Necrotising retinitis is a rare ocular infection that historically led to high rates of visual morbidity. While acute retinal necrosis occurs in immunocompetent patients, the majority of cases are ...associated with immunocompromise such as in cytomegalovirus retinitis and progressive outer retinal necrosis. This review summarises the clinical and diagnostic features, management, and outcomes of herpetic retinitis. Iatrogenic immunosuppression is increasingly being utilised for a wide range of indications, and biologic agents especially so due to their targeted nature. While the intended actions are well‐studied, the flow‐on effects and complex interaction with host immunity are not well understood. Furthermore, biologics are frequently used concomitantly with other immunosuppressive agents, potentiating the immunodepression. This article reviews the literature on biologic immunosuppression and viral retinitis, and presents an approach to the vulnerable or affected patient. Early identification, prompt and aggressive treatment, and a multidisciplinary approach to managing immunodeficiency are the cornerstones of management.
Importance
Cataract is one of the most common complications associated with uveitis, and is the leading cause of vision loss in these patients.
Background
The study aimed to evaluate the effect of ...phacoemulsification on the long‐term clinical outcome and inflammation control in uveitis patients.
Design
Longitudinal study.
Participants
Of 1907 eyes with uveitis, 309 eyes underwent phacoemulsification were compared to a control group of 300 phakic eyes with uveitis.
Method
The risk of vision loss and macular oedema in pseudophakic eyes were compared to the phakic group. The rates of corticosteroids administration and uveitis relapse were also measured in pseudophakic eyes and compared to preoperative period.
Main Outcome Measures
Change in uveitis activity post phacoemulsification by measuring rate of uveitis relapse and use of topical and systemic steroids. Also, to measure the risk of vision loss and macular oedema post surgery.
Results
Over a median follow‐up time of 6.7 years or 2249 eye‐years (EY), pseudophakic eyes had a greater risk of vision loss (hazard ratio HR 2.4, CI 1.4 to 4.0; P < 0.001) and macular oedema (HR 2.2, CI 1.4 to 3.4, P < 0.001) compared to the phakic uveitis group. Over 5 years post‐surgery, the annual rate of uveitis relapses was less than the same period pre surgery (−1.2, 95% CI −2.0 to −0.2, P = 0.012) with no significant change in the annual rate of using topical and systemic prednisolone >7.5 mg/day.
Conclusions and Relevance
There was no significant increase in uveitis relapse rate post‐phacoemulsification with the use of current prophylactic inflammation control measures.
To describe factors that predict visual loss and complications in intermediate uveitis.
Cross-sectional study.
Subjects with intermediate uveitis were identified from a database of 1254 uveitis ...patients seen in the clinic of a single consultant (S.L.L.) between 2011 and 2013.
Information was gathered from the clinical notes of all subjects examined in clinic.
Best-corrected visual acuity (BCVA), moderate visual loss (MVL; ≤20/50), severe visual loss (SVL; ≤20/200).
Three hundred and five subjects (550 eyes) were included in the study, comprising 24.3% of subjects seen in clinic. Mean (± standard deviation) age at diagnosis was 40.9±16.9 years, and 64.6% of subjects were female. Median follow-up was 8.2 years (mean, 9.7 years, 5452 eye-years). Systemic diagnosis was made in 36.1% of patients, with sarcoidosis (22.6%) and multiple sclerosis (4.6%) the most frequent systemic associations. Median BCVA was 20/30 (mean logarithm of the minimum angle of resolution logMAR 0.26±0.38, n = 550 eyes) at presentation, 20/30 (mean logMAR 0.22±0.42, n = 430) at 5 years, and 20/30 (mean logMAR 0.23±0.46, n = 260) at 10 years. Macular edema was observed in 224 eyes (40.7%) and was associated with idiopathic disease (P = 0.001) and diabetes (P = 0.001). Topical therapy was used in 82.7%, and 34.2% received local injections of corticosteroids. A total of 50.5% required oral steroids and 13.8% required second-line immunosuppression. Subjects with a diagnosis of sarcoidosis were less likely to require a second-line agent (4.3% vs. 16.2%, P = 0.011). On multivariate analysis, visual acuity at referral, retinal pigment epithelial atrophy, and macular scarring were associated with increased risk of MVL; and visual acuity at referral, local therapy, macular scarring, retinal detachment, and hypotony and phthisis were associated with increased risk of SVL.
Intermediate uveitis has a long disease course with frequent complications and often requires systemic treatment. Despite this, most subjects are still able to achieve good long-term visual outcomes.
To evaluate the long-term clinical and functional outcome, risks, and causes of vision loss and burden of disease among patients with uveitis.
Cross-sectional study.
The study included 1076 patients ...diagnosed with uveitis who attended the uveitis clinic at Moorfields Eye Hospital, London, United Kingdom, between 2011 and 2013.
Information was gathered from the notes of all patients who were examined in the clinic.
Best-corrected visual acuity (BCVA), causes of moderate vision loss (MVL; 20/50-20/120), and severe vision loss (SVL; ≤ 20/200).
The study included 1799 eyes of 1076 patients with an average follow-up of 7.97 ± 0.17 years (median, 5.6 years; range, 1 month-54 years; 8159 patient-years; 14 226 eye-years). Average BCVA remained stable for patients with anterior uveitis (20/30 at baseline to 20/33 at 10 years), as well as for those with nonanterior uveitis (20/50 at baseline to 20/47 at 10 years). Vision loss was noted in 19.2% of eyes, with an incidence for MVL of 0.01 per eye-year or 0.02 per patient-year and for SVL of 0.01 per eye-year or 0.02 per patient-year. Patients were more at risk of vision loss if they had non-anterior uveitis disease, vitreous opacities, retinal detachment, cystoid macular edema (CME), macular scarring, macular hole, optic neuropathy, or macular ischemia. Chronic CME was the most common cause of MVL (3.55%), and macular scarring was the most common cause for irreversible SVL (4%). Among 525 patients (48.7%) who received oral prednisolone, 320 (61%) required a dose of more than 40 mg/day and 130 (24.8%) also required 1 or more second-line agents. Patients were reviewed on average 33.7 ± 0.7 times or 5.9 ± 0.46 times/year.
Long-term functional outcome among uveitis patients is good, with BCVA remaining stable for more than 10 years of follow-up. In cases when vision loss occurs, it is related mainly to retinal changes. The burden on clinical services is similar regardless of the severity of disease or the risk of vision loss.
Purpose
To examine the prognostic value of the extent of damage to the ellipsoid zone (EZ) and external limiting membrane (ELM) in response to the treatment of age-related macular degeneration (AMD) ...eyes switched from ranibizumab to aflibercept.
Methods
This is a retrospective study of patients with neovascular AMD resistant to ranibizumab defined as having persistent intra- or subretinal fluid on OCT scans despite at least 6-month treatment and switched to aflibercept. Clinical data was collected and quantitative measurements of the area of EZ and ELM damage were obtained, on en-face optical coherence tomography images, at the time of switch to aflibercept (baseline) and up to 6 months of follow-up.
Results
The study included 71 eyes (52.1% right eye) of 71 patients. At baseline, there was a correlation between the size of the EZ and ELM damaged area and BCVA (
R
= −0.39,
p
= 0.001 and
R
= −0.47,
p
< 0.001, respectively). The EZ and ELM damaged areas maintained correlation with BCVA at 6 months (
R
= −0.28,
p
= 0.01 and
R
= −0.39,
p
= 0.001, respectively). Central retinal thickness did not correlate with BCVA at the time of switch (
p
= 0.38) or at 6 months (
p
= 0.36).
Conclusions
The extent of damage to the EZ and ELM correlates with BCVA following a switch in treatment.
To describe the long-term outcome of eyes with uveitis after repeated treatment with dexamethasone implants (Ozurdex; Allergan, Inc., Irvine, CA).
Retrospective, observational case series.
...Thirty-eight eyes of 27 patients with uveitis that were treated with 61 dexamethasone implants.
All eyes underwent dexamethasone pellet implantation. Anatomic and functional outcomes, as well as ocular complications, were noted.
Best-corrected visual acuity (BCVA), central retinal thickness (CRT), vitreous haze score, and presence of increased intraocular pressure or cataract.
Average follow-up was 17.3 ± 1.8 months after the first implant (median, 13.3 months; range, 3-54.5 months; 54.65 eye-years), with 14 eyes (36.9%) receiving a single implant and 24 eyes (63.1%) receiving multiple implantations. After the first implantation, average BCVA improved significantly from 0.47 ± 0.05 logarithm of the minimum angle of resolution (logMAR) units (Snellen equivalent, 20/60) to 0.27 ± 0.07 logMAR (Snellen equivalent, 20/37; P<0.001); CRT decreased by 263 ± 44.22 μm (P = 0.003), although macular edema persisted in 50% of eyes, and the percentage of eyes achieving a vitreous haze score of 0 increased from 58% to 83% (P = 0.03). The median duration of therapeutic effect after the first injection was 6 months (range, 2-42 months), with a similar response achieved after each repeat implantation. The accumulated effect of repeat dexamethasone implants resulted in a continued improvement in BCVA (R(2) = 0.91; P<0.0001), with significant improvement and stabilization of CRT. After repeated implantations, 2 eyes had progression of posterior subcapsular opacities, although neither required surgery. There were 7 instances of increased intraocular pressure of more than 21 mmHg at a rate of 0.13 per eye-year, all of which responded to pharmacologic treatment.
The accumulated effect of repeat dexamethasone pellet implantations improves retinal thickness and resolves ocular inflammation, resulting in restoration of ocular function. Ocular complications were minimal, with no eyes requiring surgery for increased ocular pressure or progression of cataract.
Purpose
The literature on retinal vascular occlusions in Behçet disease (BD) patients is limited. The aim of this study is to thoroughly investigate retinal vascular occlusions among ocular BD ...patients.
Methods
Retrospective, multicentre case–control study. Three‐hundred and three eyes of 175 patients with ocular BD, from 13 hospitals in Israel and Palestine, were included. Patients were assigned into two groups according to the presence of retinal vascular occlusion. Epidemiology, systemic and ocular manifestations, treatments and outcomes were compared between the groups and risk factors for retinal vascular occlusions were identified.
Results
One hundred twenty‐five patients (71.4%) were male. The mean age at presentation was 28.2 ± 0.86 years. Retinal vascular occlusions were found in 80 eyes of 54 (30.9%) patients, including branch retinal vein occlusion (51.3%), peripheral vessels occlusions (32.5%), central retinal vein occlusion (13.8%) and arterial occlusions (7.5%). Systemic manifestations were similar among both groups. Anterior uveitis was more common in non‐occlusive eyes (p < 0.01). Non‐occlusive retinal vasculitis (p = 0.03) and ocular complications were more common in occlusive eyes (p < 0.01). Treatments including mycophenolate mofetil, Infliximab or a combination therapy of anti‐metabolite and calcineurin inhibitor were more commonly used by occlusive patients (p < 0.05). Occlusive patients underwent more cataract surgeries (p = 0.03). The occlusive group had worse mean best‐corrected visual acuity (BCVA) throughout follow‐up (p < 0.01). Risk factors for retinal vascular occlusions included male sex and Jewish ethnicity (p < 0.05).
Conclusion
Retinal vascular occlusions were found in a third of ocular BD patients. Occlusive eyes had a worse prognosis. Risk factors for vascular occlusions were identified.
Purpose
Retinal sensitivity (RS) can be a valuable indicator of retinal function in response to intravitreal steroid or anti-VEGF treatment in the eyes with diabetic macular edema (DME), macular ...edema post retinal vein occlusion (RVO), or uveitis.
Methods
This prospective longitudinal study included 68 patients (96 eyes) with macular edema (ME) secondary to diabetes mellitus (42 eyes), uveitis (36 eyes), or RVO (18 eyes). In addition to best corrected visual acuity (BCVA) and retinal thickness, Nidek MP1 microperimetry was used to quantify RS at baseline visit and to look at the mean difference (MD) at 3–6 months and 1–2 years post intravitreal therapy with corticosteroids or anti-VEGF.
Results
There was a significant negative correlation between the central RS and BCVA (
r
= − 0.47,
p
< 0.001), including DME (
r
= − 0.42,
p
= 0.006) and uveitis (
r
= − 0.60,
p
< 0.001), but not RVO (
r
= − 0.37,
p
= 0.12). At 2-year follow-up, the overall CST was reduced from baseline (MD − 147 μm, 95% C.I − 192 to − 102,
p
< 0.001) with improved BCVA (MD − 0.12 LogMAR, 95% C.I − 0.23 to − 0.01,
p
= 0.01), but no improvement in the RS in any of the disorders. Both anti-VEFG and steroid groups showed significant improvement in CST at 2 years from baseline (MD − 101 μm,
p
= 0.001 and − 167 μm,
p
< 0.001, respectively) with only improvement in BCVA among anti-VEGF group (MD − 0.16 LogMAR, 95% C.I − 0.26 to − 0.07,
p
= 0.008).
Conclusion
The long-term follow-up of ME cases did not show a significant improvement in RS following treatment even with reduced macular thickness at 2-year follow-up.
To examine a large cohort of subjects with punctate inner choroidopathy (PIC) looking at risk factors for development of choroidal neovascular membrane (CNVM) and visual loss.
Retrospective case ...series.
A total of 203 participants (318 eyes) with PIC seen at Moorfields Eye Hospital between 1996 and 2016.
Information was gathered from the clinical notes of all subjects identified with PIC.
Development of CNVM, moderate visual loss (MVL) (≤20/50), and severe visual loss (SVL) (≤20/200).
Participants were predominantly young (median age at presentation, 32.9 years; interquartile range IQR, 26.1-42.2), myopic (91.5%), female (87.2%), and white (75.9%). Disease was bilateral at presentation in 115 participants (56.7%), and CNVM was present at presentation in 152 eyes (47.8%). Median follow-up was 8.4 years. New CNVM occurred in 58 eyes (33.5% of affected eyes and 4.3% of initially unaffected eyes). An increased risk of developing CNVM was associated with the presence of a CNVM in the fellow eye (P < 0.0005; hazard ratio HR, 2.73), and previous oral corticosteroid treatment was associated with halving of the risk of developing CNVM (P = 0.035; HR, 0.45). No difference was observed in visual outcome with oral corticosteroids, but subjects treated with anti-VEGF had better visual outcomes (12-month median visual acuity, logarithm of the minimum angle of resolution logMAR 0.00 with anti-VEGF and 0.20 without; P = 0.018). Median best-corrected visual acuity (BCVA) was 20/30 at presentation (IQR, 0.00-0.50) and remained at 20/30 throughout all follow-up periods. Moderate visual loss occurred in 40 eyes (12.6%), with an incidence of 0.01 per eye-year, and SVL occurred in 49 eyes (15.4%), with an incidence of 0.01 per eye-year. Female participants were half as likely as male participants to develop MVL (P = 0.030; HR, 0.448), and participants with CNVM had a higher risk of MVL (P = 0.003; HR, 21.074).
Visual loss is common in subjects with PIC, predominantly secondary to late development of CNVM. Treatment with oral corticosteroids may help to reduce the risk of CNVM development, and anti-VEGF therapy for CNVM was associated with better clinical outcomes.
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