DR. sudha madhavi. K. M post graduate student in m. S. Ophthalmology kims, hubli



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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.
ANNEXURE II
PORFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION


1.


NAME OF THE CANDIDATE AND

ADDRESS


DR. SUDHA MADHAVI. K. M

POST GRADUATE STUDENT IN

M.S. OPHTHALMOLOGY

KIMS, HUBLI-22



2.


NAME OF THE INSTITUTION


KARNATAKA INSTITUTE OF MEDICAL

SCIENCES, HUBLI-22


3.


COURSE OF STUDY AND

SUBJECT



M.S. IN OPHTHALMOLOGY


4.


DATE OF ADMISSION TO COURSE


03.04.2008.




5.

TITLE OF TOPIC

A CLINICAL STUDY OF ANTERIOR UVEITIS AT KIMS, HUBLI”.




6.


BRIEF RESUME OF THE INTENDED WORK

6.1 Need for the study:

“Uveitis” is one of the most common forms of intraocular inflammation. It includes a large group of intraocular inflammatory diseases of diverse etiology. It causes vision loss both directly through inflammation and via complications such as macular edema, glaucoma, cataract, and others. The variation in the spectrum of disease is largely due to complex geographic, ecological, racial, nutritional, and socioeconomic differences.

Anterior uveitis which can be categorized as iritis, anterior cyclitis and iridocyclitis is the most common type of all uveitic entities. It often causes a painful red eye. Acute anterior uveitis causes mild vision loss but still contributes significantly to the total burden. The precise cause of anterior uveitis is often obscure and the correct diagnosis is often challenging. The treatment for uveitis itself can result in both ocular and systemic complications. The morbidity associated with the disease is moderately high.

KIMS, Hubli being tertiary care hospital and major referral center we get fair number of cases of anterior uveitis per OPD.Hence in the study conducted every effort is made to establish the exact cause and accurate diagnosis in all the cases. Early institution of the treatment with monitoring is done for better results.


6.2 Review of literature:

Anterior uveitis is the commonest form of all uveitis (57.4%). Anterior uveitis has an incidence of roughly 17 cases per 100,000 population.1 On the basis of overall clinical presentation, acute unilateral, non-infectious and nongranulomatous forms occur more frequently. Idiopathic anterior uveitis is common in all age groups. Mean age at presentation is 38.3yr and commonly affects middle aged (17-59)yr. It is more common in males (61.3%) compared to females (38.6%).

Herpetic anterior uveitis (16.7%), lens induced uveitis (14.6%) and leprosy uveitis (4.9%) are more common in elderly population. Fuch’s heterochromatic uveitis (9.8%), uveitis associated with spondyloarthropathy (8.2%), herpetic uveitis(8.2%) and traumatic (7.8%) are common in middle aged 2.Ankylosing spondylitis(18.91%)is the most common cause for non-infective anterior uveitis and tuberculosis (7.9%) for infective anterior uveitis.3

HLA A9 and B27 is more common in acute anterior uveitis associated with Ankylosing Spondylitis(AS)4. It is sudden in onset and the inflammation is active in one eye, but the attacks tend to recur , often in the contralateral eye. Complete resolution within several months of the onset is the rule.

Tuberculosis is a well known cause of acute or chronic granulomatous anterior uveitis that may be associated with iris or angle granulomas with mutton fat keratic precipitates (KP’s) and posterior synechiae.5

Varicella zoster virus (VZV) typically causes unilateral acute anterior uveitis. The intensity of iris atrophy and pupil distortion, but not ocular hypertension , correlate with the viral load of VZV in the aqueous humour.6

Fuch’s heterochromic iridocyclitis (FHI) is a rare form of unilateral anterior uveitis which is characterised by diffuse, stellate KP’s and iris heterochromia. Bilateral diffuse stellate KP’s are a more specific sign.7 Any surgical intervention into the anterior chamber produces hemorrage and is termed Amsler’s sign.

The commonest form of anterior uveitis in leprosy is a chronic , low grade bilateral uveitis which produces minimal or no symptoms until late in the disease process. Acute anterior iridocyclitis is uncommon and occurs bilaterally.8

Vogt-Koyanagi-Harada (VKH) syndrome is reported to recur, typically as a recurrent anterior uveitis with or without recurrent posterior involvement.This is directly related to the failure to prescribe adequate corticosteroid therapy in the initial phase of the syndrome.9

Morbidity arises from iritis and any associated disease process, if present. Associated ocular complications (eg: cataract, glaucoma, macular edema) may result in severe vision loss.

Acute anterior uveitis is associated with lowest rate of complications and lower frequency of visual loss. Chronic anterior uveitis with iris changes has a higher frequency of complications and visual loss.10

Management:

The etiology of anterior uveitis is diverse and hence its differential diagnosis. The diagnosis depends on patient’s history, detailed clinical examination and laboratory investigations which are tailored accordingly.

Corticosteroids have long been the cornerstone of treatment. The principles for uveitis treatment espoused by the International Uveitis Study Group advise to use steroids aggressively as the first step on a step ladder algorithm through all routes necessary to achieve algorithm through all routes necessary to achieve resolution of the inflammation. A slow taper is important to help maintain the level of remission. Other available modalities of treatment are cycloplegics, NSAID’s and immunomodulators.

The medications used are not free of side effects, this necessitates close monitoring.11



6.3 Aims and Objectives:

Clinical study of anterior uveitis concerns with



  • Incidence

  • Mode of onset- Acute, chronic or recurrent

  • Associated and precipitating factors

  • Clinical presentation

  • Complications

  • Investigations to establish the exact cause and accurate diagnosis.

  • The efficacy of the treatment to be given and prognosis.





7.



Materials and methods:

7.1 Source of data:

It is a study conducted on patients aged 20 years and above who were diagnosed to have anterior uveitis in the ophthalmology department, KIMS, Hubli during a peroid of one and half years from Dec 2008 to May 2010 applying following inclusion and exclusion criteria.


INCLUSION CRITERIA:

All patients aged 20 years and above with anterior uveitis characterised by pain, blurred vision, photophobia, ciliary congestion ,tenderness, keratic precipitates, aqueous flare and cells.




EXCLUSION CRITERIA:

Patients with fallowing criteria are excluded from the study,



  • Patients aged below 20 years

  • Intermediate uveitis

  • Posterior uveitis

  • Uveitis developing postoperatively

  • Sympathetic ophthalmitis

  • Masquerade syndromes

Follow up:

It is individualized. During follow up, patients are examined for improvement in symptoms and signs and to rule out possible complications.


7.2 Methods of collection of data(including the sampling procedure if any):

The study will be conducted on all patients of anterior uveitis which fulfil the above inclusion and exclusion criteria in the department of ophthalmology, KIMS, Hubli for a period of one and half years from Dec 2008 to May 2010 as time bound study. Patients will be subjected to detailed ophthalmic evaluation and the data will be recorded in a specially designed proforma which will be transferred to master sheet. The data will be subjected to statistical analysis by the biostatistician of our institution.


7.3 Does the study require any investigations or interventions to be conducted on

patients. If so please describe briefly.

Yes, this study requires investigations.

Routine investigations like, Hb%, complete blood count, ESR, RBS, Urine-sugar, albumin, microscopy and VDRL test and Ophthalmological investigations like



  • Slit lamp boimicroscopy

  • Schiotz tonometry

  • Lacrimal sac syringing

  • Gonioscopy

  • Fundus evaluation under Slit lamp with Goldmann 3-mirror gonioscopy lens or +90D lens.

  • Direct and indirect ophthalmology are done in all patients with anterior uveitis.

Specific investigations will be considered whenever necessary according to the need of the case.
7.4 Has the ethical clearance been obtained from your institution in case of 7.3?

Yes , Ethical clearance has been obtained from KIMS Institutional Ethics Committee (IEC) KIMS, Hubli.



8.


List of references:

  1. Martin TM, Smith JR, Rosenbaum JT. Anterior uveitis: current concepts of pathogenesis and interactions with the Spondyloarthropathies. Curr opin Rheumatol 2002; 14(4):337-41.

  2. Rathinam SR, Namperumalsamy P.Global variation and pattern changes in epidemiology of Uveitis. Indian J Ophthalmol 2007;55:173-83.

  3. Singh R, Gupta V, Gupta A. Pattern of Uveitis in a Referral Eye Clinic in North India. Indian J Ophthalmol 2004; 52: 121-25.

  4. Gupta SS, Jain IS, Jain GC, Deodhar SD. HLA antigens in acute anterior uveitis in North Indians. Indian J Ophthalmol 1978;26: 26-9.

  5. Gupta V, Gupta A, Rao NA. Intraocular Tuberculosis—An Update. Surv Ophthalmol 2007;52: 561-587.

  6. Kido S, Sugita S, Horie S, Miyanaga M, Miyata K, Shimizu N et al. Association of Varicella zoster virus load in the aqeous humour with clinical manifestations of anterior uveiyis in herpes zoster ophthalmicus and zoster sine harpete. Br J Ophthalmol 2008; 92(4): 505-508.

  7. Fearnley IR, Rosenthal AR. Fuchs’ heterochromic iridocyclitis revisited. Acta Ophthalmol Scand 1995;73:166-70.

  8. Espiritu CG, Gelber R, Ostler HB. Chronic anterior uveitis in leprosy: an insidious cause of blindness. Br J Ophthalmol 1991;75:273-275.

  9. Simon T, Susan L, Recurrent Anterior Uveitis in Patients With Vogt-Koyanagi-Harada Syndrome .Arch of Ophthalmol 2004; 122(6): 922-923.

  10. Maini R, O’Sullivan J, Reddy A, Watson S, Edelsten C. The risk of complications of uveitis in a district hosoital cohort. Br J Ophthalmol 2004; 88(4): 512-517.

  11. Abelson M, Foster S, Gupta G. Diagnosing and Managing Anterior Uveitis. Rev Ophthalmol 2002; 9: 23-27.





9.


SIGNATURE OF THE CANDIDATE



10.


REMARKS OF THE GUIDE



11.


NAME AND DESIGNATION

11.1 GUIDE


Dr. G.N.PATIL

M.S

PROFESSOR AND H.O.D,

Department of OPHTHALMOLOGY,

KIMS, Hubli.


11.2 SIGNATURE




11.3 CO-GUIDE (IF ANY)




11.4 SIGNATURE




11.5 HEAD OF THE DEPARTMENT


Dr. G.N.PATIL

M.S

PROFESSOR AND H.O.D,

Department of OPHTHALMOLOGY,

KIMS, Hubli.


11.6 SIGNATURE



12


12.1 REMARKS OF THE CHAIRMAN AND THE PRINCIPAL






    1. SIGNATURE










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