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ORIGINAL ARTICLE
Year : 2019  |  Volume : 11  |  Issue : 2  |  Page : 54-58

Patterns of uveitis at a tertiary care hospital in Kolkata, Eastern India


1 Department of Ophthalmology, R.G. Kar Medical College and Hospital, Kolkata, West Bengal, India
2 Department of Ophthalmology, Murshidabad Medical College, Berhampore, West Bengal, India

Date of Submission24-Dec-2019
Date of Decision02-Jan-2020
Date of Acceptance12-Jan-2020
Date of Web Publication09-Mar-2020

Correspondence Address:
Dr. Sabyasachi Bandyopadhyay
11/11, Ghosal Para Road, Dakshin Para, Barasat, Kolkata - 700 124, West Bengal
India
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DOI: 10.4103/sjopthal.sjopthal_31_19

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  Abstract 


Purpose: The purpose of this study is to study the pattern of uveitis at a tertiary care hospital in Eastern India. Materials and Methods: This is a prospective study of new cases of uveitis attending our tertiary care hospital in Kolkata, Eastern India, from July 1, 2016, to June 30, 2019. Data regarding patient demographic profile, clinical features, anatomical locations, and etiological diagnosis were evaluated. Results: Among 331 patients, 142 (42.9%) were male and 189 (57.1%) were female (P < 0.05). The mean age at uveitis onset was 32.4 ± 21.13 years (range: 5–61 years). Uveitis was mostly unilateral (77.64%) and nongranulomatous (85.2%). A specific etiology was identified in 187 patients (56.5%). Anterior uveitis was the most common form (183 patients; 55.29%), followed by posterior uveitis (79 patients; 23.87%), panuveitis (51 patients; 15.4%), and intermediate uveitis (18 patients; 5.44%). The most common cause of anterior uveitis was idiopathic (92 cases; 50.27%), followed by seronegative spondyloarthropathy (25 cases; 13.66%). In intermediate uveitis, a specific diagnosis was obtained in eight (44.45%) cases. Presumed tuberculosis, sarcoidosis, and seronegative spondyloarthropathy were among the specific etiological causes. In posterior uveitis, toxoplasmosis was the leading etiological cause (18 cases; 22.78%), followed by presumed tuberculosis and Behçet's disease. In panuveitis cases, a specific diagnosis was established in 33 cases (64.71%). The most common etiology was Behçet's disease (11 cases; 21.57%), followed by Vogt–Koyanagi–Harada disease and presumed tuberculosis. Conclusion: Anterior uveitis was the most common form of uveitis. A specific etiology was found in 56.5% of cases. Behçet's disease, seronegative spondyloarthropathy, presumed tuberculosis, and toxoplasmosis were the leading causes of uveitis.

Keywords: Behçet's disease, Eastern India, epidemiology, panuveitis, uveitis


How to cite this article:
Bandyopadhyay S, Ghanta AK, Mandal A. Patterns of uveitis at a tertiary care hospital in Kolkata, Eastern India. Sudanese J Ophthalmol 2019;11:54-8

How to cite this URL:
Bandyopadhyay S, Ghanta AK, Mandal A. Patterns of uveitis at a tertiary care hospital in Kolkata, Eastern India. Sudanese J Ophthalmol [serial online] 2019 [cited 2020 Mar 30];11:54-8. Available from: http://www.sjopthal.net/text.asp?2019/11/2/54/280248




  Introduction Top


Uveitis is a set of conditions defined by intraocular inflammation involving mainly the uveal tract along with the adjacent retina and vitreous. It is believed to be the cause of up to 10% of cases of legal blindness in the United States or approximately 30,000 new cases of blindness per year.[1],[2] Uveitis can be classified following the Standardization of Uveitis Nomenclature based on the anatomical location, i.e., anterior uveitis (iritis, anterior cyclitis, and iridocyclitis), intermediate uveitis (posterior cyclitis, pars planitis, hyalitis, and basal retinochoroiditis), posterior uveitis (choroiditis, chorioretinitis, retinochoroiditis, and neurouveitis), and panuveitis.[3] Unlike common age-related eye disorders, uveitis affects younger working-age patients, leading to the strong adverse socioeconomic effects.[1]

The most frequently reported symptoms include pain, eye redness, blurred vision, and photophobia. Such symptoms are nonspecific and can be easily misdiagnosed as other conditions, including conjunctivitis and keratitis. Based on the course of the condition, uveitis can be classified as acute, with sudden onset inflammation lasting for <3 months; chronic uveitis, with inflammation lasting for more than 3 months; and recurrent, when repeated episodes of intraocular inflammation were separated by the periods of inactivity without treatment for ≥3 months.[3] Patients are classified as having nongranulomatous uveitis if there are small keratic precipitates on the corneal endothelium without iris nodules or choroidal granulomas or granulomatous uveitis if large ”mutton-fat” keratic precipitates, iris nodules, and/or optic disc and choroidal granulomas are present.[1],[3] Anterior uveitis is the most common form of uveitis found in North India, South India, South Iran, Brazil, China, and Italy.[4],[5],[6],[7],[8],[9] However, one study based on Northeastern Iran reported that panuveitis was the most common variety of uveitis.[10]

The etiology of uveitis can be broadly categorized into infectious and noninfectious, and it is frequently associated with systemic disease. Among the noninfectious forms of uveitis, the most common systemic associations include seronegative spondyloarthropathy, Behçet's disease, sarcoidosis, and Vogt–Koyanagi–Harada (VKH) disease.[4],[5],[6],[7],[8],[9],[11],[12],[13] Presumed tuberculosis, herpetic uveitis, toxoplasmosis, and toxocariasis are the common infectious causes.[4],[5],[6],[8],[11],[12],[13]

Although there are several studies regarding clinical and epidemiological parameters of patients with uveitis in southern, northern, and north-eastern regions of India, the corresponding data in Eastern India are lacking.[4],[5],[11] Therefore, we planned to perform the above-mentioned study at our tertiary care hospital in Kolkata, Eastern India.


  Materials and Methods Top


This is a prospective study of new patients with active uveitis attending the outpatient department of our tertiary care hospital, Kolkata, Eastern India, from July 1, 2016, to June 30, 2019. The study was approved by the Institutional Ethics Committee and adhered to the tenets of the Declaration of Helsinki. Informed consent was obtained from all the patients/their guardians in case of minors. After taking a detailed clinical history, all patients underwent ophthalmologic examinations, including the determination of Snellen visual acuity, slit-lamp biomicroscopy, applanation tonometry, dilated fundus examination, and thorough physical examination. The laboratory tests were performed in a tailored approach depending upon the eye examination findings and systemic symptom associations. Complete blood count, erythrocyte sedimentation rate, urinalysis, C-reactive protein level, venereal disease research laboratory test or fluorescent treponemal antibody absorption for syphilis, chest X-ray or high-resolution computed tomography of the chest for sarcoidosis and tuberculosis (TB), sputum smear and culture and purified protein derivative skin test for TB, polymerase chain reaction of aqueous and vitreous samples for tubercular, herpetic, and cytomegalovirus uveitis, anti-toxoplasma and anti-Toxocara antibody assessment, antinuclear antibody testing, antineutrophil cytoplasmic antibody testing, angiotensin-converting enzyme level, human leukocyte antigen (HLA) typing, and HIV I and II testing were performed in appropriate cases.

Whenever a specific ocular cause or any systemic disease was not detected, despite all ocular and systemic evaluations, the disease was classified as ”idiopathic.” Patients were classified according to the International Uveitis Study Group definitions based on the anatomical locations comprising anterior (iritis/iridocyclitis), intermediate (inflammation in posterior ciliary body and vitreous cavity), posterior (intraocular inflammation primarily involving the retina and choroid), and panuveitis (inflammation in the anterior chamber, vitreous, retina, and choroid). Patients with mutton-fat keratic precipitates, iris nodules, or choroidal or optic nerve head granuloma were classified as having granulomatous uveitis. Other cases with small keratic precipitates on the posterior corneal surface were classified as nongranulomatous uveitis.

Only one eye of each patient was included in the study. In bilateral cases, the eye with more severe disease (higher grade of anterior chamber reaction or worse BCVA if inflammation was symmetrical) was included in the analysis. Patients with postsurgery uveitis, trauma, endophthalmitis, or Eales disease were excluded from the study.

Descriptive statistical analysis was conducted with the variables regarding demographic profiles and classification and etiology of uveitis using the SPSS software version 16 (SPSS Inc., Chicago, IL, USA). P <0.05 was considered statistically significant.


  Results and Analysis Top


Altogether, 331 participants fulfilling the above criteria were evaluated. Among them, 142 patients (42.9%) were male and 189 patients (57.1%) were female, which was statistically significantly different (P < 0.05). The mean age at the onset of uveitis was 32.4 ± 21.13 years (range, 5–61 years). Uveitis was unilateral in 257 (77.64%) and bilateral in 74 (22.36%) patients [Table 1]. A specific etiology was identified in 187 patients (56.5%); the rest were classified as idiopathic (144 patients; 43.5%). Anterior uveitis was the most common type of inflammation (183 patients; 55.29%), followed by posterior uveitis (79 patients; 23.87%), panuveitis (51 patients; 15.4%), and intermediate uveitis (18 patients; 5.44%) [Table 2]. Nongranulomatous uveitis (282 patients; 85.2%) was more common than that of granulomatous uveitis (49 patients; 14.8%).
Table 1: Demographic profile of patients with uveitis

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Table 2: Etiological causes of different types of uveitis

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The most common cause of anterior uveitis was idiopathic (92 cases; 50.27%), followed by seronegative spondyloarthropathy (25 cases; 13.66%), herpetic uveitis (19 cases; 10.38%), Fuchs' heterochromic iridocyclitis (18 cases; 9.84%), presumed TB (12 cases; 6.56%), and Behçet's disease (8 cases; 4.37%).

Regarding intermediate uveitis, a specific diagnosis was obtained in eight cases (44.45%). Presumed tuberculosis, sarcoidosis, and seronegative spondyloarthropathy were among the specific etiological causes (two patients in each category). In the posterior uveitis group, 24 cases (30.38%) were idiopathic. Toxoplasmosis was the leading specific etiological cause (18 cases; 22.78%), followed by presumed TB and Behçet's disease (nine patients each). Regarding panuveitis cases, a specific diagnosis was established in 33 cases (64.71%) and 18 cases (35.29%) were idiopathic. The most common specific cause was Behçet's disease (11 cases; 21.57%), followed by VKH disease (8 cases; 15.69%) and presumed TB (4 cases; 7.84%).


  Discussion Top


There is significant variability in the patterns of uveitis in different studies worldwide, which is largely dependent on their geographical location and patient demographics, as well as ecological, nutritional, and socioeconomic conditions. Uveitis mostly affects young adults placing a large economic burden on the individual and society.[10],[14],[15] In our study, the mean age of onset was 32.4 years (range: 5–61 years).

Female patients were more common in our study than male patients were and this was consistent with the studies of Rahimi and Mirmansouri and Khairallah et al.[6],[16] However, Das et al. and Singh et al. found a male predominance in North and Northeast India.[4],[17] We had a specific diagnosis of uveitis in 56.5% of cases, despite the performance of all possible laboratory investigations and ancillary tests, which is similar to other studies that reported the rates ranging from 47.1% to 71.5%.[4],[5],[9],[10],[18],[19],[20] However, there are large inconsistencies among investigators regarding the use of diagnostic tests for uveitis, which necessitate the evidence-based guidelines.[21]

Anterior uveitis was the most common variety of uveitis in our study, followed by posterior uveitis, panuveitis, and intermediate uveitis. Most cases were unilateral and nongranulomatous, similar to the other studies.[4],[6],[10] We found that idiopathic anterior uveitis was the most common cause of anterior uveitis, similar to the results from South India, North India, and Southern Iran.[4],[6],[22] However, this was different from a report from Iran where Behçet's disease and Fuchs heterochromic iridocyclitis were the more prevalent.[14]

Posterior uveitis was the second most common type of uveitis, similar to most other studies.[4],[6],[22] However, a study in Northeast Iran showed it to be the least common, after panuveitis, anterior uveitis, and intermediate uveitis.[10] Toxoplasmosis was the most common cause of posterior uveitis in our study, similar to the findings reported by Rahimi and Mirmansouri and Mercanti et al.[6],[9] However, Singh et al. found that serpiginous choroidopathy was the leading cause of posterior uveitis in North India.[4]

Panuveitis was more common than intermediate uveitis in our study, consistent with the findings from North Africa, Northeast India, North India, and South Iran.[4],[6],[16],[17] In panuveitis, the idiopathic form was the most common, followed by Behçet's disease in our study. Whereas, Rahimi and Mirmansouri and Singh et al. found Behçet's disease and sympathetic ophthalmia, respectively, as the most common causes.[4],[6]

Most studies of the patterns of uveitis, including our observations, are institution based, so it is not possible to calculate the incidence and prevalence rates of uveitis in the general community. However, in the retrospective, large population-based ”Pacific ocular inflammation study,” Acharya et al. observed that the overall uveitis incidence rate was 24.9 cases/100,000 person years. The annual prevalence rates for 2006 and 2007 were 57.5 and 58.0/100,000 persons, respectively.[12] Dandona et al. found an age-adjusted prevalence rate of uveitis of 0.73% in the Andhra Pradesh Eye Disease Study, which included 2522 participants. The prevalence of visual impairment due to uveitis of <6/60 in both eyes was 0.03%, <6/60 in at least one eye was 0.16%, and <6/18 in at least one eye was 0.27%.[22]

Camilo et al. in a prospective, observational study of patients with active uveitis in an emergency eye care center in Brazil observed that the most frequent symptoms were ocular pain (76.9%), eye redness (59.8%), and visual blurring (46.2%). Anterior uveitis was observed in 70.1% patients, posterior uveitis in 26.5%, and panuveitis in 3.4%.[7] In an Italian study by Cimino et al., the most frequent causes of uveitis were Fuchs' uveitis, herpes, toxoplasmosis, HLA B27–associated uveitis, and Behçet's disease.[23]

Yalçındaǧ et al. observed that Behçet's disease (24.9%) was the most common cause of uveitis, followed by seronegative spondyloarthropathy (9.7%), toxoplasmosis (7.1%), and Fuchs' heterochromic iridocyclitis (6.3%).[24] In a study in China by Chen et al., it was found that anterior uveitis was the most common, followed by panuveitis, posterior uveitis, and intermediate uveitis.[8] In a study in Tunisia, Khairallah et al. reported that Behçet's disease, toxoplasmosis, and VKH disease were the leading causes of posterior uveitis and panuveitis.[16] Mercanti et al. in Italy observed that ocular toxoplasmosis was the most common cause of posterior uveitis, which was similar to our study.[9]

Singh et al. in a retrospective study on 1233 uveitis patients, in a referral center in North India observed that anterior uveitis was the most common (49.23%), followed by posterior uveitis (20.23%), intermediate uveitis (16.06%), and panuveitis (14.68%).[4] Das et al. conducted an institutional-based retrospective study of 308 uveitis patients and analyzed the pattern of uveitis in Northeast India. Anterior uveitis was the most common type (47.07%), followed by posterior (29.87%), intermediate (12.98%), and panuveitis (10.06%).[17] In our study, anterior uveitis was the most common type, but the intermediate variety was the least common.

Biswas et al. studied the pattern of uveitis in South India. A specific diagnosis was identified in 66.2% of cases. Anterior uveitis was seen in 35.22%, intermediate uveitis in 30.11%, posterior uveitis in 25%, and panuveitis in 9.65% of cases. They found that TB was the most common cause of posterior uveitis, in contrast to toxoplasmosis in our study.[5]

One limitation of the present study is that it is a hospital-based study and cannot be interpreted in the context of the general population. Further prospective studies with a larger number of cases and longer duration are needed.


  Conclusion Top


Our study reports the pattern of uveitis at a tertiary care hospital in Eastern India. Based on our data and other epidemiological studies, a specific uveitis workup can be performed that is tailored to a systematic approach of thorough history-taking, detailed clinical examination, and most suitable laboratory investigations to arrive at an etiological diagnosis. Thus, limited and valuable resources can be properly utilized in reducing the ocular morbidity from uveitis and eventual prevention of blindness.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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