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March 2003 Brief Reports 77

Brief Reports

Recurrent Anterior Uveitis and Healed
Retinal Vasculitis associated with
Multiple Sclerosis
Kannan M Narayana, DOMS; Rupesh Agrawal, DO;
Jyotirmay Biswas, MS; Deepak Arjundas, DM (Neuro)
We describe the occurrence of anterior uveitis with
healed retinal vasculitis in an Asian-Indian woman.
She had features of anterior uveitis and healed retinal
vasculitis. This rare disease in India may be associated
with intraocular inflammation.
Key Words: Multiple sclerosis, anterior uveitis, retinal
vasculitis
Indian J Ophthalmol 2003;51:77-79
Multiple sclerosis is suspected to be of autoimmune
origin. It predominantly involves the white matter of
the central nervous system. It is more common among
the Caucasian population. Several authors have
observed the association of uveitis with multiple
sclerosis. 1-3 Common intraocular associated
inflammations include retinal periphlebitis (10-20%), 1
peripheral uveitis (15-27%)3 and iridocyclitis (4.3-5.5%).2
Multiple sclerosis, though relatively uncommon in the
Indian population, has been reported in the Indian
literature. 4 However, to our knowledge (Medline
search), uveitis with multiple sclerosis has not been
reported so far in Indian subjects. We report a case of
recurrent anterior uveitis and healed retinal vasculitis
in a patient with multiple sclerosis.
showed partial resolution of the lesion. No fresh lesions were
seen. A diagnosis of demyelinating disease, possibly multiple
sclerosis, was made by the neurologist. As the lesion was
spontaneously regressing, the patient was not advised any
treatment. She had recently seen an ophthalmologist and
was diagnosed with chronic anterior uveitis.
She had also undergone investigations for uveitis,
including: total leukocyte count (6700 cells/mm 3 ,
neutrophils-61%, lymphocytes-37%, eosinophils-1%), ESR
11mm at first hour, normal lipid profile, normal renal
function parameters, negative enzyme linked
immunosorbent assay (ELISA) for toxoplasmosis, normal
serum angiotensin converting enzyme (ACE), negative
antinuclear antibody negative and negative anti-ds-DNA
antibody. The patient was negative for human
immunodeficiency virus (HIV) infection and the chest X
ray showed no abnormalities. The patient was using 1%
prednisolone acetate eye drops 4 times a day and 0.5%
timolol maleate eye drops twice a day in the left eye.
The best corrected vision was 6/6,N6 in both eyes. Ocular
motility was normal. Slitlamp examination of anterior
segment in the right eye was normal. The left eye had 2+
flare, 2+ cells in the anterior chamber, old and fresh,
medium-sized keratic precipitates, large posterior synechiae
(Figure 2a) and early posterior subcapsular cataract.
Intraocular pressure (IOP) by applanation tonometry was 12
mm of Hg in the right eye and 26 mm of Hg in the left eye.
Gonioscopy showed 360 open angles in both the eyes and
peripheral anterior synechiae in the left eye. Indirect
ophthalmoscopy showed no abnormalities in the right eye

Case report
A 46-year-old lady presented with history suggestive of
recurrent anterior uveitis in her left eye for the past 7 years.
She had a history of left-sided lower motor neuron type
facial palsy 20 years ago and left hemi-paresis 8 years ago.
She had recovered from both conditions spontaneously.
Magnetic resonance imaging (MRI) of brain, done 8 years
ago, showed a large hyperintense lesion in the posterior limb
of the right internal capsule and corona radiata suggestive of
demyelination (Figure 1). The magnetic resonance
angiogram had confirmed the non-vascular nature of the
lesion. The pattern VEP (Visually Evoked Potentials),
auditory evoked potentials, and somatosensory evoked
potentials were normal. A follow-up MRI 10 days later

Medical and Vision Research Foundations (KMN, RA, JB), and

Mercury Nursing Home (DA), Chennai, India

Reprint requests to Dr. Jyotirmay Biswas, Medical and

Vision Research Foundation, Sankara Nethralaya,
18 College Road, Chennai - 600 006, India. E-mail: Figure 1. MRI of the brain: T-2 weighted image shows an
<drjb@sankaranethralaya.org> oval hyperintense lesion in the posterior limb of right
Manuscript received: 8.10.2001; Revision accepted: 15.5.2002 internal capsule and corona radiata

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78 INDIAN JOURNAL OF OPHTHALMOLOGY
2a
Figure 2a. Anterior segment photograph of left eye showing large posterior synechiae; b. Fundus photograph showing
healed peripheral retinal periphlebitis in the inferior periphery of the left eye.
fundus. Left eye showed glaucomatous cupping of the optic
disc with cup-disc ratio of 0.8. There was an area of
perivascular sheathing in the inferior periphery, without any
overlying vitritis, suggestive of healed perivasculitis (Figure
2b). The patient was asked to continue prednisolone acetate
and timolol eye drops; 0.2% brimonidine 3 times a day and
2% Homatropine twice a day in the left eye were added. She
was instructed to return for regular follow-ups.
Discussion
Multiple sclerosis is a demyelinating disorder in which
there is normal formation of myelin, which is
subsequently damaged by an as yet unrecognised
mechanism. The disease principally affects young adults
in all countries and is slightly more common in women.
Nearly two-thirds of patients experience symptoms
between 20 and 40 years of age. Epidemiologically three
frequency zones have been identified:4 (1) high risk zone
which includes United Kingdom, Western Europe, the
northern United States and southern Canada
(prevalence rate 30-80/100,000), (2) medium risk zone
(prevalence after 5-15/100,000) which includes southern
Europe, the southern United States and Australia and
(3) low risk zone (prevalence below 5/1,00,000) which
includes Asia and Africa. Association with HLA-A3, B7,
B12 have been found in various studies. The most
common presentations include limb weakness (50%),
and visual disturbances such as blurred vision,
blindness due to optic nerve involvement, and diplopia
(30%). The signs and symptoms remit, but relapses
occur at varying intervals. Despite remissions patients
are usually left with residual neurological deficits.
The aetiopathogenesis of multiple sclerosis remains
uncertain. Autoimmune mechanism is the most
commonly accepted explanation. Ohguro et al found a
high rate of positive serum antibodies reactive with
-arrestin and arrestin in patients with multiple
sclerosis.5 They also suggested that the course of disease
Brief_Reports_F.p65 78
Vol. 51 No. 1
2b
progression might be related to the presence of these
antibodies. We believe that uveitis is a part of the
autoimmune disease process of multiple sclerosis.
Many authors have described an association between
multiple sclerosis and uveitis.1-3 In these reports presence
of granulomatous anterior uveitis, retinal periphlebitis or
intermediate uveitis are reported. To our knowledge
(Medline search), multiple sclerosis associated with
recurrent uveitis has not been reported in Indian subjects.
Anterior uveitis with retinal periphlebitis has been
described in systemic lupus erythomatosis, Behcets
disease, and polyarteritis nodosa. Sometimes sarcoidosis
patients can also present initially with non
granulomatous uveitis. Our patient did not have any
history, systemic features or investigations suggestive of
any of these disorders. We excluded other disorders by
detailed history, examination and relevant investigations.
Multiple sclerosis has been reported to occur in the
Indian subcontinent. However, Asia and Africa are
designated as low-risk zones (with prevalence rate
below 5/100,000).4
Our case indicates that it might be prudent to elicit
any neurological symptoms in all patients with
recurrent uveitis to rule out multiple sclerosis. A
detailed fundus examination is required to rule out
peripheral retinal periphlebitis. Neurological
consultation with MRI may be needed in patients with
a history of neurological deficits with recurrent uveitis
or active or healed retinal vasculitis.
References
1. Arnold AC, Usaf MC, Pepose JS, Helper RS, Froos RY. Retinal
periphlebitis and retinitis in multiple sclerosis. Ophthalmology
1984;91:255-62.
2. Breger BC, Leopod IH. The incidence of uveitis in multiple
sclerosis. Am J Ophthalmol 1966;62:540-45.
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March 2003
3. Lim JI, Tessler HH, Goodwin JA. Anterior granulomatous uveitis
in patients with multiple sclerosis. Ophthalmology 1991;98:142-45.
4. Singhal BS. Demyelinating and dysmyelinating disorders. In
Chopra JS, Arjundas G, Prabhakar S, editors. Textbook of Neurology.
New Delhi, B I Churchill Livingstone, 2001. pp 339-54.
Recurrent Shield Ulcer following
Penetrating Keratoplasty for Kerato-
conus associated with Vernal Kerato-
conjunctivitis
Prashant Garg, MS; Aashish K Bansal, MS; Virender S
Sangwan, MS
Though penetrating keratoplasty for keratoconus
secondary to vernal keratoconjunctivitis (VKC)
invariably carries a good prognosis, the postoperative
course may be complicated by recurrent
epitheliopathy. Despite good medical control of VKC
shied ulcer is still a possibility.
Key Words: Shield ulcer, keratoconus, vernal
keratoconjunctivitis, penetrating keratoplasty
Indian J Ophthalmol 2003;51:79-80
The association of keratoconus with vernal
keratoconjunctivitis (VKC) is well known.1-3 However,
there are a few reports on penetrating keratoplasty (PK)
for keratoconus associated with VKC.3, 4 We report one
case of postoperative reactivation of VKC with
consequent superficial vascularisation, punctate
epithelial erosions and shield ulcer in the graft even
though the surgery was performed after the disease was
medically controlled.
Case Report
A 14-year-old female underwent PK with cataract extraction
and posterior chamber intraocular lens implantation in the
left eye for keratoconus and corticosteroid-induced cataract
in May 1999. She had been treated for vernal
keratoconjunctivitis since 1993. At the time of surgery the
eye was symptom-free, with topical sodium chromoglycate
L V Prasad Eye Institute, Hyderabad, India
Financial Support: Hyderabad Eye Research Foundation,
Hyderabad, India
Proprietary Interest: None
Correspondence to Dr. Prashant Garg, L V Prasad Eye Institute,
L V Prasad Marg, Banjara Hills, Hyderabad - 500 034, India. E-
mail: prashant@lvpeye.stph.net
Manuscript received: 3.7.2001; Revision accepted: 6.10.2002
Brief_Reports_F.p65 79
Brief Reports 79
5. Ohguro H,Chiba S,Igarashi Y, Matsumoto H, Akino T, Palezewski
K. -arrestin and arrestin are recognized by autoantibodies in sera
from multiple sclerosis patients. Proc Natl Acad Sci USA
1993;90:3241-45.
(2%) and polyvinyl alcohol (1.4%). Surgery was performed
using a 7.7 mm donor button on 7.7 mm recipient opening
and 16 interrupted 10.0 nylon sutures. Postoperatively, she
was treated with topical prednisolone acetate (1%) four times
a day and polyvinyl alcohol (1.4%) six times a day. At the
one-month follow-up she presented complaining of a
pricking sensation in the left eye. The tarsal conjunctiva of
the upper lid showed papillary reaction (Figure 1a). The
bulbar conjunctiva was hyperemic. The graft showed diffuse
punctate epithelial erosions. There was superficial
vascularisation between the 10 and 2 o clock positions
extending up to the graft host junction. There were two loose
sutures, which were removed (Figure 1b). She was
subsequently managed with tapering doses of topical
prednisolone acetate (1%) and polyvinyl alcohol (1.4%), and
was followed up every 4 weeks.
Nine months following surgery, she complained of
marked itching, watering, redness and decreased vision in
both eyes. She was using topical prednisolone acetate (1%)
once daily and polyvinyl alcohol (1.4%) six times a day in
the left eye. Her visual acuity had reduced from 6/15 to 6/
36. The tarsal conjunctiva of the left upper lid showed severe
papillary reaction (Figure 2a). The bulbar conjunctiva was
injected. The graft showed an oval area of epithelial defect at
the 12 o clock position near the graft host junction
measuring 2.5 x 1.2 mm in size (Figure 2b). The margins of
the defect were elevated and the ulcer bed was transparent.
The surrounding cornea showed multiple punctate epithelial
erosions. Corneal scraping from the base of the ulcer showed
plenty of eosinophils but no organisms.
She was diagnosed with reactivation of VKC with shield
ulcer involving the graft. She was prescribed bandage
contact lens (BCL) and topical fluorometholone (0.25%) six
times a day, sodium chromoglycate (2%) four times a day
and polyvinyl alcohol (1.4%) six times a day. Initially the
shield ulcer regressed though it recurred at the same site
after 2 months and subsequently after 4 months. At the last
follow-up (20 months) her best-corrected visual acuity was
6/15, intraocular pressure was 14 mmHg, and the graft was
clear except for the scar at the site of shield ulcer.
Discussion
VKC generally is a benign and self-limiting condition,
but has the potential to produce serious complications.
In addition to the complications associated with
longterm corticosteroid use, recurrent or persistent
epitheliopathy and shield ulcer may result in corneal
scarring, vascularisation, sterile stromal melt and even
corneal perforation.2 This may also predispose the
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