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ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 3  |  Page : 127-131

Pattern of uveitis in a tertiary eye care center in Western India


1 Department of Opthalmology, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India
2 Department of Research, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India

Date of Web Publication11-Oct-2017

Correspondence Address:
Aratee C Palsule
Department of Opthalmology, Deenanath Mangeshkar Hospital and Research Center, Erandwane, Pune - 411 004, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_40_16

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  Abstract 

Context: Uveitis is potentially sight-threatening disease. The age-sex adjusted prevalence of uveitis in India is 0.73%. Few studies from South and North India have reported the pattern of uveitis but none from Western India. Aim: The aim of the study was to report the pattern of uveitis in Western India and compare the findings with those seen in other studies from various parts of India and abroad. Settings and Design: This study was a retrospective study. Subjects and Methods: The diagnosis of uveitis and the associated systemic diseases was based on a detailed clinical history, ophthalmological, general physical examination, and laboratory tests. Anatomical location of the inflammation was assigned based on the Standardization of Uveitis Nomenclature criteria. Results: One hundred and ninety-eight patients were included in the study. Nearly 55.6% were female; mean age at presentation was 39.70 ± 14.06 years. Anterior uveitis was the most common variant (n = 82 [41.4%]), followed by panuveitis (n = 42 [21.2%]), posterior (n = 41 [20.7%]), and intermediate uveitis (n = 33 [16.7%]). Out of 198 patients, 98 (49.5%) were idiopathic and 100 (50.5%) patients with specific etiology. Fifty-five patients were diagnosed to have infectious etiology and 45 were noninfectious. Presumed ocular tuberculosis was leading cause for infectious etiology seen in 29 (52.73%) patients. Among the noninfectious patients, human leukocyte antigen B-27 (HLA B-27)-associated uveitis was the most common cause seen in 24 (53.33%) patients. Conclusions: Pattern of uveitis is not entirely same in different geographic areas. HLA B-27-associated uveitis was the most common noninfectious entity, and presumed ocular tuberculosis was leading cause for infectious entities in Western India.

Keywords: Human leukocyte antigen B27, presumed ocular tuberculosis, uveitis, Western India


How to cite this article:
Palsule AC, Jande V, Kulkarni AA, Beke NN. Pattern of uveitis in a tertiary eye care center in Western India. J Clin Ophthalmol Res 2017;5:127-31

How to cite this URL:
Palsule AC, Jande V, Kulkarni AA, Beke NN. Pattern of uveitis in a tertiary eye care center in Western India. J Clin Ophthalmol Res [serial online] 2017 [cited 2017 Dec 14];5:127-31. Available from: http://www.jcor.in/text.asp?2017/5/3/127/216432



Uveitis is potentially sight-threatening disease presently the third leading cause of blindness in the United States.[1] One of the primary deciding factors in the management of uveitis is a correct etiological diagnosis, for example, infectious, autoimmune, and traumatic. The etiologies can have multitude of regional variations attributable to environmental factors, racial and genetic diversities.

The correct diagnosis of uveitis is often challenging, as many of these disorders share common and often overlapping clinical patterns. In spite of advances in diagnostic techniques, the etiology of uveitis remains uncertain in many cases, and they are labeled idiopathic. According to some studies, a better understanding of genetic, ethnic, demographic, and environmental factors influencing uveitis has led to elaboration of newer patterns.[2],[3],[4]

The literature includes many reports from the Western world describing the epidemiology of uveitis in Caucasians.[5],[6],[7],[8],[9] From India, a study by Dandona et al. showed that an age-sex adjusted prevalence of uveitis is 0.73%.[10] A study by Rathinam and Namperumalsamy suggested that nearly 1 in 200 persons in rural South India have been affected by ocular inflammation in at least one eye by mid-to-late adulthood.[2] Studies from some parts of India[2],[11] have shown a higher percentage of infectious uveitis than other developed countries.[5],[12],[13] Biswas et al. and Singh et al. have reported the pattern of uveitis from tertiary eye centers in South and North India.[11],[14] Till date, no study was carried out to see the pattern of uveitis in urban area of Western India; hence we planned a retrospective analysis in Department of Ophthalmology of a tertiary teaching hospital in Pune, Maharashtra, with objective of describing the epidemiological pattern of uveitis and to compare the same with that seen in other parts of India.


  Subjects and Methods Top


The study was approved by the Institutional Ethics Committee of our hospital in Pune, Maharashtra, India. This observational study included an analysis of medical records of 198 consecutive patients with ocular inflammation, who presented to the uveitis services in the Department of Ophthalmology in a tertiary care hospital at Pune, from December 2011 to July 2015. Patients who did not have adequate record to classify anatomically or etiologically were excluded from the study. Demographic information such as age and gender, details of ocular examination, investigations, diagnosis, course and duration of disease, laterality, anatomical location, and systemic disease association were noted for all patients.

The diagnosis for uveitis and associated systemic diseases was based on a detailed clinical history, ophthalmological and general physical examination, and laboratory tests. Ocular examination included visual acuity, detailed slit-lamp examination, and intraocular pressure. Anatomical location of the inflammation and classification as acute or chronic uveitis was assigned based on the Standardization of the Uveitis Nomenclature (SUN) criteria.[15] The laboratory investigations were ordered keeping in mind the probable differential diagnosis in each case and included a subset of complete blood count, erythrocyte sedimentation rate, C-reactive protein, urine analysis, Mantoux test, blood sugar level, renal function test, and liver function test. Antineutrophil cytoplasmic antibodies, antinuclear antibodies, human leukocyte antigen B-27 (HLA B-27), serum angiotensin-converting enzyme levels, serum calcium levels serologic tests for human immunodeficiency virus (HIV), venereal disease research laboratory test, anti-toxoplasmosis antibodies, and anti-West Nile River virus antibodies. Radiological investigations included X-rays of chest, sacroiliac joints, and lumbosacral spine and in some patients high-resolution computed tomography of chest were also performed. Consultation was sought from physicians, rheumatologists, chest physician, infectious disease specialist, and oncologist when indicated.

Presumed ocular tuberculosis was diagnosed based on clinical signs of granulomatous uveitis, iris nodules, broad-based posterior synechiae, intermediate uveitis, choroidal tubercles; serpiginous-like chorioditis and retinal vasculitis. Diagnosis was made if one or more of these signs were present along with positive Mantoux test or positive QuantiFERON Gold test, evidence of old healed pulmonary tuberculosis.[16] None of the patients had polymerase chain reaction or biopsy for demonstrating bacilli. All other possible causes of uveitis were excluded before the diagnosis of presumed ocular tuberculosis.


  Results Top


The records of 198 patients with a mean age of 39.7 ± 14.06 years were analyzed retrospectively. Male:female ratio was 1:1.25 and 55.6% were female. At presentation, 125 (63.1%) patients had acute, 45 (22.7%) had chronic, and 28 (14.1%) had recurrent disease. Ninety-six (48.5%) patients had unilateral disease and 102 (51.5%) had bilateral disease. Among anterior uveitis patients, 56 (68.3%) had unilateral disease whereas 39 (92.9%) panuveitis patients had bilateral disease. Anatomical distribution of the disease (according to SUN classification) revealed anterior uveitis as the most common variant (n = 82 [41.4%]), followed by panuveitis (n = 42 [21.2%]), posterior (n = 41 [20.7%]), and intermediate uveitis (n = 33 [16.7%]) [Table 1]. Out of 198 patients, 98 (49.5%) were idiopathic and 100 (50.5%) patients with specific etiology.
Table 1: Comparison of anatomical presentation of uveitis with other studies (percentage of total patients)

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Fifty-five patients were diagnosed having infectious etiology, of which presumed ocular tuberculosis was the most common infection seen in 29 (52.7%). Among the noninfectious 45 patients, HLA B-27-associated uveitis was the most common etiology seen in 24 (53.3%) followed by Vogt–Koyanagi–Harada (VKH) syndrome in 5 (13.3%) patients [Table 2]. Among patients with specific etiology, patients with anterior uveitis had maximum (78.9%) noninfectious etiology whereas posterior uveitis patients had maximum, i.e., 26 (92.85%) infectious etiology [Table 3].
Table 2: Infectious and noninfectious etiologies in the patients with a definite diagnosis (percentage of total patients)

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Table 3: Anatomical classification of infectious and noninfectious cases in patients with definite diagnosis (n=100) (percentage of total patients)

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Out of 82 patients of anterior uveitis, specific diagnosis could be reached in 38 (46.3%) patients. HLA B-27-associated uveitis was the most common etiology seen in 24 (29.3%) patients. Among the posterior uveitis cases (n = 41 [20.7%]), specific diagnosis could be reached in 28 (68.3%) patients. Presumed ocular tuberculosis seen in eight patients (19.5%) and toxoplasmosis seen in eight (19.5%) patients [Table 4]a.
Table 4a: Comparison of the most common causes of anterior uveitis and posterior uveitis with other studies (percentage of total patients)

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In panuveitis (n = 42 [21.2%]), specific diagnosis could be made in 24 (57.1%) patients; of which presumed ocular tuberculosis was the most common cause seen in 9 (21.4%) patients followed by VKH syndrome in 6 (14.3%) patients. Intermediate uveitis (n = 33 [16.7%]) had highest number of pars planitis in 23 patients (69.7%) and specific diagnosis could be made in 10 (30.3%) patients. The most common cause that could be determined was presumed ocular tuberculosis in 8 (24.3%) patients [Table 4]b.
Table 4b: Comparison of the most common causes of intermediate uveitis and panuveitis with other studies (percentage of total patients)

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In this study, ten (5.1%) patients were retroviral disease (RVD) positive. Seven patients showed posterior uveitis, two patients showed anterior uveitis, and one showed intermediate uveitis. Among RVD-positive patients, specific diagnosis could be reached in eight patients, two patients had presumed ocular tuberculosis, four patients had cytomegalovirus (CMV), and herpes and cryptococcal infection was seen in one patient each. CD4 count of all CMV retinitis patients was <100.


  Discussion Top


Uveitis is a disease with myriad presentations and etiologies. For optimal and prompt management of any uveitic entity, reaching a probable diagnosis is vital, which is influenced by clinical signs in a patient as well as other epidemiological factors. For any clinical parameter with comparable likelihood ratios, the final diagnosis will be made depending on the prevalence (a major factor influencing pretest probability) of various etiological factors in that geographical area.[18] Hence, the anatomical and etiological distribution of uveitic entities would vary in different geographical regions depending on “host” factors (e.g., genetic makeup of the population) and other environmental factors (e.g., prevalent infectious agents). In a geographically vast country like India, these variations are expected in different regions of the same country. There is also a temporal variation in the distribution of uveitis in studies from the same geographical region, possibly due to evolving understanding of uveitic entities and identification of newer diagnostic patterns.[19] This was the rationale behind the present study to assess the profile of uveitis patterns in this part of India and comparing the same with that from other parts of India as well as overseas data.

In the present retrospective, single tertiary health-care center-based study conducted in Western India, case records of 198 patients of uveitis were analyzed for the epidemiological characters. The study population largely included a homogenous pool of urban individuals residing in Western India.

Anatomical distribution of uveitis in the present study was comparable with other regional studies in India [Table 1].[11],[17],[20] However, the distribution varies in other countries from the developing world.[13],[21],[22],[23] In a study by Zheng et al.[21] from China, the intermediate uveitis accounted for only 1% of the study population, whereas the study by Pathanapitoon et al.[22] from Thailand reported posterior uveitis accounting for 46% among the uveitis patients. On the other hand, a landmark study from the developed world shows patterns comparable with those in the present study.[5] Overall, among the anterior uveitic entities, the leading cause was HLA B-27-associated diseases (29.3%), which was comparable with other series [Table 4]a.[11],[17] In posterior uveitic entities, the leading causes were infectious entities such as tuberculosis and toxoplasmosis (19.5% each) which is significantly different from a study by Singh et al.,[11] in which tuberculosis accounted for 8.9% and a study by Das et al. had reported tuberculosis in 5.43% [Table 4]a.[17] However, the study by Singh et al.[11] did not include the cases with serpiginous choroidopathy in the presumed ocular tuberculosis group. The majority of the serpiginous choroiditis in India are now labeled as multifocal serpiginoid choroiditis, an entity that is thought to be linked with tubercular hypersensitivity in India; a testimony to the evolving understanding of pathogenesis of uveitic entities. This could explain the seemingly different distribution of etiologies of posterior uveitis in these studies from the same country.

Among the panuveitic entities, our study found a large number of idiopathic uveitis (42.9%) cases; however, few of these may be advanced VKH patients that could not be labeled as such due to lack of prior records and late presentation to an uveitis expert. The panuveitis patients with definitive cause, tuberculosis was seen as the predominant cause, accounting for 21.4%, comparable with 26% in the study by Singh et al. [Table 4]b.[11]

The significant deviation from other studies occurred in our intermediate uveitis group, which showed 24.3% patients to be due to presumed tubercular etiology, which accounted for only a minority in other case series 4% in the study by Singh et al.[11] and 10% in the study by Das et al. [Table 4]b.[17] However, a latter study by Parchand et al.[24] found the tubercular etiology in 46.7% intermediate uveitis patients.

Pathanapitoon et al. from Thailand have reported 31% of their uveitis patients as HIV positive and CMV retinitis in 26.5% of all the patients with uveitis.[22] A study from Japan has reported sarcoidosis in 6.9% and VKH in 11%.[23] In China, they have reported Behcet's disease (10.1%) and VKH (9.5%).[21] Within India, some differences were observed in the etiology. Das et al.[17] reported toxoplasmosis as a major cause (40.21%) of posterior uveitis, which is much higher than any reports from India including ours. Rathinam et al.[25] found leptospirosis is a leading cause of anterior uveitis (9.7%), which has not been reported from any other part of the country. Increased use of newer diagnostic techniques may help to reduce the number of idiopathic cases.


  Conclusions Top


HLA B-27-associated uveitis is the most common noninfectious entity and presumed ocular tuberculosis is leading cause for infectious entities in Western India. Presumed ocular tuberculosis remains an important cause of uveitis in our part of the world, and active efforts should be made to look for it. There are regional trends in the etiological pattern and anatomical distribution of uveitis. The knowledge of prevalence of different etiologies in a region helps in diagnosing the uveitic entities.

Acknowledgment

Authors would like to acknowledge Department of Ophthalmology at Deenanath Mangeshkar hospital and research center for their support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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