Uveitis is a disease process that involves inflammation of uvea. There are multiple different causes of uveitis. These include infection , inflammatory diseases, trauma and idiopathic .[1] 

Uveitis can be acute , recurrent or chronic. Acute uveitis is characterized by sudden onset of inflammation < 3 months duration. In recurrent uveitis there are repeated episodes separated by disease inactivity >/ 3 months. Chronic uveitis is defined as persistent uveitis > 3 months. [3]

About 25% blindness in India and other developing countries is attributed to uveitis and its complications [23]. In developed countries in contrast, the incidence of blindness from uveitis varies from 3% to 10% [2].

The clinical presentation of recurrent acute anterior uveitis include recurrent acute episodes of ocular pain , eye congestion, photophobia, diminution of vision. The degree of inflammation varies from mild anterior chamber reaction to fibrinous hypopyon. Subsequently repetitive episodes of intraocular inflammation can lead to tissue damage and several serious complications including glaucoma, cystoid macular oedema, cataract and eventually permanent visual disability [13]. Chronic and recurrent anterior uveitis compromise of approximately 11% -31% [14,15]. Because anterior uveitis is still considered as less sight threatening disease, large scale clinical trials are mainly focusing on non- infectious non anterior uveitis that often require immunomodulation [16]. Whereas studies on anterior non-infectious recurrent and chronic uveitis are limited 

In our study risk for developing recurrent acute anterior uveitis were identified. There was no study clearly stating the predictive factors for the following uveitis episodes [8].  Nutnicha neti et al study shows that  Stress and inadequate sleep may lead to future episodes of acute anterior uveitis in recurrent acute anterior uveitis. Both physical and emotional stress management should be advised to recurrent acute anterior uveitis patients to minimize recurrences and further complication [8]. Vassallo et al study suggested that smoking increases the risk of relapse of inflammatory and autoimmune diseases in general [17,18].  Pinazo-Duran et al study found that Inflammation is present in quiescent stages of uveitis, IL-6 being the most outstanding cytokinin in the process [19]. In that study they  found that IL-6 represents an important biomarker for recurrent acute anterior uveitis. 

DHA-TG (Triglyceride containing docosahexaenoic acid) reduces inflammatory load and potentially supplies an immunomodulating prophylaxis adjunctive mediator for patient risk of vision loss [19]. 

There are many studies on acute anterior uveitis. But there are very few studies that focus on recurrence of acute anterior uveitis. So keeping this in mind we did this  study to analyze clinical profiles , long term clinical outcomes of patients with recurrent acute anterior uveitis. The aim of this study is clinical profiles , investigation to establish etiology ,response to treatment ,complications of recurrent acute anterior uveitis. 

A prospective clinical study was conducted in 46 eyes of 46 cases aged between 20 years to >/ 50 years attending OPD in the department of ophthalmology PGIMER and capital hospital , Bhubaneswar Odisha during December 2023 to November 2024 diagnosed with recurrent acute anterior uveitis (RAAU). Required clearance from the ethical committee was obtained and informed consent was taken from each patient. 

INCLUSION CRITERIA: Patients diagnosed clinically acute anterior uveitis those who had repeated episodes separated by disease inactivity >/ 3 months , age > 20 years.

EXCLUSION CRITERIA: No history of previous attack , chronic anterior uveitis, ocular injuries, recent intraocular surgery, masquerade syndrome presenting as anterior uveitis , age < 20 years.

Detailed history of present illness , past history/ record of previous episodes, course of diseases, number of flare ups  , presence of ocular and concomitant systemic diseases, previous treatment history. Complete ocular examination was done including visual acuity testing using snellens’ s chart. Slit lamp examination was done , conjunctival congestion grading was done on JOAS classification (24), types of keratic precipitates and their distributions  were  noted. Anterior chamber  depth, cells and flares were graded using the SUN working group (3) . Any iris nodules, iris atrophic patches, peripheral anterior synechiae, posterior synechiae were looked for and was noted , pigment dispersion over lens capsule, lens transparency were noted. Intraocular pressure was measured using a noncontact tonometer(NCT) and gonioscopy was done using Goldmann double mirror gonioscopy  lens. Detailed fundus examination was done using +90 D and by indirect ophthalmoscope.Ultrasound B scan was done where fundus was not visible due to lenticular opacity . Recurrent acute anterior uveitis was diagnosed on the basis of Standardization of uveitis nomenclature (SUN) working group.

The investigations were done depending on differential diagnosis. Complete hemogram , ESR , C reactive protein , Rheumatoid factor , antinuclear antibody ,HLA B 27 , ELISA for HIV , serum viral antibody , Quantiferon TB gold , CT chest , CT and x ray of sacroiliac joints and lumbosacral spine. Whichever cases required clinical special consultation with specialists was referred .

All patients were treated medically with topical steroid (prednisolone acetate 1%) and topical atropine or homatropine . Steroid frequency was titrated according to severity of uveitis . Appropriate treatment was given when etiology was found out . Systemic steroids were given when inflammation was severe , not responding to topical medication . Patients with secondary glaucoma were treated with topical anti glaucoma medication. 

In whom uveitis was associated with visually significant cataract, surgery was done 3 months after when active inflammation subsided. 

All patients were followed up weekly for 4 weeks , then  monthly upto 6 months. Best corrected visual acuity was recorded and Complications were noted. 

STATISTICAL ANALYSIS: Statistical analysis was performed by SPSS 20 software. Interpretation was done through precise statistical assessments to find out the statistical significance. P value <0.05 was statistically significant. 

During our study period 310 cases of uveitis were detected, out of which recurrent acute anterior uveitis cases were 46  (14.8%). All cases were diagnosed according to SUN Working group anatomical classification.

TABLE -1: Demographic and clinical characteristics of the patients

Mean age of presentation was  39 14 years.34 (73.91%)  of patients were male , 12( 26%) were female. The disease was unilateral 45 (97.8%) patients and bilateral 1 (2.2%) .

Table-2: Correlation between recurrence and etiology

The patients who had recurrence once 14.28% were viral (HSV) etiology , 3.5%  diagnosed with rheumatoid arthritis, 78.57 % cases no etiology could detect . 23% patients had ankylosing spondylitis among patients who had recurrence twice. The patients who had recurrence thrice or more 60% cases etiology was Rheumatoid arthritis.

Table - 3: Clinical features

Conjunctival congestion grading done with JOAS grading. 0 =none 1 = mild, 2 = moderate , 3 = severe. Those patients  who were in group 1 in them conjunctival congestion was of grade 3, hypopyon developed 2(7.1%) cases and 14.2% patients had exudative membrane at pupillary area. The group 2 and 3 patients had conjunctival congestion of  grade 2/ grade 1. In that study group neither hypopyon nor exudative membrane was found.

TABLE 4: Visual acuity before and after treatment

All 46 patients were treated with topical steroids initially. 4 (8.6%) patients required systemic steroids. Majority patients (76%) had visual acuity range of 6/18 -6/60 at the time of presentation. Following treatment visual acuity of 91.3% improved to 6/6 to 6/12. Few patients' visual acuity improved marginally because of associated complications such as complicated cataract and secondary glaucoma.

TABLE-5 : COMPLICATIONS

Most common complication was persistent posterior synechiae. Those who had recurrence more than twice  40% patients developed complicated cataracts and 2o% developed secondary glaucoma.

Recurrent anterior uveitis is defined as a process in which episodes were separated by at least three months of inactivity without treatment.[3]. Approximately half of patients with acute anterior uveitis will develop recurrence in the ipsilateral eye and one quarter will have recurrence in the contralateral eye.[4] In our study total cases of  uveitis were 310. Out of which recurrent acute anterior uveitis were 46 (14.8%). A study by Mishra et alI showing results of recurrent acute anterior uveitis is 13 %[5]. 

A study by Jarwal et al from  showing recurrence of acute anterior uveitis is 6% [9]. A study  by Vinutha et al showing recurrence acute anterior uveitis 3.8%[6]. 

Our study shows  26 (56%) of cases were in the age group of 20-40 years, whereas only 2( 4.8 % )cases were above 50 years. Mean age of presentation in our study was 39.14 years. A study from Israel  by Sharon et al shows mean age at diagnosis of recurrent acute anterior uveitis was 51.2 years [7]. A study  by Nutnicha et al from Bangkok , Thailand found the mean age of presentation of recurrent acute anterior uveitis was 50.7 years [8]. A study by James t et al  from New Zealand shows the mean age of presentation was 46.1 years [4]. Lucia sorbin et al [12] study shows older age at presentation was associated with higher incidence of remission. From this analysis it is evident that the mean age of presentation of recurrent acute anterior uveitis in India is early compared to other parts of the world.Our analysis suggests that recurrence risk varies by age. Younger adults have more recurrence chances. 
In our study male patients accounted for  34 (74%) , whereas female cases were found  12(26%). But study from Thailand gender distribution predominantly female (64%) [8]. 

A study from New Zealand shows 45% were female [4]. Study from Israel shows 57% were female and 42% were male [7]. 

In our study unilateral involvement was 45( 97.8%). Etiological diagnosis was established in 39.13% of the study population. 60.8% of the study population could not be established as idiopathic.  Most common cause for recurrence was Rheumatoid arthritis  6 (13%), Ankylosing spondylitis  4  (8.6%) , Viral (HSV) 4 ( 8.6%), Juvenile rheumatoid arthritis  2(4.34%) , Posner Schlossman syndrome  2 (4.34%). The study population group of those who had recurrence once  ( n=28) Group 1 14.28% etiology was clinically diagnosed viral (HSV) followed by Rheumatoid arthritis 3.5%. The study population group those who had recurrence twice  (n=3) Group 2 among them 23% had ankylosing spondylitis , 15% had Rheumatoid arthritis  , 15% had juvenile rheumatoid arthritis. The patients who had recurrence thrice or more (n=5) group 3 among them 60% had rheumatoid arthritis, 20% had ankylosing spondylitis and 20% was idiopathic. Spondyloarthropathy and HLA B-27 positive status are well known to be risk factors for anterior uveitis [20]. A study showing recurrence of anterior uveitis in HLA B-27 positive patients with mean number of attacks ranging from 0.6 to 3.3 per patient per year follow up.[20]. Another study found an equal number of recurrences per eye in HLA B-27 positive patients compared to HLA B-27 negative patients.[21].  James T el [4] showing recurrence was 38.5% among  HLA B-27 related diseases. From our study we found that idiopathic recurrent acute anterior uveitis recurrence rarely occurs more than twice. In our study the most common cause  of recurrence was rheumatoid arthritis. Sharon et al [7] reported idiopathic 56% , HLA B-27 associated uveitis 38%, Bechet’s disease associated uveitis 1.3%, Sarcoidosis related 2.6%. But in our study we did not  find any sarcoidosis, Bechet’s disease.

Clinical features were studied among the study population. Those patients who were in group 3 among them ocular pain were less compared  to group 2 and 1.Conjunctival congestion of grade 2/ grade 1,Hypopyon and exudative membrane was associated with only patients of group 1. Due to less signs and symptoms among a group of patients who had recurrence twice or more present to ophthalmologist at later stage. 

We treated all patients with topical steroids initially. 8.6% of patients needed systemic steroids in our study population. Tomkin Netzer et al reported < 7% of patients treated with immunosuppressant[10]

In our study visual acuity at presentation were 6/18 or worse in 14 (30%)  cases and 4( 8.6%) cases had vision 6/60 to 3/60. This results shows a good number of patients came to hospital after gross diminution of vision. In our study population we observed that the patients with recurrent acute anterior uveitis had conjunctival congestion mild to moderate degree and ocular pain was mild to moderate degree compared to acute anterior uveitis. This may be the reason for gross diminution of vision of 13% of the study population. Some of our patients already developed complicated cataracts at the presentation. There are a number of reasons for anterior uveitis being less studied; anterior uveitis in adults  is generally regarded as a milder form of uveitis compared to intermediate and posterior types with a better long term outcome. Tomkins-Netzer et al [10] reported stable visual acuity in patients with anterior uveitis after 10 years follow up (20/30 at baseline to 20/33 at 10 years),lower rate of ocular complications and fewer IMAs that were prescribed compared to non anterior uveitis. In another study by AL Aniet al [11] visual loss was an uncommon complication in patients with anterior uveitis and risk was greatest in those with chronic anterior uveitis.

In study our unilateral involvement was 97.8%. 60 % of our study population had ipsilateral recurrence. Patients with viral disease have highest risk of ipsilateral recurrence and lower risk of contralateral recurrence [4] 

Lucia sorbin et al [12] study shows approximately one third of patients with chronic anterior uveitis remit within 5 years. 
To study Ocular complication among our study population was another important objective. In our study the most common complication was persistent posterior synechiae. The group 3 of the study population  had  complicated cataract  2 (40%), secondary glaucoma 1  (20%). In our study no patient had cystoid macular oedema.

The Limitation of this study was that patients were followed up to six months. As study was done at tertiary care centers dealing with many referred cases, so cases may have been in severe form, therefore prone to recurrence which could overestimate recurrence rate.

Visual outcomes of Recurrent acute anterior uveitis generally good. But patients mostly associated with fewer signs and symptoms consult a doctor at a later stage of inflammation. Complication increased proportionally with the number of episodes of recurrence. Therefore patients should be informed that risk of recurrence is high and should explain regarding signs and symptoms of uveitis, so that they can recognize relapse.They can present early and avoid chance of ocular morbidity.

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