Introduction
Background
Gout is one of the oldest diseases in the medical literature and has been characterized as a condition caused by indiscretions of diet and alcohol. Since the time of the Greeks, many authors have written about gout as the result of personal excess. However, among the abstinent was John Milton, who lived a life of rigorous self-discipline and yet, to his anger and despair, suffered from what commonly was regarded as just punishment of the dissolute.
Gout, the king of diseases and the disease of kings, is an illness that produces signs and symptoms secondary to elevated levels of uric acid salts in the serum and the resulting deposition of these salts within target organs, primarily the joints of the extremities, the kidneys, and the urinary collecting system.
Rarely, gout can produce significant ocular findings. The incidence of age-related macular degeneration (ARMD) is higher in patients with gout.
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Frequency
United States
Unknown
International
Unknown
Mortality/Morbidity
During an attack, the patient is incapacitated by pain in the affected area.
Race
No racial predilection is known.
Sex
Males are affected more commonly than females.
Age
The onset of this condition generally occurs in patients aged 30-50 years.
Clinical
History
With joint involvement, patients experience pain in the distal extremities. With kidney stones, patients experience acute flank pain.
Physical
The classic attack of acute primary gouty arthritis occurs in a portly middle-aged man and produces fairly sudden inflammation of a single joint, most commonly the metatarsal-phalangeal joint of the great toe, resulting in intense pain, tenderness, and swelling.
The folklore surrounding gout has also involved the eye, and, prior to the 20th century, a myriad of common and unusual ocular symptoms were falsely ascribed to the gout. All manifestations of gout in the eye are secondary to deposition of urate crystals within the ocular tissue.
- Conjunctival nodules containing needlelike crystals have been described within the interpalpebral areas, sometimes associated with a mild marginal keratitis.
- Band keratopathy with refractile, yellow crystals in the deep corneal epithelial cells and at the level of the Bowman membrane are not uncommon.
- Symptoms of visual blurring from the corneal haze or foreign body sensation due to epithelial breakdown can be treated with scraping of the epithelium and removal of the crystals.
- Gout rarely can be associated with anterior uveitis and has been mentioned by Duke-Elder in his textbook as a cause of hemorrhagic iritis.
- Scleritis and tenonitis also have been described.
- In addition to the cornea, urate crystals have been described clinically in the iris, anterior chamber, lens, and sclera, and, on postmortem examination, in the tarsal cartilage and in the tendons of extraocular muscles.
- Uric acid nodules called tophi have been described in the eyelids.
Causes
Attacks are caused by the deposition of monosodium urate monohydrate within the joint space. Precipitating factors can include emotional stress, dehydration, surgery, and thiazide diuretics. Attacks tend to be recurrent and usually are self-limited. Recurrent attacks of acute gouty arthritis can result in chronic arthritis with limitation of joint mobility.
Uric acid levels may be elevated as a result of primary gout. Primary gout is an autosomal dominant error of metabolism. Primary gout can occur secondarily from increased production of uric acid or decreased excretion of uric acid. The latter is seen in chronic renal disease.
- Excessive uric acid production primarily occurs in patients on chemotherapy for malignancies, especially those of the hematopoietic or lymphatic systems. This can be expected because uric acid is the metabolic end product of purines, which are present in high concentration in cell nuclei.
- Decreased levels of serum uric acid have been found in patients with demyelinating disease.
Other causes of secondary gout include chronic lead poisoning, polycystic kidney disease, systemic cyclosporine therapy, various antimitotic chemotherapeutic agents, sarcoidosis, psoriasis, and hyperparathyroidism.
More on Gout |
 Overview: Gout |
| Differential Diagnoses & Workup: Gout |
| Treatment & Medication: Gout |
| Follow-up: Gout |
| References |
| Next Page » |
References
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Choi HK, Atkinson K, Karlson EW, et al. Alcohol intake and risk of incident gout in men: a prospective study. Lancet. Apr 17 2004;363(9417):1277-81. [Medline].
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Coassin M, Piovanetti O, Stark WJ, et al. Urate deposition in the iris and anterior chamber. Ophthalmology. Mar 2006;113(3):462-5. [Medline].
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Klein R, Klein BE, Tomany SC, et al. Association of emphysema, gout, and inflammatory markers with long-term incidence of age-related maculopathy. Arch Ophthalmol. May 2003;121(5):674-8. [Medline].
Knapp CM, Constantinescu CS, Tan JH, et al. Serum uric acid levels in optic neuritis. Mult Scler. Jun 2004;10(3):278-80. [Medline].
Margo CE. Use of standard hematoxylin-eosin to stain gouty tophus specimens. Arch Ophthalmol. Apr 2004;122(4):665. [Medline].
Mcwilliams JR. Ocular findings in gout; report of a case of conjunctival tophi. Am J Ophthalmol. Dec 1952;35(12):1778-83. [Medline].
Morris WR, Fleming JC. Gouty tophus at the lateral canthus. Arch Ophthalmol. Aug 2003;121(8):1195-7. [Medline].
Slansky HH, Kubara T. Intranuclear urate crystals in corneal epithelium. Arch Ophthalmol. Sep 1968;80(3):338-44. [Medline].
Wyngaarden JB. Gout. In: The Metabolic Basis of Inherited Disease. 1966:667-728.
Further Reading
Keywords
gout, uric acid, urate crystals, ocular tissue, kidneys, kidney stones, urinary collecting system, joint inflammation, joint destruction, tophus, tophi, alcohol, uric acid salts, uric acid metabolism, uric acid nephropathy, chronic tophaceous gout, tophaceous gout, gouty arthritis, primary gout, secondary gout, acute gout, chronic gout, polyarticular gout, hyperuricemia, acute monoarticular arthritis, polyarticular arthritis
