Acta Ophthalmologica 2008

Fuchs heterochromic uveitis: a longitudinal clinical study

Kerstin Norrsell and Lena Sjo dell
Department of Ophthalmology, Sahlgrenska University Hospital, Gothenburg, Sweden

ABSTRACT. Purpose: To carry out a longitudinal study of patients with Fuchs heterochromic uveitis (FHU) in western Sweden and to establish the factors responsible for diagnostic delay. Methods: A sample of 54 patients, 51 with monocular and three with binocular FHU, were followed for periods ranging from 8 months to 15 years. Firm diagnostic criteria were set. A detailed anamnesis regarding ocular and extraocular symptoms was taken. The eyes were repeatedly examined. Toxoplasma serology was analysed. Complications were noted. Results: The delay between the rst visit to an ophthalmologist and diagnosis was 0)26 years. The most common rst symptom was oaters. Iris heterochromia was absent in 11 patients and discrete in 26. Iris atrophy (a diagnostic criterion) was easy to miss. Chorioretinal scars were found in six patients. Toxoplasma serology was positive in 18 (35%) patients. The only serious complication was glaucoma. Conclusions: The most important reason for delay in diagnosis of FHU is, in our opinion, failure to consider the disease as a diagnosis. This failure may occur because heterochromia is often missing or discrete, iris atrophy is easily overlooked, and vitreous opacities are common, often cause early symptoms and can explain prolonged workup and therapy. A connection with toxoplasmosis in individual cases cannot be excluded but toxoplasmosis cannot be considered a major aetiological factor. If detailed anamnesis is negative and diagnostic criteria are fullled, no further workup is required.
Key words: Fuchs heterochromic uveitis diagnostic delay heterochromia iris atrophy vitreous opacities toxoplasmosis cataract glaucoma

Acta Ophthalmol. 2008: 86: 5864

Copyright Acta Ophthalmol Scand 2007.

doi: 10.1111/j.1600-0420.2007.00990.x

Introduction
The present longitudinal study aimed to make a clinical analysis of a cohort of patients with Fuchs heterochromic uveitis (FHU) in western Sweden. Results from laser are measurements and uorescein iris angiography in

some of these patients were published earlier (Norrsell et al. 1998). One important incitement for this study was our observation that many patients with FHU are not correctly diagnosed until many years after their rst visit to an ophthalmologist. We therefore focused on initial symptoms

and signs. We calculated the length of delay from the rst visit to an ophthalmologist to correct diagnosis and discuss possible reasons for the failure to recognize FHU and the implications of this failure for the individual patient. Several clinical studies of FHU have been published (Liesegang 1982; Jones 1991; La Hey et al. 1991; Fearnley & Rosenthal 1995). Many different aetiologies for FHU have been proposed (La Hey et al. 1994). When this study started, toxoplasmosis was discussed as a possible aetiology (Schwab 1991). Recently, strong support has emerged for the theory that FHU is driven by the rubella virus (Quentin & Reiber 2004; de Groot-Mijnes et al. 2006). It is important to establish a clear denition of FHU. It is a purely clinical diagnosis and has no supporting laboratory tests. By tradition, heterochromia of the irides has been cited as a hallmark of the disease. Observations regarding heterochromia and complications were published during the 19th century, but it was Ernst Fuchs (1906) who put the disease on the map. (See OConnor 1985 for further references.) Most authors include iris atrophy, small, greyish, round or stellate keratic precipitates, slight or no are in the anterior chamber, some cells in the anterior vitreous, absence of redness and pain, cataract in many patients and glaucoma in some. Most authors have found that the posterior segment of the eye is not affected, with the exception of chorioretinal scars in some patients (see Discussion about toxoplasmosis), and that posterior

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synechiae are extremely uncommon. Iris nodules can be seen mostly on the pupillary margin (Koeppe) but in some cases even on the iris stroma (Busacca) (Jones 1993; Rothova et al. 1994). Vitreous opacities are mentioned but often not emphasized. According to Jones (1993), the prevailing opinion regarding the low signicance of the vitreous in FHU has been reected in many ophthalmology textbooks. Jones (1991) found vitreous opacities in 66.6% of cases in his report on 103 patients with FHU and described sudden dense vitreous opacication, requiring vitrectomy, in three of them. We believe there are two important reasons why the diagnosis of FHU is often delayed or totally missed. Firstly, the attribute heterochromic puts too much emphasis on colour. In our opinion, iris atrophy is necessary for the diagnosis, but heterochromia per se is not. Secondly, vitreous opacities often represent the rst symptom and may be substantial. We believe that vitreous opacities should be emphasized as an important and common part of, although not absolutely necessary for, the diagnosis of FHU. We adhere to the same diagnostic criteria dened in an earlier article (Norrsell et al. 1998). These are: chronic low-grade, mainly anterior, uveitis; absence of signicant acute exacerbations; diffusely spread keratic precipitates; diffuse iris atrophy with or without obvious heterochromia, and lack of posterior synechiae. In this article we discuss the following items: time span from rst visit to correct diagnosis; rst subjective symptoms; vitreous opacities; iris pathology; cataract and cataract surgery; glaucoma; retinal scars; toxoplasma; rubella, and therapy.

Materials and Methods

A total of 54 patients (21 men and 33 women) diagnosed with FHU were

followed by the authors at the Uveitis Section, Eye Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden. The clinic serves as the referral centre for uveitis in western Sweden. All patients diagnosed with FHU who visited Sahlgrenska University Eye Clinic were followed by us and many were referred to us for uveitis workup. Patients came from a restricted part of western Sweden, mainly from the city of Gothenburg, but also from the towns and rural areas within the region. This is not a population study. Some of the patients were diagnosed and are being followed by our colleagues in the region. Our study was longitudinal and many patients (30) were followed for more than 5 years. The study started in 1987 and nished in 2003. New patients were continuously included and followed during this time. One author (KN) saw all patients at least once. The following diagnostic criteria were required for inclusion: low-grade, chronic, mainly anterior uveitis without posterior synechiae; absence of signicant acute exacerbations; small, greyish, round or stellate, diffusely spread keratic precipitates, and diffuse iris atrophy with or without heterochromia. A total of 51 (94%) patients had unilateral FHU, 20 in the right eye and 31 in the left. Three (6%) patients had bilateral FHU. According to the histories and earliest records of bilateral cases, both eyes were involved from onset. These bilateral cases were examined, followed and variously treated for many years before they were diagnosed with FHU. Of the 38 patients who experienced a delay of > 3 months from rst visit to FHU diagnosis, only six did not receive any treatment. Twenty-three patients were treated with topical steroid drops and nine also received systemic steroids. Toxoplasmosis was initially suspected and treated in two of these patients. Two patients were treated according to a presumed diagnosis of pars planitis and ve received systemic steroids for substantial vitreous opacities. Patient ages at rst consultation ranged between 19 years and 57 years (mean 37 years, median 37 years). Follow-up periods ranged between 8 months and 15 years (mean 5 years, 11 months, median 5 years, 4 months). Most patients were Scandinavian by

heritage. Eight patients came from southern countries: Iran (ve); Jordan (one); Lebanon (one) and Bosnia (one). As far as the aetiology of FHU is concerned, we did not perform a comprehensive analysis of different laboratory tests or X-rays. We focused on a detailed anamnesis and repeated examinations of the eyes. According to anamnesis, all patients were in good health except for minor complaints. In these cases blood tests, X-ray of the lungs or referrals to a general practitioner were made according to the symptoms. In many patients an extensive uveitis workup had been performed before referral to our unit. One patient had a slightly elevated level of angiotensin-converting enzyme (ACE) and involvement of the lungs on X-ray. Sarcoidosis was considered highly probable, although a biopsy from the bronchial tree did not show any typical granuloma. She was treated with inhalation steroids for some time and had no extraocular symptoms several years later at the end of the study.
Methods

The patients were questioned regarding earlier and present ailments, contacts with medical care, medications and sick leave. More specically, symptoms from joints and skin, and the alimentary, respiratory and nervous systems were discussed. No further investigation was carried out if the answers to these questions did not raise any suspicion of a uveitis-related disease. The only laboratory test performed in the majority of patients (all except two) was toxoplasma serology. The reason for carrying out this test is that a possible connection between FHU and toxoplasmosis has been suggested (de Abreu et al. 1982; Schwab 1991). Visual acuity (VA) was measured. All patients were examined with a slitlamp microscope. Special attention was paid to keratic precipitates, are and cells in the anterior chamber, iris structure and colour, as well as occurrence of vessels in the iris (gonioscopy was not systematically performed). After dilation of the pupil, the lens, vitreous body and fundus were thoroughly examined. The location and appearance of opacities in the lens

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were noted and detachment of and opacities in the vitreous body were investigated with a pre-set 90-D lens. The retina was examined with direct and indirect ophthalmoscopy, as well as with a pre-set 90-D lens. Signs of chorioretinitis and or old scars were carefully searched for. Intraocular pressure (IOP) was measured with applanation tonometry. Iris photographs were assessed independently by both authors. Toxoplasma serology (enzyme-linked immunosorbent assay [ELISA] and indirect immunouorescence test [IFL]) was performed in 52 patients. Some of the younger patients were questioned about rubella vaccination. In order to achieve a basal clinical state, all eventual steroids, local or systemic, were discontinued when we rst decided upon or strongly suspected FHU as the diagnosis. A further examination was carried out about a month later. Systemic steroids were not reinstituted except in connection with cataract extractions. This treatment was recently abandoned. Local steroid drops were sometimes given for short periods when patients experienced irritation or blur.

18 16 14 Number of patients 12 10 8 6 4 2 0 0 >0-1 >1-3 >3-5 >5-7 >7-9 Time (years) >9-11 >11-13 >13-15 >15

Fig. 1. Delay in diagnosis.

Table 1. Presenting symptoms. Reason First for symptom consultation Floaters 24 Visual impairment 13 Floaters and 15 visual impairment Photophobia 1 Red eye 1 Referred by optician* * Contact lens control. 16 25 9 2 1 1

Table 2. Findings (during the entire followup period). Patients Keratic precipitates* Iris atrophy* Heterochromia Obvious Discrete Posterior synechiae Cataract Vitreous opacities Glaucoma Chorioretinal scars * Required for diagnosis. 54 54 15 26 0 50 50 6 6

Results
Diagnostic delay

optician, who had found precipitates during an examination for contact lenses. Four patients had experienced pain in addition to other symptoms.
Vitreous opacities

The interval between the rst visit to an ophthalmologist and diagnosis ranged from no time to 26 years (mean 3 years, median 12 months) (Fig. 1). Sixteen patients were diagnosed within 3 months, eight of whom were diagnosed at the rst visit to an ophthalmologist.
Symptoms

The most common rst symptom was oaters. Floaters as the sole symptom were experienced by 24 patients (Table 1). Floaters in combination with decreased vision were experienced by 15 patients. Non-specic visual impairment represented the rst symptom in 13 patients. However, only 16 patients reported oaters as the main reason for consulting an ophthalmologist. Visual impairment was cited as the main reason by 25 and a combination of the two by nine patients. The remaining patients had photophobia (two) or red eye (one). One patient was referred by her

Because of the frequent complaints of oaters, special attention was paid to the vitreous. The vitreous was recorded as detached in 48 patients, attached in one and was not documented or was unable to be assessed in ve. A great majority of patients had signicant opacities in the vitreous but not a signicant amount of cells. In three (6%) patients, the vitreous was clear at the rst examination we carried out. Findings are presented in Table 2. We did not notice any substantial increase in vitreous opacities during the study. The patients who required vitrectomy had experienced considerable problems with oaters when they entered the study. Vitrectomies were performed in six patients (seven eyes). Three eyes underwent combined cataract and vitreous surgery. Vitrectomy was performed after cataract extraction in four eyes because the patients were not satised. Only one patient

underwent vitrectomy as the sole operation. Two of the bilateral FHU patients underwent vitrectomy, one in both eyes. The results of the vitrectomies were good.
Iris atrophy and heterochromia

The irides were carefully examined, mostly for atrophy and heterochromia. Noduli were observed in some, but were not systematically studied. Iris atrophy was diffuse and no localized segmental atrophies involving the pupillary sphincter were seen (cf. Norrsell et al. 1998). No posterior synechiae were found. Photographs of the irides were taken in 53 patients. At the end of the study, all iris photographs were assessed by both authors independently for heterochromia and atrophy. The identities of the patients were not displayed during assessment. There were minor discrepancies in the grading of the heterochromia. In 15 patients the heterochromia was considered obvious, in 26 discrete and in 11 no colour differences were observed (Fig. 2). Two of these latter

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(A)

(B)

(C)

cataract operation before the diagnosis of FHU and another 27 patients were operated upon during the study. Three of these patients had bilateral FHU and cataract extraction was performed in both eyes. The results of the cataract operations were good. Twelve patients required YAG-laser capsulotomy. Thirty-two (94%) eyes had VA 0.5 and 24 (79%) had VA 0.8. Of the unoperated patients, only four had a clear lens at their last examination. Glaucoma was diagnosed in six (11.1%) patients. Two of these patients had bilateral FHU and glaucoma in both eyes. One patient was blind in his FHU eye as a result of glaucoma, which was severely advanced at his rst visit. All the glaucoma patients were on topical medication. The blind eye was treated with diode laser, as was one eye in one patient with bilateral FHU. One patient underwent a trabeculectomy. Another seven patients had occasionally raised IOP but had not developed glaucoma by the end of the study.
Retinal scars and toxoplasma serology

Fig. 2. Different degrees of iris heterochromia in three FHU patients. The normal iris is presented to the left. (A) Pronounced heterochromia. Greenish iris colour in the normal eye in contrast to the blue-grey appearance of the sick iris. (B) Brown eyes. The heterochromia is not obvious but the atrophy is. The velvety look of the normal iris has been replaced by a motheaten appearance of the sick iris. (C) Blue eyes with a slight heterochromia and atrophy.

patients had bilateral FHU. One patient with bilateral FHU had a large iris naevus, which made the assessment difcult. Fifty patients were considered to have atrophy of the iris in one eye and two to have it in both eyes. These two had bilateral FHU. In the patient with a large iris naevus described above, atrophy was not observed in the photographs but was apparent in the microscope. A total of 32 patients were photographed on two or more occasions. The time period between the rst and last pictures ranged from 1 year to 11 years (mean 4 years, median 3.5 years). We were unable to discern any progression of atrophy or any further changes in iris colour in any of these patients. Patients were very uncertain about whether their iris colour had changed over time. In no

case can we determine when the atrophy or heterochromia began.

Cornea and anterior chamber

According to our denition, keratic precipitates are a requirement for diagnosis and were accordingly seen in all patients. They were small, round or stellate, greyish, never conuent and although they were sometimes more numerous in the lower part of the cornea, they were never conned to this region. Flare was never substantial and often missing. A few cells were often seen.
Complications

Toxoplasma serology, IgG (ELISA and IFL) and IgM (IFL) were performed in 52 (96%) patients, 45 of whom were Scandinavians and seven of whom came from southern countries. IgG was positive in 18 (35%) patients, including 13 (29%) Scandinavians and ve (71%) immigrants. There was no positive IgM titre. Six (11%) patients had chorioretinal scars, ve in the FHU eye and one in the opposite eye. Four of them had a positive toxoplasma serology and their scars resembled toxoplasma retinochoroiditis. Scars were in the FHU eye in three patients and in the opposite eye in one. The remaining two patients had negative toxoplasma serology. One of them had small, pigmented atrophies in the periphery. This patient had a probable sarcoidosis and the atrophies may agree with this diagnosis. We did not see any active inammation. No vasculitis was observed. Transitory macular oedema was seen in one patient after cataract extraction.
Rubella

A majority of the patients had or developed a cataract. Eleven patients had a clear lens at the rst examination. Four patients underwent a

Ten of the youngest patients were asked about rubella. Six had been vaccinated at the age of 13 years and four had had the disease in childhood.

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Discussion
There are often delays between presentation and diagnosis of FHU. Our patients had a mean delay of 3 years (range 026 years) (Fig. 1). Fearnley & Rosenthal (1995) found a mean delay of 6.7 years (range 130 years). Evidence sourced from the journals of referred patients and from talking to referring colleagues has convinced us that there are two main reasons why the diagnosis of FHU is missed: iris heterochromia is absent or is difcult to see, and substantial vitreous opacities are not considered as part of the diagnosis. In some patients, especially those with considerable vitreous opacities, different types of uveitis workup were carried out before the correct diagnosis was established. Toxoplasma retinochoroiditis was suspected and treated in two patients. Some patients had been thought to have pars planitis or non-specic uveitis and had been treated with systemic steroids. The effect on vitreous opacities of systemic steroids was very limited and always temporary. Many patients had been treated for long periods with topical steroids, which often removes or diminishes keratic precipitates but only for as long as the treatment is continued. What are the implications of a delay in diagnosis for the individual patient? Firstly, the inability to put a name to the disease is unsatisfactory. Secondly, continuous local steroid treatment or, even more severely, systemic treatment, is troublesome and may cause unwanted side-effects such as cataract and glaucoma and, in the case of systemic treatment, extraocular side-effects. In our experience, the great majority of patients who have been treated with local drops (mostly steroids but, in some cases, diclophenac) are happy to stop and do not experience any deterioration of symptoms. Our policy has been to discontinue all therapy as soon as the diagnosis has been established. Local steroids have been prescribed for short periods when patients were experiencing local irritation and increased blur. Few patients have noticed any relief of symptoms that justify the treatment. In our opinion, systemic steroid treatment is never indicated in FHU.

A total of 39 (71%) patients recalled oaters as their rst symptom but most of them did not see a doctor immediately. Floaters only and oaters in combination with visual impairment constituted the main reasons to consult an ophthalmologist in 16 and nine patients, respectively. The presence of oaters as a symptom agreed rather well with the nding of vitreous opacities. However, some patients with vitreous opacities did not experience oaters, but only unspecic visual impairment. In our material, it was often vitreous opacities that gave rise to diagnostic and therapeutic problems. Substantial vitreous opacities tend to direct the doctors attention towards the posterior uvea and retina. The diagnosis of FHU may be difcult in some selected cases but we believe that failure to consider the diagnosis is the main reason behind failure to diagnose FHU. We believe that uveitis workup is called for when the ocular ndings deviate from the given criteria or when the anamnesis indicates extraocular disease. Other authors have also reported high frequencies of oaters. Fearnley & Rosenthal (1995) reported nding oaters in 83.9% of patients and stressed oaters as an important sign in FHU that is often overlooked. Scott et al. (2001) reported good results of pars plana vitrectomy with improved VA and relief from symptoms of oaters. Vitrectomy was performed in six of our patients (seven eyes) with good results. Combined vitrectomy and cataract surgery were performed in three eyes. We did not nd a sudden, pronounced increase in vitreous opacities, as described by Jones (1991). Heterochromia is often considered to be a hallmark of FHU diagnosis (as the name of the disease suggests). However, in our material (53 patients with photographs) only 15 (28%) patients had obvious heterochromia (Fig. 2A). Eleven (20%) patients had no heterochromia and in 26 (49%) patients the heterochromia was discrete. Heterochromia is often absent in heavily pigmented eyes (Fig. 2B). A certain atrophy is however obvious, but nding it requires careful searching. Neither heterochromia nor atrophy are easy to see in light blue eyes (Fig. 2C). All patients had iris atrophy (a diagnostic criterion). Atrophy can

be difcult to see in bilateral cases as there is no normal eye with which to make comparisons. In two of the bilateral cases, iris atrophy was pronounced. Other authors have also emphasized atrophy. La Hey et al. (1992) used iris atrophy as a diagnostic criterion, but not heterochromia. Fearnley & Rosenthal (1995) cited iris atrophy with iris transillumination defects with or without heterochromia iridum as a clinical feature but not as an obligate criterion: 94.4% of patients in their material had a stromal atrophy and 70.1% had heterochromia. In our material we found incidences of 100% for atrophy and 77% for heterochromia. Cataract is a well known complication of FHU. More than half our patients had undergone a cataract operation (31 patients, 34 eyes). No complications affecting surgical results occurred. Most patients were treated with systemic steroids pre- and postoperatively, but this schedule was abandoned recently with no adverse effects. Most patients were satised after the operation. The main reasons for dissatisfaction were disturbing oaters and progressive deterioration of VA caused by posterior capsular opacication. Vitrectomy or YAGlaser treatment were performed according to complaints and ndings, with good results. A total of 32 (94%) eyes had VA 0.5 and 24 (79%) eyes had VA 0.8 at the last visit. The most serious problem with FHU is glaucoma. Six (11%) patients had glaucoma. Two of them had bilateral FHU and glaucoma in both eyes. Prevalences of glaucoma reported earlier vary markedly. La Hey et al. (1993) reported a prevalence of 27%, including glaucoma suspects. In 13 reported series of FHU cited in a review by Jones (1993), the incidence of glaucoma varied between 6.3% and 59%. The mean incidence of all patients in these series was about 20% (Jones 1993). The large variations in reported incidences of glaucoma probably result from differing denitions of glaucoma. Seven patients in our study had occasionally raised IOP, most of them after cataract surgery or in connection with local steroid therapy for other reasons. If we include these patients, the incidence of glaucoma in our material rises to 24%.

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The aetiology of FHU is still unknown. Toxoplasmosis has been associated with FHU. Schwab (1991) found an epidemiological association between FHU and toxoplasmosis. He presents the idea that toxoplasmosis might create a chronic condition resembling FHU. A case report supporting this concept was recently presented (Ganesh et al. 2004). By contrast, La Hey et al. (1992) claim that there is no association between FHU and toxoplasmosis. In our study, 29% of Scandinavians had positive toxoplasma IgG titres, compared with 71% of immigrants. The gure for Scandinavians is not exceptionally high. According to Ljungstro m et al. (1994), the seroprevalence levels among pregnant women in four different areas in Sweden in 198788 varied from 12% to 26%. Longitudinal surveillance data (Forsgren et al. 1991) have shown that immigrants have higher toxoplasma seroprevalence levels than the indigenous population and, although small, our data are consistent with this. We found three patients with chorioretinal scars in the FHU eye and positive toxoplasma serology. We can safely draw one conclusion from our ndings and earlier results: toxoplasma is not a major cause of FHU. It is not inconceivable, however, that, in some rare cases, toxoplasma may cause the clinical syndrome we name FHU. Goble & Murray (1995) reported ve cases in which there was a possible connection between FHU and sarcoidosis. In our material, we found one patient with probable sarcoidosis. The diagnosis was based on raised ACE and pulmonary changes on chest X-ray. We can neither prove nor disprove a connection in this particular case, but we do not believe that sarcoidosis workup is called for if the clinical FHU diagnosis is clear and a detailed anamnesis gives no suspicion of systemic disease. In a clinical overview of 103 patients with FHU, (Jones (1991) discussed the possibility that FHU might be the end-stage of several different conditions. Apart from possible sarcoidosis in one case and toxoplasma scars in some, we did not nd any ocular signs and were not told of events in earlier life that might be signicant in terms of aetiology.

Recently intraocular synthesis of rubella antibodies was found in 52 eyes of 52 patients with FHU (Quentin & Reiber 2004). The rubella genome was detected in the aqueous humour in some younger patients and the authors concluded that FHU is a virus-driven disease. Some of their results were reproduced by de GrootMijnes et al. (2006). Vaccination was not mentioned in any of these articles. Might FHU possibly be extinguished through rubella vaccination? Rubella vaccination was introduced in Sweden in 1972 for girls and in 1979 for boys. We asked our younger patients about rubella. Six patients had been vaccinated, which would imply that a living attenuated vaccine may induce FHU. We cannot be absolutely sure, however, that these subjects did not contract a subclinical rubella infection before vaccination. Until more is known, we consider that FHU is mainly a clinical diagnosis and that a strict denition is required. When in doubt, the analysis of aqueous humour for rubella antibodies might be helpful. The diagnosis of FHU is often, at least in monocular cases, quite straightforward, provided that the diagnosis is kept in mind. Fuchs heterochromic uveitis patients often ask about the risk for the second eye being involved. Three of our patients (6%) had binocular FHU. All had binocular engagement at the rst visit to the ophthalmologist and we did not see a single case where the second eye became involved later on. It is worth mentioning that two of the three bilateral cases in this material ran a much more serious course of disease than the others. They seemed to have a more aggressive disease. Both underwent bilateral cataract extraction. Both underwent vitrectomy, one bilateral and the other unilateral. They had severe glaucoma in both eyes. One had repeated spontaneous bleedings from pathological iris vessels. We have no explanation for the exceptional behaviour of these bilateral cases. A comparatively large number of patients (eight, 14.8%) came from Iran, Jordan, Lebanon and Bosnia. A total of 2% of the entire population of the western region of Sweden (Va stra Go taland) and 2.6% of the population of Gothenburg come from this part of the world (personal

communication, Statistics Sweden, 2007). This high gure is interesting and should be borne in mind, but we do not want to draw any conclusions regarding racial or geographical differences from this small material.

Acknowledgement
The study was supported by the Ahrnberg Foundation.

References
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Ljungstro m I, Gill E, Nokes J, Linder E & Forsgren M (1994): Seroepidemiology of Toxoplasma gondii among pregnant women in different parts of Sweden. Eur J Epidemiol 11: 149156. r AK & Jacobson H Norrsell K, Holme (1998): Aqueous are in patients with monocular iris atrophy and uveitis. A laser are and iris angiography study. Acta Ophthalmol Scand 76: 405412. OConnor (1985): Doyne lecture. Heterochromic iridocyclitis. Trans Ophthalmol Soc UK 104: 219231. Quentin CD & Reiber H (2004): Fuchs heterochromic cyclitis: rubella virus antibodies

and genome in aqueous humor. Am J Ophthalmol 138: 4654. Rothova A, La Hey E, Baarsma GS & Breebaart A (1994): Iris nodules in Fuchs heterochromic uveitis. Am J Ophthalmol 118: 338342. Schwab IR (1991): The epidemiologic association of Fuchs heterochromic iridocyclitis and ocular toxoplasmosis. Am J Ophthalmol 111: 356362. sio C Scott RA, Sullivan P, Aylward W, Pave & Charteris D (2001): The effect of pars plana vitrectomy in the management of Fuchs heterochromic cyclitis. Retina 21: 312316.

Received on January 27th, 2006. Accepted on May 26th, 2007.

Correspondence: Lena Sjo dell gonkliniken O S U Mo lndal 431 80 Mo lndal Sweden Tel: + 46 31 343100 Fax: + 46 31 825770 Email: lena.sjodell@vgregion.se

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