To determine the viral diagnosis and factors affecting the visual outcome of eyes with acute retinal necrosis.
Nonrandomized, retrospective, interventional, noncomparative series.
A cohort of 22 ...human immunodeficiency virus-negative patients with acute retinal necrosis (ARN). There were 17 unilateral and 5 bilateral cases.
Diagnostic vitreous biopsy for polymerase chain reaction (PCR) viral DNA analysis, prophylactic barrier laser posterior to necrotic retina to try to prevent rhegmatogenous retinal detachment (RD), intravenous acyclovir in combination with oral, and vitrectomy for RD repair.
Results of PCR viral DNA analysis, relationship between prophylactic barrier argon laser photocoagulation and occurrence of RD, and visual acuities at presentation and follow-up.
Varicella-zoster virus (VZV) was detected in 66.7% (12/18) of eyes (66.7% of patients 10/15) with vitreous biopsy and herpes simplex virus (HSV) in 22.2% (4/18) of eyes (20% of patients 3/15). Epstein-Barr virus (EBV) was detected in 16.7% (3/18) of eyes (20% of patients 3/15), and all the EBV-positive eyes were also positive for VZV. Polymerase chain reaction results were identical in both eyes of bilateral cases (5 patients) and were negative in 11.1% (2/18) of eyes (13.3% of patients 2/15) biopsied. Systemic corticosteroid treatment given before ARN diagnosis did not appear to increase the risk of developing RD (P = 0.69). Rhegmatogenous RD occurred in 35.3% (6/17) of eyes given prophylactic argon laser treatment and in 80% (8/10) of eyes that could not be lasered prohylactically. Of RDs, 96.3% (13/14) occurred after the third week and up to 5 months from onset of symptoms. The VA after surgical repair of RD improved relative to the presentation acuity in 33.3% (4/12) of eyes.
Varicella-zoster virus is the leading cause of ARN. We recommend the management of ARN to include prompt diagnosis; prophylactic argon laser retinopexy, preferably within the first 2 weeks to reduce risk of RD; systemic acyclovir; and corticosteroids to control the severe inflammation associated with ARN. Despite the guarded visual prognosis, RD repair may result in improved visual outcomes.
The purpose of this study was to determine classification criteria for sarcoidosis-associated uveitis.
Machine learning of cases with sarcoid uveitis and 15 other uveitides.
Cases of anterior, ...intermediate, and panuveitides were collected in an informatics-designed preliminary database, and a final database was constructed including cases achieving supermajority agreement on the diagnosis, using formal consensus techniques. Cases were analyzed by anatomic class, and each class was split into a training set and a validation set. Machine learning using multinomial logistic regression was used in the training sets to determine a parsimonious set of criteria that minimized the misclassification rate among the uveitides. The resulting criteria were evaluated in the validation sets.
A total of 1,083 cases of anterior uveitides, 589 cases of intermediate uveitides, and 1,012 cases of panuveitides, including 278 cases of sarcoidosis-associated uveitis, were evaluated by machine learning. Key criteria for sarcoidosis-associated uveitis included a compatible uveitic syndrome of any anatomic class and evidence of sarcoidosis, either 1) tissue biopsy results demonstrating non-caseating granulomata or 2) bilateral hilar adenopathy on chest imaging. The overall accuracy of the diagnosis of sarcoidosis-associated uveitis in the validation set was 99.7% (95% confidence interval: 98.8-99.9). The misclassification rates for sarcoidosis-associated uveitis in the training sets were 3.2% in anterior uveitis, 2.6% in intermediate uveitis, and 1.2% in panuveitis; in the validation sets, the misclassification rates were 0% in anterior uveitis, 0% in intermediate uveitis, and 0% in panuveitis.
The criteria for sarcoidosis-associated uveitis had a low misclassification rate and appeared to perform sufficiently well for use in clinical and translational research.
To evaluate the long-term outcomes of uveitic macular edema (ME).
Longitudinal follow-up of a cohort of participants in a randomized clinical trial.
A total of 248 eyes of 177 participants with ...uveitic ME enrolled in the Multicenter Uveitis Steroid Treatment (MUST) Trial and Follow-up Study.
OCT measurements, taken at baseline and annually, were graded by reading center graders masked to clinical data. Macular edema was defined as a center macular thickness (CMT) ≥240 μm on time-domain OCT or time-domain OCT equivalent. Resolution of ME was defined as normalization of macular thickness on OCT. Relapse of ME was defined as increase in macular thickness to ≥240 μm in an eye that previously had resolution. Visual acuity was measured at each visit with logarithmic visual acuity charts.
Resolution and relapse of ME. Visual acuity.
Among 227 eyes with ME followed ≥1 year, the cumulative percent of eyes with ME resolving at any point during 7 years was 94% (95% confidence interval CI, 89-97). Epiretinal membranes on OCT were associated with a lower likelihood of ME resolution (hazard ratio HR, 0.74; 95% CI, 0.55-1.01; P = 0.05). Among 177 eyes with resolved ME, the cumulative percent with relapse within 7 years was 43% (95% CI, 32-51). Eyes in which ME resolved gained a mean of 6.24 letters (95% CI, 4.40-8.09; P < 0.001) compared with eyes that remained free from ME during the 1-year follow-up intervals, whereas eyes in which ME did not resolve experienced no gain in vision (mean change -1.30 letters; 95% CI, -2.70 to 0.09; P = 0.065), and eyes that developed ME during the year (incident or relapsed) experienced a mean loss of -8.65 letters (95% CI, -11.5 to -5.84, P < 0.001).
Given sufficient time and treatment, nearly all uveitic ME resolves, but episodes of relapse were common. Visual acuity results were better among eyes with resolved ME, suggesting that control of inflammation and resolution of ME might be visually relevant treatment targets.
To evaluate agreement between fluorescein angiography (FA) and optical coherence tomography (OCT) results for diagnosis of macular edema in patients with uveitis.
Multicenter cross-sectional study.
...Four hundred seventy-nine eyes with uveitis from 255 patients.
The macular status of dilated eyes with intermediate uveitis, posterior uveitis, or panuveitis was assessed via Stratus-3 OCT and FA. To evaluate agreement between the diagnostic approaches, κ statistics were used.
Macular thickening (MT; center point thickness, ≥ 240 μm per reading center grading of OCT images) and macular leakage (ML; central subfield fluorescein leakage, ≥ 0.44 disc areas per reading center grading of FA images), and agreement between these outcomes in diagnosing macular edema.
Optical coherence tomography (90.4%) more frequently returned usable information regarding macular edema than FA (77%) or biomicroscopy (76%). Agreement in diagnosis of MT and ML (κ = 0.44) was moderate. Macular leakage was present in 40% of cases free of MT, whereas MT was present in 34% of cases without ML. Biomicroscopic evaluation for macular edema failed to detect 40% and 45% of cases of MT and ML, respectively, and diagnosed 17% and 17% of cases with macular edema that did not have MT or ML, respectively; these results may underestimate biomicroscopic errors (ophthalmologists were not explicitly masked to OCT and FA results). Among eyes free of ML, phakic eyes without cataract rarely (4%) had MT. No factors were found that effectively ruled out ML when MT was absent.
Optical coherence tomography and FA offered only moderate agreement regarding macular edema status in uveitis cases, probably because what they measure (MT and ML) are related but nonidentical macular pathologic characteristics. Given its lower cost, greater safety, and greater likelihood of obtaining usable information, OCT may be the best initial test for evaluation of suspected macular edema. However, given that ML cannot be ruled out if MT is absent and vice versa, obtaining the second test after negative results on the first seems justified when detection of ML or MT would alter management. Given that biomicroscopic evaluation for macular edema erred frequently, ancillary testing for macular edema seems indicated when knowledge of ML or MT status would affect management.
Proprietary or commercial disclosure may be found after the references.
To report the 2-year incidence of raised intraocular pressure (IOP) and glaucomatous optic nerve damage in patients with uveitis randomized to either fluocinolone acetonide (FA) implants or systemic ...therapy. Secondarily, we sought to explore patient and eye characteristics associated with IOP elevation or nerve damage.
A randomized, partially masked trial in which patients were randomized to either FA implants or systemic therapy.
Patients aged ≥ 13 years with noninfectious intermediate, posterior, or panuveitis active within the prior 60 days for which systemic corticosteroids were indicated were eligible.
Visual fields were obtained at baseline and every 12 months using the Humphrey 24-2 Swedish interactive threshold algorithm (SITA) fast protocol. Stereoscopic optic nerve photos were taken at baseline and at 3-, 6-, 12-, and 24-month follow-up visits. Masked examiners measured IOP at every study visit.
Glaucoma was diagnosed based on an increase in optic nerve cup-to-disc ratio with visual field worsening or increased cup-to-disc ratio alone, for cases where visual field change was not evaluable, because of missing data or severe visual field loss at baseline.
Most patients were treated as assigned; among those evaluated for glaucoma, 97% and 10% of patients assigned to implant and systemic treatment, respectively, received implants. More patients (65%) assigned to implants experienced an IOP elevation of ≥ 10 mmHg versus 24% assigned to systemic treatment (P<0.001). Similarly, 69% of patients assigned to the implant required IOP-lowering therapy versus 26% in the systemic group (P<0.001). Glaucomatous optic nerve damage developed in 23% versus 6% (P<0.001) of implant and systemic patients, respectively. In addition to treatment assignment, black race, use of IOP-lowering medications, and uveitis activity at baseline were associated with incident glaucoma (P<0.05).
Implant-assigned eyes had about a 4-fold risk of developing IOP elevation of ≥ 10 mmHg and incident glaucomatous optic neuropathy over the first 2 years compared with those assigned to systemic therapy. Central visual acuity was unaffected. Aggressive IOP monitoring with early treatment (often including early filtration surgery) is needed to avoid glaucoma when vision-threatening inflammation requires implant therapy.
Proprietary or commercial disclosure may be found after the references.
Eye care in the intensive care unit Hearne, Benjamin J; Hearne, Elewys G; Montgomery, Hugh ...
Journal of the Intensive Care Society,
11/2018, Letnik:
19, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Ocular surface disease is common in the intensive care population with 20–42% of patients developing corneal epithelial defects. The ocular surface is normally protected by the ability to produce ...tears, to blink and to close the eyes with rest or sleep. All of these mechanisms can be disrupted in the intensive care population, increasing the risk of developing ocular surface disease. Despite the scale of the problem, eye-care protocols are commonly not instigated and documentation of eye care is often poor. This review details the risk factors for developing ocular surface disease. It also provides evidence-based guidance on protecting the eyes in vulnerable patients, identifying diseases affecting the eye in intensive care patients and delivering the best treatment to the eye. There is growing evidence that adherence to a correctly performed eye-care guideline prevents the majority of corneal problems encountered in the intensive care unit.
To report the short-term outcome of intravitreal triamcinolone acetate (TA) in the treatment of uveitic cystoid macular edema (CME).
Retrospective noncomparative (nonrandomized, uncontrolled) ...interventional case series.
Sixty-five eyes of 54 patients with uveitis-related CME inadequately responsive to treatment combinations of oral corticosteroid, periocular orbital floor corticosteroid injections, and second-line immunosuppressive agents.
Intravitreal injection of 4 mg/0.1 ml of TA.
Visual acuity (VA), intraocular pressure (IOP), levels of inflammation, and immunosuppressive therapy were assessed. Other potential complications, including cataract progression, vitreous hemorrhage, endophthalmitis, and retinal detachment (RD), were looked for.
The mean follow-up was 8.0 months (range, 3-51), and the mean improvement of VA after intravitreal TA was 0.26 (from 0.65 to 0.39 logarithm of the minimum angle of resolution; Snellen, 6/24-6/12, approximately). This occurred at a mean of 4 weeks (range, 1-30). The improvement in VA was more significant if the duration of CME before intravitreal TA was < or =12 months (P = 0.006) and if patients were < or =60 years old (P = 0.005). Patients with the worst vision before treatment also improved the least. The most important side effect was raised IOP (mean rise, 10.3 mmHg), with 28 eyes (43.1%) experiencing an IOP rise of >10 mmHg. Patients younger than 40 years were more likely to experience this IOP rise than those older than 40. Thirty-three eyes (51%) were treated with antiglaucoma medications, with a mean duration of treatment of 17.4+/-13.3 weeks, and no patient required trabeculectomy or lost vision. The dosage of oral corticosteroids and/or second-line immunosuppressive medication was reduced or stopped altogether in 18 of 33 eyes (54.5%) during the study period. There were no cases of injection-related vitreous hemorrhage, endophthalmitis, or RD.
In patients with uveitic CME, intravitreal TA can effectively reduce CME and improve VA and, in some eyes, allows the cessation and/or reduction of immunosuppressive therapy. The period of effectivity varies in different patients and, in some eyes, is limited. Treatment was associated in 43.1% with a rise in IOP, which was transient and treatable medically.
Inflammation in Retinal Disease Whitcup, Scott M.; Nussenblatt, Robert B.; Lightman, Susan L. ...
International journal of inflammation,
01/2013, Letnik:
2013
Journal Article
Recenzirano
Odprti dostop
...evidence has also arisen supporting a prominent role for inflammation underlying the pathogenesis of a wide array of retinal diseases, including age-related macular degeneration (AMD) 2, diabetic ...retinopathy (DR) 3, retinal vein occlusion (RVO) 4, and retinitis pigmentosa (RP) 5, and has suggested a role for anti-inflammatory therapies to potentially alter the severity and course of these disorders. ...the pigment epithelial cells which line the iris, ciliary body, and retina serve an immunomodulatory role through both the secretion of soluble immunosuppressive factors as well as contact-dependent mechanisms 6. Strong associations with AMD have been identified in association with particular mutations in the complement factor H (CFH) protein (Y402H), a key regulatory component of the alternative pathway in distinguishing self from nonself 10–13. ...a growing body of histopathological, preclinical, and epigenetic data now supports a key role of inflammation in the pathogenesis of AMD, a disease which was not classically described as inflammatory in origin. 3. Chronic hyperglycemia leads to a series of biochemical changes, including activation of protein kinase C, accumulation of polyols through the aldose reductase pathway, increased formation of advanced glycation end products (AGEs), and overproduction of free radicals.
A 58-year-old Afro-Caribbean gentleman with a diagnosis of quiescent systemic lupus erythematosus- (SLE-) related occlusive retinal vasculitis was previously treated with sector pan-retinal ...photocoagulation in his right eye to control temporal retinal neovascularization. At routine review he was found to have a focal area of subretinal fluid in the temporal macula sparing an ischaemic fovea. Fundus fluorescein angiography and indocyanine green angiography confirmed a branching vascular network (BVN) and terminal polys (i.e., polypoidal choroidal vasculopathy (PCV)). Interestingly, the BVN arose within an old laser scar. To our knowledge this is the first report of PCV in uveitis in an Afro-Caribbean patient and of the lesions arising within a laser scar.
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