Radial artery occlusion, a rare presentation of Behçet's disease

Behçet's disease (BD) is a multi-system inflammatory disorder which presents with recurrent orogenital ulceration, uveitis, and erythema nodosum. Medium vessel vasculitis of upper limb is extremely rare and it is only reported in patients with Behçet's disease on long follow up. Mean duration from diagnosis of disease to development of vasculitis is 5.8 years. We present a patient who presented with gangrene of fingers with absent radial pulse and during course of his illness he developed features of Behçet's disease. Diagnosis was established by clinical features and histopathology and patient was treated with steroids and colchicine.

Molecular diagnosis of a bilateral panuveitis due to Borrelia burgdorferi sensu lato by cerebral spinal fluid analysis

The present paper describes a case of bilateral panuveitis due to Borrelia burgdorferi sensu lato diagnosed by a PCR approach using cerebral spinal fluid. Since the culture of B. burgdorferi takes a long time to grow and the accuracy of serological tests is doubtful in patients, the PCR method of amplifying a B. burgdorferi flagellin could be suitable to make a positive diagnosis in a case of atypical clinical history of Lyme disease.

Risk factors and longterm outcome of juvenile idiopathic arthritis-associated uveitis in Switzerland

OBJECTIVE

To determine rate, risk factors, and longterm outcome of uveitis in children with juvenile idiopathic arthritis (JIA) in Switzerland and compare the results with a study of a different center in Switzerland from 1992.

METHODS

Retrospective analysis of the charts and ophthalmologists' reports of all patients with JIA in a tertiary care outpatient clinic between January 1, 1997, and December 31, 2005, for diagnosis, course, and outcome of uveitis.

RESULTS

Uveitis occurred in 35/265 patients (13.2%) of our JIA cohort, which is similar to the 16% reported in the 1992 cohort. A positive test for antinuclear antibodies was the strongest risk factor. The JIA subgroup with the highest rate of uveitis was "other arthritis," followed by oligoarticular JIA. Extended and persistent course of oligoarticular JIA had a similar uveitis incidence, but all patients with extended-course disease developed uveitis before more than 4 joints were affected. After a mean followup of 5.62 years (range 0.5-15.17), 12/35 (34%) patients with uveitis had developed uveitis complications. Best corrected visual acuity was normal in 91% of patients. Only 5.6% of the affected eyes were legally blind as compared to 17.6% in the 1992 cohort.

CONCLUSION

The rate of uveitis was 13.2% in our cohort of Swiss children and has not changed since 1992. Despite the high rate of uveitis complications, the longterm visual outcome was excellent.

Long-term results of Ahmed glaucoma valve implantation for uveitic glaucoma

PURPOSE

To present long-term outcomes of Ahmed glaucoma valve implantation for uveitic glaucoma.

DESIGN

Interventional case series.

METHODS

Retrospective chart review of 60 patients (60 eyes) with uveitic glaucoma who underwent Ahmed valve implantation over a four-year period at a tertiary uveitis referral center. Success definition 1 included patients with an intraocular pressure (IOP) between 5 and 21 mm Hg, reduced by 25% from that before implantation. Success definition 2 (qualified success) excluded those patients in whom serious complications occurred.

RESULTS

Mean follow-up time was 30 months (range, six to 87 months; four-year results relate to a cohort of 15 patients). Success rates were 77% and 50% and qualified success rates were 57% and 39% at one and four years, respectively. At four years, 74% of the patients required glaucoma medication to maintain IOP control. The overall complication rate was 12%/person-years. The rate of visual acuity loss was 4%/person-years; that was most commonly attributed to corneal complications that were more likely to occur in patients with preoperative corneal disease (P = .01, Fisher exact test).

CONCLUSIONS

Ahmed glaucoma valve implantation is a safe yet moderately successful procedure for uveitic glaucoma. Long-term success rates are enhanced with the use of glaucoma medications, and corneal complications are the most common of all potential serious complications.

[The role of chemokines in uveitis]

Inflammation is part of the physiological process that aims at repairing the damage produced by different causes such as infection, trauma, and autoimmune disease. However, when this physiological process is not regulated, it can contribute to the increase in tissue damage. Chemokines and their receptors are major factors involved in the process of cell migration into inflamed tissues. In the ocular diseases, mainly in uveitis, such proteins have been identified as important mediators of the inflammation process. This review discusses the role of chemokines in several ocular diseases, with emphasis on the uveitic process.

Biological response modifier therapy for refractory childhood uveitis

PURPOSE

To evaluate the use of biological response modifiers (BRM) in the treatment of refractory childhood uveitis.

DESIGN

Retrospective non-comparative case series of pediatric patients with uveitis treated with BRM.

PARTICIPANTS

23 pediatric patients.

METHODS

All children (18 years or younger) who received a BRM were assessed for visual changes, time to control inflammation, and any associated adverse side effects. Thirteen patients were treated with infliximab, five with adalimumab, and five with daclizumab. All patients had bilateral eye involvement. Diagnoses of the participants included juvenile idiopathic arthritis, keratouveitis, sarcoid panuveitis, Adamantiades-Behcets disease, and idiopathic panuveitis.

MAIN OUTCOME MEASURES

Inflammation and visual acuity.

RESULTS

In the infliximab group 16 of 26 eyes (62%), and 10 of 13 patients (77%) demonstrated an improvement in visual acuity. Twenty of 26 eyes (77%) demonstrated an improvement in the degree of inflammation. In the adalimumab group, four of 10 eyes (40%) demonstrated an improvement in visual acuity, with five of 10 eyes (50%) demonstrating an improvement in inflammation. Four of 10 eyes (40%) in the daclizumab group demonstrated an improvement in vision with eight of 10 eyes (80%) demonstrating an improvement in inflammation.

CONCLUSION

BRM appear to be safe to use in children, and represent a useful therapeutic adjunctive drug group for treating recalcitrant childhood uveitis.

S-nitrosoglutathione Prevents Interphotoreceptor Retinoid-Binding Protein (IRBP161–180)-Induced Experimental Autoimmune Uveitis

PURPOSE

Experimental autoimmune uveitis (EAU), an animal model of human uveitis, is an organ-specific autoimmune disease mediated by various inflammatory cytokines. In particular, tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta and interferon (IFN)-gamma are known to play a role in its pathogenesis. S-nitrosothiol S-nitrosoglutathione (GSNO), a slow nitric oxide (NO) donor, was reported to have beneficial effects in inflammatory disease in ischemia-reperfusion injury. The efficacy of GSNO treatment on interphotoreceptor retinoid-binding protein (IRBP)-induced EAU was investigated, using functional, histologic, and immunologic readouts.

METHODS

Mice were immunized with a single injection of IRBP(161180) peptide to induce EAU, followed by a daily treatment with GSNO (1 mg/kg). Electroretinogram (ERG) analysis, histopathology, and immunologic responses to IRBP were analyzed. The effects of GSNO treatment on the antigen-specific T-cell recall responses and their cytokine production were determined.

RESULTS

A single immunization of IRBP(161180) peptide led to significant structural damage of the retina and concomitant elimination of ERGs. Daily oral GSNO treatment from days 1-14 following immunization was found to be effective against IRBP-induced EAU. Histopathologic and ERG analysis both demonstrated significant retinal protection in GSNO-treated mice. The GSNO treatment of EAU animals significantly attenuated the levels of TNF-alpha, IL-1beta, IFN-gamma, and IL-10 in retinas, as measured by quantitative real-time polymerase chain reaction analysis. The splenocytes isolated from EAU- and GSNO-treated mice had lower antigen-specific T-cell proliferation in response to IRBP protein, and their cytokine production was inhibited.

CONCLUSIONS

The oral administration of GSNO significantly suppressed the levels of inflammatory mediators in the retinas of EAU mice. This suppression was associated with the maintenance of normal retinal histology and function. These results clearly demonstrated the therapeutic potential of GSNO in EAU, and provide new insights for the treatment of human uveitis.

Tuberculous uveitis, a resurgent and underdiagnosed disease

BACKGROUND

Over the last decade ocular involvement due to tuberculosis has re-emerged. In non-endemic areas the low frequency of active tuberculosis is at the origin of an underestimation of the disease. The purpose of this study is to report a group of patients with presumed tuberculous uveitis and to analyse the pre-diagnostic course, the diagnostic delay and the evolution of ocular inflammation after diagnosis and anti-tuberculous treatment.

METHODS

Criteria for presumed tuberculous uveitis included the presence of a hyperpositive tuberculin skin test with compatible uveitis and the exclusion of other possible etiologies.

RESULTS

Thirty-five patients fulfilled the diagnostic criteria for presumed tuberculous uveitis and were included in the study. The diagnosis was performed at presentation in only seven patients, while the correct diagnosis was delayed in the other 30 patients. The mean diagnostic delay was 5.7 +/- 4 years. Anti-tuberculous therapy was given for a minimum of 6 to a maximum of 24 months. Post-diagnostic mean follow-up was 30.4 +/- 13.4 months. Anti-tuberculous therapy resulted in a highly significant increase in visual acuity, from 0.53 to 0.78 (P < 0.001), a highly significant decrease of recurrences, from 100 to 10% (P < 0.001), with only three recurrences observed during the follow-up, and a highly significant decrease in intra-ocular pressure, from 18.3 to 13.7 (P < 0.001).

CONCLUSIONS

Our study tends to confirm the existence of tuberculous uveitis and supports the validity of the proposed diagnostic criteria. Recognition of the correct diagnosis and specific therapy, even with substantial delay, avoids recurrences, improves visual acuity and intra-ocular inflammation and decreases intra-ocular pressure.

Protein kinase Czeta (PKCzeta) regulates ocular inflammation and apoptosis in endotoxin-induced uveitis (EIU): signaling molecules involved in EIU resolution by PKCzeta inhibitor and interleukin-13

We show that inhibitory effect of interleukin-13 on endotoxin-induced uveitis in the Lewis rat is dependent on signaling activity of protein kinase Czeta (PKCzeta). To understand the effect of interleukin-13 or PKCzeta inhibitor treatment, the activation status of rat bone marrow-derived macrophages was studied in vitro. At 6 hours, lipopolysaccharide-stimulated macrophages produced tumor necrosis factor-alpha (TNF-alpha) with nuclear factor kappaB (NF-kappaB)/p65 expression. Treatment led to absence of NF-kappaB/p65 expression and low levels of TNF-alpha, suggesting accelerated inactivation of macrophages. At 24 hours after lipopolysaccharide stimulation, nuclear NF-kappaB/p65 decreased and nuclear NF-kappaB/p50 increased, associated with nuclear BCL-3 and a low level of TNF-alpha, indicating onset of spontaneous resolution. Treatment limited PKCzeta cleavage, with expression of nuclear NF-kappaB/p50 and BCL-3 and low nuclear NF-kappaB/p65 promoting macrophage survival, as evidenced by Bcl-2 expression. At 24 hours, intraocular treatment decreased membranous expression of PKCzeta by ocular cells, reduced vascular leakage with low nitric-oxide synthase-2 expression in vascular endothelial cells, and limited inflammatory cell infiltration with decreased intraocular TNF-alpha, interleukin-6, and nitric-oxide synthase-2 mRNA. Importantly, treatment decreased nuclear NF-kappaB/p65, increased transforming growth factor-beta2, and reduced caspase 3 expression in infiltrating macrophages, implying a change of their phenotype within ocular microenvironment. Treatment accelerated endotoxin-induced uveitis resolution through premature apoptosis of neutrophils related to high expression of toll-like receptor 4 and caspase 3.

EFFECT OF TINTED OPTICAL FILTERS ON VISUAL ACUITY AND CONTRAST SENSITIVITY IN PATIENTS WITH INFLAMMATORY CYSTOID MACULAR EDEMA

PURPOSE

To ascertain the effect of tinted optical filters (TFs) on visual function in patients with inflammatory cystoid macular edema (CME).

METHODS

A prospective study included 14 patients with inflammatory CME and best-corrected visual acuity between 0.1 and 0.8 (CME group) and 16 sex-, age-, and best-corrected visual acuity-matched patients with macular disorders but no CME (non-CME group). All patients from both groups underwent the following tests: determination of visual acuity at distance, contrast sensitivity (CS) testing; and subjective grading of each TF for best-corrected visual acuity and CS compared with no TFs. All tests were performed with the following TFs: Corning photochromic filter with a cutoff at 450 nm; Zeiss filter with a cutoff at 560 nm; and cheap widely available yellow filter with a cutoff at 489 nm.

RESULTS

Without TFs, the CME and non-CME groups did not differ in best-corrected visual acuity (P = 0.79). Using the TFs, a clinically significant improvement was not achieved by any patient. However, using the definition of any improvement, best-corrected visual acuity with all TFs showed a significant improvement in the CME group compared with no TFs (P < 0.01). The CME group rated the Corning photochromic filter with a cutoff of 450 nm significantly higher than the other TFs when determining visual acuity (P = 0.05) and CS (P = 0.01) in contrast to no improvement in the non-CME group.

CONCLUSION

Although the use of TFs for the CME patients was not associated with criteria of clinically significant improvement, our results indicate that visual acuity and CS in patients with inflammatory CME might benefit from the use of TFs.

Uveitis associated with Primary Angiitis of the Central Nervous System

BACKGROUND

In Primary Angiitis of the Central Nervous System (PACNS), disease is typically limited to the brain and spinal cord although other organs may be affected. Uveitis is occasionally seen in systemic vasculitides but is not a recognized manifestation of PACNS. We describe two patients who developed PACNS following the onset of uveitis.

CASE DESCRIPTIONS

Case 1--a 47-year-old male suffered multiple TIAs and left pontine stroke shortly after two episodes of diffuse uveitis. A cerbral angiogram demonstrated multiple caliber changes within several intracranial vessels. Cyclophosphamide was added after his stroke occurred during pulse methylprednisolone therapy. Case 2--a 35-year-old male suffered a spinal cord TIA followed by hemispheric and brainstem infarctions two months after an episode of uveitis and Bell's palsy treated with oral prednisone. A cerebral angiogram demonstrated multiple caliber changes within several intracranial vessels. He was successfully treated with oral prednisone and cyclophosphamide.

CONCLUSIONS

Uveitis should be considered a recognized feature of PACNS. Combination immunosuppressive therapy with prednisone and cyclophosphamide may be necessary for successful treatment.

The role of chemokines and their receptors in uveitis

T-cell-dependent immunological events are increasingly being regarded as extremely important in the pathogenesis of uveitis. Several studies have also shown that macrophages are major effectors of tissue damage in uveitis. Neutrophils are also thought to play a central role in the pathogenesis of Behçet's disease. Chemokines are a superfamily of 8 to 10-kDa secreted proteins that direct the recruitment of leukocytes to sites of inflammation. The specific biological effects of chemokines are mediated by a family of seven transmembrane-spanning G-protein-coupled receptors. Recent studies of animals and humans suggest that chemokines and their receptors play a key role in leukocyte recruitment into the eye in uveitis. A strategy for blocking chemokines or chemokine receptors could be a new approach for treatment of uveitis.

Ocular surface and intraocular inflammation are related in SS-I and rheumatoid arthritis patients

The purpose of this study is to evaluate the intraocular inflammation at a sub clinical level, in patients suffering from Sjogren's syndrome (SS-I) and Rheumatoid Arthritis (RA), to relate it with the ocular surface status and to verify the diagnostic performance of the method. Twenty-eight patients suffering from SS-I, 31 patients suffering from RA and 31 normal subjects matched in age and gender were included in the study. A Kowa 500F laser cell flare meter was utilized to quantify the aqueous cells and flare in vivo, ocular surface inflammation was graded by conjunctival cytology and dosage of serum albumin in tears, eye dryness was scored with Tear Function Index. All data resulted significantly different in both SS-I and RA patients vs. control group and also different comparing SS-I vs. RA patients group, except for the Flare values. A blood-aqueous barrier breakdown occurs either in SS-I and RA patients; the degree of the damage is related with ocular surface inflammation and dryness. We recommend the aqueous flare be analysed in those rheumatic patients where an ocular surface inflammation has been documented.

VLA-4 blockade suppresses endotoxin-induced uveitis: in vivo evidence for functional integrin up-regulation

Leukocyte adhesion to the vascular wall is a critical early step in the pathogenesis of inflammatory diseases and is mediated in part by the leukocyte integrin, VLA-4, which binds to endothelial vascular cell adhesion molecule (VCAM) -1. Here, we investigate VLA-4's role in endotoxin-induced uveitis (EIU). At various time points (6-48 h) after EIU induction, the severity of the inflammation was evaluated by quantifying cell and protein content in the aqueous fluid, firm leukocyte adhesion in the retinal vessels, and the number of extravasated leukocytes into the vitreous. Functional activation of VLA-4 in vivo was investigated in our previously introduced autoperfused micro flow chamber assay. Firm adhesion of EIU leukocytes to immobilized VCAM-1 under physiological blood flow conditions was significantly increased compared with normal controls (P<0.05), suggesting an important role for VLA-4 in EIU. VLA-4 blockade in vivo significantly suppressed all uveitis-related inflammatory parameters studied, decreasing the clinical score by 45% (P<0.01), protein content in the aqueous fluid by 21% (P<0.01), retinal leukostasis by 68% (P<0.01), and leukocyte accumulation in the vitreous by 75% (P<0.01). Our data provide novel evidence for functional up-regulation of VLA-4 during EIU and suggest VLA-4 blockade as a promising therapeutic strategy for treatment of acute inflammatory eye diseases.

Prevalence, risk factors, and outcome of uveitis in juvenile idiopathic arthritis: A long-term followup study

OBJECTIVE

To assess the prevalence, risk factors, and long-term outcome of uveitis in patients with juvenile idiopathic arthritis (JIA).

METHODS

An inception cohort of all 1,081 patients diagnosed as having JIA at a single tertiary care center was established. A questionnaire and followup telephone calls were used to confirm the diagnosis of uveitis. Ophthalmologists' records of patients with uveitis were collected. Kaplan-Meier and Cox regression analyses were used to assess risk factors for developing uveitis and for complications of uveitis.

RESULTS

After a mean followup time of 6.9 years, 142 of 1,081 patients (13.1%) had developed uveitis. Risk factors were young age at diagnosis, female sex, antinuclear antibody positivity, and the subtype of JIA. The relative contribution of these risk factors was different for the different subtypes of JIA. Until the end of the study, uveitis complications had developed in 53 of 142 patients with uveitis (37.3%; 4.9% of the total cohort). Only 16 of 175 involved eyes (9.1%) in 14 of 108 patients (13%; 1.3% of the total cohort) for whom ophthalmology reports were available had best corrected visual acuity less than 20/40 (mean followup time for uveitis of 6.3 years). Abnormal vision was associated with synechiae or cataract.

CONCLUSION

Risk factors for developing uveitis were different among subtypes of JIA. The long-term outcome of JIA-associated uveitis in our cohort was excellent despite the high rate of complications.

Uveitic glaucoma and Rosai-Dorfman disease (sinus histiocytosis)

PURPOSE

To report a novel association of uveitic glaucoma with Rosai-Dorfman disease.

METHODS

Case report.

RESULTS

A 67-year-old Caucasian woman presented with a chronic bilateral granulomatous uveitis which did not respond to conventional topical steroid therapy. She also had raised intraocular pressures, glaucomatous optic disc changes and diffuse nodular fibrous skin lesions. Subsequent skin biopsy immuno-cytochemistry showed S-100 staining, consistent with Rosai-Dorfman disease. The uveitis and glaucoma were highly resistant to standard medical treatments, but completely resolved together with the systemic features of the disease after six months.

CONCLUSIONS

Rosai-Dorfman disease has not previously been reported to cause uveitic glaucoma and should be considered in non-responsive cases presenting with a rash. The disease is entirely self-limiting and early diagnosis may therefore avoid unnecessary trabeculectomy and/or systemic immune suppression.

Reading performance of patients with uveitis-associated cystoid macular edema

PURPOSE

To evaluate the extent of the visual impairment caused by uveitis-associated cystoid macular edema (CME) and compare the results with lesion size.

DESIGN

Observational case series.

METHODS

setting: Uveitis outpatient clinic of the Department of Ophthalmology and Optometry, Medical University of Vienna. patient population: CME was verified in 30 eyes of 30 consecutive uveitis patients with optical coherence tomography and lesion size was assessed with retinal thickness analyzer. main outcome measures: Distance visual acuity (VA) (measured with Early Treatment Diabetic Retinopathy Study charts), reading acuity, and reading speed (tested with Radner Reading Charts). Results were compared with nonaffected partner eyes.

RESULTS

Distance VA was logMAR 0.22 +/- 0.15 in CME eyes vs -0.02 +/- 0.17 in healthy controls. Reading acuity was 75% of logMAR in CME eyes vs 92% of logMAR in control eyes (P = .01). The mean reading speed was 148.4 +/- 36.6 words per minute in patients with CME vs 168.9 +/- 36.3 in patients without CME (P = .04). Reading acuity correlated with both lesion size and distance VA (r = 0.61; P = .01 and r = 0.53; P = .028, respectively). Neither anatomical classification of uveitis nor gender or age had a significant influence on the evaluated parameters.

CONCLUSIONS

Reading acuity and reading speed were considerably more impaired than distance visual acuity. The assessed parameters showed a better correlation to lesion size and seem to be a better reflection of macular dysfunction. Analyzing reading function is an important factor when following patients with CME and evaluating success of treatment modalities.

Differential effectiveness of etanercept and infliximab in the treatment of ocular inflammation

PURPOSE

Anti-tumor necrosis factor alpha (anti-TNF-alpha) agents are being used increasingly in refractory inflammatory eye diseases. We reviewed our patients on etanercept and infliximab to determine whether these medications are equally efficacious in controlling ocular inflammation.

DESIGN

Exploratory retrospective analysis.

PARTICIPANTS

Patients with ocular inflammatory disease on an anti-TNF-alpha agent (etanercept, infliximab).

METHODS

Case records of 22 patients treated with anti-TNF-alpha therapy were reviewed for demographic information, ocular and systemic diagnosis, duration and dose of anti-TNF-alpha treatment, concomitant ocular and systemic immunosuppressive medications, and treatment response.

MAIN OUTCOME MEASURES

Uveitis recurrence rate, initial treatment response, treatment response, and medication use at 6 months, 1 year, and last visit.

RESULTS

Patients treated with infliximab had a significant decrease in uveitis recurrences after starting therapy compared with those treated with etanercept (59% vs. 0%, P = 0.004). One year after treatment initiation and at final visit, more infliximab-treated patients had an improvement in their ocular inflammation (100% vs. 33%, P = 0.002, and 94% vs. 0%, P<0.001, respectively) and a decreased requirement for topical prednisolone acetate 1% (94% vs. 33%, P = 0.009, and 89% vs. 29%, P = 0.007, respectively) compared with those treated with etanercept. No significant differences in the use of oral corticosteroids and immunosuppressive agents were noted between the 2 groups at 6 months, 1 year, and final visit.

CONCLUSIONS

Infliximab was more effective than etanercept in the treatment of recalcitrant uveitis and decreased the use of topical steroids.

Impact of macular edema on visual acuity in uveitis

OBJECTIVE

To investigate the impact of cystoid macular edema (CME) on visual acuity in patients with uveitis.

DESIGN

Cross-sectional study.

PARTICIPANTS

The data from 529 patients (842 eyes) with uveitis were analyzed.

MAIN OUTCOME MEASURES

We recorded gender and age of the patients, anatomic site and diagnosis of uveitis, associations with systemic diseases, onset and duration of uveitis, presence of CME, best-corrected visual acuity, and the causes of decrease in visual acuity.

RESULTS

Cystoid macular edema was noted in 175 (33%) of all uveitis patients, of whom 77 (44%) had visual acuity of 20/60 or less in at least 1 eye. The mean visual acuity for eyes with CME was significantly worse than for eyes without CME (0.25 vs. 0.4; P = 0.003). Of all uveitis patients, 185 (35%) had visual acuity of 20/60 or less in at least 1 eye, which was caused by CME in 77 (42%) patients. Poor visual acuity in patients with CME was associated with the advanced age of the patients, chronic inflammation, and various specific uveitis entities. The development of visually impaired or blind eyes in patients with panuveitis and intermediate uveitis was caused in most cases by CME (59% and 85%, respectively).

CONCLUSIONS

Cystoid macular edema was a major cause of visual loss in patients with uveitis. The unsatisfactory visual acuity in patients with uveitis underlines the need for improved management of this complication.

Color Doppler imaging of ocular hemodynamic changes in Behçet disease and uveitis patients with different etiologies

PURPOSE

To investigate blood flow velocity changes and resistivity index values of orbital vessels in Behçet disease with or without ocular involvement, in uveitis patients with different etiologies, and in healthy volunteers.

METHODS

Subjects were divided into four groups: those with ocular involvement in Behçet disease (group I), those without ocular involvement in Behçet disease (group II), uveitis patients with different etiologies (group III), and a control group (group IV). Twenty-seven eyes in group I, 14 eyes in group II, 25 eyes in group III, and 27 eyes in group IV were investigated. The blood flow in the central retinal artery (CRA), ophthalmic artery (OA), nasal posterior ciliary artery (NPCA), and the temporal posterior ciliary artery (TPCA) was measured using color Doppler ultrasonography (CDU) to determine the peak systolic velocity (PSV), end diastolic velocity (EDV), and resistivity index (RI).

RESULTS

The PSV and EDV value of CRA in groups I, II, and III were found to be significantly lower than those in the control group (p < 0.05 for each). The PSV and EDV values of TPCA and NPCA in groups I, II, and III were significantly lower than those in the control group (p < 0.05 for each). Resistivity indexes of all arteries were higher in groups I, II, and III than the control group. The PSV and EDV in CRA, TPCA, and NPCA in Behçet disease patients with ocular involvement were significantly lower than all other groups (p < 0.05).

CONCLUSIONS

There are significant reductions in the blood flow values of the orbital arteries in patients with Behçet disease and uveitis patients with different etiologies when compared with healthy volunteers. The decrease in blood flow values in Behçet disease is more evident in patients with ocular involvement than the patients without ocular involvement. This might be the result of occlusive vasculitis, which is frequently seen in the retinal vessels of patients with Behçet disease.

Mycophenolate mofetil in the treatment of uveitis in children

BACKGROUND

Mycophenolate mofetil (MMF) is a new immunosuppressive agent that effectively controls the intraocular inflammation in adults.

PURPOSE

To assess the efficacy of MMF in uveitis in children and to analyse the possible side effects.

PARTICIPANTS AND METHODS

A retrospective analysis was carried out on 17 children (32 eyes) with intraocular inflammation treated with MMF and followed up at the University Eye Hospital Tuebingen, Tuebingen, Germany, between 2000 and 2005. All children had chronic non-infectious uveitis and received MMF for at least 6 months. All patients were given steroids or other immunosuppressive agents before initiating treatment with MMF.

RESULTS

17 children (10 boys and 7 girls) with a mean age of 8 (range 2-13) years at the onset of uveitis were examined. The average duration of follow-up after initiation of MMF was 3 (range 2-5) years. A steroid-sparing effect was achieved in 88% of the patients. The oral prednisolone was successfully discontinued in 41% children and reduced to a daily dose of < or =5 mg in 47% of the children. 24% of the patients remained relapse-free during the treatment, but a reduction in the relapse rate was observed in all other patients except one. Visual acuity was increased or maintained in 13 children (76%). Mild side effects (headache, rash, gastrointestinal discomfort) occurred in 7 patients (41%) and were the cause of discontinuation of MMF in 1 patient.

CONCLUSION

The results of our study are encouraging and suggest that MMF is an effective agent also in the treatment for uveitis in children, with marked steroid-sparing potential and an acceptable side effect profile.

Patterns of exacerbations of chronic non-infectious uveitis in pregnancy and puerperium

PURPOSE

To determine patterns of exacerbations of recurrent non-infectious uveitis during pregnancy and puerperium.

DESIGN

Retrospective cohort study.

METHODS

The medical records of 32 women with a history of chronic non-infectious uveitis, who were pregnant during their follow-up at the Ocular Immunology and Uveitis Service of the Massachusetts Eye and Ear Infirmary, from 1983 through 2003, were reviewed. The uveitis relapse rate during pregnancy was compared to the relapse rate during pregnancy-free periods in these women and to the relapse rate in a control group of women of childbearing age with recurrent non-infectious uveitis.

RESULTS

Among the 32 women who were pregnant during follow-up (40 pregnancies), the rate of flare-ups during pregnancy (1.0 recurrence per year) was lower than that observed during non-pregnant periods (2.4 per year; p<0.001) and lower than that observed in the non-pregnant control group (3.1 per year; p<0.001). Flare-ups were most frequent in the first trimester of pregnancy and decreased markedly in the second and third trimesters (2.3, 0.5, and 0.4 recurrences per year, respectively; p<0.001).

CONCLUSIONS

Pregnancy is associated with lower numbers of flare-ups of non-infectious uveitis compared to the non-pregnant state. If flare-ups do occur during pregnancy, they happen predominantly in the first trimester.

Melanocortin 5 receptor and ocular immunity

The nervous system contributes to the mechanisms of ocular immune privilege by the constitutive presence of the immunosuppressive neuropeptide alpha-melanocyte stimulating hormone (alpha-MSH) in the eye. Alpha-MSH through the melanocortin 5 receptor (MC5r) mediates induction of CD4+ regulatory T cells that suppress in an antigen specific manner autoimmune disease. We investigated whether there was a role for MC5r expression in ocular immunity and the natural induction of regulatory T cells that emerged following resolution of experimental autoimmune uveoretinitis (EAU). Unlike wild type mice, EAU in MC5r-/- mice caused severe retinal damage, did mice expressed a not induce the emergence of ocular autoantigen regulatory immunity in the spleen, and the MC5r-/- classical memory immune response when reimmunized with ocular autoantigen. There was expression of MC5r in retinal pigment epithelial cells, in the ganglion cell and neural outer plexiform layers of healthy wild type mice retinas. The recovery of the ocular microenvironment from EAU was not dependent on the expression of MC5r, nor was the recovery dependent on the induction of CD4+ regulatory T cells (Treg cells) in the spleen. However, protection of the retina from the inflammatory damage of EAU and the induction of ocular autoantigen-responsive CD4+ Treg cells in the post EAU spleen requires expression of MC5r.

Étiopathogénie des modifications de la pression intraoculaire au cours des uvéites

Uveitic glaucoma is a secondary form of glaucoma. Treatment is essentially medical, based on antiglaucomatous medications and immunomodulatory therapy. Therefore, some patients may need filtrating surgery to control intraocular pressure. Understanding the cellular and biochemical modifications of aqueous humor that occur during intraocular inflammation and identification of anatomical modifications of the iridocorneal angle, trabecula, pupil, and ciliary body allow physicians to adapt management depending on the different clinical patterns of uveitic glaucoma. We propose a general review of the role of inflammatory mediators and etiopathogenic mechanisms involved in uveitic glaucoma.