SHORT REPORT Multiple Sclerosis 2008; 14: 415417

Uveitis associated with multiple sclerosis

Julie Le Scanff1, Pascal Sve1, Christel Renoux2, Christiane Broussolle1, Christian Confavreux2
and Sandra Vukusic 2

Our study aimed to determine the frequency of uveitis among MS patients through the Lyon MS
Database and compare the clinical spectrum and time course of MS in patients with or without
uveitis. Twenty-eight patients with uveitis were detected. The prevalence of uveitis in our population
was 0.65% (28/4300). Uveitis preceded onset of MS in 46% of the patients; it occurred simultane-
ously or after MS, in 18% and 36% of the cases, respectively. The topography and timing of uveitis
were not associated with any significant difference in MS course and prognosis. There was no differ-
ence in the course and prognosis in patients with or without uveitis. Multiple Sclerosis 2008; 14:
415417. http://msj.sagepub.com

Key words: multiple sclerosis; uveitis

Introduction de Neurologie since 1957 [5]. Since 1990, data have

Uveitis is an inflammation of the uveal tract which
appears unusually in multiple sclerosis (MS)
patients. The reported frequency of uveitis in MS
patients varies widely, from 0.4% to 26.9% [1].
Surprisingly, the prevalence of MS in the total pop-
ulation of patients with uveitis is 12% [1,2]. Two
large studies have recently investigated the fre-
quency and clinical aspects of uveitis in MS
patients [3,4] and showed conflicting results with
regard to the interval between onset of neurological
and ocular symptoms, and to the patterns of uveitis
associated with MS. Our study presents the clinical
findings for the Lyon Multiple Sclerosis cohort. Our
aim was first to determine the frequency of uveitis
in this large population of MS patients, and second
to compare the clinical spectrum and time course
of MS in patients with or without uveitis.
Methods
Patient population and data collection
Patients were identified through the Lyon Multiple
Sclerosis Database, registered at the Lyon Clinique
been computerized using specific software, the
European Database for Multiple Sclerosis (EDMUS)
system [5]. Data confidentiality and security were
ensured in keeping with the recommendations of
the French Commission Nationale Informatique et
Liberts, which gave approval. All patients gave
their informed consent for their data to be saved in
the database.
Definition of cases
Uveitis was registered in the EDMUS software as a
symptom of MS. Patients were examined every six
months and were interviewed about the occurrence
of visual symptoms. Patients with uveitis were auto-
matically extracted and their source medical records
were subsequently reviewed for confirmation.
Uveitis was classified anatomically according to the
International Uveitis Study Group criteria [6]. Cases
of uveitis not related to MS were excluded.
A series of clinical variables was systematically
assessed for each patient: gender, date of MS onset,
age at MS onset and uveitis onset, type of uveitis,
presence of pars planitis or periphlebitis, and dis-
ability assessed through the Kurtzke Disability
Status Scale (DSS) [7].

1
Department of Internal Medicine, Hospices Civils de Lyon, Hotel Dieu, 1 place de lHpital, 69288 Lyon Cedex 02,
France and University Claude Bernard Lyon 1, Lyon, France
2
Department of Neurology A and EDMUS Coordinating Center, Hpital Neurologique, Hospices Civils de Lyon, Lyon,
France; INSERM U842, Lyon, France; Universit Lyon 1, Lyon, France
Author for correspondence: P Sve, Department of Internal Medicine, Htel Dieu, 1 place de lHpital, 69288 Lyon
Cedex 02, France. E-mail: pascal.seve@chu-lyon.fr
Received 21 February 2007; accepted 27 July 2007

2008 SAGE Publications 10.1177/1352458507083444

Los Angeles, London, New Delhi and Singapore
416 JL Scanff et al.
Definition of the control group
The control group was identified through the Lyon
natural history cohort of 1844 patients. The database
was locked in 1997, before the first immunoactive
drugs with proven efficacy in MS were marketed [5].
Because this subgroup of patients have been exten-
sively studied, their data are rather exhaustive,
which is not always the case for the patients recent-
ly registered in the database.
Results
Thirty-one of the 4300 patients making up the
Lyon MS database had experienced uveitis at least
once. Two patients with uveitis associated with
HLAB27 antigen and one patient with Fuchs dis-
ease were excluded. Finally, 28 patients distributed
into 19 women and 9 men were analyzed. The
prevalence of uveitis in our population was 0.65%
(28/4300).
Clinical characteristics of MS patients with
concomitant uveitis
The detailed clinical characteristics of our 28
patients are presented in Table 1. MS course was
relapsing-remitting in 20 patients (71.4%) and sec-
ondary progressive in eight (28.6%) patients. None
had progressive onset. Mean age at onset of uveitis
was 29.6 years and mean age at onset of neurologi-
cal symptoms was 28.1 years. Uveitis preceded neu-
rological symptoms in 13 of the 28 patients
(46.4%). In five patients (17.9%), neurological and
ocular symptoms developed simultaneously. In 10
patients (35.7%), uveitis lasted from one to 28 years
(mean, 10.9 years) after onset of MS. Uveitis preced-
ing MS onset had no specific (e.g., anatomic) features
and median time to reach DSS was not significantly
different according to the timing of uveitis.
Posterior uveitis was the most common present-
ing feature (10 patients, 35.7%). Isolated anterior
uveitis was observed in eight patients (28.6%),
panuveitis in eight patients (28.6%) and intermedi-
ate uveitis in two patients (7.1%). Retinal
periphlebitis was noted in five patients (17.8%).
The time course of uveitis was acute in five
patients, all with anterior uveitis (1 granulomatous)
and chronic (more than 3 months) in 23. Fourteen
patients (50%) had bilateral uveitis and five
patients showed a relapsing course of uveitis.
Median follow-up was 13 years (range 138).
Comparative demographic and disease-related
characteristics of MS patients with or without uveitis
The data of the 28 MS patients with uveitis were
compared to those of 1553 MS patients from the
Multiple Sclerosis 2008; 14: 415417
Lyon natural history, without uveitis. MS duration
was similar between the two groups, with a mean of
12.9 years and 11.5 years, respectively, in patients
with and without uveitis (P
0.44). There was no
significant difference between patients with and
without uveitis for sex ratio (P
0.49), mean age at
MS onset (P
0.40), or overall disease course
(P
0.44). Median times to reach DSS 4 and DSS 6
were respectively 12 and 23.9 years in patients with
uveitis and 11.4 and 24.9 years in patients without
uveitis (P
0.44 and P
0.66, respectively).
Discussion
The association of MS and uveitis is rare, occurring
in only 0.65%. Earlier studies reported a higher
frequency, but two late studies of larger cohorts
with neurological symptoms describe a similar
prevalence of 1% (12 out of 1098 patients) [3] and
1.7% (8 out of 450 patients) [4]. The prevalence of
uveitis in our local area is approximately 38 cases
per 100 000 inhabitants in the general population
[8], making uveitis 17 times more common in MS
patients.
Posterior uveitis was the most frequent presenta-
tion in our study, whereas intermediate uveitis and
panuveitis had previously been reported to be the
most common types of uveitis in MS patients
referred to uveitis clinics [1]. In other studies
however [4,9], anterior and particularly chronic
bilateral granulomatous anterior uveitis were the
most frequent types of uveitis associated with MS.
Intermediate uveitis may be difficult to diagnose.
In our study, as most symptomatic attacks of uveitis
were not diagnosed in uveitis clinics, we may have
underestimated the frequency of pars planitis and,
in some cases, of panuveitis.
Malinowski et al. [10] found that 16.2% (/6.2)
patients with pars planitis could develop MS within
five years. In our study though, uveitis preceding
MS onset had no specific (e.g., anatomic) features.
One explanation for these heterogeneous results
may be recruitment bias, as most reports have been
written by ophthalmologists before assessing
patients for ocular disorder [1,3]. Differing results
may also express the broad clinical spectrum of
ocular inflammation in MS. Our series offers the
advantage of being representative of MS patients in
our region.
Our results confirm previous reports of the liter-
ature on the clinical characteristics of MS patients.
Patients with MS-associated uveitis are usually
young adult or middle-aged Caucasians, most of
them female. In accordance with Biousses study
[3], onset of uveitis usually preceded MS diagnosis
or was concomitant. There was no correlation
between the time course of uveitis and MS, and
http://msj.sagepub.com
 Uveitis associated with multiple sclerosis 417

Table 1 Clinical characteristics of MS patients with uveitis

Age at uveitis Uveitis Age at MS MS course (at last Follow-up

Patient Sex onset (years) Type of uveitis evolution onset (years) follow-up) (years)

1 M 29 Anterior acute 27 Relapsing-Remitting 2

2 F 31 Anterior acute 35 Relapsing-Remitting 1
3 F 44 Panuveitis chronic 30 Relapsing-Remitting 23
4 F 26 Posterior periphlebitis chronic 38 Relapsing-Remitting 23
5 M 9 Intermediate chronic 12 Secondary-Progressive 19
6 F 27 Intermediate chronic 27 Relapsing-Remitting 11
7 F 23 Anterior acute 34 Relapsing-Remitting 2
8 F 21 Posterior chronic 24 Relapsing-Remitting 19
9 F 25 Anterior granulomatous chronic 27 Relapsing-Remitting 11
10 F 15 Anterior chronic 25 Relapsing-Remitting 19
11 F 30 Panuveitis chronic 22 Secondary-Progressive 21
12 M 51 Anterior acute 39 Secondary-Progressive 13
13 F 25 Posterior chronic 27 Relapsing-Remitting 6
14 M 41 Panuveitis chronic 41 Secondary-Progressive 15
15 M 24 Panuveitis chronic 27 Relapsing-Remitting 5
16 F 33 Anterior acute 42 Relapsing-Remitting 3
17 F 20 Panuveitis chronic 14 Secondary-Progressive 18
18 F 55 Posterior periphlebitis chronic 27 Relapsing-Remitting 30
19 F 8 Posterior chronic 16 Relapsing-Remitting 5
20 F 15 Panuveitis periphlebitis chronic 15 Relapsing-Remitting 4
21 M 46 Posterior periphlebitis chronic 32 Relapsing-Remitting 13
22 F 25 Panuveitis chronic 24 Relapsing-Remitting 13
23 F 44 Panuveitis periphlebitis chronic 40 Relapsing-Remitting 5
24 F 31 Posterior chronic 34 Relapsing-Remitting 13
25 M 26 Anterior chronic 26 Relapsing-Remitting 4
26 M 30 Posterior chronic 31 Secondary-Progressive 15
27 M 27 Posterior chronic 27 Secondary-Progressive 13
28 F 49 Posterior chronic 23 Secondary-Progressive 38

M, male; F, female; UA, anterior uveitis; UP, posterior uveitis; PU, panuveitis; UI, intermediate uveitis; RR, relapsing-remitting;
SP, secondary-progressive

the clinical course or severity of MS. It does not References

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ly developed uveitis. As in other studies [3,4], com-
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out uveitis has not confirmed the hypothesis of MS
patients with ocular inflammation being distinct as
to clinical course and disability.
Conclusion
Our study shows a prevalence of uveitis in MS
patients of 0.65% which, though low, is much
higher than expected in the general population.
Posterior uveitis was the most common type of
uveitis. MS course and prognosis were not associated
with the presence or absence of symptomatic uveitis,
as it was also the case for topography and timing
of uveitis.
Contributions
Dr. Le Scanff and Dr. Sve contributed equally to
this study.
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