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Clinical analysis of uveitis.

Uveitis can be classified in a variety of ways and this fact makes it difficult to compare results. Therefore we classified uveitis by the location with the method of Henderly; anterior-, posterior-, intermediate- and panuveitis. We determined the frequency of occurrence, etiology and clinical characteristics of various forms of uveitis. We conducted a retrospective analysis of 683 patients with uveitis seen at Seoul National University Hospital from January 1978, to December 1987. The results were as follows. 1. 192 cases (28.1%) occurred as anterior uveitis, 218 cases (31.9%) as posterior uveitis, 166 cases (24.3%) as panuveitis and 107 cases (15.7%) as pars planitis. Posterior uveitis was the most common form of uveitis. 2. In cases of anterior uveitis, 142 cases (74.0%) were idiopathic, traumatic uveitis was seen in 18 cases. In posterior-uveitis, 111 cases (50.9%) were idiopathic, retinal vasculitis including Eales' disease in 60 cases (27.5%), toxoplasmosis in 23 cases (10.6%). In cases of panuveitis, idiopathic form occurred in 80 cases (48.2%), Behçet's disease in 41 cases (24.7%). The idiopathic form was the most common entity in all locations of uveitis.

Adolescent↗

Incidence of glaucoma in patients with uveitis.

PURPOSE: To evaluate the incidence of glaucoma and elevation of intraocular pressure (IOP) in patients with inflammatory eye disease. METHODS: Retrospective review of medical records of 391 consecutive patients with uveitis attending a uveitis clinic of an academic Department of Ophthalmology from January 1999 to August 2002. Demographic, ocular and systemic variables were recorded. The diagnosis and treatment of uveitis were recorded. Uveitis was classified according to standard anatomic, etiological and clinical criteria. "Glaucoma" was defined as elevated IOP (>21 mm Hg) or glaucomatous optic nerve damage requiring medical and/or surgical anti-glaucoma treatment. Kaplan-Maier analysis and log-rank tests were used to evaluate and compare the incidence of glaucoma. RESULTS: The incidence of glaucoma as defined above at 3 and 12 months after acute uveitis was 7.6%. In patients with chronic uveitis (n = 337), the incidence of glaucoma at 1 and 5 years was 6.5% and 11.1%, respectively. There was no statistically significant difference in the incidence of glaucoma between different types of uveitis, idiopathic versus non-idiopathic, and among anterior, intermediate, posterior and panuveitis. Visual loss occurred more frequently in patients with glaucoma than in patients without glaucoma. CONCLUSION: In patients with chronic inflammatory eye disease, the presence of glaucoma was associated with an increasing risk of visual loss. The incidence of glaucoma increased with time and was similar among the different types of uveitis.

Acute Disease↗

Population based assessment of uveitis in an urban population in southern India.

AIM: To assess the prevalence of active and inactive uveitis unrelated to previous surgery or trauma in an urban population in southern India. METHODS: As part of the Andhra Pradesh Eye Disease Study, 2522 subjects (85.4% of those eligible), a sample representative of the population of Hyderabad city in southern India, underwent interview and detailed dilated eye examination. Presence of sequelae of uveitis without current active inflammation was defined as inactive uveitis. RESULTS: Unequivocal evidence of active or inactive uveitis unrelated to previous surgery or trauma was present in 21 subjects, an age-sex adjusted prevalence of 0.73% (95% confidence interval (CI) 0.44-1.14%). Active uveitis was present in eight subjects, an age-sex adjusted prevalence of 0.37% (95% CI 0. 19-0.70), of which 0.06% was anterior, 0.25% intermediate, and 0.06% posterior. The 0.36% (95% CI 0.17-0.68%) prevalence of inactive uveitis included macular chorioretinitis scars (0.26%), anterior (0. 07%) and previous vasculitis involving the whole eye (0.03%). The prevalence of visual impairment due to uveitis of less than 6/18 in at least one eye was 0.27%, less than 6/60 in at least one eye was 0. 16%, and less than 6/60 in both eyes was 0.03%. CONCLUSION: These population based cross sectional data give an estimate of the prevalence of various types of uveitis in this urban population in India. Active or past uveitis that might need treatment at some stage was present in one of every 140 people in this population.

Acute Disease↗

Evaluation of foldable intraocular lenses in patients with uveitis.

OBJECTIVE: To evaluate various foldable posterior chamber intraocular lenses (IOLs) after phacoemulsification in patients with uveitis. DESIGN: A prospective, noncomparative, interventional case series. PARTICIPANTS: Forty-nine consecutive patients (60 eyes) with various types of uveitis (anterior, n = 20; posterior, n = 1; panuveitis, n = 37, intermediate, n = 2). INTERVENTION: All patients underwent phacoemulsification with foldable posterior chamber IOL implantation. All eyes were free of active inflammation at the time of surgery. A variety of IOL biomaterials were implanted: acrylic (n = 30), silicone (n = 17), and hydrogel (n = 13). MAIN OUTCOME MEASURES: Detailed examination was performed by one masked observer. Several parameters were compared for each implant biomaterial, including level of best corrected Snellen visual acuity at final follow-up, presence of posterior synechiae, anterior capsular phimosis, posterior capsule opacification, and the degree of cellular deposits on the IOL optic. RESULTS: There were 26 males and 23 females, aged 9 to 83 years (mean, 48 years). Follow-up ranged from 1 to 33 months (mean, 17.03 months). At final follow-up, 56 eyes (93.3%) had an improvement in visual acuity compared with preoperative levels as follows: 34 eyes (56.6%) achieved an improvement of four or more Snellen lines, and 44 eyes (73.3%) achieved 20/30 or better. Giant cells, observed on the IOL optic in 19 eyes (31.7%), were most often seen on the acrylic biomaterial at the 1-month follow-up, although this was not found to be statistically significant. Scratch marks produced by the lens-introducing forceps were seen in 24 eyes (40.0%), mainly on the acrylic and hydrogel optics. Posterior capsule opacification (PCO) occurred in 49 eyes (81.7%), with only 5 eyes requiring laser capsulotomy. There was no association between PCO and the various lens biomaterials. Other causes for reduced visual acuity included glaucomatous optic neuropathy (n = 5) and cystoid macular edema (n = 8). CONCLUSIONS: The use of foldable IOLs in eyes with uveitis is safe, but the optimal biomaterial has yet to be found.

Acrylic Resins↗

Laser flare photometry and complications of chronic uveitis in children.

PURPOSE: To investigate possible relationships between laser flare photometry values, complications of uveitis, and outcomes in children with chronic uveitis. DESIGN: Retrospective chart review. METHOD: We evaluated patients with active, noninfectious anterior, intermediate, or panuveitis who were 16 years of age or younger and who had laser flare photometry at one of two academic institutions. Complications enumerated at baseline and during follow-up were compared with laser flare photometry values and to anterior chamber cell counts. RESULTS: At least one laser flare photometry value ("flare"), defined as baseline measurement, was available for 59 patients (41 girls, 18 boys; mean age, 10.3 +/- 3.5 years); 38 of these patients had at least one additional measurement during follow-up (median 11 months). Complications of uveitis were present in 35 patients (59%) at baseline. There was a positive association between increased laser flare photometry values and complications at baseline (any complication [P =.007], posterior synechiae [P =.003]). The development of complications during follow-up was associated with the presence of complications at baseline (P =.018). A subgroup of patients with low flare at baseline had no complications during follow-up regardless of treatment given. CONCLUSIONS: There is a positive relationship between laser flare photometry values and the prevalence of complications of uveitis in children. Laser flare photometry provides a novel way to monitor children with uveitis. Future study will be needed to determine whether values have prognostic importance and whether a treatment strategy that minimizes flare results in fewer uveitic complications.

Aqueous Humor↗

Causes of uveitis in the general practice of ophthalmology. UCLA Community-Based Uveitis Study Group.

PURPOSE: Most uveitis case series have come from tertiary care centers, and the relative frequencies of disorders they report may reflect referral bias. We sought information about the types of uveitis encountered in the general practice of ophthalmology. METHODS: We prospectively examined 213 consecutive cases of general uveitis, defined as intraocular inflammation other than cytomegalovirus retinopathy, seen by a group of community-based comprehensive ophthalmologists. This group of cases was compared with 213 consecutive cases of general uveitis examined by a uveitis specialist at a university referral center in the same community. All cases were categorized by anatomic site of inflammation and disease course, and, if possible, they were assigned a specific diagnosis. Cases of cytomegalovirus retinopathy and masquerade syndrome seen during the same intervals were recorded separately. RESULTS: The distribution of general uveitis cases by anatomic site of disease was significantly different between the community-based practices (anterior, 90.6%; intermediate, 1.4%; posterior 4.7%; panuveitis, 1.4%) and the university referral practice (anterior, 60.6%; intermediate, 12.2%; posterior, 14.6%; panuveitis, 9.4%; P < .00005). A cause or clinical syndrome could be assigned to 47.4% of cases in the community-based practices, and to 57.8% of cases in the university referral practice (P = .03). HLA-B27-associated anterior uveitis, cytomegalovirus retinopathy, and toxoplasmic retinochoroiditis were among the five most common forms of uveitis in both practice settings. CONCLUSION: The relative frequencies with which various forms of uveitis are seen in a tertiary referral center do not necessarily reflect the experience of ophthalmologists from the community in which the center is located. Anterior uveitis and disorders of sudden onset constitute a greater proportion of cases seen by community-based comprehensive ophthalmologists.

Adolescent↗

Uveitis presenting de novo in the elderly.

Seventy-one consecutive patients presenting with their first episode of uveitis at the age of 60 or more years, were studied retrospectively. The majority were found to have idiopathic uveitides on investigation. In those who did have associated systemic disease, the commonest finding was non-insulin-dependent diabetes mellitus or an autoimmune disease. There were no cases of ocular lymphoma in this series. We conclude that, contrary to some previous reports, idiopathic uveitis may occur in the elderly, and that the relative frequencies of acute anterior, chronic anterior, intermediate and posterior uveitides are similar to those seen in young patients.

Age Factors↗

Lipid mediators of tumor necrosis factor-alpha-induced uveitis.

The authors tested the hypothesis that platelet-activating factor (PAF) and cyclooxygenase metabolites of arachidonic acid mediate the ocular inflammatory response to intravitreally injected tumor necrosis factor-alpha (TNF alpha). Rabbits were treated with the PAF receptor antagonist SRI 63-441, the cyclooxygenase inhibitors indomethacin and naproxen, or SRI 63-441 and indomethacin. At 24 hr after intravitreal injection of TNF (20,000 U), the severity of inflammation was assessed based on iridal hypermia, aqueous humor leukocyte number and aqueous humor protein, immunoreactive-prostaglandin E (I-PGE), and leukotriene B4 (LTB4) concentrations. Although all of the treatments significantly reduced the severity of anterior uveitis, SRI 63-441 plus indomethacin was the most effective, indomethacin and naproxen were intermediately effective, and SRI 63-441 was the least effective. The results of this study are consistent with an important role for cyclooxygenase metabolites of arachidonic acid in the inflammatory response to TNF alpha, particularly with respect to dilation of iridal blood vessels. Although naproxen was nearly as effective as indomethacin in reducing aqueous humor I-PGE levels, indomethacin conferred significantly more protection to the blood-aqueous barrier as shown by lower protein levels in the aqueous humor. Thus, although cyclooxygenase inhibition may partially explain the protection afforded the blood-aqueous barrier by these nonsteroidal anti-inflammatory agents, the data suggest that indomethacin may also exert anti-inflammatory effects that are independent of cyclooxygenase inhibition. Furthermore, the data are consistent with TNF alpha releasing PAF in the eye and PAF acting both directly, by increasing vascular permeability, and indirectly, by promoting release of cyclooxygenase and lipoxygenase metabolites of arachidonic acid.

Animals↗

Intermediate-term results of a randomized clinical trial of the 350- versus the 500-mm2 Baerveldt implant.

BACKGROUND: The Baerveldt glaucoma implant is a large equatorial aqueous shunting device that is installed through a single-quadrant conjunctival incision. The intermediate-term results of a randomized study comparing the 350- and 500-mm2 Baerveldt implants are reported. METHODS: Seventy-three patients with medically uncontrollable, nonneovascular glaucomas associated with aphakia, pseudophakia, or failed filters were enrolled in a randomized, prospective study comparing 350- and 500-mm2 Baerveldt implants. Surgical success was defined as 6 mmHg < or = final intraocular pressure < or = 21 mmHg without glaucoma reoperation or devastating complication. RESULTS: Of patients with 350- and 500-mm2 implants, 93% and 88%, respectively, achieved surgical success (18-month life-table analysis, P = 0.93). The 500-mm2 implants afforded intraocular pressure control with significantly fewer medications (0.7 versus 1.3; P = 0.006). The postoperative visual acuities remained within one line of the preoperative visual acuities or improved in 62% and 66% of patients in the 350- and 500-mm2 groups, respectively (P = 0.93). Complication rates were statistically similar. The most frequent ones in the 350- and 500-mm2 groups, respectively, were serous choroidal effusion (16% and 32%), strabismus (16% and 19%), anterior uveitis (14% and 11%), and corneal or corneal graft edema (11% each). CONCLUSION: The intermediate-term results of the 350- and 500-mm2 Baerveldt implants were statistically comparable with respect to surgical and visual outcomes, as well as complications, although the larger implant was associated with a higher rate of some complications. However, the 500-mm2 Baerveldt implant afforded intraocular pressure control with fewer medications than the 350-mm2 implant.

Adolescent↗

Uveitis in children: population-based study in Finland.

PURPOSE: To investigate the incidence and prevalence rates of different types of uveitis in children, and to compare them with the rates in adults. SUBJECTS AND METHODS: For this population-based retrospective study the medical records of all residents of the district of Turku University Hospital with a diagnosis of uveitis seen at the Eye Clinic of Turku University Hospital during the years 1980-1982 and 1988 were reviewed. RESULTS: A total of 1122 uveitis cases were identified, and 55 (4.9%) of them were children under 16 years. The incidence per 100 000 population per year for all uveitis cases in children was 4.3 (95% confidence interval [CI], 2.2 to 6.4), and the prevalence was 27.9 (95% CI, 17.1 to 38.6), which was significantly lower compared with the rates in adults (p=0.001 for incidence and prevalence). The vast majority of children, 50 (90.9%), had anterior uveitis (AU), and the incidence and prevalence rates of AU were significantly lower than in adults (p=0.001 for incidence and prevalence). Three (5.5%) children had posterior uveitis (PU), but there was no significant difference in the incidence and only marginally significant difference in the prevalence rate of PU in children compared with the rates in adults (p=0.33 for incidence, and p=0.07 for prevalence). Only one case (1.8%) was found with intermediate and one with panuveitis, but no new cases. The commonest diagnostic groups in children were AU associated with juvenile rheumatoid arthritis, idiopathic acute anterior uveitis, and idiopathic chronic anterior uveitis. Toxoplasmic retinochoroiditis was found in all of the PU cases with the incidence 0.3, and the prevalence 1.1, which did not differ significantly from the rates in adults (p=1.0 for incidence, and p= 0.48 for prevalence). CONCLUSION: Uveitis is rarer in children than in adults. However, in contrast to studies from tertiary referral centers, the distribution of different forms of uveitis in children in this population-based study seems to resemble the distribution in adults.

Adolescent↗

Summary of the Third International Conference on Behçet's Disease, Tokyo, Japan, October 23-24, 1981.

Behçet's disease was associated with HLA-B5, DR5, and MT2 antigens in Japanese. No virus or other agent was clearly implicated. Pathologic studies showed brainstem strokes and gut perforation from discrete ulcers. There was a significant reduction in T4 inducer-helper lymphocytes. Immune complexes in serum were detected in 30 to 50% of patients, and antibodies to the glycolipid GA1 were found in 91% of patients with neurologic involvement. Although several neutrophil functions were enhanced, for example, chemotaxis, phagocytosis, and generation of oxygen intermediates, mononuclear cells seemed to be of primary immunopathogenic importance. Treatment with chlorambucil appeared superior to other reported treatments of uveitis and meningoencephalitis.

Behcet Syndrome↗

Indocyanine green angiography in systemic lupus erythematosus-associated uveitis.

PURPOSE: To report indocyanine green (ICG) angiography findings in a patient with systemic lupus erythematosus-associated uveitis. METHODS: Review of the patient's clinical records. RESULTS: ICG angiography revealed dilatation of individual choroidal vessels in the early phase. Furthermore, two types of hypofluorescent areas became visible from the intermediate up to the late phase: the first type was small, round, and better defined, while the second type consisted of larger, ill-defined areas seen around fixation in the right eye and temporal to fixation in the left eye. These hypofluorescent areas were not visible on either clinical examination or fluorescein angiography. CONCLUSIONS: The results of ICG angiography suggest choroidal involvement in patients with systemic lupus erythematosus-associated uveitis.

Choroid↗

Indocyanine green angiographic findings for patients with systemic lupus erythematosus nephropathy.

PURPOSE: To study indocyanine green (ICG) angiographic findings for patients with systemic lupus erythematosus (SLE) nephropathy. In particular, the presence of choroidal abnormalities at ICG angiography, which could not be detected by fluorescein angiography, was studied. DESIGN: Observational case report study. METHODS: Nine consecutive female patients (mean age +/- SD, 38.2 +/- 9.7 years) with SLE-related nephropathy underwent simultaneous ICG angiography and fluorescein angiography according to a standard angiographic protocol for uveitis. RESULTS: Two findings were revealed by ICG angiography: focal, transient hypofluorescent areas in the early phase; and spots of choroidal hyperfluorescence visible from the intermediate to late phase. CONCLUSIONS: ICG angiography can provide information that is not detectable by clinical or fluorescein angiographic examination for patients with lupus nephropathy. This information may prove useful in better understanding the pathogenesis of SLE choroidopathy.

Adult↗

The role of mast cells in endotoxin-induced uveitis.

PURPOSE: To investigate the role of mast cells in the induction of endotoxin-induced uveitis (EIU). METHODS: We previously showed that the mean mast cell number in the anterior uvea was greatest for Lewis rats, lowest for Brown Norway (BN) rats, and intermediate for LBNF1 rats. In the current experiment, we assessed the time of onset and severity of EIU in these three rat strains. We then studied changes in mast cell numbers in the anterior uvea during the induction period of EIU. RESULTS: Time of onset and severity of EIU were related to the number of mast cells in the anterior uvea. EIU occurred earliest in the Lewis rats, and the maximum mean grade of ocular inflammation on a scale of 0 (no inflammation) to 4 (severe inflammation) +/- standard error of the mean was 3.87 +/- 0.13 for Lewis rats, 1.06 +/- 0.06 for BN rats, and 1.19 +/- 0.12 for LBNF1 rats. The difference between the mean grade of inflammation in the Lewis rats and the other two strains was highly statistically significant (P < .001). In the Lewis rats, mast cell numbers +/- SEM decreased from 68.9 +/- 10.8 at baseline to 49.6 +/- 5.9 4 hr after lipopolysaccharide (LPS) injection and to 27.6 +/- 8.4 8 hr after LPS injection, suggesting that mast cell degranulation occurs before the development of EIU. CONCLUSION: Mast cells in the anterior uvea appear to potentiate endotoxin-induced ocular inflammation.

Animals↗

Indocyanine green angiographic features in tuberculous chorioretinitis.

PURPOSE: To determine choroidal involvement in presumed tuberculous posterior uveitis by examining indocyanine green angiographic features. METHODS: Indocyanine green angiography was performed according to a standard uveitis angiographic protocol in eight consecutive patients (15 eyes) with presumed posterior tuberculous uveitis. RESULTS: In 100% of the 15 examined eyes, indocyanine green angiography disclosed choroidal lesions that were subclinical, not detected by fundus examination or fluorescein angiography, in six (40%) of 15 eyes. Findings were classified into four main angiographic signs: (1) irregularly distributed, hypofluorescent areas in the early and intermediate phases of angiography that either became isofluorescent (type 1 hypofluorescence) or remained hypofluorescent (type 2 hypofluorescence) in the late phase; (2) numerous, small, focal, hyperfluorescent spots; (3) choroidal vessels that appeared fuzzy in the intermediate phase because of leakage, leading in the late phase to (4) diffuse choroidal hyperfluorescence. Type 1 hypofluorescent lesions, fuzzy choroidal vessels, and diffuse choroidal hyperfluorescence tended to regress after the initiation of antituberculous and corticosteroid treatment. Focal hyperfluorescence tended to be associated with longstanding disease. CONCLUSIONS: Indocyanine green angiography was useful in assessing and quantifying the as yet unknown extent of choroidal involvement in tuberculous posterior uveitis. Its characteristic appearance may be a valuable contribution to the diagnosis and monitoring of treatment response.

Chorioretinitis↗

An association between susceptibility to experimental autoimmune uveitis and choroidal mast cell numbers.

An association was found in rats of different strains between the susceptibility to EAU and the number of mast cells in the choroid of the eye. High responder rats (Lewis, CAR) had strikingly more choroidal mast cells than the low responder BN animals, whereas intermediate numbers of mast cells were found in the F1 hybrids of Lewis and BN (LBNF), which exhibited an average level of susceptibility to EAU. LeR rats, derived from the Lewis strain, developed EAU only when treated with B. pertussis, and their number of choroidal mast cells was only about 1/5 of that found in the Lewis rats. Unlike the differences in the number of choroidal mast cells, small variations were found in the skin mast cell numbers of the tested rats. It is proposed that the number of local mast cells may be one mechanism by which the susceptibility to an organ-specific autoimmune disease is genetically regulated.

Animals↗

Assessment and classification of choroidal vasculitis in posterior uveitis using indocyanine green angiography.

BACKGROUND: By allowing one to detect fluorescence beyond the retinal pigment epithelium, indocyanine green angiography (ICGA) has made it possible to analyse the choroidal vessels. Our aim was to characterize choroidal vasculitis in posterior uveitis using ICGA. METHODS: Charts of active posterior uveitis patients with a specific diagnosis seen in the different centers participating in the study who had undergone dual fluorescein and ICG angiography were reviewed. The type of inflammatory involvement of the choroidal circulation at entry and the treatment response on follow-up angiograms were analysed. RESULTS: A total of 129 patients were analysed. Choroidal vasculitis could be subdivided into two main patterns: (1) primary inflammatory choriocapillaropathy and (2) stromal inflammatory vasculopathy. The first pattern consisted of hypofluorescent areas up to the late phase of angiography characteristic for choriocapillaris non-perfusion and included entities such as multiple evanescent white dot syndrome (MEWDS), acute posterior multifocal placoid pigment epitheliopathy (APMPPE), multifocal choroiditis (MC), ampiginous choroidopathy and serpiginous choroidopathy. The second pattern consisted of fuzzy indistinct appearance of vessels in the intermediate angiographic phase and diffuse choroidal hyperfluorescence in the late phase indicating inflammatory vasculopathy of larger choroidal vessels. This pattern was found in all cases of active Vogt-Koyanagi-Harada disease, ocular sarcoidosis and tuberculosis and birdshot chorioretinopathy. In Behçet's uveitis of recent onset, choriocapillaris perfusion delay and fuzzy choroidal vessels without diffuse late choroidal hyperfluorescence was found. In posterior scleritis, enlargement of vorticous veins was an additionnal ICGA sign. Stromal inflammatory vasculopathy always responded to anti-inflammatory therapy. A third group of patients with severe retinal or choroidal inflammation presented with associated secondary inflammatory choriocapillaropathy angiographically identical to the primary involvement. CONCLUSIONS: ICGA allowed the hitherto impossible characterization of inflammatory involvement of the choroidal vessels, showing either predominant inflammation of the choriocapillaris or predominant inflammation of the stromal choroidal vessels with or without secondary choriocapillaritis. ICGA will be indispensable for the correct evaluation and follow-up of posterior inflammation with suspected choroidal involvement.

Angiography↗