Current Eye Research
Volume 9 supplement 1990
Jorge Palmares, Maria Fatima Coutinho and Jose Castro-Correia
Curr Eye Res Downloaded from informahealthcare.com by Flinders University of South Australia on 01/10/15 For personal use only.
Department of Ophthalmology, Faculty of Medicine, Hospital S. Joiio, 4200 Porto, Portugal
ABSTRACT During the p a s t f o u r years 450 p a t i e n t s (247 female mean age 36 years and 203 male mean age 34 years) with i n t r a o c u l a r i n f l a m m a t i o n were evaluated u s i n g standard d i a g n o s t i c c r i t e r i a , t o e s t a b l i s h a u v e i t i s survey p r o f i l e . P a t i e n t s were d i v i d e d i n t o f o u r anatomic groups: a n t e r i o r u v e i t i s (270 cases = 60%), p o s t e r i o r u v e i t i s (108 cases = 2 4 % ) , p a n u v e i t i s (54 cases = 12%) and i n t e r m e d i a t e u v e i t i s (18 cases = 4 % ) . A probable a e t i o l o g i c a l d i a g n o s i s was made i n 232 cases (51.5%). Rheumatic diseases were diagnosed most commonly (55 cases = 12.2%), mainly a n k y l o s i n g s p o n d y l i t i s , as i s t r u e f o r o t h e r European c o u n t r i e s . Ocular toxoplasmosis was a f r e q u e n t cause o f u v e i t i s , as i n B r a z i l and West A f r i c a , thus r e q u i r i n g a prompt d i a g n o s i s and treatment. BehCet’s syndrome was associated w i t h HLA B 5 (65%) as i n Japanese and Mediterranean populations. I n our area AIDS r e t i n i t i s i s becoming an i m p o r t a n t d i f f e r e n t i a l diagnosis.
-
-
be i n v a l u a b l e t o understand t h e a e t i o l o g y o f t h e disease and t h e proper c l a s s i f i c a t i o n o f i t s subtypes.
I n order t o obtain a c o r r e c t incidence
o f u v e i t i s , a common s e t o f c r i t e r i a f o r d i f f e r e n t d i a g n o s i s must be defined. T h i s survey corresponds t o t h e update o f t h e o n l y d a t a e x i s t a n t f o r t h e Portuguese p o p u l a t i o n , which we i n i t i a t e d i n 1985 and was p u b l i s h e d as a p r e l i m i n a r y r e p o r t (3).
Our h o s p i t a l i s a major r e f e r r a l c e n t r e (for p r i m a r y care and a l s o t e r t i a r y care) c o v e r i n g t h e Northern P o r t u g a l , down t o t h e Oouro r i v e r ; t h i s area i s i n h a b i t e d by 3 m i l l i o n people (1981 census).
The aim o f t h e p r e s e n t study was t o
determine t h e i n c i d e n c e o f u v e i t i s among our
INTRODUCTION
h o s p i t a l p a t i e n t s and t o i d e n t i f y t h e d i f f e r e n t
Epidemiologic s t u d i e s o f u v e i t i s , although
u n d e r l y i n g causes or syndromes.
i m p o r t a n t as i n o t h e r n o s o l o g i c a l e n t i t i e s , a r e
c o u l d then b e compared w i t h s i m i l a r d a t a bases
d i f f i c u l t t o organise because, as P e r k i n s (1)
from o t h e r areas and used t o e s t a b l i s h e f f e c t i v e
noted, i t i s n o t easy t o make v a l i d comparisons
measures f o r t h e d i a g n o s i s and t r e a t m e n t o f
between u v e i t i s s t a t i s t i c s from d i f f e r e n t coun-
uveitis.
tries,
T h i s d a t a base
due t o d i f f e r e n t d i a g n o s t i c c r i t e r i a and
a e t i o l o g i c a l theories. Moreover, t h e eye u s u a l l y responds i n a very s i m i l a r way t o a l a r g e range o f systemic diseases and l o c a l i n f e c t i o n s , f o r a g i v e n human popul a t i o n l i v i n g i n a g i v e n environmental s e t t i n g .
PATIENTS AND METHOOS From J u l y 1985 t o J u l y 1989, 450 p a t i e n t s were observed ( n e a r l y 51 new c a s e d y e a r ) : 247 female
-
mean age 36 years (range 9-79) mean age 34 years (range 3-80).
and 203 male
Our d a t a a r e
I t i s w e l l known t h a t some forms o f u v e i t i s have
b i a s e d by r e f e r r a l method.
a d e f i n i t e geographical d i s t r i b u t i o n such as
i n t r a o c u l a r i n f l a m m a t i o n was i n v e s t i g a t e d accord-
onchocerciasis, histoplasmosis, Behcpt’s syndrome
i n g t o s t a n d a r d d i a g n o s t i c c r i t e r i a as r e p o r t e d
( I ) , so t h a t s t u d i e s on t h e i n c i d e n c e o f u v e i t i s
by Smith and Nozik ( 4 ) , i n c l u d i n g : p a t i e n t s ’
w i t h i n a community a r e i m p o r t a n t t o enable
h i s t o r y , c l i n i c a l examination and l a b o r a t o r y
r a t i o n a l i n v e s t i g a t i o n and management (2).
s t u d i e s , and X-ray and f l u o r e s c e i n angiography as
Therefore, epidemiologic s t u d i e s i n u v e i t i s may
0 Oxford University Press
I n every p a t i e n t
i n d i c a t e d . The w i d e l y known c l a s s i f i c a t i o n o f t h e
31
Current Eye Research International Uveitis Study Group (5) was used.
in 171 cases (38% o f total), acute in 40% and
Cases of endophthalmitis and traumatic uveitis
chronic in 60%. In 99 cases (36.7% of anterior
(sympathetic ophthalmia excepted) were excluded
uveitis) diagnosis was obtained, including by
from this series, since the patients are seldom
order of‘ frequency mainly herpes simplex kerato-
referred to our uveitis clinic.
uveitis, ankylosing spondylitis, Fuchs’ hetero-
Some patients, presenting simultaneously with uveitis and focal infections (dental and tonsil
chromic iridocyclitis, syphilis, tuberculosis, In posterior uveitis cases, a diagnosis was
abscesses, upper respiratory tract viral
Curr Eye Res Downloaded from informahealthcare.com by Flinders University of South Australia on 01/10/15 For personal use only.
herpes zoster keratouveitis and Reiter’s syndrome.
infections), were included in the idiopathic
made in 72.3% o f cases including: toxoplasmosis
group. The “mixed” group mentioned in the Table 2
retinocToroiditis, BehGet’s syndrome, lupus
includes rare cases, as listed at the end of the
retinitis, CMV retinitis in AIDS patients,
results section.
sarcoidosis, syphilis; retinal vasculitis was seen in 1 6 patients without an underlying cause. Panuveitis was observed in 54 patients. The
RESULTS Patients were divided into four anatomic groups
aetiology was determined in 34 cases including
(Table 1).
mainly Behqet’s syndrome (8 cases), toxoplasmosis
As reported in Table 2, a probable aetiologic
diagnosis was made in 232 cases (51.5%).
No sig-
(7 cases) and sympathetic ophthalmia (3 cases).
Patients with intermediate uveitis formed the
nificant difference was observed between males
smallest group, perhaps because pars planitis is
and females regarding the onset age of uveitis. Iridocyclitis (anterior uveitis) was idiopathic
often misdiagnosed at the first visit (primary care). Rheumatic diseases (55 cases) were the most common. Ocular toxoplasmosis, herpes simplex
Table 1: Uveitis by location Anterior uveitis 270 cases (60%) Posterior uveitis Panuveitis Int,ermediate uveitis
708 54 18
(24%) (12%) ( 4%)
keratouveitis, and BehFet’s syndrome (65% of them B5+ve) were the next most common group to be diagnosed. The rheumatic diseases included
-
ankylosing spondylitis (27 cases 85% of them B27+ve), systemic lupus erythematosus (7 cases), Reiter’s syndrome (6 cases), juvenile chronic arthritis (4 cases), rheumatic fever (3 cases),
Table 2: AetioloQy and disease associations Idiopathic uveitis Rheumatisms
218 cases (48.5%) 55 (12.2%)
Toxoplasrnosis
41
( 9.1%)
Herpes simplex
28
Eehqet’s syndrome
20
Pars planitis
18
It
( 6.2%) ( 4.5%) ( 4.0%)
Syphilis Fuchs’ heterochromic
13 10
‘I If
( 2.9%) ( 2.2%)
Tuberculosis
10
If
( 2.2%)
Sarcoidosis CMV retinitis
7
( 1.6%)
6
Herpes zoster
6
( 1.3%) ( 1.3%) ( 4.0%)
Mixed _-
32
18
rheumatoid arthritis (3 cases), polymyalgia rheumatica (3 cases) and psoriatic arthritis
(2 cases). Mixed causes of ocular inflammation were toxocara (3 cases), sympathetic ophthalmia (3 cases), acute retinal necrosis (3 cases), multiple sclerosis (3 cases), brucellosis (2 cases), meningococcal meningitis (2 cases) and rickettsia1 infection ( 2 cases). DISCUSSION
There have been surprinsingly few epidemiologic studies concerning uveitis. The results of the present study, the first performed in the Portu-
Current Eye Research guese population, do, however, confirm the simi-
tions (13). A similar result (4.2%) in an Aus-
larity between the pattern of uveitis syndromes
tralian survey may be due to a large proportion
seen in this country and other previously pub-
of the population from Greek or Italian descent (2). The presence of 85 in the Northern Portugal
lished studies. The differential diagnosis of uveitis has been
population may include an intense interchange
revised in the last four decades, due mainly to
with the Middle East since the X W I century, and
either new diseases being recognized (such as
the settlement by Jews, besides the Silk Route theory postulated by Ohno (13).
Curr Eye Res Downloaded from informahealthcare.com by Flinders University of South Australia on 01/10/15 For personal use only.
AIDS), or to a better understanding of common
Intermediate uveitis still remains frequently
disorders using better diagnostic techniques. In this series the most common type of uveitis
underdiagnosed, specially in young adults; ac-
was the anterior form, usually idiopathic (63.3%)
cording Henderly et a1 ( 1 4 ) , was the most fre-
or associated with a rheumatic disease (17.8%).
quently diagnosed form of uweitis (15.4%),
Patients presenting with acute iridocyclitis have,
pared to the low figures of Perkins and Folk
in half of the cases, a 827 HLA haplotype (6) and
(4.6%)(15),
association with various seronegative spondylo-
com-
Schlaegel (4.6%)(16) and ours ( 4 . 0 % ) .
In a study o f patients with retinal vasculitis,
arthropaties (ankylosing spondylitis, Reiter’s
Graham et a1 (17) concluded that ophthalmological
syndrome, psoriatic arthritis); in our study, 85%
features can discriminate between patients with
of ankylosing spondylitis are B27+ve. Therefore,
isolated retinal vasculitis and those with retinal
it is advisable to refer all 827+ve acute iri-
vasculitis associated with systemic inflammatory
docyclitis patients to a rheumatologist, and to
disease. In o u r study, we were unable to identify
inform the patients about possibility of a
the underlying cause in the 16 retinal vasculitis
recurrence.
cases. Although the importance of syphilis and tubercu-
Toxoplasmic retinochoroiditis, a leading cause of posterior uveitis (7), and generally accepted as congenital, may be difficult to diagnose. W e
losis has decreased dramatically over the past four decades ( 1 6 ) , we are facing a resurgence of
followed the currently held opinion that a positive test by any of the serologic methods is
these diseases, making it imperative to recognise
compatible with the diagnosis of ocular toxo-
For syphilis, the effect of therapy was evaluated
plasmosis, although Rothova et a1
(8) concluded
that a precise diagnosis is not yet feasible and
them as possible causes of ocular inflammation. by the W.D.R.L.
test, followed by FTA-A05 in
positive cases; for tuberculosis, tuberculin skin
negative tests in adults should be the only ones
test and chest X-rays were routinely used.
relied upon. Toxoplasmosis is the first ( 9 , l O ) or second
Sarcoidosis is quite rare (1.5%)
(II,I~) most importante cause of uveitis in some
in our area,
contrary to other studies (1,12,14,15). Although uncommon in this series, AIDS uveitis
surveys, emphasizing the need of early pro-
is rapidly becoming an important differential
phylaxis, diagnosis and specific therapy, namely
diagnosis, mainly due to a large immigration from Africa.
where it is prevalent and widespread: West Africa, West Indies ( 1 ) and Brazil (10). In o u r survey, toxoplasmosis was the second most common cause of uveitis - 9.1% - similarly to Western European series
(I,I~).
We found an association between Beh~et’ssyn-
The aetiology of many cases o f ocular inflammation remains unknown. In our series we are able to establish a presumptive diagnosis in only 232 cases (51.5%). Extensive monitoring of the local population is required in the near future, to
drome (complete type) (4.4% of total) and HLA 65,
detect any small change in epidemiologic patterns,
as is true for Japanese and Mediterranean popula-
so to implement effective treatment measures.
33
Current Eye Research ACKNOWLEDGEMENTS Jorge Palmares i s p a r t i a l l y s u p p o r t e d by a I N I C (Portuguese N a t i o n a l I n s t i t u t e f o r S c i e n t i f i c Research) g r a n t .
73,
CORRESPONDING AUTHOR
Jorge Palmares, Department o f Ophthalmology, F a c u l t y o f Medicine, H o s p i t a l S. So&,
Porto,
Curr Eye Res Downloaded from informahealthcare.com by Flinders University of South Australia on 01/10/15 For personal use only.
Portugal.
REFERENCES 1. P e r k i n s , E. 5. (1976) Epidemiology o f uveitis,. Trans. Ophthal. SOC. U.K. 96, 105-107. 2. Wakefield, D., McCluskey, P.J., Dunlop, I . and Penny, R. (1986) U v e i t i s : a e t i o l o g y and d i s e a s e a s s o c i a t i o n s i n an A u s t r a l i a n p o p u l a t i o n . Aust. J. Ophthalmol. l4, 181-787. 3. Palmares, J., Coutinho, P1.F. ano L a s t r o - C o r r e i a , J. (1988) U v e i t i s s u r v e y : p r e l i m i n a r y r e s u l t s of a r e t r o s p e c t i v e s t u d y . I n "Ophthalmology Today", (Ed. F s r r a z D l i v e i r a , L.N.) Pp. 435-436. E x c e r p t a Medica, Amsterdam, N. York, Oxford. 4. S m i t h , R.E. and N o z i k , R.A. (1983) U v e i t i s : A C l i n i c a l Approach t o D i a g n o s i s and Management. W i l l i a m s & Wilkins, B a l t i m o r e , London. (1984) C l a s s i f i c a t i o n o f u v e i t i s . 5 . O'connor, G.R. I n " U v e i t i s Update", (Ed. S a a r i , K.M.) Pp. 3-6. E l s e v i e r Science P u b l i s h e r s B.W., Amsterdam. 6. Rothova, A., van Veenondaal, W.G., L i n s s e n , A., G l a s i u s , E., K i j l s t r a , A. and de Jong, P.T.M. (1987) C l i n i c a l f e a t u r e s o f a c u t e a n t e r i o r u v e i t i s . Am. J. Ophthalmol. 103, 137-145. 7. Vadot, E., E a r t h , E. and B i l m , P. (1984) Epidemiology o f u v e i t i s preliminary results o f a p r o s p e c t i v e s t u d y i n Savoy. I n " U v e i t i s Pp. 13-16. E l s e v i e r Update" (Ed. S a a r i , K.M.) Amsterdam. Science P u b l i s h e r s B.W., 8. Rothova, A., van Knapen, F., Baarsma, G.S., K r u i t , P.J., Loewer-Sieger, D.H. and K i j l s t r a , A. (1986) S e r o l o g y i n o c u l a r t o x o p l a s m o s i s . B r . J. Ophthalmol. 70, 615-622. (1961) U v e i t i s 9. Woods, A.C. and A b r x a m s , I . W . 51, 761-760. survey. Am. J. Ophthalmol. H i r a t a , P.S., B e l f o r t J r , R. and lO.Abreu, M.T., (1980) U v e i t e s ern Sg; Paulo, e s t u d o Neto, 5.D: e p i d e m i o l o g i c o , c l h i c o e t e r a p e u t i c o . Arq. Bras. O f t a l . 43, 10-16. 11.Haut, ( 1 9 6 n C l a s s i f i c a t i o n 6 t i o l o g i q u e de 850 u v e i t e s . Arch. Ophtalmol. ( P a r i s ) 26, 691-694. Friedman, A . I . and Graham, E. IZ.James, D.G., (1976) U v e i t i s : a s e r i e s o f 368 p a t i e n t s . Trans. Ophthal. SOC. U.K. 2, 108-112. 13.0hn0, S. (1981) HLA and B e h p t ' s disease. A c t a Ophthalmol 62 (Suppl. ) 40-45. G e n s t l e r , A.J., S m i t h , R.E. 14.Henderly, D.E., and Rao, N.A. (1987) Changing p a t t e r n s o f u v e i t i s . Am. J. Ophthalmol. 103, 131-136. I S . P e r k i n s , E.S. and F o l k , J. (1984) U v e i t i s i n London and Iowa. Ophthalmologica, 36-40. 16.Schlaegel Jr, T.F. (1987) E t i o l o g i c d i a g n o s i s
-
-
?.
-
.
,
189,
34
o f u v e i t i s . I n I I C l i n i c a l Ophthalmology11, ~ 0 1 . 4 . (Eds. Duane, T.D. and Jaeger, E.A. ). Harper & Row, P h i l a d e l p h i a . Sanders, M.D., I?.Graham, E.M., S t a n f o r d , M.R., Kasp, E. and Durnonde, D.C. (1989) A p o i n t p r e v a l e n c e s t u d y o f 150 p a t i e n t s w i t h i d i o p a t h i c r e t i n a l v a s c u l i t i s : 1. D i a g n o s t i c v a l u e o f o p h t h a l m o l o g i c a l f e a t u r e s . B r . J. Ophthal714-721. mol.
Volume 9 supplement 1990
Jorge Palmares, Maria Fatima Coutinho and Jose Castro-Correia
Curr Eye Res Downloaded from informahealthcare.com by Flinders University of South Australia on 01/10/15 For personal use only.
Department of Ophthalmology, Faculty of Medicine, Hospital S. Joiio, 4200 Porto, Portugal
ABSTRACT During the p a s t f o u r years 450 p a t i e n t s (247 female mean age 36 years and 203 male mean age 34 years) with i n t r a o c u l a r i n f l a m m a t i o n were evaluated u s i n g standard d i a g n o s t i c c r i t e r i a , t o e s t a b l i s h a u v e i t i s survey p r o f i l e . P a t i e n t s were d i v i d e d i n t o f o u r anatomic groups: a n t e r i o r u v e i t i s (270 cases = 60%), p o s t e r i o r u v e i t i s (108 cases = 2 4 % ) , p a n u v e i t i s (54 cases = 12%) and i n t e r m e d i a t e u v e i t i s (18 cases = 4 % ) . A probable a e t i o l o g i c a l d i a g n o s i s was made i n 232 cases (51.5%). Rheumatic diseases were diagnosed most commonly (55 cases = 12.2%), mainly a n k y l o s i n g s p o n d y l i t i s , as i s t r u e f o r o t h e r European c o u n t r i e s . Ocular toxoplasmosis was a f r e q u e n t cause o f u v e i t i s , as i n B r a z i l and West A f r i c a , thus r e q u i r i n g a prompt d i a g n o s i s and treatment. BehCet’s syndrome was associated w i t h HLA B 5 (65%) as i n Japanese and Mediterranean populations. I n our area AIDS r e t i n i t i s i s becoming an i m p o r t a n t d i f f e r e n t i a l diagnosis.
-
-
be i n v a l u a b l e t o understand t h e a e t i o l o g y o f t h e disease and t h e proper c l a s s i f i c a t i o n o f i t s subtypes.
I n order t o obtain a c o r r e c t incidence
o f u v e i t i s , a common s e t o f c r i t e r i a f o r d i f f e r e n t d i a g n o s i s must be defined. T h i s survey corresponds t o t h e update o f t h e o n l y d a t a e x i s t a n t f o r t h e Portuguese p o p u l a t i o n , which we i n i t i a t e d i n 1985 and was p u b l i s h e d as a p r e l i m i n a r y r e p o r t (3).
Our h o s p i t a l i s a major r e f e r r a l c e n t r e (for p r i m a r y care and a l s o t e r t i a r y care) c o v e r i n g t h e Northern P o r t u g a l , down t o t h e Oouro r i v e r ; t h i s area i s i n h a b i t e d by 3 m i l l i o n people (1981 census).
The aim o f t h e p r e s e n t study was t o
determine t h e i n c i d e n c e o f u v e i t i s among our
INTRODUCTION
h o s p i t a l p a t i e n t s and t o i d e n t i f y t h e d i f f e r e n t
Epidemiologic s t u d i e s o f u v e i t i s , although
u n d e r l y i n g causes or syndromes.
i m p o r t a n t as i n o t h e r n o s o l o g i c a l e n t i t i e s , a r e
c o u l d then b e compared w i t h s i m i l a r d a t a bases
d i f f i c u l t t o organise because, as P e r k i n s (1)
from o t h e r areas and used t o e s t a b l i s h e f f e c t i v e
noted, i t i s n o t easy t o make v a l i d comparisons
measures f o r t h e d i a g n o s i s and t r e a t m e n t o f
between u v e i t i s s t a t i s t i c s from d i f f e r e n t coun-
uveitis.
tries,
T h i s d a t a base
due t o d i f f e r e n t d i a g n o s t i c c r i t e r i a and
a e t i o l o g i c a l theories. Moreover, t h e eye u s u a l l y responds i n a very s i m i l a r way t o a l a r g e range o f systemic diseases and l o c a l i n f e c t i o n s , f o r a g i v e n human popul a t i o n l i v i n g i n a g i v e n environmental s e t t i n g .
PATIENTS AND METHOOS From J u l y 1985 t o J u l y 1989, 450 p a t i e n t s were observed ( n e a r l y 51 new c a s e d y e a r ) : 247 female
-
mean age 36 years (range 9-79) mean age 34 years (range 3-80).
and 203 male
Our d a t a a r e
I t i s w e l l known t h a t some forms o f u v e i t i s have
b i a s e d by r e f e r r a l method.
a d e f i n i t e geographical d i s t r i b u t i o n such as
i n t r a o c u l a r i n f l a m m a t i o n was i n v e s t i g a t e d accord-
onchocerciasis, histoplasmosis, Behcpt’s syndrome
i n g t o s t a n d a r d d i a g n o s t i c c r i t e r i a as r e p o r t e d
( I ) , so t h a t s t u d i e s on t h e i n c i d e n c e o f u v e i t i s
by Smith and Nozik ( 4 ) , i n c l u d i n g : p a t i e n t s ’
w i t h i n a community a r e i m p o r t a n t t o enable
h i s t o r y , c l i n i c a l examination and l a b o r a t o r y
r a t i o n a l i n v e s t i g a t i o n and management (2).
s t u d i e s , and X-ray and f l u o r e s c e i n angiography as
Therefore, epidemiologic s t u d i e s i n u v e i t i s may
0 Oxford University Press
I n every p a t i e n t
i n d i c a t e d . The w i d e l y known c l a s s i f i c a t i o n o f t h e
31
Current Eye Research International Uveitis Study Group (5) was used.
in 171 cases (38% o f total), acute in 40% and
Cases of endophthalmitis and traumatic uveitis
chronic in 60%. In 99 cases (36.7% of anterior
(sympathetic ophthalmia excepted) were excluded
uveitis) diagnosis was obtained, including by
from this series, since the patients are seldom
order of‘ frequency mainly herpes simplex kerato-
referred to our uveitis clinic.
uveitis, ankylosing spondylitis, Fuchs’ hetero-
Some patients, presenting simultaneously with uveitis and focal infections (dental and tonsil
chromic iridocyclitis, syphilis, tuberculosis, In posterior uveitis cases, a diagnosis was
abscesses, upper respiratory tract viral
Curr Eye Res Downloaded from informahealthcare.com by Flinders University of South Australia on 01/10/15 For personal use only.
herpes zoster keratouveitis and Reiter’s syndrome.
infections), were included in the idiopathic
made in 72.3% o f cases including: toxoplasmosis
group. The “mixed” group mentioned in the Table 2
retinocToroiditis, BehGet’s syndrome, lupus
includes rare cases, as listed at the end of the
retinitis, CMV retinitis in AIDS patients,
results section.
sarcoidosis, syphilis; retinal vasculitis was seen in 1 6 patients without an underlying cause. Panuveitis was observed in 54 patients. The
RESULTS Patients were divided into four anatomic groups
aetiology was determined in 34 cases including
(Table 1).
mainly Behqet’s syndrome (8 cases), toxoplasmosis
As reported in Table 2, a probable aetiologic
diagnosis was made in 232 cases (51.5%).
No sig-
(7 cases) and sympathetic ophthalmia (3 cases).
Patients with intermediate uveitis formed the
nificant difference was observed between males
smallest group, perhaps because pars planitis is
and females regarding the onset age of uveitis. Iridocyclitis (anterior uveitis) was idiopathic
often misdiagnosed at the first visit (primary care). Rheumatic diseases (55 cases) were the most common. Ocular toxoplasmosis, herpes simplex
Table 1: Uveitis by location Anterior uveitis 270 cases (60%) Posterior uveitis Panuveitis Int,ermediate uveitis
708 54 18
(24%) (12%) ( 4%)
keratouveitis, and BehFet’s syndrome (65% of them B5+ve) were the next most common group to be diagnosed. The rheumatic diseases included
-
ankylosing spondylitis (27 cases 85% of them B27+ve), systemic lupus erythematosus (7 cases), Reiter’s syndrome (6 cases), juvenile chronic arthritis (4 cases), rheumatic fever (3 cases),
Table 2: AetioloQy and disease associations Idiopathic uveitis Rheumatisms
218 cases (48.5%) 55 (12.2%)
Toxoplasrnosis
41
( 9.1%)
Herpes simplex
28
Eehqet’s syndrome
20
Pars planitis
18
It
( 6.2%) ( 4.5%) ( 4.0%)
Syphilis Fuchs’ heterochromic
13 10
‘I If
( 2.9%) ( 2.2%)
Tuberculosis
10
If
( 2.2%)
Sarcoidosis CMV retinitis
7
( 1.6%)
6
Herpes zoster
6
( 1.3%) ( 1.3%) ( 4.0%)
Mixed _-
32
18
rheumatoid arthritis (3 cases), polymyalgia rheumatica (3 cases) and psoriatic arthritis
(2 cases). Mixed causes of ocular inflammation were toxocara (3 cases), sympathetic ophthalmia (3 cases), acute retinal necrosis (3 cases), multiple sclerosis (3 cases), brucellosis (2 cases), meningococcal meningitis (2 cases) and rickettsia1 infection ( 2 cases). DISCUSSION
There have been surprinsingly few epidemiologic studies concerning uveitis. The results of the present study, the first performed in the Portu-
Current Eye Research guese population, do, however, confirm the simi-
tions (13). A similar result (4.2%) in an Aus-
larity between the pattern of uveitis syndromes
tralian survey may be due to a large proportion
seen in this country and other previously pub-
of the population from Greek or Italian descent (2). The presence of 85 in the Northern Portugal
lished studies. The differential diagnosis of uveitis has been
population may include an intense interchange
revised in the last four decades, due mainly to
with the Middle East since the X W I century, and
either new diseases being recognized (such as
the settlement by Jews, besides the Silk Route theory postulated by Ohno (13).
Curr Eye Res Downloaded from informahealthcare.com by Flinders University of South Australia on 01/10/15 For personal use only.
AIDS), or to a better understanding of common
Intermediate uveitis still remains frequently
disorders using better diagnostic techniques. In this series the most common type of uveitis
underdiagnosed, specially in young adults; ac-
was the anterior form, usually idiopathic (63.3%)
cording Henderly et a1 ( 1 4 ) , was the most fre-
or associated with a rheumatic disease (17.8%).
quently diagnosed form of uweitis (15.4%),
Patients presenting with acute iridocyclitis have,
pared to the low figures of Perkins and Folk
in half of the cases, a 827 HLA haplotype (6) and
(4.6%)(15),
association with various seronegative spondylo-
com-
Schlaegel (4.6%)(16) and ours ( 4 . 0 % ) .
In a study o f patients with retinal vasculitis,
arthropaties (ankylosing spondylitis, Reiter’s
Graham et a1 (17) concluded that ophthalmological
syndrome, psoriatic arthritis); in our study, 85%
features can discriminate between patients with
of ankylosing spondylitis are B27+ve. Therefore,
isolated retinal vasculitis and those with retinal
it is advisable to refer all 827+ve acute iri-
vasculitis associated with systemic inflammatory
docyclitis patients to a rheumatologist, and to
disease. In o u r study, we were unable to identify
inform the patients about possibility of a
the underlying cause in the 16 retinal vasculitis
recurrence.
cases. Although the importance of syphilis and tubercu-
Toxoplasmic retinochoroiditis, a leading cause of posterior uveitis (7), and generally accepted as congenital, may be difficult to diagnose. W e
losis has decreased dramatically over the past four decades ( 1 6 ) , we are facing a resurgence of
followed the currently held opinion that a positive test by any of the serologic methods is
these diseases, making it imperative to recognise
compatible with the diagnosis of ocular toxo-
For syphilis, the effect of therapy was evaluated
plasmosis, although Rothova et a1
(8) concluded
that a precise diagnosis is not yet feasible and
them as possible causes of ocular inflammation. by the W.D.R.L.
test, followed by FTA-A05 in
positive cases; for tuberculosis, tuberculin skin
negative tests in adults should be the only ones
test and chest X-rays were routinely used.
relied upon. Toxoplasmosis is the first ( 9 , l O ) or second
Sarcoidosis is quite rare (1.5%)
(II,I~) most importante cause of uveitis in some
in our area,
contrary to other studies (1,12,14,15). Although uncommon in this series, AIDS uveitis
surveys, emphasizing the need of early pro-
is rapidly becoming an important differential
phylaxis, diagnosis and specific therapy, namely
diagnosis, mainly due to a large immigration from Africa.
where it is prevalent and widespread: West Africa, West Indies ( 1 ) and Brazil (10). In o u r survey, toxoplasmosis was the second most common cause of uveitis - 9.1% - similarly to Western European series
(I,I~).
We found an association between Beh~et’ssyn-
The aetiology of many cases o f ocular inflammation remains unknown. In our series we are able to establish a presumptive diagnosis in only 232 cases (51.5%). Extensive monitoring of the local population is required in the near future, to
drome (complete type) (4.4% of total) and HLA 65,
detect any small change in epidemiologic patterns,
as is true for Japanese and Mediterranean popula-
so to implement effective treatment measures.
33
Current Eye Research ACKNOWLEDGEMENTS Jorge Palmares i s p a r t i a l l y s u p p o r t e d by a I N I C (Portuguese N a t i o n a l I n s t i t u t e f o r S c i e n t i f i c Research) g r a n t .
73,
CORRESPONDING AUTHOR
Jorge Palmares, Department o f Ophthalmology, F a c u l t y o f Medicine, H o s p i t a l S. So&,
Porto,
Curr Eye Res Downloaded from informahealthcare.com by Flinders University of South Australia on 01/10/15 For personal use only.
Portugal.
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