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BJO Online First, published on August 28, 2014 as 10.1136/bjophthalmol-2014-305518 Clinical science
Characterisation of uveitis in association with multiple sclerosis Wyatt Messenger,1 Lena Hildebrandt,2 Friederike Mackensen,2 Eric Suhler,1 Matthias Becker,3 James T Rosenbaum1,4 1
Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, USA 2 Department of Ophthalmology, Interdisciplinary Uveitis Center, University of Heidelberg, Heidelberg, Germany 3 Tremlispital, Zurich, Switzerland 4 Legacy Devers Eye Institute, Portland, Oregon, USA Correspondence to Dr James Rosenbaum, Casey Eye Institute, 3375 SW Terwilliger Blvd, Portland, OR 97239, USA; [email protected] Received 20 May 2014 Revised 22 July 2014 Accepted 26 July 2014
ABSTRACT Purpose To characterise uveitis in association with multiple sclerosis (MS). Methods We conducted a retrospective chart review of patients with uveitis and MS at two uveitis centres (Portland, Oregon, USA and Heidelberg, Germany). Baseline characteristics and ophthalmic data were collected at the patient’s first and last visits. Additionally, neurological records were obtained when possible. Results We identified 113 patients (196 eyes) with uveitis and MS. Of these, 53 had a diagnosis of MS confirmed by review of neurological records, 50 additional patients fulfilled the Poser criteria for MS and 10 with MS were referred by an outside neurologist. Among them, 83 (73%) were women and the mean age of presentation was 40.6 years (range 13–64 years). The average visual acuity in affected eyes at presentation was 20/39. There were 90 patients (80%) who presented with intermediate uveitis and 24 patients (15%) with anterior uveitis. Posterior and pan-uveitis were found in four patients (3%) and two patients (2%), respectively. During a median follow-up of 3.2 years (range 0.04– 21 years), visual acuity improved –0.09 logMar/year. Compared with our location-matched controls with idiopathic intermediate uveitis (n=16), patients with MS and intermediate uveitis were significantly older when diagnosed with uveitis ( p=0.027) and more likely to be female ( p=0.01). There was no statistical difference in visual acuity or rate of vision change between our cases and controls ( p=0.58 and p=0.36, respectively). Conclusions Uveitis with MS generally presents as intermediate uveitis with a minority presenting with anterior uveitis. Patients are significantly older and more likely to be women than patients with idiopathic intermediate uveitis. The visual prognosis is generally favourable.
INTRODUCTION
To cite: Messenger W, Hildebrandt L, Mackensen F, et al. Br J Ophthalmol Published Online First: [please include Day Month Year] doi:10.1136/ bjophthalmol-2014-305518
The association between uveitis and multiple sclerosis (MS) has been known for several decades. As early as 1910, Winmuller published a case report of a patient with choroiditis and MS.1 By the middle of the 20th century, anterior, intermediate, posterior and pan-uveitis had been documented in patients with MS; however, MS was most commonly associated with pars planitis.1 2 While difficult to measure due to the differences in methods and small sample sizes, the prevalence of uveitis has been estimated at between 1% and 10% of patients with MS.3 4 Despite being recognised over 100 years ago, the association remains poorly understood and the description has been limited to several small case series.
The purpose of this study was to add to the understanding of this association by (1) characterising the anatomy, laterality and continuity of uveitis in patients with MS; (2) describing the time of presentation of uveitis with respect to MS and (3) clarifying the visual prognosis in patients with MS and uveitis.
METHODS Institutional review board approval for this study was obtained at Oregon Health & Science University and the University of Heidelberg. A database search was completed of all patients treated for uveitis and MS at the Casey Eye Institute and University of Heidelberg uveitis clinics between 1985 and 2013 for the Oregon clinic and between 1998 and 2013 for the Heidelberg clinic. Classification of uveitis was based on the Standardization of Uveitis Nomenclature (SUN) workshop.5 For clinic visits prior to 2005, patients were reclassified using the SUN criteria. Neurology notes were obtained in patients with suspected MS by a referring provider or at the university-affiliated neurology clinic. Patients were included in the study if they had a neurologist-confirmed diagnosis of MS; they fulfilled the Poser criteria for the diagnosis of MS based on their history and a review of their medical record; or they had a referral from a neurologist for MS but documentation was not available at the time of our chart review.6 For each eligible patient, age, gender, bestcorrected visual acuity, intraocular pressure, age of uveitis diagnosis, anatomic location of uveitis, laterality, continuity, presence of optic neuritis, central macular thickness by optical coherence tomography (Spectralis, Heidelberg Engineering, Heidelberg, Germany) and medications were recorded at the first and last visits to the uveitis clinic. Only data from affected eyes were included in the analysis. Additionally, age of MS diagnosis, MRI and cerebrospinal fluid findings and type of MS were recorded from the patient’s neurology records when available. We identified a control group by randomly selecting 16 patients treated for idiopathic intermediate uveitis at the Casey Eye Institute uveitis clinic. Patients were excluded if they were suspected to have MS or had only one clinic visit. Controls were compared with the 16 patients with intermediate uveitis and MS from the same clinic for age, gender, age of uveitis diagnosis, continuity of disease and rate of visual decline. Statistical significance was calculated using an unpaired t test for continuous variables and a χ2 test for categorical variables. Statistical significance was defined as p
BJO Online First, published on August 28, 2014 as 10.1136/bjophthalmol-2014-305518 Clinical science
Characterisation of uveitis in association with multiple sclerosis Wyatt Messenger,1 Lena Hildebrandt,2 Friederike Mackensen,2 Eric Suhler,1 Matthias Becker,3 James T Rosenbaum1,4 1
Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, USA 2 Department of Ophthalmology, Interdisciplinary Uveitis Center, University of Heidelberg, Heidelberg, Germany 3 Tremlispital, Zurich, Switzerland 4 Legacy Devers Eye Institute, Portland, Oregon, USA Correspondence to Dr James Rosenbaum, Casey Eye Institute, 3375 SW Terwilliger Blvd, Portland, OR 97239, USA; [email protected] Received 20 May 2014 Revised 22 July 2014 Accepted 26 July 2014
ABSTRACT Purpose To characterise uveitis in association with multiple sclerosis (MS). Methods We conducted a retrospective chart review of patients with uveitis and MS at two uveitis centres (Portland, Oregon, USA and Heidelberg, Germany). Baseline characteristics and ophthalmic data were collected at the patient’s first and last visits. Additionally, neurological records were obtained when possible. Results We identified 113 patients (196 eyes) with uveitis and MS. Of these, 53 had a diagnosis of MS confirmed by review of neurological records, 50 additional patients fulfilled the Poser criteria for MS and 10 with MS were referred by an outside neurologist. Among them, 83 (73%) were women and the mean age of presentation was 40.6 years (range 13–64 years). The average visual acuity in affected eyes at presentation was 20/39. There were 90 patients (80%) who presented with intermediate uveitis and 24 patients (15%) with anterior uveitis. Posterior and pan-uveitis were found in four patients (3%) and two patients (2%), respectively. During a median follow-up of 3.2 years (range 0.04– 21 years), visual acuity improved –0.09 logMar/year. Compared with our location-matched controls with idiopathic intermediate uveitis (n=16), patients with MS and intermediate uveitis were significantly older when diagnosed with uveitis ( p=0.027) and more likely to be female ( p=0.01). There was no statistical difference in visual acuity or rate of vision change between our cases and controls ( p=0.58 and p=0.36, respectively). Conclusions Uveitis with MS generally presents as intermediate uveitis with a minority presenting with anterior uveitis. Patients are significantly older and more likely to be women than patients with idiopathic intermediate uveitis. The visual prognosis is generally favourable.
INTRODUCTION
To cite: Messenger W, Hildebrandt L, Mackensen F, et al. Br J Ophthalmol Published Online First: [please include Day Month Year] doi:10.1136/ bjophthalmol-2014-305518
The association between uveitis and multiple sclerosis (MS) has been known for several decades. As early as 1910, Winmuller published a case report of a patient with choroiditis and MS.1 By the middle of the 20th century, anterior, intermediate, posterior and pan-uveitis had been documented in patients with MS; however, MS was most commonly associated with pars planitis.1 2 While difficult to measure due to the differences in methods and small sample sizes, the prevalence of uveitis has been estimated at between 1% and 10% of patients with MS.3 4 Despite being recognised over 100 years ago, the association remains poorly understood and the description has been limited to several small case series.
The purpose of this study was to add to the understanding of this association by (1) characterising the anatomy, laterality and continuity of uveitis in patients with MS; (2) describing the time of presentation of uveitis with respect to MS and (3) clarifying the visual prognosis in patients with MS and uveitis.
METHODS Institutional review board approval for this study was obtained at Oregon Health & Science University and the University of Heidelberg. A database search was completed of all patients treated for uveitis and MS at the Casey Eye Institute and University of Heidelberg uveitis clinics between 1985 and 2013 for the Oregon clinic and between 1998 and 2013 for the Heidelberg clinic. Classification of uveitis was based on the Standardization of Uveitis Nomenclature (SUN) workshop.5 For clinic visits prior to 2005, patients were reclassified using the SUN criteria. Neurology notes were obtained in patients with suspected MS by a referring provider or at the university-affiliated neurology clinic. Patients were included in the study if they had a neurologist-confirmed diagnosis of MS; they fulfilled the Poser criteria for the diagnosis of MS based on their history and a review of their medical record; or they had a referral from a neurologist for MS but documentation was not available at the time of our chart review.6 For each eligible patient, age, gender, bestcorrected visual acuity, intraocular pressure, age of uveitis diagnosis, anatomic location of uveitis, laterality, continuity, presence of optic neuritis, central macular thickness by optical coherence tomography (Spectralis, Heidelberg Engineering, Heidelberg, Germany) and medications were recorded at the first and last visits to the uveitis clinic. Only data from affected eyes were included in the analysis. Additionally, age of MS diagnosis, MRI and cerebrospinal fluid findings and type of MS were recorded from the patient’s neurology records when available. We identified a control group by randomly selecting 16 patients treated for idiopathic intermediate uveitis at the Casey Eye Institute uveitis clinic. Patients were excluded if they were suspected to have MS or had only one clinic visit. Controls were compared with the 16 patients with intermediate uveitis and MS from the same clinic for age, gender, age of uveitis diagnosis, continuity of disease and rate of visual decline. Statistical significance was calculated using an unpaired t test for continuous variables and a χ2 test for categorical variables. Statistical significance was defined as p
