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Bilateral Simultaneous-Onset Nongranulomatous
Acute Anterior Uveitis
Clinical Presentation and Etiology
Andrea D. Birnbaum, MD, PhD; Yi Jiang, MD; Roshni Vasaiwala, MD; Howard H. Tessler, MD; Debra A. Goldstein, MD
Objective: To describe the etiology and outcome of pa- younger than the entire cohort of new patients with uve-
tients with simultaneous-onset nongranulomatous bi- itis who were evaluated during the same time period
lateral acute anterior uveitis. (P=.002). For 14 of the 15 patients with at least a year
of follow-up (93%), the disease duration was limited (3
Methods: The medical records of patients who pre- months). Of these 14 patients, 7 (50%) developed recur-
sented to a single tertiary care center with simultaneous- rent disease, with an average time to first recurrence of
onset nongranulomatous bilateral acute anterior uveitis 20 months (range, 7.5-40 months) after resolution of the
between January 1990 and May 2010 were retrospec- initial inflammatory episode.
tively reviewed; the clinical presentation, results of di-
agnostic testing, and outcome data are described. Conclusions: Simultaneous-onset nongranulomatous bi-
lateral acute anterior uveitis is a rare clinical entity that
Results: A total of 4288 new patients with uveitis were is more common in younger patients and is most fre-
evaluated by the Uveitis Service at the University of Il- quently associated with recent infection and/or sys-
linois at Chicago Eye and Ear Infirmary between Janu- temic antibiotic use. Tubulointerstitial nephritis and uve-
ary 1990 and May 2010. Of these new patients, 44 (1%) itis syndrome should also be considered as a diagnosis.
presented with simultaneous-onset nongranulomatous Diagnostic evaluation should include serum antistrep-
bilateral acute anterior uveitis. The most common eti- tolysin-O titers, HLA-B27 antigen, and urine 2 micro-
ologies were postinfectious or drug-induced uveitis (23 globulin levels because these may reveal systemic dis-
of 44 patients [52%]) and idiopathic uveitis (15 pa- ease that requires therapy.
tients [34%]). Tubulointerstitial nephritis and uveitis syn-
drome, HLA-B27associated uveitis, inflammatory bowel Arch Ophthalmol. 2012;130(11):1389-1394.
disease, and Kawasaki disease each made up fewer than Published online July 9, 2012.
5% of diagnoses. Overall, this group of patients was doi:10.1001/archophthalmol.2012.2006
A
NTERIOR UVEITIS REFERS TO simultaneous-onset nongranulomatous bi-
inflammation located in the lateral acute anterior uveitis (BAAU) evalu-
anterior chamber (iritis) or ated by the Uveitis Service at the Univer-
with associated anterior sity of Illinois at Chicago Eye and Ear
vitreousinvolvement(irido- Infirmary between 1990 and 2010.
cyclitis), and is the most common presen-
tation of uveitis.1-3 Frequent diagnoses, aside METHODS
from idiopathic disease, include HLA-B27
associated disease, Fuchs heterochromic
We were granted permission by the institu-
iridocyclitis,juvenileidiopathicarthritis,and
tional review board of the University of Illi-
herpetic disease.1-3 nois at Chicago to retrospectively review ex-
Acute anterior uveitis describes epi- isting medical records of patients evaluated by
sodic inflammation of sudden onset and the Uveitis Service between January 1990 and
Author Affiliations:
limited duration (3 months).4 Patients May 2010 with a diagnosis of acute anterior
Author Affil
Department of Ophthalmology, are symptomatic, usually experiencing uveitis. The charts of patients with acute an- Department
Northwestern University pain, redness, photophobia, and de- terior uveitis were then reviewed to identify Northwester
(Dr Birnbaum), Rush University creased vision. The disease typically pre- those patients who presented with sympto- (Dr Birnbaum
Medical School (Dr Jiang), and matic simultaneous-onset BAAU. Patients with Medical Scho
sents unilaterally, although episodes may granulomatous inflammation (based on the
Department of Ophthalmology Department
alternate between eyes. Less well de- presence of mutton fat keratic precipitates or
and Visual Sciences, University and Visual S
of Illinois at Chicago scribed is acute anterior uveitis that pre- granulomatous iris nodules) were excluded. To of Illinois at
(Drs Vasaiwala, Tessler, and sents with bilateral, simultaneous onset. be considered symptomatic, patients had to (Drs Vasaiwa
Goldstein), Chicago, Illinois. We present data on a series of patients with have at least 1 ocular complaint consistent with Goldstein), C
a Antistreptolysin-O titers were elevated in 60% of children tested, and 36% of all patients diagnosed with postinfectious or drug-induced uveitis. Three patients
had elevated urine 2 microglobulin levels; these elevated levels were associated with tubulointerstitial nephritis and uveitis syndrome in 2 patients and a kidney
stone in 1 patient.
Abbreviations: ASO, antistreptolysin-O antibody; B2, urine 2 microglobulin; MRSA, methicillin-resistant Staphylococcus aureus; S, confirmed streptococcal
throat infection; URI, upper respiratory tract infection; , negative (laboratory value within the normal range); , positive (elevated laboratory value).
a A specific site of infection was identified in all but 5 patients (ie, patients 10, 11, 12, 15, and 19). These patients all reported generalized malaise and/or flulike
symptoms prior to the development of ocular symptoms. Ten patients also received systemic antibiotic therapy. All antibiotics were given orally, unless specified
otherwise.
No. (%)
Disease Rash Oral Ulcers Back Pain Arthritis
Total (n = 44) 7 (16) 7 (16) 9 (20) 3 (7)
Postinfectious or drug-induced uveitis (n=23) 2 (9) 4 (17) 6 (26) 2 (9)
Idiopathic uveitis (n=15) 3 (20) 3 (20) 3 (20) 1 (7)
TINU syndrome (n=2) 1 (50) 0 (0) 0 (0) 0 (0)
Kawasaki disease (n=1) 1 (100) 0 (0) 0 (0) 0 (0)
Inflammatory bowel disease (n=1) 0 (0) 0 (0) 0 (0) 0 (0)
firmation of diagnosis by a nephrologist. One patient with flammation, even at our tertiary referral service. In this
TINU syndrome tested positive for HLA-B27. Kawasaki series, it comprised 44 of 4288 new patients with uveitis
disease and inflammatory bowel disease were each diag- (1%), which was only 6% of the 687 new patients with
nosed in 1 patient, and both of these patients had been nongranulomatous acute anterior uveitis. Other se-
referred with the diagnosis. ries5-7 have reported somewhat higher percentages of si-
Systemic symptoms at presentation are shown in multaneous-onset BAAU. In one study5 from the United
Table 5. The most common complaint was back pain, States, 4% of all patients with uveitis had this presenta-
which was present in 9 of 44 patients with BAAU (20%) tion, although this study5 included patients who devel-
and 6 of 23 patients with postinfectious or drug- oped bilateral involvement within 16 weeks of initial on-
induced uveitis (26%). Of the 44 patients with BAAU, 8 set of unilateral inflammation vs 4 weeks in our study.
(18%) had a history of oral ulcers, and 7 (16%) had a re- In Turkey, simultaneous-onset BAAU was reported in 7%
cent rash. Only 3 of the 44 patients (7%) reported ar- of patients who tested positive for HLA-B27 and in 26%
thritis or joint pain, 2 of whom were diagnosed with of patients who tested negative.6 This patient popula-
postinfectious or drug-induced uveitis. tion was different, however, because only those retro-
Fifteen patients had at least 1 year of follow-up, with spectively determined to have iridocyclitis of sudden on-
a mean follow-up time of 33.5 months (range, 12-67 set and limited duration were included in the study,6
months) (Table 6). Of these 15 patients, 14 (93%) had whereas our series included patients with uveitis of both
acute disease that resolved within 3 months, and 1 (7%) limited and persistent duration. Finally, a study7 of pa-
had chronic disease with ultimate resolution by 6 months. tients with uveitis in Spain reported 2.7% of patients with
Of the 14 patients with acute disease and at least a year this presentation (ie, BAAU), which is similar to that re-
of follow-up, 7 (50%) developed recurrent inflamma- ported in our study.
tion. The second episode of inflammation was bilateral More than half (52%) of the patients in this series were
in 6 of the 7 patients and occurred, on average, 20 months diagnosed with postinfectious or drug-induced anterior
(range, 5-49 months) after resolution of the initial epi- uveitis. Within the spectrum of postinfectious disease is
sode. Finally, 9 of the patients had more than 2 years of the clinical entity poststreptococcal syndrome uveitis. First
follow-up (range, 24-67 months). None had active described in 1991, the syndrome is common in younger
chronic disease. Four of the 8 patients with acute disease patients (40 years) and usually presents 1 to 6 weeks
(50%) developed a recurrent but limited episode of after onset of systemic symptoms.8 The disease is typi-
inflammation. cally bilateral and associated with elevated serum ASO
titers in more than 95% of cases.8 Titers are normally el-
COMMENT evated 1 week after infection with group A Streptococcus
and peak between 3 to 6 weeks. A decrease begins after
Nongranulomatous acute anterior uveitis with bilateral 6 to 8 weeks, but some patients maintain elevated levels
simultaneous onset is a rare presentation of ocular in- for longer periods of time.9 Posterior segment involve-