CASE REPORT

An atypical case of HLA-B27-associated with and posterior segment involvement

by thoMaS XiE, oD & Etty bitton, oD, MSc, Faao Introduction cases.7-10 Furthermore, anterior and AbSTrACT intermediate uveitis cases have a veitis, the most common form lower risk of hypopyon compared to The presence of a hypopyon and of inflammatory , is posterior segment involvement U patients with only anterior uveitis.6 an important public health concern. are uncommon clinical findings in This report highlights an atypical It accounts for a significant percent- HLA-B27-associated uveitis. Further- case of HLA-B27-associated uveitis more, first-time attacks rarely occur in age (estimated at 10–15%) of preva- that presented with both a hypopyon the elderly. This report highlights an lent cases of legal blindness in the atypical uveitis case involving an older and severe intermediate uveitis in an United States.1 The most frequent patient, an evident hypopyon and elderly man. severe intermediate uveitis in one eye. subtype is anterior uveitis, represent- The 60-year-old Caucasian male was ing up to 92% of total cases in com- 2 admitted for a painful, with munity-based ophthalmic practices. Case report a sudden decreased vision to hand HLA (human leukocyte antigen)- A 60-year-old Caucasian male was motion, in the affected eye. Ocular and B27 positivity, a human major his- seen in the eye clinic of a hospital systemic history were unremarkable. tocompatibility complex (MHC), is reporting a red, painful right eye An anterior chamber examination of the eye revealed extensive cells and the most common identifiable cause with decreased vision. The patient flare with a conspicuous hypopyon. An of anterior uveitis and accounts for was in fact seen three days earlier for evaluation of the posterior segment about 50% of the cases in different pain and inflammation from a right revealed significant vitreous haze, populations.3,4 HLA-B27-associated shoulder injury for which he was obstructing all view to the . Despite the age and the atypical ocular uveitis is characterized by recurrent put on a narcotic analgesic (oxy- findings of the patient, a diagnosis of alternating acute unilateral attacks codone 5 mg and acetaminophen HLA-B27-associated uveitis was made of intraocular inflammation of the 325 mg marketed as Percocet, one following an extensive clinical and anterior segment of the eye, and tablet every four hours as needed). laboratory evaluation. The inflammatory 5 condition was successfully managed typically affects young male adults. The onset of his ocular symptoms with a combination of intravenous, In uveitis related to HLA-B27, the coincided with the introduction of topical and oral tapered presence of a hypopyon – a layer Percocet so he discontinued the over the course of a few weeks, and of white blood cells in the anterior drug after one day, however, his visual acuity recovered to 20/30. chamber – and posterior segment vision continued to worsen. Ocular This case is an important reminder involvement of the eye are uncom- history was unremarkable with no that atypical signs, such as a hypopyon or intermediate uveitis, can occur mon. reports of trauma, surgery, inflam- and may be a significant sign of A hypopyon suggests severe mation or infection. Medication was HLA-B27-associated uveitis. Clinicians anterior segment intraocular inflam- limited to the recent use of Percocet should be aware of the diverse mation and is a rare occurrence in for the shoulder and the occasional manifestations of HLA-B27-associated uveitis and be careful to include a patients with uveitis, occurring in nonsteroidal anti-inflammatory drug 6 comprehensive assessment of both the less than 1% of all uveitis patients. (naproxen) for nonspecific pain in anterior and posterior segments of any Posterior segment involvement, the body with no reported allergies presenting painful, red eye. namely intermediate and/or pos- to any medication. Review of all Keywords: anterior uveitis, intermediate terior uveitis, is also infrequent and systems revealed episodes described uveitis, HLA-B27, hypopyon has been reported in up to 25% as podagra (i.e. inflammation on the of HLA-B27-associated uveitis big toe related to episodes of gout)11

C a n a d i a n J o u r n a l o f o p to m e t r y | r e v u e C a n a d i e n n e d ’ o p to m é t r i e vol 74 | no 1 | 2012 47

d1071 new text.indd 47 12-04-18 11:26 AM within the past year (although he was Table 1: Clinical findings at initial presentation never officially diagnosed with gout) and a history of papular rashes on rIgHT EYE (OD) LEFT EYE (OS) his forehead and both his shins with mild erythema and some excoria- Visual acuity Hand motion 20/30 tion (abraded areas where the skin reactions Normal Normal is torn or worn off). Upon further Extraocular movements Normal Normal questioning, the patient reported Tonometry (Tonopen) 21 mmHg 22 mmHg no history of ulcers, sores, irritable Bulbar 2+ injection bowel disease, bloody stool, urina- tion difficulties or shortness of Fine keratic precipitates widely distributed breath. The patient’s family history Anterior chamber 4+ cells and flare, fibrin production with a 1.5 mm high hypopyon, grade IV Van Herick angle was unremarkable. The patient also Unremarkable denied excessive nicotine or alcohol Crystalline 1+ nuclear sclerotic without posterior use, and had not engaged in any synechiae sexual activity recently. The patient Posterior segment Severe vitreous haze (grade 4+ vitreous cell) with was oriented to time, place and per- extensive vitreous debris son, and was lucid at the time of the examination. nongranulomatous anterior and Upon ocular examination, visual intermediate hypopyon uveitis, with acuity (VA) was hand motion OD a tentative HLA-B27 association. (without improvement with pinhole) The patient received 125 mg of and 20/30 OS. Slit lamp examina- intravenous anti-inflammatory tion of the right eye revealed 2+ glucocorticoid (methylprednisolone injection of the bulbar conjunctiva. sodium succinate) coupled with a Fine keratic precipitates (KPs) were topical anti-inflammatory corticoste- widely distributed throughout the roid (1% acetate qh, cornea, although no corneal thin- with a loading dose before bedtime ning was noted. Anterior chamber and upon awakening), a cycloplegic/ Figure 1 – A hypopyon (height of (AC) examination of the right eye mydriatic agent (atropine 1% tid), 1.5mm) seen at the lower quadrant of revealed 4+ cells and flare (without and an oral anti-inflammatory the anterior chamber convection current), fibrin produc- (prednisone 80 mg tion with a 1.5 mm hypopyon in the daily). The patient was then sent to B27 positivity. The patient did not lower quadrant as seen in Figure 1. the laboratory to have his blood have a primary care provider, so a Dilated funduscopic examination drawn for further analysis. consultation with a rheumatologist (DFE) revealed severe vitreous haze A subsequent review of his was recommended. (grade 4+ vitreous cells), obstructing laboratory examination revealed an The patient responded well to all view to the retina. B-scan ultra- elevation of ESR, CRP and white therapy. Ten days after treatment sound revealed extensive vitreous blood cells. Laboratory results were was initiated, VA of the right eye debris. The left eye revealed only an positive for the following markers: improved to 20/60, IOP was early nuclear sclerotic cataract with HLA-B27, HSV IgG and HSV IgM. 16 mmHg, anterior segment re- no evidence of active or past inflam- (SeeTable 2) The remainder of the vealed few fine KPs inferiorly, 1+ mation. A summary of the ocular work-up, including ACE, Toxoplas- cells and flare in the AC and a findings is shown in Table 1. ma, FTA-ABS, RPR and VZV titre, <0.5 mm hypopyon. A DFE dem- Given the B-scan, the patient was was negative. The etiology of the onstrated 1+ anterior vitreous cells, diagnosed with acute unilateral uveitis was thus confirmed as HLA- snowbanks and snowballs resting

48 vol 74 | no 1 | 2012 C a n a d i a n J o u r n a l o f o p to m e t r y | r e v u e C a n a d i e n n e d ’ o p to m é t r i e

d1071 new text.indd 48 12-04-18 11:26 AM Table 2: Clinical laboratory results

pUrpOSE NOrmAL vALUES rESULT

Erythrocyte Inflammation ≤ 30 mm/hr Elevated (110 mm/hr) Sedimentation Rate (ESR) C-Reactive Protein (CRP) Inflammation <6 mg/L Elevated (19.35 mg/L) White blood cells Inflammation 4 × 109 to Mild leukocytosis 1.1 × 1010/L (13.1 x 109/L) Human Leukocyte Specific protein Negative Positive Antigen B27 (HLA-B27) strongly associated with spondyloarthropathies Figure 2: Anterior segment photo illustrating the resolved hypopyon and a Herpes Simplex Virus Herpes simplex Negative Positive (HSV) IgG virus-specific antibody clear anterior chamber Herpes Simplex Virus Herpes simplex Negative Positive (HSV) IgM virus-specific antibody Angiotensin-Converting Negative Negative Enzyme (ACE) The patient was initially diagnosed Toxoplasma Toxoplasmosis Negative Negative with an acute nongranulomatous Treponema Pallidum Syphilis Negative Negative uveitis with a tentative HLA-B27 Antibody (FTA-ABS) association, however, the hypopyon Rapid Plasma Regain Syphilis Negative Negative and intermediate uveitis were atypi- (RPR) cal. Ramsay and Lightman (2001) Varicella-Zoster Virus Varicella zoster virus Negative Negative classified the causes of hypopyon (VZV) titer antibodies into non-infectious causes, infec- tious agents, neoplasms, and corneal inferiorly. The macula, and anterior segment was unremarkable, disorders.26 Table 4 shows the most the rest of the retina were unremark- and a posterior segment examination common differential diagnosis for able. Due to the marked subjective revealed grade 0.5+ vitreous cells, hypopyon, anterior uveitis and inter- and objective improvement, tapering inferior snowballs from five to eight mediate uveitis. of oral prednisone was initiated (60 o’clock. The patient was to return for In both intraocular infection and mg for 5 days, 40 mg for 5 days, 30 regular monitoring in one month. inflammation, hypopyon consists mg for 5 days, 20 mg for 5 days, 10 largely of tissue debris, fibrin, mg for 5 days, 5 mg for 5 days, then Discussion inflammatory by-products and leu- discontinued). The differential diagnosis for this kocytes, and signifies severe anterior At week 3, clinical evolution was patient included infectious and non- segment intraocular inflammation.6 favourable with VA at 20/30-2. The infectious etiologies for the uveitis, A study by Zaidi et al,6 indicates that KPs and hypopyon disappeared which includes, HLA-B27 positivity, hypopyon is an uncommon finding (Figure 2), however grade 0.5+ cells Herpes simplex virus (HSV), Be- in patients with uveitis, occurring in and flare remained in the AC, grade hçet’s disease, sarcoidosis, toxoplas- around 8.57 patients per 1000 0.5+ cells in the anterior vitreous, mosis, Varicella-zoster virus (VZV), person-years (0.86%), even in ter- and persistent snowbanks and snow- syphilis and tuberculosis. Multiple tiary uveitis practices. This retrospec- balls. The left eye remained stable sclerosis, and Barton- tive study indicated that hypopyon and quiet throughout the episode. ella, although less probable culprits, was more common among patients At his last follow up at week nine, could also have been on the list of with uveitis limited to the anterior the patient had already discontinued differentials. A brief description of chamber than in patients who also both systemic and topical medication each can be found in Table 3. had intermediate uveitis as a part a week prior. His VA was maintained of their diagnosis, but was nearly at 20/30-1, IOP was 16 mmHg,

C a n a d i a n J o u r n a l o f o p to m e t r y | r e v u e C a n a d i e n n e d ’ o p to m é t r i e vol 74 | no 1 | 2012 49

d1071 new text.indd 49 12-04-18 11:26 AM Table 3: Possible etiologies for uveitis

gENErAL DESCrIpTION OCULAr mANIFESTATIONS

HLA-B27 positivity5 Genetic marker associated with spondyloarthropathies Anterior uveitis Most common identifiable cause of anterior uveitis (50%) Herpes simplex Uveitis caused by Herpes simplex virus Corneal scarring uveitis12, 13, 35-38 Secondary to herpetic Unilateral recurrent anterior uveitis Absence of corneal disease in 15% atrophy, elevated IOP, KPs and synechiae Hypopyon possible Posterior segment inflammation in 15%

Behçet’s disease14 Systemic vasculitis disorder of unknown etiology Sudden attacks of anterior uveitis with hypopyon Relapsing episodes of oral ulcers, genital ulcers and skin lesions Sarcoidosis15, 16, 17 Chronic non-caseating granulomatous systemic disease of Chronic bilateral anterior uveitis unknown etiology Iris nodules, posterior synechiae, KPs and peripheral A third of patients have ocular involvement anterior synechiae Posterior segment involvement possible Toxoplasmosis2, 18, 19 Infection caused by the parasite Toxoplasma gondii Can cause anterior uveitis and Most common infectious cause of intraocular inflammation in immunocompetent patients

Herpes zoster Reactivation of the Varicella-zoster virus High incidence of secondary ophthalmicus 50% develop ocular complications, with uveitis occurring in 43% Uveitis is uniphasic and short-lived (ocular shingles) 20

Syphilis21-24 Sexually-transmitted infectious disease by Treponema pallidum Can mimic many ocular conditions Many people do not have symptoms Uveitis can be unilateral or bilateral, acute or chronic Can initially present as anterior uveitis Can cause hypopyon

Tuberculous uveitis25 Rare Chronic granulomatous anterior uveitis Caused by Mycobacterium tuberculosis Disseminated choroiditis with vitritis 2% of active tuberculosis Cystoid macular oedema

as frequent among patients with probably because the haze associated clinical features are vitreous cells, posterior or panuveitis. The most with a hypopyon was a reversible with or without snowballs and snow common risk factors for hypopyon cause of vision loss.28 banking. The intermediate uveitis are Behçet’s disease and HLA-B27 Intermediate uveitis is diagnosed found in this case was atypical in that positivity, conferring respectively an when intraocular inflammation pri- it was monocular and not associated approximate five-fold and two-fold marily involves the vitreous, periph- with the aforementioned diseases. increased risk of hypopyon. In fact, eral retina and ciliaris.29 In the case reported here, the HLA-B27 hypopyon uveitis occurs It is the type of uveitis with the patient’s laboratory results were posi- in 5.7% of all uveitis cases and is longest clinical duration.30 The syn- tive for HLA-B27, HSV IgG and more common among Caucasians.27 drome is more frequent in the third HSV IgM, which pointed towards Even though hypopyon is an indica- and fourth decade.31 Intermediate an etiology of either an HLA-B27- tor of remarkably severe inflamma- uveitis has been reported to make associated uveitis or Herpes simplex tion, eyes that develop hypopyon do up 1.4 – 22% of all uveitis cases.32 uveitis. not appear to have adverse visual Although the majority of cases are Acute HSV uveitis is typically sec- outcomes more often than eyes of unknown etiology, a significant ondary to herpetic keratitis, although without it. A previous study on association between intermediate 15% of patients may not experience Behçet’s disease showed that patients uveitis and , sar- corneal involvement.35, 39 Clinical who developed hypopyon were coidosis and Lyme disease has been signs of HSV uveitis include corneal more likely to gain three lines of reported.33, 34 Intermediate uveitis is scarring, focal or patchy iris atrophy, vision at any point during follow-up, bilateral 80% of the time. Main iris transillumination defects, KP,

C a n a d i a n J o u r n a l o f o p to m e t r y | r e v u e C a n a d i e n n e d ’ o p to m é t r i e vol 74 | no 1 | 2012 51

d1071 new text.indd 51 12-04-18 11:26 AM Table 4: Most common differential diagnosis of hypopyon, anterior uveitis and intermediate uveitis

HYpOpYON ANTErIOr UvEITIS INTErmEDIATE UvEITIS

l Non-infectious l Idiopathic l Idiopathic HLA-B27 l hLA-b27 l Multiple sclerosis Behçet’s disease l Reactive arthritis (Reiter’s syndrome) l Sarcoidosis Spondyloarthropathy Iatrogenic/Neoplasm/Trauma l Ankylosing spondylitis l Lyme disease l Sarcoidosis l Infectious Endogenous l Syphilis Toxoplasmosis l hSV Syphilis l Trauma Hansen’s disease l Posner-Schlossman Syndrome Brucellosis HSV l Neoplasm Keratitis Lymphoma, leukemia, retinoblastoma l Other l Other

posterior synechiae, and elevated systemic diseases, namely ankylosing The classic presentation of IOP.39-41 A unilateral anterior uveitis spondylitis, inflammatory bowel dis- HLA-B27-associated ocular disease coupled with an elevated IOP point eases or reactive arthritis (formerly is acute anterior uveitis (AAU).10 The to HSV uveitis. The presence of referred to as Reiter’s syndrome).42 onset is typically abrupt and symp- patchy iris atrophy and transillumina- Thus, a referral to rheumatology toms include , ocular tion defects corroborates the diag- was recommended to rule these out. pain, epiphoria, ocular redness, and nosis. Since the clinical presentation The patient has been educated that mild-to-severe visual blurring. Cases of this case did not involve the iris recurrences are highly possible, and are generally unilateral but a recur- or an elevated IOP, HSV uveitis was that this process may be part of a rent attack may affect the contralat- rejected as a potential diagnosis and systemic inflammatory condition, eral eye. Although the inflammation HLA-B27 positivity was favoured as which may require steroids and/or is usually nongranulomatous, it may the main etiology. chronic immunosuppressive therapy. be severe enough to cause a hypo- Despite the atypical presentation, However, the patient was not seen in pyon or a plasmoid aqueous. the prognosis was positive for this a follow-up after the referral. HLA-B27-associated AAU is in fact patient, like in most HLA-B27- the most common cause of hypo- associated uveitides. With only topi- hLA-b27-associated uveitis pyon uveitis in North America.27 cal and systemic steroids, the clinical As the most common specific Uncommon cases (less than 25.1%) progression was favourable and cases may involve the posterior -1 uveitis diagnosis, HLA-B27- 7 the patient regained VA to 20/30 associated uveitis accounts for segment. Such posterior segment within 9 weeks. The patient suf- approximately 13–17% of all involvement is recognized as vitritis, fered from inflammation of his right uveitis cases.2, 43 About 50% of cystoid macular oedema, papillitis shoulder just before the onset of patients suffering from acute and retinal vasculitis, and is thought his uveitis attack. It is unclear at this to be secondary to anterior segment anterior uveitis are HLA-B27 posi- 10, 45 time whether the shoulder inflam- tive.5 HLA-B27-associated uveitis inflammation. Thus, HLA-B27- mation and the uveitis are is three times more common in associated uveitis may be unusually two separate inflammatory events, males.44 The average age of onset severe and may cause a panuveitis, or whether they are part of a which is an under-recognized of the disease is 35, although cases 46 single systemic problem. HLA-B27- have been reported in children phenomenon. During an acute associated anterior uveitis patients (10% of cases begin prior to 20 attack, IOP is generally lowered due with concomitant posterior segment years old) and late adulthood (5% to the shutdown of the . manifestations have a significantly after 55 years of age).10 Nevertheless, increased IOP higher incidence of associated and secondary glaucoma is a

52 vol 74 | no 1 | 2012 C a n a d i a n J o u r n a l o f o p to m e t r y | r e v u e C a n a d i e n n e d ’ o p to m é t r i e

d1071 new text.indd 52 12-04-18 11:26 AM well-recognized complication due to Periocular injections (transseptally, with HLA-B27-associated uveitis, iris bombé or synechial angle in the sub-tenon’s space or subcon- around 70% will have an associ- closure. Uveitis attacks are normally junctivally) are designed as depot ated (rheumatoid factor) seronega- short-lived and resolve within three injections (e.g. triamcinolone acetate) tive spondyloarthropathy of which months. Recurrent episodes are and therefore, are effective for an approximately 50% will not have common, but the frequency varies extended period of time.51 Intravit- been diagnosed or will have been between multiple attacks per year to real injections are effective for three misdiagnosed. Seronegative spon- single attacks separated by one or to six months, minimize systemic dyloarthropathy includes ankylosing more decades.46 side effects, and have the benefit spondylitis, reactive arthritis (Reiter’s There is a stepladder approach of treating macular oedema caused syndrome), psoriatic arthropathy, to the management of uveitis.47 by posterior uveitis.52 On the other and arthritis associated with inflam- The immediate goal is to control hand, ocular complications (e.g. cata- matory bowel disease. Patients with the inflammation and ciliary spasm, racts and increased IOP) are more posterior segment manifestations with a long-term goal of addressing common with intravitreal injections have a significantly higher incidence the underlying cause of the uveitis. than with systemic steroids. of such systemic diseases.42, 57 In ad- First-time occurrences and uncom- Extreme sight-threatening cases dition, around 30 – 90% of patients plicated recurrences can be treated may require pulse intravenous (IV) with HLA-B27-associated uveitis with topical corticosteroid, such as steroids to bring the inflammation suffer from associated joint disease.58 prednisolone acetate 1%, which has under control more quickly and to As a result, HLA-B27 testing can be a moderate potency and is appropri- prevent irreparable damage. The beneficial in improving management ate for many cases. Although the risk recommended regimen for such of the patient’s overall systemic of systemic side effects is low, 1% of cases is methylprednisolone 1 g IV health. patients experience increased IOP, per day for 3 days, with subsequent in which case a milder formulation transition to oral therapy, starting at Summary such as rimexolone and lotoprednol 1 mg/kg per day.47, 53, 54 For recalci- 48 In this case report, a final diagnosis can be utilized. The concomitant trant cases, steroid-free strategies can of HLA-B27-associated uveitis was use of a cycloplegic/mydriatic be considered, such as oral NSAID made following an extensive clinical drop, such as atropine sulphate 1%, therapy or immunosuppressive 55, 56, 47 and laboratory evaluation despite the reduces pain from ciliary spasm therapy. atypical presentation. The hypopyon and may break or prevent posterior Patients on topical or systemic and its associated anterior and in- synechiae. steroids for an extended period of termediate uveitis were successfully More severe cases may require time (i.e. over two weeks) should treated with topical and systemic a combination of oral, topical, be tapered off over the course of steroids. This case is an important periocular or intravitreal treatments. several weeks to avoid rebound reminder that, although uncommon, Systemic corticosteroid administra- inflammation after topical use, or hypopyon and posterior segment tion is required in 24% of patients. inducing adrenal crisis from abrupt involvement may be present in an A typical oral starting dose is 1 mg/kg stoppage of oral corticosteroid use. HLA-B27-associated uveitis, and can of prednisone daily. Side effects Patients requiring immunosuppres- even affect the elderly. Furthermore, resulting from a short course of sive therapy should remain on their it is important to include a com- systemic steroids are infrequent but regimen without dose reductions to prehensive assessment of both the include sleep disturbances, weight prevent any recurrences, which may anterior and posterior segments of gain, increased appetite, mood im- be difficult to control. 49 any presenting painful, red eye for a balance and more. In extreme cases HLA-B27 testing in patients with full clinical appreciation. of uveitis involving the posterior uveitis is useful because it may help segment, periocular or intravitreal to identify a previously undiagnosed corticosteroids may be considered.50 systemic disease. Among patients

C a n a d i a n J o u r n a l o f o p to m e t r y | r e v u e C a n a d i e n n e d ’ o p to m é t r i e vol 74 | no 1 | 2012 53

d1071 new text.indd 53 12-04-18 11:26 AM Acknowledgement characteristics’. Ocul Immunol Inflamm 23. Tucker JD, Li JZ, Robbins GK, et al. 2000;8(1):73-5. Ocular syphilis among HIV-infected We would like to thank Gerald patients: a systematic analysis of 10. Tay-Kearney ML, Schwam BL, Lowder the literature. Sex Transm Infect Abruzzese, OD from the Syracuse C, et al. Clinical features and associated 2011;87(1):4-8. Veterans Affairs Medical Center for his systemic diseases of HLA-B27 uveitis. help and guidance. Am J Ophthalmol 1996;121(1):47-56. 24. Lutchman C, Weisbrod DJ, Schwartz CE. Diagnosis and management of 11. Schumacher HR, Jr. The pathogenesis syphilis after unique ocular presentation. of gout. Cleve Clin J Med 2008;75 Suppl This paper was presented in part, as Can Fam Physician 2011;57(8):896-9. as poster at the American Academy of 5:S2-4. 25. Varma D, Anand S, Reddy AR, et al. 12. Dawson CR, Togni B. Herpes simplex Optometry’s Annual meeting in Boston Tuberculosis: an under-diagnosed eye infections: clinical manifestations, on October 14, 2011. etiological agent in uveitis with an pathogenesis and management. Surv effective treatment. Eye (Lond) Ophthalmol 1976;21(2):121-35. 2006;20(9):1068-73. References 13. Santos C. Herpes simplex uveitis. Bol 26. Ramsay A, Lightman S. Hypopyon uveitis. 1. Rothova A, Suttorp-van Schulten MS, Asoc Med P R 2004;96(2):71-4, 7-83. Frits Treffers W, Kijlstra A. Causes and Surv Ophthalmol 2001;46(1):1-18. 14. Mendes D, Correia M, Barbedo M, et al. frequency of blindness in patients with 27. D’Alessandro LP, Forster DJ, Rao NA. Behcet’s disease--a contemporary review. intraocular inflammatory disease. Br J Anterior uveitis and hypopyon. Am J J Autoimmun 2009;32(3-4):178-88. Ophthalmol 1996;80(4):332-6. Ophthalmol 1991;112(3):317-21. 15. Cozier YC, Berman JS, Palmer JR, 2. McCannel CA, Holland GN, Helm CJ, 28. Nussenblatt RB. Uveitis in Behcet’s et al. Sarcoidosis in black women et al. Causes of uveitis in the general disease. Int Rev Immunol 1997;14(1): in the United States: data from the practice of . UCLA 67-79. Community-Based Uveitis Study Group. Black Women’s Health Study. Chest Am J Ophthalmol 1996;121(1):35-46. 2011;139(1):144-50. 29. Jabs DA, Nussenblatt RB, Rosenbaum JT. Standardization of uveitis 16. Uyama M. Uveitis in sarcoidosis. Int 3. Brewerton DA, Caffrey M, Nicholls A, nomenclature for reporting clinical Ophthalmol Clin 2002;42(1):143-50. et al. Acute anterior uveitis and HL-A data. Results of the First International 27. Lancet 1973;302(7836):994-6. 17. Jones NP. Sarcoidosis and uveitis. Workshop. Am J Ophthalmol 4. Feltkamp TE. Ophthalmological Ophthalmol Clin North Am 2005;140(3):509-16. 2002;15(3):319-26, vi. significance of HLA associated uveitis. 30. Bloch-Michel E. Opening address: Eye (Lond) 1990;4 ( Pt 6):839-44. 18. Park YH, Han JH, Nam HW. Clinical intermediate uveitis. Dev Ophthalmol 5. Wakefield ,D Chang JH, Amjadi S, et al. features of ocular toxoplasmosis in 1992;23:1-2. Korean patients. Korean J Parasitol What is new HLA-B27 acute anterior 31. Chan SM, Hudson M, Weis E. Anterior 2011;49(2):167-71. uveitis? Ocul Immunol Inflamm and intermediate uveitis cases referred 2011;19(2):139-44. 19. Bornand JE, de Gottrau P. Uveitis: to a tertiary centre in Alberta. Can J 6. Zaidi AA, Ying GS, Daniel E, et al. is ocular toxoplasmosis only a Ophthalmol 2007;42(6):860-4. clinical diagnosis? Ophthalmologica Hypopyon in patients with uveitis. 32. Babu BM, Rathinam SR. Intermediate 1997;211(2):87-9. Ophthalmology 2010;117(2):366-72. uveitis. Indian J Ophthalmol 7. Kase S, Namba K, Horie Y, et al. 20. Thean JH, Hall AJ, Stawell RJ. Uveitis 2010;58(1):21-7. in Herpes zoster ophthalmicus. Clin Repeated exacerbations of ocular 33. Zierhut M, Foster CS. Multiple sclerosis, Experiment Ophthalmol 2001;29(6):406- inflammation with sarcoidosis and other diseases in patients 10. in a patient with HLA-B27 associated with pars planitis. Dev Ophthalmol uveitis. J Med Invest 2007;54(3-4):350-3. 21. Hong MC, Sheu SJ, Wu TT, Chuang CT. 1992;23:41-7. Ocular uveitis as the initial presentation 8. Dodds EM, Lowder CY, Meisler DM. 34. Breeveld J, Rothova A, Kuiper H. of syphilis. J Chin Med Assoc Posterior segment inflammation in Intermediate uveitis and Lyme 2007;70(7):274-80. HLA-B27+ acute anterior uveitis: borreliosis. Br J Ophthalmol clinical characteristics. Ocul Immunol 22. Reddy S, Cubillan LD, Hovakimyan 1992;76(3):181-2. Inflamm 1999;7(2):85-92. A, Cunningham ET, Jr. Inflammatory 35. Miserocchi E, Waheed NK, Dios E, et syndrome (IOHS) 9. Rothova A. Comment on ‘Posterior al. Visual outcome in herpes simplex in patients with syphilitic uveitis. Br J segment inflammation in HLA-B27+ virus and varicella zoster virus uveitis: Ophthalmol 2007;91(12):1610-2. acute anterior uveitis: clinical a clinical evaluation and comparison. Ophthalmology 2002;109(8):1532-7.

54 vol 74 | no 1 | 2012 C a n a d i a n J o u r n a l o f o p to m e t r y | r e v u e C a n a d i e n n e d ’ o p to m é t r i e

d1071 new text.indd 54 12-04-18 11:26 AM