|Year : 2017 | Volume
| Issue : 2 | Page : 73-76
Pattern of posterior uveitis in a tertiary care government eye hospital in South India
Sikander Ali Khan Lodhi, Sudhakar G Reddy, Amena Maryam
Department of Ophthalmology, Retina Unit, Sarojini Devi Eye Hospital, Osmania Medical College, Hyderabad, Telangana, India
|Date of Submission||17-Jul-2015|
|Date of Acceptance||02-May-2016|
|Date of Web Publication||25-Apr-2017|
Sikander Ali Khan Lodhi
“Hill View”, 10-3-300/3, Humayun Nagar, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Background: The spectrum of uveitis cases is largely influenced by genetic, geographic, and environmental factors. The causes and types of posterior uveitis cases in patients attending a Tertiary Care Eye Hospital, attached to Government Medical College, in a major South Indian city catering to two important states were studied. Aim: To analyze the pattern of posterior uveitis in a tertiary care government eye hospital. Design: Retrospective noncomparative case series. Materials and Methods: A retrospective analysis of 101 posterior uveitis cases attending the retina/uvea outpatient department of a major government eye hospital, seen between January 2014 and June 2015, was done to know the clinical pattern of the posterior uveitis entities. A comprehensive eye examination with a tailored laboratory investigations approach was used to arrive at a diagnosis. Results: Of the 101 patients, there were 56 (55.5%) males and 45 (44.5%) females, in the age group of 15–65 years. A specific diagnosis could be established in 75% of the patients, including infections in 19 cases (18%), specific ocular disease in 45 cases (44.5%). Idiopathic group comprised 25 cases (24.75%). In the infective group, tuberculosis was more than toxoplasmosis. Vogt-Koyanagi-Harada (VKH) cases, presenting as posterior uveitis, comprised 19 cases (18.8%). Conclusion: Tuberculosis and toxoplasmosis were the common infective causes, and VKH, multifocal choroiditis, and serpiginous choroidopathy were the common noninfective entities.
Keywords: Choroiditis, posterior uveitis, toxoplasmosis, tuberculosis, Vogt-Koyanagi-Harada
|How to cite this article:|
Lodhi SA, Reddy SG, Maryam A. Pattern of posterior uveitis in a tertiary care government eye hospital in South India. J Clin Ophthalmol Res 2017;5:73-6
|How to cite this URL:|
Lodhi SA, Reddy SG, Maryam A. Pattern of posterior uveitis in a tertiary care government eye hospital in South India. J Clin Ophthalmol Res [serial online] 2017 [cited 2017 Dec 14];5:73-6. Available from: http://www.jcor.in/text.asp?2017/5/2/73/205188
Uveitis is a term applied to a wide range of conditions that are characterized by intraocular inflammation. The inflammation involves not only the uveal tract but also the adjacent retina and vitreous. The pattern of uveitis is influenced by genetic, ethnic, geographic, and environmental factors. The pattern has undergone a change over time with the emergence or identification of newer types of uveitic patterns. This is also due to the availability of better diagnostic techniques.
Uveitis includes a large number of intraocular inflammatory conditions of different etiologies. However, still, the etiological diagnosis remains a challenge in spite of better understanding and advanced diagnostic techniques. The standardization of uveitis nomenclature (SUN) working group classifies uveitis according to the site of primary inflammation as “anterior uveitis,” “intermediate uveitis,” “posterior uveitis,” and “panuveitis.”
A number of studies on the patterns of uveitis are reported from Southern, Eastern, and Northern India.,, We present this study on the pattern of cases of posterior uveitis from the retina/uvea clinic of a Tertiary Care Eye Hospital, attached to Government Medical Colleges in a major South Indian city, catering to two important neighboring states.
| Materials and Methods|| |
The clinical data of all patients of posterior uveitis seen at our clinic between January 2014 and June 2015 were analyzed retrospectively. The study was approved by the ethics subcommittee of the hospital and adhered to the tenets of the declaration of Helsinki. All patients had a comprehensive eye examination and a thorough systemic evaluation. Complete ophthalmic examination including visual acuity, slit lamp examination, applanation tonometry, dilated fundus examination with 90 diopter (D), and indirect ophthalmoscope was done in all cases. Laboratory tests such as complete blood picture, erythrocyte sedimentation rate, Mantoux test, random blood sugar, human immunodeficiency virus test, X-ray chest, and venereal disease research laboratory test were done in all cases. Other investigations were tailored according to the need in a given case. These include fundus fluorescein angiography (FFA), optical coherence tomography, ultrasound B scan (USG), TORCH profile, QuantiFERON-TB GOLD test, and RA factor. Rheumatogist's, endocrinologist's, and pulmonologist's opinion, whenever necessary, were sought in most of the cases.
The diagnosis of intraocular tuberculosis was made if the patient fulfilled the criteria A with B or C:
- A - Clinical suspicion if any two of the following features present: (i) Granulomatous anterior uveitis, (ii) active periphlebitis, (iii) neuroretinitis, (iv) retinochoroiditis, (v) subretinal granuloma
- B - Corroborative evidence (any of the two) (i) Mantoux >20 mm, (ii) positive X-ray chest, (iii) aqueous or vitreous tap positive for polymerase chain reaction, (iv) sputum positive for acid-fast Bacilli, (v) histopathological evidence of tuberculosis from cervical or parahilar lymph nodes
- C - Response to antituberculous treatment.
The diagnosis of choroiditis was made in the presence of a focal retinochoroiditis lesion with overlying viritis, supported by positive toxoplasma serology. The diagnosis of Vogt-Koyanagi-Harada (VKH) was made according to the revised diagnostic criteria for VKH disease. All cases of VKH with posterior segment findings of serous detachments, choroidal thickening on B-scan (USG), and characteristic findings on FFA (early hypofluorescence, multiple pinpoint hyperfluorescent lesions, and pooling of dye in serous detachments) were included in the study. Idiopathic posterior uveitis was referred to cases where no specific cause could be attributed to an infective cause, any underlying systemic disease, or any specific ocular cause.
| Results|| |
The records of 101 posterior uveitis patients during January 2014 and June 2015 were analyzed. There were 56 (55.5%) males and 45 (44.5%) females. The mean age at presentation was 29.5 years in males and 32.6 in females (range of 15–65 years).
A specific diagnosis [Table 1] could be established in 75% of the cases, including infections in 19 cases (18%), specific ocular disease in 45 cases (44.5%). Idiopathic cases comprised 25 cases (24.75%). In the infective group, the number of tuberculosis cases (nine cases 8.9%) was more than the cases of toxoplasmosis etiology determined (seven cases 6.9%). Different types of presumed tubercular posterior uveitis are shown in [Figure 1],[Figure 2],[Figure 3],[Figure 4]. Different types of toxoplasma retinochoroiditis are shown in [Figure 5] and [Figure 6]. There were two cases of cytomegalovirus retinitis and one case of dengue retinal vasculitis [Figure 7].
|Figure 6: Active toxoplasma choroioretinitis (the classic “headlight in fog” appearance)|
Click here to view
Multifocal choroiditis (15 cases 14.9) was the most common specific diagnosis followed by serpiginous choroiditis (nine cases 8.9%).
VKH cases comprised 19 cases (18.8%). Most of these cases belong to “probable VKH (isolated ocular disease)” group. Some of the manifestations of VKH cases are shown in [Figure 8],[Figure 9],[Figure 10],[Figure 11].
|Figure 8: Multiple serous retinal detachments in a case of Vogt-Koyanagi-Harada|
Click here to view
|Figure 9: Fundus fluorescein angiography shows multiple pinpoint leaks and pooling of dye in serous retinal detachments|
Click here to view
|Figure 11: Optical coherence tomography scan in a case of Vogt-Koyanagi-Harada shows multilobular serous detachments, intraretinal edema with subretinal septae|
Click here to view
| Discussion|| |
The patterns and causes of uveitis vary from center to center depending upon the geographic, ecological, nutritional, racial, and socioeconomic differences. Ours is a government eye hospital, a government medical college hospital, catering to all the districts of Telangana and Andhra Pradesh. The population of posterior uveitis cases presented in this study is from two important South Indian states. This population has a fairly uniform background. Higher incidence is seen in males (55.5%) as compared to females (44.5%). This is similar to various studies from other centers in India.,, The most common entity causing posterior uveitis was VKH. VKH in this study is included as a posterior uveitis entity because all these cases presented with multiple serous retinal detachments (RDs). It is very surprising to see a very high number of cases of VKH. Maybe with more awareness and better diagnostic techniques, we are diagnosing more number of cases of VKH as a cause for multiple serous RDs. Otherwise, the other most common specific uveitis entity is multifocal choroiditis, which is significantly less than the study from North India  and another study from Tamil Nadu, South India. Serpiginous choroidopathy constituted 8.9% of the total causes for posterior uveitis, which is much less than the study from North India by Singh et al. and from Northeast India by Das et al., but it is comparable to a similar study from Tunisia [Table 2]. Toxoplasmosis and tuberculosis are comparable with the study from North India. However, the studies by Das et al. from Northeast India and Khairallah et al. from Tunisia show a very high incidence of toxoplasmosis; this may be due to differences in geographic factors within the same country and between different countries.
The causative pattern of posterior uveitis with changes in geographic, ecological, racial, and socioeconomic factors is reflected in this uveitic population. Specific entities such as multifocal choroiditis, serpiginous choroiditis, and VKH are identified in this study. These findings together with reports from other parts of the country reflect a significant population of uveitis patients with visual impairment due to uveitis. In most of the cases of tuberculosis, we are still making a diagnosis of “presumed ocular tuberculosis.” There is a need for better facilities to diagnose and start antitubercular treatment under physicians' supervision whenever there is a strong suspicion of ocular tuberculosis.
|Table 2: Comparison of common causes of posterior uveitis with other studies (percentage of total patients)|
Click here to view
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Barry RJ, Nguyen QD, Lee RW, Murray PI, Denniston AK. Pharmacotherapy for uveitis: Current management and emerging therapy. Clin Ophthalmol 2014;8:1891-911.
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.
Biswas J, Narain S, Das D, Ganesh SK. Pattern of uveitis in a referral uveitis clinic in India. Int Ophthalmol 1996-1997;20:223-8.
Singh R, Gupta V, Gupta A. Pattern of uveitis in a referral eye clinic in North India. Indian J Ophthalmol 2004;52:121-5.
] [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]
Read RW, Holland GN, Rao NA, Tabbara KF, Ohno S, Arellanes-Garcia L, et al.
Revised diagnostic criteria for Vogt-Koyanagi-Harada disease: Report of an international committee on nomenclature. Am J Ophthalmol 2001;131:647-52.
Khairallah M, Yahia SB, Ladjimi A, Messaoud R, Zaouali S, Attia S, et al.
Pattern of uveitis in a referral centre in Tunisia, North Africa. Eye (Lond) 2007;21:33-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
[Table 1], [Table 2]