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      Clinical association and visual morbidity in uveitis with systemic diseases: An analysis from a tertiary ophthalmic center

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          Abstract

          AIM:

          The aim of this study was to identify the incidence, etiology, most common presentations, complications, and the causes of visual loss in posterior uveitis (PU).

          MATERIALS AND METHODS:

          A retrospective study was conducted on a cohort of 125 patients with PU with a minimum follow-up of 6 months. Ocular evaluation consisted of slit-lamp examination, indirect ophthalmoscopy, tonometry, and refraction. Ancillary ophthalmic investigations such as fundus fluorescein angiography, optical coherence tomography, and B-scan ultrasonography were done. Laboratory tests were performed on blood on all patients and in aqueous humor samples obtained by anterior chamber paracentesis in cases of diagnostic dilemmas. All the data were analyzed using SPSS program.

          RESULTS:

          PU occurred in 61%. Infections were noted in 34% and autoimmune diseases in 27%. The most frequent presentation was choroiditis. The most common etiologies were tubercular uveitis in 50%, Toxoplasma retinochoroiditis in 23%, and autoimmune category of serpiginous choroiditis in 56% of patients. Complications occurred in 27% and were most commonly cystoid macular edema and macular scarring. Polymerase chain reaction (PCR), nested PCR, and real-time PCR on ocular fluids were required for diagnosis in 30%. A combination of laboratory investigations on blood and aqueous humor samples were confirmation in 88%.

          CONCLUSION:

          PU and its sequelae are known to be sight threatening and are associated with systemic diseases. They have diverse etiologies and presentations. Identification of etiology is important as management is diametrically opposite in infections and autoimmune diseases.

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          Most cited references18

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          Standardization of Uveitis Nomenclature for Reporting Clinical Data. Results of the First International Workshop

          To begin a process of standardizing the methods for reporting clinical data in the field of uveitis. Consensus workshop. Members of an international working group were surveyed about diagnostic terminology, inflammation grading schema, and outcome measures, and the results used to develop a series of proposals to better standardize the use of these entities. Small groups employed nominal group techniques to achieve consensus on several of these issues. The group affirmed that an anatomic classification of uveitis should be used as a framework for subsequent work on diagnostic criteria for specific uveitic syndromes, and that the classification of uveitis entities should be on the basis of the location of the inflammation and not on the presence of structural complications. Issues regarding the use of the terms "intermediate uveitis," "pars planitis," "panuveitis," and descriptors of the onset and course of the uveitis were addressed. The following were adopted: standardized grading schema for anterior chamber cells, anterior chamber flare, and for vitreous haze; standardized methods of recording structural complications of uveitis; standardized definitions of outcomes, including "inactive" inflammation, "improvement'; and "worsening" of the inflammation, and "corticosteroid sparing," and standardized guidelines for reporting visual acuity outcomes. A process of standardizing the approach to reporting clinical data in uveitis research has begun, and several terms have been standardized.
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            Tubercular serpiginous-like choroiditis presenting as multifocal serpiginoid choroiditis.

            To describe the clinical features, course, and outcome in tubercular serpiginous-like choroiditis. Retrospective cohort study. A total of 105 patients (141 eyes) between May 2002 and July 2010. Patients had the following inclusion criteria: (1) complete clinical records and digital fundus images at baseline and follow-up visits, (2) positive tuberculin skin test or QuantiFERON-TB Gold (Cellestis International Pty Ltd. Chadstone, Victoria, Australia) test result, (3) active serpiginous-like choroiditis in at least 1 eye, (4) all known causes of infectious (except tuberculosis) and noninfectious uveitis ruled out, and (5) a minimum of 9 months of follow-up from initiation of treatment that included antitubercular therapy (ATT) with oral corticosteroids (93 patients) or corticosteroids alone (12 patients). Clinical characteristics and evolution of choroiditis lesions from the acute to healed stage, recurrence, visual outcome, and complications. Mean age was 33 ± 9.3 years (range, 12-54 years; 75 male and 30 female patients). Serpiginous-like choroiditis was bilateral (at least 1 eye active) in 66 patients (62.9%). Of 171 affected eyes, 141 (82.45%) had active lesions at presentation. Of 141 eyes, 115 (81.56%) showed vitreous inflammation. Lesions were multifocal in 133 eyes (94.3%), were noncontiguous to optic disc in 122 eyes (86.52%), and involved the macula in 125 eyes (88.65%). Of patients receiving ATT, all showed resolution of lesions and 9 (9.7%) developed recurrences (median follow-up, 21 months). In addition, 12 patients (12.9%) showed continued progression over a median 3.5 weeks after initiation of therapy. Of 12 patients treated with corticosteroids alone, none showed progression but 9 (75%) developed recurrence (median, 26.5 months). Final visual acuity of ≥ 6/12 was achieved in 108 eyes (76.60%) versus 72 eyes (51.06%) before treatment. Fovea was spared in 95 of 125 eyes (76%) with macular involvement. Five eyes (3.5%) developed choroidal neovascular membrane. Tubercular serpiginous-like choroiditis presented as multifocal serpiginoid choroiditis affecting predominantly young to middle-aged men. It was frequently bilateral with vitreous inflammation and characterized by multifocal lesions that were noncontiguous to the optic disc and showed serpiginoid spread. Antitubercular therapy significantly reduced recurrences. Lesions responded to combined antitubercular and steroid therapy, usually spared fovea, and had a good final visual acuity. Copyright © 2012 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.
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              Usefulness of aqueous humor analysis for the diagnosis of posterior uveitis.

              To assess the clinical usefulness of aqueous fluid analysis for the diagnosis and treatment of patients suspected of having infectious posterior uveitis (PU). Case-control study. From 2002 through 2005, 152 eyes from 152 patients with active PU (16 of whom were immunosuppressed) underwent diagnostic aqueous testing. As controls, 20 patients with Fuchs' heterochromic uveitis and 20 patients with age-related cataract were included. Aqueous samples were examined by real-time polymerase chain reaction (PCR) and by pathogen-specific analysis of intraocular antibody production (Goldmann-Witmer coefficient [GWC]) for herpes simplex virus (HSV), varicella zoster virus (VZV), cytomegalovirus (CMV), and the parasite Toxoplasma gondii. Results of aqueous analysis and any adverse effects of aqueous sampling. Correlations between the results of aqueous testing and clinical characteristics as well as the treatment of patients. Of 152 patients, 44 (29%) had positive results for at least one diagnostic assay (37/136 [28%] immunocompetent and 7/16 [44%] immunocompromised patients). None of the controls had positive results using PCR or GWC. A positive result was obtained predominantly in patients with focal chorioretinitis (37/87 [40%]) and in extensive retinitis (7/9 [78%]), whereas in multifocal chorioretinitis, neuroretinitis, and retinal vasculitis only a few samples demonstrated positive results (2/19, 1/29, and 0/10, respectively). Of 37 immunocompetent PU patients with positive results, 28 (76%) cases were caused by T. gondii, whereas viral infections were most common in immunocompromised patients (5/7 [71%]). In immunocompetent and toxoplasmosis PU patients, GWC was the most informative assay (34/37 [92%] and 28/30 [93%], respectively), in contrast to immunosuppressed patients (PCR positive in 5/7 and GWC positive in 4/7). Independent of the immune status of patients, positive PCR results were observed more frequently in viral infections than in toxoplasmosis (P<0.001). As a consequence of aqueous analysis, change of treatment was necessary in 36 patients (24%). None of the patients experienced complications during or after aqueous sampling. Despite the posterior location of inflammation, aqueous analyses with PCR and GWC for HSV, VZV, CMV, and T. gondii revealed an infectious cause in 29% of patients with PU.
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                Author and article information

                Journal
                Oman J Ophthalmol
                Oman J Ophthalmol
                OJO
                Oman J Ophthalmol
                Oman Journal of Ophthalmology
                Wolters Kluwer - Medknow (India )
                0974-620X
                0974-7842
                Sep-Dec 2023
                18 October 2023
                : 16
                : 3
                : 472-477
                Affiliations
                [1 ] Department of Ophthalmology and Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
                [2 ] Department of Ophthalmology, Sankara Nethralaya, Chennai, Tamil Nadu, India
                Author notes
                Address for correspondence: Dr. Radha Annamalai, Department of Ophthalmology, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai - 600 116, Tamil Nadu, India. E-mail: drradhasrmc@ 123456gmail.com
                Article
                OJO-16-472
                10.4103/ojo.ojo_250_22
                10697255
                38059097
                e3e6c4b6-9803-416c-8b1d-a7bc492eb15d
                Copyright: © 2023 Oman Ophthalmic Society

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                : 31 August 2022
                : 10 March 2023
                : 03 September 2023
                Categories
                Original Article

                Ophthalmology & Optometry
                choroiditis,posterior uveitis,serpiginous choroiditis,toxoplasma retinochoroiditis,tuberculosis

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