Therapeutic benefit of melatonin in experimental feline uveitis

Uveitis is a frequent ophthalmic disorder which constitutes one of the main causes of blindness in domestic cats. The aim of this report was to analyze the effect of melatonin on experimentally induced uveitis in cats. Bacterial lipopolysaccharide (LPS) was injected intravitreally into one eye from intact cats, while the contralateral eye was injected with vehicle. Melatonin was orally administered every 24 hr to a group of ten cats, from 24 hr before until 45 days after intravitreal injections. Eyes were evaluated by means of clinical evaluation, intraocular pressure (IOP), blood-ocular barrier integrity (via measurement of protein concentration and cell content in samples of aqueous humor [AH]), electroretinogram (ERG), and histological examination of the retinas. In LPS-treated eyes, several clinical signs were observed until day 45 postinjection. The treatment with melatonin significantly decreased clinical signs and prevented the reduction in IOP induced by LPS. In LPS-injected eyes, melatonin significantly preserved the blood-ocular barrier integrity, as shown by a decrease in the number of infiltrating cells and protein concentration in the AH. Mean amplitudes of scotopic ERG a- and b-waves were significantly reduced in eyes injected with LPS, whereas melatonin significantly prevented the effect of LPS. At 45 days after injection, LPS induced alterations in photoreceptors and at the middle portion of the retina, whereas melatonin preserved the retinal structure. These results indicate that melatonin prevented clinical, biochemical, functional, and histological alterations induced by LPS injection. Thus, melatonin might constitute a useful tool for the treatment of feline uveitis.

Comparison of retinal thickness and fundus-related microperimetry with visual acuity in uveitic macular oedema

PURPOSE

Macular oedema is a common complication and vision-limiting factor in uveitis. The aim of this study was to compare retinal thickness as measured by optical coherence tomography and photoreceptor function as measured by fundus-related microperimetry with respect to their correlation with visual acuity.

METHODS

Prospective observational monocentre study. Thirty-one patients (53 eyes) with endogenous uveitis and fluorescein angiographically confirmed macular oedema were evaluated. Foveal thickness was analysed using spectral-domain (Spectralis(TM) ; Heidelberg Engineering, Heidelberg, Germany) OCT and retinal sensitivity was assessed using fundus-related microperimetry (MP1; Nidek Technologies, Padova, Italy). All findings were correlated with best-corrected visual acuity (BCVA).

RESULTS

Foveal thickness was correlated with BCVA [p = 0.005, r = 0.38, 95% confidence interval (CI) 0.12-0.59]. For microperimetry measurements, a negative correlation with logMAR visual acuity was found. Fixation abnormalities were not associated with poor visual acuity, increased foveal thickness or retinal sensitivity. In eyes with cystoid changes in the outer plexiform and inner nuclear layer, foveal thickness was increased (p < 0.0001). Epiretinal membrane formation was present in 70%. In these eyes, foveal thickness was significantly increased (p = 0.003) and visual acuity was worse (p = 0.08).

CONCLUSION

Foveal thickness and fundus-related microperimetry were correlated with visual acuity. Cystoid changes in the outer plexiform and inner nuclear layer and the presence of epiretinal membrane were associated with poor visual acuity. Fixation abnormalities were not associated with poor visual acuity.

Periocular corticosteroid injection in the management of uveitis in children

PURPOSE

To report the outcome of orbital floor corticosteroid injection (OFCI) in the management of uveitis in children.

METHODS

  A retrospective noncomparative interventional case series. The medical records of 15 consecutive children (19 eyes) with various forms of uveitis treated with OFCI of 40 mg/ml methylprednisolone acetate or a combination of 20 mg/0.5 ml Triamcinolone and 2 mg/0.5 ml dexamethasone were reviewed. Data were collected 6 months postinjection and included details of uveitis, best corrected visual acuity (BCVA), ocular inflammation, systemic therapy required and potential complications of OFCI.

RESULTS

The mean BCVA improvement was 0.18 logarithm of the minimum angle of resolution (p < 0.001), at a mean of 6 weeks (range, 4-20). Fourteen eyes (74%) had significant improvement in inflammation, 4-7 weeks post-OFCI, with a median of 4 weeks. Anterior uveitis was treated effectively in all eyes, vitritis resolved in all but one case and resolution of cystoid macular oedema was achieved in six eyes (55%). Uveitis relapsed in seven eyes (50%) after a median time of 4 months (range, 2-5 months). Four eyes (21%) underwent more than one injection. The dosage of immunosuppressive systemic therapy was reduced or able to be stopped in three patients (50%). Steroid-induced cataract was observed in four eyes (21%), 5 months post-OFCI. One patient developed cushingoid features 6 weeks post his second OFCI.

CONCLUSION

Corticosteroid orbital floor injections resulted in control of active uveitis and visual acuity improvement in most children. However, the effect might be transient and induce cataract formation.

Complications of presumed ocular tuberculosis

PURPOSE

To determine the effect of steroid treatment on visual outcome and ocular complications in patients with presumed ocular tuberculosis.

METHODS

Retrospective review of patients with presumptive ocular tuberculosis. The clinical diagnosis was made based on ocular findings, positive purified protein derivative (PPD) testing of more than 15 mm induration, exclusion of other causes of uveitis and positive ocular response to anti-tuberculous therapy (ATT) within 4 weeks. Group 1 included patients who had received oral prednisone or subtenon injection of triamcinolone acetonide prior to ATT. Group 2 included patients who did not receive corticosteroid therapy prior to administration of ATT.

RESULTS

  Among 500 consecutive new cases of uveitis encountered in 1997-2007 there were 49 (10%) patients with presumed ocular tuberculosis. These comprised 28 (57%) male and 21 (43%) female patients with a mean age of 45 years (range 12-76 years). Four (20%) patients in group 1 had initial visual acuity of 20/40 or better, in comparison to eight (28%) patients in group 2. At 1-year follow-up, six (30%) patients in group 1 had a visual acuity of 20/40 or better compared with 20 (69%) patients in group 2 (p = 0.007). Of 20 eyes (26%) in group 1 that had visual acuity of < 20/50 at 1-year follow up, 14 (70%) eyes developed severe chorioretinal lesion (p = 0.019).

CONCLUSION

Early administration of corticosteroids without anti-tuberculous therapy in presumed ocular tuberculosis may lead to poor visual outcome compared with patients who did not receive corticosteroids prior to presentation. Furthermore, the severity of chorioretinitis lesion in the group of patients given corticosteroid prior to ATT may account for the poor visual outcome.

Doppler sonography of ocular and carotid arteries in Behçet patients

PURPOSE

To evaluate by Doppler sonography carotid and ocular hemodynamics in Behçet disease with and without ocular involvement.

METHODS

Seventy-six patients with Behçet disease (BD) were separated into three groups: with active uveitis, with inactive uveitis, and without uveitis, and compared with 23 controls. We used duplex Doppler sonography to measure peak systolic (PSV), end-diastolic (EDV), and time-averaged mean (Vmean) blood flow velocity in the ophthalmic, central retinal (CRA), temporal posterior ciliary, nasal posterior ciliary (NPCA), common carotid (CCA), internal carotid (ICA) arteries, and maximum flow velocity (Vmax) in the central retinal veins. We then calculated resistance and pulsatility indexes of all arteries. Comparisons were carried out by two-way ANOVA and Holm-Sidak method.

RESULTS

Only two patients (2.6%) had atherosclerotic plaques, without significant hemodynamic consequence. Patients with uveitis had significantly lower ICA PSV and EDV (p < 0.05), and lower CRA PSV, EDV, and Vmean (p < 0.001) than controls. Patients with active uveitis had lower NPCA PSV and EDV than patients without uveitis or controls (p < 0.01). There were no differences in temporal posterior ciliary, ophthalmic, and CCA PSV, EDV, and in Vmean between groups (p > 0.05). Patients with uveitis had lower central retinal veins Vmax than patients without uveitis and than controls (p < 0.01). Resistance index, pulsatility index of retrobulbar arteries, CCA, and ICA were similar in the four groups (p > 0.05).

CONCLUSIONS

Patients with Behçet disease and ocular involvement have lower CRA, CRV, NPCA, and ICA blood flow velocities than healthy volunteers.

Imbalance of Th17 to Th1 cells in Behçet's disease

OBJECTIVES

Behçet's disease (BD) is a helper T cell-mediated autoimmune disease characterised by recurrent orogenital ulcers, uveitis and skin lesions. The helper T cells are divided into Th1, Th2 and Th17 cells according to the pattern of cytokine secretion. Th1 and Th17 cells can contribute to the development of the disease with their respective proinflammatory cytokines, IFN-γ and IL-17. In this study, we investigated the relative role of Th17, Th1 and Th2 cells in BD.

METHODS

Peripheral blood mononuclear cells were isolated from 30 patients with BD, for whom the detailed clinical manifestations and medication history were investigated and recorded. Surface markers and intracellular levels of IL-17, IFN-γ and IL-4 in isolated CD4+ T cells were measured using flow-cytometry from these patients and from two control groups, 34 rheumatoid arthritis patients and 24 healthy blood donors to analyse the relationship of Th1, Th17 and Th2 cells in BD.

RESULTS

The ratio of Th17/Th1 cells was significantly increased in BD compared to healthy controls (0.16±0.09 vs. 0.10±0.04, p=0.012), while there was no difference in the ratios of Th1/Th2 or Th17/Th2 cells. Th17/Th1 ratio was elevated in BD patients with uveitis or folliculitis compared to those without it (0.21±0.10 vs. 0.13±0.06, p=0.045 for uveitis; 0.18±0.10 vs. 0.12±0.05, p=0.036 for folliculitis).

CONCLUSIONS

Our results confirm that TH17 cells are instrumental in Behçet's uveitis and folliculitis. Furthermore, our findings suggest that the role of Th17 cells should be interpreted in the context of their ratio to Th1 cells.

The importance of visual function in the quality of life of children with uveitis

BACKGROUND

Studies of quality of life (QOL) in children with juvenile idiopathic arthritis (JIA) have focused on changes in musculoskeletal function secondary to arthritis. The role of visual functionality as a result of JIA-associated uveitis and its complications has not been examined. We evaluated the individual impact of physical and visual disability on QOL in children with and without uveitis.

METHODS

We administered patient-based questionnaires that measured visual function, physical function, and overall QOL to 27 children with JIA or idiopathic uveitis. Demographic data, assessed joint involvement, and reviewed medical records were recorded. Groups with and without uveitis were compared for differences in arthritis and uveitis disease characteristics with use of the Wilcoxon-Mann-Whitney, chi2, and Fisher exact tests. Associations between physical or visual function, and overall QOL were measured with use of Pearson's correlation coefficient.

RESULTS

Of 27 patients, 85.2% had had arthritis and 51.9% had had uveitis. The group without uveitis had increased morning stiffness (p = 0.036). Patients with uveitis reported more eye redness (p = 0.033) and photophobia (p = 0.013) than those without uveitis. We observed moderate associations between overall QOL and visual function in the uveitis group (r = -0.579) and overall QOL and physical function in the nonuveitis group (r = -0.562).

CONCLUSIONS

This study demonstrates that visual impairment is an important component of QOL in children with uveitis. It suggests that QOL studies should incorporate both visual and physical function measures in their analyses, especially because many children with JIA also suffer from uveitis and visual impairment.

Mycophenolate mofetil for ocular inflammation

PURPOSE

To evaluate mycophenolate mofetil as a single noncorticosteroid immunosuppressive treatment for noninfectious ocular inflammatory diseases.

DESIGN

Retrospective cohort study.

METHODS

Characteristics of patients with noninfectious ocular inflammation treated with mycophenolate mofetil at 4 subspecialty clinics from 1995 to 2007 were abstracted by expert reviewers in a standardized chart review of every eye at every visit. Main outcomes measured were control of inflammation, corticosteroid-sparing effects, and discontinuation of mycophenolate mofetil (including the reasons for discontinuation). Survival analysis was used to estimate the incidence of outcomes, and to identify risk factors for each.

RESULTS

Among 236 patients (397 eyes) treated with mycophenolate mofetil monotherapy, 20.3%, 11.9%, and 39.8% had anterior uveitis, intermediate uveitis, and posterior uveitis or panuveitis respectively; 14% had scleritis; 7.6% had mucous membrane pemphigoid; and 6.4% had other ocular inflammatory diseases. By Kaplan-Meier estimation, complete control of inflammation--sustained over consecutive visits spanning at least 28 days--was achieved in 53% and 73% of patients within 6 months and 1 year respectively. Systemic corticosteroid dosage was reduced to 10 mg of prednisone or less, while maintaining sustained control of inflammation, in 41% and 55% of patients in 6 months and 1 year respectively. Twelve percent of patients discontinued mycophenolate mofetil within the first year because of side effects of therapy.

CONCLUSIONS

Given sufficient time, mycophenolate mofetil was effective in managing ocular inflammation in approximately half of the treated patients. Treatment-limiting side effects were observed in 12% of patients and typically were reversible.

[Effects and safety of infliximab administration in refractory uveoretinitis with Behçet's disease]

PURPOSE

To evaluate the efficacy and safety of infliximab administration in refractory uveoretinitis in Behçet's disease (BD).

METHODS

The subjects were 22 consecutive BD patients with refractory uveoretinitis treated with infliximab. Three patients dropped out from the therapy. The other 19 patients received the therapy for 6 months or longer. The efficacy was evaluated by the ocular attacks and best corrected visual acuity at remission in the 19 patients and the safety was evaluated in all 22 patients.

RESULTS

The incidence of ocular attacks in the 6 months before and after the infliximab therapy were 3.0+/-2.6 and 0.4+/-1.1, respectively (p<0.0005). Infliximab was very effective in 7 patients where no ocular attacks occurred throughout infliximab therapy, effective in 10 patients where ocular attacks was reduced, and non-effective in 2 patients. The vision was either improved or unchanged in all eyes at the 6th months therapy. Various adverse effects were seen in 14 patients, but non were serious.

CONCLUSIONS

Infiximab therapy is effective in managing the refractory uveoretinitis in BD, but elucidation of the safety needs more patients and a longer follow-up period.

Cyclophosphamide for ocular inflammatory diseases

PURPOSE

To evaluate the outcomes of cyclophosphamide therapy for noninfectious ocular inflammation.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Two hundred fifteen patients with noninfectious ocular inflammation observed from initiation of cyclophosphamide.

METHODS

Patients initiating cyclophosphamide, without other immunosuppressive drugs (other than corticosteroids), were identified at 4 centers. Dose of cyclophosphamide, response to therapy, corticosteroid-sparing effects, frequency of discontinuation, and reasons for discontinuation were obtained by medical record review of every visit.

MAIN OUTCOME MEASURES

Control of inflammation, corticosteroid-sparing effects, and discontinuation of therapy.

RESULTS

The 215 patients (381 involved eyes) meeting eligibility criteria carried diagnoses of uveitis (20.4%), scleritis (22.3%), ocular mucous membrane pemphigoid (45.6%), or other forms of ocular inflammation (11.6%). Overall, approximately 49.2% (95% confidence interval [CI], 41.7%-57.2%) gained sustained control of inflammation (for at least 28 days) within 6 months, and 76% (95% CI, 68.3%-83.7%) gained sustained control of inflammation within 12 months. Corticosteroid-sparing success (sustained control of inflammation while tapering prednisone to 10 mg or less among those not meeting success criteria initially) was gained by 30.0% and 61.2% by 6 and 12 months, respectively. Disease remission leading to discontinuation of cyclophosphamide occurred at the rate of 0.32/person-year (95% CI, 0.24-0.41), and the estimated proportion with remission at or before 2 years was 63.1% (95% CI, 51.5%-74.8%). Cyclophosphamide was discontinued by 33.5% of patients within 1 year because of side effects, usually of a reversible nature.

CONCLUSIONS

The data suggest that cyclophosphamide is effective for most patients for controlling inflammation and allowing tapering of systemic corticosteroids to 10 mg prednisone or less, although 1 year of therapy may be needed to achieve these goals. Unlike with most other immunosuppressive drugs, disease remission was induced by treatment in most patients who were able to tolerate therapy. To titrate therapy properly and to minimize the risk of serious potential side effects, a systematic program of laboratory monitoring is required. Judicious use of cyclophosphamide seems to be beneficial for severe ocular inflammation cases where the potentially vision-saving benefits outweigh the substantial potential side effects of therapy, or when indicated for associated systemic inflammatory diseases.

Administration of Mycobacterium leprae rHsp65 aggravates experimental autoimmune uveitis in mice

The 60 kDa heat shock protein family, Hsp60, constitutes an abundant and highly conserved class of molecules that are highly expressed in chronic-inflammatory and autoimmune processes. Experimental autoimmune uveitis [EAU] is a T cell mediated intraocular inflammatory disease that resembles human uveitis. Mycobacterial and homologous Hsp60 peptides induces uveitis in rats, however their participation in aggravating the disease is poorly known. We here evaluate the effects of the Mycobacterium leprae Hsp65 in the development/progression of EAU and the autoimmune response against the eye through the induction of the endogenous disequilibrium by enhancing the entropy of the immunobiological system with the addition of homologous Hsp. B10.RIII mice were immunized subcutaneously with interphotoreceptor retinoid-binding protein [IRBP], followed by intraperitoneally inoculation of M. leprae recombinant Hsp65 [rHsp65]. We evaluated the proliferative response, cytokine production and the percentage of CD4(+)IL-17(+), CD4(+)IFN-gamma(+) and CD4(+)Foxp3(+) cells ex vivo, by flow cytometry. Disease severity was determined by eye histological examination and serum levels of anti-IRBP and anti-Hsp60/65 measured by ELISA. EAU scores increased in the Hsp65 group and were associated with an expansion of CD4(+)IFN-gamma(+) and CD4(+)IL-17(+) T cells, corroborating with higher levels of IFN-gamma. Our data indicate that rHsp65 is one of the managers with a significant impact over the immune response during autoimmunity, skewing it to a pathogenic state, promoting both Th1 and Th17 commitment. It seems comprehensible that the specificity and primary function of Hsp60 molecules can be considered as a potential pathogenic factor acting as a whistleblower announcing chronic-inflammatory diseases progression.

Referral Patterns, Demographic and Clinical Features, and Visual Prognosis of Turkish Patients with Sarcoid Uveitis

The purpose of this study was to investigate the referral patterns, demographic and clinical features, and visual prognosis of patients with sarcoid uveitis seen at 2 tertiary eye care centers in Turkey. A retrospective study was made of 44 patients with uveitis associated with biopsy-confirmed or presumed sarcoidosis. Thirty-four patients (77%) were female and 10 (23%) were male. The mean age at onset of uveitis was 39.8 years. Twenty-seven patients (61%) were referred without a diagnosis of sarcoidosis and 17 (39%) patients were referred with a diagnosis of systemic sarcoidosis. The duration of uveitis prior to referral was 2-15 years in 52% of the patients in the former group. At presentation, 37 patients (84%) had bilateral and 7 patients (16%) had unilateral uveitis, and 17 patients (39%) had only anterior uveitis. The most common ocular findings were granulomatous keratic precipitates, persistent posterior synechiae, and snowball vitreous opacities. Kaplan-Meier survival analysis estimated the risk of recurrence as 30% at 6 months and 61% at 5 years. New complications developed in 18 patients. Potential visual acuity was better than 0.4 in 80% of eyes. The estimated risk of losing potential visual acuity by at least 2 lines was 7% at 6 months and 43% at 5 years. None of the eyes lost useful vision (> 0.1) under the authors' care. The referral patterns suggest underrecognition of sarcoidosis as a cause of uveitis in Turkey. The demographic and clinical features of these patients were mostly similar to those reported from other countries, suggesting that the diagnosis may not be difficult in Turkish patients but requires an increased awareness of the disease in this population.

Multiple sclerosis-associated uveitis

BACKGROUND/AIMS

To describe the clinical characteristics and course of 16 patients with uveitis associated with multiple sclerosis (MS).

METHODS

The records of 1254 patients with uveitis were reviewed. Sixteen of these patients had MS. The history, review of systems, ocular findings, and clinical test results of each of these 16 subjects were analyzed. The mean follow-up time was 38 months.

RESULTS

Most patients with MS-associated uveitis were white females between 20 and 50 years of age. The diagnosis of MS preceded the onset of uveitis in 56%, followed it in 25%, and was made concurrently in 19% of the cases. In 94%, the uveitis was bilateral. Pars planitis was the most frequent form of uveitis in our study population (81%); concomitant anterior chamber inflammation was common and was granulomatous in nature 56% of the time. Forty-one percent of the eyes with MS-associated uveitis had 20/30 or better initial visual acuity. Among these treated patients, significant loss of visual acuity was uncommon.

CONCLUSIONS

MS-associated uveitis should be suspected in white female patients with bilateral uveitis, especially if pars planitis is present. These patients often retain useful vision for many years if treated.

Blocking CD200-CD200 receptor axis augments NOS-2 expression and aggravates experimental autoimmune uveoretinitis in Lewis rats

PURPOSE

Tissue expression of CD200 generates inhibitory or down-regulatory signals to macrophages and microglia within CNS and retina. Our interests were to investigate whether blocking CD200 receptor (CD200R) signalling in vivo results in macrophage activation and thus aggravation of EAU in Lewis rats.

METHODS

Retinal extract-immunised Lewis rats were treated day 3 and 5 post-immunisation with CD200R mAb or normal mouse serum. Phenotypic analysis of the leucocyte infiltrate and disease severity was clinically and histogically examined.

RESULTS

Rats administered with CD200R mAb developed earlier onset of EAU and more severe disease. Blocking CD200R increased retinal neuronal CD200 expression and, although disease severity was increased concomitant with an increase in NOS-2 expression, retinal macrophage numbers were not increased.

CONCLUSIONS

Contemporaneous with data from CD200KO mice, these results support the notion that CD200-CD200R signalling suppresses macrophage activation. Exacerbation of EAU in both CD200KO mice and Lewis rats when CD200-CD200R interaction is blocked suggests that this could be an avenue for therapeutic intervention.

Role of the NOD2 genotype in the clinical phenotype of Blau syndrome and early-onset sarcoidosis

OBJECTIVE

Blau syndrome and its sporadic counterpart, early-onset sarcoidosis (EOS), share a phenotype featuring the symptom triad of skin rash, arthritis, and uveitis. This systemic inflammatory granulomatosis is associated with mutations in the NOD2 gene. The aim of this study was to describe the clinical manifestations of Blau syndrome/EOS in Japanese patients and to determine whether the NOD2 genotype and its associated basal NF-kappaB activity predict the Blau syndrome/EOS clinical phenotype.

METHODS

Twenty Japanese patients with Blau syndrome/EOS and NOD2 mutations were recruited. Mutated NOD2 was categorized based on its basal NF-kappaB activity, which was defined as the ratio of NF-kappaB activity without a NOD2 ligand, muramyldipeptide, to NF-kappaB activity with muramyldipeptide.

RESULTS

All 9 mutations, including E383G, a novel mutation that was identified in 20 patients with Blau syndrome/EOS, were detected in the centrally located NOD region and were associated with ligand-independent NF-kappaB activation. The median age of the patients at disease onset was 14 months, although in 2 patients in Blau syndrome families (with mutations R334W and E383G, respectively) the age at onset was 5 years or older. Most patients with Blau syndrome/EOS had the triad of skin, joint, and ocular symptoms, the onset of which was in this order. Clinical manifestations varied even among familial cases and patients with the same mutations. There was no clear relationship between the clinical phenotype and basal NF-kappaB activity due to mutated NOD2. However, when attention was focused on the 2 most frequent mutations, R334W and R334Q, R334W tended to cause more obvious visual impairment.

CONCLUSION

NOD2 genotyping may help predict disease progression in patients with Blau syndrome/EOS.

Comparison between intravitreal and orbital floor triamcinolone acetonide after phacoemulsification in patients with endogenous uveitis

PURPOSE

To compare the effect of intravitreal and orbital floor triamcinolone acetonide (TA) on macular edema, visual outcome, and course of postoperative inflammation after cataract surgery in uveitis patients.

DESIGN

Prospective, randomized clinical trial.

METHODS

Monocenter study (40 patients) with chronic endogenous uveitis who underwent phacoemulsification with intraocular lens implantation with either 4 mg intravitreal TA (n = 20) or 40 mg orbital floor TA (n = 20). The primary outcome was influence on cystoid macular edema (CME). Secondary outcome measures were best-corrected visual acuity (BCVA), anterior chamber cell grade, laser flare photometry, giant cell deposition, posterior capsule opacification (PCO), and intraocular pressure.

RESULTS

Mean central foveal thickness decreased in the intravitreal TA group and increased in the orbital floor TA group (P < .001 at one and three months). CME improved in 50% of patients after intravitreal TA, whereas it was unchanged after orbital floor TA (difference between the groups at three months, P = .049). Mean BCVA (logarithm of the minimal angle of resolution) improved postoperatively (P < .001) from 0.76 and 0.74 to 0.22 and 0.23 in the intravitreal TA and orbital floor TA group, respectively. Anterior chamber cell count at one month was lower in the intravitreal TA than in the orbital floor TA group (P = .02). Laser flare photometry values and giant cell numbers were slightly higher after orbital floor TA than after intravitreal TA. The groups did not differ with respect to PCO rate and ocular hypertension.

CONCLUSIONS

The CME improvement and anti-inflammatory effect after intravitreal TA was better than after orbital floor TA injection in cataract surgery in uveitis patients.

Flare-up rates with bimatoprost therapy in uveitic glaucoma

PURPOSE

To evaluate the rate of flares in patients with uveitic glaucoma treated with topical bimatoprost and to assess its effect on intraocular pressure (IOP) in this subset of patients.

DESIGN

Retrospective case series.

METHODS

All patients seen at one subspecialty uveitis practice with history of uveitic glaucoma treated with topical bimatoprost were identified and the data collected, which included onset, type, duration of uveitis, onset of secondary glaucoma, and previous therapies for glaucoma. The time of onset of bimatoprost therapy, the IOP, and flare-up rate before and after initiation of treatment with bimatoprost were recorded at one week and one, three, and six months of follow-up.

RESULTS

Of the 42 patients (59 eyes) identified, 12 patients had used other topical lipid agents, which were replaced by bimatoprost. Twenty-three patients had not used any lipid agents and bimatoprost was added to their existing antiglaucoma regimen. Seven patients were newly diagnosed with uveitic glaucoma and were commenced with topical bimatoprost. The rate of uveitis flares while on other antiglaucoma therapy was 52 per 100 person-years follow-up, while on bimatoprost therapy it was 32.4 per 100 person-years follow-up (P = .206). The mean IOP prior to bimatoprost therapy was 27 +/- 13.2 mm Hg and after initiation of topical bimatoprost was 15 +/- 5.5 mm Hg at the end of six months (P = .0008).

CONCLUSION

These data suggest that bimatoprost is an effective IOP-lowering agent in patients with uveitic glaucoma in whom the uveitis is controlled on immunomodulatory therapy, and it does not increase the rate of flares of uveitis in these patients.

Ocular regulatory T cells distinguish monophasic from recurrent autoimmune uveitis

PURPOSE

To determine whether CD4(+)CD25(+) T-regulatory cells (Tregs) from the eyes of rats with recurrent (r) experimental autoimmune uveitis (EAU) were less efficient in suppressing intraocular inflammation than those from rats with monophasic (m) disease (m-EAU).

METHODS

m-EAU and r-EAU were induced in Lewis rats by immunization with R16 or by adoptive transfer of R16-specific T cells, respectively. Ocular CD4(+)CD25(+) Tregs were separated from CD4(+) CD25(-) T-effector cells, and the inhibitory functions of Tregs were determined. Aqueous humor (AqH) from m-EAU and r-EAU was collected and studied for its ability to enhance ocular Treg function.

RESULTS

The authors found that the number of ocular CD4(+)CD25(+) (Tregs) increased in the eye during resolution of the first acute attack of intraocular inflammation in m-EAU and r-EAU. However, the suppressor function of these cells was weaker in r-EAU. The suppressor function of ocular Tregs in r-EAU was enhanced by incubation with AqH from animals recovering from m-EAU. Moreover, the weaker suppressor function of ocular Tregs in r-EAU correlated with low or undetectable levels of IL-10 in the AqH and was reversed by the addition of IL-10 to the AqH. Finally, the transfer of ocular Tregs from animals with m-EAU converted r-EAU to a monophasic disease.

CONCLUSIONS

This study demonstrated that although a number of mechanisms may contribute to the recurrence of intraocular inflammation, dysregulation and malfunction of Tregs in the eye are important factors in disease recurrence.

A failed case to diagnose cardiac sarcoidosis presenting advanced atrioventricular block

A 53-year-old-male developed atrioventricular block in January 2001. A chest X-ray and laboratory tests, including serum angiotensin converting enzyme, were normal. The patient underwent permanent pacemaker implantation and attended for semiannual follow-up after discharge since the etiology of advanced atrioventricular block remains unknown. One year later, the patient was diagnosed with uveitis related to sarcoidosis. No clinical finding specific to cardiac sarcoidosis was notable at that time. Four years after onset, the patient developed congestive heart failure. An echocardiogram revealed diffuse LV hypokinesis, but no asymmetric interventricular septal thinning. Laboratory tests showed normal angiotensin converting enzyme. Noncaseating granuloma was not confirmed by transbronchial biopsy. Despite normal myocardial uptake of gallium-67, uptake of (18)F-Fluorodeoxyglucose increased in the myocardium. Nevertheless, clinical manifestations did not match the criteria for cardiac sarcoidosis. Prednisolone was administered daily. Two months after tapering dosage, the patient developed multiple organ failure and died. Post mortem histological findings were consistent with cardiac sarcoidosis. We experienced great difficulty in detecting cardiac involvement in the early stage of sarcoidosis. A specific method with greater sensitivity is required to diagnose cardiac involvement in the early stages of sarcoidosis.