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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 59  |  Issue : 3  |  Page : 265-269

A clinical study of anterior uveitis at India


Department of Ophthalmology, Jaipuriya Hospital, Jaipur, Rajasthan, India

Date of Submission14-Jul-2020
Date of Acceptance21-Sep-2020
Date of Web Publication09-Sep-2021

Correspondence Address:
Dr. Pawan Jarwal
Department of Ophthalmology, Jaipuriya Hospital, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_89_20

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  Abstract 


Purpose: To evaluate the etiological pattern, treatment, and its outcome and complications of anterior uveitis. Uveitis, a complex intraocular inflammatory disease, results from several etiological entities. The cause of inflammation might be an infectious agent or trauma, but in most cases, the underlying mechanism appears to be autoimmune in nature.[1] Methods: A prospective clinical study was done in the department of ophthalmology at a general hospital in Jaipur, during July 2017 to June 2018. All patients between 20 and 80 years of age clinically presenting with anterior uveitis were studied. A thorough clinical evaluation followed by investigations was done to determine etiology. Patients were put on specific and nonspecific treatment and were followed up for a period of 6 months. Complications were noted. Results: The etiology of uveitis remained unknown in most cases (42%). The most common cause was observed to be blunt trauma (20%) followed by phacolytic (12%). Most cases responded well to treatment. The most common complication was posterior persistent synechiae (23.64%), and cataract was the second common (14.54%). Conclusion: Etiological diagnosis remains undetermined in majority of cases. A thorough examination and investigation is required in each case to facilitate a final diagnosis. Prompt treatment ensures good visual outcome. Ocular morbidity is common in chronic and recurrent cases.

Keywords: Anterior uveitis, complications, etiology, treatment


How to cite this article:
Jarwal P. A clinical study of anterior uveitis at India. TNOA J Ophthalmic Sci Res 2021;59:265-9

How to cite this URL:
Jarwal P. A clinical study of anterior uveitis at India. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2021 Dec 1];59:265-9. Available from: https://www.tnoajosr.com/text.asp?2021/59/3/265/325746




  Introduction Top


Uveitis' is one of the most common forms of intraocular inflammation and affects mainly children and young adults. It includes a large group of intraocular inflammatory diseases of diverse etiology.[1] The cause of inflammation might be an infectious agent or trauma, but in most cases, the underlying mechanism appears to be autoimmune in nature.[2] The anterior uveitis can be categorized as iritis, anterior cyclitis, and iridocyclitis. It often causes a painful red eye. Patients with anterior uveitis complain of redness, photophobia, tearing, and blurred vision.[3] Acute anterior uveitis causes mild vision loss but still contributes significantly to the total burden. It causes vision loss both directly through inflammation and via complications such as macular edema, glaucoma, cataract, and others. The treatment for uveitis itself can result in both ocular and systemic complications.[4] The morbidity associated with the disease is moderately high.[5]

Propose

To study:

  • Clinical presentation
  • Complications
  • Investigations to establish the exact cause and accurate diagnosis
  • Response to treatment and prognosis in terms of visual outcome.



  Methods Top


A prospective clinical study was conducted. The material for this study included 50 patients between age 20 and 80 years, attending outpatient department, department of ophthalmology at a general hospital in Jaipur, during July 2017 to June 2018 with signs and symptoms of anterior uveitis.

The anterior uveitis following penetrating ocular injuries, corneal ulcer, intraocular surgeries, and if associated with intermediate, posterior, or panuveitis were excluded from this study. Masquerade syndromes presenting as anterior uveitis has also been excluded.

A standard clinical pro forma was filled in all cases, which included salient feature in history, visual acuity using Snellen's visual acuity chart, clinical findings, laboratory investigations, and the final etiology. All patients were examined under slit lamp. Details on disease severity, laterality, chronicity, ocular signs, and associated systemic conditions were noted.

Presentation was considered as unilateral if active inflammation was present in only one eye and bilateral if both eyes presented with active inflammation.

The inflammation was defined as acute if symptoms were present for <3 months, chronic if symptoms were present for 3 months or more, and recurrent if two or more episodes of inflammation were separated by a disease-free period. Anterior uveitis was defined granulomatous if large keratic precipitates, nodules at pupillary margin (Koeppe nodules) or nodules on or within the anterior iris stroma (Busacca nodules) were present.

A short differential diagnosis was made in each case. Subsequently, a tailored laboratory investigation was carried out. Investigations included total and differential counts, erythrocyte sedimentation rate, urine and stool examination, and Mantoux test. Serological tests for syphilis, HIV, and rheumatoid factor were done in all cases. Radiological investigations included X-ray of chest, lumbosacral and knee joints. Other special investigations were considered whenever necessary. Consultation was done with other medical specialties, whenever needed.

The final etiological diagnosis was made based on history, clinical features, laboratory investigations, and systemic evaluation by other medical specialties.

The anterior uveitis was considered to have idiopathic etiology when it was not associated with human leukocyte antigen-B27 haplotype and neither with defined clinical syndromes nor with definitive etiology.[6]

All patients were treated medically with topical steroids (prednisolone acetate 1%) and topical cycloplegic mydriatics (atropine or homatropine). Steroids frequency was titrated according to severity of uveitis. Appropriate treatment was given whenever etiology was known. Systemic antimicrobials were administered when an infectious agent was found to be the cause. Systemic steroids were used when inflammation was severe, not responding to treatment and patients with macular edema.

Patients with lens-induced inflammation were treated surgically. In patients with uveitis associated with visually significant cataract, cataract surgery was done 3 months after active inflammation had subsided. These patients were given with high doses of topical and systemic steroids 1 week prior to surgery and then gradually tapered.

Cases of anterior uveitis with secondary glaucoma were treated with T. Acetazolamide 250 mg BD/TID and/or timolol 0.5% eye/drops BD along with topical steroids.

Each patient was followed up for 6 months. The complications were noted, and the response to treatment was recorded and evaluated in each patient


  Results Top


The present study was conducted in the department of ophthalmology at a general hospital in Jaipur, during July 2017 to June 2018, 50 patients in the age group of 20–80 years were studied, and during the study, following observations were made.

[Table 1] shows the age distribution. In the present study, anterior uveitis accounted to 40% in 20–30 years' age group, 24% in 31–40 years' age group, 16% in 41–50 years' age group, 10% in 51–60 years' age group, 6% in 61–70 years' age group, and 4% in 71–80 years' age group. It was seen most commonly in the 20–40 year age group, accounting for 64%. It was less common in patients over 60 years (10%).
Table 1: Age distribution

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[Table 2] shows the sex distribution. In the present study, males accounted for 56% and females accounted for 44%. Hence males were affected more than females.
Table 2: Sex distribution

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As [Table 3] shows, in the present study, the incidence of anterior uveitis was highest amongst the laborer (48%), followed by officials (22%), then homemakers (20%), and less common among businessman (6%) and students (4%).
Table 3: Occupation

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As [Table 4] shows, in the present study, unilateral involvement was seen in 90% of cases and bilateral involvement in 10% of cases. Unilateral involvement was more than bilateral involvement.
Table 4: Laterality

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[Table 5] shows the clinical presentation of cases. In the present study, it was observed that the most common presentation was acute anterior uveitis, accounting for 76%, then chronic 18%, and only 6% of the patients had recurrent anterior uveitis.
Table 5: Clinical presentation

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As [Table 6] shows, in the present study, 45 (90%) patients had nongranulomatous inflammation, and in 5 (10%) patients, it was granulomatous inflammation. Thus nongranulomatous inflammation was more common than granulomatous inflammation.
Table 6: Type of inflammation

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As [Table 7] shows that in this study, etiology remains undetermined in 21 (42%) cases and specific diagnosis was reached in 29 (58%) cases. Anterior uveitis following blunt trauma was seen in 10 cases (20%), and phacolytic uveitis was detected in 6 cases (12%). Herpes zoster was responsible in 5 (10%) cases and tuberculosis (TB) in 3 (6%) cases. Iridocyclitis associated with arthritis, septic focus, Fuchs' heterochromic iridocyclitis, leprosy, and inflammatory bowel disease was observed in 1 case (2%) each.
Table 7: Etiological distribution

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Perception of light, perception of rays

[Table 8] shows the visual acuity observed in 55 eyes before and after treatment. Before treatment 4 eyes had visual acuity perception of light + perception of rays + (7.27%), 6 eyes had <6/60 (10.91%),9 eyes 6/60 (16.36%), 5 eyes 6/36 (9.09%), 6 eyes 6/24 (10.91%),7 eyes 6/18 (12.73%), 11 eyes 6/12 (20%), 6 eyes 6/9 (10.91%) and 1 eye 6/6 (1.82%). Following treatment, 70.91% of patients regained visual acuity of 6/9 or better. In a few patients, visual acuity improved only marginally because of associated complications, such as complicated cataract and secondary glaucoma commonly seen in chronic and recurrent cases
Table 8: Visual acuity before and after treatment

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[Table 9] shows the treatment. In the present study, all the 50 patients (100%) were treated with topical steroids and cycloplegics-mydriatics. Periocular steroid was given in 9 patients (18%) of which one had bilateral chronic anterior uveitis and received injections to both the eyes. Systemic steroids were used in 18 patients (36%), which included 6 patients of phacolytic uveitis, 5 herpetic uveitis patients, 3 patients of TB, 2 idiopathic, and one each in leprosy and psoriatic patient. 13 patients (26%) received antiglaucoma therapy. Three patients (6%) received anti-TB antivirals were considered in 5 cases (10%), and all of them had herpetic anterior uveitis. One patient who had already been started on antileprosy therapy was continued. Systemic antibiotics were given in 13 patients (26%) (7 underwent cataract extraction, 4 chronic idiopathic cases, one each in inflammatory bowel disease and septic arthritis)
Table 9: Treatment

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Majority of patients responded well to medical line of treatment. A case of visually significant complicated cataract underwent synechiotomy and extracapsular cataract extraction with posterior chamber intraocular lens implantation.

As [Table 10] shows, in the present study, complications were observed in 18 eyes (32.72%). The most common complication was persistent posterior synechiae seen in 13 eyes (23.64%), cataract in 8 eyes (14.54%), secondary glaucoma in 7 eyes (12.73%) followed by iris atrophy in 3 eyes (5.45%), and macular edema in 1 eye (1.82%). Most of the eyes which had complications had more than one complication.
Table 10: Complications

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  Discussion Top


The present study was conducted in the in the department of ophthalmology at a general hospital in Jaipur, during July 2017 to June 2018 and fifty cases of anterior uveitis were studied.

The incidence was found to be high between 20 and 40 years of age (64%) and less common over 60 years (10%). Idiopathic anterior uveitis was the commonest cause which can be explained by high antigenicity found in this age group.

In older age group, anterior uveitis was usually of phacolytic origin.

It was observed that males were affected more (56%) compared to females (44%). This may be because men tend to seek medical attention more often than women, and socio-economic habits may put male patients at a greater risk for development of anterior uveitis. In Rathinam et al. study, 61.3% were males and 38.7% were females.[7] Alezandro Rodriguez et al. reported 38.9% male and 61.1% female involvement in their study [as shown in [Table 11]].[7]
Table 11: Gender comparison

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Majority of patients were laborers (46%). The most common cause of anterior uveitis in laborers was blunt trauma. This may be due to occupational exposure.

Majority of patients came with unilateral presentation (90%). This finding was comparable with that of Rathinam et al. study (85.3%).[2] However, there was no significant predilection for either the right or left eye.

The most common presentation was acute iridocyclitis (76%) than chronic (18%) and recurrent iridocyclitis (6%). Rathinam et al. reported 71.9% acute, 24.3% chronic and 3.8% recurrent. The findings are comparable in both the studies [Table 12].
Table 12: Chronicity comparison

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In this study, 45 patients (90%) had non granulomatous inflammation and in 5 patients (10%), it was granulomatous. Findings are comparable with previous studies. Out of 5 granulomatous inflammation, 4 were chronic and 1 patient had recurrent presentation. Granulomatous type of inflammation was observed in three patients of TB, one patient of herpes, and one patient of leprosy [Table 13].
Table 13: Comparison of type of inflammation

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In the present study, blunt trauma (20%) was the most common cause of anterior uveitis followed by phacolytic (12%) etiology. Although herpes zoster accounted for 10% of the cases, which is comparable with the other two studies where it stood first, it is not the most common in the present study. However, it was the most common infectious cause in our study. 6% of the patients had tubercular anterior uveitis which is comparable with Rathinam et al. and Singh et al. study, whereas there is no data in Henderly et al. study. This difference may be because all other studies were conducted at referral centers, where cases, usually chronic and recurrent ones, are referred from primary and secondary centers. Whereas the present study was done in a general ophthalmic clinic, and most people were from villages.[8]

In the present study, uveitis was found to be associated with diabetes mellitus in five patients (10%) and hypertension in two (4%) patients. All those who had diabetes mellitus were above 50 years of age. Three out of five diabetes mellitus patients had chronic uveitis. In a study of uveitis presenting in the elderly, it was noted that diabetes should probably be considered a risk factor for uveitis development.[9]

Visual acuity was 6/12 or worse in majority (87.3%) of eyes at presentation. Following treatment, most eyes regained visual acuity of 6/9 or better (70.91%). In few eyes with complicated cataract or macular edema, visual acuity improved only marginally.[10]

No complications were seen in 37 eyes (67.27%). Complications were commonly noted in chronic and recurrent cases. The most common complication observed was persistent posterior synechiae in 13 eyes (23.64%), cataract in 8 eyes (14.54%). Secondary glaucoma was seen in 7 eyes (12.73%), which included 2 herpetic eyes, both the eyes in a psoriatic patient, two idiopathic, and one eye in TB anterior uveitis. Iris atrophy was seen in 3 eyes (5.45%), two of them in a leprosy patient, and the third was in a herpetic patient and macular edema was seen in 1 eye (1.82%).

A short differential diagnosis was made in each case after complete ocular and systemic examination with tailored approach to the laboratory investigations.

All patients were treated medically by topical steroids and cycloplegics-mydriatics. Treatment with antibiotics, antitubercular drugs, antileprosy and antiviral drugs were considered in appropriate cases. Periocular and systemic steroids were used in cases with severe inflammation which was not controlled by topical steroids. A case of visually significant complicated cataract underwent synechiotomy and extracapsular cataract extraction with posterior chamber intraocular lens implantation. Cataract extraction with posterior chamber intraocular lens implantation was done in all cases of phacolytic anterior uveitis. In all cases, surgery was done under cover of systemic steroids.[11]

Majority of the patients responded well to the medical line of treatment.

This is a prospective study done during July 2017 to June 2018. We studied 50 cases of anterior uveitis, with emphasis on evaluating the possible etiology, associated complications, and treatment outcome.

  1. Anterior uveitis is a relatively common ocular condition
  2. In the present study, males were affected more than the females
  3. Patients in the age group of 20-40 years were commonly involved
  4. Laborers were by for the commonly involved group in this study, blunt trauma was the leading cause in them, and this may be due to the risk of injury at their workplace. The next common group was that of officials, and most of them had an idiopathic disease
  5. Majority of the patients had acute presentation
  6. 90% of the patients presented with unilateral ocular involvement; among them, right eye involvement was slightly more than the left eye involvement in the ratio of 5:4. Both eyes' involvements was seen in 10% of the patients, all of them had either chronic or recurrent disease, and four of them had identifiable etiology
  7. Nongranulomatous inflammation was the commonest form accounting for 90% of the cases. Granulomatous inflammation was seen only in chronic cases excepting one patient who had recurrent anterior uveitis
  8. Despite efforts, diagnosis remained obscure in 42% of the cases. Blunt trauma was the most common identifiable cause in 20% of the cases, more so in laborers. Herpetic etiology topped the list of infectious cause followed by TB. Septic foci, iridocyclitis associated with arthritis, Fuchs' heterochromic iridocyclitis, leprosy, inflammatory bowel disease are all relatively less common causes of anterior uveitis
  9. The challenge in anterior uveitis is to develop tailored laboratory investigations that will facilitate a diagnosis. This can be done by first considering the probable diagnosis based on the patent profile and then performing tailored laboratory evaluation
  10. A thorough systemic examination should be done to rule out any systemic disease, as it may be an early manifestation of systemic disease
  11. Majority of anterior uveitis patients respond to medical line of treatment
  12. Chronicity increases the risk of complications as does delay in receiving appropriate therapy, but early recognition and treatment of patients who are prone to recurrences can improve their outcome.



  Conclusion Top


Early diagnosis and treatment of patients results in good visual prognosis and is the key in management of anterior uveitis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rathinam SR. CME Series. All India Ophthalmological society. Uveitis made simple Work Up and Management Vol. 20. p. 1-42.  Back to cited text no. 1
    
2.
Rathinam SR, Namperumalsamy P. Global variation and pattern changes in epidemiology of uveitis. Indian J Ophthalmol 2007;55:173-83.  Back to cited text no. 2
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3.
Yanoff M, Duker JS, Augsburger JJ, Azar DT, Diamond GR, Dutton JJ, et al. Ophthalmology. 2nd ed., Vol. 2. Missouri (MO): Mosby; 2004. p. 1105-12.  Back to cited text no. 3
    
4.
Alio J, Ben Ezra D. Priority features of intraocular inflammation. Highlights Ophthalmol 2002;30:1-2.  Back to cited text no. 4
    
5.
Martin TM, Smith JR, Rosenbaum JT. Anterior uveitis: Current concepts of pathogenesis and interactions with the spondyloarthropathies. Curr Opin Rheumatol 2002;14:337-41.  Back to cited text no. 5
    
6.
Venkataraman A, Rathinam SR. A pre-and post-treatment evaluation of vision-related quality of life in uveitis. Indian J Ophthalmol 2008;56:307-12.  Back to cited text no. 6
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7.
Rodriguez A, Calonge M, Pedroza-Seres M, Akova YA, Messmer EM, D'Amico DJ, et al. Referral patterns of uveitis in a tertiary eye care center. Arch Ophthalmol 1996;114:593-9.  Back to cited text no. 7
    
8.
Singh R, Gupta V, Gupta A. Pattern of uveitis in a referral eye clinic in North India. Indian J Ophthalmol 2004;52:121-5.  Back to cited text no. 8
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9.
Brewerton DA, Caffrey M, Nicholls A, Walters D, James DC. Acute anterior uveitis and HLA-B27. Lancet 1973;3:994-6.  Back to cited text no. 9
    
10.
McCannel CA, Holland GN, Helm CJ, Cornell PJ, Winston JV, Rimmer TG. Causes of uveitis in the general practice of ophthalmology. UCLA Community-Based Uveitis Study Group. Am J Ophthalmol 1996;121:35-46.  Back to cited text no. 10
    
11.
Kido S, Sugita S, Horie S, Miyanaga M, Miyata K, Shimizu N, et al. Association of varicella zoster virus load in the aqueous humor with clinical manifestations of anterior uveitis in herpes zoster ophthalmicus and zoster sine herpete. Br J Ophthalmol 2008;92:505-8.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13]



 

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