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 Table of Contents  
GUEST EDITORIAL
Year : 2021  |  Volume : 33  |  Issue : 1  |  Page : 3-7

Spectrum of uveitis in India


Department of Uveitis and Ocular Inflammation, Prabha Eye Clinic and Research Center, Vittala International Institute of Ophthalmology, Bengaluru, Karnataka, India

Date of Submission18-Jan-2021
Date of Acceptance19-Jan-2021
Date of Web Publication19-Apr-2021

Correspondence Address:
Dr. Kalpana Babu
Prabha Eye Clinic & Research Centre, 504, 40th Cross, Jayanagar 8th Block, Bangalore - 560 070, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_19_21

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  Abstract 


We look at the spectrum of uveitis in India before the year 2010 and after the year 2010, the changing patterns in uveitis over time, the probable factors for the changing patterns and newer uveitis entities in India.

Keywords: India, infections, patterns, spectrum of uveitis


How to cite this article:
Babu K, Mukesh K. Spectrum of uveitis in India. Kerala J Ophthalmol 2021;33:3-7

How to cite this URL:
Babu K, Mukesh K. Spectrum of uveitis in India. Kerala J Ophthalmol [serial online] 2021 [cited 2021 Jul 25];33:3-7. Available from: http://www.kjophthal.com/text.asp?2021/33/1/3/314090






  Introduction Top


Uveitis is a sight-threatening disease and can arise from many causes. If not diagnosed and treated early and adequately it leads to irreversible blindness. Diagnosis is often challenging despite a better understanding of the pathogenesis and newer diagnostic modalities. Geographic factors play an important role in identifying the cause of uveitis. The pattern of uveitis in India differs considerably from that seen in the developed world.

In the 90s and early 2000, uveitis was a niche area in ophthalmology with only a handful of specialists in India and uveitis care was mainly restricted to tertiary care centers. However, in recent years, there has been an increase in the number of uveitis specialists all over India which is evident by the increasing number of articles on uveitis from the subcontinent. In this review, we aim to look at the spectrum of uveitis in India, the changing patterns over the years, probable factors resulting in the changing patterns and newer uveitis entities by a literature review.


  Materials and Methods Top


Literature search pertaining to the spectrum of uveitis in India published in PubMed, EMBASE, and MEDLINE was done. MESH terms like “Pattern of Uveitis”/”India,” “Spectrum of Uveitis”/”India,” “Uveitis”/”India,” “Ocular Inflammation”/”India” were used. A manual search of references cited by retrieved articles for additional references were also done. Furthermore, authors conducted independent systemic review of the literature and retrieved the data. The data retrieved were separated into articles from India before the year 2010 and those after 2010 and the data analyzed.


  Results Top


[Table 1] and [Table 2] provide the pattern of uveitis in India before and after years 2010 respectively.
Table 1: Pattern of uveitis in India from various studies before year 2010

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Table 2: Pattern of uveitis in India from various studies after year 2010

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  Discussion Top


Before 2010, uveitis care was restricted to tertiary referral centers due to the availability of only handful of uveitis specialists. There were only 4 major retrospective studies from India regarding the pattern of uveitis: 2 from south, 1 from north and 1 from the east.[1],[2],[3],[4] Anterior uveitis was the most common type of uveitis across all 4 studies (39%–57%). In the late 90s and early 2000, >50% of uveitis cases were idiopathic. Infectious uveitis constituted 11.9%–30.7% in various studies. Toxoplasmosis was the most common type of infectious uveitis along with tuberculosis and leptospirosis. VKH was the most common type of noninfectious uveitis. Post 2010, there were more number of studies from all over India (2 from north, 1 each from south, central, western and eastern India).[5],[6],[7],[8],[9],[10] This indicates that the number of uveitis specialists has increased across India and management is now no longer restricted to tertiary referral centers. Anterior uveitis was still the most common type of uveitis seen across all the studies (41.4%–55.29%). Interestingly, in contrast to earlier years, it was possible to identify the etiology in >50% of uveitis. Infectious cause constituted 9%–33.42% of cases of uveitis. Interestingly tuberculosis was the most common type of infection across all the studies (8.16%–60%). Among the noninfectious uveitis, HLAB27 anterior uveitis was most common.

Changing patterns

These studies at different timelines suggest changing patterns in uveitis. In recent years, in infectious uveitis, there has been a significant increase in the prevalence of ocular TB (22.5% vs. 0.64%, P < 0.0001). There has been an increasing trend of viral uveitis, especially a significant increase in viral retinitis (from 0.76% to 6.81%, P < 0.05). There has been declining trend in toxoplasmosis (P = 0.0545) and cytomegalovirus (CMV) retinitis. In the noninfectious uveitis, there has been an increase in HLAB27 positivity (29.83% vs14.5%; P < 0.05) and ocular sarcoidosis.[11]

One of the important aspects in the changing pattern of uveitis is the possibility to establish the etiology in >50% of cases. This is probably due to the availability of newer diagnostic technologies in India. This includes ocular imaging (ICG, Spectral OCT, OCT-angiography, adaptive optics, etc.), polymerase chain reaction (PCR), availability of high resolution computed tomography scans and endobronchial ultrasound-guided transbronchial lymph node aspirations to get a definitive diagnosis. Ocular imaging has definitely helped us to understand the level of pathology and hence, the pathogenesis better. PCR has played a very important role in infectious uveitis, especially the identification of viral etiology, especially CMV and tuberculosis.[12],[13],[14] Chest X-ray is more often replaced by HRCT thorax[15] in many cases of uveitis, especially granulomatous uveitis and availability of EBUS-TBNA have helped us to achieve a biopsy-proven diagnosis in many of our cases of tuberculosis or sarcoidosis.[16]

Multicentric studies across India have set diagnostic criteria including recognition of clinical parameters/phenotypes for the diagnosis of ocular tuberculosis and ocular sarcoidosis. Noted among these are Collaborative ocular tuberculosis[17] and the ocular sarcoidosis[18] studies. In addition, individual studies from the subcontinent have contributed significantly to identifying clinical predictors and prognostic factors for TB associated uveitis.[19],[20],[21] If we look at the literature before 2010, it is noted that many cases of serpiginous choroiditis were placed in the noninfectious group and were treated with immunosuppression. However, this clinical phenotype of serpiginous like choroiditis is now increasingly recognized to be presumed ocular tuberculosis in high Tb endemic countries like ours and are now treated with antitubercular therapy. Similarly, Eales disease, once thought to be idiopathic, is increasingly recognized to be associated with tubercular etiology especially in high TB endemic countries like ours.[22] We believe that the availability of these newer diagnostic modalities and multicentre studies have played an important role in identifying cases of ocular tuberculosis and thus the most common cause of infectious uveitis across India. Sarcoidosis was once considered a disease of the developed world. In recent years, there have been increasing reports of sarcoidosis from our part of the world. It is now being considered routinely in the differential diagnosis of both ocular and nonocular diseases. The role of mycobacterium tuberculosis in the development of sarcoid is being increasingly investigated due to the clinical, radiological and histopathologic similarities with tuberculosis. This is one of the reasons to differentiate between ocular tuberculosis and ocular sarcoidosis in high TB endemic countries like ours. The multicentre study from India on the diagnostic markers in ocular sarcoidosis in a high TB endemic population is useful in differentiating the 2 conditions to some extent.[18]

Another important factor in identifying the etiology is the multidisciplinary approach which is being followed in recent years. Over the years, we have learnt a lot from our colleagues in rheumatology, pulmonary medicine, dermatology, etc., and the availability of their expertise and newer diagnostics in their respective fields have helped us in identifying the cause of uveitis. One of the significant changes has been in juvenile idiopathic arthritis (JIA). In earlier years, children with JIA with uveitis presented with sequelae such as band-shaped keratopathy, occlusio and seclusio pupillae, and glaucoma as they presented very late in the disease course to an ophthalmologist. However, in recent years, children are being increasingly referred for an ophthalmic evaluation at the time of detection of JIA and hence seldom see such bad sequelae. Blau syndrome was thought to be very rare in India. However, due to the recent availability of genetic testing, there have been increasing reports of blau syndrome from our part of the world.[23]

Third, the availability of newer drugs now to treat ocular inflammation. We have come a long way from steroids to immune suppressives and now to targeted therapy in the form of biologics. Our lower threshold for immunosuppression and targeted therapy has led to better control of inflammation and better prognosis in our cases. On the flip side, we are seeing more cases of drug-induced uveitis in recent times.[24] Local therapy such as implants and biosimilars have reduced the cost of treatment significantly.

Fourthly, there has been an impact of national disease control programs on the changing patterns of uveitis. Noted among this is the national aids control programme. The NACO 2015 report[25] shows a declining trend in estimated newer HIV infections and AIDS-related deaths in India [Figure 1]. This is possible due to the easy availability of free antiretroviral therapy. The National tuberculosis control program is another national wide program rolled out in recent years to eradicate tuberculosis.
Figure 1: Photograph showing decreasing trend of new HIV infections in India and increased use of antiretroviral therapy. NACO 2015 report

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Newer uveitis entities

In recent times, we have seen the resurgence of older diseases such as syphilis in non-HIV patients. The RPR titers are higher in patients with HIV than in non-HIV patients. We have also had epidemics of chikungunya, dengue, and West Nile fever. These have led us to see newer uveitis patterns such as multifocal retinitis. Interestingly all of them follow a similar pattern and are generally associated with a favorable prognosis unless associated with vascular occlusions. New terminology has been coined to describe this pattern of retinitis called “post fever retinitis.”[26],[27] Although CMV retinitis in HIV has declined considerably, we are seeing an increase in the incidence of CMV retinitis in non-HIV cases Eg; post intravitreal steroid injections and implants. Unlike the CMV retinitis in HIV, the CMV retinitis in non-HIV are refractory to treatment requiring multiple injections of ganciclovir and progression to neovascularisation due to associated vasculopathy and ischemia. Rickettsia retinitis is a newer uveitis entity especially in south India.[28] It may be associated with vascular occlusions. Rickettsia infections especially in children with a history of pyrexia of unknown origin are increasingly more common. They respond very well to doxycycline and cephalosporins. Lyme disease was never a part of differential diagnosis in India. Recently there has been an increasing number of case reports of Lyme disease in India. In a recent study, it was noted that there is a high seroprevalence (19.9%) of borrelia burgdorferi infection in the Western ghats region in south India. This was also confirmed with western blot (15.6% positivity).[29] Incidentally, another study confirmed the presence of Ixodes ticks in these regions. There have also been case reports and series of neuroretinitis in patients from this region responding well to doxycycline. Thus any patient hailing with characteristic symptoms and signs from these regions, Lyme disease must be kept as a differential diagnosis even in a country like India. Due to the global coronavirus (SARS-CoV-2) outbreak, reports of Kawasaki disease, increase in IOP, retinal vascular occlusions, hyperreflective lesions in the inner retina and papillomacular bundle, panuveitis, and optic neuritis have been described.[30]

So what has been the real change in our practice of management of uveitis? It is our approach to these cases. Uveitis is no longer a niche area in ophthalmology. Thanks to efficient dissemination of information in the form of study groups, newsletters, conducting CMEs, training at both national and international levels, we have more number of ophthalmologists treating uveitis cases across India. There is also an increased awareness of varying aetiologies and presentations (from infective to autoimmune). Regular updates in newer developments in pathogenesis, diagnostics, and therapeutics and rapid progress in diagnostics (ophthalmology and nonophthalmology) and therapeutics have played an important role in uveitis care. A multidisciplinary approach, involving working closely with other departments in internal medicine have helped us to work as a team resulting in better uveitis care and hence better prognosis for our uveitis patients.


  Conclusion Top


The spectrum of uveitis in India is changing rapidly due to global migration, increasing uveitis specialists in India, the availability of improved diagnostics and therapeutics, and utilizing a multidisciplinary approach. These have resulted in improved uveitis care in India and a better prognosis our uveitis patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Babu K, Konana VK, Ganesh SK, Patnaik G, Chan NS, Chee SP, et al. Viral anterior uveitis. Indian J Ophthalmol 2020;68:1764-73.  Back to cited text no. 12
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Sharma K, Gupta V, Bansal R, Sharma A, Sharma M, Gupta A. Novel multi-targeted polymerase chain reaction for diagnosis of presumed tubercular uveitis. J Ophthalmic Inflamm Infect 2013;3:25.  Back to cited text no. 14
    
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