|Year : 2022 | Volume
| Issue : 4 | Page : 307-311
Pattern of uveitis in a rural eye care hospital in Tamil Nadu
AC Aparna1, Rangini Sundararajan1, V Raghuraman2, P Cynthia3
1 Consultant Ophthalmologist, BEENT Eye Hospital, Chengalpet, Tamil Nadu, India
2 VR Services, BEENT Eye Hospital, Chengalpet, Tamil Nadu, India
3 Medical Retina Services, BEENT Eye Hospital, Chengalpet, Tamil Nadu, India
|Date of Submission||17-Mar-2022|
|Date of Decision||07-Oct-2022|
|Date of Acceptance||07-Oct-2022|
|Date of Web Publication||19-Dec-2022|
A C Aparna
No: 76, Voltas Colony, 6th Street, Nanganallur, Chennai - 600 061, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Aim: The aim of this study is to analyse the pattern of uveitis in a rural eye care hospital in Tamil Nadu. Understanding the shifting paradigm in uveitis, demographic differences in presentation, early diagnosis and treatment are very important in preventing ocular morbidity. Settings and Design: Retrospective Case study. Materials and Methods: Analysis of all the new cases of uveitis registered in our uvea clinic between December 2020 and April 2021 was done. Comprehensive eye examination and tailored investigations were done. Results: Among the 85 new cases of uveitis registered in the uvea clinic, 78 patients were included in the study. The mean age at presentation was 38.38 and ranged (4–77) years. The male: female ratio was 0.73. Anterior uveitis was the commonest type of uveitis (44.87%) followed by intermediate uveitis (24.35%), posterior uveitis (17.94%) and pan uveitis (12.82%). Aetiology was unknown in 30.76% (24/78) cases. HLA B27 association was noted in 22.8% of anterior uveitis cases. Sixteen patients had tuberculous aetiology. Ocular complications were noted in about 23.07% of patients and cataract was the most common complication. Conclusions: This study aims at analysing the pattern of uveitis in a rural area. Understanding the aetiology of uveitis whether infectious or autoimmune is of paramount importance to advice tailored investigations and to start early specific treatment. Delay in presentation and irregular follow-up, especially in patients from rural areas would result in permanent damage to ocular tissues and loss of visual function.
Keywords: Aetiology, complications, rural areas, uveitis
|How to cite this article:|
Aparna A C, Sundararajan R, Raghuraman V, Cynthia P. Pattern of uveitis in a rural eye care hospital in Tamil Nadu. TNOA J Ophthalmic Sci Res 2022;60:307-11
|How to cite this URL:|
Aparna A C, Sundararajan R, Raghuraman V, Cynthia P. Pattern of uveitis in a rural eye care hospital in Tamil Nadu. TNOA J Ophthalmic Sci Res [serial online] 2022 [cited 2023 Feb 8];60:307-11. Available from: https://www.tnoajosr.com/text.asp?2022/60/4/307/364241
| Introduction|| |
Uveitis is a vision-threatening disease with varied aetiology. It is characterised by intraocular inflammation. In rural areas, there is a delay in initial diagnosis due to late presentation to the eye hospitals. The cost of laboratory investigations done for diagnosis and treatment of a few uveitic conditions also indirectly causes a delay in treatment. Irregular follow-up and discontinuation of treatment despite proper education on the disease pose a risk of recurrences and ocular complications that can lead to partial or complete loss of vision in these patients. This study aims at understanding the pattern of uveitis in a rural eye hospital and to plan tailored investigations and treatment accordingly.
| Subjects and Methods|| |
Retrospective analysis of case records of all the new cases of uveitis seen in our uvea clinic between December 2020 and April 2021 was done. Among the 85 patients with uveitis, 78 patients who had a regular follow-up for at least 2 months were included in the study. Patients who lost to follow-up were excluded from the study. Demographic details and history including the specific uveitic history were noted. All the patients had undergone complete ophthalmic evaluation, which included best-corrected visual acuity, slit-lamp examination of the anterior segment and fundus examination by slit-lamp biomicroscopy with +90 D lens and indirect ophthalmoscopy with +20 D lens. Intraocular pressure was recorded with Goldmann Applanation tonometer. Findings of the comprehensive eye evaluation done at the time of presentation were analysed. Details of the ancillary investigations that aid in the diagnosis of the disease like fundus fluorescein angiography, optical coherence tomography or B scan ultrasonography were noted. Laboratory investigations were done according to the clinical diagnosis made. Basic uveitis workup included total leucocyte count, differential count, erythrocyte sedimentation rate and blood sugar levels. Mantoux test, Immunoglobulin release assay (Quantiferon TB Gold Test), serum angiotensin-converting enzyme levels, Venereal Diseases Research laboratory (VDRL) test, TPHA (Treponema Pallidum Heam Agglutination), ELISA for HIV, Anti-Toxoplasma antibodies titre, C Reactive protein, Rheumatoid Factor, Anti-Nuclear Antibodies andHuman leucocyte antigens HLA B27 and HLA B51 were done according to the clinical suspicion and the reports were noted. Radiological investigations like Chest X-ray, High-resolution CT scan of the chest and X-ray of the sacroiliac joints if done were noted. Few patients who were referred to the internist, rheumatologist or pulmonologist for management of the associated systemic conditions were asked to have a proper follow-up and the details of the systemic disease and the treatment given were noted. Anatomical diagnosis was made based on the Standardisation of Uveitis Nomenclature (SUN) classification as anterior, intermediate, posterior or panuveitis. Aetiological classification was made after a study of the investigations was done and classified as idiopathic, infectious or non-infectious uveitis. Diagnosis of ocular tuberculosis was made based on the guidelines given by Gupta et al. Diagnosis of sarcoidosis was made based on the ocular sarcoidosis criteria by International Workshop on Ocular Sarcoidosis (IWOS). The study is a retrospective study done by collecting the details from the records of patients seen. No interventional study was done in the hospital.
| Results|| |
Retrospective analysis of 85 new cases of uveitis registered in the uvea clinic between December 2020 and April 2021 was done. Seventy-eight patients who had a follow-up for at least 2 months were included in the study. Mean age at presentation was 38.38 [Figure 1].
Among the 78 patients, 33 were male and 45 were female. The male: female ratio was 0.73. Unilateral disease was noted in 38 cases and bilateral disease in 40 cases. [Table 1]
In our study, we found that anterior uveitis (n = 35) was the most common type, followed by intermediate uveitis (n = 19), posterior uveitis (n = 14) and panuveitis (n = 10). Based on the aetiological diagnosis made, idiopathic uveitis was noted in 24/78 cases (30.6%). Among patients with non-infectious uveitis, HLA B27-positive spondylo arthropathy was associated with anterior uveitis in six patients (7.69%) and sarcoidosis was diagnosed in six cases (7.69%) Traumatic anterior uveitis was noted in 11.4% patients. [Table 2]. Ocular tuberculosis 16/78 (20.51%) cases were the most common infection. Post fever uveitis was noted in three patients
Among 78 cases, 18 cases (23.07%) were observed to have complications of uveitis. Complicated cataract was the most common complication noted at the time of presentation in 10/18 (12.8%) patients. Other complications such as secondary glaucoma, cystoid macular oedema and band-shaped keratopathy were also noted and the details are given in [Table 3].
| Discussion|| |
Our study included patients belonging to rural areas. Delayed presentation to the clinic, difficulty in making an aetiological diagnosis, completing the course of treatment and having a regular follow-up become difficult in most of the patients due to economic reasons. Our study showed that the male: female ratio was 0.7. Other similar studies showed that males were more affected. Study by Biswas et al. comparing the changing uveitis patterns over 2 decades found that gender-wise, there was a significant decline in male preponderance from 64% to 56% (P = 0.0187). Unilateral disease was noted in 38 cases. Unilateral disease was more common in anterior and posterior uveitis and bilateral disease in intermediate and panuveitis.
Anterior uveitis (n = 35) was the most common type noted in 44.8% of our patients. This was comparable with other studies from northeast India and central India., Patients with anterior uveitis were found to have unilateral disease more commonly than bilateral disease. Intermediate uveitis had a bilateral presentation, which is similar to other studies mentioned above.
Among the 35 patients with anterior uveitis, 34.2% (n = 12) had idiopathic disease. HLA B27-associated anterior uveitis was seen in six cases. Five out of six of these cases had unilateral disease. A study by Majumdar et al. on the clinical profile of HLA B27-associated anterior uveitis observed a male predominance (67%), and more unilateral involvement (58%) in their patients. One of our patients had a typical bamboo spine appearance on radiological examination at the time of presentation to the ophthalmologist. All the patients were referred to a rheumatologist for systemic evaluation of disease activity and were started on oral steroids and immune suppressants or biological agents. Four patients with anterior uveitis had a history of trauma and one among them presented with an associated traumatic cataract. A study by Borde et al. showed that traumatic aetiology was noted in 14.5% of their patients. In our study, traumatic uveitis was noted in 5.1%. Fuchs heterochromic iridocyclitis (FHI) was diagnosed based on clinical examination in patients presenting with typical signs like stellate keratic precipitates and absence of posterior synechiae. Analysis of aqueous humour for infections like rubella or toxoplasmosis to rule out Fuchs-like uveitis was not done. One of the three patients of FHI who presented with us with elevated intraocular pressure and complicated cataract underwent cataract surgery with IOL implantation after control of glaucoma. Another patient with FHI was diagnosed with pseudophakic cystoid macular oedema and was treated with intravitreal dexamethasone implant and the intraocular pressure was within normal limits. Study by Babu et al. on associations of Fuchs heterochromic iridocyclitis in a south Indian patient population showed that among the 58 patients, 33 were males and 25 were females and complicated cataract was seen in 22 eyes and intraocular pressure (IOP) was raised in 10 eyes (16.95%). An 8-year-old patient who presented with acute anterior granulomatous uveitis with band-shaped keratopathy had a negative tuberculin test and elevated serum ACE levels for that age. Child responded to topical steroids. Systemic evaluation was done by a rheumatologist and is on regular follow-up for juvenile rheumatological conditions and sarcoidosis. Other features suggestive of Blau syndrome were not made out. Study on paediatric uveitis by Ganesh et al. showed that 2% of cases of anterior uveitis were associated with sarcoidosis. Though leprosy-associated uveitis is rarely seen, one of our patients with a history of treatment for leprosy taken 15 years earlier had presented with acute anterior uveitis. He was referred for systemic evaluation at Central Leprosy Training and Research Institute and was found not to have an active systemic infection. One of our patients on brimonidine eye drops for glaucoma presented with bilateral granulomatous anterior uveitis. Systemic investigations were normal and responded well on using alternate antiglaucoma drug. Descriptive case series on brimonidine-associated uveitis by Hopf et al. showed that granulomatous anterior uveitis following topical brimonidine use and the mean age of the patient was 76 years (SD) ± 10 years.
Intermediate uveitis was found to be idiopathic in 47% of our patients' incidence of which is higher when compared with the study by Das et al. from northeast India, which showed that intermediate uveitis was noted in 12.9% of their patients and among them, 77.5% were found to be idiopathic. Ocular tuberculosis was diagnosed in six (35%) of our patients. Two patients presented with vitritis and normal fundus examination had a history of fever lasting for 2 to 3 days just 3 weeks prior to the appearance of floaters. Investigations were within normal limits and were diagnosed as fever-associated intermediate uveitis. Oral steroids were started after systemic evaluation by an internist and both of them responded well to treatment. According to the study on the pattern of uveitis in a tertiary eye care centre in central India, posterior uveitis was noted in 12.8%. In our study, 14 (17.9%) had posterior uveitis. Tuberculosis was associated with two patients and one of them presented with multifocal choroiditis. [Figure 2] and [Figure 3]. Two patients had typical toxoplasma retinochoroiditis diagnosed clinically and confirmed by raised immunoglobulin G and M levels and had good recovery following treatment with anti-toxoplasma drugs given under oral steroid cover [Figure 4]. One of our patients presented with a history of blurring of vision. There was no history of viral prodrome. Examination showed visual acuity of 6/9 and multiple subretinal lesions without evidence of vitritis. Systemic investigations were normal and follow-up showed fading lesions and there was complete disappearance of the lesions after 2 weeks with only topical anti-inflammatory medications. [Figure 5]. Two of our patients had retinal vasculitis and one of them had a chicken pox infection 2 weeks prior to the onset of visual symptoms. Patient recovered well on treatment with oral steroids started after consultation with the internist. Another patient with retinal vasculitis had latent tuberculosis. A 13-year-old female patient with a history of undiagnosed fever and lower motor neuron facial palsy presented to us with panuveitis and elevated IOP. Clinical diagnosis of viral uveitis was made. Serum Ig G for VZV was positive and was treated with systemic antiviral treatment and steroids. A case of viral uveitis following VZV infection was reported by Buragohain et al.
|Figure 2: Colour fundus photograph of the posterior pole showing multiple active choroidal lesions associated with tuberculosis|
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|Figure 3: Fundus picture of the same patient as in figure 2, showing multifocal choroiditis and vasculitis|
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|Figure 4: Colour fundus photograph of the left eye showing an active choroiditis lesion close to a scar suggestive of toxoplasma retinochoroiditis|
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|Figure 5: Colour fundus photo of the right eye showing multiple faint subretinal lesions following a history of fever|
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|Figure 6: Colour fundus photo of the inferior retina showing vitreous opacities, perivascular sheathing and multiple yellowish choroidal lesions in a patient with sarcoidosis|
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Panuveitis was noted in 10 patients. Four out of 10 cases had ocular tuberculosis. Among the 78 uveitic patients included in our study, 16 cases (20.51%) were diagnosed as intraocular tuberculosis (IOTB). Study by Biswas et al. showed that the incidence of IOTB was 0.6% of all uveitis patients. Study by Dogra et al. from north India showed that 22.9% of cases of infectious uveitis were due to tuberculosis. VKH syndrome was diagnosed in two cases and one of them presented with inflammatory CNV. According to the study on the patterns of uveitis at a tertiary care hospital in Kolkata, Eastern India, panuveitis was seen in 22.7% and Behcet's disease (21.6% cases) was found to be more common than VKH syndrome (15.7%). In our study, Behcet's disease was not diagnosed in any patient. Panuveitis associated with sarcoidosis was noted in one patient. [Figure 6].
In our study, complications of uveitis were noted in 23.07%. Cataract was noted in 12.8% of the patients with complications. Cystoid macular oedema and secondary glaucoma were noted in 11.1% of the 18 patients with complications. Study on the pattern of uveitis in a tertiary eye care centre of central India by Borde et al. also found that cataract was the most common complication noted in 19.5% of their patients.
The limitation of our study is that the sample size is smaller and the period of study is short. Also, investigations like polymerase chain reaction of the aqueous humour for identification of the aetiological agent in a few cases where it was indicated could not be done.
| Conclusion|| |
In rural areas, it is difficult to perform battery of investigations or prescribe expensive agents in management of uveitis. We hope this study gives us an idea of the pattern of uveitis and will help us to advice tailored investigations, early identification and proper treatment which would definitely reduce the ocular morbidity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gupta A, Sharma A, Bansal R, Sharma K. Classification of intraocular tuberculosis. Ocul Immunol Inflamm 2015;23:7-13.
Mochizuki M, Smith JR, Takase H, Kaburaki T, Acharya NR, Rao NA, et al
. Revised criteria of International workshop on ocular sarcoidosis (IWOS) for the diagnosis of ocular sarcoidosis. Br J Ophthalmol 2019;103:1418-22.
Biswas J, Kharel Sitaula R, Multani P. Changing uveitis patterns in South India-Comparison between two decades. Indian J Ophthalmol 2018;66:524-7.
] [Full text]
Das D, Bhattacharjee H, Bhattacharyya PK, Jain L, Panicker MJ, Das K, et al
. Pattern of uveitis in North East India: A tertiary eye care center study. Indian J Ophthalmol 2009;57:144-6.
] [Full text]
Borde P, Priyanka, Kumar K, Takkar B, Sharma B. Pattern of uveitis in a tertiary eye care center of central India: Results of a prospective patient database over a period of two years. Indian J Ophthalmol 2020;68:476-81.
] [Full text]
Majumdar AK, Kumar A, Roy R, Dutta Majumder P. Clinical profile of HLA B-27-Associated uveitis patients in a tertiary care eye hospital in Eastern India. Ocul Immunol Inflamm 2019;27:718-21.
Babu K, Adiga M, Govekar SR, Kumar BR, Murthy KR. Associations of fuchs heterochromic iridocyclitis in a South Indian patient population. J Ophthalmic Inflamm Infect 2013;3:14.
Ganesh SK, Bala A, Biswas J, Ahmed AS, Kempen JH. Pattern of pediatric uveitis seen at a tertiary referral center from India. Ocul Immunol Inflamm 2016;24:402-9.
Hopf S, Mercieca K, Pfeiffer N. Brimonidine-associated uveitis-a descriptive case series. BMC Ophthalmol 2020;20:489.
Buragohain S, Das D, Misra P, Chaudhary P, DasMohapatra SS, Agarwalla I, et al
. Varicella zoster virus infection presenting with unilateral panuveitis. TNOA J Ophthalmic Sci Res 2019;57:316-8. [Full text]
Biswas J, Narain S, Das D, Ganesh SK. Pattern of uveitis in a referral uveitis clinic in India. Indian J Ophthalmol 1995;43:117-21.
] [Full text]
Dogra M, Singh R, Agarwal A, Sharma A, Singh SR, Gautam N, et al
. Epidemiology of uveitis in a tertiary-care referral institute in North India. 2017;25(sup 1):S46-53.
Bandyopadhyay S, Ghanta AK, Mandal A. Patterns of uveitis at a tertiary care hospital in Kolkata, Eastern India. Sudanese J Ophthalmol 2019;11:54-8. [Full text]
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]