OCT IN ACUTE ANTERIOR UVEITIS

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1 ARCH SOC ESP OFTALMOL 2009; 84: ORIGINAL ARTICLE OCT IN ACUTE ANTERIOR UVEITIS OCT EN UVEÍTIS ANTERIORES AGUDAS MORENO-ARRONES JP 1, GORROÑO-ECHEBARRÍA MB 2, TEUS MA 3 ABSTRACT Purpose: To evaluate macular thickening, the state of the optic disc and retinal nerve fibers layer (RFNL) in patients with an actual episode of acute anterior uvetis (AAU) by optical coherence tomography (OCT), and compare them with a control group. Methods: In this prospective, cross-sectional, observational and controlled study we recruited 27 consecutive eyes of 20 patients with an actual episode of AAU, age and sex-matched with 40 healthy eyes of 20 volunteers. The age ranged between 8 and 78 years old, and all were evaluated by the «fast macular thickness», «fast optic disc» and «fast RFNL thickness» scans by OCT. The patients were evaluated twice in a period of 1 month in order to obtain an average between the two measurements by OCT. Results: We found a statistically significant increase in macular volume in AAU eyes compared with control eyes. Total macular volume in uveitic eyes was 7.3 SD 0.6 mm 3 and in healthy eyes was 7.01 SD 0.3 mm 3 (mean SD standard deviation) (p<0.001). Indeed, we found a statistically significant increase in the superior RFNL thickness compared with controls. The Smax/Imax measurement was 1.05 SD 0.1 in pathological eyes and in healthy eyes it was 0.97 SD 0.1 (p<0.02). RESUMEN Propósito: Evaluar el grosor macular, el estado del nervio óptico y de la capa de fibras nerviosas retinianas (CFNR) en pacientes con un episodio de uveítis anterior aguda (UAA) mediante OCT, y comparar los resultados con un grupo control. Método: En este estudio prospectivo, transversal, observacional y controlado, reclutamos 27 ojos de 20 pacientes con brote agudo de UAA, a los cuales se les empató por sexo y edad con 40 ojos de 20 voluntarios sanos. El rango de edad de los pacientes fue 8-78 años, siendo evaluados mediante los scans de OCT «fast macular thickness», «fast optic disc» and «fast RFNL thickness». Se hicieron dos mediciones por OCT a los pacientes, una al inicio y otra al mes del episodio, para obtener una medida promedio. Resultados: Encontramos un incremento en el volumen macular estadísticamente significativo en los ojos con UAA comparados con los ojos controles. El volumen macular total en los ojos con brote fue 7,3 DE 0,6 mm 3 mientras que en los ojos controles fue 7,01 DE 0,3 mm 3 (p<0,001) (DE significa desviación estándar). Además, encontramos un aumento estadísticamente significativo en el grosor de las fibras del hemicampo superior de la CFNR comparadas con las de los controles. El cociente Received: 24/5/07. Accepted: 2/4/09. University Hospital Príncipe de Asturias. Alcalá University. Madrid. Spain. 1 Graduate in Medicine. Alcalá University. 2 Ph.D. in Medicine. Alcalá University. 3 Ph.D. in Medicine. Chief Ophthalmology Professor. Head of the Ophthalmology Service. Paper presented at the LXXXIII Congress ofs.e.o. (Las Palmas de Gran Canaria 2007). Correspondence: Javier Paz Moreno-Arrones Hospital Universitario Príncipe de Asturias C/. Andújar, Alcalá de Henares (Madrid) Spain javier_paz_moreno@hotmail.com

2 MORENO-ARRONES JP, et al. Conclusion: We found by OCT that patients suffering an AAU showed an increase in macular volume and superior RFNL thickness versus control eyes in the acute episode (Arch Soc Esp Oftalmol 2009; 84: ). Key words: OCT, macula, edema, uveitis, inflammation. Smax/Imax fue 1,05 DE 0,1 en los ojos patológicos y en los controles fue 0,97 DE 0,1 (p<0,02). Conclusiones: Encontramos que los pacientes que presentaban un brote agudo de UAA tenían un incremento del volumen macular y del grosor de la capa de fibras del hemicampo superior retiniano comparados con los ojos controles. Palabras clave: OCT, mácula, edema, inflamación, uveítis. INTRODUCTION Acute anterior uveitis (AAU) is the most frequent presentation of uveitis. The involvement of the posterior pole of the ocular globe as well as the cystic macular edema (CME) or posterior vitritis is rare but it can entail a reduction of visual acuity which is sometimes difficult to treat (1,2,4). On the other hand, optical coherence tomography (OCT) provides is a quantitative, objective and reproducible measure the thickness of the retinal nervous fiber layer (RNFL), of a papillary morphology and of the different morphometric parameters of the macular area obtained directly from an image of the retina (3). Accordingly it allows for a clinical study of the microscopic anatomy and other pathological changes in these structures and, in a manner previously unavailable, of its thickness and its layers in the anterior posterior planes. This means we also have the possibility of studying the relationship of the retina with adjacent structures such as the vitreous and the choroids with a much higher resolution than the one afforded by echography. Fluorescein angiography has been the gold standard for detecting disruptions in the hemato-retinal barrier and diagnosing cystic macular edema. However, it is an invasive technique which may give rise to severe complications and it does not always have clinical significance because hyper fluorescence is not always accompanied by reductions in visual acuity. Traill et al (4) observed that macular changes in patients who had an acute anterior uveitis episode over six months ago persisted in 45% of patients, suggesting that the evolution of the macular edema in uveitis was an all or nothing event. Clinically evident CME could be at one end of the range of macular changes which frequently occur in patients with ocular inflammation. However, said authors had a bias in the selection of patients because they only followed up those whose inflammation was moderate to severe, with losses in the follow up of those with a slight inflammation. We studied a group of patients for one month without any losses in the follow ups and without the masked observer knowing whether the inflammation of each patient had been slight, moderate or severe. SUBJECTS, MATERIAL AND METHOD We carried out a prospective, cross-sectional, observational and controlled study with a masked observer in which we recruited 27 consecutive eyes of 20 patients with an actual episode of AAU, age and sex-matched with 40 healthy eyes of 20 volunteers. The patients with the acute outbreak were assessed twice in the one-month period (at the beginning and one month later) in order to obtain a mean value of both measurements. All other patients were examined before the OCT by an observer who is an expert in uveitis, adequately treating and following their pathology. The study was carried out in the Ophthalmology Service of the «Príncipe de Asturias» University Hospital of Alcalá de Henares, respecting the principles of the 1975 Helsinki Declaration in its 1983 revised version. All of the patients agreed of their own free will and without any commitment to have the measures taken by means of OCT. The criteria utilized for defining the current AAU episode were the signs and symptoms which constituted said process, i.e., in slit lamp exploration, the presence of cilliar injection, myosis, keratinic precipitates, tyndall effect, inflammatory cells in the 186 ARCH SOC ESP OFTALMOL 2009; 84:

3 OCT in acute anterior uveitis pupil edge and on the surface of the lens anterior capsule as well as a reduction of the intraocular pressure together with a variable involvement of visual acuity, with funduscopic assessment under midriasis being normal. Both explorations, performed with OCT Stratus 3.0 version 0052 (Carl Zeiss Meditec, Inc, Dublin, California), were carried out by a single masked examiner. All explorations involved three consecutive series of the scans to be studied, choosing the one which exhibited best signal quality. All the measurements were taken under the same environmental light conditions, with midriasis being necessary by means of pharmacological dilatation with tropicamide and 10% phenylephrine. The images on the thickness of the macular area were made by means of the Fast Macular Thickness scan and the data were analyzed with the Macular Thickness Tabular program. With the Fast RNFL Thickness scan the thickness of the nervous fiber layer was analyzed utilizing the RNFL Thickness Average program in accordance with the database included in OCT Stratus ; and by means of the Fast Optic Disc scan we analyzed the morphometric characteristics of the optic disc utilizing the Optic Nerve Head program. In all cases a detailed anamnesis was carried out recording the age, the sex and ocular and systemic history at the personal and family level. In both explorations the visual acuity was measured by means of Snellen s card and the Log- MAR scale as well as a careful exploration of the anterior segment by means of slit lamp biomicroscopy in order to detect activity. All the patients were submitted to a funduscopic exploration with direct and indirect ophthalmoscopy as well as biomicroscopy with non-contact pre-corneal lens to evaluate the existence of sequels in the RNFL, the macula or the optic disc. Table I. Study of morphological parameters of the macula in eyes with AAU episode compared to control eyes. Nonmatched double tail T for student test TFM Microns A/F Microns A/TIM Microns A/SIM Microns A/NIM Microns A/IIM Microns A/TOM Microns A/SOM Microns A/NOM Microns A/IOM Microns S/IO T/NI V/NO V/F mm 3 V/TIM mm 3 V/SIM mm 3 V/NIM mm 3 V/IIM mm 3 V/TOM mm 3 V/SOM mm 3 V/NOM mm 3 V/IOM mm 3 TVM mm 3 MFT mm 3 MMT mm 3 A value of p < 0,05 is considered significant (SD=Standard deviation). Measured parameters: TMF: Thickness foveal minimum; A/F: average retinal thickness/fovea; A/TIM: average retinal thickness/temporal inner macula; A/SIM: average retinal thickness/superior inner macula; A/NIM: average retinal thickness/nasal inner macula; A/IIM: average retinal thickness/inferior inner macula; A/TOM; average retinal thickness/ temporal outer macula; A/SOM: average retinal thickness/superior outer macula; A/NOM: average retinal thickness/nasal outer macula: A/IOM: average retinal thickness/inferior outer macula; S/IO: superior/inferior outer; T/NI: temporal/nasal inner; T/NO: temporal/nasal outer; V/F: volume/fovea; V/TIM: volume/temporal inner macula; V/SIM: volume/superior inner macula; V/NIM: volume/nasal inner macula; V/IIM: volume/inferior inner macula; V/TOM: volume/temporal outer macula; V/SOM: volume/superior outer macula; V/NOM: volume/nasal outer macula; V/IOM: volume/inferior outer macula; TMV: total macular volume. ARCH SOC ESP OFTALMOL 2009; 84:

4 MORENO-ARRONES JP, et al. The statistical analysis was carried out utilizing the SPSS 11.5 for Windows (SPSS Inc., Chicago, Illinois, USA) statistical program. The possible differences study parameters were analyzed for the macula, the optic nerve and RNFL by means of parametric studies (double tail non-matched t for Student). In the study of the RNFL thickness parameters statistically significant differences were also found between both groups. The superior hemi-retinal fibers become thicker in a statistically significant manner compared to the inferior fibers in the study group as regards the control group. No clear explanation was found for this result (Table 3). RESULTS The study included 20 patients,12 men and eight women in ages comprised between 8 and 78, matched by sex and age with 20 healthy volunteers (10 men and 10 women) with ages comprised between 14 and 76. The mean outbreak in patients was of 3.2 SD 3.4. As regards the intra-ocular pressure (IOP) statistically significant differences were found between the case group eyes (13.5 SD 2.5) and the control group (14.4 SD 1.3) with a p=0,02 (SD means a standard deviation). As regards the VA measured according to the Logmar scale, statistically significant differences were found between the measure of the case group eyes (0.19 SD 0.15) and the group of healthy volunteers (0.06 SD 0.08) with p= In a representative manner, in the morphological parameters of the macula we found statistically significant differences in all the parameters measured with OCT, except in A/NOM, S/IO and V/NOM. We still have not found an explanation for the absence of changes in these parameters (table I). In what concerns the morphological parameters of the optic disc, statistically significant morphometric differences were found between both groups because the volume of the case eyes was statistically higher than in the control eyes (Table II). DISCUSSION In what concerns VA measured according to the Logmar scale, it was observed that in the eyes with AAU outbreaks there was a notorious reduction compared to the control group eyes. This was to be expected due to the inflammation in the anterior chamber. However, as shown in the macular morphological parameters of the OCT analysis results, the increase in the thickness of the total macular volume in the affected eyes could also account for the visual acuity reduction. It is known that in AAU outbreaks the IOP tends to diminish due to the increase of prostaglandins in the anterior chamber. This was also verified in our series. The most frequent forms of AAU are those related to the haplotype HLA-B27, which is mostly associated to cystic macular edema in comparison with the HLA-B27 negative forms(5). The OCT analysis revealed the existence of morphological changes in the posterior pole of the ocular globe, even though the inflammation was contained in the anterior chamber, at least from the viewpoint of the observer. Obviously our sample is very small, but we haven t found in the literature any study comparing patients with an acute AAU outbreak with two measures to establish an average of both against a control group, having an adequate treatment and follow up, with an additional assessment utilizing OCT to evaluate the Table II. Study of optic disc morphological parameters in eyes with AAU episode compared to control eyes. Double tail non-matched t for student test Volumen mm 3 Integrated ring width mm 2 Disc area mm 2 Excavation area mm 2 Ring area mm 2 Area radius Horizontal radius Vertical radius A value of p < 0.05 Is considered significant (SD=Standard Deviation). 188 ARCH SOC ESP OFTALMOL 2009; 84:

5 OCT in acute anterior uveitis Table III. Study of RNFL thickness parameters in eyes with UAA episode compared to control eyes. Double tail nonmatched t for student test IMAX/SMAX SMAX / IMAX SMAX / TAVG IMAX / TAVG SMAX / NAVG MAX-MIN microns SMAX microns IMAX microns SAVG microns IAVG microns AVG.GROSOR microns A value of p < 0.05 is considered significant. (SD=Standard Deviation). Measured parameters: Imax/Smax: inferior maximum/superior maximum; Smax/Imax: superior maximum/inferior maximum; Smax/Tavg: superior maximum/temporal average; Imax/Tavg: inferior maximum/temporal average; Smax/Navg: superior maximum/nasal average; Max-Min: maximum-minimum; Smax: superior maximum; Imax: inferior maximum; Savg: superior average; Iavg: inferior average; Avg.Thick: average thickness. thickness of the RNFL, the optic disc and the macular. It is necessary to carry out new studies with OCT and other imaging tests to confirm our results and to quantify the extent in which the information of the anterior chamber, or the edema of the posterior pole structures, can affect the eyesight. REFERENCES 1. Brewerton DA, Caffrey M, Nicholls A, Walters D, James DC. Acute anterior uveitis and HLA B-27. Lancet 1973; 2: Feltkamp TE. Ophthalmological sifnificance of HLA associated uveitis. Eye 1990; 4: Rothova A, van Veenedal WG, Linssen A, Glasius E, Kijlstra A, de Jong PT. Clinical features of acute anterior uveitis. Am J Ophthalmol 1987; 103: Schuman JS, Pedut-Kloizman T, Hertzmark E, Hee MR, Wilkins JR, Coker JG, et al. Reproducibility of nerve fiber layer thickness measurements using optical coherence tomography. Ophthalmology 1996; 103: Zeboulon N, Dougados M, Gossec L. Prevalence and characteristics of uveitis in the spondyloarthropathies: a systematic literature review. Ann Rheum Dis. 2008; 67: ARCH SOC ESP OFTALMOL 2009; 84:

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