INTRODUCTION

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 The uvea also called the uveal layer; uveal coat, uveal tract, vascular
tunic or vascular layer is the vascular, pigmented middle of the three concentric layers
that make up an eye. It has three segments: iris, ciliary body, and choroid. In general,
uveitis is the inflammation of uveal tissue secondary to a vast range of etiological
agents.1 Uveitis is a major cause of preventable blindness and majority of affected age
group is in 3rd and 4th decade.2-5

Uveitis is classified by standardization of uveitis nomenclature (SUN) working

group based on anatomical location into anterior uveitis, intermediate uveitis, posterior
uveitis and panuveitis. Based on clinical course it is classified as acute, chronic or
recurrent.6

Uveitis is a relatively common eye disease and one of the important causes for
visual impairment throughout the world. Uveitis is a major cause of visual morbidity
worldwide in working age group.7 Currently, uveitis is the third major cause of blindness
in United States.8

The incidence of blindness due to uveitis in developed countries is in the range of

3% to 10%. The incidence of blindness due to uveitis in the United States mainly from
California is 10% whereas in Europe it is in the range of 3% to 7%.9 Uveitis and its
complications such as secondary cataract, glaucoma, cystoid macular edema, retinal
photoreceptor or optic nerve damage are responsible for 25% of total blindness in India
and developing countries.10

Etiological differences of uveitis can play a significant role in causing blindness

in developing countries. According to various studies the etiology of uveitis varies for
different age groups, gender, geographical areas, socio-economic conditions and races.
Genetic and ethnic factors also contribute to pattern of uveitis.11

Some infectious diseases are endemic in their geographical area. In developing

countries the etiological pattern of uveitis is prone for infectious etiology where as in
developed countries for non-infectious conditions. In north India, tuberculosis was the
most common cause of infectious uveitis.2,12In south India, idiopathic etiology was found
to be most common cause.13In western India tuberculosis again was the most common

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cause of infectious uveitis.5 In north east India, idiopathic etiology was most common
cause of anterior uveitis.3 In Bangladesh, Vogt Koyanagi Harada syndrome was found to
be the most common cause of non-infectious uveitis.14 In New Zealand,HLA-B27
associated disease was the most common cause of anterior uveitis.15With time, clinical
pattern of uveitis trends has also show changes that might be because of increasing
migratory fluxes, changing life style, and environmental factors. A study by Biswas J et
al. found that HLA-B27 associated uveitis had increased while trend of toxoplasmosis
had decreased in present era associated with overall increased in tubercular uveitis. 16
Wakabayashi T et al. in their study had also found similar increase in trend of
tuberculosis where as trend of behcet‟s disease had shown decline.17

The systemic association of uveitis is well known. A study by Rothova et al.

noted 25% of cases of uveitis were systemically co-related with certain diseases like
tuberculosis, sarcoidosis, and ankylosing spondylitis.18 Eye can be mirror of systemic
disease without any sign of inflammation or systemic problem in an individual. A case
report by Parchand SM et al found choroidal mass can be presenting feature of
disseminated tuberculosis.19 Hence it is important that all the patients with uveitis should
undergo systemic evaluation.

Numerous studies had been carried out in different geographical parts in India.2, 13,3,

5
Within India, there is large variation in climatic condition, lifestyle, eating habits,
development status of region, referral patterns, customs and traditions. There are various
reports on pattern of uveitis from north and south India showing different trends but none
from central India. Ours is tertiary referral institute for uveitis located in Central India.
Also most of the previous studies in literature are retrospective studies. So, this
prospective study was designed to evaluate the demographic and pattern of uveitis in
Central India in a tertiary eye care institute.

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REVIEW OF LITERATURE

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 Articles were searched in PubMed for references upto April 2019 using following
keywords: uveitis, pattern, epidemiology, demography etc. Other relevant references
from articles thus obtained were also accessed. Standard text included as per requirement.
The articles in language other than English are not included.

Demography and patterns of uveitis in world:

Wakabayashi et al. in a retrospective study examined 189 cases enrolled from

April 1999 to march 2001. Women (55.02%) were more commonly affected than men
(44.97%). Mean age of uveitis affecting patients was 45 years. In laterality, bilateral
disease (59.3%) was more common compare to unilateral disease (40.7%). They found
posterior uveitis (31.2%) was most common, followed by panuveitis (30.7%), anterior
uveitis (29.6%), intermediate uveitis (6.9%) and papillitis (1.6%). They found vogt
koyanagi harada syndrome (10.1%) as most common cause of posterior uveitis followed
by sarcoidosis (9.5%). They noticed decrease incidence of behcet‟s disease (5.8%) and
increase frequency of ocular tuberculosis (6.9%).17

A retrospective study by P Yang et al. included 1752 patients. Males were more
commonly affected than females. They found anterior uveitis was most common (45.6%),
followed by panuveitis (41.5%), posterior uveitis (6.8%), and intermediate uveitis (6.1%).
Idiopathic anterior uveitis was the most common entity (27.0%). Behcet‟s disease
(16.5%) and Vogt Koyanagi Harada (VKH) syndrome (15.9%) were the predominant
cause of panuveitis.20

In a retrospective study, Khairallah M et al. included 472 patients of uveitis. Third decade
population was more commonly affected. Males were more commonly affected than
females. In laterality, unilateral disease (59.7%) was more common compare to bilateral
disease (40.3%). Anterior uveitis was most common (35.2%), followed by posterior
uveitis (28.2%), panuveitis (21.2%) and intermediate uveitis (15.5%).
Herpetic uveitis was the most common cause of anterior uveitis (33.7%). The cause of
posterior uveitis was toxoplasmosis (38.3%). Intermediate uveitis was most commonly
idiopathic (86.3%) in nature. The cause of panuveitis was Behçet's disease (36%)
followed by Vogt Koyanagi Harada (VKH) disease (15%).21

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 A cross sectional population based study published by Suhler EB et al. reported
the incidence and prevalence of uveitis. They found a crude incidence of 25.6/100,000
person-years and crude prevalence of 69 cases/100,000 persons. In their study, they
found uveitis was more prevalent in the younger age groups (45 to 64 years). Anterior
uveitis was more common than other uveitis. Idiopathic type was found to be most
common cause of uveitis in half of the cases followed by HLA-B27 related diseases.22

Rahman Z et al. in a retrospective study analyzed all uveitis cases visiting uveitis
clinic of Bangladesh eye hospital. They found males (52.2%) were more commonly
affected as compared to females (47.8%). Third decade population were more commonly
affected by uveitis. Unilateral disease (57.4%) was more common than bilateral disease
(42.6%).The prevalence of anterior uveitis (39.2%) was most common, followed by
intermediate uveitis (22.2%), posterior uveitis (22%) and panuveitis (16.4%).
Tuberculosis was most common cause of infectious uveitis while HLA-B27 and Vogt
Koyanagi Harada syndrome was most common cause of non-infectious uveitis.14

Again in another retrospective study from Srilanka, Siak J et al examined 750

patients of uveitis. Prevalence of anterior uveitis was 38%, posterior uveitis 25%,
intermediate uveitis 20% and panuveitis was 17%. They found 65% cases of uveitis were
idiopathic. Seronegative-spondyloarthopathy (13%) was common etiology of anterior
uveitis. Toxoplasmosis (18%) was common etiology of posterior uveitis whereas
sarcoidosis (14%) was common etiology of panuveitis. In children idiopathic
intermediate uveitis was the most common presentation..23

Wong A et al. published a retrospective study showing pattern of uveitis in New

Zealand. They included 1260 patients of uveitis among which 70.3% had anterior uveitis.
HLA-B27 associated disease was the most common cause of anterior uveitis. The
common cause of posterior uveitis and panuveitis was toxoplasmosis and sarcoidosis,
respectively. They also found more prevalence of herpetic anterior uveitis and drug
induced uveitis in patients above 60 years of age.15

Luca C et al. in a retrospective study examined 990 cases of uveitis at tertiary

referral center of North Italy. Females (59%) were more commonly affected then males

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with a median age of 44 years. Anterior uveitis was most common (53.5%), followed by
panuveitis (22.8%), posterior (16.2%) and intermediate uveitis (5.5%). Granulomatous
form was more prevalent in anterior and panuveitis. Anterior herpetic uveitis (15.6%)
was most common specific diagnosis followed by Fuchs uveitis (9.7%) and HLA-B27
positive anterior uveitis (7.7%).Infectious uveitis was found in 30% of cases, most due to
HSV (51%) followed by tuberculosis (19%) and toxoplasmosis (16%).24

A cross sectional retrospective study published by Hosseini SM et al. reported pattern of

uveitis. They examined 235 patients of uveitis of which females (60%) were more
commonly affected then males (40%). Third decade population was more commonly
affected. Bilateral disease (64%) was more common than unilateral disease (36%).
Non‑ granulomatous (76%) type of inflammation was predominant. The prevalence of
Panuveitis (46.8%) was most common, followed by anterior (37%), intermediate (11.9%)
and posterior uveitis (4.25%). They found idiopathic etiology in anterior 27.5% and
intermediate uveitis 60.7%. Toxoplasmosis (30%) was common etiology of posterior
uveitis whereas Behçet (22.72%) and Vogt‑ Koyanagi‑ Harada diseases (22.72%) was
common etiology of panuveitis. Noninfectious etiology found in 80.42% of patients. Out
of which anterior uveitis was 82.75%, panuveitis was 78.18%, intermediate uveitis was
92.85% and posterior uveitis was 50%. Behcet disease was most commonly associated
systemic disease.25

Demography and patterns of uveitis in India:

In one of the earliest study from India done between 1992 and 1994, Biswas J et
al. reported the pattern of uveitis in 1,273 uveitis cases. They found that 4th decade was
most commonly affected age group while incidence of uveitis was less below 10 yrs old
age and over 60 yrs of age. Males (62.21%) were more affected than females (37.79%).
The reported prevalence of anterior uveitis was 39.28%, posterior uveitis 28.75%,
intermediate uveitis 17.44 % and panuveitis 14.53%. Idiopathic type (59.31%) was the
most common type of uveitis. Anterior uveitis was most commonly idiopathic (58.6%).
Toxoplasmosis was the most common cause of posterior uveitis whereas most common
cause of panuveitis was Vogt Koyanagi Harada syndrome (21.08%).13

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 A study by Rathinam S R et al. found that the incidence of uveitis was 0.8%. Out
of 9378 patients of uveitis, 619 patients were excluded from study because they were
unable to attend the follow up visits. They found that the mean age of patients affected
with uveitis was 36.5 yrs. Males (62.2%) were more commonly affected than females
(37.8%). Anterior uveitis (57.4%) was more common type of uveitis followed by diffuse
uveitis (22.4%), posterior uveitis (10.6%) and intermediate uveitis (9.5%). Idiopathic
type (44.6%) was the most common type of uveitis followed by infectious (30.5%) and
non-infectious (24.9%), respectively. In infectious etiology, leptospirosis (9.7%) found to
be most common cause of uveitis followed by tuberculosis (5.6%) and herpetic disorders
(4.9%). In pediatric age group, parasitic anterior chamber granuloma (49.3%) found to be
most common cause of uveitis, while in elderly, herpetic anterior uveitis (16.7%) was
most common. Intermediate uveitis was more commonly idiopathic in all age groups. In
posterior uveitis, toxoplasmosis was the most common cause in all age groups.11

A retrospective study from north India by Singh R et al. included 1233 patients,
out of which 51.98% were males and 48.01% were females. In this study, anterior uveitis
was seen in 49.23%, followed by posterior uveitis (20.23%), intermediate uveitis
(16.06%) and panuveitis (14.68%). Etiology of uveitis was identified in 48.82%.
Tuberculosis followed by toxoplasmosis was found as the most common cause of
infectious uveitis. Most common cause of non-infectious uveitis was ankylosing
spondylitis followed by serpiginouschoroidopathy.12

In a retrospective study, Sabhapandit S et a.l reported the epidemiology of uveitis

in two urban centers in south India. They examined 1123 patients with uveitis in 2014.
They found 48.9% cases had anterior uveitis, 20.5% cases posterior uveitis, 17.3% cases
intermediate uveitis and 13.3% patients had panuveitis. The most common cause of non
infectious uveitis was idiopathic and that of infectious uveitis was tuberculosis. Pediatric
uveitis was seen in 6.9% cases and toxoplasmosis was more common etiology.26

In another retrospective study, Das D et al. examined 308 patients of uveitis to

analyze the pattern of uveitis in northeast India. In this study, patients in 3rd decade were
most commonly affected. The ratio of males (67.85 %) was higher than females
(32.14%). The prevalence of anterior uveitis was 47.07%, posterior uveitis 29.87%,

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intermediate uveitis 12.98% and panuveitis was 10.06%. The most common etiology of
anterior uveitis was idiopathic (45.51%) and toxoplasmosis (40.21%) was the most
common cause of posterior uveitis.3

In a prospective prevalence study at tertiary eye care institute in India, Venkatesh

P et al. included 980 patients with uveitis. They found 42.14% patients had anterior
uveitis, 16.83% had posterior uveitis, 13.36% had intermediate uveitis, 9.2% had
panuveitis and 4.7% had retinal vasculitis. Etiology was identified in 23% cases and
infectious uveitis constituted 9% of all cases. Tuberculosis (5%) was the most common
cause of infectious uveitis whereas ankylosing spondylitis followed by sarcoidosis and
juvenile rheumatoid arthritis were common causes of non-infectious uveitis. Amongst
known uveitic syndrome, serpiginous like choroiditis was the most common diagnosis
followed by APMPPE and Fuch‟s heterochromic uveitis.4

Recently, Dogra M et al. published a large retrospective study on epidemiology of

uveitis in tertiary care referral institute of north India. They evaluated 1912 patient with
uveitis. Uveitis was unilateral in 57.47% and bilateral in 42.52%. A total of 1125 patient
had persistent uveitis whereas 787 patients had bilateral uveitis. Authors found anterior
uveitis in 43.04 % of cases, posterior uveitis in 24.58 %, panuveitis 16.21% and
intermediate uveitis in 10.66 % of cases. Idiopathic (60.56%) form of uveitis was most
common. Tuberculosis (22.9%) was the more common cause of infectious uveitis and
HLA-B 27 (9.46%) was most common cause of non-infectious uveitis. Juvenile
idiopathic arthritis was most common cause in children.2

A study by Palsule AC et al. examined 198 patients out of which females (55.6%)
were more commonly affected than males (44.4%). Unilateral disease (48.5%) was more
common than bilateral disease (51.5%). Sixty-three percentage of patients had acute
onset, 22.7% had chronic onset and 14.1% had recurrent onset. The reported prevalence
of anterior uveitis was 41.4%, panuveitis was 21.2%, posterior uveitis was 20.7% and
intermediate uveitis was 16.7%. Tuberculosis (52.7%) was most common cause of
infectious uveitis and HLA-B27 (53.3%) followed by Vogt Koyanagi Harada syndrome
(13.3%) was most common cause of non-infectious uveitis.5

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Changing pattern of uveitis in India:

A study conducted by Biswas J et al., to compare the changing pattern between

uveitis patients of 2013 and 1995. They found that prevalence of anterior uveitis was
common in both study but the prevalence of intermediate uveitis was more common
instead of posterior uveitis. They observed a sharp and significant decline in the
idiopathic cause of uveitis from 58.7% in the past to 33.8% in present study. HLA-B27
associated significant change in anterior uveitis was seen in the present study as
compared to past study (30% vs. 14.5%). They also reported increased prevalence of TB
in the present era (22.5% vs. 0.64%).16

Das D et al. studied uveitic pattern in 2012 and compared with their previous
study in 2005 and reported change in the pattern of uveitis. They recognized an increase
of HLA-B27 associated anterior uveitis in present study from past study (40.85% vs.
23.44%). Tuberculosis associated intermediate uveitis showed significant change in 2012
(20.98% vs. 10%). In posterior uveitis, tubercular cases (37.5%) increased while
toxoplasmosis cases (14.28%) decreased in present study. In panuveitis, VKH cases
showed a decreasing trend in present study (15.62%) compared to past study (45.16%).27

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AIM AND OBJECTIVES

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AIM: The aim is to study demographic and clinical patterns of uveitis in tertiary eye care
institute of central India.

OBJECTIVES:

Primary objective: To identify demographic profile and clinical patterns of uveitis in

tertiary eye care institute of central India.

Secondary objective: To compare the similarities and differences in the distribution of

uveitis entities with that of other studies.

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MATERIAL AND METHODS

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STUDY AREA: The setting of the study was the outpatient department of MGM Eye
Institute (MGMEI), Raipur (Chhattisgarh).

STUDY POPULATION: All new patients diagnosed with uveitis presenting to the out-
patient department of the institute during the study period.

SAMPLE SIZE: Considering the incidence of 1.3% calculated sample size was 20
patients.2 So with the sample size of 20 the current study was not feasible. Hence, we
reviewed the data of fresh uveitis patients in MGMEI for last 3 years (Table 1).

Table 1 – Fresh cases of uveitis in the institute according to year

YEAR TOTAL PATIENTS NUMBER OF NEW

UVEITIS PATIENTS
2015 15,296 202
2016 16,682 216
2017 18,171 203

Taking an average of last 3 years patients, sample size was calculated to be 207. As study
duration period was of 10 months, estimated sample size was 173.

STUDY DESIGN: Prospective observational study.

STUDY DURATION: July 2018 to April 2019.

INCLUSION CRITERIA: All new cases diagnosed with uveitis presenting to the out-
patient department of the institute were included in the study.

EXCLUSION CRITERIA:

1. The patient who lost to follow up

2. Uveitis secondary to:
 Endophthalmitis
 Uveitis following trauma

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  Intraocular surgery
 Corneal ulcer
 Lens induced uveitis
 Episcleritis
 Scleritis
METHODOLOGY:

After detailed clinical history taking and ocular examination, patients of uveitis
who had fulfilled the inclusion criteria were selected for study purpose. Informed consent
in the language familiar to the subject was obtained on the Patient Information Sheet
(Annexure IA) and Informed Consent Form (Annexure IB) after explaining about the
study and examination protocol.

Parameters that were included in study were age, gender, visual acuity, systemic
symptoms and associated systemic disease of the patients along with anatomical location
of the inflammation and final diagnosis. Single examiner took detailed history, performed
thorough ocular examination and reviewed all the investigations.

Visual acuity: Best corrected distance visual acuity was assessed by LogMAR
visual acuity chart available in both English and illiterate E chart. Near visual acuity was
assessed by Roman test type or reduced Snellen‟s chart at 33 cm distance. Pre-verbal
children were assessed by response to light (blink to lights); their ability to fix, follow
and maintain central and steady fixation. Preschool children were assessed by Lea
Symbols chart.

Slit lamp biomicroscopy (HAAG STREIT®, BM 900 USA) was done in all cases
of uveitis to know the extent of anterior segment inflammation. Anterior chamber
reaction including cells and flare were assessed using SUN working group classification
using a 1×1 mm high power beam at full intensity at 45o – 60o angle in dark room.6
(Table 2)(Table 3).

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Table 2 - The SUN working group grading scheme for anterior chamber cells

Grade Cells in field

0 <1
0.5+ 1-5
1+ 6-15
2+ 16-25
3+ 26-50
4+ >50

Table 3 - The SUN working group grading scheme for anterior chamber flare

Grade Description
0 None
1+ Faint
2+ Moderate (iris and lens details clear)
3+ Marked (iris and lens details hazy)
4+ Intense (fibrin or plasmoid aqueous)

Intraocular pressure with Goldmann applanation tonometry (HAAG STREIT ®,

AT 900, USA) was performed in all cases. Posterior segment evaluation was done by slit
lamp using 90 diopter (D) (VOLK® - USA) or indirect ophthalmoscope (HEINE
OMEGA 500® DUBLIN, GERMANY) using 20 D (VOLK® - USA). Uveitis was
classified according to standardization of uveitis nomenclature (SUN) working group
classification based on anatomical location of the inflammation and also disease
description.6

Uveitis was called anterior when it involves anterior chamber (AC) and it includes
iritis, iridocyclitis, and anterior cyclitis. It was called intermediate when vitreous is the
primary site of involvement and it includes pars planitis, posterior cyclitis, hyalitis. It was

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called posterior when retina and choroid is the primary site of inflammation, and it
includes focal, multifocal, or diffuse choroiditis, chorioretinitis, retinochoroiditis,
retinitis, and neuroretinitis. In panuveitis, inflammation is diffuse involving anterior
chamber, vitreous and retina and/or choroid.6

Base on onset: Uveitis was labeled as sudden or insidious in onset. Duration of

uveitis was further classified as limited (≤3month) or persistent (>3 month).6 Acute
uveitis was defined as sudden onset of intraocular inflammation which last for less than 3
month. Chronic uveitis was defined when uveitis was persistent with relapse in <3
months after discontinuing treatment. Recurrent uveitis was defined as repeated episodes
separated by periods of inactivity without treatment for ≥3 months duration.6

Pathologically, it was classified as granulomatous or non-granulomatous. Uveitis

was labeled as granulomatous if they showed large, greasy „mutton fat‟ keratic
precipitates (KPs) on corneal endothelium, dense posterior synechiae, koeppe nodules
(present on pupillary border) or busacca nodules (present on peripheral part of the
anterior surface of the iris) or choroidal granulomas. Uveitis was labeled as non-
graulomatous uveitis if fine KPs were present with considerable flare and cells in the
AC.6 If none of the above sign present then uveitis was labeled as undetermined type.
The unilateral or bilateral type of uveitis was also recorded.

Ancillary tests like B-scan ultrasonography (SONOMED ESCALON®, VuMAX,

U.S.A.), posterior segment optical coherence tomography (OCT) (CARL ZEISS ®,
CIRRUS HD OCT 500, GERMANY), fundus fluorescein angiography (FFA) (CARL
ZEISS VISULAS®, FF450PLUS GERMANY) were perform whenever requires for
diagnosis and management of disease. For each case naming-meshing system was done
to arrive at differential diagnosis. Subsequently, tailored laboratory
investigations were done to determine the underlying etiology of uveitis. All new patients
who were diagnosed as case of uveitis were subjected to basic investigations such as
complete blood count (CBC), erythrocyte sedimentation rate (ESR), human
immunodeficiency virus I and II (HIV I and II), treponema pallidum haemagglutination
test (TPHA) or venereal disease research laboratory test (VDRL) and X-ray chest
postero-anterior view. If the anterior uveitis was of granulomatous type, patients

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subjected to test like Mantoux test and serum angiotensin converting enzyme (ACE). If
the anterior uveitis was of non-granulomatous type, investigations such as human
leucocyte antigen (HLA) B27, rheumatoid factor (RA factor), anti-nuclear antibodies
(ANA), anti-nuclear cytoplasmic antibodies (ANCA) and X-ray sacroiliac joint antero-
posterior view. If patients were diagnosed as case of intermediate uveitis, he was advised
Mantoux test, serum ACE level and VDRL. In patients of retinitis, HIV I and II,
toxoplasma serology and viral serology was advised. Mantoux test and serum ACE level
were advised in patients of choroiditis and vasculitis. Patients with features suggestive of
neuroretinitis were subjected to Bartonella and Lyme serology. Quantiferon gold TB was
advised as per discretion of treating ophthalmologist on case to case basis. Magnetic
Resonance imaging (MRI) of brain and orbit and computerized tomography (CT) of chest
were done as supportive evidence towards making an association between uveitis and
suspected initial systemic pathology. Patients were referred to concerned medical
specialist whenever needed. When the diagnostic procedure was completed, the patients
were classified as infectious or non-infectious. When the extensive work up failed to
establish the diagnosis, uveitis of idiopathic type was considered.

Here, we had briefly illustrated our approach for making specific diagnoses.

1. HLA-B27 positive anterior uveitis: when patient presents with acute non-
granulomatous relapsing anterior uveitis, and typed for the presence of the HLA-
B27, regardless of the presence of systemic disease. All cases of HLA-B27
positive uveitis were further evaluated by radiology and rheumatology
departments to rule out any underlying sero-negative spondyloarthropathy as per
current rheumatologic criteria.29
2. Juvenile idiopathic arthritis (JIA) associated with uveitis: young adults or
adolescents with chronic bilateral anterior uveitis that remained active for several
years.30
3. The diagnosis of herpetic anterior uveitis was based on suggestive clinical
features: positive history for HSV keratitis, clinical observation of corneal
sensation depression, stromal keratitis, high intraocular pressure, and iris
atrophy.31

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4. The diagnosis of Fuchs heterochromic uveitis was based on finding of unilateral,
presentation involving the anterior segment and the vitreous, diffusely scattered
stellate keratic precipitates, iris stromal atrophy/heterochromia, absence of
macular edema, and the lack of synechiae.32
5. The diagnosis of ocular toxoplasmosis was mostly clinical and presentation of
yellowish white retinochoroiditis lesion with overlying vitritis (head-light in fog
appearance) with or without associated healed pigmented lesion. If any doubt it
toxoplasma serology was performed.33
6. The diagnosis of presumed sarcoidosis was made on presence of clinical findings
with two of the following three diagnostic criteria: elevated angiotensin
converting enzyme or lysozyme, cutaneous anergy, and/or with positive chest
tomography.34
7. The diagnosis of pars planitis (PP) was established in children or adolescents with
idiopathic, chronic, bilateral intermediate uveitis where there were snow balls
and/or snowbank formation.6
8. The diagnosis of behcet‟s disease was made in patients fulfilling the diagnostic
criteria of the International Study Group for Behcet‟s disease.34
9. The diagnosis of Presumed ocular tuberculosis was diagnosed based on
clinical signs of granulomatous uveitis, iris nodules, broad based posterior
synechiae, intermediate uveitis, choroidal tubercles; serpiginous like
chorioditis and retinal vasculitis. Diagnosis was made if one or more of
these signs were present along with positive Mantoux test or positive
QuantiFERON Gold test, evidence of old healed pulmonary tuberculosis.35
10. The diagnosis of Eales disease was established in young males with recurrent,
unilateral peripheral retinal perivasculitis, retinal and vitreous hemorrhage, and
subsequent involvement of sound eye.36
11. Vogt Koyanagi Harada (VKH) disease was diagnosed based on revised diagnostic
criteria for Vogt Koyanagi Harada disease based on report of an International
37
committee on Nomenclature.
12. Syphilis: Diagnosis was based on clinical findings of uveitis and positive
VDRL/TPHA test.38

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 13. Acute retinal necrosis was diagnosed based on American Uveitis society criteria
for diagnosis of acute retinal necrosis (ARN) syndrome.39
14.
DATA COLLECTION METHOD:

All the findings obtained during clinical history, examination and associated
laboratory investigations as per the protocol enumerated above was entered in a Data
Collection software (Annexure II) and then transferred to Microsoft Excel® Spreadsheet
for statistical analysis.

STATISTICAL ANALYSIS:

Sample size calculation has already been described above. The statistical analysis
was performed by using SPSS 16.0 software. Descriptive statistic was used for age and
duration. To compare visual acuity amongst anatomical location, we used one way
ANOVA. Chi square test was used to see association of anatomical location with age,
sex, occupation, chronology, laterality, severity, pathology, pattern and etiology.
Differences was considered to be statistically significant at the 5% level.

ETHICAL CONSIDERATIONS:

This research protocol has been submitted to the Scientific Committee of the
Institute and after obtaining its approval, was submitted to the Ethics Committee. This
protocol has obtained approval from the Ethics Committee of MGM Eye Institute and all
human subjects included in the study were treated under the tenets of the Declaration of
Helsinki.

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RESULT

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 During the study period (July 2018–April 2019), 15,342 fresh patients visited our
tertiary care eye institute. Of these fresh patients, 202 patients were diagnosed as a case
of uveitis. Out of 202 patients 174 patients fulfilled inclusion criteria and were included
in study for further analysis (Figure 1). The incidence of uveitis in our hospital was
1.13%. Amongst patients of uveitis the mean age at presentation was 40.66 ± 14.85 years
(range 7-83 years) of which 92 (52-9%) were male and 82 (47.1%) were females. Eight
patients (4.6%) were of pediatric group (< 16 years) with mean age of 13.25 ± 2.7 years
(range 7 to 16) and 16 patient (9.2%) were elderly age group (>60 years) with mean age
69.44 ± 14.85 years (range 60 to 83).

Total number of fresh patients

visited the hospital (n=15,342)

New patients of uveitis (n=202)

Included patients (n=174) Excluded patients (n=28)

Lost to follow up (n=17)

Intraocular surgery (n=3)

Traumatic
Endophthalmitis (n=3)

Lens induced uveitis

(n=2)

Episcleritis (n=2)

Scleritis (n=1)

Endogenous
Endophthalmitis (n=1)

Figure 1 Flow chart showing study

population

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22
 Maximum number of patients belonged to middle age group (17-59 year) with
mean age of 39.05 ± 10.8 years (range 17 to 59). However, on comparing different
anatomical diagnoses according to age groups, no significant difference in distribution of
pattern of anatomical involvement of uveitis was found (P = 0.678, Chi-square test).
Uveitis was more in urban (95 patients, 54.6%) than rural population (79 patients,
45.4%). This difference was statistically significant (P = 0.045, Chi square test).

Symptomatology:

Most common symptoms among patients presenting with uveitis was blurred
vision (113 patients). Other symptoms were redness in 96 patients (55.17%), pain in 89
patients (54.14%), watering in 27 patients (15.51%), photophobia in 20 patients (11.49%)
and floaters in 13 patients (7.47%) (Figure 2).

Figure 2 – Symptomatology of uveitis

120 113
96
100 89
Number pf patients

80

60

40
27
20 Symptoms
20 13

Symptoms

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23
Anatomical diagnosis:

According to anatomical location, 117 (67.2%) had anterior uveitis, 25 (14.4%)

had posterior uveitis, 24 (13.8%) had intermediate uveitis and 8 (4.6%) had panuveitis
(Figure 3).

Figure 3 –Anatomical distribution of uveitis

Incidence of uveitis - Anatomical location

5%

14%

Anterior (n=117)
Intermediate (n=24)
14% Posterior (n=25)
Panuveitis (n=8)
67%

Etiological diagnosis:

Out of all uveitis patients definite etiological correlation could be made out in 80
patients (45.97) while rest 94 patients (54.02%) were labeled as idiopathic. Patients who
had specific diagnosis were further classified as non-infectious and infectious. Among
non-infectious diagnosis, 24 patients were HLA B27 positive, 8 had Fuchs uveitis, 4 had
Sarcoidosis, 3 had Vogt koyanagi harada‟s (VKH) disease, and 1 had sympathetic
ophthalmia. Infectious etiology was identified in 39 patients (22.41%). Among infectious
etiology, 28 patients were diagnosed with Presumed intraocular tuberculosis, 4 with
Ocular Toxoplasmosis, 2 patients each with Hansens disease and herpetic uveitis and 1
patient each with syphilis, acute retinal necrosis and cytomegalovirus. Two patients were
diagnosed as cases of Acquired Immunodeficiency Syndrome (AIDS).

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24
 Systemic symptoms were present in 19 patients (10.91 %). Amongst systemic
complaints, back pain (11 patients), was most frequently reported symptom followed by
peripheral joint pain (9 patients), skin lesions (2 patients) and oral ulcer (1 patient).

Anterior uveitis:

Anterior uveitis was present in 117 (67.2%) patients; of which 63 (53.8%)

patients were male and 54 (46.2%) patients were females. Mean age was 40.79 years,
range (7 to 83 years). Redness was the most common presenting feature of anterior
uveitis in 85 (72.6%) patients followed by pain in 75 (64.1%) patient, blurred vision in 67
(57.3%) patients, watering in 26 (22.2%) patients, photophobia in 18 (15.3%) patients
and floaters in 3 (2.5%) patients (Table 5). Ninety five (81.2%) patient had unilateral
disease while 22 (18.8%) patient had bilateral presentation (Figure 4). Onset of uveitis
was sudden in 94 (80.34%) patients whereas it was insidious in 23 (19.65%) patients.
Duration was limited in 98 patients (83.76%) whereas it was persistent in 19 patients
(16.23%). Course of disease was acute in 81 (69.2%) patients, acute recurrent in 19
(16.23%) patients and chronic in 17 (14.52%) patients. Anterior uveitis was non
granulomatous in 103 patients (88.0%) and granulomatous in 14 patients (12.0%) (Table
4). Seventy-one patients (60.7%) had idiopathic type of anterior uveitis. Non-infectious
association of anterior uveitis was found in 33 patients. Of non-infectious causes, 24
patients were HLA B27 positive and 8 patients had Fuchs uveitis. Infectious etiology was
found in 13 patients (11.1%). Of infectious etiology, 10 patients had presumed ocular
tuberculosis, 2 had herpes and 1 patient had Hansens disease (Figure 5). Best-corrected
mean visual acuity was 0.2668 ± 0.45 and IOP was 12.22 ± 4.80 mm Hg. At presentation,
anterior uveitis related ocular complications were noted in 49 eyes (35.25%). Thirty eight
eyes had cataract, 9 eyes had glaucoma, macular edema and epiretinal membrane in 1 eye
each (Table 6).

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 Table 4: Demography characteristic and etiology of study
population
parameters Total Anterior Intermediate Posterior Panuveitis P value
(n = 174) (n = 117) (n = 24) (n = 25) (n = 8)
N (%) N (%) N (%) N (%) N (%)
Age

Children (<16) 8 4.6 7 6.0 0 0 1 4.0 0 0 0.49

0.49
Middle age (17-59) 150 86.2 97 82.9 22 91.7 24 96.0 7 87.5

Elderly (>60) 16 9.2 13 11.1 2 8.3 0 0 1 12.5

Gender 0.16

Male 92 52.9 63 53.8 13 54.2 16 64.0 0 0 0.16

Female 82 47.1 54 46.2 11 45.8 9 36.0 8 100
Laterality 0.16

Unilateral 135 77.6 95 81.2 17 70.8 19 76.0 4 50.0 0.169

Bilateral 39 22.4 22 18.8 7 29.2 6 24.0 4 50.0
Onset

Sudden 136 78.16 94 80.34 15 62.5 20 80.0 7 87.5

0.237
Insidious 38 21.83 23 19.65 9 37.5 5 20.0 1 12.5
Duration 0.013

Limited 140 80.45 98 83.76 14 58.3 22 88.0 6 75.0

0.025
Persistent 34 19.54 19 16.23 10 41.7 3 12.0 2 25.0
Chronicity

Acute 119 68.39 81 69.2 9 37.5 22 88.0 7 87.5

<0.004
Acute recurrent 25 14.36 19 16.23 6 25.0 0 0 0 0
Chronic 30 17.24 17 14.52 9 37.5 3 12.0 1 12.5
Pathology

Non-granulomatous 117 67.2 103 88.0 7 29.2 4 16.0 3 37.5

<0.001
Granulomatous 21 12.1 14 12.0 0 0 2 8.0 5 62.5 <0.001
Not applicable 36 20.7 0 0 17 70.8 19 76.0 0 0
Etiology

Idiopathic 94 54.02 71 60.7 13 54.2 8 32.0 2 25.0

<0.001
Infectious 39 22.41 13 11.1 8 33.3 17 68.0 1 12.5
Non-infectious 41 23.57 33 28.2 3 12.5 0 0 5 62.5

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 Table 5 - Correlation of symptoms according to anatomical location

Symptoms Anterior Intermediate Posterior Panuveitis P

(n= 117) (n = 24) (n = 25) (n= 8) value
n (%) n (%) n (%) n (%)
Pain 75 64.1 5 20.8 4 16.0 3 37.5 <0.00
Redness 85 72.6 7 29.2 3 12.0 0 0 <0.00
Blurring of 67 57.3 20 83.3 17 68.0 8 100 <0.009
vision
Watering 26 22.2 0 0 1 4.0 0 0 <0.006
Photophobia 18 15.3 1 4.1 1 4.0 0 0 0.143
Floaters 3 2.5 4 16.6 5 20.0 1 12.5 <0.005

Figure 4 –Unilateral / bilateral presentation of uveitis

95
100
90
80
Number of cases

70
60
50
40
30 22 19
17
20 7 6 4 4
10
0
Anterior Intermediate Posterior Panuveitis

Anatomical location

Unilateral (n=135) Bilateral (n=39)

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27
Figure 5 –Etiological distribution of anterior uveitis

Etiology of anterior uveitis

2%

7%
9% Idiopathic
HLA B 27
Presumed ocular tuberculosis
21% Fuchs heterochromic uveits
61%
Others

Table 6 - Ocular complications related with anatomical location

Complication Number Anterior Intermediate Posterior Panuveitis

(eyes) (eyes) (eyes) (eyes) (eyes)
Cataract 44 38 4 2 0
Glaucoma 10 9 0 1 0
Macular edema 5 1 1 3 0
Foveal 3 0 1 2 0
thinning
Neurosensory 2 0 1 1 0
detachment
Epiretinal 2 1 1 0 0
membrane
Vitreomacular 1 0 0 1 0
traction
Disc oedema 12 0 4 4 4
NVE 1 0 0 1 0
Combined RD 1 0 0 1 0
RRD 1 0 0 1 0
Vitreous 1 0 1 1 0
hemorrhage
Total 84 49 13 18 4

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Intermediate uveitis:

Intermediate uveitis was present in 24 (13.8%) patients; of which 13 (54.2%)

patients were male and 11 (45.8.2%) patients were females. Mean age was 42.79±12.1
years, range (25 to 68 years). Blurred vision was the most common presenting feature of
intermediate uveitis in 20 (83.3%) patients followed by redness in 7 (29.2%) patient, pain
in 5 (20.8%) patients, floaters in 4 (16.6%) patients, and photophobia in 1 (4.1%) patients
(Table 5). Seventeen (70.8%) patients had unilateral disease while 7 (29.2%) patients had
bilateral presentation (Figure 4). Onset of uveitis was sudden in 15 (62.5%) patients
whereas it was insidious in 9 (37.5%) patients. Duration was limited in 14 patients
(58.3%) whereas it was persistent in 10 patients (41.7%). Course of disease was acute in
9 (37.5%) patients, acute recurrent in 6 (25%) patients and chronic in 9 (37.5%) patients
(Table 4).Thirteen (54.2%) had idiopathic type of intermediate uveitis. Infectious
etiology was found in 8 patients (33.3%). Of infectious etiology, 7 patients had presumed
intraocular tuberculosis, and 1 patient had syphilis. Non-infectious association of anterior
uveitis was found in 3 patients and all 3 patients had Sarcoidosis (Figure 6). Best-
corrected mean visual acuity was 0.38 ± 0.46 and IOP was 12.76 ± 7.81 mm Hg. At
presentation, intermediate uveitis related ocular complications were noted in 13 eyes
(41.93%). Four eyes had cataract, 4 eyes had disc edema, and macular edema, foveal
thinning, neurosensory detachment, vitreous hemorrhage and epiretinal membrane was
present in 1 eye each (Table 6).

Figure 6 –Etiological distribution of intermediate uveitis

Etiology of intermediate uveitis

4%
13% Idiopathic

Presumed ocular
tuberculosis
Sarcoidosis
54%
29%
Syphilis

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29
Posterior uveitis:

Posterior uveitis was present in 25 (14.4%) patients; of which 16 (64%) patients

were male and 9 (36%) patients were females. Mean age was 38.44±11.5 years, range (13
to 55). Blurred vision was the most common presenting feature of anterior uveitis in 17
(68%) patients followed by floaters in 5 (20%) patient, pain in 4 (16%) patients, redness
in 3 (12%) patients, watering in 1 (4%) patient and photophobia in 1 (4%) patient (Table
5). Nineteen (76%) patients had unilateral disease while 6 (24%) patients had bilateral
presentation (Figure 4). Onset of uveitis was sudden in 20 (80%) patients whereas it was
insidious in 5 (20%) patients. Duration was limited in 22 (88%) patients whereas it was
persistent in 3 (12%) patients. Course of disease was acute in 22 (88%) patients and
chronic in 3 (12%) patients. Two patients had associated granulomatous uveitis (Table 4).
Posterior uveitis was further classified according to morphological patterns that include
retinitis in 2 eyes, choroiditis in 11 eyes, retinochoroiditis in 4 eyes, vasculitis in 12 eyes,
neuroretinitis in 1 eye and subretinal abscess in 1 eye. Eight (32%) patient had idiopathic
type of posterior uveitis. Infectious etiology was found in 17 patients (68.0%). Of
infectious etiology, 11 patients had presumed ocular tuberculosis, 4 had ocular
toxoplasmosis and 1 patient had ARN disease and CMV retinitis each (Figure 7).
Morphological type and associated etiology is mentioned in Table 7. Best-corrected mean
visual acuity was 0.60 ± 0.77 and IOP was 12.60 ± 3.378 mm Hg. At presentation,
posterior uveitis related ocular complications were noted in 18 eyes (58.06%). Four eyes
had disc edema, 3 eyes had macular edema, 2 eyes had cataract, 2 eyes had foveal
thinning, and glaucoma, neuro-sensory detachment, vitreo-macular traction,
neovascularization elsewhere, combined retinal detachment, rhegmatogenous retinal
detachment and vitreous hemorrhage in 1 eye each (Table 6).

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Figure 7– Etiological distribution of posterior uveitis

Etiology of posterior uveitis

8.0%

16.0% Presumed ocular tuberculosis

44.0% Idiopathic
Toxoplasmosis
Others
32.0%

Table 7 –Morphological classification with etiology of posterior uveitis

Parameters Eyes (n=31) %

Retinitis 2 6.4
Acute retinal 1 3.2
necrosis
Cytomegalovirus 1 3.2
Choroiditis 11 35.48
Presumed ocular 8 25.8
tuberculosis
Idiopathic 3 9.6
Vasculitis 12 38.70
Idiopathic 7 22.5
Presumed ocular 5 16.1
tuberculosis
Retinochoroiditis 4 12.9
Toxoplasmosis 4 12.9
Neuroretinitis 1 3.2
Idiopathic 1 3.2
Others 1 3.2
Subretinal Presumed ocular 1 3.2
abscess tuberculosis

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31
Panuveitis

Panuveitis was present in 8 (4.6%) patients; of all were females. Mean age was
39.38± 19.1 years, range (17 to 70 years). Blurred vision was the most common
presenting feature of posterior uveitis in all patients followed by pain in 3 (37.5%)
patients, and floaters in 1 (12.5%) patient (Table 5). Four (50%) patients had unilateral
disease while 4 (50%) patients had bilateral presentation (Figure 4). Onset of uveitis was
sudden in 7 (87.5%) patients whereas it was insidious in 1 (12.5%) patients. Duration was
limited in 6 (75%) patients whereas it was persistent in 2 (25%) patients. Course of
disease was acute in 7 (87.5%) patients and chronic in 1 (12.5%) patient. Panuveitis was
granulomatous in 5 patients (62.5%) and non-granulomatous in 3 patients (37.5%) (Table
4).Non-infectious association of panuveitis was found in 5 (62.5%) patients. VKH was
seen in 3 patients, sympathetic ophthalmia in 1 patient and sarcoidosis in 1 patient.
Panuveitis in one patient was associated with Hansen‟s disease. Panuveitis was idiopathic
in 2 (25.0%) patients (Figure 8). Best-corrected mean visual acuity was 0.34 ± 0.44 and
IOP was 12.75 ± 3.69 mm Hg. At presentation, panuveitis related ocular complications
were noted in 4 eyes (33.3%) and all 4 eyes had disc edema (Table 6)

Figure 8– Etiological distribution of panuveitis

Etiology of Panuveitis

25% Vogt koyanaga harada

syndrome
37%
Idiopathic

Sympathetic ophthalmia
13%
Others

25%

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32
 Since in our study, we identified HLA B27 and Presumed ocular tuberculosis as
most common association of uveitis, we further analysed these subset of patient
individually.

HLA B 27 related uveitis:

HLA B27 related uveitis was seen in 24 patients. Middle age group population
17-59 years (23 patients, 95.8%) was most commonly affected. Female (13 patients,
54.2%) was affected more than male (11 patients, 45.8%). Unilateral cases (23 patients,
95.83%) were found more common with acute course (17 patients, 70.8%) of uveitis.
Pain (22 patients, 91.7%) and redness (23 patients, 95.8%) were most common symptoms
found in HLA B27 associated anterior uveitis. At presentation, mean best-corrected
visual acuity was 0.19 ± 0.47 and mean IOP was 12.12 ± 3.12 mm Hg (Table 8).

Table 8 – Demographic and symptoms of HLA B27 associated anterior

uveitis

Parameters Number (n) %

Age
Age < 16 yrs 1 4.2
Between 17 to 59 yrs 23 95.8
>60 yrs 0 0
Sex
Male 11 45.8
Female 13 54.2
Laterality
Unilateral 23 95.83
Bilateral 1 4.16
Best corrected visual acuity (mean) 0.19 ± 0.47
IOP (mean) 12.12 ± 3.12
Chronology
Acute 17 70.8
Acute recurrent 7 29.2
Chronic 0 0
Symptoms
Redness 23 95.8
Pain 22 91.7
Blurring of vision 13 54.2
Watering 10 41.66
Photophobia 6 25.0
Floaters 1 4.16

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Presumed Intraocular Tuberculosis:
Out of 174 patients, Mantoux test was advised in 97 patients. Presumed
intraocular tuberculosis was diagnosed in 28 patients. Mantoux test was positive in 28
patients. Of 28 patients, 4 were also positive for Quantiferon gold test (Table 9).

Table 9 - Demographic and clinical features of presumed ocular tuberculosis

Parameters Number (n) %

Age
Age < 16 yrs 1 3.57
Between 17 to 59 yrs 25 89.28
>60 yrs 2 7.14
Sex
Male 17 60.71
Female 11 39.28
Laterality
Unilateral 23 82.14
Bilateral 5 17.85
Best corrected visual acuity (mean) 0.44 ± 0.50
IOP (mean) 12.29 ± 4.46
Chronology
Acute 17 60.71
Acute recurrent 3 10.71
Chronic 8 28.57
Pathology
Nongranulomatous 11 39.28
Granulomatous 2 7.14
Not applicable 15 53.57
Anatomical
Anterior 10 35.71
Intermediate 7 25.0
Posterior 11 39.28
Panuveitis 0 0
Symptoms
Blurring of vision 16 57.14
Redness 11 39.28
Pain 6 21.42
Floaters 6 21.42
Photophobia 3 10.71
Watering 2 7.14
Mantoux positive 28 100
Quantiferon gold 4 14.28

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34
 Out of 28 patients, 25 patients (89.28%) were in middle age group (17 – 59 years
age). Males (17 patients, 60.71%) were most commonly affected. Unilateral uveitis was
common presentation in 82.14%. Best-corrected mean visual acuity was 0.44 ± 0.50. The
mean IOP was 12.29 ± 4.46 mm Hg. Floaters (21 patients, 75%), photophobia (20
patients, 71.42%), was most common presenting complaints.

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35
DISCUSSION

Page
36
 Uveitis is one of the major cause of vision loss in patient all around the globe
contributing to 10-25% of legal blindness.9 It is known from the literature that pattern of
uveitis not only vary among various countries but also within different regions within
same country. The variation in the spectrum of uveitis is largely due to complex
geographic, ecological, racial, nutritional and socioeconominc differences. Identifying
demography and clinical patterns of uveitis in particular region is important for optimal
management of patient. Our uveitis study population had fairly homogenous background;
all patients were Asian Indians and majority of them belonged to Central India. We
observe in our study that anterior uveitis is the most common subtype followed by
posterior uveitis, intermediate uveitis and at last panuveitis.

In the present study, most commonly affected age group was 17 - 59 years
(86.2%). This result was comparable with other studies done by Sabhapandit et al.26
(82.9%) and Dogra et al.2 (86.24%). In the age group 17 - 59 years incidence of anterior
uveitis (64.6%) was higher followed by posterior (16%) intermediate (14.6%), and
panuveitis (4.7%). According to Sabhapandit et al. anterior uveitis (47.51%) was most
common followed by posterior uveitis (21.10%), panuveitis (15.69%) and intermediate
uveitis (14.71%) in middle age group population.26 Another study by Dogra et al.
reported same incidence of anterior uveitis (41.54%), posterior uveitis (25.71%),
panuveitis (16.37%) and intermediate uveitis (10.30%) in similar age group.2 In children
and elderly group, incidence of uveitis was found to be 4.6% and 9.2%. This finding was
comparable with studies done by Dogra et al.2 (6.64% and 7.11%), Sabhapandit et al.26
(6.9% and 7.2 %) and Khairallah et al.21 (10% and 7.6%). In the present study, 6% of
anterior uveitis was found to be in children, which was comparable with Sabhapandit et
al.26 (5.2%) and Dogra et al.2 (7.53%). In present study, we found only 1 child having
posterior uveitis. Contrary to this finding Sabhapandit et al. reported 13.1% of children
having posterior uveitis.26 This difference could be due to higher percentage of
toxoplasmosis cases in the their study.

In the present study, males (52.9%) had higher incidence of uveitis than females
(47.1%), which was comparable with the study done by Dogra et al. (56.64% vs
43.36%).2 Contrary to this, higher incidence of uveitis in females were reported by

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37
Sabhapandit et al.26 (51.5%), Khairallah et al.21 (52.5%), Wakabyashi et al.17 (55.02%),
Palsule et al.5 (55.6%) and Luca et al.24 (59.0%). Khairallah et al.21 from Tunisia and
Wakabyashi et al.17 from Japan reported higher number of VKH cases in their study. This
could be the probable reason for uveitis to be higher in the females in these studies. One
of the possible reason for male predominance in our study could be due to fact that men
tends to seek more medical care as they are wage earners in a developing countries.

In terms of laterality, we found unilateral uveitis (77.6%) to be more common

than bilateral uveitis (22.4%). Dogra et al.2 (57.74%), Sabhapandit et al.26 (59.7%), and
Khairallah et al.21 (59.7%) had similar comparable results. This can be explained mainly
due to preponderance of anterior uveitis as the main anatomical category encountered in
most settings both in developing and developed countries. In the present study, acute
course of uveitis was found in 68.39% patients followed by chronic in 17.24% and acute
recurrent course in 14.36%. Palsule et al. reported acute course (63.1%) as most common
followed by chronic (22.7%) and acute recurrent (14.1%).5 Rathinam et al. reported
70.3% of uveitic patients having acute course followed by chronic (26.2%) and acute
recurrent (3.4%).11 Another study by Acharya et al. reported 43% uveitis patients
presenting with acute course disease followed by recurrent (26%) and chronic course
(25%), however, 5% of the cases could not be assessed.40 Contrary to this Khairalla et al.
reported more cases with Chronic uvetitis than acute uveitis.21 This is mainly due to large
number of patients presenting with herpetic uvetitis, Behcets disease and VKH disease in
their study.

In the current study, limited duration (81.6%) of uveitis was found to be more
common than persistent duration (18.4%). However, Dogra et al. reported persistent
duration (58.83%) as the most common presentation than limited duration (41.16%).2
This could be due to more patients having viral etiology that is known to have a chronic
course in study by Dogra et al. as compared to our study.2

In the present study, incidence of non-granulomatous uveitis (67.2%) was noted

to be higher than granulomatous uveitis (12.1%). Higher incidence of non-granulomatous
uveitis was also reported by Khairallah et al.21 (89%) and Hosseini et al.25 (76%). Luca et

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38
 al. found nearly equal incidence of non-granulomatous and granulomatous uveitis in their
study.24 Granulomatous uveitis was more common in panuveitis (62.5%) group and this
could be attributed to higher incidence of VKH, in the present study. Luca et al. found
granulomatous uveitis to be predominant in the anterior uveitis (57.24%) group, because
of higher number of herpetic uveitis cases.24

Blurred vision (64.94%) was most common symptoms associated with uveitis in
current study. Redness (55.17%), pain (54.14%), watering (15.51%), photophobia
(11.49%) followed by floaters (7.47%) were other symptoms of uveitis.

Distribution of uveitis according to anatomical location is given in table 10.

Table 10 - Distribution of uveitis according to anatomical location in various studies

Anatomica Dogra Sabhapan Palsule Khairallah Wakabayas Luca Present

l location et al. dit et al. et al. et al. (%) hi et al. (%) et al. study
(%) (%) (%) (%) (%)

Total cases 1912 1123 198 472 189 990 174

(n)

Anterior 43.04 48.44 41.4 35.2 29.6 53.5 67.24

Intermedia 10.66 15.04 16.7 15.5 6.9 7.5 13.80
te
Posterior 24.58 20.92 20.7 28.2 31.2 16.2 14.36
panuveitis 16.21 14.42 21.2 21.2 30.7 22.8 4.60

In the current study, the anatomical distribution of uveitis was consistent with studies
reported from other states in India. In most of the studies including present study, anterior
uveitis has been the most common type of uveitis. Although, the incidence of anterior
uveitis in our study (67.24%) was higher as compared to the studies done by Sabhapandit
et al.26 (43.04%) and Dogra et al.2 (48.44%). Greater incidence of panuveitis has been
reported from Japan17 (30.7%) and Tunisia21 (21.2%). In the same study from Japan,
higher incidence of posterior (31.2%) than anterior uveitis (29.6%) was reported.17
Higher prevalence of VKH, Sarcoidosis and Behcet‟s disease in Japan17 and Tunisia21
was responsible for more patients presenting with posterior and panuveitis.

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39
 Anterior uveitis (67.2%) was most common anatomical type of uveitis in the
current study. The most common underlying etiology found was idiopathic (60.7%)
followed by HLA B27 (20.51%) associated uveitis. Ramaneep et al.11 and Palsule et al.5
reported comparable incidence of idiopathic followed by HLA B27 associated uveitis.
However, Sabhapandit et al. reported idiopathic (41.5%) as common entity followed by
Fuchs heterochromic uveitis (14.7%).26 Study from the Tunisia by Khairallah et al.
reported higher incidence of idiopathic (35.5%) uveitis followed by herpetic uveitis
(33.7%).21 Contrary to this, Luca et al. reported herpetic uveitis (38.8%) as most common
cause of anterior uveitis followed by Fuchs heterochromic uveitis (23.9%).24

Posterior uveitis (14.4%) was second most common entity in the present study.
Presumed ocular tuberculosis (44.0%) was the most common underlying etiology
followed by idiopathic cause (32.0%). Sabhapandit et al. reported comparable incidence
of presumed ocular tuberculosis (34.3%) followed by idiopathic cause (32.5%).26
However, Palsule et al.5 and Wakabayashi et al.17 reported idiopathic cause were most
common followed by tuberculosis. Contrary to this, Luca et al. reported primary
inflammatory choriocapillaropathies (34.8%) were most common cause followed by
toxoplasosis (27.8%).24

In present study, idiopathic was most common cause of intermediate uveitis

(54.16 %) followed by presumed ocular tuberculosis (29.16%). Dogra et al. reported
similar incidence of idiopathic (44.61%) followed by presumed ocular tuberculosis
(43.14%).2 Sabhapandit et al.26 (39.3%), Rathinam et al.11 (81.6%), Khairallah et al.21
(86.3%) and Luca et al.24 (89.2%) reported idiopathic as most common etiology of
intermediate uveitis. Conflicting to this, Parchand et al. reported TB as most common
cause of intermediate uveitis.41 Wakabayashi et al. reported sarcoidosis (53.8%) as most
common cause of intermediate uveitis.17

We found lower incidence of panuveitis (4.6%) as compared to other Indian

studies. Sabhapandit et al.26 (14.42%), Dogra et al.2 (16.21%) and Palsule et al.5 (21.2%)
reported higher incidence of panuveitis compared to present study. In present study, VKH
(37.5%) followed by idiopathic (25.0%) was the most common cause of panuveitis

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40
 whereas Palsule et al.5 and Dogra et al.2 reported idiopathic followed by TB as the most
common cause of Panuveitis. Contrary to this, Sabhapandit et al. reported VKH and
Sarcoidosis to be the most common cause.26

The incidence of different etiology of uveitis is mentioned in table 11.

Etiology Dogra Sabhapandit Palsule Khairallah Wakabayashi Luca Present

et al. et al. (%) et al. et al. (%) et al. (%) et al. study
(%) (%) (%) (%)

Idiopathic 39.43 38.5 49.5 35.16 42.32 23.0 55.7

Infectious 33.42 27.6 27.80 29.02 - 25.95 22.41
Tuberculosis 18.35 19.61 14.64 1.05 6.87 5.65 16.09

Toxoplasmosis 0.67 2.99 4.04 10.80 3.70 4.74 2.30

Viral 6.11 5.867 5.05 12.92 3.17 18.18 2.30
Immunological 27.14 26.74 22.72 35.80 - 51.05 21.83
Fuchs 7.37 7.9 0.5 2.97 0.52 9.70 4.60
HLA B27 17.93 5.98 12.12 1.05 2.64 7.67 13.80
Sarcoidosis 2.09 6.24 1.51 1.70 9.52 4.34 2.30
VKH 2.98 4.32 2.52 4.40 10.05 4.14 1.72

Behcet‟s 0.47 0.23 0 12.29 5.82 4.84 0

disease
Idiopathic uveitis (55.7%) has been found to be the most common type of uveitis
in the present study and has been the most common entity in the previously published
studies as well. Studies from the Tunisia by Khairallah et al.21 (35.16%) and Japan by
Wakabayashi et al.17 (42.32%) and from India, by Sabhapandit et al.26 (38.5%), Dogra et
al.2 (39.43%), and Palsule et al.5 (49.5%) also reported idiopathic as the most common
type of uveitis. However, the incidence reported from these studies is comparatively less
than the present study. This could be due to limited availability of sophisticated
investigation like PCR for various infectious etiology. A study by Luca C et al. from
Northen Italy reported that tendency to diagnose anterior herpetic uveitis has increased

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41
from 9.1% in 2008 to 15.6% in 2015 mainly due to better diagnostic test including
PCR.24

Non-infectious uveitis syndromes are more common in developed countries

owing to low prevalence of the various infectious forms of uveitis. Non-infectious uveitis
syndromes are more common in developed countries owing to the low prevalence of the
various infectious forms of uveitis. In most studies from these regions, uveitis associated
with seronegative spondyloarthropathies was most common. In our series too,
seronegative arthropathy-associated uveitis (13.79 %) was the most common association
and was followed by Fuchs uveitis (4.5%) and Sarcoidosis (2.29 %). Behcet‟s disease
was the most common identifiable specific diagnosis, accounting for 12.3% of all uveitis
cases and for 36% of panuveitis in this North African, South Mediterranean series.21
Contrary to this we did not have any patient with Behcets disease in our study. This could
be due to limited duration of our study and geographic distribution of Behcet‟s disease in
the old silk route between latitudes 30 degree and 45 degree North.

In our study, the incidence of infectious etiology (22.4%) was consistent with
other studies, where it ranged from 26% to 34%. However, the cause of infectious
etiology was different. In India, tuberculosis is the most common cause, however, in
Tunisia21 and Japan17 herpes is the most common reported caused of uveitis. Khairallah et
al. however, reported the incidence of toxoplasmosis to be 10.80%.21 Tuberculosis being
endemic disease in developing countries, high prevalance of both pulmonary and
extrapulmonary TB including ocular tuberculosis is reported from India. Poor
socioeconomic condition, incomplete treatments and increasing incidence of HIV
infection add to the rising prevalence of TB. In the present study, the incidence of TB
was 16.6% and it was comparable with other Indian studies reported by Palsule et al. 5
(14.64%), Dogra et al.2 (18.35%) and Sabhapandit et al.26 (19.61%). However, studies
done by Khairallah et al.21 (1.05%) Luca et al.24 (5.65%) and Wakabayashi et al.17
(6.87%) reported lesser incidence of TB. Despite increasing trends of HIV, we reported
CMV retinitis in only 1 case. This could be attributed to the advent of highly active
antiretroviral therapy (HAART) that is now freely available to HIV patients in our
country.

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 Another important cause of posterior uveitis was Toxoplasmosis accounting for
12.9% cases of posterior uveitis. Our incidence of Ocular toxoplasmosis was lower as
compared to studies of Das et al.3 (40.21%) from Northeast India and Biswas et al.13
(27.87%) from South India. In Assam, ocular toxoplasmosis was found around the main
river Brahmaputra. This was responsible for high incidence of toxoplasmosis in their
study.

It is important to mention that leptospira, onchocerciasis, Lyme disease, birdshot

retinochoroido-pathy, diffuse unilateral subacute neuroretinitis and presumed ocular
histoplasmosis syndrome were not diagnosed in our series.

The criteria to diagnose Ocular tuberculosis varies in various studies. Some

studies take consider strong Mantoux test (>10 mm induration), while some studies
consider positive Quantiferon gold TB test or positive PCR test to diagnose ocular TB.
Though association between Quantiferon TB positivity and serpiginous choroidopathy
has been reported, there is a lack of correlation between Quantiferon and Mantoux
results. We have observed similar lack of correlation in current study. A recent report has
also shown that despite successful treatment of presumed ocular tuberculosis with
antitubercular therapy, Quantiferon gold test remains persistently positive.42 One survey
showed that ophthalmologist in India prefer to use a combination of results of Mantoux
test and Quantifereon TB test for diagnosis of Tuberculosis.43 But, recently WHO has
banned use of Quantiferon TB test to diagnose latent/active TB in endemic area due to
the high false positive results.44 Similarly, due to BCG vaccination, chance of positive
Mantoux test is quite high in India. Hence we considered tuberculosis only when patient
has signs predictive of ocular tuberculosis and positive Mantoux test.

Ng KK et al.45 and Agrawal et al.46 have studied cases of uveitis with tubercular
etiology (Table 12). In present study, we found higher incidence of unilateral presentation
of presumed ocular tuberculosis while Ng KK et al. (69.0%) and Agrawal et al. (58.8%)
had high incidence of bilateral presentation. Non-granulomatous type (39.28%) of
inflammation was more common than granulomatous type in current study. However, Ng
KK et al reported 18.0% of granulomatous uveitis. In present study, vitritis (67.85%) was
most common clinical sign whereas, Agrawal et al. reported lower incidence of vitritis

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(45.4%). Posterior uveitis (39.28%) followed by anterior uveitis (35.71%) was most
common anatomical type of uveitis in the current study. Ng KK et al. reported similar
incidence of Posterior uveitis (33.0%) followed by anterior uveitis (26.0%). However,
Agrawal et al. reported posterior uveitis (36.3%) followed by panuveitis (35.3%) as the
most common anatomical type of uveitis. Choroiditis was most common form of
posterior uveitis in present study. However, Ng KK et al. reported choroiditis only in
15.0%.

Table 12 – Demography and clinical spectrum of uveitis with tuberculosis etiology

Parameters Ng KK et al. (%) Agrawal et al. (%) Present study (%)

Mean age (years) - 40.5±14.8 37.93±13.26
Known h/o TB 23.0 20.34 21.42
Gender
Male 44.0 51.6 60.71
Female 56.0 48.4 39.28
Laterality
Unilateral - 41.2 82.14
Bilateral 69.0 58.8 17.85
Course
Acute 62.0 - 60.71
Recurrent 15.0 - 10.71
Chronic 28.57
Pathology
Non- - - 39.28
granulomatous
Granulomatous 18.0 - 7.14
Symptoms
Blurred vision - - 57.14
Redness - - 39.28
Sign
Vitritis / vitreous haze - 45.4 67.85
Posterior 33.0 - 17.85
synechiae
cataract 51.0 - 57.14
Anatomical location
Anterior 26.0 12.5 35.71
Intermediate 21.0 15.9 25.0
Posterior 33.0 36.3 39.28
choroiditis 15.0 - 54.54
vasculitis 41.0 - 36.36
Panuveitis 21.0 35.3 9.09

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 Among the non- infectious causes of uveitis, HLA B27 associated anterior uveitis
(13.8%) was common in our study, which was comparable with studies done by Dogra et
al.2 (17.9%) and Palsule et al.5 (12.1%). However, studies reported by Khairallah et al.21
and Wakabayashi et al.17 found lower incidence of HLA B27, 1.05% and 2.6%,
respectively. This discrepancy probably reflects racial differences in the frequency of
HLA B27 in the general population.

HLA B27 associated acute anterior uveitis has been extensively studied by Wang
et al.47, Majumdar et al.48 and selective demographic profile and clinical spectrum were
found to be comparable with the present study (Table 13).

Table 13- Demography and clinical spectrum of HLA B27 associated anterior uveitis in
various studies

Parameters Wang et al. (%) Majumdar et al. Present study (%)

(%)
Mean age (years) 37±12 44.7±11.7 38.56±12.71
Back pain - 74.4 45.8
Gender
Male 70.41 67.4 45.8
Female 29.59 32.5 54.2
Laterality
Unilateral 62.08 58.1 95.83
Bilateral - -
Course
Acute 47.1 - 70.8
Recurrent 52.9 - 29.2
Symptoms
Pain - 100 91.7
Redness - 100 95.8
Blurred - 55.8 54.2
vision
Sign
Fibrin in AC 75.0 29.1
Posterior 25 - 33.3
synechiae
Cataract 9.2 67.2 25
X ray spine - - 8.3

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 In current study, the incidence of HLA B27 associated anterior uveitis was higher
in female (54.2%) compared to male (45.8%). However, Wang et al.47 (70.41%) and
Majumdar et al.48 (67.4%) reported higher incidence of uveitis in male. In present study,
uveitis was unilateral in 95.83%. Wang et al.47 (62.08%) and Majumdar et al.48 (58.1%)
reported similar incidence of unilateral presentation of uveitis. Acute course (70.8%) of
disease was more common in current study followed by recurrent course (29.2%).
However, Wang et al.47 reported recurrent course (52.9%) of disease more common than
acute course (471%).

We found lower incidence of Fuchs heterochromic uveitis (4.6%) as compared to

other Indian studies by Dogra et al.2 (7.3%) and Sabhapandit et al.26 (7.9%). Palsule et
al.5 (0.5%), Wakabayashi et al.17 (0.52%) and Khairallah et al.21 (2.97%) also reported
lower incidence of Fuchs heterochromic uveitis. A study by Luca et al. found Fuchs
heterochromic uveitis (9.7%) as the most common cause of uveitis in the non-infectious
group.24

Accorinti et al.49 and Tandon et al.50 have studied cases of Fuchs heterochromic
uveitis (Table 14). We found unilateral (88.8%) uveitis as most common presentation
than bilateral uveitis (11.1%). Accorinti et al.49 (99.37%) and Tandon et al.50 (91.8%)
had similar comparable results. In present study, iris heterochromia was present in 88.8%
of patients. Accorinti et al. reported higher incidence of iris heterochromia.49 Contrary to
this, Tandon et al. reported lower incidence of iris heterochromia (88.8%).50 In current
study, loss of iris collarets was present in 11.1% of patients.

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Table 14 - Demography and clinical spectrum of Fuchs heterochromic uveitis in various
studies

Parameters Accorinti et al. (%) Tandon et al. (%) Present study (%)
Mean age 29.22 ±11.31 30.4 ±9.4 42 ±20.13
Gender
Male - 53 50
Female - 47 50
Laterality
Unilateral 99.37 91.8 88.8
Bilateral 0.62 8.2 11.1
Symptoms
Blurred vision 54.5 93.9 75.0
Floaters 40.5 25.2 0.0
Signs
Stellate kps - - 44.4
Fine diffuse kps 76.3 87.4 55.5
Iris atrophy 86.8 38.9 0.0
Iris 68.3 24.7 88.8
heterochromia
Loss of iris collarets - - 11.1
Cataract 63.5 70.2 77.7

The incidence of Sarcoidosis (2.3%) was less in our study, which was consistent
with other studies reported by Palsule et al.5 (1.51%), Khairallah et al.21 (1.7%) and
Dogra et al.2 (2.07%). On the contrary, Sabhapandit et al.26 (6.24%) and Wakabayashi et
al.17 (9.52%) reported higher incidence. We found lower incidence of Vogt Koyanagi
Harada syndrome (1.7%) as compared to other studies by Palsule et al.5 (2.52%), Dogra
et al.2 (2.98%), Luca et al.24 (4.1%), Sabhapandit et al.26 (4.32%), and Khairallah et al.21
(4.4%). Study by Wakabayashi et al. reported VKH to be as high as 10.05%, the most
common non-infectious etiology.17

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 In our study, the most common ocular complication was cataract (20.56%)
followed by disc edema (5.6%), glaucoma (4.6%), and macular edema (2.3%).
Sabhapandit et al. reported cataract (26.03%) as the most common complication followed
by glaucoma (7.81%) and cystoid macular edema (7.5%).26 Luca et al. also reported
cataract (19%) as the most common complication but it was followed by posterior
synechiae (14%), macular edema (13%) and glaucoma (11%).24 On the contrary,
Khairallah et al. reported cystoid macular edema (23.3%) as the most common
complication followed by raised intraocular pressure (15.9%) and cataract (15.6%).21

Strength

Nevertheless, we believe that the results of our study provide further useful
information regarding the current epidemiology and pattern of uveitis. To best of our
knowledge, this study is the first prospective study to provide data on uveitis from
Central India. We also followed standard international Uveitis nomenclature in this study.
Stick inclusion and exclusion criteria were adhered while performing in this study. We
believe that further advances in diagnostic methods and large collaborative studies in the
coming years would help in improving levels of clinical evidence that would enable us to
make an irrefutable association between uveitis and an infectious agent.

Limitations

The limitations of our study include referral bias, since the data were collected
from a single tertiary referral centre of central India and data from a single setting might
be different from that of a community setting. Limitation of making valid comparisons
between uveitis statistic of different countries due to different diagnostic criteria and
concepts of uveitis. And also the study being held for a brief period of time. Laboratory
tests on aqueous humour aspirates or vitreous biopsy, analyzing antibodies against
viruses HSV or VZV, or detecting viral or bacterial genome particles using PCR, might
be useful in diagnosing atypical presentations of viral and bacterial infections. Such
laboratory tests could not be performed for our patients. This explained high prevalence
of idiopathic type of uveitis in our study.

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SUMMARY

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49
 The incidence of uveitis in India is in the range of 0.8 to 1.3. Uveitis is the major
cause of visual morbidity in the world. Demographic profile and etiology of uveitis are
different worldwide. It depends upon various factors such as host, genetics, ethnicity,
geography and environmental factors. So, these epidemiological variations are important
in deriving a differential diagnosis precise to a certain region. There was no prospective
study conducted from central India. Therefore, the present study aimed to study
demographic and clinical patterns of uveitis in central India.

A prospective study was conducted at MGM Eye Institute, Raipur (Chhattisgarh),

from July 2018 to April 2019. Number of new cases of uveitis of any age groups that
were included in this study was 174. Uveitis secondary to endophthalmitis, trauma,
intraocular surgery, corneal ulcer, lens induced uveitis, episcleritis, scleritis and patients
who lost to follow up were excluded. Uveitis was classified by Standardization of Uveitis
Nomenclature (SUN) working group classification.

Details regarding demographical profile were taken. Examination includes brief

history, best corrected visual acuity, slit lamp biomicroscopy, intraocular pressure
measurement, fundus evaluation, ancillary test and tailored laboratory investigations.
Demographic data and clinical patterns were evaluated according to anatomical location.
Statistical analysis was done and p value less than 0.05 were considered as statistically
significant.

The incidence of uveitis in the present study was 1.13. A higher incidence of
uveitis was seen at the age of 40 years, which was similar to other studies conducted in
India. Following observations were made from the study:

1. Best corrected mean visual acuity was 0.36

2. Mean intraocular pressure was 12.49 mm Hg
3. Uveitis was found more in urban population
4. Uveitis was more common in male than female. However, the difference was not
significant when compared to anatomical location
5. Unilateral uveitis was more common but the difference was not statistically
significant

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6. Acute course of uveitis was more common than acute recurrent and chronic
uveitis and this difference was highly significant
7. The clinical presentation was more of limited duration but the difference was
statistically significant
8. Non-granulomatous inflammation was more common than granulomatous uveitis
and this difference was highly significant
9. Anterior uveitis was more common followed by posterior uveitis, intermediate
uveitis and panuveitis
10. Idiopathic etiology was more common than non-infectious than infectious
etiology
11. Among non-infectious etiology, HLA B27 was most common cause followed by
Fuchs heterochromic uveitis
12. Among infectious etiology, presumed ocular tuberculosis was most common
cause followed by toxoplasmosis
13. Cataract was the most frequent complication associated with uveitic cases

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CONCLUSION

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 In the present study from tertiary eye care center from central india, uveitis was
more commonly seen in middle age group. The mean age at presentation was 40 years.
We found idiopathic etiology as most common cause of uveitis. As far as location
concerned, anterior uveitis was most common followed by posterior uveitis, intermediate
uveitis and panuveitis. Among infectious group, presumbed ocular tuberculosis was most
common cause of uveitis. Among non-infectious group, HLA B27 associated anterior
uveitis was most common cause of uveitis. We presume that the knowledge about
spectrum of disease in particular region is very important for diagnosis and optimal
management of uveitis patients.

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ANNEXURE

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 Patient Information Sheet

Principle Investigator: Dr Prerna Agrawal

Introduction: You are invited to participate in a study, and this form will give you the
information about it. The participation is voluntary. You can ask any question regarding
this study and tests to be performed.
Purpose: To study demographic and clinical pattern of uveitis in all age groups
Information: Following tests will be performed: detail clinical history, visual acuity, slit
lamp examination, intraocular pressure, dilated fundus examination, ancillary test,
and tailored laboratory investigations.
Risks: There will be no added risk in this study nor the management protocol is
going to change when you are included in the study.
In case of Emergency: Subject will be advice to visit any ophthalmologist or at
MGM eye institute in case of any simple or serious adverse effect.
Benefit: This study will help to find out the prevalence of uveitis in central India
which will help us in better managing these patients.
Confidentiality: Data will be retained in the Medical Record Department of the hospital,
and person other than PI and Co-I, will not be allowed to assess the data.
In case of any loss of data, institute will take the responsibility.
You can contact with principle investigator at any time.
Dr. Prerna Agrawal,
MGM eye institute Raipur
Participation: Your participation will be voluntary in this study. You can leave the study
any time. There will not be any harm to your legal rights after signing this form.

Signature of Participant Date

I have read all the information, and I am giving my consent for participation.
A copy of this form is provided to me.
Participants name:
Medical record No.:
Contact no. and address:
Name of witness
Signature/ thumb impression of witness:
Person taking the consent:
Signature of person taking the consent:

Page
61
 lwpuk i=
eq[; vUos{kd dk uke % MkW- izsj.kk vxzoky

ifjp; %&vkidks ,d v/;;u esa Hkkx ysus ds fy, vkeaf=r fd;k tk jgk gSA bl nLrkost esa vkidks v/;;u
esa Hkkx ysus ds fy, dgk tk jgk gS vkSj mldk fooj.k fn;k x;k gSA v/;;u esa vkidh Hkkxhnkjh LoSfPNd gSA
v/;;u esa Hkkx ysus ls igys vkSj viuh lgefr nsus ls igys vki lHkh fooj.k dh iwNrkN dj ldrs gSA

mn~ns'; %& ;qfovkbfVl ds tulkaf[;dh; vkSj uSnkfud iSVuZ dk lHkh vk;q lewgksa esa v/;;u djus ds fy,
lwpuk %& fuEufyf[kr ijh{k.k fd, tk,axs% foLrkj fDyfudy bfrgkl] n`”; rh{.krk] fLyV ySEi ijh{k.k]
baVªkvksdqyj ncko] jsfVuk ijh{k.k] lgk;d ijh{k.k vkSj vuq:i iz;ksx”kkyk tkapA
tksf[ke %& bl v/;;u esa dksbZ vfrfjDr tksf[ke ugha gksxk vkSj u gh tc vki v/;;u esa “kkfey gksrs gSa rks
izca/ku izksVksdkWy cnyk tk,xkA
vkikrdkfyu fpfdRlk ns[kHkky %& ejhtksa dks dksbZ Hkh lk/kkj.k ;k xaHkhj izfrdwy izHkko gksus ij rqjar ,e-th-
,e us= fpfdRlky; esa bykt fd;k tk;sxk ;k utnhdh fpfdRlky; esa laidZ djus dh lykg nh tk;sx
a hA

ykHk %& ;g v/;;u e/; Hkkjr esa ;qfovkbfVl ds izlkj dks tkuus esa enn djsxk tks mfpr jksxh izca/ku dks
fu/kkZfjr djus esa gekjh lgk;rk djsxkA
xksiuh;rk %& v/;;u ds fjdkWMZ esa tkudkjh dks xksiuh; j[kk tk,xk vkSj uSnkfud pkVZ ,e-th-,e- us=
fpfdRlky; ifjlj esa fLFkr gks tk,xkA MkVk lqjf{kr :i ls laxzfgr fd;k tk,xk vkSj dsoy v/;;u ds
vk;kstu lacaf/kr O;fDr;ksa dks vkSj fu;a=d vf/kdkfj;ksa dks miyC/k djk;k tk,xkA vkidh fo”ks’k :i ls
fyf[kr esa vuqefr nsus ij MkVk fdlh vkSj dks miyC/k fd;k tk,xkA

izksVksdksy ls lacaf/kr {kfr gksus ij laLFkku mlds fy, U;kf;d :i ls ftEesnkj gksxkA

vki v/;;u ;k izfØ;kvksa ds ckjs esa fdlh Hkh le; iz”u dj ldrs gS ;k “kks/kdrkZ ls laidZ dj ldrs gSA
MkW- izsj.kk vxzoky & 9860671707

,e-th-,e- fpfdRlky;-

Hkkxhnkjh %& bl v/;;u esa vkidh Hkkxhnkjh LoSfPNd gSA vki fdlh Hkh le; Hkkx ysus ls badkj dj ldrs
gSA bl nLrkostksa ij gLrk{kj djus ij vkids dkuwuh vf/kdkjksa ij dksbZ izHkko ugha iM+x
s kA

izfrHkkxh ds gLrk{kj fnukad

eSaus mijksDr tkudkjh i<+h gS] vkSj eSa bl v/;;u esa Hkkx ysus ds fy, lger gWaAw eq>s bl QkWeZ dh ,d izfr
feyh gSA
izfrHkkxh dk uke% esfMdy fjdkMZ uacj %
eksckbZy uacj ,oa fuokl LFkku %
xokg dk uke% gLrk{kj ;k vaxwBs dk fu”kku ,oa fnukad

lgefr ysus okys O;fDr dk uke%

lgefr ysus okys O;fDr ds gLrk{kj ,oa fnukad%

Page
62
 Informed Consent Form
Subject identification number for this trial ______________________________
Title of the Project: Demographic and clinical pattern of uveitis in tertiary eye care center
of central India
Name of the Principal Investigator: Dr Prerna Agrawal Mob. No. 9860671707
I have received the information sheet on the above study and have read and / or
understood the written information.
I have been given the chance to discuss the study and ask questions.
I consent to take part in the study and I am aware that my participation is voluntary.
I understand that I may withdraw at any time without this affecting my future care.
I understand that the information collected about me from my participation in this
research and sections of any of my medical notes may be looked at by responsible
persons (ethics committee members / regulatory authorities). I give access to these
individuals to have access to my records.
I understand I will receive a copy of the patient information sheet and the informed
consent form.
_________________________ __________________
Signature / Thumb Impression of subject Date of signature

______________________________
Name of the subject in capitals
___________________________ __________________
Signature / Thumb Impression of legally Date of signature
accepted representative

_______________________________________________
Name of legally acceptable representative in capitals
______________________________________________________
Relationship of legally accepted representative to subject in capitals
_______________________________________ __________________
Signature of the person conducting the Date of Signature
Informed consent discussion
_________________________________
Name of the person conducting the Informed consent discussion in capitals
________________________________________ __________________
Signature of impartial witness Date of signature
________________________________________
Name of the impartial witness in capitals

Page
63
 Informed Consent Form

Participant name:
Subject identification number for this trial ______________________________
Title of the Project: Demographic and clinical pattern of uveitis in tertiary eye care center
of central India
Name of the Principal Investigator: Dr Prerna Agrawal Mob. No. 9860671707
I have received the information sheet on the above study and have read and / or
understood the written information.
I have been given the chance to discuss the study and ask questions.
I give consent for my child to take part in the study and I am aware that my participation
is voluntary.
I understand that I may withdraw at any time without this affecting future care of my
child.
I understand that the information collected about my child from its participation in this
research and sections of any of its medical notes may be looked at by responsible persons
(ethics committee members / regulatory authorities). I give access to these individuals to
have access records of my child.
I understand I will receive a copy of the patient information sheet and the informed
consent form.
__________________________ __________________
Signature / Thumb Impression of parent Date of signature
______________________________
Name of the parent in capitals
___________________________ __________________
Signature / Thumb Impression of legally Date of signature
accepted representative
_______________________________________________
Name of legally acceptable representative in capitals
______________________________________________________
Relationship of legally accepted representative to subject in capitals
_______________________________________ __________________
Signature of the person conducting the Date of Signature
Informed consent discussion
_______________________________________
Name of the person conducting the Informed consent discussion in capitals
________________________________________ __________________
Signature of impartial witness Date of signature
______________________________________
Name of the impartial witness in capitals

Page
64
 lgefr i=

izfrHkkxh dk esfMdy fjdkWMZ uacj -----------------------------------------------------------------------------------------------------------------------

v/;;u uke% e/; Hkkjr ds V”kZjh ns[kHkky vka[k dsUnz esa ;qfovkbfVl ds tulkaf[;dh; vkSj uSnkfud iSVuZ

eq[; vUos{kd dk uke% MkW- izsj.kk vxzoky eksckby uacj 9860671707

eq>s bl v/;;u dh lwpuk i= izkIr gks pqdk gS] rFkk eSaus iwjh tkudkjh le> yh gSA

eq>s bl v/;;u ds ckjs esa iz”u djus dk ekSdk fn;k x;k gSA

eSa bl v/;;u esa Hkkx ysus dh lgefr nsrk gwW] ,oa esjh lgHkkfxrk LoSfPNd gSA

eq>s tkudkjh gS fd eSa fdlh Hkh le; bl v/;;u dks NksM+ ldrk gwW] vkSj mldk esjs bykt ij Hkfo’; esa dksbZ izHkko
ugha iMsx
+ kA
eq>s Kkr gS fd bl v/;;u ds fjdkWMZ esa tkudkjh dks xksiuh; j[kk tk,xkA MkVk lqjf{kr :i ls laxzfgr fd;k tk,xk
vkSj dsoy v/;;u ds vk;kstu lacaf/kr O;fDr;ksa dks vkSj fu;a=d vf/kdkfj;ksa dks miyC/k djk;k tk,xkA ftldh
vuqerh esjs }kjk nh xbZ gSaA

eq>s ,d&,d izfr lwpuk i= ,oa lgefr i= nh tk jgh gSA

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& &&&&&&&&&&&&&&&&&
gLrk{kj@vaxwBs dk fu”kku gLrk{kj dh fnukad
&&&&&&&&&&&&&&&&&&&
izfrHkkxh dk uke
&&&&&&&&&&&&&&&&&&&&&&&& &&&&&&&&&&&&&&&&&
dkuwuh rkSj ij ns[kHkky djus okys O;fDr dk gLrk{kj dh fnukad
gLrk{kj@vaxwBs dk fu”kku

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
dkuwuh rkSj ij ns[kHkky djus okys O;fDr dk uke

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
izfrHkkxh ls fj”rk

&&&&&&&&&&&&&&&&&&&&&& &&&&&&&&&&&&&&&&&&&&
lgefr ysus okys O;fDr dk gLrk{kj gLrk{kj dh fnukad

&&&&&&&&&&&&&&&&&&&&&&&&&&&&
lgefr ysus okys O;fDr dk uke

&&&&&&&&&&&&&&&&&&&&&&& &&&&&&&&&&&&&&&&&&
xokg dk gLrk{kj@vaxwBs dk fu”kku gLrk{kj dh fnukad

&&&&&&&&&&&&&&&&&&&&&&&&&
xokg dk uke

Page
65
 lgefr i=

izfrHkkxh dk esfMdy fjdkWMZ uacj -----------------------------------------------------------------------------------------------------------------------

v/;;u uke% e/; Hkkjr ds V”kZjh ns[kHkky vka[k dsUnz esa ;qfovkbfVl ds tulkaf[;dh; vkSj uSnkfud iSVuZ

eq[; vUos{kd dk uke% MkW- izsj.kk vxzoky eksckby uacj 9860671707

eq>s bl v/;;u dh lwpuk i= izkIr gks pqdk gS] rFkk eSaus iwjh tkudkjh le> yh gSA

eq>s bl v/;;u ds ckjs esa iz”u djus dk ekSdk fn;k x;k gSA

eSa bl v/;;u esa esjs cPps dks Hkkx ysus dh lgefr nsrk gwW] ,oa esjh lgHkkfxrk LoSfPNd gSA

eq>s tkudkjh gS fd eSa fdlh Hkh le; bl v/;;u dks NksM+ ldrk gwW] vkSj mldk esjs bykt ij Hkfo’; esa esjs
cPps ij dksbZ izHkko ugha iMsx
+ kA

eq>s Kkr gS fd bl v/;;u ds fjdkWMZ esa tkudkjh dks xksiuh; j[kk tk,xkA MkVk lqjf{kr :i ls laxzfgr
fd;k tk,xk vkSj dsoy v/;;u ds vk;kstu lacaf/kr O;fDr;ksa dks vkSj fu;a=d vf/kdkfj;ksa dks miyC/k djk;k
tk,xkA ftldh vuqerh esjs }kjk nh xbZ gSaA eSa vius cPPkksa ds vfHkxe fjdkWMZ j[kus ds fy, bu O;fDr;ksa rd
igqap iznku djrk gwAa
eq>s ,d&,d izfr lwpuk i= ,oa lgefr i= nh tk jgh gSA

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& &&&&&&&&&&&&&&&&&
vfHkHkkod ds gLrk{kj@vaxwBs dk fu”kku gLrk{kj dh fnukad
&&&&&&&&&&&&&&&&&&
vfHkHkkod dk uke
&&&&&&&&&&&&&&&&&&&&&&&& &&&&&&&&&&&&&&&&&
dkuwuh rkSj ij ns[kHkky djus okys O;fDr dk gLrk{kj dh fnukad
gLrk{kj@vaxwBs dk fu”kku
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
dkuwuh rkSj ij ns[kHkky djus okys O;fDr dk uke

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
f”k”kq ls fj”rk

&&&&&&&&&&&&&&&&&&&&&& &&&&&&&&&&&&&&&&&&&&
lgefr ysus okys O;fDr dk gLrk{kj gLrk{kj dh fnukad

&&&&&&&&&&&&&&&&&&&&&&&&&&&&
lgefr ysus okys O;fDr dk uke
&&&&&&&&&&&&&&&&&&&&&&& &&&&&&&&&&&&&&&&&&
xokg dk gLrk{kj@vaxwBs dk fu”kku gLrk{kj dh fnukad

&&&&&&&&&&&&&&&&&&&&&&&&&
xokg dk uke

Page
66
DATA COLLECTION FORM

S.NO: MR No.:

Name:

Age: _______ year

Gender: Male Female

Residence: Urban Rural

Occupation: Private Government Business

Other

Laterality: Unilateral Unilateral alternating Bilateral

Primary Symptoms: Pain Redness Watering Blurred vision

Photophobia Floaters Photopsia Scotoma

Metamorphopsia Others

Duration: Limited Persistent

Onset: Sudden Insidious

Severity: Mild Moderate Severe

Course: Acute Chronic Acute recurrent

Page
67
Associated findings: Back pain Joint pain Albinism Recurrent aphthous
ulcer

Others

Systemic risk factor: None Hypertension Diabetes mellitus Tuberculosis

Asthma Malignancy Arthritis Chicken pox

Others

Social history:

1. History of migration Yes No

2. Exposure to dog or cat Yes No
3. History of consuming raw meat Yes No
4. History of consuming unpasteurized milk Yes No
5. History of consuming untreated stream, well or lake water Yes No
6. History of smoking Yes No
7. History of intravenous drug abuser Yes No

Treatment history:

Eye Drug name Duration Dosage Control

Surgery history:

 Ocular surgery

Eye Surgery name Date

 Systemic surgery

Surgery name Date

Page
68
Miscellaneous:

Injury: Yes No

If yes, details

Ocular examination:

Right eye Left eye

Visual acuity (PH)
Best corrected visual acuity
Intraocular pressure
Visual axis Orthophoric Yes No Yes No
Esophoric Yes No Yes No
Exophoric Yes No Yes No
Conjunctiva Perilimbal congestion Perilimbal congestion
Diffuse congestion Diffuse congestion
Quiet Quiet
Cornea Sensation Present Present
Diminished Diminished
Absent Absent
Epithelium Intact Intact
Defect Defect
Edema Edema
Opacity Opacity
Stroma Normal Normal
Edema Edema

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69
 Opacity Opacity
Endothelium KPs Absent Absent
Present Present

Fine KPs Fine KPs

Mutton fat KPs Mutton fat KPs
Old KPs Old KPs
Pigment Yes No Yes No
Anterior Cells Quiet Quiet
chamber Present Present
Flare Quiet Quiet
Present Present
Fibrin Yes No Yes No
Pigment Yes No Yes No
Iris Nodule Yes No Yes No
Posterior synechiae Yes No Yes No
Atrophy Absent Absent
Sectorial Sectorial
Diffuse Diffuse
Heterochromia Yes No Yes No
NVI Yes No Yes No
Pupil Round Yes No Yes No
Regular Regular Regular
Irregular Irregular
Reaction Normal  Normal 
Sluggish Fixed Sluggish Fixed
RAPD Yes No Yes No
Angles Peripheral Anterior Yes No Yes No
synechiae
NVA Yes No Yes No
Lens Clear Cataract Clear Cataract

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70
Posterior Vitreous Vitritis Yes No Yes No
segment Vitreous Yes No Yes No
hemorrhage
Snow balls Yes No Yes No
Snow banking Yes No Yes No
Optic Normal Yes No Yes No
nerve Disc odema Yes No Yes No
Disc hyperemia Yes No Yes No
Disc Yes No Yes No
neovascularization
Optic atrophy Yes No Yes No

Retina Normal Yes No Yes No

Retinitis Yes No Yes No
Retinal vasculitis Yes No Yes No
Retinochoroiditis Yes No Yes No
Choroidal Yes No Yes No
neovascular
membrane
Cystoid macular Yes No Yes No
odema
Macular atrophy Yes No Yes No
Macular scaring Yes No Yes No
Epiretinal Yes No Yes No
membrane
Choroid Normal Yes No Yes No
Choroidal Yes No Yes No
granuloma
Choroidal abscess Yes No Yes No
Choroiditis Yes No Yes No
Chorioretinitis Yes No Yes No

Page
71
Ancillary ocular investigations (FFA/OCT/Bscan):

Relevant Systemic examination:

Descriptive naming:

Age: Severity

Pediatrics Mild

Young adults Moderate

Geriatrics Severe

Page
72
Chronology: Pathology

Acute Nongranulomatous

Acute recurrent Granulomatous

Chronic

Anatomical

Anterior

Intermediate

Posterior

Panuveitis

Laterality Etiology

Unilateral Infectious

Unilateral alternating Immunologic

Bilateral Masquerade

Idiopathic

Page
73
Investigations:

Sr. no. Test Result

1 TLC
2 DLC
3 ESR
4 C-Reactive Protein
5 Mantoux test
6 Quantiferon gold
7 S. ACE level
8 VDRL
9 HIV
10 RA factor
11 HLA B27
12 ANA
13 ANCA
14 IgG toxoplasmosis
15 IgM toxoplasmosis
16 Viral serology
17 IgM Bartonela
18 Lyme serology
19 X ray chest
20 X ray sacroiliac joint
21 CECT/HRCT chest
22 MRI head

Final Diagnosis:

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74