Keywords inflammatory bowel disease - ocular manifestations
Palavras-chave doença inflamatória intestinal - manifestações oculares
Introduction
The manifestations of the two types of inflammatory bowel disease (IBD), Crohn disease
and ulcerative colitis, are not restricted to the gastrointestinal tract. Unfortunately,
the patients may develop various extraintestinal manifestations (EIMs),[1 ] whose onset may be at any time during the course of the disease, and musculoskeletal
conditions are considered one of the most common, followed by mucocutaneous and ophthalmic
diseases.[2 ]
[3 ] But other organs, such as the skin, the liver, and the kidney, as well as the endocrine
systems, can be involved, leading to significant morbidity and representing a challenge
to the clinicians who manage those patients. In fact, many general practitioners are
unaware of the variety and severity of ocular affections in cases of IBD. These ocular
complications are usually of an inflammatory origin,[4 ]
[5 ] and they are classified into primary, secondary, and coincidental. Primary complications
are temporally related to IBD exacerbations, and usually respond to anti-inflammatory
drugs. These include keratopathy, episcleritis, and scleritis. Secondary complications,
such as scleromalacia due to scleritis, and dry eye due to hypovitaminosis A following
gut resection, occur as a result of the primary complications. Coincidental complications
commonly occur in the general population, and cannot be correlated to IBD alone. These
include conjunctivitis, recurrent corneal ulcer, and corneal erosions.[6 ] The goal of the present prospective randomized clinical study was to assess the
prevalence of EIMs among IBD patients at the Kafrelsheikh governorate, and to evaluate
the different ocular affections and their relationship to the severity of the disease.
Patients and Methods
Participants
The present is a cross-sectional study performed on 120 patients who had been previously
diagnosed with IBD at the Kafrelsheikh University Hospital from December 2018 to December
2019. We included patients previously diagnosed with IBD by endoscopy and histopathological
examinations, and excluded patients with previous chronic eye disease that was not
related to IBD, as well as those who refused the follow-up evaluation.
Baseline Evaluation
All patients were required to provide a detailed medical history, and they underwent
a complete clinical examination for any EIMs (especially ocular manifestations), associated
autoimmune diseases, and endocrinological diseases or evidences thereof. Stool samples
were taken and tested regarding the level of calprotectin, and the eye examination
consisted of the slit-lamp exam, tonometry, visual acuity, and indirect ophthalmoscopy.
Ethics and Consent
The present study was approved by the institutional Ethics Committee, and permission
was obtained from all department heads, who were assured that confidentiality would
be maintained and ethical principles would be followed. Before the beginning of the
study, a background about it and the reason for it were explained, and the targeted
population were encouraged to participate without any undue pressure, and written
informed consent was be obtained.
Statistical Analyses
Sorting and the analysis of the data were performed the using Statistical Package
for Social Sciences (SPSS, IBM Corp., Armonk, NY, US), version 21. In this study the
qualitative variables were prescribed using number and percent, Chi-square test was
used for analysis (Mont Carlo exact test and Fishers exact test were used as alternatives
for Chi-square test if there were many small expected values). Numerical variables
were expressed as mean ± standard deviation or median (IQR). The independent sample
t -test (for normal distributed data) or Mann-Whitney U-test (for non-normal distributed
data) were used for comparison between groups. P value (≤ 0.05) was adopted as the
level of significance.
Results
A total of 120 patients with IBD were enrolled in the present study.
[Table 1 ] shows the demographics of the sample, which was composed of 52 (43.3%) male patients
and 68 (56.7%) were female patients whose mean age was 35.5 ± 13.3 years.
Table 1
Demographic characteristics of patients with inflammatory bowel disease who underwent
an ophthalmologic examination
Characteristic
Total (n = 120)
Ulcerative colitis (n = 97)
Crohn disease (n = 23)
p -value
Age (years) mean ± standard deviation
35.5 ± 13.3
36.3 ± 13.8
32 ± 10.8
.107
Gender – n (%)
.020*
Male
52 (43.3)
47 (48.5)
5 (21.7)
Female
68 (56.7)
50 (51.5)
18 (78.3)
Other extraintestinal manifestations – n (%)
.542
Hypothyroidism
1 (0.8)
1 (1.0)
0 (0.0)
Mullerin agenesis
1 (0.8)
0 (0.0)
1 (4.3)
Systemic lupus erythematosus
1 (0.8)
1 (1.0)
0 (0.0)
Patients with ocular manifestations – n (%)
27 (22.5)
23 (23.7)
4 (17.4)
.514
Note: *Statistically significant value.
Ocular affections represent ∼ 22.5% of EIMs; other EIMs were observed in 41 (34.1%)
patients in the sample: in 29.9% of those with ulcerative colitis, and in 52% of those
with Crohn disease ([Table 2 ]). The incidence of EIMs such as associated systemic lupus erythematosus (SLE), hypothyroidism
and mullerin agenesis did not exceed 0.8% (one case for each diagnosis).
Table 2
Distribution of extraintestinal manifestations
Axial arthralgia
Cut. Fistula
Erythema nodosum
Musculo-skeletal
Perianal fistula
PSC
Pyoderma
Musculoskeletal pyoderma
Renal stone
Ulcerative colitis – n (%)
0 (0.0%)
0 (0.0%)
9 (9.3%)
7 (7.2%)
0 (0.0%)
4 (4.1%)
4 (4.1%)
0 (0.0%)
5 (5.2%)
Crohn disease – n (%)
1 (4.3%)
3 (13.0%)
2 (8.7%)
3 (13.0%)
1 (4.3%)
0 (0.0%)
0 (0.0%)
2 (8.7%)
0 (0.0%)
Total – n (%)
1 (0.8%)
3 (2.5%)
11 (9.2%)
10 (8.3%)
1 (0.8%)
4 (3.3%)
4 (3.3%)
2 (1.7%)
5 (4.2%)
There were no statistically significant differences in the presence of ocular involvement
in relation to the Montreal classification of two types of IBD (ulcerative colitis:
p = 0.269; Crohn disease: p = 1.00; [Table 3 ]).
Table 3
Incidence of ocular involvement in cases of ulcerative colitis and Crohn disease
Ocular involvement – n (%)
p -value
Ulcerative colitis
E1
(
n
= 26)
9 (34.6)
.269
E2
(
n
= 46)
10 (21.7)
E3
(
n
= 25)
4 (16.0)
Total (
n
= 97)
23 (23.7)
Crohn disease
A1L3B1
(
n
= 13)
2 (15.4)
1.00
A2L3B2
(
n
= 10)
2 (20.0)
Total (
n
= 23)
4 (17.4)
Abbreviations: E1, extension limited to the rectum; E2, Left sided UC (distal UC);
E3, Extensive UC; A1, age of diagnosis = 16 years or younger; A2 and A3, age of diagnosis
at 17–40 years and >40 years, respectively; L3, ileocolonic; B1, non-stricturing,
non-penetrating; B2, stricturing.
[Table 4 ] shows a comparison of the median level of calprotectin in relation to the presence
of ocular involvement in the two types of IBD, with no statistically significant difference
(ulcerative colitis: p = 0.562; Crohn disease: p = 0.968).
Table 4
Median level of calprotectin in relation to the presence or absence of ocular involvement
Level of calprotectin
Median (IQR)
p -value
Ulcerative colitis
With ocular involvement: 800(528.50-997.25);
without ocular involvement: 685 (500-913)
0.458
Crohn disease
With ocular involvement: 750(133.25-2462.50);
without ocular involvement: 1000(320-1500)
0.785
The most common ocular findings were conjunctivitis: in 31 cases (25.8%), anterior
uveitis in 13(10.8%), scleritis in 11 (9.2%), cataract in 10 (8.3%), posterior uveitis
in 4 (3.45%), and 3 cases in glaucoma (2.5%), with no statistically significant difference
between ulcerative colitis and Crohn disease ([Fig. 1 ]
[2 ]
[3 ]).
Fig. 1 Ocular manifestation on patient with inflammatory bowel disease.
Fig. 2 Recurrent anterior uveitis with secondary intraocular lens after complicated cataract.
Fig. 3 Conjunctivitis, scleritis and episcleritis.
Discussion
The ocular complications of IBD are still a problematic issue not only in Egypt; they
are an ongoing worldwide challenge, due to their early onset and silent progressive
course. In the present study, EIMs were in 41 (34.1%) patients: in 29.9% of those
with ulcerative colitis, and in 52% of those with Crohn disease. Peyrin-Biroulet et
al4 stated that the prevalence of EIMs is variable, and it ranges between 12% and 35%
in cases of ulcerative colitis, and between 25% and 70% in cases of Crohn disease.
In the present study, dermatological and musculoskeletal manifestations are the second
most common after ocular affections, a result which is in line with the one reported
by the guidelines of the Brazilian Study Group of Inflammatory Bowel Diseases.[7 ]
The eyes are involved in about 22.5% of all EIMs; nevertheless Felekis et al.,[8 ] in a prospective study, performed complete eye examinations in 60 IBD patients,
and found a frequency of 43% of ocular EIMs. However, this higher percentage could
be due to the inclusion of patients with previous chronic eye diseases.
In their study, Akpek et al.[6 ] stated that ocular involvement does not always coincide with an active intestinal
flare. In the present study, we observed no statistically significant differences
in the presence of ocular involvement in relation to the Montreal classification of
two types of IBD (ulcerative colitis: p = 0.269; Crohn disease: p = 1.00), or regarding the mean level of calprotectin.
Different incidence rates of ocular EIMs have been reported in previous studies[8 ]
[9 ]; in the present study, the most common ocular findings were conjunctivitis: in 31
cases (25.8%), anterior uveitis in 13(10.8%), scleritis in 11 (9.2%), cataract in
10 (8.3%), posterior uveitis in 4 (3.45%), and 3 cases in glaucoma (2.5%) with no
statistically significant differences between ulcerative colitis and Crohn disease.
In another study, Petrelli et al.,[9 ] stated that the prevalence of ocular complications observed in cases of IBD varies
among studies (uveitis: 0.0001% to 0.01%; conjunctivitis: 0.1% to 7%; blepharitis:
3.5% to 15%; and cataract: 0.3% to 15%).
The present study has several limitations, such as the relatively small sample size
and no addressing of correlation between laboratory findings and the severity of eye
affection.
Conclusion
Ocular manifestations among IBD patients are common and usually nonspecific in their
presentation; therefore, eye examinations should be a part of the routine assessment
and follow-up of IBD patients. The early diagnosis and management of ocular EIMs may
prevent serious complications that could be associated with significant visual deterioration.
In addition, the general practitioner and gastroenterologist should be aware of the
frequency and variety of EIMs in general, such as uveitis and sclerites, for they
might precede a diagnosis of ulcerative colitis or Crohn disease.
