Ocular Immunology & Inflammation, 19(4), 219226, 2011

Copyright 2011 Informa Healthcare USA, Inc.

ISSN: 0927-3948 print/ 1744-5078 online
DOI: 10.3109/09273948.2011.580071

Original Article

Characteristics of Uveitis Presenting for the First Time in

the Elderly: Analysis of 91 Patients in a Tertiary Center
Marie-Alix Grgoire, MD1, Laurent Kodjikian, MD, PhD2, Loig Varron, MD1,
Jean-Daniel Grange, MD2, Christiane Broussolle, MD, PhD1, and Pascal Seve, MD, PhD1
Department of Internal Medicine, Htel Dieu, Hospices Civils de Lyon, Lyon, France; and University Claude Bernard,
Lyon, France, and 2Department of Ophtalmology, Croix-Rousse University Hospital, Lyon, France; and University
Claude Bernard, Lyon, France

ABSTRACT
Purpose: To describe uveitis clinical characteristics in the elderly.
Methods: Retrospective review of 91 patients at the age of 60 or more years at the authors uveitis tertiary
center over a 7-year period.
Results: Uveitis in the elderly accounted for 30.1% of this population. Uveitis localization was anterior in
22.0% of patients, intermediate in 8.8%, posterior in 20.9%, while 41.7% patients presented with panuveitis.
Sarcoidosis (37.4%) and idiopathic uveitis (36.3%) accounted for the majority of cases, whereas other diagnostic
entities accounted for 26.3%. Panuveitis (41.7%) and sarcoidosis (37.4%) were detected at a significantly higher
frequency than in the younger population. Contrarily, ankylosing spondylitis and established ophthalmological entities (pars planitis, Birdshot chorioretinopathy, Fuchs heterochromic cyclitis) were more common in
patients younger than 60 years old.
Conclusion: In the authors experience, sarcoidosis is the leading cause of uveitis in the elderly. Idiopathic
uveitis and other specific entities account for less than two-thirds of cases.
Keywords: diagnosis, elderly, epidemiology, sarcoidosis, uveitis

Uveitis is a significant public health problem, with

published series estimating that uveitic diseases may
account for up to 10% of legal blindness in Western
countries.1 Uveitis in patients older than 60 years has
been considered uncommon, but two recent epidemiologic studies showed that the burden of uveitis
in elderly population is significant.2, 3 First, Gritz
and Wong reported a cross-sectional study of 2070
people within 6 Northern Californian medical center
communities.2 They observed that the incidence of
uveitis rose with age, peaking at 102.7/100,000 in
subjects aged 65 years and older. Prevalence findings
were similar, rising up to a high of 234.6/100,000 in
patients at the age of 60 or more years. Reeves etal.
used longitudinal Medicare claims data to estimate
the annual incidence and prevalence of uveitis in
the U.S. elderly population.3 They found an average cumulative incidence of 340.9/100,000 persons
per year and a doubling of the cumulative incidence
from 511/100,000 in 1991 to 1231/100,000 in 1999.

Several case series examining referral populations

have addressed the elderly population.4-9 In those
studies published between 1982 and 2003, idiopathic
uveitis accounted for the majority of cases. Recent
advances have been made in recognizing, diagnosing, and classifying uveitis and associated systemic
disease. Given these data, we decided to perform a
retrospective analysis of elderly, newly diagnosed,
patients seen at our tertiary ophthalmology center
from March 2003 to February 2010. We described the
clinical features and systemic associations of those
patients and compared the data with the results in
the younger population.

Patients and Methods

We present the clinical records of 302 consecutive patients with newly diagnosed uveitis. They
were referred to the Internal Medicine Department,

Received 22 August 2010; revised 01 April 2011; accepted 05 April 2011

Correspondence: Pascal Sve. Department of Internal Medicine, Htel Dieu, 1 place de lHpital, 69288 Lyon Cedex 02, France. E-mail:
pascal.seve@chu-lyon.fr

219

220 M-A Grgoire etal.

Htel-Dieu Hospital, University of Lyon, by the
Ophthalmological Department between March 2003
and February 2010. These records were retrospectively
reviewed. Among these patients, the reports of 91
patients at the age 60 or more years were analyzed and
compared to the younger patients.
Exclusion criteria were exogenous endopthalmitis
(postoperative or traumatic) and uveitis associated with
HIV. Patients seen at the Ophthalmological Department
with obvious ophthalmological entities (e.g., typical
toxoplasmic retinochoroiditis or anterior uveitis with
keratitis) were not referred to the Internal Medicine
Department and therefore were not included.
Each patient had a full ophthalmologic examination, including slit-lamp examination, tonometry, often
laser flare meter testing, and indirect ophthalmoscopy.
Ancillary ophthalmic tests (e.g., optical coherence
tomography, fluorescein and indocyanin angiography,
visual field testing) were performed, depending on the
clinical presentation. The terminology and classification of uveitis used, including anatomic criteria, were
those given by the International Uveitis Study Group.10
We also identified ocular features: granulomatous and
nongranulomatous uveitis.
Depending on the anatomical classification, all
patients underwent the standard screening protocol
for uveitis, which included tuberculosis skin test,
determination of C-reative protein level and erythrocyte sedimentation rate (ESR), complete blood cell
count (CBC), serological test for HIV and syphilis,
and radiological chest examination. Patients were
not on immunosuppression at time of testing. Human
leukocyte antigen (HLA)-B27 typing was performed
for patients with nongranulomatous acute anterior
uveitis. In case of chronic uveitis or granulomatous
uveitis, evaluations of serum angiotensin-converting enzyme (ACE) and serum lysozyme levels and
chest CT scan were performed. Serological tests for
Toxoplasma gondii, lumbar puncture, chest CT scan,
and cerebral MRI were performed in patients with
posterior uveitis or panuveitis. This workup was
completed for some patients with anterior chamber
paracentesis (polymerase chain reaction, e.g., herpes
virus, Toxoplasma, Bartonella, Tropheryma whipplei,
RNA16, IL-10, and IL-6 measurement) and vitreous
biopsy, if appropriate.
The diagnostic battery for sarcoidosis also included
conjunctiva or skin biopsy, when clinically suspicious
features were present. Some patients underwent salivary gland or transbronchial lung biopsy, bronchoalveolar lavage (BAL), and nuclear imaging (gallium scan
or fluorine-18 fluorodeoxyglucose positron emission
tomography (18F-FDG PET).
The criteria used for the diseases most commonly
diagnosed in this study were as follows. Ocular toxoplasmosis was diagnosed based on examination and
elevated IgG anti-Toxoplasma serology. The presence of

a typical fundus change of focal retinochoroiditis was

rarely observed for our patients; they often presented
atypical ocular manifestations like papilledema alone.
Syphilis was diagnosed when treponemal hemagglutination (TPHA) and nontreponemal (VDRL) tests were
positive. Herpetic keratouveitis or uveitis was diagnosed based on the presence of corneal scars compatible with a previous herpetic keratitis and/or sectorial
iris atrophy and/or ocular hypertension and positive
IgG serologic findings. Ocular syndromes included a
clearly defined uveitis entity without systemic involvement, such as HLA-B27-associated anterior uveitis (AU)
(typical unilateral AU with sudden onset and duration
< 3 months in HLA-B27-positive individuals without
joint involvement) or Fuchs uveitis syndrome (typical
low-grade unilateral anterior and intermediate uveitis
with insidious onset, chronic course, iris transillumination defects or heterochromia, diffuse stellar corneal
precipitates, resistance to local or oral prednisone and
with later development of subcapsular cataract and
glaucoma).
Evaluation of patients with uveitis potentially
associated with spondylarthropathies was based
on the European Spondylarthropathy Study Group
Criteria.11 A diagnosis of Behet disease was based on
the International Study Group Classification Criteria
for Behcets Disease.12 Vogt-Koyanagi-Harada disease
was diagnosed according to the revised criteria.13 A
diagnosis of sarcoidosis was based on criteria very
similar to those proposed by Abad et al.14 For these
authors, sarcoidosis is considered proven when pathologic examination of biopsy material showed a noncaseating granuloma; presumed when the patients met at
least 2 of 4 of the following criteriapathologic chest
radiography or computed tomography, predominantly
CD4 lymphocytosis in BAL fluid, elevated serum ACE
level, elevated gallium uptakebut biopsy results were
normal or unavailable; and indeterminate when only 1
criterion is met. We used equally fluorine-18 fluorodeoxyglucose positron emission tomography (18F-FDG
PET) and gallium uptake to diagnose sarcoidosis-associated uveitis, based on previous studies showing that
18
F-FDG PET is more accurate than gallium for assessing both extrapulmonary and pulmonary involvement
in sarcoidosis patients.15, 16
Cases of uveitis that were not associated with a
detectable infectious agent or the above systemic disorders were classified as idiopathic.

Statistical Analysis
Analysis used the Statview version 5.0 statistical package (SAS Institute, Cary, NC). Results are expressed as
means standard deviation or median (range). Groups
were compared by Mann-Whitney test, chi-square test,
or Fishers exact test as appropriate.

Ocular Immunology & Inflammation

Uveitis in the Elderly 221

Results
Demographics
In the population, we identified 91 patients (30.1%) presenting with their first episode of uveitis at the age of 60
or more years. The average age at onset of the disease
was 70 years old (range, 6084 years). Our population
comprised 56 women and 35 men. Most of them were
Caucasian (90%) and 6 were African (10%).
Classification of Disease by Intraocular Location and
Complications
The localization of uveitis was anterior in 20 cases
(22%). Intermediate uveitis was diagnosed in 8 patients
(8.8%) and posterior uveitis was diagnosed in 19 patients
(20.9%). Thirty-eight patients (41.7%) presented with
panuveitis. Six patients (6.6%) presented with anterior
uveitis associated with intermediate uveitis. Chronic
uveitis occurred more often: 69 patients (75.8%), 34 with
panuveitis, 17 with posterior uveitis, 8 with intermediate uveitis, 7 with anterior uveitis and 3 with anterior
and intermediate uveitis. Overall, 52.7% of the patients
suffered from bilateral involvement. Thirty-eight cases
of uveitis (42%) were granulomatous (11 anterior uveitis
and 27 panuveitis).

Diagnoses
Table 1 summarizes the various causes and associated
systemic factors observed in the population. Sarcoidosis
was the most frequent etiology (37.4 %), including
biopsy-proven sarcoidosis in 16 patients. In 3 of these
patients, 18F-FDG-PET identified occult sites, and subsequent mediastinal or subclavicular biopsy revealed a
noncaseating granuloma without evidence of infection.
In 12 other patients, the clinical suspicion of sarcoidosis
(presumed sarcoidosis) was supported by a positive chest
Table 1 Distribution of specific diagnostic entities in elderly
patients presenting with uveitis.
Diagnosis
Number of patients (%)
Sarcoidosis
34 (37.4)
Proven
16
Presumed
12
Indeterminate
6
Idiopathic uveitis
33 (36.3)
HLA-B27-associated uveitis
5 (5.5)
Herpes simplex virus
4 (4.4)
Intraocular Lymphoma
4 (4.4)
Toxoplasmosis
3 (3.2)
Tuberculosis
3 (3.2)
Toxocariasis
1 (1.1)
Herpes zoster ophthalmicus
1 (1.1)
Fuchs heterochromic cyclitis
1(1.1)
Birdshot chorioretinopathy
1 (1.1)
Wegeners granulomatosis
1 (1.1)
Total
91 (100.0)
2011 Informa Healthcare USA, Inc.

x-ray or chest CT in combination with an elevated ACE

level (7 patients); a positive chest x-ray or chest CT in
combination with a CD4 lymphocytosis in BAL fluid (2
patients); a positive chest x-ray or chest CT associated
with hypermetabolic foci on 18F-FDG PET scan consistent with sarcoidosis (3 patients). Six other patients were
considered cases of indeterminate sarcoidosis, on the sole
basis of FDG uptake (3 patients).
Other specific diagnoses included HLA-B27associated uveitis (5/91, 5.5%), herpes simplex uveitis
(4/91, 4.4%), toxoplasmosis (3/91, 3.3%), tuberculosis
(3/91, 3.3%), herpes zoster ophthalmicus (1/91, 1.1%),
toxocariasis (1/91, 1.1%), and Wegener granulomatosis (1/91, 1.1%). Diagnostic vitrectomy performed in
8 patients uncovered 4 cases of intraocular large cell
lymphoma. Established ophthalmological entities
included birdshot chorioretinopathy (1/91, 1.1%) and
Fuchs heterochromic cyclitis (1/91, 1.1%). Idiopathic
uveitis accounted for 33 patients (36.3%).

Treatment
Twenty-three patients (25.2%) received topical or
regional steroids (with or without concomittant administration of systemic nonsteroidal anti-inflammatory
agents). Of these cases, there were 14 patients with idiopathic uveitis, 5 patients with sarcoidosis (2 proven and
3 presumed sarcoidosis), 2 with HLA-B27-associated
uveitis, 1 with toxocariasis, and 1 patient with herpes
simplex uveitis. Twenty-eight patients (30.8%) required
the addition of systemic steroids: 21 patients with sarcoidosis (10 with proven sarcoidosis, 7 with presumed sarcoidosis, and 4 with indeterminate sarcoidosis), 6 with
idiopathic uveitis, and the last patient presented with
HLA-B27-associated uveitis. Seven patients received
antibiotics: 3 patients treated for tuberculosis, 3 patients
treated for toxoplasmosis, and the last one for whom
toxoplasmosis was first suspected (but finally classified
as idiopathic uveitis). Four patients received anti-viral
therapy: acyclovir or valaciclovir for herpes uveitis.
Four patients with lymphoma received specific therapeutics (radiotherapy, chemotherapy). Two patients
were treated with salazopyrin, for HLA-B27-associated
uveitis. Imunosuppressive agents were proposed for 2
other patients (methotrexate and anti-TNF drugs for
Wegener granulomatosis, methotrexate for presumed
sarcoidosis). Twenty-one patients did not receive any
treatment (12 patients with idiopathic uveitis, 7 patients
with sarcoidosis, 1 patient with birdshot chorioretinopathy, and 1 patient with Fuchs heterochromic cyclitis).
Comparison of Elderly Patients and Younger Patients
(Tables 2a and 2b)
Our study found that the epidemiological characteristics of uveitis in the elderly differed markedly from
those in younger patients. After the age of 60 years,
panuveitis and sarcoidosis were statistically more
common (38/91 versus 56/211, p=.008; 34/91 versus

222 M-A Grgoire etal.

32/211, p <.001). On the contrary, anterior uveitis and
ankylosing spondylitis were more common in the
younger population (respectively 20/22 versus 83/211,
p=.003; 0/91 versus 16/211, p=.007). Differences in
birdshot chorioretinopathy and Fuchs heterochromic
cyclitis were not statistically significant between the
older and younger patients. Behet disease and VogtKoyanagi-Harada disease were not reported in the
group of elderly patients.

Discussion
Elderly patients presenting for the first time with uveitis
do not seem to be uncommon. They accounted for 30.1%
of our series of patients, a percentage much higher than
those reported in previous series,5, 6, 9 but close to the
percentage seen in Kirchs study.8 Uveitis encompasses
a wide range of underlying etiologies. It may be idiopathic or associated with systemic disease, or result
from a variety of infectious diseases. Knowledge of
these various etiologies in a particular population is
important in diagnosis and management.
Little is known about the epidemiology of uveitis
in the elderly population over the age of 60 years as
there is a paucity of population-based epidemiology data for this age. Only 6 studies have specifically
evaluated the clinical characteristics of uveitis de novo
in the elderly (Tables 3 and 4). All these studies were
retrospective and all but one were published more than
10 years ago. In term of demographics, our study does
not differ from the previous reports. In 1982, Makley
and Orlando reported 337 patients (16%) over 50
years of age among 1820 patients seen at their uveitis
clinic.9 Out of these, 229 (13%) had real uveitis. These
older patients had uveal inflammatory diseases similar to those of younger patients. In 1994, Barton etal.
described a sample of 71 patients with a first episode
of uveitis occurring after the age of 60 years.4 Among
the 50 patients who were investigated for an underlying cause of their uveitis, 34 (68%) were idiopathic. The
most common associated diseases were non-insulin-

dependent diabetes (8%) and autoimmune disease

(7%), including sarcoidosis (3 cases) and Crohn disease
(1 case). Also in 1994, Favre etal. analyzed 94 patients
(21.8%) who presented a first episode of uveitis after the
age of 60 years, among 435 patients seen in their uveitis
clinic.7 As in our study, these authors found that the
characteristics of uveitis in the elderly differed markedly from those in younger patients. After the age of 60
years, granulomatous anterior uveitis, panuveitis, and
the specific diagnoses of varicella-zoster uveitis and sarcoidosis were statistically more common. Conversely,
HLA-B27-positive acute anterior uveitis, pars planitis, and nongranulomatous anterior uveitis were less
common. In 1998, Chatzistefanou et al. described a
population of 138 patients older than 60 years (10.4%)
among their total study population of 1328 patients
with uveitis.6 The anatomic distribution of uveitis in
elderly patients differed from younger patients in the
prevalence of intermediate uveitis. Idiopathic uveitis
accounted for the majority of cases (31.2%), whereas
herpes virus infections were particularly prevalent in
older patients (18.1%). In 2000, Bouillet etal. reported
19 patients (15.2%) in a population of 125 patients seen
at their institution.5 The anatomic distribution of uveitis
in elderly patients did not differ from that for younger
patients. Systemic diseases were the leading cause in
older patients (50 vs. 29.2%), including sarcoidosis (3
cases) and HLA-B27-positive acute anterior uveitis and
spondylarthropathy (3 cases), whereas infectious diseases were more frequent in younger patients (55.5%
versus 21%). Finally, Kirch etal. analyzed the records
of 51 elderly patients (26.4%) among 193 patients with
uveitis referred to their department of ophthalmology.8
Idiopathic uveitis accounted for the majority of cases
(50.9%). Whereas herpes viruses were the most frequent
specific diagnosis (15.6%), birdshot chorioretinopathy
(9.8%), presumed sarcoidosis, and HLA-B27-positive
acute anterior uveitis (5.8% both) were identified as the
other leading diagnostic entities of uveitis presenting
for the first time in this study.
The epidemiology of uveitis varies with geographic
and genetic factors. Other factors include the referral

Table 2a Characterization of the uveitis in elderly patients and younger patients.

Elderly patients
Sex
91
Men
35 (38.5%)
Women
56 (61.5%)
Characterization of the uveitis
Anterior uveitis
20 (22%)
Intermediate uveitis
8 (8.8%)
Posterior uveitis
19 (20.9%)
Panuveitis
38 (41.7%)
Anterior and intermediate associated uveitis
6 (6.6%)
Granulomatous uveitis
38 (42%)
Anterior nongranulomatous uveitis
9 (9.9%)
Acute uveitis
22 (24.1%)
Chronic uveitis
69 (75.8%)

Younger patients
211
94 (44.5%)
117 (55.5%)

.291
.326

83 (39.4% )
28 (13.2%)
33 (15.6%)
56 (26.6%)
11 (5.2%)
49 (23.2%)
68 (32.2)
90 (42.6%)
110 (57.4%)

.003
.411
.268
.008
0.467
.001
<.001
.002
<.001

Ocular Immunology & Inflammation

Uveitis in the Elderly 223

pattern of uveitis, the investigations performed to determine the cause of the intraocular inflammation, and the
criteria used for the disease classification. Such factors
may explain some of the discrepancies observed among
studies that aimed to describe the clinical characteristics
of uveitis presenting de novo in the elderly.
The anatomic distribution of uveitis in our series of
elderly patients differs from younger patients. Panuveitis
was statistically more common in the first group. The
prevalence of elderly patients with panuveitis (41.7%)
was higher than the percentages reported by Favre etal.7
(15.9%), but similar to the report of Bouillet etal.5 (42%).
On the contrary, the percentage of older patients with
anterior uveitis was much lower than those reported by
most of authors in previous studies.

In our study, 33 patients (36.3 %) were designated

as idiopathic uveitis cases. This percentage does not
differ significantly from that of other series of uveitis
in elderly patients5-7 and confirms that a precise underlying etiology is discovered at a similar rate in older
patients as in the general uveitis population.
As in other studies in patients after the age of 60, a
remarkably wide range of specific uveitis entities were
diagnosed in our series. However, as in the studies
of Chatzistefanou and Favre, several entities (Reiter
uveitis, Posner-Schlossmann syndrome, Behet uveitis,
Vogt-Koyanagi-Harada disease) were not encountered
after the age of 60 years.6, 7 Fuchs heterochromic iridocyclitis is very unusual since it was reported for 1 of our
patients, for 2 patients in Kirschs study, and for 1 patient

Table 2B Diagnosis of the uveitis in elderly patients and younger patients.

Diagnosis
Elderly patients
Sarcoidosis
34 (37.4)
Proven sarcoidosis
16
Presumed sarcoidosis
12
Indeterminate sarcoidosis
6
Idiopathic uveitis
33 (36.3)
HLAB27 associated
5 (5.5%)
Herpes simplex virus
4 (4.3%)
Herpes zoster ophthalmolicus
1 (1.1%)
Intraocular lymphoma
4 (4.4%)
Toxoplasmosis
3 (3.2%)
Tuberculosis
3 (3.2%)
Toxocariasis
1 (1.1%)
Fuchs heterochromic cyclitis
1 (1.1%)
Birdshot chorioretinopathy
1 (1.1%)
Wegener's granulomatosis
1 (1.1%)
Ankylosing spondylitis
0
Pars planitis
0
Behet disease
0
Multiple sclerosis
0
Syphilis
0
Ulcerative colitis
0
Vogt-Koyanagi-Harada
0
Leptospirosis
0
Lyme disease
0
Others
0
Table 3 Comparison of localization of uveitis in our study and series of the literature.
Favre7
Barton4
Chatzistefanou6
Makley9
Total number of patients
1820
435
71
1328
Frequency of elderly patients (%)
229 (13)
94 (21.8)
71 (100)
138 (10.4)
Percentage of female patients
51.0
59.6
ND
74.0
Percentage of white patients
ND
ND
ND
95.0
Percentage of black patients
ND
ND
ND
2.0
Percentage of hispanicpatients
ND
ND
ND
1.5
Anterior uveitis
85 (37.1)
62 (66.0)
44 (61.9)
78 (56.5)
Intermediate uveitis
0
4 (4.2)
6 (8.4 )
2 (1.4)
Posterior uveitis
139 (60.7)
13 (13.8)
7 (9.4)
35 (25.4)
Panuveitis
5 (2.2)
15 (15.9 )
14 (19.7)
23 (16.7)
Note. ND, not developed in the original article.
2011 Informa Healthcare USA, Inc.

Younger patients
32 (15.2)
14
10
8
82 (38.9)
18 (8.5%)
4 (1.9%)
2 (0.9%)
4 (1.9%)
5 (2.4%)
3 (1.4%)
0
6 (2.4%)
9 (4.3%)
0
16 (7.6%)
9 (4.3%)
5 (2.4%)
3 (1.4%)
3 (1.4%)
2 (0.9%)
2 (0.9%)
1 (0.5%)
1 (0.5%)
4 (1.9%)

Bouillet5
125
19 (15.2)
74.0
ND
ND
ND
5(26.3)
0
6 (31.6)
8 (42.0)

Kirsch8
193
51 (26.4)
60.8
ND
ND
ND
24 (47.0)
5 (9.8)
11 (21.5)
11 (21.5)

p
<.001
.004
.009
.288
.667
.361
.214
.903
.214
.645
.284
.127
.355
.158
.127
.007
.045
.139
.253
.253
.351
.351
.510
.510
.186

Our study
302
91 (30.1)
61.5
90.0
10.0
0
22 (24.1)
9 (9.9)
17 (18.7)
40 (44.0)

224 M-A Grgoire etal.

in Favres study.7, 8 Toxoplasmosis retinochorodoiditis
was never diagnosed in the studies of Favre, Barton,
and Kirsch, while it accounted for a small percentage
in Chatzistefanous and our study (2.9 and 3.2%).4, 6-8
In accordance to previous reports, we showed that
other entities, including ankylosing spondylitis, HLAB27-associated uveitis, and birdshot chorioretinopathy,
continued to make their first appearance in patients
after the age of 60 years.
We subsequently compared the frequency of the
most common diagnostics entities in the elderly with
their frequency in younger patients examined in our
center. As reported by other authors, intraocular lymphomas represent a small proportion of our population
of elderly patients, which does not markedly differ with
the frequency observed in younger patients.5-7 A previous study identified an age peak for ocular lymphoma
between 60 and 65 years old, but we had not reported a
high prevalence of this diagnosis in our study.17
In our study, sarcoidosis was statistically more common in older patients (37.4%), which was much higher
than the percentage reported in other studies. On the

contrary, ankylosing spondylitis and established ophthalmological entities, including pars planitis, were
more common in the younger population. These data are
similar to the analysis reported by Favre etal.7 but differ from the results of Chatzistefanou etal.6 and Kirsch
etal.8. In the latter studies, herpes virus infections were
the most frequent specific entities (respectively 18.1 and
15.6%). We need to consider the referral tertiary bias of
our study, which could explain the low rate of uveitis
linked to infections (toxoplasmosis or herpes simplex
virus).
The high proportion of sarcoidosis in our population
may be explained, in part, by the extended diagnostic
battery for sarcoidosis, which included invasive and
modern investigations, such as chest CT, bronchoalveolar lavage fluid examination, salivary gland biopsy, and
FDG-PET. Another explanation is the diagnosis criteria
we used (Abad criteria)14; other studies used different
diagnosis criteria. In Chatzistefanous study,6 the diagnosis of presumed sarcoidosis was based on at least
two of the following three features: (1) elevated serum
ACE level; (2) symmetric hilar lymphadenopathy on

Table 4 Distribution of specific diagnostic entities in our study and series of the literature.
Favre7
Barton4
Chatzistefanou6
Diagnosis
Makley9
Idiopathic uveitis
12 (5.2)
23 (25.4)
34 (68.0)
43 (31.2)
Sarcoidosis
3 (1.3)
18 (19.8)
3 (4.2)
11(8.0)
Herpes viruses
9 (3.9)
30 (46.4)
1 (1.4)
25 (18.1)
Tuberculosis
10 (4.4)
0
0
0
Syphilis
0
0
0
6 (4.3)
Ankylosing spondylitis
0
0
0
6 (4.3)
Birdshotchorioretinop.
0
1 (1.0)
0
5 (3.6)
Fuchs iridoc cyclitis
0
2 (2.0)
0
0
Multifocal Choroiditis
0
0
0
5 (3.6)
Intraocular lens-related
0
0
0
5 (3.6)
Toxoplasmosis
34 (14.8)
0
0
4 (2.9)
Wegeners granulomatosis
0
0
0
3 (2.2)
HLA-B27- associated uveitis
0
4 (4.4)
0
3 (2.2)
Intraocular lymphoma
0
1 (1.0)
0
2 (1.4)
Systemic lupus erythematosus
0
0
0
2 (1.4)
Sympathetic ophthalmia
0
0
0
2 (1.4)
Lens-induced uveitis
0
0
0
2 (1.4)
Diabetes mellitus
0
0
5 (7.0)
0
Neoplasia
0
0
2 (2.8)
0
Other
161 (70.4)
15 (16.0)
26 (36.6)
14 (10.1)
Total
229
94
71
138

Bouillet5
5 (26.3)
3 (15.8)
0
0
0
2 (10.5)
2 (10.5)
0
0
0
1 (5.3)
1 (5.3)
1 (5.3)
2 (10.5)
0
0
0
0
0
2 (10.5)
19

Kirsch8
26 (50.9)
3 (5.8)
8 (15.6)
2 (3.9)
0
0
5 (9.8)
1 (1.9)
0
0
0
0
3 (5.8)
0
0
0
0
0
0
3 (5.9)
51

Our study
33(36.3)
34 (37.4)
5 (5.3)
3 (3.2)
0
0
1 (1.1)
1 (1.1)
0
0
3 (3.2)
1 (1.1)
5 (5.5)
4 (4.4)
0
0
0
0
0
1
91

Table 5 Categories of sarcoidosis for each study.

Favre7
Barton4
Chatzistefanou6
Bouillet5
Kirsch8
Our study
Diagnosis
Makley9
Sarcoidosis
3 (1.3%)
18 (19.8)
3 (4.2%)
11 (8.0%)
3 (15.8%)
3 (5.8%)
34 (37.4%)
Proven
3 (1.3%)
0
1 (1.4%)
3 (2.2%)
ND
ND
16 (17.6%)
Presumed
0
2 (2.8%)
8 (5.8%)
ND
ND
12 (13.2%)
18*
Indeterminate
0
0
0
0
ND
ND
6 (6.6%)
Proven and presumed sarcoidosis 3 (1.3%)
18 (19.8)
3 (4.2)
11 (8.0%)
ND
ND
28 (30.8%)
Note. ND, not developed in the original article.
*We considered the 18 patients in the study with presumed sarcoidosis; but the diagnosis criteria differed from others studies.
Indeed, Favre etal. used these criteria: suggestive intraocular signs of sarcoidosis and 2 positive tests among the elevated ACE and/or
elevated serum lysozyme, positive chest-x ray, and cutaneous anergy to tuberculin.
Ocular Immunology & Inflammation

Uveitis in the Elderly 225

chest x-ray; and (3) consistent gallium scan findings.
The criteria used by Favre et al.7 were suggestive
intraocular signs of sarcoidosis and 2 positive tests
among the following: elevated ACE and/or elevated
serum lysozyme, positive chest-x ray, and cutaneous
anergy to tuberculin. In Bartons study, diagnosis of
sarcoidosis was made from positive chest radiograph
findings or from biopsy of a skin lesion.4 Makley etal.
reported only proven sarcoidosis, which is why they
obtained the lowest rate of sarcoidosis (1.3%). We diagnosed sarcoidosis based on only one of the diagnosis
criteria (6 indeterminate sarcoidosis), but in 3 cases,
it was based on the FDG-PET. Previous reports have
shown that FDG-PET is as sensitive as gallium scan to
diagnose pulmonary and extrapulmonary sarcoidosis.15,
17
Moreover, if the 6 cases of indeterminate sarcoidosis
are excluded, the incidence of sarcoidosis (proven and
presumed sarcoidosis) stays high: 30.8% (Table 5 summarizes the different categories of sarcoidosis for each
study). But we also should note that if the 6 cases of
indeterminate sarcoidosis are excluded, these patients
would increase the percentage of patients with idiopathic uveitis. In that event, idiopathic uveitis becomes
the most frequent etiology (42.8%), before sarcoidosis
(30.8%).
In most studies on ocular sarcoidosis, two age peaks
are noted: the first between 20 and 30 years and the
second around 60 years.1820 Moreover, several studies
with chest CT have shown that sarcoidosis was probably underestimated in uveitis patients older than 60
years.21, 22

Conclusions
Our study shows that characteristics of uveitis in
elderly people differ from those in younger patients.
Sarcoidosis and idiopathic uveitis accounted for the
majority of cases, whereas HLA-B27-associated uveitis,
herpes virus infections, and intraocular lymphoma were
the other most frequent specific diagnostic entities.
Intraocular lymphomas represented a small proportion
of our population. Sarcoidosis is most common in the
elderly and statistically significant when compared to
its prevalence in younger patients. Idiopathic uveitis
is the next most common diagnosis; its prevalence is
essentially no different than in the younger patients.
This study shows that specific etiologies have to be discussed in the case of uveitis in the elderly. Indeed, the
possibilities of sarcoidosis and its impact outside of the
eye have to be taken into account, especially in terms of
pulmonary complications.
Our patient group represents a tertiary referral
center selected sample of patients, and this obviously
should be taken into account in the evaluation and
generalization of our findings. However, in terms of
demographics, our work doesnt differ from previous

2011 Informa Healthcare USA, Inc.

studies (percentage of female, racial distribution). These

data should influence the diagnostic approach in elderly
patients presenting with uveitis.

Acknowledgment
Study performed at Hospices Civils de Lyon, Quai des
Clestins, 69288 Lyon Cedex 02, France.
Declaration of interest: The authors report no conflicts
of interest. The authors alone are responsible for the
content and writing of the paper.

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