|Year : 2015 | Volume
| Issue : 2 | Page : 124-128
Study of clinical and aetiological pattern of anterior uveitis in middle Karnataka
KM Sudha Madhavi1, RC Kumaraswamy2
1 Department of Ophthalmology, Basaveshwara Medical College Hospital and Research Center, Chitradurga, Karnataka, India
2 Department of General Medicine, Basaveshwara Medical College Hospital and Research Center, Chitradurga, Karnataka, India
|Date of Web Publication||16-Mar-2015|
R C Kumaraswamy
Department of General Medicine, Basaveshwara Medical College Hospital and Research Center, NH-4 By-pass, Near Housing Board Colony, Chitradurga - 577 501, Karnataka
Source of Support: None, Conflict of Interest: None
Background and Objectives: Uveitis, a complex intraocular inflammatory disease results from several aetiological entities. The cause of inflammation might be infectious agent or trauma, but in most cases the underlying mechanism appears to be autoimmune in nature. Anterior uveitis is most common form of uveitis and accounts for an annual incidence rate of about 17 cases/1,00,000 population. Objective of this study is to evaluate the aetiological pattern, treatment and its outcome and complications of anterior uveitis. Methods: A prospective clinical study was done in the Department of Ophthalmology, Karnataka during December 2012 to May 2014. 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 determined aetiology. Patients were put on specific and nonspecific treatment and were followed up for a period of 6 months. Complications were noted. Results: The aetiology of uveitis remained unknown in most cases (42%). Most common cause was observed to be blunt trauma (20%) followed by phacolytic (12%). Most cases responded well to treatment. Commonest complication was posterior persistent synechiae (23.64%), and cataract was the second common (14.54%). Interpretation and Conclusion: Aetiological diagnosis remains undetermined in majority of cases. A thorough examination and investigation are 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: Aetiology, anterior, pattern, uveitis
|How to cite this article:|
Sudha Madhavi K M, Kumaraswamy R C. Study of clinical and aetiological pattern of anterior uveitis in middle Karnataka. CHRISMED J Health Res 2015;2:124-8
|How to cite this URL:|
Sudha Madhavi K M, Kumaraswamy R C. Study of clinical and aetiological pattern of anterior uveitis in middle Karnataka. CHRISMED J Health Res [serial online] 2015 [cited 2019 Jul 22];2:124-8. Available from: http://www.cjhr.org/text.asp?2015/2/2/124/153256
| Introduction|| |
Uveitis includes a varied group of intraocular inflammatory conditions that may occur at any age, but affecting mostly people of working age.  The average annual incidence of uveitis has been reported as approximately 14-17/1,00,000. ,,,, However in recent reports, its prevalence is almost tripled.  The total population prevalence of uveitis varies globally with an estimated prevalence of 730 cases/1,00,000 in India. 
Anterior uveitis is the most common intraocular inflammatory disease with a varying incidence across the globe.  The potential and severe consequences of untreated or recurrent anterior uveitis are probably underestimated and under-reported.  Anterior uveitis which can be categorized as iritis, anterior cyclitis and iridocyclitis, the last one is the most common type of all uveitic entities.  Anterior uveitis often causes a painful red eye with mild to moderate vision loss, but its long-term sequelae contribute significantly to the total burden. The precise cause of anterior uveitis is often obscure, and the correct diagnosis is often challenging. The treatment for uveitis itself can result in both ocular and systemic complications. The morbidity associated with the disease is moderately high. This study is done to assess the clinical ant etiological spectrum of anterior uveitis.
| Materials and methods|| |
This is a prospective clinical study which included 174 patients aged between 20 and 80 years, attending Outpatient Department of a Tertiary Care Teaching Hospital, with signs and symptoms of anterior uveitis. Necessary clearance from the Institutional Ethical Committee was taken, and informed consent was taken from all the study participants.
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 proforma was filled in all cases, which included salient feature in the history, visual acuity using snellens visual acuity chart, clinical findings, laboratory investigations, and the final aetiology. 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. Intraocular inflammation was assigned anterior uveitis based on International Uveitis Study Group Criteria.
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 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, mantoux test. Serological tests for, syphilis, HIV, rheumatoid factor was done in all cases. Radiological investigations included X-ray of chest, lumbosacral and knee joints. Other special investigations were considered whenever necessary.
Final aetiological diagnosis was made based on history, clinical features, laboratory investigations and systemic evaluation by other medical specialities.
The anterior uveitis was considered to have idiopathic aetiology when it was not associated with human leukocyte antigen-B27 haplotype and neither with defined clinical syndromes nor with definitive aetiology. 
All patients were treated medically with topical steroids (prednisolone acetate 1%) and topical cycloplegic mydriatics (atropine or homatropine). Steroids frequency was titrated according to the severity of uveitis. Appropriate treatment was given whenever etiology was known. Systemic antimicrobials were administered when infectious agent was found to be the cause. Systemic steroids were used when inflammation was severe, not responding to treatment and patients with macular oedema.
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|| |
A prospective observational study conducted at a multispecialty tertiary care hospital for 24 months period. [Table 1] summarizes the sociodemographic and clinical characteristics of the study participants. Male patients dominated the study accounting for 55.75% and the participants age varied from 20 to 80 years, but 63.8% of patients were young patients, aged between 20 and 40 years.
In our study majority of patients (89.66%) presented with uniocular involvement. About 75.86% of the patients presented with acute and 17.82% presented with chronic disease, 6% had recurrent uveitis. Nongranulomatous inflammation predominated the clinical presentation.
Graph 1 [Additional file 1] shows the occupation of the study participants. Most of the patients were manual laborers, officials and housewives accounted for almost equal proportions.
Graph 2 [Additional file 2] shows the distribution of etiological factors in our study. It was noted that cause was not recognized in significant (42%) number of patients. Among the identifiable diseases, blunt trauma accounted for 20% followed by phacolytic uveitis, which was the second most common identifiable cause. Herpes zoster was responsible for 10% of the disease.
[Table 2] shows the complications observed in the present study. Nearly 42% of the patients had no complications. Persistent posterior synechea was the most commonly observed complication followed by cataract. Secondary glaucoma was seen in 12.5%.
[Table 3] summarizes the visual outcome in our study participants. It is observed that nearly 34% of the patients had visual acuity of ≤6/60 at the time of presentation and the numbers improved to just over 2% after treatment. It is noted that vision of 82% of the patients improved to 6/12 or better as against 30% before therapy.
| Discussion|| |
In our study, 64% of patients were between 20 and 40 years of age and only 10% of the patients were aged over 60 years. This age predilection is similar many reported studies. , Idiopathic anterior uveitis was the commonest cause and which is similar previous reports. ,, This 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 more (56%) affected compared to females (44%), which is similar to observations made by Rathinam et al., , but in contrary Alezandro Rodriguez et al.  reported female preponderance of the disease. This may be because men tend to seek medical attention more often than women, and socioeconomic habits may put male patients at a greater risk for development of anterior uveitis.
Majority of patients in our study were laborers by occupation (47.7%). Most common cause of anterior uveitis in them was blunt trauma. This may be due to their occupational risk.
Majority of patients came with unilateral presentation (90%). This finding was comparable with that of Rathinam et al. , study (85.3%). 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 the recurrent iridocyclitis (6%). Rathinam et al. reported 71.9% acute, 24.3% chronic and 3.8%. In this study, 156 patients (90%) had nongranulomatous inflammation and in 18 patients (10%) it was granulomatous. Findings are comparable with previous studies; the findings were consistent with previous studies.  Out of 18 granulomatous inflammation 14 were chronic, and four patient had recurrent presentation. Granulomatous type of inflammation was observed in three patients of tuberculosis, one patient of herpes and one patient of leprosy.
In the present study, of the identifiable causes, 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 other two studies where it stood first, 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 are 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 present study was done in a general ophthalmic clinic and most people were from villages.
In present study, uveitis was found to be associated with diabetes mellitus in 17 patients (10%) and hypertension in 7 (4%) patients. All those who had diabetes mellitus were above 50 years of age. Ten out of 17 diabetes mellitus patients had chronic uveitis. In a study of uveitis presenting in elderly, it was noted that diabetes should probably be considered a risk factor for uveitis development. 
Visual acuity was 6/12 or worse in the 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.
No complications were seen in 80 eyes (41.7%). Complications were commonly noted in chronic and recurrent cases. Most common complication observed was persistent posterior synechiae in 45 eyes (23.43%), cataract in 28 eyes (14.6%). Secondary glaucoma was seen in 24 eyes; Iris atrophy was seen in 11 eyes (5.73%), and macular edema was seen in 4 eye (2.1%).
| Conclusion|| |
Despite exhaustive efforts to identify the cause, majority of the cases remained idiopathic. However, the prompt diagnosis and early initiation of appropriate treatment can save the vision without significant sequelae and good visual outcome.
| References|| |
Durrani OM, Tehrani NN, Marr JE, Moradi P, Stavrou P, Murray PI. Degree, duration, and causes of visual loss in uveitis. Br J Ophthalmol 2004;88:1159-62.
Darrell RW, Wagener HP, Kurland LT. Epidemiology of uveitis. Incidence and prevalence in a small urban community. Arch Ophthalmol 1962;68:502-14.
Mortensen KK, Slolie AK, Goldschmidt E. Uveitis, eine epdemiologische Unterschung. Ger Stsch Ophthalmol Ges 1981;78:97-101.
Vadot E, Barth E, Billet P. Epdemiology of uveitis-preliminary results of a prospective study in Savoy. In: Saari K, editor. Uveitis Update. Amsterdam: Elsevier; 1984. p. 13-6.
Baarsma GS. The epidemiology and genetics of endogenous uveitis: A review. Curr Eye Res 1992;11 Suppl: 1-9.
Tran VT, Auer C, Guex-Crosier Y, Pittet N, Herbort CP. Epidemiology of uveitis in Switzerland. Ocul Immunol Inflamm 1994;2:169-76.
Gritz DC, Wong IG. Incidence and prevalence of uveitis in Northern California; the Northern California Epidemiology of Uveitis Study. Ophthalmology 2004;111:491-500.
Dandona L, Dandona R, John RK, McCarty CA, Rao GN. Population based assessment of uveitis in an urban population in southern India. Br J Ophthalmol 2000;84:706-9.
Rothova A, Suttorp-van Schulten MS, Frits Treffers W, Kijlstra A. Causes and frequency of blindness in patients with intraocular inflammatory disease. Br J Ophthalmol 1996;80:332-6.
Jabs DA, Nussenblatt RB, Rosenbaum JT, Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol 2005;140:509-16.
Nussenblatt RB, Whitcup SM. Uveitis Fundamentals and Clinical Practice. 3 rd
ed. Pennsylvania (PA): Mosby; 2004. p. 273-86.
Rathinam SR, Namperumalsamy P. Global variation and pattern changes in epidemiology of uveitis. Indian J Ophthalmol 2007;55:173-83.
Singh R, Gupta V, Gupta A. Pattern of uveitis in a referral eye clinic in North India. Indian J Ophthalmol 2004;52:121-5.
Ozdal MP, Yazici A, Tufek M, Ozturk F. Epidemiology of uveitis in a referral hospital in Turkey. Turk J Med Sci 2014;44:337-42.
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.
Henderly DE, Genstler AJ, Smith RE, Rao NA. Changing patterns of uveitis. Am J Ophthalmol 1987;103:131-6.
Power JW. Introduction to uveitis. In: Albert DM, Jakobiec FA, Azar DT, Gragoudas ES, Power SM, Robinsom NL, editors. Principles and Practice of Ophthalmology. 2 nd
ed., Vol. 2. Pennsylvania (PA): WB Saunders Company; 2000. p. 1189-216.
[Table 1], [Table 2], [Table 3]