JUNIPER
PUBLISHERS- JOJ Ophthalmology
Abstract
Purpose: The aim of the present study is to
describe the epidemiological and clinical features of recently presented
patients with uveitis in a tertiary referral hospital in Bulgaria.
Material and methods: We conducted a
retrospective observational study on the clinical records of 42 patients
with uveitis of the Department of Ophthalmology, Alexandrovska Eye
Hospital, Medical University - Sofia, Bulgaria. The period of the study
was from March 2016 until December 2016. Follow-up ranged from 1 to 9
months. The diagnosis of the individual cases was based on a complete
eye examination, review of systems, and additional laboratory and
specialized testing methods.
Results: Forty-two new patients with uveitis
presented to our clinic in 2016. Out of them, 28 (66.7%) were female and
14 (33.3%) - male (2:1 ratio). With the exception of one, who was
racially mongoloid, all cases were white-caucasian. The age of the
patients varied from 28 to 70 years, with a mean value of 51.9, median -
50.5, and mode of 40 years. Uveitis was bilateral in 25 (59.5%) and
monolateral in 17 (40.5%) cases. We observed 17 cases (40.5%) of
anterior uveitis, 5 patients (11.9%) with posterior, and 20 (47.6%) with
panuveitis. The major infectious etiologic agents were viruses from the
herpes family, namely herpes simplex virus type -1 and varciella-zoster
virus and toxoplasma gondii.
Conclusion: Uveitis comprises a diverse group
of inflammatory conditions, which affect people of both genders and all
ethnic groups at a relatively young and active age. Visual and anatomic
outcomes may be excellent with timely diagnosis and treatment to prevent
the development of vision-threatening complications. The epidemiologic
data from this small cohort of patients from Bulgaria corresponds well
with the already published literature for other different ethnic groups.
The most common infectious etiologic agents for anterior and panuveitis
belonged to the herpetic viruses family - 16.7%. Non-infectious uveitis
was associated most often with seronegative spondyloarthropathies and
sarcoidosis.47.6% of all cases were classified as idiopathic.
Keywords: Uveitis; Epidemiology; PanuveitisIntroduction
Uveitis is a broad concept, defining inflammation of
the uveal tract, consisting of the iris, ciliary body, and choroid. Any
compartment of the uvea may be affected distinctly or in association
with the other parts and/or additional ocular structures [1,2]. Epidemiologically uveitis has been described in people of both genders, all ages, and in every racial group [1-3].
However, data regarding uveitis cases from Bulgaria, Europe, are
lacking. The etiology is extremely diverse and there are many infectious
and noninfectios conditions which may incite intraocular inflammation [1,2].
The presence of intraocular inflammation may lead to serious and
irreversible vision-threatening structural and functional complications [1,2,4].
Purpose
The aim of the present study is to describe the
epidemiological and clinical features of recently presented patients
with uveitis in a tertiary referral centre in Bulgaria.
Material and Methods
We conducted a retrospective observational study on
the clinical records of 42 patients with uveitis of the Department of
Ophthalmology, Alexandrovska Eye Hospital, Medical University - Sofia,
Bulgaria. The period of the study was from March 2016 until December
2016. Follow-up ranged from 1 to 9 months. All uveitis patients who had
presented prior to March 2016 were excluded from the study. The research
was done with the consent and agreement of the Head of the Department
of Ophthalmology. The diagnosis of the individual cases was based on a
complete eye examination, review of systems, and additional laboratory
and specialized testing methods. For data analysis, descriptive
statistical methods were used.
Results
Forty-two new patients with uveitis presented to our
clinic in 2016. Out of them, 28 (66.7%) were female and 14 (33.3%) -
male (2:1 ratio). With the exception of one, who was racially mongoloid,
all cases were white-caucasian. The age of the patients varied from 28
to 70 years, with a mean value of 51.9, median - 50.5, and mode of 40
years. Uveitis was bilateral in 25 (59.5%) and monolateral in 17 (40.5%)
cases. From anatomical standpoint, we distinguished 17 cases (40.5%) of
anterior uveitis, 5 patients (11.9%) with posterior, and 20 (47.6%)
with panuveitis. No cases of distinct intermediate uveitis were observed
in this cohort.
With regard to anterior uveitis, there were 11
female(64.7%) and 6 male patients (35.3%). Bilateral involvement was
noted in 8 cases (47.1%) and monocular in 9 (52.9%). The presenting age
was from 30 to 78, and most often 40 years (mean 55.9, median 58, mode
40). The inflammation was acute in 8 (47.1%) patients (monocular
involvement in all but one), recurrent - in 4 (23.5%), and chronic in - 5
(29.4%), most often bilateral. Etiologically, it was associated with
herpetic infection in 3 (17.6%) cases (keratouveitis), toxoplasmosis
(manifesting as Fuchs heterochromic phenotype) - 1 (5.9%), psoriasis -
in 2 (11.8%) (one with scleral involvement), Bechterew spondyloarthritis
- in 1 (5.9%), reactive arthritis - in 1 (5.9%), cataract surgery - 1
(5.9%), corneal trauma with vegetable matter - in 1 (5.9%), antiglaucoma
medications (dorzolamide/ timolol and brimonidine) -1, and no definite
extraocular cause was assumed in 6 (35.3%). The visual acuity ranged
between no light perception and 20/20, most frequently - 20/20. The
ocular complications observed were most commonly ocular hypertension in 4
patients (23.5%), cataract - in 3 (17.6%), macular oedema - in 2
(11.8%), posterior synechiae- in 2 (11.8%), corneal scarring - in 1
(5.9%).
Concerning posterior uveitis, there were 3 female
(60%) and 2 male (40%) patients. Bilateral involvement was noted in 3
cases (60%) and monocular in 2 (40%). The presenting age was from 28 to
50 (mean 39, median 40, mode - not applicable). The inflammation was
chronic in 4 patients (80%) and recurrent - in 1 (20%). Etiologically
all cases were idiopathic. Two male patients conformed to the punctate
inner choroiditis (PIC) type of uveitis and one of them had Bechterew
spondyloarthritis. One woman had focal granulomatous inflammation with
adjacent vasculitis with evidence of old foci of inflammation in the
retinal periphery. There was one case with bilateral serpiginous-like
chorioretinitis with associated retinal optic nerve arteriolitis and one
female with uveitis resembling either PIC or acute posterior multifocal
pigment epitheliitis. Visual acuity varied from counting fingers to
20/20, most commonly - 20/25. The major disturbing complaint was
metamorhopsia. The ocular complications were most commonly intraretinal
hemorrhages in 2 cases (40%), atrophy of the retinal pigment epithelium
and outer retinal layers- in 4 eyes (80%), choroidal neovascular
membrane and macular oedema - in 1 eye (20%). From the associated ocular
conditions, 4 patients (80%) had myopia.
Panuveitis was encountered slightly more frequently
than the other types, mostly because of our tertiary referral centre
status. There were 14 female (70%) and 6 male (30%) patients. Bilateral
involvement was noted in 14 (70%) and monocular in 6 (30%) of the cases.
The presenting age was from 30 to 76 - mean 51.7 years. The
inflammation was acute in 1 (5%), recurrent - 8 (40%), and chronic in 11
cases (55%). Final visual acuity ranged between no light perception and
20/20, on average 20/50. Etiologically we found associations with
herpetic infection in 4 patients (20%), sarcoidosis - in 4 (20%),
toxoplasmosis in -1 (5%), Behcet disease - in 1 (5%), malignant
hypertension (masquerade syndrome) - in 1 (5%), and the remaining 9
(45%) were designated as idiopathic. The ocular complications included -
cataract - in 7 patients (35%), preretinal membrane - in 6 (30%),
ocular hypertension - in 5 (25%), macular oedema - in 4 (20%), secondary
glaucoma - in 3 (15%), retinal detachment - in 3 (15%), vireopapillary
traction syndrome - in 3 (15%), posterior synechiae - in 3 (15%),
extensive chorioretinal atrophy - in 2 (10%), anterior synechiae - in 1
(5%), optic nerve atrophy - in 1 (5%), vitreoretinal traction syndrome -
in 1 (5%), hypotony - in 1 (5%).
Discussion
In general, uveitis was not a common diagnosis at our
institution for a period of 9 months. In terms of gender and age, our
data correspond to the already published figures, indication overall
female preponderance [1,5,6] and onset most frequently around the age of 40 [1,2,7,8].
This was especially true for the cases of anterior and panuveitis,
regardless of the diverse etiology. Anterior uveitis is usually the most
common type of intraocular inflammation reported worldwide [1,2].
In the present study, however, panuveitis was the most frequent uveitis
entity at 47.6%, but we assume this to be due to referral bias.
Concerning the causative factors the major infectious
agents were viruses from the herpes family, namely Herpes simplex virus
type -1 and Varciella-zoster virus, and toxoplasma gondii. In those
cases the diagnosis was corroborated by typical clinical findings,
polymerase chain reaction of aqueous humour, and the response to
therapy. With regard to noninfectious causes of uveitis, seronegative
spondyloarthropathies were associated with 4 cases of anterior uveitis,
sarcoidosis - with 4 patients with panuveitis, and Behcet disease with 1
patient with bilateral generalized intraocular inflammation. Secondary
to failure to identify definitive etiologic factors, many cases were
classified as being idiopathic - 6 with anterior uveitis (35%), all 5
with posterior (100%), and 9 with panuveitis (45%). All in all, 20 cases
were idiopathic (47.6%). There was a relatively high frequence of
myopia in the patients with posterior uveitis in our group, which had
also been described for similar cases by other authors [1].
The visual prognosis was excellent in the cohort with
anterior uveitis and it was twice as worse and guarded in those with
panuveitis. Timely and sensible treatment were the necessary conditions
for a good outcome. The reason for the poorer vision in the panuveitis
group was largelly due to a significant delay in the institution of
systemic therapy, including immunomodulatory medications, which had led
to the development of irreversible vision-limiting complications.
The ocular complications of uveitis were not
infrequent and often there were multiple alterations in a single
patient. Structural and functional complications were observed more
frequently in the panuveitis group and in the whole cohort consisted
predominantly of cataract (23.8%), ocular hypertension (21.4%), macular
oedema (16.7%), and preretinal membrane (14.3%). Some of those would
necessitate additional conservative and surgical treatment. Albeit the
small size of the analyzed sample, the relative percentages of the
various complications are very similar to the reported in the literature
for other populations [1,4,7-11].
Conclusion
Uveitis comprises a diverse group of inflammatory
conditions, which affect people of both genders and all ethnic groups at
a relatively young and active age. Visual and anatomic outcomes may be
excellent with timely diagnosis and treatment to prevent the development
of vision-threatening complications. The epidemiologic data from this
small cohort of patients from Bulgaria corresponds well with the already
published literature for other different ethnic groups. The most common
infectious etiologic agents for anterior and panuveitis belonged to the
herpetic viruses family - 16.7%. Non-infectious uveitis was associated
most often with seronegative spondyloarthropathies and sarcoidosis.
47.6% of all cases were classified as idiopathic.
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