Anterior uveitis as a manifestation of ocular tuberculosis / Uveíte anterior como manifestação de tuberculose ocular

ABSTRACT Tuberculosis (TB) is an infectious disease of great magnitude in the world. Of patients with extrapulmonary disease, ocular manifestations are rare but among reported cases the most common ocular manifestation is uveitis. The diagnosis of ocular TB should be made as early as possible so that treatment is initiated and the risks of ocular complications are minimized. The objective of this study is to report an ocular TB case that presented as anterior uveitis. A 52-year-old female patient, a nursing technician at a large hospital, presented a history of low visual acuity associated with myiodesopsia for 4 days. Her ophthalmologic history included an iridotomy due to narrow angle in both eyes. On examination, the best corrected visual acuity was 20/100, right eye, and 20/80, left eye. Among the most significant ocular alterations were granulomatous keratic precipitates, anterior chamber reaction, flare and light vitreitis, corresponding to anterior uveitis. Based on clinical history and ophthalmologic examination, tests were ordered that corroborated the diagnosis of ocular TB. Thereafter, antituberculous therapy was instituted with a good response in 15 days, including improvement in visual acuity. The patient was followed-up by ophthalmology and infectology. Intraocular TB should be considered in the differential diagnosis of any type of intraocular inflammation. The diagnosis of presumed ocular TB is a clinical challenge with the diagnosis modalities currently available. The faster the onset of treatment, the better the visual prognosis of the affected patient.

RESUMO A tuberculose (TB) é uma doença infecciosa de grande magnitude no mundo. Dos pacientes com doença extrapulmonar, as manifestações oculares são raras, mas entre os casos relatados, a manifestação ocular mais comum é a uveíte. O diagnóstico de TB ocular deve ser feito o mais precoce possível para que o tratamento seja iniciado e os riscos de complicações oculares sejam minimizados. O objetivo deste estudo é relatar um caso de TB ocular que se apresentou como uveíte anterior. Uma paciente do sexo feminino, 52 anos, técnica de enfermagem de um hospital de grande porte, apresentou história de baixa acuidade visual associada à miodesopsia por 4 dias. Sua história oftalmológica incluía uma iridotomia devido ao ângulo estreito em ambos os olhos. No exame, a melhor acuidade visual corrigida foi 20/100, olho direito, e 20/80, olho esquerdo. Dentre as alterações oculares mais significativas, destacam-se precipitados ceráticos granulomatosos, reação de câmara anterior, flare e vitreíte leve, correspondendo à uveíte anterior. Com base na história clínica e no exame oftalmológico, foram solicitados exames que corroboram o diagnóstico de TB ocular. Posteriormente, a terapia antituberculosa foi instituída com uma boa resposta em 15 dias, incluindo melhora na acuidade visual. A paciente foi acompanhada pelas especialidades: oftalmologia e infectologia. A TB intraocular deve ser considerada no diagnóstico diferencial de qualquer tipo de inflamação intraocular. O diagnóstico presumível de tuberculose ocular é um desafio clínico com as modalidades de diagnóstico atualmente disponíveis. Quanto mais rápido o início do tratamento, melhor o prognóstico visual do paciente afetado.

Uveítis anterior aguda asociada a raquitismo renal hipofosfatémico / Acute anterior uveítis associated to hypophosphatemic renal ricketts

Los raquitismos hipofosfatémicos hereditarios son un grupo de enfermedades caracterizadas por la pérdida renal de fosfatos. Cursan con hipocrecimiento disarmónico y deformidades óseas. La forma más común es el raquitismo hipofosfatémico ligado al cromosoma X, el cual es causado por mutaciones inactivantes en el gen PHEX. El objetivo de nuestro trabajo fue describir las alteraciones oculares encontradas y la evolución clínica en un paciente con raquitismo hipofosfatémico hereditario y uveítis anterior. Se presenta un niño de 9 años de edad con diagnóstico de raquitismo hipofosfatémico hereditario, valorado en el Servicio de Uveítis del Instituto Cubano de Oftalmología Ramón Pando Ferrer por presentar dolor ocular y molestias a la luz en el ojo derecho. En la exploración oftalmológica se constata una uveítis anterior con hipopión en el ojo derecho y depósitos de cristales en todo el espesor corneal y el iris en ambos ojos. Se indicaron esteroides tópicos con resolución del proceso inflamatorio. Los hallazgos en el segmento anterior del paciente son sugestivos de cistinosis, donde el acúmulo de cristales es la alteración corneal más típica de las manifestaciones oculares, con una incidencia del 90 por ciento en niños menores de un año, y los primeros órganos afectados son los riñones. Los raquitismos hipofosfatémicos hereditarios pueden cursar con depósitos de cristales corneales y procesos inflamatorios de la úvea anterior(AU)

Hereditary hypophosphatemic rickets are a group of diseases characterized by renal loss of phosphates. They appear with disharmonic hypogrowth and bone deformities. The most common form is the X-chromosome-linked hypophosphatemic rickets which is caused by inactivating mutations in PHEX gene. The objective of our work was to describe the ocular alterations and the clinical evolution in a patient with hereditary hypophosphatemic rickets and previous uveitis. Here is the case of a 9 years-old boy diagnosed with hereditary hypophosphatemic rickets, who was seen at the Uveitis Service of Ramon Pando Ferrer Cuban Institute of Ophthalmology. He presented with ocular pain and feeling of discomfort to light in his right eye. The ophthalmological exam yielded anterior uveitis with hypopyon in his right eye and crystal depots in the whole corneal thickness and the iris of both eyes. Topical steroids were prescribed to treat the inflammatory process. The findings in the anterior segment of the patients indicated the presence of cystinosis in which the accumulation of crystals is the most typical corneal alteration among the ocular manifestations. Its incidence reaches 90 percent in under one year-old children and the first affected organs are the kidneys. The hereditary hypophosphatemic rickets may appear with corneal crystal depots and inflammatory processes in the anterior uvea(AU)

Manejo de la uveítis asociada a espondiloartropatías / Managment of uveitis associated to spondiloarthropaties

Alrededor de un tercio de los afectados por espondiloartropatías hará uveítis. Casi siempre serán uveítis anteriores, agudas, unilaterales y autolimitadas, que alter-narán entre uno y otro ojo. El tratamiento de elección es el corticoide tópico du-rante la crisis, que habitualmente resolverá en un plazo no mayor a doce semanas. Hay varias estrategias para reducir la frecuencia e intensidad de las crisis, las que han sido evaluadas en pequeños estudios en sujetos con tres o más episodios anuales. Han sido beneficiosos el metotrexato, sulfasalazina y antiinflamatorios no esteroidales (AI-NEs), estos últimos en dosis de dos veces por día, no así los AINEs en toma única diaria. Los agentes biológicos anti factor de necrosis tumoral (anti-TNF por su sigla en in-glés), excepto el etanercept, se asocian a muy altos índices de prevención de recidivas en estudios observacionales, pero los estudios comparativos sólo se han hecho para uveítis no-anteriores.

About one third of all subjects affected by spondiloarthropaties will suffer from uve-itis. These will happen to be acute, anterior, unilateral and self-limited uveitis attacks, alternating between one and other eye. First choice treatment consists of topical cor-ticosteroid during the episode that will usually resolve in no more than twelve weeks. There are several useful strategies to reduce the frequency and intensity of the uveitis at-tacks. These have been studied in small trials with reduced number of subjects suffering from three or more episodes per year. They have shown a beneficial effect for methotrex-ate, sulfasalazine and non-steroidal anti-inflammatory drugs (NSAIDs), these last when prescribed twice a day, without proven benefit from taking single daily doses of NSAIDs. Anti-tumor necrosis factor (anti-TNF) biologic agents, except for etanercept, are asso-ciated to a huge reduction in the frequency of uveitis attacks in observational studies, but comparative trials available have addressed non-anterior uveitis exclusively.

Bilateral Acute Anterior Uveitis and Optic Disc Edema Following a Snake Bite

The authors wish to report a case of bilateral acute anterior uveitis and optic disc edema following a hemotoxic snake bite, in order to highlight the concomitant occurrence of these conditions and the potential adverse effects of anti-snake venom (ASV). A 35-year-old male was bitten by a viper at seventeen thirty hours, and was started on ASV. Two days following treatment he experienced sudden onset redness and painful diminution of vision in both eyes (OU). On examination, the patient's visual acuity (VA) in OU was 20/200. Examination revealed fresh keratic precipitates, cells, and flare in the anterior chamber (AC), posterior synechiae, sluggish and ill-sustained pupillary reaction, and hyperemic, edematous disc with blurred margins in OU. He was started on topical steroids, cycloplegics and intravenous methylprednisolone. Following treatment, the patient showed improvement and was continued on topical medications and oral prednisolone tapered over 3 weeks, after which VA OU improved, the AC showed no cells and flare and disc edema resolved. Uveitis and optic disc edema in snake bite can either be due to the direct toxic effects of the venom or the effect of ASV. Steroids have a beneficial role in the management of these symptoms.

Demographic, clinical, laboratory and treatment characteristics of spondyloarthritis patients with and without acute anterior uveitis / Características demográficas, clínicas, laboratoriais e de tratamento entre pacientes com espondiloartrite com e sem uveíte anterior aguda

CONTEXT AND OBJECTIVE: Acute anterior uveitis is a common extra-articular manifestation in spondyloarthritis patients. The aim of this study was to compare demographic, clinical, laboratory and treatment data among spondyloarthritis patients with and without acute anterior uveitis. DESIGN AND SETTING: This was a cross-sectional analytical study at the Rheumatology Outpatient Clinic of the Evangelical University Hospital, Curitiba, Brazil. METHODS: Spondyloarthritis patients with without acute anterior uveitis were compared regarding demographic data, spondyloarthritis subtype, peripheral arthritis, enthesitis, disease activity, functional index, physical examination, radiological involvement, HLA-B27 and treatment. RESULTS: Presence of acute anterior uveitis was not found to have any relationship with functional index, degree of radiological involvement, peripheral arthritis or enthesitis. Acute anterior uveitis showed a negative association with skin manifestations (P = 0.04) and a trend towards higher disease activity (P = 0.06). CONCLUSION: In the study sample, it could not be shown that AAU had any association with the functional and radiological prognoses. The patients with spondyloarthritis with and without acute anterior uveitis did not differ clinically except for a higher proportion of ankylosing spondylitis and smaller presence of skin involvement in those with uveitis.

CONTEXTO E OBJETIVO: Uveíte anterior aguda é uma manifestação extra-articular comum em pacientes com espondiloartrite. O objetivo deste estudo foi comparar achados demográficos, clínicos, laboratoriais e de tratamento em pacientes com espondiloartrite com e sem uveíte anterior aguda. TIPO DE ESTUDO E LOCAL: Este é um estudo transversal analítico realizado no Ambulatório de Reumatologia do Hospital Universitário Evangélico de Curitiba, Brasil. MÉTODOS: Pacientes com espondiloartrite com e sem uveíte anterior aguda foram comparados quanto a dados demográficos, subtipo de espondiloartrite, artrite periférica, entesite, atividade da doença, índice funcional, exame físico, envolvimento radiológico, HLA-B27 e tratamento. RESULTADOS: Não se encontrou associação entre presença de uveíte anterior aguda e índice funcional, grau de envolvimento radiológico, artrite periférica e entesite. Encontrou-se uma associação negativa de uveíte anterior aguda com manifestações de pele (P = 0,04) e uma tendência para maior atividade de doença (P = 0,06). CONCLUSÃO: Na amostra estudada, não foi possível demonstrar associação entre uveíte anterior aguda no prognóstico funcional e radiológico. Pacientes com espondiloartrite com e sem uveíte anterior aguda não diferem clinicamente exceto por uma maior proporção de espondilite anquilosante e uma presença menor de envolvimento cutâneo naqueles com uveíte.

Fibrinous anterior uveitis following laser in situ keratomileusis.

A 29-year-old woman who underwent laser in situ keratomileusis (LASIK) for myopic astigmatism in both eyes presented with severe pain, photophobia and decreased visual acuity in the left eye eight days after surgery. Examination revealed severe anterior uveitis with fibrinous exudates in the anterior chamber, flap edema and epithelial bullae. Laboratory investigations for uveitis were negative and the patient required systemic and intensive topical steroids with cycloplegics to control the inflammation. This case demonstrates that severe anterior uveitis may develop after LASIK and needs prompt and vigorous management for resolution.

Keratouveitis caused by Euphorbia plant sap.

The milky sap or latex of Euphorbia plant is highly toxic and an irritant to the skin and eye. This report illustrates the spectrum of ocular inflammation caused by accidental inoculation of latex of Euphorbia plant. Three patients presented with accidental ocular exposure to the milky sap of Euphorbia species of recent onset. The initial symptoms in all cases were severe burning sensation with blurring of vision. Visual acuity reduced from 20/60 to counting fingers. Clinical findings varied from kerato-conjunctivitis, mild to severe corneal edema, epithelial defects, anterior uveitis and secondary elevated intraocular pressure. All symptoms and signs had resolved by 10-14 days with active supportive medication. People who handle Euphorbia plants should wear eye protection. It is always advisable to ask the patient to bring a sample of the plant for identification.

Anterior segment manifestations of human immunodeficiency virus/acquired immune deficiency syndrome.

Ocular complications are known to occur as a result of human immunodeficiency virus (HIV) disease. They can be severe leading to ocular morbidity and visual handicap. Cytomegalovirus (CMV) retinitis is the commonest ocular opportunistic infection seen in acquired immune deficiency syndrome (AIDS). Though posterior segment lesions can be more vision-threatening, there are varied anterior segment manifestations which can also lead to ocular morbidity and more so can affect the quality of life of a HIV-positive person. Effective antiretroviral therapy and improved prophylaxis and treatment of opportunistic infections have led to an increase in the survival of an individual afflicted with AIDS. This in turn has led to an increase in the prevalence of anterior segment and adnexal disorders. Common lesions include relatively benign conditions such as blepharitis and dry eye, to infections such as herpes zoster ophthalmicus and molluscum contagiosum and malignancies such as squamous cell carcinoma and Kaposi's sarcoma. With the advent of highly active antiretroviral therapy, a new phenomenon known as immune recovery uveitis which presents with increased inflammation, has been noted to be on the rise. Several drugs used in the management of AIDS such as nevirapine or indinavir can themselves lead to severe inflammation in the anterior segment and adnexa of the eye. This article is a comprehensive update of the important anterior segment and adnexal manifestations in HIV-positive patients with special reference to their prevalence in the Indian population.

Herpes simplex uveitis

BACKGROUND: Uveitis in herpes simplex virus (HSV) ocular disease is usually associated with corneal stromal disease. It has generally been believed that herpetic uveitis in the absence of corneal disease is very rare. When seen it is usually attributed to varicella zoster virus (VZV) infections. The diagnosis of uveitis caused by herpes simplex is often not diagnosed resulting in inadequate treatment and a poor visual result. METHODS: Seven patients from a large uveitis practice who presented with a clinical picture of: anterior uveitis and sectoral iris atrophy without keratitis, a syndrome highly suggestive of herpetic infection, are reported. Polymerase chain reaction (PCR) was done in the aqueous of four of them and was positive for HSV. One patient had bilateral disease. Most of the patients also had severe secondary glaucoma. RESULTS: Of the seven patients presented five had no history of any previous corneal disease. Two had a history of previous dendritic keratitis which was not active at the time of uveitis development. One patient with bilateral disease was immunosuppressed at the time when the uveitis developed. Six of the seven patients had elevated intraocular pressures at the time of uveitis and five required glaucoma surgery. Intractable glaucoma developed in two patients leading to rapid and severe visual loss despite aggressive management. CONCLUSION: Findings suggest that uveitis without corneal involvement may be a more frequent manifestation of ocular herpes simplex disease than previously thought. Absence of corneal involvement delays a correct diagnosis and may worsen visual outcome. Primary herpetic uveitis (when there is no history of previous corneal disease) seems to be more severe than the uveitis in patients with previous corneal recurrences. The associated glaucoma may be a devastating complication

Uveitis in a child: masquerade syndrome revisit.

We present a case of relapsing acute lymphoblastic leukemia (ALL) in the anterior chamber, uveitis masquerade syndrome, which was confirmed by anterior chamber paracentesis and aqueous fluid cytology. Three months previously, the patient developed anterior uveitis without hematologic relapse. The uveitis responded well to topical steroid. After anterior chamber paracentesis, bone marrow relapse was detected. High doses of chemotherapy were prescribed. Ocular radiation was planned but the patient developed septicemia and expired. In our opinion, paracentesis should be performed without delay when uveitis develops in ALL, regardless of systemic relapse. Ocular manifestation may be the only sign of leukemic relapse or may present several months prior to systemic relapse.

IGEGAM: Efecto en el tratamiento de la Uveítis anterior aguda / IGEGAM: Effect on the treatment of acute anrterior uveitis

Se realizaron estudios diagnósticos e inmunológicos a 15 pacientes con uveitis anterior aguda, a quienes se les indicó tratamiento con IGEGAM, ganmaglobulina enriquecida en IgA e IgM de producción nacional, y se obvió el tratamiento convencional. Se logró una reducción de la enfermedad en sólo 2 semanas de crisis de agudización durante 48 meses

Non-steroidal anti-inflammatory drug and endotoxin induced uveitis

Suprofen eye drop was instilled into one eye of 10 pigmented rabbits and then anterior uveitis was induced by intraperitoneal injection of endotoxin of Shigella flexneri serotype 1A to evaluate the effects of non-steroidal anti-inflammatory drug on endotoxin induced uveitis. The pupillary diameters were measured, and aqueous cell and flare gradings were recorded in 20 eyes of 10 rabbits for one week at an interval of 12 hours for the first 24 hours and then every 24 hours for a week. A difference between the treated and control groups were investigated. All the above parameters showed greatest changes at 12 or 24 hours after injection and became normal by one week. The two groups demonstrated statistically significant difference at 12 hours, day 1 and day 2 as for pupillary diameter, at day 1 and day 2 as for cell and at 12 hours and day 1 as for flare. Thus, it can be concluded that prostaglandins play a role in miosis, in the appearance of inflammatory cells and flare in endotoxin induced uveitis and the topical administration of non-steroidal anti-inflammatory drug can alleviate signs of anterior uveitis. Specific relationship between leukotriene B4 and aqueous cell was not demonstrated.