[Ultrasound biomicroscopy in intermediate uveitis]

OBJECTIVE

To investigate the character of intermediate uveitis by ultrasound biomicroscopy (UBM) and determine the potential and usefulness of UBM as a diagnostic procedure in intermediate uveitis.

METHODS

Twenty-one cases (35 eyes) of intermediate uveitis were diagnosed by slit lamp biomicroscopy and indirect binocular ophthalmoscopy with scleral indentation. UBM was performed on 35 eyes of 21 patients with intermediate uveitis in order to determine the configuration of pars, plana peripheral retina and vitreous.

RESULTS

In 31 of 35 eyes, pathological structures such as spotted or membraneous vitreous condensations, vitreoretinal adhesions with traction on the peripheral retina and ciliary body detachment were identified by UBM. In four eyes, no abnormalities were identified by UBM.

CONCLUSION

UBM seems to be a valuable diagnostic technique for the evaluation of patients with intermediate uveitis.

[Intermediate uveitis]

Intermediate uveitis is a chronic and insidious disease. Children and young adults are preferentially affected. Vision loss and floaters are commonly reported in a quiet eye. The inflammation predominates in the vitreous and some characteristic peripheral exsudates may be observed. Intermediate uveitis is generally idiopathic but may sometimes be associated with a systemic disease that must be researched and treated. The treatment of the idiopathic form is only necessary in case of complications and will consist in corticosteroids eventually combined with immunosuppressive drugs. Surgery (cryotherapy, vitrectomy) will be reserved for complications non responding to medical therapy.

[Laser tyndallometry and monitoring of treatment in 20 children with juvenile uveitis]

BACKGROUND

Treatment of children with juvenile uveitis requires adequate control of inflammation while minimizing systemic or ocular side effects. The study was performed to evaluate the potential use of the laser flare-cell meter in monitoring and adjustment of therapy in juvenile uveitis.

PATIENTS AND METHODS

Retrospectively, we monitored 20 children (11 girls and 9 boys) with an age range from 3 to 15 years presenting with juvenile iridocyclitis (10/20), intermediate (5/20) or posterior (5/20) uveitis. During the follow-up period (median 25.2 months, range: 2 to 83 months) multiple clinical controls were performed. We recorded clinical data, present therapy, and measurements using the laser flare-cell meter (Kowa FC-1000).

RESULTS

Laser flare-cell meter measurements were easily obtained and highly reliable even in these young patients. During follow-up, 36 recurrences of intraocular inflammation were detected in 19 eyes. Relapses of inflammation as well as a response to treatment were seen at an early stage. Semiquantitative observations of cells and aqueous flare in the anterior chamber, or visual acuity of patients were less reliable in predicting recurrences.

CONCLUSIONS

Laser tyndallometry offers a reliable, examiner-independent method to assess intraocular inflammation in children with juvenile uveitis and to adjust the necessary treatment.

Optical coherence tomography in uveitis patients

PURPOSE

To evaluate optical coherence tomography in allergy-prone uveitis patients.

METHODS

Thirty-four patients (43 eyes) with posterior uveitis (31 eyes) and intermediate uveitis (12 eyes) were evaluated by fluorescein angiography, indocyanine green angiography, and optical coherence tomography. Follow-up examinations used optical coherence tomography in allergy-prone patients.

RESULTS

Optical coherence tomography identified epiretinal membranes, which were removed surgically (three eyes); persistent cystoid macular edema, which resolved with cytotoxic treatment (12 eyes); and juxtafoveolar membranes, which were treated by diode laser (six eyes) and excision (two eyes).

CONCLUSION

Optical coherence tomography may provide useful information on complications developing in uveitis patients.

[Uveitis in patients with HIV infection]

We carried out a retrospective analysis of 581 patients with uveitis seen over an 11-year period, to determine the prevalence of HIV infection in these patients and to look for associated diseases and the possible causes of uveitis in HIV-infected patients. All patients underwent routine eye examination and most also underwent a general examination and complementary tests. The prevalence of HIV infection was 14.3% (89 patients). Anterior uveitis (62%) was the most frequent, followed by posterior uveitis (22%), panuveitis (12%) and intermediate uveitis (4%). Associated conditions or causes were identified in 88% of the HIV-infected patients, with herpes zoster ophthalmicus the most frequent (43 %), followed by tuberculosis (16%), CMV infection (12%) and toxoplasmosis (10%). Thus, uveitis in HIV-infected patients is frequently associated with opportunistic infections.

Medical treatment of macular edema in patients with uveitis

PURPOSE

To determine the efficacy of medical treatment of cystoid macular edema (CME) in patients with uveitis.

METHODS

Retrospective study of 40 patients (57 eyes) with uveitis and CME. Inclusion criteria were presence of CME with minimal and no macular pathology, or vascular disease which could account for CME. Patients who had undergone intraocular surgery or had visual acuity (VA) of > or = 20/40 were excluded. The diagnosis of CME was based on clinical and/or angiographic findings. Three treatment groups were defined: (1) transseptal injection of steroids (n=13 eyes); (2) systemic non steroidal anti-inflammatory drugs (NSAIDs) (n=11 eyes); both 1 and 2 (n=33 eyes).

RESULTS

Overall, 79% of eyes improved 3 or more lines of Snellen VA after treatment: 51% improved 4 or more lines. The average number of lines improved was 3.8 for eyes treated with transseptal injections of steroids, 2.9 for eyes treated with NSAIDs, and 4 for eyes treated with both. For all 3 treatment groups between 60-70% of eyes improving 2 or more lines reached best VA only after a minimum of 6 months of follow up.

CONCLUSIONS

CME, a vision threatening complication of uveitis, respond fairly well to medical treatment; however, the best VA is achieved after several months. The improvement in VA did not differ markedly among the three treatment groups.

[Semiology and classification of uveitis]

Defined as an intraocular inflammation, uveitis may be linked to a systemic disease or represent an isolated entity. Screening for associated extra-ocular manifestations is mandatory in uveitis patients. The localisation of inflammation may be uni- or bilateral, anterior, intermediate or diffuse (panuveitis). Other main elements of the evaluation are the acute or chronic mode and the detection of a granulomatous presentation. In some cases, the examination of intraocular structures may be enough for the diagnosis of uveitis. When a correct approach is taken to the diagnosis of uveitis, causes are identified in approximately 50% of cases and presumed in 25% of patients; in one-fourth of cases, the origin of inflammation remains idiopathic.

[The intermediate uveitis with systemic symptoms: a case report]

The case of 26-year old male patient with typical clinical intermediate uveitis (vitritis, periphlebitis) with accompanying leucopenia, bradycardia and demyelination focal areas in brain of unknown etiology is presented. The asymptomatic periphlebitis was also found in the eyes of his twin brothers (30 years old) and sister (20 years old).

Soluble ICAM-1 serum levels in patients with intermediate uveitis

AIM

To investigate whether serum levels of soluble intercellular adhesion molecule 1 (sICAM-1) can serve as a marker of the presence of systemic disease in intermediate uveitis.

METHODS

In a multicentre study sICAM-1 serum levels were measured in 61 patients with idiopathic intermediate uveitis, controls included 56 uveitis patients with a systemic disease (26 sarcoid associated uveitis and 30 HLA-B27 positive acute anterior uveitis), 58 uveitis patients without systemic disease (30 toxoplasma chorioretinitis and 28 Fuchs' hetrochromic cyclitis), and 21 normal controls. The clinical records of the patients with intermediate uveitis were analysed for disease characteristics at the time of blood sampling and for a relation with the development of a systemic disease after a mean follow up of 4.5 years.

RESULTS

Increased serum levels of sICAM-1 were found in 34 out of 61 patients with intermediate uveitis and were significantly different when compared with toxoplasmosis, Fuchs' cyclitis, and healthy controls (p<0.001). Elevated sICAM-1 levels were also found in 18 out of 26 patients with sarcoid uveitis and in 11 out of 30 patients with HLA-B27 associated anterior uveitis. Raised sICAM-1 levels in the intermediate uveitis group were significantly associated with active ocular disease (p<0.01) and the presence of vitreous exudates (p<0.05). Increased levels of sICAM-1 correlated with interleukin 8 levels (IL-8) (tested in a previous study in the same group of intermediate uveitis patients) in patients with active systemic involvement. Follow up of the patients showed that an established or suspected systemic disease was found more often in the 21 intermediate uveitis patients with increased sICAM-1 and IL-8 levels compared with the other 40 patients with intermediate uveitis (p<0.01).

CONCLUSIONS

The measurement of both sICAM-1 and IL-8 can be used as a marker for ocular disease activity and for a predisposition of developing an associated systemic disease in intermediate uveitis patients.

[Uveitis masquerade syndrome in Gaucher disease. Causal treatment by alglucerase substitution therapy]

BACKGROUND

Gaucher's disease, a sphingolipidose transmitted by autosomal-recessive inheritance, is caused by a deficiency of the lysosomal enzyme beta-glucocerebrosidase which is responsible for hydrolysation of glucocerebroside to ceramid and glucose. Thus glucocerebroside is accumulated in the reticuloendothelial cells of spleen, liver and bone marrow and pathognomonic Gaucher's cells are formed.

CASE REPORT

In May 1997 a 42-year-old female patient presented with left-sided intermediate uveitis of unknown origin and decreasing visual acuity to perception of hand movements and intact projection of light since September 1996. To exclude a systemic disease a thorough medical examination--showing hepatoslpenomegaly, anemia, thrombocytopenia and bone lesions--was initiated and revealed advanced M. Gaucher (Type I) by bone marrow punction. Intravenous therapy with alglucerase was administered promptly. After five months of treatment vitreous opacities resolved almost completely and visual acuity increased to 0.7.

CONCLUSIONS

The dramatic improvement occurred under treatment with alglucerase after no response to steroid treatment. Thus intermediate uveitis with severe vitritis can be interpreted as uveitis masquerade syndrome with M. Gaucher. To the best of our knowledge, this is the first case of M. Gaucher presenting initially as intermediate uveitis and showing successful clinical improvement during administration of alglucerase.

Glaucomatocyclitic crisis in a child

PURPOSE

To report a case of glaucomatocyclitic crisis (Posner-Schlossman syndrome) in a child.

METHOD

Case report. A 13-year-old boy presented with decreased vision, photophobia, halos, and pain in the right eye.

RESULT

Findings in this child were consistent with a diagnosis of Posner-Schlossman syndrome.

CONCLUSION

Glaucomatocyclitic crisis can occur in a child and must be included in the differential diagnosis of uveitis and glaucoma in pediatric patients.

The etiology of uveitis: the role of infections with special reference to Lyme borreliosis

PURPOSE

To assess the distribution of different uveitis entities and to evaluate their associations with infections, especially Lyme borreliosis.

METHODS

During a one-year period 160 consecutive uveitis patients were evaluated in a university clinic. Selected tests were performed depending on the medical history of the patient and the clinical picture of the ocular inflammation.

RESULTS

Uveitis was classified into selected entities for 74.4% of the patients. A direct infection was suggested to be linked with uveitis in 23 patients (14.4%). Lyme borreliosis, toxoplasmosis, and herpetic infections were the most frequently seen, in seven patients (4.3%) each. All patients with Lyme uveitis had manifestations of the posterior segment of the eye, such as vitritis, retinal vasculitis, neuroretinitis, chorioretinitis, or optic neuropathy.

CONCLUSION

Infections are an important cause of uveitis in a university clinic. Lyme borreliosis is a newly recognised uveitis entity which should be kept in mind in the differential diagnosis of intermediate or posterior uveitis in areas endemic for Lyme borreliosis.

Course and complications of intermediate uveitis

Intermediate uveitis is associated with a wide variety of complications, particularly in patients attending uveitis referral centres, but little information exists on the frequency of these complications in a general pool of patients. We reviewed all the cases known to have originated in one English county. 86 eyes of 48 patients with a mean follow-up of 48 months were affected. The principal threat to sight was cystoid macular oedema (31%). Other complications included vitreous haemorrhage (8%), disc swelling (5%), periphlebitis (21%) and cataract (5%). Most patients required no treatment other than observation and overall the visual outcome was good with 85% of patients and 63% of eyes having vision of 6/9 or better. Cystoid macular oedema and snowbanking were significantly associated with a worse visual outcome, whilst the other complications were not.

[Intermediate uveitis in clinical practice]

OBJECTIVE

Evaluation of experience with the diagnosis and treatment of intermediate uveitis in the Czech population.

METHODS

The retrospective study summarizes the results assembled in 21 patients (37 eyes) investigated at the First Ophthalmological Clinic in 1988-1995.

RESULTS

A diffuse type of inflammation was revealed in 15 patients (26 eyes), exsudative type in 6 patients (11 eyes). In three patients the inflammation did not call for treatment. Long-term remission was achieved in 3 patients by periocular injections of steroids, in 11 patients by systemic Prednisone treatment, in 4 patients by combined immunosuppression. In one patient cryotherapy was performed, in two patients PPV. In 31 eyes (84%) vision was the end of the observation period 6/12 better.

CONCLUSION

From the results of the investigation ensues that intermediate uveitis occurs in our geographical zone more frequently in younger age groups and is manifested as a rule by a milder, diffuse type of inflammation. The prerequisite of successful patient care is early diagnosis and correct indication of treatment.

Intermediate uveitis and retinal vasculitis as manifestations of cat scratch disease

PURPOSE

To study the ocular manifestations of systemic Rochalimaea infection.

METHODS

We examined a healthy 21-year old woman who had floaters in both eyes. A bilateral mild vitreitis and multiple foci of retinal vasculitis were found; during the ensuing two weeks, exudates appeared over the inferior pars plana. The patient owned five kittens but had no history of cat bites or scratches. Serum levels of antibodies to Rochalimaea were elevated.

RESULT

The retinal vasculitis and vitreitis resolved after three weeks of therapy with ciprofloxacin hydrochloride without concomitant anti-inflammatory therapy.

CONCLUSION

Rochalimaea infection should be considered in the differential diagnosis of intermediate uveitis and retinal vasculitis.

[Intraocular malignant melanoma in intermediate uveitis treated conservatively and surgically for a prolonged period]

The authors give an account of a 28-year-old female patient treated for a prolonged period in the out-patient department on account of intermediary uveitis with subsequent pars plana vitrectomy of the left eye. After repeatedly deteriorating local findings after a 4-month interval in the punctate of the anterior chamber cells of non-differentiated malignant melanoma were detected; histological examination of the enucleated bulbus confirmed the diagnosis of malignant melanoma penetrating into the optic nerve.

Systemic diseases associated with intermediate uveitis

BACKGROUND

Intermediate uveitis is characterized by vitreal inflammation with associated inflammation of the vitreous base and peripheral anterior retina and choroid. It may be found as an isolated and idiopathic condition or in association with systemic disorders such as multiple sclerosis and sarcoidosis.

OBJECTIVE

To identify the clinical features of intermediate uveitis and assess its association with systemic diseases.

METHODS

Retrospective study of 83 patients presenting with intermediate uveitis between 1970 and 1991.

RESULTS

Evidence of systemic disorders was found in 26 of 83 patients (31.3%). Of these 26 patients, 10 had presumed sarcoidosis, 6 had multiple sclerosis, 2 had isolated optic neuritis, 2 had inflammatory bowel disease, 4 had isolated thyroid abnormalities, and 2 had histories suggestive of Epstein-Barr virus infection. Associated ocular findings included cystoid macular edema, peripheral retinal perivascular sheathing, cataracts, posterior vitreous detachment, fine keratic precipitates, preretinal macular fibrosis, retinal tears, retinal detachment, and optic disc edema.

CONCLUSIONS

Patients with intermediate uveitis may have associated systemic diseases and should have careful follow-up with regular systemic evaluation.

[Intermediate uveitis]

In a group of 50 patients with intermediary uveitis (IU) the authors evaluated the clinical finding, diagnosis with which the patients were referred to the institute and considered the problem of corticotherapy. The majority of patients was referred with a vague and inaccurate diagnosis: uveitis chronica (34%) and uveitis posterior (20%). 96% patients were treated by locally applied corticosteroids which are justified only in case of marked participation of the anterior segment of the eye. The development of posterior subcapsular cataract in 20% of the patients is according to the authors associated with overdosage of local corticotherapy. They recommend general and parabulbar corticotherapy only if cystoid oedema of the macula and oedema of the papilla develops, or in case of massive formation of an exudate on the pars plana. In patients with IU corticosteroid treatment should be indicated with great care, as complications may develop which are more serious than the disease.

[Lyme disease in Switzerland: ocular involvement]

Lyme disease is a multisystem disorder caused by the spirochete Borrelia burgdorferi, which is transmitted by a tick (Ixodes Ricinus). Lyme disease is divided into three stages (infection, dissemination and immunological reactions). Ocular manifestations are rare except for conjunctivitis and facial nerve palsy. Switzerland is an endemic zone for Lyme disease; the presence of an atypical pars planitis should prompt a search for Lyme disease.

[Intermediate uveitis]

Presented are contemporary opinions on the etiopathogenesis, epidemiology and clinical course of intermediate uveitis. Discussed are also the diagnostics and the trials of treatment of this condition.

[Use of distant thermography in uveitis in children]

Forty-four children aged 6 months to 14 years, suffering from endogenous uveitis of various sites were examined at different phases of the diseases by a scanning type apparatus, AGA-780M-thermographer (Sweden). The results permit a conclusion that long-distance thermography may be effectively used to assess the ocular status even in small restless children. Uveitis active phase was found associated with a hyperthermal reaction in all the examined sites. Hyperthermia was found related to uveitis localization. The authors suggest that thermoasymmetry parameters and the corneolimbic gradient be used as additional objective criteria for the assessment of uveitis activity and dissemination in children.

[Emergencies in uveitis]

The authors insist on the emergency state each ophthalmologist has to consider during the diagnosis of uveitis. The key symptoms are shown and the therapy of uveitis is updated.