The Role of Sex in Uveitis and Ocular Inflammation

Ian Y. L. Yeung, MD; Nicholas A. Popp, BS; Chi-Chao Chan, MD


Int Ophthalmol Clin. 2015;55(3):111-131. 

In This Article

Infectious Uveitides

In infectious uveitides for which there is no element of sexual transmission, the prevalence of ocular disease is roughly equal between men and women. However, variation exists between different infectious uveitides due to the influence of occupational exposures, sexual behaviors, and other environmental factors that differ between the sexes (Table 2).[9]

Some infectious conditions are more prevalent in men. Eighty-seven percent to 90% of systemic and ocular syphilis occurs in men.[9,75,76] The high prevalence of syphilis in men is thought to be due to unsafe sexual practices mainly among men who have sex with men, who account for 73% of infectious syphilis. Ocular syphilis can cause an anterior, intermediate, posterior, or pan-uveitis along with optic neuritis and interstitial keratitis.[76]

Acute retinal necrosis (ARN) is a rare but devastating condition that usually occurs in immunocompetent individuals. The causative agents are thought to be varicella zoster virus, herpes simplex virus, and possibly Epstein-Barr virus and cytomegalovirus (CMV). ARN is characterized by discrete foci of peripheral retinal necrosis, circumferential spread, occlusive arteriolar retinopathy, vitreous or anterior chamber reaction, and rapid disease progression.[147] Secondary retinal detachment is a known possible complication of ARN.[148] ARN has an increased prevalence in men with 56% to 72% of ARN patients being male.[35,147–149] Further, ARN severity is correlated with sex; in 1 study of 22 individuals with ARN, male sex was a risk factor for severe vision loss at 6 and 12 months (P=0.019 and P=0.008, respectively).[149]

Progressive outer retinal necrosis (PORN) is another viral-mediated infectious uveitides which is more prevalent in men (83% to 86%).[158,159] PORN occurs in immunocompromised individuals and is due to varicella zoster or herpes simplex viral infection.[160] It usually presents as a minimal nongranulomatous anterior uveitis without vitritis but is associated with a bilateral necrotizing retinitis. The retinitis starts at the posterior pole and spreads peripherally. Like ARN, PORN can also lead to secondary retinal detachment.[161]

CMV retinitis (CMVR) is a similar viral-mediated infectious uveitides that is more common in men. In human immunodeficiency virus (HIV)-infected patients, up to 77% of CMVR patients are male.[152] Although uncommon in non–HIV-infected patients, 60% to 80% of these CMVR patients are male.[153,154] CMVR is characterized with dense, white confluent retinal lesions with hemorrhages and vascular sheathing. Similar to ARN and PORN, a secondary retinal detachment can occur.[161] CMV can also cause anterior uveitis. Similar to CMVR, there is a male predominance with 56% to 78% of CMV anterior uveitis patients being male.[142,155–157] CMV anterior uveitis can be acute or chronic. It can present like Posner-Schlossman syndrome or Fuchs heterochromic iridocyclitis and may be associated with acute relapsing or chronic raised intraocular pressure.[155]

There are infectious uveitides without sex preference. Toxoplasma is a sex-neutral infection that can result in uveitis. Brazil has a high prevalence of toxoplasma chorioretinitis, and toxoplasma seropositivity occurs across both sexes in the same households. Sharing of and ingestion of contaminated food or similar environmental factors within the same family could account for this sex neutrality.[9,41]