Pattern of Uveitis in a Referral Hospital in Bangladesh

Purpose: To report the pattern of uveitis in a tertiary eye care center in Bangladesh.

Methods: Retrospective analysis of all uveitis cases visiting uveitis clinic of Bangladesh Eye Hospital between January, 2009 and April, 2015.

Results: In total, 652 patients (mean age 32.3 years, female 47.8%) were included in the study. Uveitis was bilateral in 42.6% of cases. Anterior uveitis was the most common (39.2%) case, closely followed by intermediate uveitis (22.2%), posterior uveitis (22%), and panuveitis (16.4%). Specific diagnosis was established in 53.3% of patients. The three most common specific diagnoses were ocular tuberculosis (10.7%), followed by HLA-B27-related uveitis (10.1%) and Vogt–Koyanagi–Harada disease (VKHD; 8.4%).

Conclusion: Ocular tuberculosis remained an important cause of uveitis in Bangladesh while HLA-B27 and VKHD were found to be the most common non-infectious uveitic entity.     

Chikungunya Virus Infection Manifesting as Intermediate Uveitis

Purpose: To describe a case of intermediate uveitis caused by chikungunya virus infection in the Western Hemisphere.

Methods: Case report of a patient diagnosed with chikungunya infection presenting with blurry vision and floaters.

Results: Exam revealed a unilateral intermediate uveitis, with an extensive work-up positive for chikungunya virus immunoglobulin M and G titers. The patient responded to oral corticosteroids with signs and symptoms resolving over the course of 3 months’ treatment.

Conclusions: While anterior uveitis and retinitis are the most common ocular manifestations of chikungunya infection, we report here a case of chikungunya infection presenting as an intermediate uveitis, responding well to oral corticosteroids. This case demonstrates the varied presentation of chikungunya-related uveitis and highlights its consideration in the differential diagnoses of those who have had preceding systemic viral symptoms and uveitis.     

Brimonidine Induced Anterior Uveitis

Purpose: To present the largest series reported so far of brimonidine induced granulomatous anterior uveitis.

Methods: Retrospective chart review of patients with chronic glaucoma on treatment with brimonidine presenting with anterior uveitis.

Results: 19 eyes of 12 patients with chronic glaucoma developed anterior uveitis with granulomatous keratic precipitates after being treated with brimonidine for periods of 7 days to 5 years (mean 19.7 months, +18.6 months). One patient had a gap of 1 year between onset in one eye and onset in the other. Ten eyes (52.6%) had concurrent granulomatous conjunctivitis; 16 eyes were pseudophakic. Stopping brimonidine led to complete, rapid resolution of uveitis in all patients, in most cases (11 eyes, 58%) without topical corticosteroids. No recurrences have occurred after withdrawal of brimonidine, over a follow-up period of 12–52 months (mean 27.9 months, +13.8 months).

Conclusions: Ophthalmologists should be aware of this easily reversible uveitis syndrome that is induced by a common glaucoma medication. Familiarity with this entity is essential in making the correct diagnosis and avoiding unnecessary investigations and interventions.     

Tonic Pupil in Cytomegalovirus Anterior Uveitis in an Immunocompetent Adult Male – A Case Report

Purpose: To report an interesting case of development of tonic pupil in an immunocompetent male with cytomegalovirus (CMV) anterior uveitis.

Methods: Retrospective case report

Results: A 30-year-old Iranian healthy male was diagnosed to have Posner–Schlossman syndrome (OS). Aqueous tap was positive for CMV by multiplex Polymerase chain reaction (PCR). Adequate control of inflammation and Intraocular pressures (IOP) were achieved with topical steroids, ganciclovir gel, and antiglaucoma medications. On a follow-up visit, he complained of recent onset of blurring of vision (OS) despite appropriate refractive correction, quiet anterior chamber, and normal IOP. Pupillary examination showed anisocoria (larger pupil in OS). Pupillary constriction (OS) on instillation of 0.125% pilocarpine drops confirmed the diagnosis of a tonic pupil.

Conclusion: We describe a unique finding of tonic pupil on a follow-up examination in an immunocompetent adult male with CMV anterior uveitis. A prior association has not been described in literature (Medline Search).     

Intravitreal Adalimumab in Active Noninfectious Uveitis: A Pilot Study

Purpose: To evaluate the short-term efficacy of intravitreal adalimumab (IVA) for the treatment of eyes with active noninfectious uveitis.

Methods: Consecutive eyes with active noninfectious uveitis were injected with IVA at 0, 2, then every 4 weeks for total of 26 weeks.

Results: Six out of 7 patients (12 of 13 eyes) completed 26 weeks of treatment. One patient (1 eye) failed treatment. Seven out of 12 eyes had improvement of ≥2 ETDRS lines. Three out of three eyes had resolution of anterior chamber cells. And 9 of 10 eyes with vitreous haze had zero haze at 26 weeks. Five out of 8 eyes with macular edema had complete resolution. Median fluorescein angiography score improved from 14 to 4 on last follow-up.

Conclusions: IVA was effective in controlling the inflammation, decreasing the macular edema, and improving the best corrected visual acuity in the majority of eyes in this series.     

Change in Visual Function in Uveitis Patients after Treatment: An Experience from Nepal

Purpose: To assess the change in visual function in uveitis patients after treatment.

Materials and methods: This one and a half year prospective study was conducted among 180 new uveitis patients. A questionnaire was used to assess the visual function in uveitis cases and analysis of effect size change was also done.

Results: The male to female ratio was 1.3:1. The mean vision at presentation was 0.49 logMAR units, which improved to 0.39 logMAR units and 0.35 logMAR units by the 1st and 4th week but deteriorated to 0.62 logMAR units at the 6th week. Anterior uveitis and posterior uveitis patients had significant improvement (p≤0.001) in all three scales but panuveitis and intermediate uveitis had significant improvement (p<0.05) in two scales. The effect size showed small to large change in all three scales.

Conclusions: Visual function is adversely affected by uveitis, which can be improved after treatment.     

Occurrence of and Risk Factors for Ocular Hypertension and Secondary Glaucoma in Juvenile Idiopathic Arthritis-associated Uveitis

Purpose: To describe the incidence of ocular hypertension (OHT) and secondary glaucoma (SG) in JIA-associated uveitis, identify risk factors for development of these complications, and describe their effect on visual outcomes.

Methods: A retrospective cohort of 108 patients (196 eyes) with JIA-associated uveitis seen over 30 years at an academic practice.

Results: Of examined eyes, 40% had OHT or SG at presentation. These eyes had a nearly three-fold higher incidence of legal blindness during follow-up, compared with eyes without OHT or SG. An additional 41 eyes developed OHT or SG during follow-up. Presenting with anterior uveitis, active inflammation, and using systemic corticosteroids were risk factors for developing OHT, while use of immunosuppressive medication at presentation reduced this risk. Risk factors for developing SG included anterior uveitis and use of systemic corticosteroids.

Conclusions: OHT and SG were common in patients with JIA-associated uveitis. Use of immunosuppressive drugs may decrease the risk of developing OHT.     

Bilateral Herpes Simplex Uveitis: Review of the Literature and Own Reports‏

Purpose: Herpes simplex-associated uveitis is usually considered a unilateral eye disease, and rarely included in the differential diagnosis whenever there is bilateral involvement. We report three cases of bilateral herpetic anterior uveitis.

Methods: We evaluated three patients who presented with clinical manifestations of bilateral uveitis suggestive of viral origin.

Results: We found intraocular hypertension, cells in the anterior chamber, paralytic mydriasis, iris atrophy with transillumination defects, and variable anterior vitreous cellularity. According to the clinical findings, supported with herpes-specific antibody titers and aqueous humor PCR results in two of them, they were diagnosed with bilateral anterior herpetic uveitis.

Conclusions: Our patients were initially misdiagnosed as having non-infectious uveitis and were treated with immunomodulatory medications, which could have favored the extension of infection bilaterally. Although uncommon, bilateral herpetic uveitis should always be considered in the differential diagnoses, when patients present with hypertensive uveitis in both eyes.     

Clinical Patterns and Causes of Uveitis in a Referral Eye Clinic in Qatar

Purpose: To determine the patterns and causes of uveitis in a referral eye clinic in Qatar.

Methods: A retrospective study was conducted on all cases of uveitis that presented to the Uveitis Clinic at Hamad Medical Corporation from March 2007 to February 2011. All patients had detailed ocular, medical examination, and uveitis work up.

Results: The study included 310 patients. Anterior uveitis was noted in 53.2% of cases (165/310), followed by panuveitis 16.8% (52/310), intermediate uveitis 16.5% (51/310), and posterior uveitis 13.6% (42/310). Causes of uveitis were determined in 69.7% (216/310) of cases. The most commonly identified causes of uveitis in our study were presumed ocular tuberculosis (14.5%), Fuchs uveitis (11.0%), Behçet disease (7.4%), and VKH disease (6.8%).

Conclusions: Anterior uveitis is the most common anatomic/clinical form of uveitis in Qatar and the etiologic diagnosis of uveitis should focus in particular on presumed ocular tuberculosis, Fuchs uveitis, Behçet disease, and VKH disease.     

Efficacy of Anti-TNF-α Therapy for the Treatment of Non-infectious Uveitis: A Retrospective Study of 21 Patients

Purpose: To assess the efficacy of anti-TNF alpha (TNF-α) therapy in patients with non-infectious uveitis.

Methods: This was a monocentric observational study of 21 patients with non-infectious uveitis treated with anti-TNF-alpha. The primary endpoint was the control of ocular inflammation. The secondary endpoints included the study of macular thickness and visual acuity, changes in other treatments, and adverse effects.

Results: The etiologies of uveitis were Behçet disease (33.3%), birdshot (14.3%), sarcoidosis (9.5%), and idiopathic uveitis (42.9%). Ocular inflammation was controlled at 3 months for 80.9% of patients, at 6 months for 94.7%, at 12 months for 83.3%, and at >12 months for 86.7%. Central macular thickness improved from 452 µm at baseline to 307.5 µm at 12 months (p = 0.002). Visual acuity also improved from 0.51(logMAR) before treatment to 0.24 at 12 months. The mean daily dose of prednisone decreased from 19.7 mg before treatment to 5.2 mg at 12 months (p < 0.001). A total of 9.5% of patients experienced serious side-effects.

Conclusions: Our study confirms the efficacy of anti-TNF for the control of short-term and long-term ocular inflammation, with high rates of complete clinical remission.     

Clinical Characteristics of Herpes Simplex Virus Associated Anterior Uveitis

Purpose: The aim of this study is to describe the clinical characteristics of molecularly proven Herpes simplex virus (HSV) anterior uveitis.

Methods: The literature on HSV anterior uveitis whereby the diagnosis was confirmed by polymerase chain reaction (PCR) and or Goldmann–Witmer coefficient in aqueous humor was reviewed. Three studies from Europe and one from Japan could be included.

Results: It was observed that HSV anterior uveitis is mostly an acute unilateral disease mainly occurring in middle-aged people with a predominance in females. The incidence of keratitis in HSV is between 33 and 41%. High intraocular pressure is frequently observed and ranged from 46 to 90%. Sectorial iris atrophy may be absent, especially early in the disease.

Conclusion: The clinical characteristics of HSV anterior uveitis can mimic other viral and non-infectious anterior uveitis entities especially at onset. Aqueous humor analysis for PCR and GWC can be useful in case of suspected viral uveitis.     

In Vivo Laser Confocal Microscopy Using the HRT-Rostock Cornea Module: Diversity and Diagnostic Implications in Patients with Uveitis

Purpose: Keratic precipitates (KP) are a common feature of uveitis. We prospectively examined KP with the Heidelberg Retinal Tomograph II confocal laser scanning microscope and Rostock Corneal Module (HRT-RCM) to explore their diagnostic implications.

Methods: Prospective, observational, multicenter study. HRT-RCM images were classified by two masked observers.

Results: 120 scans on 120 eyes from 110 subjects were included. The majority (N = 93) had non-infectious uveitis. Sixty eyes had active disease at scanning. Eight KP morphologies were defined. Agreement between the two masked graders was high (Kappa value across all categories = 0.81). Cluster and nodular KP were associated with active infectious uveitis (p < 0.01): patients with cluster KP (odds ratio [OR] = 3.03, 95% confidence interval [CI]: 1.43, 6.45) and nodular KP (OR = 3.89, 95% CI: 1.42, 10.65) were more likely to have infectious uveitis than those without.

Conclusions: Laser confocal microscopy of KP may have a role in determining between infectious and non-infectious uveitis.     

Chronic Anterior Uveitis in Children

Purpose: To describe the visual prognosis and remission rate of chronic anterior uveitis in pediatric patients.

Methods: A retrospective case series of children with chronic anterior uveitis treated in the University of Buenos Aires. Juvenile idiopathic arthritis was defined according to the International League of Associations for Rheumatology criteria. Uveitis remission was defined according to SUN criteria.

Results: There were 35 pediatric patients (61 eyes), mean age of uveitis onset was 7.69 ± 3 years, 60% were females and 74% had bilateral disease, median follow-up was 60 months (range: 12–192 months). JIA was more frequent in females (80.95 vs 21.43; p<0.0001) and oligoarthritis was the most common form. Remission rate was higher in males (HR = 4.99; 95% CI = 1.16–21.51; p = 0.031). More than 40 eyes remained with the same BCVA at 1 year of follow-up.

Conclusions: Although remission was not common and only occurred after long-term follow-up, visual prognosis was good

Received 30 August 2015; revised 6 March 2016; accepted 14 March 2016; published online 18 May 2016     

Complications of Uveitis: The Northern California Epidemiology of Uveitis Study

Purpose: To describe the uveitis complications in a large, community-based cohort.

Methods: Retrospective, community-based, cross-sectional cohort study analyzing complications and associations with complications.

Results: A total of 844 cases of uveitis were found; 342 were new-onset, and 462 were prior-onset. In total, 29.5% of patients were affected by one or more complications associated with age, gender, course, and anatomic location of uveitis. Visual loss was experienced by 19.1% of patients and was associated with age, course of disease, and anatomic location of uveitis. Of the patients who developed glaucoma or elevated intraocular pressure over 30 mmHg, 3.9% (n = 33) were related solely to uveitis; 5.2% (n = 44) had an unclear or combined mechanism; and 1.8% (n = 15) were related solely to steroid response. Cystoid macular edema was associated with course of disease and anatomic location of uveitis.

Conclusions: Complications affect a significant portion of uveitis patients, and are often associated with demographic and clinical factors.     

Visual Prognosis and Associated Factors of Phacoemulsification and Intraocular Lens Implantation in Different Uveitis Entities in Han Chinese

Purpose: To address the visual prognosis and associated predictors of phacoemulsification and intraocular lens implantation in different uveitis entities in Han Chinese.

Methods: A retrospective review of the uveitis patients who underwent phacoemulsification and intraocular lens implantation in our center between 2004 and 2014.

Results: The 158 patients (226 eyes) included anterior uveitis (45 eyes), posterior/pan-uveitis (61 eyes), Vogt–Koyanagi–Harada disease (79 eyes) and Behçet disease (41 eyes). At 6 months after surgery, best-corrected visual acuity (BCVA) significantly improved (p < 0.001) in all uveitis groups with 134 (59.3%) eyes achieving 20/40 or better. The anterior uveitis and Behçet disease groups had significantly better and worse visual outcomes than other groups, respectively. Poor preoperative BCVA, macular lesions, and secondary glaucoma were independent variables that predicted a poor visual outcome.

Conclusions: Our current study revealed a generally favorable outcome and associated predictors of phacoemulsification and intraocular lens implantation in uveitic cataracts in Han Chinese.     

Ankylosing Spondylitis Patients with HLA-B*2704 have More Uveitis than Patients with HLA-B*2705 in a North Chinese Population

Purpose: To investigate the correlation between clinical features of ankylosing spondylitis (AS) and different human leukocyte antigen (HLA)-B27 subtypes.

Methods: We conducted a cross-sectional study of 216 patients with AS. HLA-B27 and its subtypes were detected by polymerase chain reaction with sequence specific primer (PCR-SSP). Clinical features were compared between the different HLA-B27 subtypes. A meta-analysis on uveitis frequencies in AS patients with HLA-B*2705 vs 2704 was performed.

Results: The most prevalent subtypes of HLA-B27 were HLA-B*2704 (66.1%) and HLA-B*2705 (32.2%). There were 57 HLA-B27-positive AS patients with the history of uveitis; 45 were B*2704 and 12 were B*2705. Patients with B*2704 had more uveitis than B*2705 (p = 0.021). After meta-analysis, there was no significant difference in the presence of uveitis between HLA-B*2704 and HLA-B*2705.

Conclusions: AS patients with B*2704 have a higher risk of uveitis than AS with B*2705 in a north Chinese people.     

Visual Functioning and Health-related Quality-of-Life are Compromised in Patients with Uveitis

Purpose: To assess the vision-related (VR) and health-related (HR) quality-of-life (QoL) of patients with uveitis.

Methods: In total, 60 patients with uveitis, 81 patients with diabetic retinopathy (DR), and 70 healthy subjects completed the National Eye Institute Visual Functioning Questionnaire and the Medical Outcome Study 36-Item Short Form.

Results: Patients with uveitis reported lower HR- and VR-QoL than healthy subjects (p<0.05) and lower VR-QoL (p<0.001) than patients with DR. For patients with uveitis, multiple linear regression analyses indicated that lower HR-QoL scores were predicted by younger age (p<0.01), while lower VR-QoL scores were predicted by poorer visual acuity (p<0.001), ocular comorbidities (p<0.05), and female sex (p<0.05).

Conclusions: Patients with uveitis have significantly poorer VR- and HR-QoL than healthy control subjects. Uveitis has a more debilitating impact on VR-QoL than DR.     

Polymerase Chain Reaction and its Correlation with Clinical Features and Treatment Response in Tubercular Uveitis

Purpose: Correlation of results of polymerase chain reaction for Mycobacterium tuberculosis (MTB PCR) with clinical features and treatment response in tubercular uveitis.

Methods: Retrospective case study.

Results: Among 56 patients, 31 (55.3%) had acute and 25 (44.6%) had chronic uveitis. Uveitis was unilateral in 40 (71.4%) and bilateral in the remaining 16 (28.6%). Anatomical subtypes of uveitis were: anterior in 10 (13.9%) eyes, intermediate in 9 (12.5%), posterior in 17 (23.6%), and pan uveitis in 36 (50%) eyes. MTB PCR was positive in 24 patients. There was an 80% correlation between clinical response to antitubercular therapy (ATT) and PCR results. Twenty-two patients with positive PCR had a good clinical response. The sensitivity and specificity was 73.3% and 92.3%, respectively.

Conclusions: The diagnosis of intraocular TB requires strong clinical suspicion with corroborative laboratory and radiological evidence. A positive PCR is reliable whereas negative results should be correlated with clinical features. An adequate response to ATT supports PCR results.     

Multiple Sclerosis-related Uveitis: Does MS Treatment Affect Uveitis Course?

Purpose: Few data are available regarding the optimal treatment of multiple sclerosis (MS)-related uveitis. The aim of this study was to describe clinical features of MS-associated uveitis and determine how MS treatment affects the course of uveitis.

Methods: Retrospective, multicenter study. Patients were divided into two groups according to the use (group 2) or not (group 1) of immunomodulatory drugs. Characteristics of uveitis and treatment were reviewed.

Results: A total of 68 eyes from 36 patients (17 in group 1 and 19 in group 2) were included. All patients were treated with topical and/or systemic steroids for uveitis. Uveitis occurred 1–17 years prior to neurologic symptoms in 78% of patients. Uveitis was more severe in group 2 (p<0.05), with a tendency toward a higher rate of chronic uveitis (p = 0.06).

Conclusions: MS-related uveitis has often a favorable evolution. Patients on interferon-beta have more severe and chronic uveitis. As far as we are concerned, interferon-beta given on the sole indication of uveitis is not recommended. If steroid-sparing agent is required for intraocular inflammation, immunosuppressive drugs should be considered.     

Medical Malpractice in Uveitis: A Review of Clinical Entities and Outcomes

Purpose: To guide risk management in uveitis.

Methods: Retrospective review of malpractice verdicts, rulings, and settlements.

Results: The WestLaw® database was reviewed for lawsuits related to uveitis in the United States from 1930–2014. Twenty-five cases met inclusion criteria, and 48% of these were infectious. Overall, 64% of outcomes favored the defendant ophthalmologist. The most common diagnoses were viral retinitis (28%), iritis (12%), syphilis (8%), and toxoplasmosis (8%). Seven suits (28%) were resolved by settlement, with mean adjusted indemnities of $724,302 (median, $409,390; range, $127,837–2,021,887). Two cases (8%) resulted in plaintiff verdict, with adjusted awards of $1,399,800 and $630,799.

Conclusions: Despite being a rare diagnosis, viral retinitis (especially acute retinal necrosis) is the most common clinical entity associated with litigation in uveitis and should be considered early. Educating patients about potential adverse events, early testing for syphilis, and maintaining a positive relationship may also minimize risk.