Dear Editor,
Multiple sclerosis (MS) is an immune-mediated, chronic inflammatory disorder of the central nervous system (CNS) that primarily affects young adults (20–40 years).[1] Once considered uncommon in the Indian population, MS has been increasingly reported in recent years.[2,3] This rise has been attributed to improved accessibility and availability of radiological imaging such as magnetic resonance imaging (MRI), consultation with neurologists, and increased public awareness.[2,3] Similarly, there is a dearth of ophthalmic literature that associates uveitis with MS patients from India, although there have been a few case reports published from India. We present a case series involving five patients with MS who developed uveitis.
While the most common ocular manifestation of MS remains optic neuritis, uveitis in MS is relatively rare and includes anterior uveitis, intermediate uveitis, and retinal vasculitis. The prevalence of uveitis associated with MS varies, with rates ranging from 0.058% in the general population to 0.65%–1.09% in large cohorts.[1] A female predominance is observed in MS as well as in uveitis linked to the disease, and the majority of the involvement is bilateral.[1,2] All our patients were female, and the majority of them had bilateral involvement. Except for one, all our patients had peripheral retinal peri phlebitis. Among all subtypes of uveitis, intermediate uveitis is more common, and concomitant history or evidence of optic neuritis is common in these MS patients with uveitis as evidenced in the index study.[4,5]
One of our patients developed granulomatous anterior uveitis [Figs 1 and 2] with pars planitis and peripheral retinal vasculitis initially, and 1 year later, a diagnosis of MS was established when she developed bilateral optic neuritis and systemic symptoms. Uveitis can manifest as an initial presentation of MS, with systemic and CNS involvement potentially being absent or subclinical initially. In the absence of neurological symptoms, an episode of uveitis in these patients might initially be managed as idiopathic, and without proper follow-up, ophthalmologists could overlook such associations if the patient does not return for visits.
Figure 1.
(a and b) Slit-lamp photograph showing granulomatous anterior uveitis in patient 1; (c and d) Fundus photograph in the same patients showing vitritis
Figure 2.
(a) MRI brain (T2 coronal) showing hyperdense white matter lesions perpendicular to the body of lateral ventricle (red arrow) and central hypodense with rim of hyperdense lesion indicating chronicity of MS (yellow arrow); (b) MRI brain (T2 sagittal) of patient 4 showing periventricular white matter lesions perpendicular to the body of the lateral ventricle (yellow arrow)
In conclusion, the report describes five patients with uveitis in MS [Table 1], a clinical association that has been sparsely reported from India. Granulomatous anterior uveitis with peripheral retinal vasculitis and vitritis is common among these patients, and uveitis can rarely present as the initial presentation of MS.
Table 1.
Clinical profile of patients presenting with uveitis and multiple sclerosis
| Patient number | Age | Sex | Eye | Anterior Segment | Posterior Segment | Follow-up (in years) | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 49 | F | OU | Mutton fat KPs, AC 2+cells, Posterior synechiae, complicated cataract | Vitreous | 7 | ||||||
| 2 | 18 | F | OU | Mutton fat KPs, AC cells 1+Flare 1+, Peripheral anterior synechiae | Vitritis, snowballs, and snow banking, peripheral periphlebitis | 12 | ||||||
| 3 | 36 | F | OS | AC cells 2+ | Optic neuritis, vitritis, snowballs, peripheral peri phlebitis | 3 | ||||||
| 4 | 40 | F | OU | AC cells 1+, Koeppe nodule, Posterior synechiae, secondary open-angle glaucoma | Vitritis, snowballs, peripheral periphlebitis | 20 | ||||||
| 5 | 46 | F | OS | Medium-sized KPs, AC cells 2+, Flare 2+, Posterior synechiae and complicated cataract | Healed perivasculitis, glaucomatous cupping | 7 |
F=Female, KP=Keratic Precipitates, AC=Anterior Chamber, OU=Both eyes, OS=Left eye
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Nil.
Conflicts of interest:
There are no conflicts of interest.
References
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