Blindness from uveitis in a hospital population in Sierra Leone

Reggio Emilia (Northern Italy) Interdisciplinary Uveitis Clinic: What We Have Learned in the Last 20 Years

PURPOSE

To analyze the referral patterns and the clinical and therapeutic features of patients diagnosed with uveitis in an Italian tertiary referral center to provide a comparison with previously published series from the same center.

METHODS

Retrospective retrieval of data on all new referrals to the Ocular Immunology Unit in Reggio Emilia (Italy) between November 2015 and April 2022 and comparison with previously published series from the same center.

RESULTS

Among the 1557 patients, the male-to-female ratio was 1:1.27. Anterior uveitis was the most common diagnosis (53.7%), followed by posterior (21.6%), pan- (18.5%), and intermediate (6.2%) uveitis. The most identifiable specific diagnoses were anterior herpetic uveitis (18.4%), Fuchs uveitis (12.8%), and tuberculosis (6.1%). Infectious etiologies were the most frequent (34.1%) and were more diffuse among non-Caucasian patients (p < 0.001), followed by systemic disease-associated uveitis (26.5%), and ocular-specific conditions (20%). Idiopathic uveitis accounted for 19.4% of cases. Fuchs uveitis presented the longest median diagnostic delay (21 months). Immunosuppressants were administered to 25.2% of patients. Antimetabolites, calcineurin inhibitors, and biologicals were prescribed to 18.4%, 3%, and 11.4% of cases, respectively. Compared to our previous reports, we observed a significant increase in foreign-born patients and in infectious uveitis, a decrease in idiopathic conditions, and an increasing use of non-biological and biological steroid-sparing drugs.

CONCLUSIONS

The patterns of uveitis in Italy have been changing over the last 20 years, very likely due to migration flows. Diagnostic improvements and a more widespread interdisciplinary approach could reduce the incidence of idiopathic uveitis as well as diagnostic delay.

Ocular Inflammation Post-Vaccination

The association between vaccines and ocular disorders has attracted significant attention in scientific research. Numerous mainstream vaccines are associated with a range of uveitis types, including anterior, intermediate, and posterior uveitis. Additionally, they are associated with distinct ocular diseases such as multifocal choroiditis, Vogt-Koyanagi-Harada (VKH) disease, acute posterior multifocal placoid pigment epitheliopathy (APMPPE), and multiple evanescent white dot syndrome (MEWDS). These ocular conditions are often transient, with a vast majority of patients experiencing improvement after steroid intervention. To date, numerous cases of vaccine-induced uveitis have been reported. This study analyzed the correlation between antiviral vaccines, including the hepatitis B virus (HBV), human papillomavirus (HPV), measles-mumps-rubella (MMR), varicella zoster virus (VZV), and influenza vaccines, and different manifestations of uveitis. This is the first comprehensive study to offer a detailed analysis of uveitis types induced by antiviral vaccines. Through an extensive database search, we found a particularly strong link between influenza vaccines, followed by VZV and HPV vaccines. While anterior uveitis is common, conditions such as APMPPE, MEWDS, and VKH are particularly notable and merit careful consideration in clinical practice. Corticosteroid treatment was effective; however, half of the observed patients did not achieve full recovery, indicating potentially prolonged effects of the vaccine.

Pattern of Uveitis at a Tertiary Eye Care and Training Center, North-West Ethiopia

PURPOSE

The aim of this study was to determine the clinical presentations of uveitis at the University of Gondar Tertiary Eye Care and Training Center, North-West Ethiopia.

METHODS

A cross sectional study was performed at the center from August 2017 to July 2018. Study patients underwent complete ophthalmic evaluation and relevant ancillary tests. Data was gathered using a data extraction format and analyzed.

RESULTS

A total of 105 eyes of 82 patients were studied. The mean age was 33.8 ± 14.8 years,53 (65%) were male and uveitis was unilateral in 72%. Anterior uveitis was the commonest, 57%, followed by Intermediate uveitis 21.7%. Sixty-six of the 105 (63%) of eyes were blind. Cataract was the commonest complication identified.

CONCLUSION

This study showed that uveitis is prevalent in the working age group with a significant number of blindness. Anterior uveitis was the commonest type of Uveitis and cataract was the commonest complication.

Ophthalmic manifestations and vision impairment in Lassa fever survivors

The purpose of this study was to describe the ocular findings, structural ocular complications, and vision impairment in a cohort of Lassa fever survivors in Kenema, Sierra Leone. A retrospective, uncontrolled, cross-sectional study of 31 Lassa fever survivors (62 eyes) who underwent an ophthalmic evaluation in January 2018 at the Kenema Government Hospital in Kenema, Sierra Leone was performed. Data collection included demographic information, ocular/systemic symptoms, visual acuity (VA), and ophthalmic examination findings. Main outcome measures included anterior and posterior segment ophthalmic manifestations and level of VA impairment in Lassa fever survivors. Anterior segment findings included cataract (18%) and pterygium (2%), while posterior segment manifestations consisted of glaucoma (6%), preretinal hemorrhage (2%), and lattice degeneration (2%). Findings suggestive of prior sequelae of uveitis included chorioretinal scarring (5%), retinal fibrosis (3%), and vitreous opacity (2%). Visual acuity was normal/mildly impaired in 53 eyes (85%), moderately impaired in 6 eyes (10%), and 3 eyes (5%) were considered blind by the World Health Organization (WHO) criteria. Median VA was worse in Lassa fever survivors with ophthalmic disease findings (p<0.0001) for both anterior segment (p<0.0001) and posterior segment disease (p<0.013). Untreated cataract was a significant cause of visual acuity impairment (p<0.0001). Lassa fever survivors in this cohort were found to have cataract and posterior segment findings that potentially represent sequelae of uveitis associated with visual impairment. Future studies are warranted to improve our understanding of the spectrum of ocular disease in this emerging infectious disease of public health consequence.

Pattern of Uveitis Associated with Behçet's Disease in an Egyptian Cohort

Purpose

To report the clinical experience of uveitis associated with Behçet's disease in a cohort of Egyptian patients.

Methods

The present study is a retrospective analysis of the medical charts of patients with Behçet's disease, who were referred to a tertiary eye care center in Egypt between June 2010 and June 2018.

Results

The current study included 1301 eyes of 681 patients with Behçet's disease. The mean age of the patients at the time of referral was 27.2 ± 3.9 years. Panuveitis was the most common presentation. About 28% of all involved eyes had a final visual acuity <20/200, by the last follow-up visit.

Conclusion

Behçet's disease is an important cause of uveitis in Egypt, and despite the fact that the prognosis of Behçet's uveitis has globally improved in recent years, the visual outcome in Egypt is still not favorable especially in case of delayed referral to tertiary centers.

Uveitis and deficient lens capsules: Effect of glued intraocular lens on the visual outcome and the reactivation of inflammation

Purpose:

To evaluate the visual outcome and complication profile after glued intraocular lens (IOL) in post uveitic eyes.

Methods:

Patients with history of uveitis who had glued IOL with 3 months antecedent quiet anterior chamber (AC) were included in this prospective observational case series. Visual acuity, slit-lamp examination, fundus evaluation, optical coherence tomography, intraocular pressure, specular count and AC inflammation were analyzed before and after glued IOL procedure. Glued IOL eyes were also compared with their fellow normal capsular bag IOL.

Results:

Overall 17 eyes (50.7 ± 16.1 years) were analyzed. It included 41.8%, 23.5%, and 35.29% anterior, posterior, and pan uveitis, respectively. The etiologies were tuberculosis (23.53%), toxoplasmosis (11.77%), Fuch's heterochromic cyclitis (5.88%), HLA B27 (11.77%), psoriatic arthritis (5.88%), Rheumatoid arthritis (5.8%), sarcoidosis (11.77%), herpetic kerato-uveitis (5.88%), and idiopathic (17.65%). Cataractous subluxated lens (35.3%), aphakia (23.5%), decentered IOL (23.5%) and intraoperative capsular rupture (17.6%) were the surgical indications. A significant improvement in the mean uncorrected and best corrected visual acuity (P < 0.001) was recorded. The complications were IOL pigment dispersion (47%), macular edema (41%), and epiretinal membrane (24%). There was significant rise in AC reaction on day 1 (P < 0.001) and normal AC was attained by 88.2% eyes at 6 months. AC inflammation reactivation was noted in 11.7% of eyes. Though inflammatory reactivation was similar to the normal IOL, macular edema was higher in glued IOL.

Conclusion:

Glued IOL can cause inflammation in uveitis eyes which can be managed medically with minimal complications.

A Longitudinal Study of Ebola Sequelae in Liberia

BACKGROUND

Multiple health problems have been reported in survivors of Ebola virus disease (EVD). Attribution of these problems to the disease without a control group for analysis is difficult.

METHODS

We enrolled a cohort of EVD survivors and their close contacts and prospectively collected data on symptoms, physical examination findings, and laboratory results. A subset of participants underwent ophthalmologic examinations. Persistence of Ebola virus (EBOV) RNA in semen samples from survivors was determined.

RESULTS

A total of 966 EBOV antibody-positive survivors and 2350 antibody-negative close contacts (controls) were enrolled, and 90% of these participants were followed for 12 months. At enrollment (median time to baseline visit, 358 days after symptom onset), six symptoms were reported significantly more often among survivors than among controls: urinary frequency (14.7% vs. 3.4%), headache (47.6% vs. 35.6%), fatigue (18.4% vs. 6.3%), muscle pain (23.1% vs. 10.1%), memory loss (29.2% vs. 4.8%), and joint pain (47.5% vs. 17.5%). On examination, more survivors than controls had abnormal abdominal, chest, neurologic, and musculoskeletal findings and uveitis. Other than uveitis (prevalence at enrollment, 26.4% vs. 12.1%; at year 1, 33.3% vs. 15.4%), the prevalence of these conditions declined during follow-up in both groups. The incidence of most symptoms, neurologic findings, and uveitis was greater among survivors than among controls. EBOV RNA was detected in semen samples from 30% of the survivors tested, with a maximum time from illness to detection of 40 months.

CONCLUSIONS

A relatively high burden of symptoms was seen in all participants, but certain symptoms and examination findings were more common among survivors. With the exception of uveitis, these conditions declined in prevalence during follow-up in both groups. Viral RNA in semen persisted for a maximum of 40 months. (Funded by the National Institute of Allergy and Infectious Diseases and the National Eye Institute; PREVAIL III ClinicalTrials.gov number, NCT02431923.).

Novel Retinal Lesion in Ebola Survivors, Sierra Leone, 2016

A lesion specific to Ebola virus disease showed an anatomical distribution suggesting neuronal transmission.

We conducted a case–control study in Freetown, Sierra Leone, to investigate ocular signs in Ebola virus disease (EVD) survivors. A total of 82 EVD survivors with ocular symptoms and 105 controls from asymptomatic civilian and military personnel and symptomatic eye clinic attendees underwent ophthalmic examination, including widefield retinal imaging. Snellen visual acuity was <6/7.5 in 75.6% (97.5% CI 63%–85.7%) of EVD survivors and 75.5% (97.5% CI 59.1%–87.9%) of controls. Unilateral white cataracts were present in 7.4% (97.5% CI 2.4%–16.7%) of EVD survivors and no controls. Aqueous humor from 2 EVD survivors with cataract but no anterior chamber inflammation were PCR-negative for Zaire Ebola virus, permitting cataract surgery. A novel retinal lesion following the anatomic distribution of the optic nerve axons occurred in 14.6% (97.5% CI 7.1%–25.6%) of EVD survivors and no controls, suggesting neuronal transmission as a route of ocular entry.

A Focus on the Epidemiology of Uveitis

PURPOSE

Uveitis is a common, sight-threatening inflammatory ocular disease and includes multiple heterogeneous clinical entities. The prevalence of various types of uveitis depends upon multiple factors, such as age, sex, race, geographic distribution, environmental influence, genetics, and social habits. Epidemiologic research of uveitis is necessary to understand the etiology and immunopathogenesis of this group of diseases. The present study attempts to concentrate on the most recent information on the epidemiology of uveitis and compare it with previous knowledge.

METHODS

An extensive literature search was performed in the Medline database (PubMed) and included surveys completed until 2015. Articles that reported prevalence and incidence were studied. References cited in the articles were also studied.

RESULTS

The incidence and prevalence of uveitis differs based on age, anatomic location of the inflammatory process (anterior, intermediate, posterior uveitis, panuveitis), gender, histopathology (granulomatous, non-granulomatous), type of inflammatory process (acute, chronic, recurrent), and etiology (infectious, non-infectious). Prevalence differs by geographic location. Idiopathic anterior uveitis is the most common form of uveitis in the community. Infectious causes are common (30-60%) in the developing countries. Herpes and toxoplasmosis are the leading infectious causes of uveitis. Non-infectious uveitic conditions are generally more common in the developed world. An increase in the prevalence of infectious etiologies, including tuberculosis and syphilis, has been seen in developed countries. Introduction of new treatment options has also changed patterns of disease.

CONCLUSIONS

Introduction of new uveitis entities, changes in the incidence of already known disease and increased availability of diagnostic testing have all altered the epidemiology of uveitis in recent years. Knowledge of regional patterns of disease is essential. A more detailed classification of uveitis with the establishment of uniform diagnostic criteria and prospective population based studies would certainly benefit epidemiologic research and clinical practice.

Diagnosis and treatment of anterior uveitis: optometric management

Anterior uveitis encompasses inflammation of the iris and/or ciliary body and is one of the most common types of ocular inflammation that primary eye care practitioners will encounter. Anterior uveitis may be caused by a variety of etiologies, including infectious, non-infectious, and masquerade diseases. The short-term and long-term treatment of uveitis should include the evaluation of location, duration, pathology, and laterality, in addition to presenting signs and symptoms of the disease. A complete review of systems, thorough examination, and laboratory testing, may assist the practitioner in narrowing the list of possible causes for the uveitis. This is imperative as once a list of diagnoses has been made, a targeted approach to treatment can be pursued.

Negatively regulating TLR4/NF-κB signaling via PPARα in endotoxin-induced uveitis

Toll-like receptor (TLR) signaling plays a fundamental role in the induction and progression of autoimmune disease. In the present study, we showed that lipopolysaccharide (LPS), a TLR4 ligand, functions as an antagonist of peroxisome proliferator-activated receptor alpha (PPARα), a nuclear transcription factor. Using endotoxin induced uveitis (EIU) as a model, we found that TLR was negatively regulated by PPARα. Our data revealed that treatment with the PPARα agonist fenofibrate dramatically prevented LPS-induced uveitis and inhibited TLR/ Nuclear factor-kappaB (NF-κB) signaling during inflammation. Evaluation of the severity of anterior uveitis further showed that PPARα agonist treatment significantly decreased inflammatory cell infiltration, total protein concentration, vessel density, inflammatory cytokine production, and clinical scores in the anterior section of the eye during EIU. Moreover, fenofibrate administration recovered retinal function and decreased the production of inflammatory cytokines, retinal vascular leukostasis, and inflammatory cell infiltration into the posterior section of the eyes during EIU. In vitro studies further showed that down-regulation or deletion of PPARα led to increased TLR4 levels and the activation of NF-κB signaling in RPE cells and also blocked the anti-inflammatory effects of fenofibrate. Furthermore, activation or up-regulation of PPARα decreased TLR4 levels and inhibited the NF-κB signaling pathway induced by LPS in RPE cells. In TLR4-expressing reporter cells, activation or up-regulation of PPARα partially inhibited the activation of NF-κB and also decreased TLR4 transcriptional activity. In conclusion, the activation of PPARα represents a novel therapeutic strategy for human uveitis, as PPARα negatively regulates TLR4 activity and therefore exerts anti-inflammatory actions.

Review on the worldwide epidemiology of uveitis

PURPOSE

We describe the worldwide epidemiology of uveitis through a systematic literature review.


METHODS

Data obtained from the most relevant studies published until November 2012 were reported.


RESULTS

Results of our research were structured in sections about the epidemiology of uveitis by anatomical location of inflammation (anterior, intermediate, posterior, and panuveitis), type of inflammation (infectious and noninfectious), and by age (children and elderly). Difficulties encountered analyzing the different epidemiologic studies were discussed in a dedicated section.


CONCLUSIONS

Limited information is available regarding the epidemiology of uveitis. Worldwide epidemiologic studies may help the clinician in the management of patients with inflammatory ocular diseases, enabling the comparison of different uveitis entities.

Epidemiology of Behçet disease

Behçet disease (BD) is a multisystem inflammatory disorder that is an important cause of morbidity worldwide. BD is most common along the ancient "Silk Road" route in the Far East and Mediterranean basin. The eye is the most commonly involved organ in BD patients.The prototypical form of involvement is a relapsing remitting panuveitis and retinal vasculitis. Less commonly, BD may present in the form of conjunctivitis, conjunctival ulcers, keratitis, episcleritis, scleritis, and extraocular muscle paralysis. Uveitis in BD carries significant implications for the patient, because it is a chronic recurrent disease characterized by explosive attacks of severe inflammation that may cause significant, cumulative damage to the intraocular structures. This review summarizes the epidemiology of systemic and ocular clinical features of BD with particular focus on risk factors, clinical characteristics, complications, and prognosis of BD-associated uveitis.

Uveitis: a global perspective

PURPOSE

To study the patterns of uveitis in various geographic regions.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Causes of blindness among adult Jordanians: a hospital-based study

PURPOSE

To assess the causes of blindness among adults aged 20 years and over who attended two big general ophthalmic clinics in Jordan.

PATIENTS AND METHODS

This hospital-based study was undertaken at Jordan University Hospital in Amman (the capital of Jordan) and Princess Basma Teaching Hospital which is affiliated with Jordan University of Science and Technology in Irbid, the third largest city in the country. A total of 2732 patients seen consecutively over 26 months were examined and the ophthalmic findings were recorded. Using standard Snellen charts, subjects were placed in one of three categories according to their best corrected visual acuity: (1) unilateral blindness: less than 6/60 in the worst eye, 6/60 or more in the better eye; (2) moderate bilateral blindness: less than 6/60 in the worst eye, less than 6/60 to 3/60 or more the better eye; and (3) severe bilateral blindness: less than 3/60 in both eyes.

RESULTS

Of the totalpatients seen, 373 were blind according to the selection criteria. Among 248 patients with unilateral blindness, diabetic retinopathy, cataract and trauma were the leading causes. Among the 81 patients with moderate bilateral blindness, diabetic retinopathy and cataract were the leading causes. Diabetic retinopathy and glaucoma were the leading causes in patients with severe bilateral blindness.

CONCLUSIONS

These data could be used in planning blindness prevention and treatment programs while awaiting a national survey on the prevalence and causes of blindness in Jordan.

Aetiology of uveitis in Sierra Leone, west Africa

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Causes and frequency of blindness in patients with intraocular inflammatory disease

AIMS/BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

Cystoid macular oedema is the most frequent complication of uveitis and its occurrence plays a decisive role in the visual outcome of this disease.