Rubella vaccination linked to declines in Fuchs heterochromic

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					                                                                              Rubella vaccination linked to declines in
Ocular Update

                                                                                    Fuchs heterochromic iridocyclitis
                Andrea Birnbaum      Debra Goldstein

                Cheryl Guttman                                                                                                                                                                       per cent) while there was somewhat
                in Fort Lauderdale                                                                                                                                                                   greater variation within the iCI patients
                                                                                                                                                                                                     (6.63 per cent to 11.32 per cent).
                THE introduction of the rubella vaccination
                                                                                                                                                                                                     Thereafter, the proportion of FHI patients
                programme in the US has been
                                                                                                                                                                                                     in the uveitis population dropped
                accompanied by a dramatic decline in the
                                                                                                                                                                                                     precipitously. Among the uveitis patients
                prevalence of Fuchs heterochromic
                                                                                                                                                                                                     born between 1958 and 1968, only 2.97 per
                iridocyclitis (FHI) among persons born in
                                                                                                                                                                                                     cent had FHI, and in the subsequent birth
                America, according to the results of an
                                                                                                                                                                                                     groups, the rate of FHI was 1.18 per cent,
                epidemiological study performed by
                                                                                                                                                                                                     1.00 per cent and 0.6 per cent, respectively.
                researchers at the University of
                                                                                                                                                                                                     In contrast, the proportions of patients
                Illinois, Chicago.
                                                                                                                                                                                                     diagnosed with iCGI and iCI remained
                    The investigators conducted a
                                                                                                                                                                                                     stable in the later birth groups.
                retrospective chart review of patients seen

                                                                                                                                                                   Courtesy of Andrea Birnbaum, MD
                                                                                                                                                                                                        Information about place of birth was
                at the uveitis clinic of the University of
                                                                                                                                                                                                     available for 307 patients, including almost
                Illinois Eye and Ear Infirmary.They
                                                                                                                                                                                                     two-thirds of the FHI patients and about
                presented their findings at the annual
                                                                                                                                                                                                     half of the iCI patients and icGI patients. In
                meeting of the Association for Research in
                                                                                                                                                                                                     the three cohorts of FHI patients born
                Vision and Ophthalmology and the study
                                                                                                                                                                                                     before 1958, the proportion of American-
                was recently published in the American
                                                                                                                                                                                                     born was stable at about 75 per cent.
                Journal of Ophthalmology.
                                                                                                                                                                                                     Thereafter, the proportion of American-
                    The researchers identified patients who
                                                                                                                                                                                                     born FHI patients decreased, falling to
                presented with FHI between 1985 and
                                                                                                                                                                                                     about 60 per cent for patients born
                2005 and extracted data on the year and
                                                               evidence of a causal link between ocular           elevated IOP, and iris atrophy, it seems                                           between 1949 and 1958 and then to about
                birthplace of each. For comparative
                                                               infection with the rubella virus and the           somewhat herpetic in nature.Yet the iris                                           50 per cent for the next three decade
                purposes, similar information was collected
                                                               development of this form of uveitis.The            atrophy is distinctly different than that seen                                     groups.The single FHI patient born after
                for two control groups comprised of
                                                               results of our epidemiological study lend          with herpes. Recently, a number of other                                           1988 originated from outside the US.
                patients diagnosed with idiopathic chronic
                                                               further support for that pathogenic                ocular diseases considered idiopathic have                                            Among the iCI patients and those with
                iridocyclitis (iCI) and idiopathic chronic
                                                               relationship,” said Andrea Birnbaum, MD, of        been shown to have an infectious aetiology.                                        icGI, there was no evidence that the
                granulomatous iridocyclitis (iCGI).
                                                               the University of Illinois.                        On that basis and since uveitis is often                                           proportion born in a foreign country
                    Patients within each diagnostic category
                                                                                                                  frustrating because its cause is unknown,                                          increased in recent decades. Instead, the
                were divided into subgroups based on
                                                                                                                  the idea that the rubella virus was involved                                       percentage of foreign-born patients
                decade of birth.Temporal changes in the
                prevalence of each disease and in the          “I have always found FHI                           in the pathogenesis of FHI was appealing,”                                         decreased slightly in the iCI group and
                                                                                                                                                                                                     remained stable and low in the cGI group.
                proportions of Americans and foreign-born                                                         Dr Goldstein said.
                patients within the various birth cohorts      to be a fascinating                                   “Our study was designed to investigate                                             “One of the limitations of our
                                                                                                                  the relationship between FHI and rubella                                           retrospective study was that birthplace
                were examined to see how they
                corresponded to the implementation of the      condition. With its                                further by exploring two hypotheses, first                                         information was not available for all of the
                                                                                                                  that the proportion of FHI cases in our                                            patients. However, we did have that data for
                rubella vaccination programme in 1969,
                which initially targeted children aged one
                                                               manifestations of fine,                            uveitis practice would decrease among                                              the majority of subjects in our three
                                                                                                                  Americans born after the launch of the US                                          diagnostic groups,” said Dr Birnbaum.
                year old through puberty and was
                subsequently expanded.
                                                               stellate keratitic                                 rubella vaccination programme and second
                                                                                                                  that an increasing proportion of FHI cases                                         International perspectives
                Trend analyses performed
                                                               precipitates, elevated IOP,                        seen would be in patients born outside the                                         In Europe, Ireland was the first country to
                                                                                                                                                                                                     launch a national rubella immunisation
                The analyses revealed that the proportion      and iris atrophy, it seems                         US.We were delighted to find the results
                                                                                                                  were a perfect fit.”                                                               programme (1971).The investigators note
                of all uveitis patients with FHI began to
                decrease with the first cohort vaccinated      somewhat herpetic in                                  During the 21-year study period, a total
                                                                                                                  of 3,856 patients were seen with uveitis,
                                                                                                                                                                                                     that because the average age of onset of
                                                                                                                                                                                                     FHI is around 40 years of age, it is too early
                (born between 1959 and 1968).Trend
                analyses were performed of log-                nature. Yet the iris atrophy                       including 131 with FHI (3.40 per cent), 288                                        to conduct analyses to identify the same
                                                                                                                                                                                                     effect of rubella vaccination on FHI
                                                                                                                  with iCI (7.47 per cent), and 168 with iCGI
                transformed databases to compare
                differences in incidence rates over time       is distinctly different than                       (4.36 per cent). Among the three                                                   prevalence in countries outside the US.
                                                                                                                  iridocyclitis groups, the mean age at                                              However, they expect to see a declining
                between the three iridocyclitis groups.
                Those results showed a significant             that seen with herpes”                             diagnosis ranged from 41 to 44 years old.                                          trend in the future as rubella vaccination is
                                                                                                                     “These features of our study group are                                          occurring in more countries. A continued
                difference between the rate of FHI over                             Debra Goldstein, MD           very consistent with published data on                                             decline of FHI in the US is expected as well
                time compared with both control groups
                                                                                                                  uveitis rates and age of onset,” noted                                             as the number of foreign-born patients at
                (p ≤0.0007) and no significant difference
                                                                  Debra Goldstein, MD, associate professor        Dr Birnbaum.                                                                       risk decreases.
                comparing iCI and iGCI groups against
                                                               of ophthalmology and director of the                  Patients born between 1949 and 1958                                                “However, we will have to wait to see
                each other.
                                                               uveitis service, University of Illinois, was the   comprised the largest age group (n = 829,                                          what the data show, and there may be
                   Furthermore, among the FHI cases seen
                                                               principal investigator for the study. She          21.5 per cent). Among those patients 38                                            some variation between countries in the
                in patients born after 1959, foreign-born
                                                               noted that the two published studies on            (4.58 per cent) had FHI, 58 (6.63 per cent)                                        rates of FHI since some vaccination
                individuals constituted a rising proportion.
                                                               ocular rubella antibody levels and FHI             were diagnosed with iCI, and 34 (4.22 per                                          programmes targeted girls only rather than
                No such pattern was observed in the
                                                               captured her attention and caused her to           cent) had iCGI.                                                                    all children,” Dr Birnbaum noted.
                control groups of patients with iCI
                                                               think that she had recently seen very few             Among patients in the three earlier birth
                and iCGI.                                                                                                                                                                  
                                                               new patients with FHI.                             cohorts (i.e., born between 1919 and
                   “Two recent studies investigating                                                                                                                                       
                                                                  “I have always found FHI to be a                1957), the proportions with FHI (3.51 per
                intraocular antibodies in patients with FHI
                                                               fascinating condition.With its manifestations      cent to 5.19 per cent) was similar to the
                and unaffected controls provided strong
                                                               of fine, stellate keratitic precipitates,          proportions with iCI (3.51 per cent to 4.72


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