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Prevalence of uveitis in indigenous populations presenting to remote clinics of Central Australia: The Central Australian Ocular Health Study
Abstract
Background:
To report the prevalence of current and previous uveitis within the indigenous population living within Central Australia.
Design:
Population-based cross-sectional study in Central Australia.
Participants:
One thousand eight hundred and eighty-four subjects who identified themselves as indigenous Australians, presenting to the remote clinics during the 36-month period between July 2005 and June 2008.
Methods:
Clinical assessments for active or previous uveitis were performed. Data were collected using a standardized form.
Main outcome measures:
Prevalence of various types of uveitis.
Results:
Four of 1881 subjects had evidence of previous or current anterior uveitis, giving a prevalence for anterior uveitis of 0.21% (95% confidence interval, 0.01-0.42%). Eleven of 1854 patients had signs of previous posterior uveitis, giving a prevalence for posterior uveitis of 0.59% (95% confidence interval 0.24-0.94%). Nine of the 11 patients with posterior uveitis cases (82%) had presumed toxoplasma retinochoroiditis. There were no cases of intermediate uveitis or panuveitis observed in this study. There were no observed cases consistent with well-recognized clinical uveitic syndromes, such as Behçet's disease or Vogt-Koyanagi-Harada syndrome.
Conclusions:
A distinct pattern of uveitis appears to be present among indigenous population of remote Central Australia. Posterior uveitis was commoner than anterior uveitis with a predominance of toxoplasma retinochoroiditis. Environmental factors appeared to be more important in this genetically distinct population, with infective causes and ocular trauma being the most common aetiologies of uveitis.
... The prevalence of uveitis in the general population was found to be at 0.5-1% [11][12][13][14] . In our study, we found a 9.33% prevalence of uveitis in MS patients. ...
... This prevalence is considered to be clinically significantly higher than in the general population, but within the published reports of the association between uveitis and MS. This association varies widely: 0.4-26.9% in patients with MS and 0.8-14% in patients with uveitis [7][8][9][10][11][12][13][14] . ...
... Uveitis showed a trend toward affecting younger male MS patients with exacerbated diseases. This prevalence is considered to be clinically significantly higher than in the general population [11][12][13][14] . It is, however, considered to be within the published reports of the association between uveitis and MS [7][8][9][10][11] . ...
Purpose:
To investigate the prevalence and pattern of uveitis in patients with multiple sclerosis (MS).
Patients and methods:
This is a cross-sectional, observational, descriptive clinical study of patients with MS who had complete ophthalmological examination. Data collected comprised demographics of the patients and complete ocular examination findings. Exclusion criteria were history of ocular surgery, trauma or diagnosis of any other ocular pathology.
Results:
Seventy-five patients with a mean age of 32.64 years (ranging from 16 to 50) diagnosed with MS of the relapsing-remitting type were included in this study. There were 34 males and 41 females, a ratio of 5:6. The mean duration of the MS disease was 5.6 years. Eight eyes of 7 patients with a mean age of 20 years had intermediate uveitis, of which 5 were males. Out of the 7 patients, 5 had exacerbated MS, and 2 were in remission; 4 had relative afferent pupillary defect. In the 8 eyes with uveitis, 6 had a best spectacle-corrected visual acuity (BSCVA) of 1, 1 had a BSCVA of 0.5 and 1 had a BSCVA of 0.25.
Conclusion:
Uveitis occurs in about 10% of patients with MS affecting younger males with exacerbated disease. Most inflammations of the uveitic MS patients were in the form of intermediate uveitis that was controlled with medication with no visual threatening complications.
... Studies exploring the clinical patterns of uveitis have been conducted on patient populations in Turkey, 7 other European nations, 8 and Australia. 9 Uveitis is estimated to be responsible for approximately one quarter of all blindness globally. 10 Managing complex uveitis often requires frequent clinical visits. ...
Aim:
The aim of this research is to evaluate the demographic attributes and clinical manifestations of uveitis in adult patients frequenting the Mansoura Ophthalmic Center.
Methods:
Utilizing a cross-sectional, prospective, analytical study design, this research engaged adult patients visiting the outpatient uveitis clinic at the Mansoura Ophthalmic Center. Comprehensive case evaluations involved collecting detailed patient histories, examining ophthalmic records, and conducting thorough ocular examinations. These examinations encompassed the assessment of visual acuity, slit-lamp examination, and fundus examination. Furthermore, selected cases underwent optical coherence tomography (OCT) and fundus fluorescein angiography (FFA).
Results:
The Study involved an examination of 411 eyes belonging to 254 uveitic patients. In the Egyptian context, anterior uveitis surfaced as the most prevalent form of uveitis. The average Best-Corrected Visual Acuity (BCVA) among the cases studied was 0.797 ± 0.77 LogMAR, with the majority of cases demonstrating vision superior to 0.3 LogMAR. Notably, the principal causes of vision loss were generally reversible. Macular edema was identified as the leading cause of vision loss, representing 20.7% of cases as evidenced by OCT. The ratio of non-infectious to infectious uveitis stood at 92.2% to 7.8%. The most commonly observed etiologies of non-infectious uveitis included Behçet's disease (33.3%), Vogt-Koyanagi-Harada (VKH) syndrome (19.7%), idiopathic causes (19.2%), and ankylosing spondylitis (AS) (11.9%). Conversely, the most frequent infectious etiologies were trematode-induced uveitis (2.9%), herpetic uveitis (1.7%), toxoplasmosis (1.5%), tuberculosis (TB) (1.5%), and brucellosis (0.2%).
Conclusions:
This study conclusively indicates that anterior uveitis is the predominant anatomical type of uveitis in Egypt. Further, etiological diagnoses of uveitis should particularly emphasize Behçet's disease, VKH syndrome, and ankylosing spondylitis.
... 13 The three remaining retrospective studies also present variable results: 58 and 24.9 per 100,000 for prevalence and incidence, respectively, in Hawaii, 10 622 and 111 per 100,000 in Taiwan, 12 and 173 and 106 per 100,000, correspondingly, in South Korea. 17 These retrospective studies present methodological differences due to: (i) using inaccurate denominators or administrative databases, 19 (ii) possibility of selection or classification bias, 10,12,17,20,25 (iii) diagnosis based on ICD or other codes, 12,19 (iv) being single centre studies, 18 and (v) different follow-up times. ...
Background: Although the impact of uveitis on people's lives is clear, the frequency of this condition is unclear.Objective: To estimate the prevalence and incidence of uveitis.Methods: A systematic review with meta-analysis was conducted. Medline, Embase, and Cochrane Library were searched from inception to January 2019. The quality of the included studies was critically appraised with a grading system based on the Oxford Levels of Evidence. A detailed description of the populations studied and of factors affecting estimates was undertaken. Pooled analyses were conducted using a random-effects approach and expressed as incidence rates per 100,000 with 95% confidence intervals. Subgroup analyses by geographical region were conducted along with meta-regression to analyze possible factors for heterogeneity.Results: A total of 49 studies were included and critically appraised. Twenty-two were population-based, and 27 hospital-based. Heterogeneity was substantial in terms of populations studied, methods for ascertaining uveitis, including definitions, and reporting of results. This was especially important in prevalence studies, with data ranging from 9 to 730 cases per 100,000. For incidence studies, the meta-analysis yielded a pooled incidence of 50.45 per 100.000. The meta-regression showed the geographic region as an important explanatory factor of the heterogeneity between studies.Conclusion: Population-based estimates of the epidemiology of uveitis vary widely, owing to methodologies employed, definitions of uveitis and geographical regions; the representativeness and generalizability of many epidemiological studies of uveitis are limited.
... There are indications that cat-dependent diseases may be more common in Australia's remote Indigenous communities, on the basis of studies reporting higher rates of T. gondii-related eye disease, and high rates of T. cati infections in cats, at some communities Thompson et al. 1993;Palmer et al. 2008;Henderson 2009;Chang et al. 2012). Further research to confirm how widespread these patterns are, and their key contributing risk factors, could help reduce disease in these vulnerable communities, particularly given that the number of pet cats living in many Indigenous communities is increasing (Kennedy et al. 2020). ...
Context
Cats are the definitive or primary host for pathogens that cause diseases in people and livestock. These cat-dependent diseases would not occur in Australia if cats had not been introduced, and their ongoing persistence depends on contacts with cats. Toxoplasma gondii is a protozoan parasite that cycles between cats and any other warm-blooded animals. People infected by T. gondii may appear asymptomatic, or have a mild illness, or experience severe, potentially lethal symptoms; the parasite may also affect behaviour and mental health. T. gondii is also a major contributor to spontaneous abortion in sheep and goats. Two species of Sarcocystis, another genus of protozoan parasite, cycle through cats and sheep, causing macroscopic cysts to form in sheep tissues that reduce meat saleability. Toxocara cati, the cat roundworm, causes minor illnesses in humans and livestock, and the bacterium Bartonella henselae causes cat scratch disease, an infection that can be contracted by people when scratched or bitten by cats carrying the pathogen.
Aims
We estimated the economic costs of cat-dependent pathogens in Australia.
Methods
We collated national and global data on infection rates, health and production consequences.
Key results
We estimated the costs of two cat-dependent diseases (toxoplasmosis, cat scratch disease) in people at AU2.11–10.7 billion) annually, and the costs to livestock production from toxoplasmosis and sarcocystosis at AU7.67–18.3 million). Most of the human health costs are due to the associations between T. gondii and higher rates of traffic accidents and mental illness in people. The causality behind these associations remains uncertain, so those costs may be overestimated. Conversely, our estimates are incomplete, infections and illness are under-reported or misdiagnosed, and our understanding of disease outcomes is still imperfect, all of which make our costs underestimated.
Conclusions
Our analysis suggests that substantial benefits to public health and livestock production could be realised by reducing exposure to cats and breaking parasite transmission cycles.
Implications
Reducing feral cat populations in farming and urban areas, reducing the pet cat population and increasing rates of pet cat containment could help reduce the burden of cat-dependent diseases to people and livestock.
... 6 This condition is the most frequently identified form of uveitis among Indigenous Australians living in Central Australia. 7 While ocular toxoplasmosis usually presents in otherwise healthy adults, the disease is more common and severe in certain groups: congenitally infected neonates, the aged and persons with co-morbidities that impact immune function. [8][9][10] These individuals also are particularly susceptible to expanded central nervous system and/or systemic pathology. ...
Objective:
Toxoplasmosis may follow consumption of undercooked meat containing Toxoplasma gondii cysts. Lamb is considered to pose the highest risk for contamination across meats. Red meat is often served undercooked, yet there are no current data on T. gondii contamination of Australian sourced and retailed lamb. We sought to address this gap in public health knowledge.
Methods:
Lamb mincemeat was purchased at the supermarket counter three times weekly for six months. T. gondii was detected by real-time polymerase chain reaction (PCR) of DNA extracted from the meat following homogenisation. Purchases were also tested for common foodborne bacterial pathogens.
Results:
Conservative interpretation of PCR testing (i.e. parasite DNA detected in three of four tests) gave a probability of 43% (95% confidence interval, 32%-54%) that lamb mincemeat was contaminated with T. gondii. None of the purchases were contaminated with Campylobacter jejuni, Salmonella species or S. enterica serovar Typhimurium, indicating sanitary meat processing.
Conclusions:
Australian lamb is commonly contaminated with T. gondii. Future studies should be directed at testing a range of red meats and meat cuts. Implications for public health: Consuming undercooked Australian lamb has potential to result in toxoplasmosis. There may be value in health education around this risk.
... Two communitybased surveys, the Andhra Pradesh eye disease study and the Aravind comprehensive eye survey, estimated the prevalence of uveitis in southern India as 73/10,000 in urban Hyderabad city and 31/10,000 in rural Tamil Nadu [11,12]. The central Australian ocular health study estimated that the prevalence of anterior uveitis presenting in remote clinics of central Australia was 21/10,000, and the prevalence of posterior uveitis was 59/10,000 [13]. Hwang and Rim used nationwide health insurance databases to estimate the epidemiology of uveitis in Taiwan and South Korea. ...
Uveitis is a sight-threatening disease. Up to 35% of patients may have impaired vision. Inflammation of the uvea tissue has more than 60 etiologies. Previous reports have shown that 20–40% of uveitis cases were noninfectious. Some of them may be associated with systemic rheumatological and autoimmune diseases but some may affect the eyes only. The epidemiology and clinical situations of some specific uveitis entities vary worldwide because they are influenced by genetic, ethnic, environmental, and socioeconomic factors. The Asia–Pacific region comprises more than 30 countries. Epidemiology and patterns of uveitis vary greatly in this region. However, some uveitis entities, such as Behcet’s disease, sarcoidosis, and Vogt–Koyanagi–Harada disease, are more common in this region. Many studies on the epidemiology, risk factors, and immune pathogenesis of this disease have been conducted. In this article, we review the epidemiology of noninfectious uveitis and special situations of these three uveitis entities in the Asia–Pacific region.
... In Japan, Behcet's Disease is one of the three most frequently diagnosed causes of uveitis in patients [20], while it is rare in Australia [7]. No case of Behcet's Disease as a cause of uveitis has been found in an indigenous Australian [39]. ...
Behcet’s Disease (BD) is a systemic vasculitis characterized by the triad of recurrent mouth and genital ulcers with eye involvement. To date there are no laboratory tests specific for the disease and diagnosis continues to remain on clinical grounds. Multiple criteria have been created as guides for diagnosis; however, given the wide spectrum of organ involvement, some cases remain undiagnosed. The diagnosis of Behcet’s Disease may only be made over time as the clinical manifestations emerge sometimes separated by months and even years. With an increased recognition of this disease it has become apparent that there is geographical variation in clinical manifestations. In particular cardiac manifestations are not seen commonly in Caucasians compared to Asian and Middle Eastern patients, while neurological manifestations are more common in Caucasians. Use of immunosuppressive and immunomodulatory drugs to suppress inflammation remains the cornerstone of treatment.
... 36,53 The ethnic or cultural subtext in etiologic diagnosis must also be kept in mind (TB or Eales in Indians; sarcoidosis in Scandinavians and African Americans; Behçet disease in East Asians; and toxoplasmosis in Europeans, native Australians, and South Americans). [53][54][55][56][57] The migration of ethnic groups across the globe has complicated the epidemiologic profile of retinal vasculitis to some extent, 57 but broad causative associations remain relevant. Finally, irrespective of geographic and ethnic riders, retinal vasculitis as the predominant feature of posterior uveitis has only a few key systemic associations: TB, sarcoidosis, and Behçet disease. ...
... In a recent study, the prevalence of anterior or posterior uveitis was 0.21 and 0.59%, respectively. 44 Psoriatic arthritis was evaluated in only one survey with a point prevalence of 0.5%, 38 and there are no published data for ankylosing spondylitis or Crohn disease in IA. This does not exclude the possibility of seronegative disease in IA. ...
The incidence and prevalence of autoimmune diseases such as rheumatoid arthritis, primary Sjögren's syndrome, scleroderma and systemic lupus erythematosus (SLE) varies with geography and ethnicity. For example, SLE is reported to be more common in populations such as African-Caribbeans and indigenous Australians (IA). As well as socio-economic status, variation in severity of disease may also show ethnic variability. The initial presentation of SLE in IA, in the context of a unique genetic background and distinctive environmental influences, is often florid with a recurring spectrum of clinical phenotypes. These clinical observations suggest a unique pathway for autoimmunity pathogenesis in this population. For example, the high prevalence of bacterial infections in IA, particularly group A streptococcus, may be a potential explanation not only for increased incidence and prevalence of SLE but also the commonly florid acute disease presentation and propensity for rapidly progressive end organ threatening disease. This article will review the state of research in autoimmune disease of IA, consider key findings related to autoimmune disease in this population, and propose a model to potentially explain the involvement of innate immunity and chronic infection in autoimmune disease pathogenesis. Ultimately, understanding of SLE at this level could affect management and result in personalised and targeted therapies to improve the health status of IA as well as better understanding of SLE pathogenesis per se.
Purpose
To evaluate choriocapillaris (CC) and choroidal vascular changes in patients with posterior uveitis using swept-source (SS) wide-field optical coherence tomography angiography (OCTA).
Method
Consecutive patients with posterior uveitis were evaluated using 3×3 mm and 12×12 mm OCTA scan patterns and montage images of 5×12×12 mm or 2×15×9 mm, covering approximately 70°–90° of the retina. The images were quantitatively and qualitatively analysed and compared with healthy controls.
Results
Eighty-six eyes of 56 patients with posterior uveitis (mean age 45.2±19.9 years; 58.9% female), and 38 eyes of 19 age-matched healthy controls (57.9% female) were included. The mean perfusion density (PD) in 3×3 mm and 12×12 mm CC scans was significantly lower in eyes with posterior uveitis compared with those of healthy controls. However, no significant difference in the mean PD of choroidal scans was found comparing eyes with posterior uveitis and healthy controls. The mean PD in eyes with active disease was significantly higher compared with the inactive eyes on 12×12 mm choroidal scans (55.61% vs 51.25%, p=0.02), while no difference was found in the CC slabs.
Conclusion
CC and choroidal assessment using OCTA provides useful information in patients with posterior uveitis. SS-OCTA metrics of the CC and choroidal slabs are promising tools in uveitis patients in the future.
Trial registration number
NCT02811536 .
Australia has one of the lowest per capita numbers of ophthalmologists among OECD countries, and they predominantly practise in metropolitan centres of the country. Increasing the size and distribution of the ophthalmology workforce is of critical importance. The objective of this review was to investigate the context of rural ophthalmology training and practise in Australia and how they relate to future ophthalmology workforce development. This scoping review was informed by Arksey and O’Malley’s framework and the methodology described by Coloqhuon et al. The search yielded 428 articles, of which 261 were screened for eligibility. Following the screening, a total of 75 articles were included in the study. Themes identified relating to rural ophthalmology training and practise included: Indigenous eye health; access and utilisation of ophthalmology-related services; service delivery models for ophthalmic care; ophthalmology workforce demographics; and ophthalmology workforce education and training for rural and remote practise. With an anticipated undersupply and maldistribution of ophthalmologists in the coming decade, efforts to improve training must focus on how to build a sizeable, fit-for-purpose workforce to address eye health needs across Australia. More research focusing on ophthalmology workforce distribution is needed to help identify evidence-based solutions for workforce maldistribution. Several strategies to better prepare the future ophthalmology workforce for rural practise were identified, including incorporating telehealth into ophthalmology training settings; collaborating with other health workers, especially optometrists and specialist nurses in eyecare delivery; and exposing trainees to more patients of Indigenous background.
Introduction : Nous avons étudié les caractéristiques des uvéites ayant justifié une prise en charge conjointe ophtalmologie-médecine interne afin d'en améliorer la prise en charge future.Patients et méthodes : Une étude épidémiologique rétrospective sur une période de huit ans de tous les patients adultes avec uvéite vus par un ophtalmologue du Centre Hospitalier Universitaire de Nancy et adressés en médecine interne pour bilan étiologique a été réalisée. Pour chaque patient, nous avons relevé les données démographiques, la localisation de l'uvéite et ses caractéristiques, les signes associés, l'étiologie éventuelle et la durée de suivi en médecine interne.Résultats : 441 patients ont été inclus. On a retrouvé 59% de femmes, 85% de patients d'origine européenne, un âge moyen de 45,9 ans avec un suivi moyen de 1,1 an. L'uvéite était unilatérale dans 59% des cas. L'uvéite antérieure était la forme de présentation la plus fréquente (40,6%), suivi par la panuvéite (35,8%), l'uvéite postérieure (19,5%) et l'uvéite intermédiaire (3,6%). Une cause infectieuse a été retrouvée dans 11,1% des cas, une pathologie non infectieuse dans 32,2% des cas ; dans 56,7% des cas, l'uvéite était considérée comme idiopathique.Conclusion : La collaboration étroite entre l'ophtalmologue et le médecin interniste demeure capitale dans la prise en charge des uvéites. Un suivi prolongé des patients avec répétition des bilans étiologiques selon l'évolution pourrait contribuer à diminuer le taux d'uvéite idiopathique
Vogt-Koyanagi-Harada disease (VKH), a severe bilateral granulomatous intraocular inflammation associated with serous retinal detachments, disc edema, and vitritis, with eventual development of a sunset glow fundus, is an autoimmune inflammatory condition mediated by T cells that target melanocytes in individuals susceptible to the disease. VKH presents clinically in four different phases: prodromal, uveitic, convalescent, and recurrent, with extra-ocular manifestations including headache, meningismus, hearing loss, poliosis, and vitiligo, to varying degrees. There have been considerable advances in imaging modalities resulting in earlier diagnosis and improved understanding of this disease. Ocular coherence tomography (OCT) has replaced other imaging modalities in the diagnosis of acute and chronic VKH by revealing exudative detachments of the retina in the acute stage, along with choroidal thickening, and demonstrating choroidal thinning in the chronic stage. Treatment of this disease is initially with corticosteroids, with a transition to immunomodulatory drugs for long-term control. Patients with VKH can have good final outcomes if treated promptly and aggressively and thus avoid complications such as sunset glow fundus, cataracts, glaucoma, subretinal fibrosis, and choroidal neovascularization.
To investigate the characteristics of uveitis in a secondary hospital in southern China.
We reviewed all records of patients with uveitis at Hengli Hospital from January 2008 to December 2011. Demographic data, past history, ophthalmic examinations and other laboratory tests were analyzed.
One hundred and ninety-nine uveitis patients were enrolled in this study, including 134 (67.3%) males and 65 females (32.7%) with an average age of 41.0±15.1y. The anatomical distribution included 103 (51.8%) cases of anterior uveitis, followed by panuveitis (65, 32.7%), posterior uveitis (29, 14.6%) and intermediate uveitis (2, 1.0%). Of the 98 (49.2%) non-idiopathic cases, there were 10.1% Behcet's disease, 9.5% Vogt-Koyanagi-Harada (VKH) syndrome, 7.5%infectious uveitis, 7.5% traumatic uveitis and 3.5% postoperative uveitis.
Idiopathic anterior and posterior uveitis, Behcet's disease, VKH syndrome, infectious uveitis and traumatic uveitis are the most common uveitis entities in a secondary hospital in southern China. Additional measures should be taken to prevent infectious and traumatic uveitis.
Infectious diseases caused by food-borne parasites have not received the same level of attention as other food-borne biological and chemical hazards. Nevertheless, they cause a high burden of disease in humans, may have prolonged, severe, and sometimes fatal outcomes, and result in considerable hardship in terms of food safety, security, quality of life, and negative impacts on livelihoods. The transmission routes for food-borne parasites are diverse. They can be transmitted by ingesting fresh or processed foods that have been contaminated via the environment, by animals or people. Additionally, notification to public health authorities is not compulsory for most parasitic diseases, so official reports do not capture the true prevalence or incidence of the diseases, as much underreporting occurs. This report presents the results of a global ranking of food-borne parasites from a food safety perspective. It also provides an overview of the current status of knowledge of the ranked parasites in food and their public health and trade impact, and provides advice and guidance on the parasite-commodity combinations of particular concern, the issues that need to be addressed by risk managers, and the risk management options available to them. It documents the ranking process used to facilitate its adoption at regional, national, or local levels. This volume and others in this Microbiological Risk Assessment
Series contain information that is useful to both risk assessors and risk managers, the Codex Alimentarius Commission, governments and regulatory agencies, food producers and processers and other institutions or individuals with an interest in foodborne parasites and their impact on food safety, public health and livelihoods.
A small survey was undertaken of commercially reared free-range chickens in Western Australia using serology and molecular detection. Eighteen out of 20 serum samples showed antibody responses with titers of 1:64 in 5 chickens and ≥1:128 in 13 chickens. DNA extracted from 22 out of 50 tissue samples, 10 brains and 12 spleens, were positive by nested PCR, and sequencing at the B1 locus on DNA from 3 brain and 3 spleen samples confirmed that 2 isolates were Toxoplasma gondii, Type I, and 4 Type II/III. The high prevalence of Toxoplasma infection found in commercial, free-range chickens raises public health issues with respect to both exposure in the workplace, during carcass processing, and subsequent transmission during food handling and/or consumption as food. The results of this study emphasize the need for more data on the incidence of Toxoplasma infection in domestic animals and humans in Australia.
Purpose:
To evaluate the patterns of acute and recurrent acute anterior uveitis (AAU) in a metropolitan tertiary referral center.
Methods:
A retrospective medical record review of a total of 241 patients with AAU presenting to Sydney Eye Hospital between June 2009 and June 2011 was performed. Patients who underwent typing for the HLA-B27 antigen were included in this study. Ninety-five patients were HLA-B27-positive and 146 were HLA-B27-negative.
Results:
Seronegative spondyloarthropathy (n = 26, 11%) was the most common systemic disease association in the HLA-B27 positive patients. Posterior synechiae was the most common complication. Complications of cataract, ocular hypertension, secondary glaucoma, and cystoid macular edema were more common in HLA-B27-negative patients with a recurrent disease course. The most common newly diagnosed systemic disease was sarcoid (n = 7), followed by ankylosing spondylitis (n = 4), tuberculosis (n = 2), and syphilis (n = 2).
Conclusions:
This case series emphasizes the key role of the ophthalmologist in identifying previously undiagnosed systemic diseases. It also highlights the importance of differentiating latent from active infection, particularly tuberculosis and syphilis, through directed investigations to assess the risk to the patient of reactivation with systemic treatment. This study adds further evidence to our understanding that HLA-B27-negative patients have a poor visual prognosis.
A bstract
Ocular toxoplasmosis results from retinal infection with the protozoan, Toxoplasma gondii. This parasite, which exists as multiple clonal subpopulations and in three stages, is capable of replication in any nucleated cell of its primary feline or multiple paratenic hosts. Human seroprevalence of toxoplasmosis is high across the globe, but with geographic variation. While prevalence of ocular toxoplasmosis is not well documented, toxoplasmic retinochoroiditis is the commonest form of posterior uveitis in many countries. Correlation of parasite genotype with disease is an important area of new research. Ocular infection with T. gondii often follows ingestion of bradyzoites in undercooked infected meat. Oocysts may survive for an extended period in the environment, and water contaminated with oocysts is an important source in toxoplasmosis epidemics. Ocular toxoplasmosis is preventable by a combination of community activities and personal measures. Public health action is well justified by the considerable burden of congenital and postnatal infections.
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.
To determine the prevalence and causes of visual impairment and blindness among indigenous Australians living in central Australia.
1884 individuals aged 20 years or older, living in one of 30 remote communities within the statistical local area of "Central Australia", were recruited for this study, from which 1883 were assessable. This equated to 36% of those > or =20 years old and 67% of those > or =40 years old within this district. Participants were recruited as they presented to the eye clinic at each remote community. Patients underwent Snellen visual acuity testing and subjective refraction. After this, an assessment of their anterior and posterior segments was made. Rates and causes of bilateral visual impairment (vision worse than Snellen visual acuity 6/12 in the better eye) and bilateral blindness (Snellen visual acuity worse than 6/60 in the better eye) were presented.
19.4% (365/1883) had bilateral visual impairment (25.1% of those > or =40 years old) and 2.8% (53/1883) had bilateral blindness (3.6% of those > or =40 years old). Refractive error followed by cataract were the main causes for bilateral visual impairment and blindness. Following these, diabetic eye disease and trachomatous corneal opacification were the main causes of bilateral visual impairment and bilateral blindness, respectively.
This study indicates that bilateral visual impairment and blindness are, respectively, 25.1% and 3.6% among indigenous Australians, four to seven times higher than among the non-indigenous Australian population. Trachoma is the leading cause of bilateral blindness after refractive error and cataract.
Vogt-Koyanagi-Harada's (VKH) disease is reported to be closely associated with the HLA class II antigen, HLA-DR4. Serologically defined DR4 is further divided into 11 alleles by molecular HLA genotyping. However, no study of HLA-DNA typing of VKH patients has been reported. To clarify molecular genetic mechanism underlying the susceptibility/resistance to VKH disease, HLA-DNA typing of DR antigens (DRB1 genotyping) by the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method was performed. It was found that DRB1*0405 showed a significant association with VKH disease compared with the healthy controls (corrected p value < 1 x 10(-5)) and that all the patients had DRB1*0405 and/or DRB1*0410. The specific amino acid residue shared only by these two alleles is Ser at position 57 which is located in the antigen binding groove and may influence the immunological function as an antigen-presenting molecule, suggesting that Ser at position 57 plays an important role in the susceptibility to VKH disease, although the possibility that the involvement of the HLA-DQ molecule, DQ4, in strong linkage disequilibrium with DRB1*0405 and DRB1*0410, cannot be excluded.
The clinical description of Fuchs' heterochromic uveitis was made in 1906. The subject was first reviewed in 1973. This paper discusses contributions to the literature on Fuchs' heterochromic uveitis since 1973. The widening diagnostic criteria are discussed, as are new theories on etiology and pathogenesis. Investigative methods include light and electron microscopy, fluorescein angiography and immunology are described. Management problems, particularly relating to cataract and glaucoma, are discussed and in the light of such data, current indications for, modalities of, and complications of treatment, are presented.
We studied the case records of 1122 patients with endogenous uveitis including 418 new cases treated at the University Eye Clinic in Turku during the years 1980-1982 and 1988. The mean annual incidence and prevalence rates of anterior uveitis were, respectively, 21.3 and 68.7 per 100,000, of posterior uveitis 0.8 and 4.6 per 100,000, of panuveitis 0.2 and 0.8 per 100 000, and of all uveitis cases 22.6 and 75.4 per 100,000 population. The incidence of uveitis was higher in the age group 20-69 years than in the age groups 0-19 years (p < 0.001) and 70 years or over (p = 0.049). The incidence rates were not different between sexes in any age group (p = 0.2). The incidence of uveitis was higher in lower socio-economic groups than in higher socio-economic groups (p < 0.001). There were no significant differences in the incidence of uveitis between sexes in different socio-economic groups (p = 0.1).
In 1992, non-onchocercal uveitis caused 9% of blindness, 8% of visual impairment, and 11% of uniocular blindness among patients visiting an eye hospital in Sierra Leone, west Africa. The aim of this study was to determine the aetiology of uveitis in this population.
General and ophthalmic examination complemented by serum and aqueous humour analyses for various infectious agents was performed for 93 uveitis patients and compared with serum (n = 100) and aqueous humour (n = 9) analysis of endemic controls.
At the initial examination, 45 patients (48%) proved to be severely visually handicapped. After clinical and laboratory analyses, an aetiological diagnosis was established for 49 patients (52%). Toxoplasma gondii was the most important cause of uveitis (40/93; 43%). Anti-toxoplasma IgM antibodies were detected in serum samples of seven of 93 patients (8%) compared with one of 100 controls (1%, p < 0.05). At least six patients (15%) with ocular toxoplasmosis had acquired the disease postnatally. Antibodies against Treponema pallidum were detected in 18 of 92 patients (20%) and in 21 controls (21%). Other causes of uveitis were varicella zoster virus (one patient), herpes simplex virus (two patients), and HLA-B27 positive acute anterior uveitis with ankylosing spondylitis (one patient), while one patient had presumed HTLV-I uveitis.
In a hospital population in Sierra Leone, west Africa, uveitis was associated with severe visual handicap and infectious diseases. Toxoplasmosis proved to be the most important cause of the uveitis. Although the distribution of congenital versus acquired toxoplasmosis in this population could not be determined, the results indicate an important role of postnatally acquired disease. The results further suggested minor roles for HIV, tuberculosis, toxocariasis, and sarcoidosis as causes of uveitis in this population.
To analyse the pattern of uveitis in a referral centre in Tunisia, North Africa.
The study included 472 patients with uveitis examined at the Department of Ophthalmology of Monastir (Tunisia) from January 1992 to August 2003. All patients had a comprehensive ocular and systemic history, including an extensive review of medical systems. Complete ophthalmic examination was performed in all cases, including best-corrected Snellen visual acuity, slit-lamp examination, applanation tonometry, and dilated fundus examination with three-mirror lens. Standard diagnostic criteria were employed for all syndromes or entities of uveitis.
The mean age at onset of uveitis was 34 years. The male-to-female ratio was 1:1.1. Uveitis was unilateral in 282 patients (59.7%) and bilateral in 190 patients (40.3%). Anterior uveitis was most common (166 patients; 35.2%), followed by posterior uveitis (133 patients; 28.2%), panuveitis (100 patients; 21.2%), and intermediate uveitis (73 patients; 15.5%). A specific diagnosis was found in 306 patients (64.8%). The most common cause of anterior uveitis was herpetic uveitis (56 patients; 33.7%). Toxoplasmosis was the most frequent cause of posterior uveitis (51 patients; 38.3%). Intermediate uveitis was most commonly idiopathic (63 patients; 86.3%). Behçet's disease was the most common cause of panuveitis (36 patients; 36%), followed by Vogt-Koyanagi-Harada (VKH) disease (15 patients; 15%). A total of 16 patients (3.4%) suffered from blindness, and 59 (12.5%) from uniocular blindness.
In a hospital population in Tunisia, the most common causes of uveitis were Behçet's disease, herpes simplex infection, toxoplasmosis, and VKH disease.
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.
Over a five-year period 245 Patients with uveitis were investigated at the Uveitis Clinic, Sydney Eye Hospital, for possible aetiological and relevant disease associations. Uveitis was anterior in 75% of patients, posterior in 21% and generalized in 4%. Anterior uveitis (AU) was idiopathic in 52% of cases. In patients tested for the HLA-B27 antigen, 47% were HLA-B27 positive, including all cases of ankylosing spondylitis (8% of cases) and Reiter's syndrome (3% of cases). There was a marked male predominance in patients with AU, especially in HLA-B27 positive individuals. Posterior uveitis (PU) was most frequently unilateral, chronic and idiopathic (24% of cases), whilst recognizable aetiologies included toxoplasmosis (20%), Behçet's syndrome (14%), sarcoidosis (12%) and pars planitis (12%). The peak age of onset in patients presenting with AU was 30 to 40 years, whilst patients with PU presented a decade earlier. There were no major differences between males and females in the age of onset of their uveitis.
This report describes a retrospective study of all new patients in our uveitis clinic between January 1992 and December 1994, undertaken to identify the pattern of uveitis in the Indian subcontinent. A standard clinical protocol, and the naming-meshing system with tailored laboratory investigations were used to arrive at a final uveitic diagnosis. Uveitis comprised 1.5% of new cases seen at the centre. Out of 1273 uveitis cases, anterior uveitis was the most common type (39.28%), followed by posterior uveitis (28.75%), intermediate uveitis (17.44%), and panuveitis (14.53%). The most commonly affected age group were patients in their forties (23.57%). Uveitis was less common in children below 10 years (3.61%) and in adults over 60 years of age (6.44%). Men (62.21%) were more commonly affected than women (37.79%). Aetiology remained undetermined in 59.31% of cases. Anterior uveitis was most commonly idiopathic (58.6%). The most common cause of posterior uveitis was toxoplasmosis (27.87%), and that of panuveitis was the Vogt-Koyanagi-Harada syndrome (21.08%). A higher incidence of microbiologically proven tubercular uveitis (5 cases), and uveitis due to live intraocular nematode (4 cases), and malaria (1 case), were seen, in contrast to other studies. Only 2 cases of AIDS with ocular lesions were seen. This paper reveals the pattern of uveitis seen at a major referral eye institute in India.
To describe the design and demographic characteristics of a study to determine the prevalence of ocular morbidity among indigenous Australians living within remote central Australia.
1884 individuals aged 20 years or older, living in one of 30 remote communities within the statistical local area of 'central Australia' were recruited for this study. Participants were recruited as they presented to the eye clinic at each remote community. Patients underwent visual acuity testing and subjective refraction. Following this they had a comprehensive ocular assessment. A baseline description of the participants is presented.
1884 participants were recruited including 689 (36.6%) males and 1195 (63.4%) females. This equates to 36% of those aged 20 years or older and 67% of those aged 40 years or older living in central Australia. 55% of participants were diabetic and 20% of participants were symptomatic of an eye condition, but the majority of these only had presbyopia. Combined, those who presented due to diabetes (regardless of symptoms), due to presbyopia, or without any symptoms made up 95% of the sample.
Despite being recruited through clinics, the majority of participants presented for a 'check-up' because the clinic was available and not due to symptoms. Therefore, the data we collected may be used to establish the current prevalence of ocular morbidity within the indigenous community living in remote central Australia with particular reference to those aged 40 years or older. As such, this can help to determine the current and future needs of this population.
To investigate frequencies and clinical features of intraocular inflammation (uveitis) in Tokyo, Japan.
Records of 834 consecutive new referral patients (352 men, 482 women) examined at the Kyorin University Hospital from April 2000 to December 2007 were retrospectively reviewed.
Mean age at onset was 44.8 years for men and 47.0 years for women. By anatomical classification, 229 patients (27.4%) had anterior uveitis, 10 (1.2%) had intermediate uveitis, 183 (21.9%) had posterior uveitis and 412 (49.4%) had panuveitis. The most common diagnoses were Vogt-Koyanagi-Harada (VKH) disease (11.0%), sarcoidosis (6.9%), acute anterior uveitis (6.5%), Behçet's disease (5.8%) and tuberculosis (4.3%). In the third and fourth decades, the most common diseases were Behçet's disease for men and VKH for women, whereas over 60 years of age, the most common diseases were VKH for men and sarcoidosis for women. Systemic corticosteroids were used in 25.5% of patients, and other immunomodulatory agents were required in 8.7% of patients.
The most frequent diagnoses were sarcoidosis, VKH disease, acute anterior uveitis, Behçet's disease and tuberculosis, with Behçet's disease being common in young men and sarcoidosis being common in elderly women. One-fourth of patients received systemic corticosteroids and 8.7% of patients required other immunomodulatory agents.
To investigate the incidence and patterns of acute anterior uveitis (AAU) in Central Australia and specifically to study the relative frequency of AAU in Australian Aborigines compared with that in non-Aboriginal patients.
Prospective, observational study of all patients seen by the Central Australian Ophthalmology service over an 8-month period.
The incidence rate of AAU in Central Australia was 35.9 cases/100,000 population per year. Forty-two per cent of the 1955 patients seen during the study period were Australian Aboriginal patients; however, all but one patient with AAU were Caucasian. The difference in the incidence of AAU between the Indigenous and non-Indigenous populations was statistically significant (p = 0.03, Fisher's exact test). Four of the nine Caucasian patients with AAU were HLA-B27-positive. The single case of AAU in an Australian Aborigine was a recurrent episode of HLA-B27-positive AAU. A family history of this patient revealed that both her grandfathers were Caucasian.
The incidence and pattern of AAU in Central Australia is comparable with that in other geographical regions. However, AAU occurs very infrequently in Australian Aborigines compared with that in the non-Indigenous population of Central Australia, further implicating the importance of genetic factors in the pathogenesis of AAU.
Vogt-Koyanagi-Harada (VKH) disease is a systemic disorder affecting systemic melanocytes including those in the eyes, meninges, ears, skin, and hair. Although the pathogenic mechanisms of the disease are still controversial, there is clinical and experimental evidence that the disease is an autoimmune disease involving melanocytes. In this study, we investigated whether patients with VKH disease have immune responses specific to melanocyte antigens, and whether T lymphocytes of these patients cross-react with peptides of melanocytes and with exogenous antigens. Cells infiltrating the eyes in HLA-DR 4+ patients with VKH contained a population of CD 4+ T lymphocytes that recognized tyrosinase and gp 100 peptides and produced cytokines in response to these two peptides. The CD 8+ T cells recognized the MART-1 melanocyte peptide, but not the CD 4+ T cells. When a search was made for molecular mimicry between melanocyte antigens and exogenous antigens by database screening, cytomegalovirus envelope glycoprotein H (CMV-egH) had high amino acid homology with the tyrosinase peptide. Some of the T cells taken from VKH patients recognized melanocyte peptides including the tyrosinase peptide as well as the CMV-egH290-302 peptide, which had a high amino acid homology to the tyrosinase peptide. CMV peptide-specific T cells showed significant proliferation in response not only to CMV-egH290-302, but also to tyrosinase450-462. The seroprevalence of CMV was significantly higher in VKH patients. In addition, all tested samples of VKH patients were negative for CMV-DNA. These results indicate that CMV infection may stimulate the production of T cells that crossreact with tyrosinase by molecular mimicry. These events may be responsible for the onset of VKH disease.
Because of the frequency of ocular toxoplasmosis and its occurrence in multiple siblings in southern Brazil, a population-based household survey was performed to better understand the epidemiologic characteristics of the disease in this region. Of 1,042 individuals examined, 184 (17.7%) were deemed to have ocular toxoplasmosis on the basis of conservative assessment of ophthalmic findings. Of those with ocular toxoplasmosis, 183 (99.5%) had specific IgG antibodies, compared with only 140 of 181 age-matched control subjects (77.4%; P less than .001). The prevalence of ocular toxoplasmosis was 0.9% in 1- to 8-year-olds, 4.3% in 9- to 12-year-olds, 14.3% in 13- to 16-year-olds, and 21.3% (95% confidence interval, 18.6% to 24.2%) in all individuals 13 years or older. The prevalence of ocular toxoplasmosis in this population was more than 30 times higher than previous estimates for the same condition elsewhere. The low prevalence in the young children we studied supplements previous data suggesting that, in this population, ocular toxoplasmosis is a sequela of postnatal rather than congenital infection.
A strong association with HLA antigens DR4, DRw53, and Bw54 has previously been reported among Japanese patients with Vogt-Koyanagi-Harada disease (VKH) and sympathetic ophthalmia (SO). In the United States, no firm association between HLA-A or -B loci and VKH has been found previously; testing for HLA-DR loci has not been performed to date. The authors performed HLA typing of 23 American patients with VKH and 8 patients with SO. When VKH patients were compared with racially matched controls without disease and patients with other types of uveitis, strong associations with HLA-DR4 and HLA-DRw53 were found. The strongest associations observed in this sample were with HLA-DQw3, an antigen which is in positive linkage disequilibrium with DR4, and with the HLA-DR4/DQw3 haplotype. The small number of patients with SO precluded statistical analysis; however, similar HLA associations were noted. The patients also were questioned regarding their ancestry. The anecdotal association of VKH with American Indian ancestry was confirmed. It appears that the ethnoracial association may be explained by HLA type. One possible explanation for identical HLA associations in two diseases with different precipitating events yet similar ocular manifestations is development of an altered immune response to exogenous microbial antigen with subsequent autoimmunity. Further definition of the genetic susceptibility to VKH and SO may help define the pathophysiology of both diseases and allow the prediction of which patients are at increased risk for SO.
Uveitis can be classified in a variety of ways and this fact makes it difficult to compare results. Therefore we classified uveitis by the location with the method of Henderly; anterior-, posterior-, intermediate- and panuveitis. We determined the frequency of occurrence, etiology and clinical characteristics of various forms of uveitis. We conducted a retrospective analysis of 683 patients with uveitis seen at Seoul National University Hospital from January 1978, to December 1987. The results were as follows. 1. 192 cases (28.1%) occurred as anterior uveitis, 218 cases (31.9%) as posterior uveitis, 166 cases (24.3%) as panuveitis and 107 cases (15.7%) as pars planitis. Posterior uveitis was the most common form of uveitis. 2. In cases of anterior uveitis, 142 cases (74.0%) were idiopathic, traumatic uveitis was seen in 18 cases. In posterior-uveitis, 111 cases (50.9%) were idiopathic, retinal vasculitis including Eales' disease in 60 cases (27.5%), toxoplasmosis in 23 cases (10.6%). In cases of panuveitis, idiopathic form occurred in 80 cases (48.2%), Behçet's disease in 41 cases (24.7%). The idiopathic form was the most common entity in all locations of uveitis.
A retrospective analysis of 33 patients with Vogt-Koyanagi-Harada disease (VKH disease) seen in São Paulo, Brazil, from 1976 to 1985 at a uveitis referral clinic revealed that VKH disease represents 2.5% of the total uveitis cases seen. All cases were bilateral, 30% being men and 70% women. The ethnic distribution was the following: 60% white (with variable Indian or black extraction), 24% darkly pigmented, 9% Orientals (Sansei, third-generation Japanese) and 6% black. The frequency among Orientals was 7 times higher than what would be expected according to the relative frequency of Japanese in the Brazilian population. The age distribution at the onset of the disease was as follows: 12% less than 20 years of age, 60% between 20 and 40 years of age and 27% over 40 years of age. The disease was classified into 3 types with variable extraocular signs. Type I disease was present in 24% of the patients, type II in 51% and type III disease in 24% of the patients. Cataract was present in 40% of the cases and glaucoma was present in 9%. No correlation was found between sex, age at onset, race, type of extraocular involvement and number of extraocular manifestations in considering either visual status or visual prognosis. All patients were treated with systemic steroids. Most of them also received cytotoxic immunosuppressive agents. In this uncontrolled clinical study cytotoxic drug-treated patients seemed to have a better clinical course.
A review of 240 consecutive Chinese patients with endogenous uveitis seen over a 3-year period was made in Taiwan. The frequency of major types of uveitis was 110 cases (45.8%) of acute anterior uveitis, 43 cases (17.9%) of Behçet's disease, 22 cases (9.2%) of Harada's disease, 10 cases (4.2%) of peripheral uveitis, 6 cases (2.5%) of virus-induced uveitis and 5 cases (2.1%) of Fuchs' heterochromic cyclitis. Only 1 case (0.4%) of sarcoidosis was found. Of the 110 cases of acute anterior uveitis, 80.9% presented with HLA-B27 antigen. The incidences of types of endogenous uveitis in Chinese differ from those in Caucasians, Japanese and Negro races in the USA.
To determine the prevalence of Giardia duodenalis and other intestinal parasites in children, dogs and cats from Aboriginal communities in the west Kimberley region of Western Australia.
A four-year parasitological survey of faecal specimens from humans and faecal and intestinal specimens from dogs and cats.
Local hospital servicing Aboriginal communities surveyed in this study and the Veterinary School, Murdoch University.
Children (under 14 years) and adults, as well as dogs and cats, from five Aboriginal communities.
G. duodenalis was the most prevalent parasite in children and adults (32.1% in children, n = 361; 12.5% in adults, n = 24). Human infections with Hymenolepis nana (20.5%) and Entamoeba coli (13.0%) were also common. Ancylostoma duodenale (1.3%), Pentatrichomonas hominis (1.0%), Chilomastix mesnili (0.52%), Entamoeba hartmanni (0.52%), Sarcocystis sp. (0.52%), Trichuris trichiura (0.26%), Enterobius vermicularis (0.26%), Strongyloides stercoralis (0.26%) and Isospora belli (0.26%) were present at low rates. Dogs were most commonly infected with Ancylostoma caninum (51.1%) and G. duodenalis (17.0%). Cats were found to have a high prevalence of Ancylostoma tubaeforme (18.2%), Toxoplasma gondii (18.2%), Isospora felis (15.1%) and Spirometra erinacei (15.1%).
This study has shown that children from Aboriginal communities in the west Kimberley region of Western Australia, particularly in the age group one to five years, are commonly infected with intestinal parasites. The dogs and cats in these communities are also infected. The high prevalence rates of Giardia and other enteric parasites in this survey are indicative of poor living conditions and low levels of hygiene. In addition, the high prevalence of hookworm and Giardia infection in dogs and hookworm and Toxoplasma infection in cats is of potential zoonotic significance for humans in these communities.
Most uveitis case series have come from tertiary care centers, and the relative frequencies of disorders they report may reflect referral bias. We sought information about the types of uveitis encountered in the general practice of ophthalmology.
We prospectively examined 213 consecutive cases of general uveitis, defined as intraocular inflammation other than cytomegalovirus retinopathy, seen by a group of community-based comprehensive ophthalmologists. This group of cases was compared with 213 consecutive cases of general uveitis examined by a uveitis specialist at a university referral center in the same community. All cases were categorized by anatomic site of inflammation and disease course, and, if possible, they were assigned a specific diagnosis. Cases of cytomegalovirus retinopathy and masquerade syndrome seen during the same intervals were recorded separately.
The distribution of general uveitis cases by anatomic site of disease was significantly different between the community-based practices (anterior, 90.6%; intermediate, 1.4%; posterior 4.7%; panuveitis, 1.4%) and the university referral practice (anterior, 60.6%; intermediate, 12.2%; posterior, 14.6%; panuveitis, 9.4%; P < .00005). A cause or clinical syndrome could be assigned to 47.4% of cases in the community-based practices, and to 57.8% of cases in the university referral practice (P = .03). HLA-B27-associated anterior uveitis, cytomegalovirus retinopathy, and toxoplasmic retinochoroiditis were among the five most common forms of uveitis in both practice settings.
The relative frequencies with which various forms of uveitis are seen in a tertiary referral center do not necessarily reflect the experience of ophthalmologists from the community in which the center is located. Anterior uveitis and disorders of sudden onset constitute a greater proportion of cases seen by community-based comprehensive ophthalmologists.
Uveitis, an intraocular inflammatory disease, is a significant cause of visual impairment. It is not known how many patients with uveitis will retain visual acuity and how many develop visual impairment or even blindness. The aim of this study was to assess the frequency of blindness in patients with uveitis and, more specifically, to identify the clinical profile of patients at risk for visual loss.
A cross sectional and retrospective study of 582 patients with uveitis who visited the ophthalmology departments of two university hospitals in the Netherlands was performed.
Within the group of 582 patients, 203 (35%) exhibited blindness or visual impairment; bilateral legal blindness developed in 22 (4%) patients, 26 (4.5%) had one blind eye with visual impairment of the other, and nine (1.5%) had bilateral visual impairment. Unilateral blindness developed in 82 (14%) patients, whereas 64 (11%) exhibited unilateral visual impairment. The most important cause of both blindness and visual impairment was cystoid macular oedema (29% and 41%, respectively). Complications of uveitis were encountered in more than half of the patients and 23% underwent one or more surgical procedures. When the patients were subdivided according to anatomical site, those with panuveitis had the worst visual prognosis. The systemic diseases associated with a poor visual prognosis were juvenile chronic arthritis and sarcoidosis. Ocular toxoplasmosis was the most frequent cause of unilateral visual loss.
Cystoid macular oedema is the most frequent complication of uveitis and its occurrence plays a decisive role in the visual outcome of this disease.
The pattern of uveitis changes over time with the emergence or identification of new uveitic entities. The aim of this prospective study was to obtain a correct incidence pattern and aetiology of uveitis cases seen in a uveitis clinic. We studied all new uveitic cases seen in a-one year period. A standard clinical protocol was followed for each case. Of the 465 new uveitic cases, anterior uveitis was most commonly encountered (170 cases, 36.5%), followed by posterior uveitis (132 cases, 28.4%), intermediate uveitis (92 cases, 19.8%) and panuveitis (71 cases, 15.3%). The aetiology remained undetermined in majority of the cases (58.7%): anterior uveitis (48.8%), posterior uveitis (45.45%), panuveitis (53.52%). The most common cause was collagen disease (29.4%) in anterior uveitis; toxoplasmosis (30.3%) in posterior uveitis; and Vogt-Koyanagi Harada's disease (25.35%) in panuveitis.
To study the patterns of uveitis in various geographic regions.
A systematic literature review was performed using the MEDLINE database, from 1966 to present. Studies that satisfied our described selection criteria were analyzed to provide a global perspective on uveitis.
Twenty-two studies, which were the best available representatives of Australia, North and South America, Europe, Asia, and Africa, were included in the final analysis. The distribution of uveitis cases according to the anatomical site of inflammation in the various regions, and the causes and clinical disease associations of anterior, intermediate, posterior, and pan-uveitis were studied for each of the regions and a comparative analysis was performed.
There are similarities and distinct differences in the patterns of uveitis in the various geographic regions. Such patterns of uveitis are influenced by combinations of geographical, environmental, and genetic factors.
To update clinical information about ocular toxoplasmosis. Part II reviews the spectrum of disease manifestations and factors that influence severity of disease. Implications for disease management are discussed.
Literature review.
Selected articles from the medical literature, information from several recent scientific meetings, and the author's personal experiences were reviewed critically in preparation for the LX Edward Jackson Memorial Lecture.
The appearance of toxoplasmic retinochoroiditis lesions varies with duration of active retinal infection and intensity of inflammation. Severe ocular disease occurs in immunocompromised hosts. Older patients who are recently infected with Toxoplasma gondii may have a higher prevalence of ocular involvement and more severe ocular disease because of altered host defenses. Most disease-producing isolates of T. gondii belong to one of three clonal lineages (types I, II, III); type I has been associated with severe disease in both animals and human beings. Many observational studies suggest a benefit of short-term antimicrobial therapy for toxoplasmic retinochoroiditis in immunocompetent patients, although the efficacy of these treatments has not been proven in randomized clinical trials. Intermittent trimethoprim/sulfamethoxazole treatment was associated with fewer recurrences than placebo during a 20-month randomized clinical trial.
Variations in disease characteristics may be related to host, parasite, or environmental factors. The genotype of the infecting parasite appears to be an important determinant of disease severity in immunocompetent patients. Secondary prophylaxis may reduce the rate of recurrences in high-risk patients. A better clinical understanding of ocular toxoplasmosis can lead to more effective prevention and treatment strategies.
Acute anterior uveitis is the most common form of uveitis. HLA-B27-associated acute anterior uveitis is a distinct clinical entity that has wide-ranging medical significance due to its ocular, systemic, immunologic, and genetic features. The association between HLA-B27 and the spectrum of HLA-B27-associated inflammatory diseases remains one of the strongest HLA-disease associations known to date. This review examines acute anterior uveitis with particular focus on HLA-B27-associated acute anterior uveitis, including the epidemiology, immunopathology, association with HLA-B27 and its subtypes, clinical features, complications, prognosis, and potential new therapies such as anti-TNFalpha therapy and oral HLA-B27-peptide tolerance. There have been substantial recent advances in both clinical and basic scientific research in this field, including studies of the various animal models of acute anterior uveitis and the HLA-B27 transgenic animals, and these are summarized in this review. To the ophthalmologist, HLA-B27-associated acute anterior uveitis is an important clinical entity that is common, afflicts relatively young patients in their most productive years, and is associated with significant ocular morbidity due to its typically recurrent attacks of inflammation and its potentially vision-threatening ocular complications. Furthermore, to the ophthalmologist and the internist, HLA-B27-associated acute anterior uveitis is also of systemic importance due to its significant association with extraocular inflammatory diseases.
To evaluate the effect of treatment on the incidence of vision impairment and structural ocular complications among patients with Vogt-Koyanagi-Harada (VKH) disease.
Retrospective cohort study.
setting: Single-center academic practice. study population: Twenty-four consecutive patients with VKH disease who were referred for evaluation and treatment from November 1984 through May 2004. procedures: Information on patients with VKH disease was entered retrospectively into a database and analyzed with time-dependent techniques. main outcome measures: Incidence of visual impairment and of structural ocular complications.
In better-seeing eyes, the frequencies of vision loss to 20/50 or worse and to 20/200 or worse at presentation were 50% and 30%, respectively. The incidence rates on follow-up examination for vision loss to 20/50 or worse and to 20/200 or worse were 9% per person-year and 7% per person-year in the better-seeing eye. Oral corticosteroid therapy was associated with a reduced risk of loss of visual acuity to the 20/200 or worse in the better-seeing eye (relative risk [RR] = 0.33; P = .05). The use of immunosuppressive drug therapy was associated with a reduced risk of vision loss to the 20/50 or worse and to the 20/200 or worse thresholds in the better-seeing eye (RR = 0.33; P = .05; and RR = 0.08; P = .04, respectively).
VKH disease may result in substantial visual impairment. The use of oral corticosteroid or immunosuppressive drug therapy may reduce the risk of vision loss during the follow-up period.
To address the clinical pattern and characteristics of uveitis in a tertiary center for uveitis in China and compare the similarity and difference in the distribution of uveitis entities between China and other countries.
A retrospective study was performed on the patients with uveitis referred to the Zhongshan Ophthalmic Center from January 1996 to December 2003. The clinical data including category, etiology, gender, and the age of the patients at uveitis presentation were analyzed and compared with studies published previously from other countries.
There were 902 male and 850 female patients in our series. The mean age of these patients at uveitis presentation was 33.8 +/- 16.5 years. Anterior uveitis (800, 45.6%) was the most common anatomical entity, followed by panuveitis (727, 41.5%), posterior uveitis (119, 6.8%), and intermediate uveitis (106, 6.1%). Further classification with the etiology criteria revealed 16 entities in anterior uveitis, with idiopathic anterior uveitis being the most common entity (473, 27.0%). Twelve entities were identified in panuveitis, of which Behçet disease (289, 16.5%) and Vogt-Koyanagi-Harada (VKH) syndrome (278, 15.9%) were the predominant ones. No specific entity was recognized in the intermediate uveitis group. Although a number of specific entities were identified in posterior uveitis, toxoplasmosis was noted in only two patients in this group.
Idiopathic anterior uveitis, Behçet disease, and VKH syndrome are the most common entities of uveitis in China. Ocular toxoplasmosis, ocular histoplasmosis, and birdshot retinochoroidopathy are less common or absent in China.
To determine whether patients with Vogt-Koyanagi-Harada (VKH) disease have immune responses specific to the melanocyte antigens tyrosinase and gp100.
T-cell clones (TCCs) were established from cells infiltrating the aqueous humor and from peripheral blood mononuclear cells (PBMCs) of patients with VKH. The target cells were LDR4-transfected cells (HLA-DRB1*0405). The TCCs were cocultured with LDR4 in the presence of tyrosinase (tyrosinase450-462: SYLQDSDPDSFQD), gp100 (gp100(44-59): WNRQLYPEWTEAQRLD), or a control peptide. The immune response was evaluated by cytokine production. The responding melanocyte peptide-specific VKH-TCCs were characterized by an immunofluorescence method with flow cytometry. A search was made for molecular mimicry among tyrosinase450-462, gp100(44-59), and exogenous antigens, such as viruses, by database screening.
Cells infiltrating the eye and PBMCs in HLA-DR4+ (HLA-DRB1*0405, 0410) patients with VKH contained a population of CD4+ T lymphocytes that recognized tyrosinase and gp100 peptides and produced RANTES and IFN-gamma in response to the two peptides. The T cells were active memory Th1-type lymphocytes, and they recognized the tyrosinase peptide and produced IFN-gamma in response to HLA-DRB1*0405+ melanoma cells. Cytomegalovirus envelope glycoprotein H (CMV-egH290-302) had high amino acid homology with the tyrosinase peptide. In addition, some of the VKH-TCCs recognized CMV-egH290-302 peptide, as well as the tyrosinase peptides.
In VKH there are tyrosinase and gp100 peptide-specific T cells that can mediate an inflammatory response. Such melanocyte antigen-specific T cells could be associated with the cause and pathology of VKH disease.
To determine the incidence and prevalence of uveitis in a large, well-defined population in Northern California.
Cross-sectional study using retrospective database and medical record review.
A group of 2070 people within 6 Northern California medical center communities (N = 731 898) who had a potential diagnosis of uveitis.
The patient database of a large health maintenance organization (2 805 443 members at time of the study) was searched for all patients who, during a 12-month period, had the potential diagnosis of uveitis. Detailed quarterly gender- and age-stratified population data were available. Medical records of patients who potentially had uveitis and who were members of the 6 target communities were reviewed by 2 uveitis subspecialists to confirm the diagnosis of uveitis and to establish time of onset. Demographic and clinical data were gathered for patients meeting the clinical definition of uveitis. Incidence rates were calculated by using a dynamic population model. Prevalence rates were based on the mid-study period population.
Presence and date of onset of uveitis.
At midstudy, the population for the 6 communities was 731 898. During the target period, 382 new cases of uveitis were diagnosed; 462 cases of uveitis were diagnosed before the target period. These data yielded an incidence of 52.4/100 000 person-years and a period prevalence of 115.3/100 000 persons. The incidence and prevalence of disease were lowest in pediatric age groups and were highest in patients 65 years or older (P<0.0001). The prevalence of uveitis was higher in women than in men (P<0.001), but the difference in incidence between men and women was not statistically significant. Comparison between the group of patients who had onset of uveitis before the target period (ongoing uveitis) and the entire cohort of uveitis patients showed that women had a higher prevalence of ongoing uveitis than men and that this difference was largest in the older age groups (P<0.001).
In this largest population-based uveitis study in the United States to date, the incidence of uveitis was approximately 3 times that of previous U.S. estimates and increased with the increasing age of patients. Women had a higher prevalence of uveitis than men, and the largest differences were in older age groups.
Epidemiological study of pati-ents with uveitis in Buenos Aires, Agentina
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Causes and frequency of blindness in patients with intraocular inflammatory disease
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