Kerala Journal of Ophthalmology

GUEST EDITORIAL
Year
: 2018  |  Volume : 30  |  Issue : 1  |  Page : 5--11

Journey in uveitis through 28 years


Jyotirmay Biswas 
 Department of Uveitis and Ocular Pathology, Sankara Nethralaya, Chennai, Tamil Nadu, India

Correspondence Address:
Jyotirmay Biswas
Department of Uveitis and Ocular Pathology, Sankara Nethralaya, Chennai, Tamil Nadu
India




How to cite this article:
Biswas J. Journey in uveitis through 28 years.Kerala J Ophthalmol 2018;30:5-11


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Biswas J. Journey in uveitis through 28 years. Kerala J Ophthalmol [serial online] 2018 [cited 2021 Sep 26 ];30:5-11
Available from: http://www.kjophthal.com/text.asp?2018/30/1/5/233770


Full Text

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The known is finite, the unknown is infinite, intellectually, we stand on an islet in the midst of ocean of inexplicability. Our business in every generation is to reclaim a little more land.

- T H Huxley.

My humble journey in uveitis started 28 years back when I returned from USA in 1989 after completing my fellowship in ophthalmic pathology at Doheny Eye Institute, University of Southern California, Los Angeles under internationally renowned uveitis specialist and ophthalmic pathologist Professor Narsing Rao. Before that I finished fellowship in vitreoretinal surgery under legendary Dr. S. S. Badrinath in Sankara Nethralaya. I started my uveitis career with a project “Ocular morbidity in active systemic tuberculosis (TB).” This study was quite relevant due to the fact that every fourth patient of TB in the world is an Indian. The questions we asked were (1) what was the ocular morbidity in active systemic TB? (2) What were the types of ocular TB seen in active systemic TB? (3) Is Eales' disease seen in active systemic TB? I did complete ophthalmic examination including indirect ophthalmoscopy of 1005 consecutive patients of active systemic TB in TB Research Center in Chetpet, Chennai. I found that ocular morbidity in active systemic TB is only 1.39%. The most common ocular lesion seen was healed focal choroiditis. Other lesions were healed multifocal choroiditis and miliary tubercle of the choroid [Figure 1]. Surprisingly, no case of Eales' disease was seen in active systemic TB.[1] Subsequently, we performed research on various clinical and laboratory studies in ocular TB (15 articles). In 1995, we published in the Retina Journal, clinicopathological study of five cases of intraocular TB. In the period from 1984 to 1994, we had seen only five cases of microbiologically and/or histopathologically proven intraocular TB. This indicated that intraocular TB, though not uncommon, is often paucibacillary. These five cases included two cases of subretinal abscess [Figure 1], one case each of granulomatous anterior uveitis with scleral perforation, exudative mass in the anterior chamber, and panuveitis with choroidal mass. Abundant acid-fast bacilli were seen in one case of subretinal abscess, which had undergone evisceration [Figure 2] and [Figure 3].[2]{Figure 1}{Figure 2}{Figure 3}

With the advent of acquired immune deficiency syndrome (AIDS), we started seeing quite a few cases of ocular TB. It comprised of 4.8% cases in our cohort of AIDS patient with ocular lesions. The most common presentation was asymptomatic choroidal tubercles. Other presentations include subretinal abscess, panophthalmitis, and conjunctival mass.[3]

We used to see a large number of cases of Eales' disease in our uveitis clinic. In fact one of every 135 patients in our hospital was diagnosed to have Eales' disease [Figure 4]. The disease was of quite interest to me. Me and my colleagues had made 30 publications of clinical and basic research on this disease including two review articles,[4],[5] one of which was a major review in Survey of Ophthalmology. Notably, we found mycobacterium TB DNA in the vitreous fluid,[6] epiretinal membrane,[7] and even in the paraffin section of enucleated globe.[8] These works were published in British Journal of Ophthalmology,[6]Investigative Ophthalmology and Visual Science,[7] and International Ophthalmology.[8] Recently, we published long-term follow-up of largest cohort of Eales' disease patients which included 898 eyes of 500 patients with mean follow-up duration of 15.8 years (10–25 years). The study showed 52% of eyes had <5 recurrences over 10 years.[9]{Figure 4}

We then started exploring on serpiginous choroiditis, a type of choroiditis common in our South Indian referral eye institute. We published the clinical profile, treatment, and visual outcome of 107 eyes of 70 patients of serpiginous choroiditis seen in our uvea clinic [Figure 5]. Our study showed that a combination of systemic steroid and immunosuppressive agents could result in resolution of choroiditis with improvement of vision. The main reason of loss of vision was macular involvement by the choroiditis.[10] We also made one of the early publications of ampiginous choroiditis, a variant of serpiginous choroiditis in 26 eyes of 16 patients [Figure 6]. The disease was found to have multiple relapses and responded to immunosuppressive and steroid.[11]{Figure 5}{Figure 6}

One of our early works was on human immunodeficiency virus (HIV) and eyes. First case of HIV infection was reported from a cohort of sex workers of Madras by Simoes et al. in 1987.[12] We published first two cases of ocular lesions in AIDS in India in 1995 [Figure 7].[13] In 2000, we published in American Journal of Ophthalmology “Ocular lesions associated with HIV infection in India in a series of 100 consecutive cases,”[14] and 40% of these patients had one or more ocular lesions. We described various ocular lesions in AIDS patients which included lid abscess with extensive molluscum contagiosum,[15] blepharitis with lid ulcer,[16] papilloedema due to cryptococcal meningitis [17] blood tinged, hypopyon [18] immune recovery uveitis,[19] panophthalmitis,[20] squamous cell carcinoma,[21] frosted branch angiitis,[22] central retinal vein occlusion,[23] and multiple cranial nerve palsy.[24] Thirteen years after the initial publication on AIDS, we published a series of 1000 consecutive HIV-positive patients in India. Cytomegalovirus retinitis was the most common opportunistic infection in highly active antiretroviral therapy (HAART) and HAART era.[25] We also studied ocular lesions due to AIDS in pediatric patients and found cytomegalovirus retinitis to be the most common ocular lesion.[26]{Figure 7}

Viral uveitis, other than HIV and parasitic infection, was also our area of interest. We published clinical features, management, and outcomes of 63 eyes of 52 patients of acute retinal necrosis in a span of 10 years [Figure 8]. Favorable visual outcome was seen in 45% cases.[27] We also described chikungunya neuroretinitis, a new viral retinal infection.[28]{Figure 8}

We have also described various clinical manifestations of intraocular parasites.[29] We did clinical and microscopic study of various intraocular parasites which included Gnathostoma spinigerum,[30]Dirofilaria,[31] botfly,[32]Brugia malayi,[33]Wuchereria bancrofti,[34] and Linguatula serrata.[35] We conducted clinicopathological study as well as scanning electron microscopic study.[30] We described unusual manifestation of cysticercus cellulosae causing fibrinous anterior uveitis [36] and endophthalmitis.[37] We published two cases of ocular malaria with pathological study of the autopsy eyes of one malaria patient [38] [Figure 9] and a case of bilateral macular hemorrhage due to Kala-azar.[39]{Figure 9}

Among the autoimmune uveitis, Vogt–Koyanagi–Harada (VKH) disease was our area of interest. We reported analysis of 87 cases of VKH disease in Japanese Journal of Ophthalmology [Figure 10] and [Figure 11]. Our study showed VKH disease is less frequent in India than Japan but as common in United States. Extraocular signs are far less common than in Japanese patients. Immunosuppressive agents are better in the management of VKH patients.[40]{Figure 10}{Figure 11}

We did seminal work in epidemiological study of uveitis in clinic-based populations.[41],[42] We were the earliest to report it in 1995, an analysis of 465 new cases in a year. Our study showed that anterior uveitis (36.5%) was the most commonly encountered uveitis followed by posterior uveitis (28.4%), intermediate uveitis (19.8%), and panuveitis (15.3%). Etiology remained undetermined in 58.7% cases. The most common cause of anterior uveitis was collagen diseases, toxoplasmosis in posterior uveitis, and VKH in pan uveitis.[41]

We also studied the pattern of uveitis in pediatric patients and found juvenile idiopathic arthritis and intermediate uveitis [43],[44] to be the most common associations. We analyzed 64 eyes of 40 patients of juvenile idiopathic arthritis-associated uveitis in India and found that the most common presentation was pauciarticular type with preponderance in males. Rheumatoid arthritis factor and antinuclear antibodies were not as common as compared to the Western population. For long-term treatment, immunosuppressive was found to be better.[45]

We worked on various ancillary tests and laboratory investigations in uveitis.[46] We described utility of ultrasound biomicroscopy [47],[48],[49] and indocyanine green angiography [50] soon after it came into vogue. We also described various types of visual field changes in serpiginous choroiditis.[51]

Since 1997 onward, we started using polymerase chain reaction (PCR) analysis, a molecular biologic technique in infectious uveitis. We published in 1998 about the usage of PCR in detection of mycobacterium TB complex DNA in suspected tubercular uveitis [Figure 12], [Figure 13], [Figure 14].[52] We published in 2002 a case of disseminated TB with choroidal tubercles where an aqueous aspirate showed mycobacterium TB DNA.[53] Subsequently, we published 27 articles of application of PCR in clinically suspected tubercular uveitis and Eales' disease.{Figure 12}{Figure 13}{Figure 14}

We started using high-resolution computerized tomography of the chest in evaluation of uveitis particularly granulomatous uveitis and found that it was more sensitive than chest X-ray and can detect lesions due to TB and sarcoidosis in the chest more efficiently.[54] We also found that it was useful in identifying tubercular chest lesions in Eales' disease.[55] Since 2010, we started using QuantiFERON TB gold test in suspected tubercular uveitis. We found it correlated better with clinically suspected tubercular uveitis than Mantoux test.[56]

The management of uveitis is of paramount importance to patients as well as uveitis specialists. I wrote a practical concept in the management of uveitis in 1993 in Indian Journal of Ophthalmology.[57] We reported in 2004 efficacy and safety of rimexolone in treatment of anterior uveitis and found that it has similar efficacy as that of prednisolone.[58] We wrote about the usage of triple immunosuppressive agents in VKH [59] and sympathetic ophthalmia.[60] We reported for the first time from India about the use of mycophenolate mofetil in the treatment of noninfectious uveitis.[61] We were the first to report full-thickness eye wall resection in tuberculous granuloma.[62] Dexamethasone intravitreal implant (Ozurdex) has recently emerged as a treatment option in noninfectious uveitis. We used Ozurdex implant in noninfectious intermediate uveitis and reported its safety and efficacy.[63] Cataract extraction in uveitis is often challenging. We described the techniques, precautions, clinical, and visual outcome of cataract extraction in various types of uveitis patients.[64]

My ongoing journey in uveitis has been eventful and enthralling. I enjoyed every bit of it. I acknowledge my patients for their cooperation and trust in me, my fellows, and postgraduate students for stimulating me, and my peers and teachers for educating me all the time.

References

1Biswas J, Badrinath SS. Ocular morbidity in patients with active systemic tuberculosis. Int Ophthalmol 1995;19:293-8.
2Biswas J, Madhavan HN, Gopal L, Badrinath SS. Intraocular tuberculosis. Clinicopathologic study of five cases. Retina 1995;15:461-8.
3Babu RB, Sudharshan S, Kumarasamy N, Therese L, Biswas J. Ocular tuberculosis in acquired immunodeficiency syndrome. Am J Ophthalmol 2006;142:413-8.
4Biswas J, Sharma T, Gopal L, Madhavan HN, Sulochana KN, Ramakrishnan S, et al. Eales disease – An update. Surv Ophthalmol 2002;47:197-214.
5Biswas J, Ravi RK, Naryanasamy A, Kulandai LT, Madhavan HN. Eales' disease – Current concepts in diagnosis and management. J Ophthalmic Inflamm Infect 2013;3:11.
6Biswas J, Therese L, Madhavan HN. Use of polymerase chain reaction in detection of Mycobacterium tuberculosis complex DNA from vitreous sample of Eales' disease. Br J Ophthalmol 1999;83:994.
7Madhavan HN, Therese KL, Gunisha P, Jayanthi U, Biswas J. Polymerase chain reaction for detection of Mycobacterium tuberculosis in epiretinal membrane in Eales' disease. Invest Ophthalmol Vis Sci 2000;41:822-5.
8Verma A, Biswas J, Dhanurekha L, Gayathri R, Lily Therese K. Detection of Mycobacterium tuberculosis with nested polymerase chain reaction analysis in enucleated eye ball in Eales' disease. Int Ophthalmol 2016;36:413-7.
9Biswas J, Reesha KR, Pal B, Gondhale HP, Kharel Sitaula R. Long-term outcomes of a large cohort of patients with Eales' disease. Ocul Immunol Inflamm 2017;27:1-7.
10Abrez H, Biswas J, Sudharshan S. Clinical profile, treatment, and visual outcome of serpiginous choroiditis. Ocul Immunol Inflamm 2007;15:325-35.
11Jyotirmay B, Jafferji SS, Sudharshan S, Kalpana B. Clinical profile, treatment, and visual outcome of ampiginous choroiditis. Ocul Immunol Inflamm 2010;18:46-51.
12Simoes EA, Babu PG, John TJ, Nirmala S, Solomon S, Lakshminarayana CS, et al. Evidence for HTLV-III infection in prostitutes in Tamil Nadu (India). Indian J Med Res 1987;85:335-8.
13Biswas J, Madhavan HN, Badrinath SS. Ocular lesions in AIDS: A report of first two cases in India. Indian J Ophthalmol 1995;43:69-72.
14Biswas J, Madhavan HN, George AE, Kumarasamy N, Solomon S. Ocular lesions associated with HIV infection in India: A series of 100 consecutive patients evaluated at a referral center. Am J Ophthalmol 2000;129:9-15.
15Biswas J, Lily T, Kumarasamy N, Solomon S. Lid abscess with extensive molluscum contagiosum in a patient with acquired immunodeficiency syndrome (AIDS). Indian J Ophthalmol 1997;45:234-6.
16Biswas J, Madhavan HN, Kumarasamy N, Solomon S. Blepharitis and lid ulcer as initial ocular manifestations in acquired immunodeficiency syndrome (AIDS) patients. Indian J Ophthalmol 1997;45:233-4.
17Battu RR, Biswas J, Jayakumar N, Madhavan HN, Kumarsamy N, Solomon S, et al. Papilloedema with peripapillary retinal haemorrhages in an acquired immunodeficiency syndrome (AIDS) patient with cryptococcal meningitis. Indian J Ophthalmol 2000;48:47-9.
18Biswas J, Samanta TK, Madhavan HN, Kumarasamy N, Solomon S. Acute panuveitis with haemorrhagic hypopyon as a presenting feature of acquired immunodeficiency syndrome (AIDS). Indian J Ophthalmol 2000;48:311-2.
19Biswas J, Choudhry S, Kumarasamy N, Solomon S. Immune recovery vitritis presenting as panuveitis following therapy with protease inhibitors. Indian J Ophthalmol 2000;48:313-5.
20Samanta TK, Biswas J, Gopal L, Kumarasamy N, Solomon S. Panophthalmitis due to rhizopus in an AIDS patient: A clinicopathological study. Indian J Ophthalmol 2001;49:49-51.
21Fogla R, Biswas J, Kumar SK, Madhavan HN, Kumarasamy N, Solomon S, et al. Squamous cell carcinoma of the conjunctiva as initial presenting sign in a patient with acquired immunodeficiency syndrome (AIDS) due to human immunodeficiency virus type-2. Eye (Lond) 2000;14(Pt 2):246-7.
22Biswas J, Raizada S, Gopal L, Kumarasamy N, Solomon S. Bilateral frosted branch angiitis and cytomegalovirus retinitis in acquired immunodeficiency syndrome. Indian J Ophthalmol 1999;47:195-7.
23Biswas J, Deka S, Padmaja S, Madhavan HN, Kumarasamy N, Solomon S, et al. Central retinal vein occlusion due to herpes zoster as the initial presenting sign in a patient with acquired immunodeficiency syndrome (AIDS). Ocul Immunol Inflamm 2001;9:125-30.
24Karna S, Biswas J, Kumarasamy N, Sharma P, Solomon S. Multiple cranial nerve palsy in an HIV-positive patient. Indian J Ophthalmol 2001;49:118-20.
25Sudharshan S, Kaleemunnisha S, Banu AA, Shrikrishna S, George AE, Babu BR, et al. Ocular lesions in 1,000 consecutive HIV-positive patients in India: A long-term study. J Ophthalmic Inflamm Infect 2013;3:2.
26Biswas J, Kumar AA, George AE, Madhavan HN, Kumarasamy N, Solomon S, et al. Ocular and systemic lesions in HIV positive children – Analysis of 12 cases. J Pediatr 2000;67:721-4.
27Roy R, Pal BP, Mathur G, Rao C, Das D, Biswas J, et al. Acute retinal necrosis: Clinical features, management and outcomes – A 10 year consecutive case series. Ocul Immunol Inflamm 2014;22:170-4.
28Nair AG, Biswas J, Bhende MP. A case of bilateral chikungunya neuroretinitis. J Ophthalmic Inflamm Infect 2012;2:39-40.
29Rathinam SR, Annamalai R, Biswas J. Intraocular parasitic infections. Ocul Immunol Inflamm 2011;19:327-36.
30Biswas J, Gopal L, Sharma T, Badrinath SS. Intraocular Gnathostoma spinigerum. Clinicopathologic study of two cases with review of literature. Retina 1994;14:438-44.
31Agarwal M, Biswas J. Live intraocular dirofilaria causing multifocal choroiditis. Retin Cases Brief Rep 2009;3:228-9.
32Parikh V, Biswas J, Vaijayanthi K, Das D, Raval V. Bilateral ocular myiasis interna caused by botfly (Oestrus ovis): A case report. Ocul Immunol Inflamm 2011;19:444-7.
33Mohan A, Verghese A, Raman M, Biswas J. Live Brugia malayi in the anterior chamber: A case report from India. Eye (Lond) 2014;28:1038.
34Ganesh SK, Babu K, Krishnakumar S, Biswas J. Ocular filariasis due to Wuchereria bancrofti presenting as panuveitis: A case report. Ocul Immunol Inflamm 2003;11:145-8.
35Bhende M, Abhishek, Biswas J, Raman M, Bhende PS. Linguatula serrata in the anterior chamber of the eye. Indian J Ophthalmol 2014;62:1159-61.
36Mahendradas P, Biswas J, Khetan V. Fibrinous anterior uveitis due to cysticercus cellulosae. Ocul Immunol Inflamm 2007;15:451-4.
37Mulla MA, Banker AS, Rishi E, Biswas J. Degenerated intravitreal cysticercus cyst masquerading as endogenous endophthalmitis. Ocul Immunol Inflamm 2012;20:378-80.
38Biswas J, Fogla R, Srinivasan P, Narayan S, Haranath K, Badrinath V, et al. Ocular malaria. A clinical and histopathologic study. Ophthalmology 1996;103:1471-5.
39Biswas J, Mani B, Bhende M. Spontaneous resolution of bilateral macular haemorrhage in a patient with Kala-Azar. Eye (Lond) 2000;14(Pt 2):244-6.
40Mondkar SV, Biswas J, Ganesh SK. Analysis of 87 cases with Vogt-Koyanagi-Harada disease. Jpn J Ophthalmol 2000;44:296-301.
41Das D, Biswas J, Ganesh SK. Pattern of uveitis in a referral uveitis clinic in India. Indian J Ophthalmol 1995;43:117-21.
42Biswas J, Narain S, Das D, Ganesh SK. Pattern of uveitis in a referral uveitis clinic in India. Int Ophthalmol 1996;20:223-8.
43Narayana KM, Bora A, Biswas J. Patterns of uveitis in children presenting at a tertiary eye care centre in South India. Indian J Ophthalmol 2003;51:129-32.
44Ganesh SK, Bala A, Biswas J, Ahmed AS, Kempen JH. Pattern of pediatric uveitis seen at a tertiary referral center from India. Ocul Immunol Inflamm 2016;24:402-9.
45Sudharshan S, Biswas J, Ganesh SK. Analysis of juvenile idiopathic arthritis associated uveitis in India over the last 16 years. Indian J Ophthalmol 2007;55:199-202.
46Majumder PD, Sudharshan S, Biswas J. Laboratory support in the diagnosis of uveitis. Indian J Ophthalmol 2013;61:269-76.
47Biswas J, Bhende MP, Mondkar S. Ultrasound biomicroscopy (UBM) in anterior inflammatory disorder. Ann Ophthalmol 2000;32:301-6.
48Bhende M, Biswas J, Sharma T, Chopra SK, Gopal L, Shroff CM, et al. Ultrasound biomicroscopy in the diagnosis and management of pars planitis caused by caterpillar hairs. Am J Ophthalmol 2000;130:125-6.
49Bhende M, Biswas J, Gopal L. Ultrasound biomicroscopy in the diagnosis and management of intraocular gnathostomiasis. Am J Ophthalmol 2005;140:140-2.
50Agrawal RV, Biswas J, Gunasekaran D. Indocyanine green angiography in posterior uveitis. Indian J Ophthalmol 2013;61:148-59.
51Balarabe AH, Biswas J. Serpiginous choroiditis in a referral clinic in India: Visual field changes and clinical correlates. Ocul Immunol Inflamm 2014;22:379-83.
52Biswas J, Therese L, Madhavan HN. Use of Polymerase Chain Reaction (PCR) in the Detection of Mycobacterium tuberculosis Complex DNA from Aqueous Sample of Suspected Tuberculosis Uveitis. Proceedings of the 4th International Symposium on Uveitis, Yokohama, Japan, 10-14 October, 1997; 1998. p. 227-30.
53Biswas J, Shome D. Choroidal tubercles in disseminated tuberculosis diagnosed by the polymerase chain reaction of aqueous humor. A case report and review of the literature. Ocul Immunol Inflamm 2002;10:293-8.
54Ganesh SK, Roopleen, Biswas J, Veena N. Role of high-resolution computerized tomography (HRCT) of the chest in granulomatous uveitis: A tertiary uveitis clinic experience from India. Ocul Immunol Inflamm 2011;19:51-7.
55Kharel Sitaula R, Iyer V, Noronha V, Dutta Majumder P, Biswas J. Role of high-resolution computerized tomography chest in identifying tubercular etiology in patients diagnosed as Eales' disease. J Ophthalmic Inflamm Infect 2017;7:4.
56Sudharshan S, Ganesh SK, Balu G, Mahalakshmi B, Therese LK, Madhavan HN, et al. Utility of QuantiFERON ®-TB Gold test in diagnosis and management of suspected tubercular uveitis in India. Int Ophthalmol 2012;32:217-23.
57Biswas J. Practical concepts in the management of uveitis. Indian J Ophthalmol 1993;41:133-41.
58Biswas J, Ganeshbabu TM, Raghavendran SR, Raizada S, Mondkar SV, Madhavan HN, et al. Efficacy and safety of 1% rimexolone versus 1% prednisolone acetate in the treatment of anterior uveitis – A randomized triple masked study. Int Ophthalmol 2004;25:147-53.
59Agarwal M, Ganesh SK, Biswas J. Triple agent immunosuppressive therapy in Vogt-Koyanagi-Harada syndrome. Ocul Immunol Inflamm 2006;14:333-9.
60Ganesh SK, Narayana KM, Biswas J. Peripapillary choroidal atrophy in sympathetic ophthalmia and management with triple-agent immunosuppression. Ocul Immunol Inflamm 2003;11:61-5.
61Rathore VM, Agrawal R, Chaudhary SP, Biswas J. Mycophenolate mofetil therapy in uveitis: Analysis of eight cases in a tertiary ophthalmic care centre in India. Int Ophthalmol 2009;29:117-22.
62Gopal L, Rao SK, Biswas J, Madhavan HN, Agarwal S. Tuberculous granuloma managed by full thickness eye wall resection. Am J Ophthalmol 2003;135:93-4.
63Palla S, Biswas J, Nagesha CK. Efficacy of ozurdex implant in treatment of noninfectious intermediate uveitis. Indian J Ophthalmol 2015;63:767-70.
64Agrawal R, Murthy S, Ganesh SK, Phaik CS, Sangwan V, Biswas J, et al. Cataract surgery in uveitis. Int J Inflam 2012;2012:548453.