|Year : 2021 | Volume
| Issue : 1 | Page : 27-33
Ocular manifestations of inflammatory bowel disease in the Taif region of Saudi Arabia during the COVID-19 pandemic, patient prospective
Abdulhamid S Alghamdi1, Nada S Alrubaie1, Jehan F Sarriyah1, Bushra A Alqahtani1, Bushra F Alshehri1, Shadi A Alghamdi1, Ali M Alahmari2, Mohammed A Attar3, Omar A Dammas4
1 Department of Ophthalmology, Faculty of Medicine, Taif University, Albaha, Saudi Arabia
2 Department of Gastroenterology, Alhada Armed Forces Military Hospital, Albaha, Saudi Arabia
3 Department of Rheumatology, Alhada Armed Forces Military Hospital, Albaha, Saudi Arabia
4 Department of Ophthalmology, King Fahad Hospital, Albaha, Saudi Arabia
|Date of Submission||18-Dec-2020|
|Date of Decision||29-Jan-2021|
|Date of Acceptance||05-Feb-2021|
|Date of Web Publication||26-Mar-2021|
Abdulhamid S Alghamdi
Department of Ophthalmology, Faculty of Medicine, Taif University, P.O. Box 641, Abha 61421
Source of Support: None, Conflict of Interest: None
Background: Ocular manifestations of inflammatory bowel disease (IBD) considered being the most common extraintestinal complication. Eventually, early detection and management improve the patient's quality of life as well as prevent potentially visually threatening complications. Objectives: To assess the prevalence and pattern of ocular manifestations among patients with inflammatory bowel disease during the COVID-19 pandemic. Materials and Methods: Cross-sectional study was performed using anonymous online surveys were administered which included the participant's demographics, prevalence and pattern of IBD intestinal and ocular manifestations, precipitating factors, and quality of life. Data were analyzed using (SPSS) version 20 (Armonk, NY: IBM Corp.). Chi-squared test Mann–Whitney and Kruskal–Wallis tests were applied. A P < 0.05 was considered statistically significant. Informed consent and ethical approval were obtained. Results: A total of 216 participants responded to the survey with 50.50% of females and 49.50% were male. About 90.3% of the participants had their GIT symptoms start before their eye symptoms. Almost two-thirds of the participants, (68.5%) suffered from frequent severe bowel symptoms that prevented them from carrying out work and/or perform the normal daily activity. Furthermore, one-third of the participants (31.6%) are unemployed and described a positive family history (32.8%). More than 75% of participants described eye symptoms associated with the intestinal disease activity which range from mild self-limiting to more severe ones that required hospital visits (50%). Although, majority of participants (90.00%) did not routinely receive official referral to ophthalmologist. The non-significant difference was found between the presence of eye symptoms and participant's gender, marital status, educational level, stress, and smoking habits. Conclusion: Most of the IBD patients suffered from significant ocular manifestations with frequent hospital visits. Misdiagnosis and/or inadequate management negatively affect the quality of life of IBD patients during the COVID-19 pandemic. Risk-based Ophthalmic screening strategy may reduce the impact of IBD.
Keywords: COVID-19 pandemic, inflammatory bowel disease, ocular manifestations, patient prospective, quality of life, Saudi Arabia
|How to cite this article:|
Alghamdi AS, Alrubaie NS, Sarriyah JF, Alqahtani BA, Alshehri BF, Alghamdi SA, Alahmari AM, Attar MA, Dammas OA. Ocular manifestations of inflammatory bowel disease in the Taif region of Saudi Arabia during the COVID-19 pandemic, patient prospective. Saudi J Health Sci 2021;10:27-33
|How to cite this URL:|
Alghamdi AS, Alrubaie NS, Sarriyah JF, Alqahtani BA, Alshehri BF, Alghamdi SA, Alahmari AM, Attar MA, Dammas OA. Ocular manifestations of inflammatory bowel disease in the Taif region of Saudi Arabia during the COVID-19 pandemic, patient prospective. Saudi J Health Sci [serial online] 2021 [cited 2021 Jul 24];10:27-33. Available from: https://www.saudijhealthsci.org/text.asp?2021/10/1/27/311958
| Introduction|| |
Inflammatory bowel diseases (IBDs) are considered the immune-mediated condition. It includes Crohn's disease (CD) and ulcerative colitis (UC). UC is a condition in which the changes either inflammatory or morphological confined to the colon. The rectum is involved in 95% of patients where the inflammation is limited primarily to the mucosa of variable severity with ulceration, edema, and hemorrhage along the length of the colon while CD can involve any part of the gastrointestinal tract from the oropharynx to the perianal area resulting in what is called “skip lesions” in which diseased segments frequently are separated by intervening normal bowel, Inflammation can be transmural, resulting in sinus tracts or fistula formation and it's most commonly involves the ileocecal region.
The exact cause of IBD is not well known and many factors can affect the development of the disease including bacterial contamination, change in the immune system, and genetic susceptibility. The prevalence of IBD was estimated to be 146.9 cases/100,000 people globally, and it is now showing a progressive increase in Asia, South America, and the Middle East including Saudi Arabia. In the Kingdom of Saudi Arabia, a retrospective study was done in a tertiary care hospital in Riyadh from January 1970 to December 2008 among 312 patients with IBD. The study found that there was 63% of patients had CD and 37% had UC. A systematic review was done in 2018 that included 15 studies reported a prevalence of ocular extraintestinal manifestation of 0.62%–1.82% among the participants. The study found that children with CD are at increased risk as compared with children with UC. The most common extraintestinal manifestations are peripheral arthritis, erythema nodosum, oral aphthous ulcers and episcleritis, pyoderma gangrenosum, uveitis, axial arthropathy, and Primary Sclerosing Cholangitis. IBD involves any organ system including the musculoskeletal, dermatologic, hepatobiliary, ocular, renal, and pulmonary systems., Ocular complications are classified as primary and secondary. Primary complications are usually temporarily and associated with IBD exacerbations and resolve with systemic treatment of the intestinal inflammation. These include episcleritis, scleritis, and keratopathy. Secondary complications include cataract formation due to treatment with corticosteroids, scleromalacia due to scleritis, and dry eye due to hypovitaminosis., It was found that there is 33% increase risk of ocular involvement in patients who had CD and arthralgia. It had been reported that around 2% to 5% of patients with IBD suffered from ocular manifestations. Fortunately, most ophthalmic manifestations are treatable once detected early.,
The reported ocular manifestations include blurring of vision, ocular pain, photophobia, conjunctival or scleral hyperemia, loss of visual acuity, and possible blindness., Unfortunately, most of the IBD patients are unaware of eye complications from IBD. The immune response to a colonic antigen may explain the reason of ocular manifestations that occur more commonly with colitis and ileocolitis than with small bowel involvement alone. Hence, patients with colitis and ileocolitis have a higher risk of ocular involvement compared to those with ileitis alone. Genetic factors may also play a role in the ocular manifestations of IBD.,
Episcleritis is the most common ocular manifestation of IBD around 2%–5%. It is found that 50% of patients with scleritis have an underlying systemic disease like IBD., Uses of topical steroids, cycloplegics, systemic steroids, immunosuppressive agents, or anti-tumor necrosis factor biological management of ocular manifestations in IBD are strongly indicated to control the systemic as well as the ocular manifestations. Ocular involvement may either precede or follow the diagnosis of IBD.
Ocular manifestations of IBD negatively affect the quality of life of affected individuals. Early diagnosis and initiation of the appropriate management would improve the visual, social outcomes and prevent devastating consequences.
This study is dedicated to assess the prevalence, pattern, and impact of the IBD on the affected individuals during the COVID-19 pandemic.
| Materials and Methods|| |
A descriptive cross-sectional study was conducted from March to July 2020. Anonymous online survey was administered to diagnosed IBD individuals in Taif Region, Saudi Arabia. The questionnaire included demographic information (section one) and the ocular manifestations of IBD (section two). The questionnaire was distributed to the respondents through social media dedicated IBD group. All online respondents with IBD of all ages and both genders were included in the study. Patients who did not accept participation were not able to read or understand the questionnaire and those who did not complete all the items of the questionnaire were excluded.
The study was approved by the research ethics committee of Taif University.
Data were coded, tabulated, and analyzed using (SPSS) version 20 (Armonk, NY, USA: IBM Corp.). Qualitative data were expressed as numbers and percentages, and the Chi-squared test was applied to test the relationship between variables. Quantitative data were expressed as mean and standard deviation (SD) (mean ± SD), where Mann–Whitney and Kruskal–Wallis tests were applied for nonparametric variables. A P < 0.05 was considered statistically significant.
| Results|| |
Around 50.5% of the participants were females, 64.8% were married, 92.6% had secondary education and higher, and almost one-third of the participants 31.6% were unemployed. 13.4% were current smokers and the mean Cigarette number per day and the mean duration of smoking/years were 8.88 ± 8.9 cigarettes and 8.92 ± 6.27 years, respectivel [Table 1].
|Table 1: Distribution of the studied participants according to their characters, smoking habits and stress level (n=216)|
Click here to view
One-third of the participants 32.8% had IBD in their 1st and 2nd-degree relatives. 96.8% of them had more than one GIT symptom related to IBD with a mean number of symptoms of (7.35 ± 2.93 symptoms). 41.2% reported that their bowel condition prevented them from carrying out their work or other normal activities for one or 2 days weekly. Most of the participants (91.7%) had their diagnosis of IBD at health care settings outside Taif city. 45.4% of the participants were diagnosed for more than 6 years and 69.4% had regular medications. Most of the participants (80.2%) had more than one symptom as exacerbation of their condition “included: mouth ulcers, angular stomatitis, joint pain, joint stiffness, joint swelling, enterocutaneous fistula, skin rash, flank pain, right upper quadrant pain, and anemia:,” with a mean number of exacerbation symptoms of 4.59 ± 2.84 symptoms. Only 9.7% were referred by the internist to an ophthalmologist [Table 2].
|Table 2: Distribution of the studied participants according to family history of inflammatory bowel disease, symptoms of inflammatory bowel disease, effect of inflammatory bowel disease on participants activities and other aspects related to the disease|
Click here to view
Majority of the participants (76.9%) suffered eye symptoms. The most common symptoms were acute redness of one or both eyes and severe irritation or blurring of vision in one or both eyes. Significant number of the participants (17.1%) had severe eye pain associated with headache or/and nausea or vomiting (8.3%) with a mean number of eye symptoms of 2.51 ± 1.46 symptom [Table 3] and [Figure 1].
|Table 3: Distribution of the studied participants according to associated eye symptoms|
Click here to view
|Figure 1: Percentage prevalence of eye symptoms among studied participants|
Click here to view
Majority of the participants 69.4% had their GIT symptoms started before their eye involvement. For 59.3% eye symptoms are related to both eyes and for 33.3% eye manifestation increase with abdominal symptoms. About 44% of the participants and (44.9%) had eye symptoms for 0–5 times/year. About 38% (38.4%) reported that they went to the hospital for their eye manifestation and 6.9% of the participants had (dry eye, allergy, and inflammation together) or (allergy and inflammation together). For 23.6% of the participants who went to the hospital for eye symptoms, cool compresses and/or topical drug was given. Only 36.6% of the participants were wearing eyeglasses and 29.2% reported that they change the eyeglass or contact lens prescription once every year [Table 4].
|Table 4: Distribution of the studied participants according to conditions related to their eye symptoms (n=166)|
Click here to view
There was no significant difference between the presence of eye symptoms and participants' gender, marital status, educational level, smoking habits, and stress level (P ≤ 0.05) [Table 5] and [Table 6].
|Table 5: Relationship between the presence of eye symptoms and participants' characters, smoking habits and stress level|
Click here to view
|Table 6: Relationship between the mean number of eye symptoms since diagnosis with inflammatory bowel disease and participants' characters, smoking habits and stress level|
Click here to view
| Discussion|| |
IBD is considered one of the most common immune-mediated diseases worldwide. The exact cause of IBD until today is unknown and its believed to be multifactorial many environmental factors such as smoking, stress, use of oral contraceptive pills, diet, breastfeeding, appendicitis, and many other factors believed to play a role in the pathogenesis of IBD. Smoking reported to be the most consistently observed risk factor that contributes to the pathogenesis of the IBD. Stress was also considered as one of the most common risk factors that might be part of the environmental factors enrolled in the pathogenesis of the disease. While in our study, population neither stress nor smoking were significantly associated with ocular manifestations. Further studies need to focus on the precipitating factors for intestinal exacerbation in the Saudi population.
Positive family history remains the strongest risk factor for the development of IBD and was found in 8%–12% of IBD patients. One-third of our respondents gave a positive family history of IBD due to the shared genetic and environmental susceptibility.,, This finding highlight the importance of family history inquiry as important section during history taking. Our finding showed a higher incidence of family history among Saudi IBD patients which could be explained by a higher percentage of consanguinity among the Saudi population.
In our study, most participants reported gastrointestinal manifestations preceded the extra-intestinal manifestations including ocular symptoms. While one-tenth of the study population reported eye symptoms before the onset of the intestinal manifestations. This observation is consistent with previous reports which highlights the importance of systemic review during history taking in patients presented with red eye. We recommend a longer observation period for individuals with suspicious ocular manifestations preceding the intestinal ones looking for possible systemic disease evolution.
Episcleritis was the most common ocular manifestation in IBD patients which is thought to be more associated with intestinal disease activity. While in pediatrics IBD patients uveitis reported to be the most common ocular manifestation. The prevalence of ophthalmic involvement in endoscopically proven IBD individuals' ranges from 0.3% to 25% and the ocular complications reported in 10% of IBD patients. Previous reports showed that 33.3% of the participants believe that ocular symptoms reactivation related to the intestinal disease activity.,, Similar findings reported by our participants were 43.4% noticed significant association between the intestinal disease activity and the ocular symptoms reactivation.
Most of the ocular manifestations with IBD are nonspecific and easily misdiagnosed. Variety of ocular manifestations reported by the majority of our respondents most of them were nonspecific to IBD. One-third reported acute red eye in one or both eyes for which they have to visit an ophthalmologist and were diagnosed as eye inflammation. Most of our respondents reported associated eye pain and visual disturbance which demand an urgent full ophthalmic examination to treat the potentially vision-threatening conditions among this high-risk group. Most of the participants in our study (44.9%) suffered from frequent eye manifestations up to five times/year of those 38.4% required to arrange a hospital visit for ophthalmic evaluation. Only one-tenth (9.7%) of our participants received medical referral to ophthalmologist. Routine referral for ophthalmic evaluation should be part of the standard medical care provided to the IBD patient.
The study had certain limitation including the online nature of questionnaire distribution, patient description about the ocular manifestation were nonspecific and lack ophthalmic examination by an ophthalmologist.
| Conclusion|| |
IBD has rising prevalence in this part of the world with variable severity negatively affecting the quality of life of the affected individuals. Positive family history is a significant risk factor in our study group which should demand further genetic studies. The routine ophthalmic evaluation may improve the quality of life of IBD individuals and reduce the potentially vision-threatening complications.
Financial support and sponsorship
Conflicts of interests
There are no conflicts of interest.
| References|| |
Wen Z, Fiocchi C. Inflammatory bowel disease: Autoimmune or immune-mediated pathogenesis? Clin Dev Immunol 2004;11:195-204.
Hendrickson BA, Gokhale R, Cho JH. Clinical aspects and pathophysiology of inflammatory bowel disease. Clin Microbiol Rev 2002;15:79-94.
Fakhoury M, Negrulj R, Mooranian A, Al-Salami H. Inflammatory bowel disease: Clinical aspects and treatments. J Inflamm Res 2014;7:113-20.
Kaplan GG. The global burden of IBD: from 2015 to 2025. Nat Rev Gastroenterol Hepatol 2015;12:720-7.
Fadda MA, Peedikayil MC, Kagevi I, Kahtani KA, Ben AA, Al Ashgar HI, et al.
Inflammatory bowel disease in Saudi Arabia: A hospital-based clinical study of 312 patients. Ann Saudi Med 2012;32:276-82.
Roberts SE, Thorne K, Thapar N, Broekaert I, Benninga MA, Dolinsek J, et al
. A Systematic review and meta-analysis of paediatric inflammatory bowel disease incidence and prevalence across Europe. J Crohns Colitis 2020;14:1119-48.
Hafiz TA. Inflammatory bowel disease in Saudi Arabia: Challenges and perspectives. EC Microbiol 2019;2:217-26.
Levine JS, Burakoff R. Extraintestinal manifestations of inflammatory bowel disease. Gastroenterol Hepatol (N Y) 2011;7:235-41.
Mady R, Grover W, Butrus S. Ocular complications of inflammatory bowel disease. ScientificWorldJournal 2015;2015:438402.
Hopkins DJ, Horan E, Burton IL, Clamp SE, de Dombal FT, Goligher JC. Ocular disorders in a series of 332 patients with Crohn's disease. Br J Ophthalmol 1974;58:732-7.
Troncoso LL, Biancardi AL, de Moraes HV Jr, Zaltman C. Ophthalmic manifestations in patients with inflammatory bowel disease: A review. World J Gastroenterol 2017;23:5836-48.
Mintz R, Feller ER, Bahr RL, Shah SA. Ocular manifestations of inflammatory bowel disease. Inflamm Bowel Dis 2004;10:135-9.
Castro-Santos P, Moro-García MA, Marcos-Fernández R, Alonso-Arias R, Díaz-Peña R. ERAP1 and HLA-C interaction in inflammatory bowel disease in the Spanish population. Innate Immun 2017;23:476-81.
Akpek EK, Thorne JE, Qazi FA, Do DV, Jabs DA. Evaluation of patients with scleritis for systemic disease. Ophthalmology 2004;111:501-6.
Manganelli C, Turco S, Balestrazzi E. Ophthalmological aspects of IBD. Eur Rev Med Pharmacol Sci 2009;13 Suppl 1:11-3.
Halling ML, Kjeldsen J, Knudsen T, Nielsen J, Hansen LK. Patients with inflammatory bowel disease have increased risk of autoimmune and inflammatory diseases. World J Gastroenterol 2017;23:6137-46.
Molodecky NA, Kaplan GG. Environmental risk factors for inflammatory bowel disease. Gastroenterol Hepatol (N Y) 2010;6:339-46.
Burke KE, Boumitri C, Ananthakrishnan AN. Modifiable environmental factors in inflammatory bowel disease. Curr Gastroenterol Rep 2017;19:21.
Santos MP, Gomes C, Torres J. Familial and ethnic risk in inflammatory bowel disease. Ann Gastroenterol 2018;31:14-23.
Torres J, Burisch J, Riddle M, Dubinsky M, Colombel JF. Preclinical disease and preventive strategies in IBD: Perspectives, challenges and opportunities. Gut 2016;65:1061-9.
Lerebours E, Gower-Rousseau C, Merle V, Brazier F, Debeugny S, Marti R, et al.
Stressful life events as a risk factor for inflammatory bowel disease onset: A population-based case-control study. Am J Gastroenterol 2007;102:122-31.
Yilmaz S, Aydemir E, Maden A, Unsal B. The prevalence of ocular involvement in patients with inflammatory bowel disease. Int J Colorectal Dis 2007;22:1027-30.
Lee DH, Han JY, Park JJ, Cheon JH, Kim M. Ophthalmologic manifestation of inflammatory bowel Disease: A review. Korean J Gastroenterol 2019;73:269-75.
Calvo P, Pablo L. Managing IBD outside the gut: Ocular manifestations. Dig Dis 2013;31:229-32.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]