See discussions, stats, and author profiles for this publication at: https://www.researchgate.
net/publication/330780631
INCIDENCE, ETIOLOGY AND MANAGEMENT OF ACUTE ANTERIOR UVEITIS: A
HOSPITAL BASED STUDY
Article · November 2018
CITATIONS READS
0 444
1 author:
Subha Soumya Dany
Veer Surendra Sai Medical College
41 PUBLICATIONS 48 CITATIONS
SEE PROFILE
Some of the authors of this publication are also working on these related projects:
Case report View project
Original research View project
All content following this page was uploaded by Subha Soumya Dany on 01 February 2019.
The user has requested enhancement of the downloaded file.
ejbps, 2018, Volume 5, Issue 11, 317-321. Research Article SJIF Impact Factor 4.918
Naik et al.
European Journal of Biomedical ISSN 2349-8870
European Journal of Biomedical and Pharmaceutical Sciences
Volume: 5
AND Pharmaceutical sciences Issue: 11
317-321
http://www.ejbps.com Year: 2018
INCIDENCE, ETIOLOGY AND MANAGEMENT OF ACUTE ANTERIOR UVEITIS: A
HOSPITAL BASED STUDY
Dr. Bishnu Prasad Mishra1, Dr. Santosh Kumar Sahu2, Dr. Choubarga Naik3* and Dr. Subha Soumya Dany4
1
Ophthalmologist, District Headquarter Hospital, Balangir, Odisha.
2
ENT Specialist, District Headquarter Hospital, Balangir, Odisha.
3
Assistant Professor, Department of Dentistry, VIMSAR, Burla, Odisha.
4
Senior Resident, Department of Dentistry, VIMSAR, Burla, Odisha.
*Corresponding Author: Dr. Choubarga Naik
Assistant Professor, Department of Dentistry, VIMSAR, Burla, Odisha.
Article Received on 26/08/2018 Article Revised on 17/09/2018 Article Accepted on 08/10/2018
ABSTRACT
Introduction: Anterior uveitis is a sight-threatening eye condition that must be diagnosed and treated early by
ophthalmologists. Due to its association with potentially serious systemic disease and when undetected can cause
loss of vision, the importance of awareness about this entity to primary eye care physician is a public health
concern. So with the limitation of a hospital based study the present study was done to find out the incidence,
etiology, and management protocol of cases of acute anterior uveitis based on the investigations and clinical
features. Materials and Methodology: A prospective clinical study was conducted in Deparment of
Ophthalmology, District Headquarter Hospital, Balangir, Odisha. Based on set inclusion and exclusion criteria 113
patients with anterior uveitis were recruited into the study. Detail clinical history, visual acuity, clinical findings,
laboratory investigation findings, serological, biochemical and radiographic findings were noted on a pre-designed
proforma. Based on etiologic diagnosis relevant treatment was given and patients were followed up for 6 months
for treatment outcomes and complications. Results: A total of 113 subjects (56.64 % male and 43.36% female)
were enrolled. Most commonly affected age group was 31-40 (38.05%). Most of the cases were unilateral
(86.73%), acute (74.34%) and non-granulomatous (90.27%). A highly significant (p=0.000) effect of the treatment
was recorded after 2 and 6 weeks. Conclusion: Acute anterior uveitis is mostly involved in middle aged persons
and in majority of cases (56.25%) it responded well to good visual outcome (6/9 or better) after adequate
treatment.
KEYWORDS: Anterior uveitis, ophthalmologists.
INTRODUCTION The precise cause of anterior uveitis is often obscure and
Uveitis is one of the most common forms of intraocular the correct diagnosis is often challenging. The cause of
inflammation involving the uveal tract and affects mainly inflammation might be infections agents or trauma, but
children and young adults. It includes a large group of in most cases underlying mechanism appear to be
intraocular inflammatory diseases of diverse etiology. On autoimmune in nature.[3] In order to enhance the
several occasions, it reflects diseases that are developing understanding and management of ocular inflammation
elsewhere in the body and uveitis may be the first International Ocular Inflammation Society (IOIS) has
evidence of such systemic diseases.[1] Variation in the been founded.[4]
spectrum of disease is largely due to complex
geographic, ecological, racial, nutritional, and Anterior uveitis is the most common form of uveitis and
socioeconomic differences. The anterior uveitis is the accounts for an annual incidence of about 17 cases per 1,
most common type of all uveitic entities (57.4%). On the 00,000 population.[5]
basis of overall clinical presentation, acute unilateral,
non-infectious and non-granulomatous forms occur more Anterior uveitis can be categorized as iritis
frequently. Idiopathic anterior uveitis is more common in (inflammation of iris), anterior cyclitis (inflammation of
all age groups. Mean age at presentation is 38.3 years anterior portion of ciliary body) and iridocyclitis
and commonly affects middle aged (17-59 years). It is (inflammation of iris and ciliary body). It often causes
more common in males (61.3%) as compared to females painful red eye, photophobia, tearing and blurring of
(38.6%).[2] vision. Acute anterior uveitis causes mild vision loss but
still contributes significantly to the total burden. It causes
www.ejbps.com 317
Naik et al. European Journal of Biomedical and Pharmaceutical Sciences
vision loss both directly through inflammation and via within the anterior iris stroma (Bausacca nodules) were
complications such as macular edema, glaucoma, present.
cataract and others. The treatment of uveitis underwent a
tremendous paradigm shift with the introduction of A short differential diagnosis was made in case.
corticosteroids in to the ophthalmic therapeutic Subsequently, a tailored laboratory investigation was
armamentarium.[6] The recent use of intra-ocularly carried out. Investigations included, total and differential
placed steroids is still being investigated, but has counts, erythrocyte sedimentation rate, urine and stool
limitations due to local adverse effects, in treatment of examination, Mantoux test. Serological test for HIV,
bilateral cases and sustained long-term therapy in syphilis, rheumatoid factor was done in all cases.
chronic/recurrent cases. The need for less toxic, effective Radiological investigations included X-ray chest,
anti-inflammatory treatment inspired the use of lumbosacral and knee joints. Other special investigations
immunosuppressive drugs for ocular inflammatory were considered whenever necessary. Consultation was
disease. The treatment for uveitis itself can result in both done with other medical specialties whenever needed.
ocular and systemic complications. [7] The morbidity
associated with the disease is moderately high. Final etiological diagnosis was made based on history,
clinical features, laboratory investigations and systemic
Therefore taking into consideration the vital functions of evaluation by other medical specialties. The anterior
uveal tract, the hazardous effect it has when inflamed, its uveitis was considered to have idiopathic etiology when
puzzling etiopathogenesis and refractories in the it was not associated with HLA-B27 haplotype and
treatment make a detailed study of incidence, etiology neither with defined clinical syndromes nor with
and management; very much necessary and important. definitive etiology.[8]
With this as the background the present study was done
to find out the incidence, etiology, and management All patients were treated medically with topical steroids
protocol of cases of acute anterior uveitis based on the (prednisolone acetate 1%, difluprednate 0.05%) and
investigations and clinical features. topical cyclopgenics mydriatics (atropine, cyclopentolate
or homatropine). Steroid frequency was titrated
MATERIALS AND METHODOLOGY according to the severity of uveitis. Appropriate
A prospective clinical study was conducted in treatment was given when etiology was known. Systemic
Deparment of Ophthalmology, District Headquarter antimicrobials were administered when infectious agent
Hospital, Balangir, Odisha between January 2016 to was found to be the cause. Systemic steroids were used
December 2017. Study subjects included all the patients when inflammation was severe and not responding to
who presented with Anterior Uveitis during the study treatment and patients with macular oedema. Patients
period in the age group of 10 to 70 years. Cases of with lens induced inflammation were treated surgically.
anterior uveitis associated with pertaining ocular injuries, In patients with uveitis associated with visually
corneal ulcer, intraocular surgeries, intermediate, significant cataract, surgery was done after active
posterior or panuveitis and masquerade syndrome inflammation had subsided and IOP reduce. These
presenting as anterior uveitis were excluded from the patients were treated with high doses of topical and
present study. systemic steroids if inflammation was not subsiding and
then gradually tapered. Cases of anterior uveitis with
A standard clinical proforma was filled in all cases, secondary glaucoma were treated with tablet
which included salient feature in history, visual acuity Acetozolamide 250mg BD/TID and /or Timolol 0.5%
using Snellens visual acuity chart, clinical findings, eye drops BD along with topical steroids.
laboratory investigations and the final etiology. All
patients were examined under slit lamp. Details on The patients were followed up for 6 months (results of
disease severity, laterality, chronicity, ocular signs and upto 6 weeks are presented over here). The
associated conditions were noted. complications and response to treatment were recorded.
Presentation was considered as unilateral if active All data were entered into Microsoft excel sheet and
inflammation was present in only one eye and bilateral if SPSS 20.0 was used for descriptive statistics. ANOVA
both eyes presented with active inflammation. was used to compare pre and post treatment outcome.
Intraocular inflammation was assigned anterior uveitis Statistical significance was set at p<0.05.
based on International Uveitis Study Group Criteria. The
inflammation was defined as acute if symptoms were RESULTS
present for less than three months, chronic if symptoms In the present study a total of 113 subjects (56.64 % male
were present for three months or more and recurrent if and 43.36% female) were enrolled during the study
two or more episodes of inflammation separated by a period based on inclusion and exclusion criteria. It was
disease free period. Anterior uveitis was defined as seen that 31-40 age group was most commonly (38.05%)
granulomatous if large keratotic precipitate nodules at presented with anterior uveitis. Laborers (43.36%) were
pupillary margin (Koeppe nodules) or nodules on or the most vulnerable population and students were least
(4.42%). Most of the cases were unilateral (86.73%),
www.ejbps.com 318
Naik et al. European Journal of Biomedical and Pharmaceutical Sciences
acute (74.34%) and non-granulomatous (90.27%). In addressed during the follow up period. A highly
30.09% cases etiology was idiopathic. Post treatment significant (p=0.000) effect of the treatment was
complications were seen in 39.06% of cases. Many cases recorded after 2 and 6 weeks.
presented with multiple complications those were
Table. 1: Demographic profile of the anterior uveitis cases.
Criteria Number of cases Percentage of cases
11-20 6 5.31
21-30 23 20.35
31-40 43 38.05
Age
41-50 18 15.93
51-60 12 10.63
>60 11 9.73
Male 64 56.64
Sex
Female 49 43.36
Laborer 49 43.36
Officials 24 21.24
Occupation Housewife 23 20.35
Business man 12 10.63
Student 5 4.42
Total 113 100
Table. 2: Clinical findings and etiology of anterior uveitis cases.
Criteria Number of cases Percentage of cases
Unilateral 98 86.73
Laterality distribution
Bilateral 15 13.27
Acute 84 74.34
Clinical presentation Chronic 20 17.70
Recurrent 9 7.96
Non-granulomatous 102 90.27
Type of inflammation
Granulomatous 11 9.73
Idiopathic 34 30.09
Phacolytic 22 19.47
Blunt trauma 15 13.27
Herpes 18 15.94
Etiology Tuberculosis 7 6.19
Septic focus 4 3.54
Iridocyclitis with arthritis 8 7.08
Leprosy 3 2.65
Inflammatory bowel disease 2 1.77
Table. 3: Treatment regimen used and complications faced in the anterior uveitis cases.
Type of Treatment Given Number of cases Percentage of cases
Topical steroids and cycloplegics mydiatrics 113 100
Periocular steroids 10 8.45
Systemic steroids 16 14.16
Anti- glaucoma 44 12.39
Anti-tubercular 7 6.19
Anti-viral 18 15.93
Anti-leprosy 3 2.66
Antibiotics 23 20.35
Cataract surgery 22 19.47
Complications Faced in Relation to the Eyes Given Treatment Number of eyes Percentage of eyes
involved involved
No complications 78 60.94
Persistent posterior synechiae 35 30.97
cataract 22 17.19
Secondary glaucoma 18 14.06
Iris atrophy 8 6.25
www.ejbps.com 319
Naik et al. European Journal of Biomedical and Pharmaceutical Sciences
Table 4: Visual acuity before and after treatment.
6 weeks after
Before treatment 2 weeks after treatment Significance (ANOVA)
Visual treatment
Sl No.
Acquity No. of No. of No. of
Percentage Percentage Percentage
eyes eyes eyes F=33.408 (p=0.000)
1 PL+PR+ 12 9.4 7 5.5 6 4.7 Tukey’s HSD: highly
2 <6/60 16 12.5 10 7.8 4 3.1 significant (p=0.000) for
3 6/60 11 8.6 8 6.2 3 2.3 before treatment V/S
4 6/36 28 21.9 13 10.2 11 8.6 both 2 & 6 weeks after
5 6/24 14 10.9 17 13.3 6 4.7 treatment and also
6 6/18 18 14.1 17 13.3 12 9.4 between 2 weeks after
7 6/12 16 12.5 23 18 14 10.9 treatment V/S 6 weeks
8 6/9 13 10.2 20 15.6 37 28.9 after treatment
9 6/6 0 0 13 10.2 35 27.3
DISCUSSION other study was conducted in referral centre where
In the present study done in the Deparment of usually chronic and recurrent ones were referred from
Ophthalmology, District Headquarter Hospital, Balangir, primary and secondary centres; whereas present study
Odisha between January 2016 to December 2017; it was was done in a general ophthalmic clinic and most people
observed that anterior uveitis was high in the age group were from nearby villages.
21-30 (20.35) and 31-40 (38.05) and least above the age
of 60 years. This finding is in accordance with study by In the present study uveitis was found to be associated
Rathinam et al.[2]; who have reported 83.3% in the age with diabetes mellitus in 20 patients (17.7%) and
group of 17-59 years. Idiopathic anterior uveitis was the hypertension in 9 (7.96%) patients. All those who had
commonest cause which can be explained by highly diabetes mellitus were above 50 years of age. Out of 20
antigenicity found in this group of population. Alezandro patients 12 had developed chronic uveitis. In a study of
Rodriguez et al.[9] reported 35% incidence in the age uveitis presenting in elderly it was noted that diabetes
group of 31-40 years is in accordance to our study but in should be considered as a risk factor for development of
their study it second most vulnerable group was 61-70 uveitis.
years which is contradictory to our study. It was
observed in the present study that males were more Visual acuity was 6/12 or worse in majority (89.8%) of
affected than females. This may be because men tend to the eyes at presentation. Following treatment most eyes
seek medical attention more than women (limitation of a regained visual acuity of 6/9 or better (56.25%). In few
hospital based study). Socio-economic habits may also eyes with complicated cataract or posterior synechiae
put male patients at greater risk of development of visual acuity improved only marginally. There was a
anterior uveitis. This trend is in accordance with previous statistically significant response to treatment (p=0.000).
studies by Rathinam et al.[2] (61.3% male & 38.7% In most of the cases no complications was seen (60.94%
female) and very much contradicting to results of of eyes).
Alezandro Rodriguez et al. 9 (38.9% male and 61.1%
female). Majority of patients were laborers and most Appropriate line of treatment was given to all the
common cause among them was blunt trauma. This may patients as deemed necessary according to their
be due to their occupational exposure to vulnerable conditions and follow up improvement or complications.
situations. Cataract extraction with posterior chamber intraocular
lens implantation was done in all cases of phacolytic
The most common clinical presentation was acute type anterior uveitis. Majority of patients responded well to
followed by chronic and recurrent. This comparable to the medical line of treatment. The above pattern changes
study by Rathinam et al.[2] who reported acute type in because of a multitude of factors including ethnic,
71.9% followed by chronic type in 24.3% and recurrent geographic and environmental factors in addition to
type in 3.8%. Results of the present study were changing factors to changing pattern of uveitis over the
comparable to Rathinam et al.[2] and Alezandro years.
Rodriguez et al.9 for type of inflammation also.
To conclude it can be made that acute anterior uveitis is
In the present study idiopathic was the most common mostly involved in middle aged persons and in majority
cause of anterior uveitis followed by phacolytic etiology. of cases it responded well to good visual outcome after
Although herpes accounted for 15.94% of the cases, but adequate treatment. India presents unique problems
is not the most common cause but is the most common because of varying socio-economic, demographic and
infectious cause. Tubercular anterior uveitis was seen in morbidity patterns. The prevalence and severity of
6.19% of patients which is comparable to Rathinam et diseases in economically deprived population vary from
al.[2] (4%) and Singh et al[10] (7.9%), whereas there is no those in the rest of the world because of lack of good
data in Henderly et al.[11] study. This may be because primary health care, poor affordability and poor
www.ejbps.com 320
Naik et al. European Journal of Biomedical and Pharmaceutical Sciences
compliance. Hence further research is required with
sufficient number of cases to reveal definite etiology,
management and to decrease the morbidity of conditions
associated with it.
REFERENCES
1. Rathiman SR. CME Series. All india
ophthalmological society. Uveitis made simple work
up ans management, 20: 1-42.
2. Rathiman SR, Namperumalsamy P. global variation
and pattern changes in epidemiology of Uveitis.
Indian J Ophthalmology, 2007; 55(3): 173-83.
3. Yanoff M, Duker JS, Augsburger JJ, Azar DT,
Diamond GR, Dutton JJ et al. Ophthalmology. 2nd
Ed. Vol 2. Missouri (MO): Mosby, 2004; 1105-12.
4. Alio J, Ben Ezra D. priority features of intraocular
inflammation. Highlights of Ophthalmology, 2002;
30(3):1-2.
5. Martin TM, Smith JR, Rosenbaum JT. Anterior
uveitis: Current concepts of pathogenesis and
interactions with the spondyloarthropathies. Current
opinion Rheumatology, 2002; 14(4): 0337-41.
6. Sangwan VS. Treatment of Uveitis: Beyond
steroids. Indian J Ophthalmol, 2010; 58: 1-2.
7. Venkatraman A, Rathiman SR. A pre and post
treatment evaluation of vision related quality of life
in uveitis. Indian J Ophthalmol, 2008; 56: 307-12.
8. Nussenblatt RB, Whitcup SM. Uveitis fundamentals
and clinical practice. 3rd Ed. Pennsylvania (PA):
Mosby, 2004; 273-86.
9. Rodriguez A, Calonge M, Pedroza-Seres M, Akova
YA, Messemer EM, D’Amico DJ et al. Referral
patterns of uveitis in a tertiary care centre. Arch
Ophthalmology, 1996; 114: 593-99.
10. Singh R, Gupta V, Gupta A. Pattern of Uveitis in a
referral eye clinic in North India. Indian J
Ophthalmol, 2004; 52: 121-25.
11. Henderley DE, Genstler AJ, Smith RE, Rao N.
Changing patterns of Uveitis. Am J Ophthalmol,
1987; 103(2): 131-36.
www.ejbps.com 321
View publication stats
