODS

Data were obtained by standardized chart review.

MAIN OUTCOME MEASURES

Time to relapse of anterior uveitis and risk factors for relapse.

RESULTS

We included 102 patients with a first episode of anterior uveitis who were seen within 90 days of first-ever uveitis onset and followed for 165 person-years after achieving remission of the initial episode. Most patients were female (60%) and white (78%). Forty patients had a recurrence of anterior uveitis. The incidence of relapse was 24% per person-year (95% confidence interval [CI], 17%-33%). At 1.5 years after remission, 61% (95% CI, 48%-71%) were still in remission. Younger adults had significantly higher relapse risk than middle-aged adults (hazard ratio [18- to 35-year-old persons vs. 35- to 55-year-old persons], 2.7; 95% CI, 1.3-6.0).

CONCLUSIONS

Our results suggest that many patients with remitted primary anterior uveitis presenting for tertiary uveitis care will relapse. Age in the young adult range was associated with higher risk of relapse. Given the high relapse risk, management of patients with primary anterior uveitis should include an explicit plan for detecting and managing relapses.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Incidence rates and risk factors for ocular complications and vision loss in HLA-B27-associated uveitis

PURPOSE

To calculate the incidence rates of ocular complications and vision loss in HLA-B27-associated uveitis and to explore the effect of chronic inflammation on clinical outcomes.

DESIGN

Retrospective longitudinal cohort study.

METHODS

The clinical records of 99 patients (148 uveitis-affected eyes) with HLA-B27-associated uveitis seen at a tertiary care center were included. The main outcome measures were ocular complications (posterior iris synechiae, band keratopathy, posterior subcapsular [PSC] cataracts, ocular hypertension, hypotony, cystoid macular edema, and epiretinal membrane) and vision loss. Anterior chamber inflammation was defined as ≥1+ grade inflammation. Chronic uveitis was defined as persistent inflammation with relapse in <3 months after discontinuing treatment or requiring medications to suppress inflammation for >3 months after reviewing the patient's entire clinical course.

RESULTS

The clinical course was most commonly acute/recurrent (75%) or chronic (20%). The most common complications to develop during follow-up were ocular hypertension (0.10/eye-year) and PSC cataracts (0.09/eye-year). In multivariate analysis, the presence of posterior synechiae at presentation, inflammation, corticosteroid-sparing therapy, corticosteroid injections, chronic disease, and male gender were associated with a statistically significant increased risk of developing vision loss (20/50 or worse). Chronic disease course was associated with a 7-fold increased risk of visual impairment (hazard ratio [HR] = 6.8, P < .0001). The presence of inflammation during follow-up was associated with an increased risk of developing visual impairment (HR = 6.2, P < .0001). In multivariate analysis, chronic disease course and topical corticosteroids were associated with an increased risk of developing any incident ocular complication (HR = 2.2, P = .04 and HR = 3.3, P = .01, respectively).

CONCLUSIONS

Poorly controlled inflammation was associated with the development of ocular complications including vision loss. Patients with chronic inflammation were also at greater risk of complications.

Clinical features and prognosis of HLA-B27 positive and negative anterior uveitis in a Korean population

Clinical features and prognosis of HLA-B27 positive anterior uveitis (AU) were assessed compared with HLA-B27 negative AU in a Korean population, based on the medical records of AU patients seen at a university hospital. Twenty-seven HLA-B27 negative, idiopathic AU patients (group I) and 55 HLA-B27 positive AU patients (group II) were studied. HLA-B27 positive group was further divided into 29 with associated systemic disease (seronegative spondyloarthropathy) (group IIA) and 26 without associated systemic disease (group IIB). Significantly more severe anterior chamber inflammation in terms of anterior chamber cells (P=0.006) and hypopyon formation (P=0.034) was observed with higher frequency of AU attacks (P=0.007) in the HLA-B27 positive group than in the HLA-B27 negative group. Systemic/periocular steroids were required in significantly more patients in the HLA-B27 positive group than in the HLA-B27 negative group (P=0.015). However, no significant differences were observed for final ocular and visual outcomes between these two groups. Associated systemic disease made no significant difference in the clinical features and prognosis in the HLA-B27 positive AU patients. In conclusion, despite more severe inflammation and a higher recurrence rate, HLA-B27 positive AU shows similar good final ocular and visual outcomes compared to HLA-B27 negative, idiopathic AU in a Korean population.

Two differing presentations of chronic bilateral anterior uveitis

BACKGROUND

Bilateral, recurrent, or chronic anterior uveitis requires a diagnostic evaluation to rule out any systemic cause. An understanding of the possible etiologies and their diagnostic criteria is needed to manage these patients. Treating any systemic cause can decrease the recurrent or chronic nature of the uveitis and favorably alter the course. Many possible systemic conditions are capable of causing anterior uveitis, including sarcoidosis.

CASE REPORTS

Two cases of chronic, recurrent, bilateral uveitis are presented. Both were evaluated for any systemic etiology. After extensive systemic workups, the first case had no identifiable systemic etiology, whereas the second case was associated with systemic sarcoidosis.

CONCLUSION

Although a medical workup may be necessary, it will not always lead to a systemic diagnosis. The literature indicates that up to about 50% of uveitic cases have no identified causes.