By Wanda M. Martinez Navarro, MD
This review of sex disparities in ocular inflammatory disorders reports that women are disproportionately affected, with the majority of affected women of childbearing age.
They write that there are well-described sex differences in many of the uveitides, particularly those associated with systemic autoimmune diseases. In most instances, females are more commonly affected than males, although in some cases female sex portends a better prognosis.
This review evaluates prevalence, incidence and severity of sex disparities of the most common infectious and noninfectious ocular inflammatory disorders. The association between uveitic entities and sex is of interest as it has diagnostic, prognostic and treatment implications.
Sex differences in uveitic diseases are not only important when describing disease incidence but also disease severity. For example, female sex is associated with poor vision in ocular sarcoidosis. Of importance, sex predilection seen in the uveitic syndrome does not always mirror the sex differences or severity of the systemic disease.
The role of sex or reproductive hormones has been proposed in many other inflammatory or autoimmune disorders, and findings from nonocular autoimmune diseases suggest a complex interaction between sex hormones, genetic factors and the immune system. Overall, the effect of hormones on the incidence and severity of inflammatory ocular diseases is not well understood.
It is known that leukocytes contain hormone receptors. Also, pregnancy is associated with a decrease in uveitis, perhaps related to the altered hormonal state and increased levels of progesterone. However, the interactions between hormones and the immune system appear to be complex. For example, an increased incidence of systemic lupus erythematosus after puberty hints at a hormonal influence but treatment with androgens has been found not to have a significant effect on the disease.
In anterior uveitis, juvenile idiopathic arthritis is more common in girls. Tubulointerstitial nephritis and uveitis is a rare disease with limited published information; however, some studies have shown slight female predilection. HLA-B27 and reactive arthritis-associated uveitis are more common in males. No sex differences have been reported for psoriatic arthritis-associated uveitis or inflammatory bowel disease-associated uveitis.
In intermediate uveitis, multiple sclerosis-associated uveitis is more common in women, with only 25% of patients male in some studies. In posterior uveitis and panuveitis, there are various entities with female predominance including multiple evanescent white dot syndrome, birdshot chorioretinopathy, multifocal choroiditis and panuveitis, punctate inner choroidopathy and acute zonal occult outer retinopathy.
Serpiginous choroidopathy appears to have no sex predilection. Ocular sarcoidosis overall has a slight female predominance, with more females presenting with ocular sarcoidosis in later stages of life. Vogt-Koyanagi-Harada syndrome is also more common in women. Ocular Behcet's disease is more common in males than females. Sympathetic ophthalmia has no gender predilection.
They conclude that sex differences in the infectious-associated uveitic syndromes may be driven by multiple factors that include not only hormonal but genetic, environmental and cultural influences. While there is a real difference between the sexes in certain uveitic syndromes, the triggers and forces that drive these differences are not yet well understood and require further research.