Journal of Medical Sciences and Health
Year: 2023, Volume: 9, Issue: 2, Pages: 224-228
Original Article
B V Vinutha1 , Rashmi Shetu2 , Sundeep 3 , Konduru Rishitha2 , V Pallavi Naragund2 , J Babitha2
1Assistant professor, Kempegowda Institute of Medical Sciences, Bengaluru,
2 Junior Resident, Kempegowda Institute of Medical Sciences, Bengaluru,
3Professor and HOD, Kempegowda Institute of Medical Sciences, Bengaluru
Address for correspondence:
Rashmi Shetu, Junior Resident, Kempegowda Institute of Medical Sciences, Bengaluru.
E-mail: [email protected]
Received Date:02 January 2023, Accepted Date:12 April 2023, Published Date:26 September 2023
Purpose: To describe the clinical features, causes and management of patients with acute anterior uveitis. Methods: A prospective study of clinical features, complication and prognosis was done on anterior uveitis patients for a period of 10 months. Detailed history, complete ocular examination, systemic evaluation and relevant investigations were done in 64 patients, appropriate systemic and ocular management was done. Results: Of 64 patients, 65.6% were male and 34.3% female. Mean age of presentation was 42.6 years. 71.8% unilateral and 28.1% bilateral eye involvement was seen. Visual acuity was between 6/18-3/60 at the time of presentation. 21.8% had Tuberculosis, 9.3% had Trauma, 4.6% had UTI, 3.1% had ankylosing spondylitis (HLA B27 associated) and 3.1% had rheumatoid arthritis, 3.1% had sarcoidosis and 1.5% had toxoplasmosis. 53.1% were idiopathic. Complications were noted in 50% of cases, 25% had secondary glaucoma, 21.8% had posterior subcapsular cataract and 3.1% has cystoid macular edema. Appropriate medical management was started in patients. Conclusion: Idiopathic uveitis was higher in our study. Trauma was the most common non-infectious entity, Tuberculosis was most common infectious cause in our study, all patients responded well with medication.
Keywords: Anterior uveitis, Etiology, Complications
Uveitis is inflammation of uvea which is the middle vascular layer of the eye. Anterior uveitis refers to inflammation of iris and anterior part of ciliary body i.e., pars plicata 1, 2. If the inflammation is confined to iris, it is called iritis. If inflammation involves iris and ciliary body, it is called iridocyclitis. Anterior uveitis can have varied presentation. Amount of inflammation can range from mild to moderate to severe reaction.
Anterior uveitis has diverse range of etiology. Etiology of anterior uveitis is influenced by various geographic and ethnic factors. In spite of better understanding of etiopathogenesis and newer diagnostic modalities, finding cause of uveitis in many cases is difficult. Uveitis may require detailed investigations to find etiological diagnosis.
Uveitis can lead to sight threatening complication if adequate and timely treatment is not given leading to blindness. It contributes to 25% of blindness in developing countries 3 . Sight threatening complications in uveitis include complicated cataract, glaucoma, cystoid macular edema and retinal damage. Accurate diagnosis and timely treatment may prevent complications and hence blindness 4, 5.
Etiology of anterior uveitis can change over time 6, 7 . Various studies on pattern of uveitis from different parts of India have been reported 8, 9, 10, 11 . This study was done at our hospital to evaluate various causes, clinical features and complications in anterior uveitis patients.
This is a hospital based prospective study done in department of Ophthalmology. Study duration was from January 2021 to October 2021. All the newly diagnosed patients with anterior uveitis who attended ophthalmology OPD were included in
69 patients were diagnosed with anterior uveitis and 64 patients were included for the study. Detailed history was taken in all the patients. Complete eye examination was done including visual acuity testing using Snellen visual acuity chart. Slit lamp examination was done to note type of keratic precipitates and their distribution. Anterior chamber cells and flare were graded. Any iris nodules, iris atrophic patches, anterior peripheral synechiae, posterior synechiae were looked for and noted. State of crystalline lens was noted. Intra ocular pressure measurement by Goldmann applanation tonometry and gonioscopy using Goldmann single mirror was done. Detailed fundus examination was done using 90D and by indirect ophthalmoscopy. OCT of macula was done in cases suspected of cystoid macular edema.
Laboratory case investigation were done depending on differential diagnosis. Complete hemogram, ESR, CRP, Urine analysis, Urine Culture and sensitivity, RA Factor, Mantoux Test, Elisa for HIV, HLA B27, Chest X-ray, X-ray of Sacroiliac and Lumbosacral Spine and CT chest were done.
Patients were treated with topical corticosteroids, topical cycloplegics and non-steroidal anti-inflammatory drugs. Depending on anterior chamber reaction, few patients received anterior subtenon triamcinolone acetonide 20mg injection under aseptic conditions. Specific treatment for underlying etiology where ever established was given. Pulmonologist consultation was taken for patients with TB and sarcoidosis. Immunologist opinion was taken in collagen vascular diseases and systemic medications were started accordingly.
Patients were followed up for 6 months. During each visit, complete ocular examination was done including visual acuity. Anterior chamber reaction was assessed and improvement on deterioration was documented.
Initially all patients were followed up weekly for 2 weeks. Later frequency of follow-up was decreased to once in 15 days for two visits and monthly for 5 months. Patients were asked to come immediately if any symptoms like pain, redness in eyes or decreased vision occurred.
Complications like raised intraocular pressure and complicated cataract were noted. Raised intraocular pressure was treated with topical antiglaucoma medication. Cataract surgery wherever required was done under corticosteroid cover. Patient were educated about the condition and need to use topical medication properly. Topical medications were tapered depending on patient’s condition.
Ethical committee clearance was taken for the study on 04/12/2020. Ethical clearance certificate number is KIMS/IEC/AO47/M/2020. Informed consent was obtained from all the patients before study. Results were expressed as percentage.
During our study period, 69 patients were diagnosed as anterior uveitis according to SUN working group anatomical classification. Among them 64 patients were included for study (based on inclusion and exclusion criteria) in our study, age of patients ranged from 25 to 60yrs. Maximum number of patients were in 40 to 49 years of age group (Table 1).
|
Age (years) |
No. of patients |
Percentage % |
|
20 – 29 |
7 |
10.9% |
|
30 – 39 |
19 |
29.6% |
|
40 – 49 |
24 |
37.5% |
|
50 – 59 |
10 |
15.6% |
|
>60 |
4 |
6.2% |
Mean age of presentation was 42.6 years. None of our patients were below 20 years. 34.3% patients were females and 65.6% were male patients. In 71.8% patients one eye was involved 28.8% patients had both eyes involved. In our study right eye was affected in 32% of patients and left eye in 40% patients. Majority of our patients (93.7%) had single episode of uveitis, whereas 6.25% patients had recurrent episodes of uveitis after 4 months of inactivity.
Visual acuity at the time of presentation ranged from 6/18 to 3/60 with majority of patients in 6/60 to 6/18 group (Table 2).
|
Visual Acuity |
Percentage % |
|
6/6 – 6/12 |
25 |
|
6/18 – 6/60 |
55 |
|
6/60 – 3/60 |
20 |
Following the treatment, visual acuity improved to 6/6 to 6/12.
Gonioscopy showed Shaffer’s Grade IV angles in 28 patients, Grade III in 34 patients and Grade II in 2 patients. Patchy hyperpigmentation of trabecular meshwork was seen in 20 patients. None of our patients had angle neovascularization or PAS.
Urine culture and sensitivity showed E. coli growth in 2 patients and Klebsiella growth in 1 patient.
Non granulomatous uveitis was seen in 70.4% patients and granulomatous uveitis developed in 29.6% patients. Despite detailed investigation, etiological diagnosis for anterior uveitis could be done in 46.9% patients and 53.1% patients were idiopathic.
Infectious etiology was found in 28.1% of patients among them, tuberculosis was the commonest accounting for 21.8%, followed by urinary tract infection in 4.6% of patients and toxoplasmosis in 1.5% patients. These patients were referred to physician and was treated with appropriate oral antibiotics for 7 days and oral Nitrofurantoin for 7 days. Noninfectious etiology accounted for 24.8% of patients, trauma was the commonest noninfectious cause, 9.3% patients followed by Ankylosing Spondylitis in 3.1% patients, sarcoidosis in 9.3% patients and rheumatoid arthritis in 3.1% patients (Table 3).
|
Etiology |
No. of patients |
Percentage |
|
Idiopathic |
34 |
53.1% |
|
Tuberculosis |
14 |
21.8% |
|
Trauma |
6 |
9.3% |
|
UTI |
3 |
4.6% |
|
Sarcoidosis |
2 |
3.1% |
|
Rheumatoid arthritis |
2 |
3.1% |
|
Ankylosing Spondylitis |
2 |
3.1% |
|
Toxoplasmosis |
1 |
1.5% |
Complicated cataract developed in 21.4% patients. These patients underwent cataract extraction with PCIOL implantation under the cover of oral corticosteroids. Cystoid macular edema developed in 6.2% patients. In our study none of the patients developed hypotony or phthisis bulbi.
Intraocular pressure ranged from 12 to 36 mm Hg with mean IOP of 18mm Hg. Elevated intraocular pressure developed in 22% of patients. These patients were medically treated with anti-glaucoma medication and IOP reduced in all of them.
Anterior uveitis has varied etiology and presentation. Diagnosis of underlying cause of uveitis and appropriate treatment results in limiting the vision threatening complications 9, 10. However, diagnosis underlying cause of uveitis is difficult in many cases due to varied ocular and systemic presentations.
Our study included 64 patients with anterior uveitis. Majority of our patients were males which correlated with Rodriguez et al 12. Mean age of presentation was 41.6 years which correlated with Borde et al. study 13, Dogra M et al. 14, Hussain SPM et al. 15
71.8 % of our patients had unilateral eye involvement, bilateral involvement was seen only in 28.8% of patients. Right eye was involved in 32% and left eye involved in 40%. Rathinam et al. 16 also reported unilateral involvement in 85.3%. 70% of our patients had non granulomatous uveitis and 29.6% granulomatous uveitis. 93.7% of our patients had single episode of uveitis recurrence was seen in 6.26%. Sudha Madhavi et al.17 study reported acute anterior uveitis in 75.85% and recurrent uveitis in 6% and Chronic uveitis in 17.8%. Chandravanshi study reported acute anterior uveitis in 82.0%, recurrent episodes in 11.32% and chronic in 6.6% cases.
Etiological diagnosis for anterior uveitis could be established in 46.9% in our study with 53.1% being idiopathic cases. This correlates with Singh et al. study which showed etiological diagnosis in 48.8%. Infectious causes accounted for 21.8% and noninfectious causes 24.8%. Tuberculosis was the commonest infectious cause (18.7%) in our study. R Singh et al. 4 and Prashant Borde et al. 13 study also reported tuberculosis as most common infectious causes for anterior uveitis. Both anterior and posterior segment of eye can be involved in tuberculosis. Granulomatous uveitis is common in tuberculosis but it can present as non-granulomatous uveitis also. These patients require standard anti tubercular treatment along with ocular management.
Urinary tract infection was seen in 9.3% patients in our study. Two patients had E. coli and one patient had Klebsiella growth in urine culture. None of our patients had leprosy or syphilis as underlying cause of uveitis.
Trauma was commonest non-infectious cause (9.3%) followed by rheumatoid arthritis (3.1%), ankylosing spondylitis (3.1%) and sarcoidosis (3.1%). These results correlate with Prashant Borde et al. study 13. Chandravanshi study reported rheumatoid arthritis in 2.8%, trauma in 0.9% and Ankylosing spondylitis in 0.9% of patients.
Complications in uveitis can be due to uveitis or secondary to treatment. Complications are influenced by time of presentation and severity of disease.
Complications were seen in 50% of patients in our study. Elevated IOP was the commonest complication (25%) followed by cataract (21.8%) and cystoid macular edema (3.1%) (Table 4).
|
Complications |
No. of patients (n) |
Percentage (%) |
|
Elevated IOP |
16 |
25 |
|
Posterior subcapsular cataract |
14 |
21.8 |
|
Cystoid macular edema |
2 |
3.1 |
Rothova A et al. 18 showed cataract in 19% and glaucoma in 11%. None of our patients developed band keratopathy or hypotony.
Anterior uveitis is important sight threatening disorder. Due to diverse underlying etiological causes, tailored tests are essential to come to definitive diagnosis. Timely recognition of complication and appropriate management is very essential in preserving vision.
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