In vivo evaluation of ocular inflammatory responses in experimental diabetes

AIMS

Diabetic patients may have abnormal inflammatory reactions to foreign or endogenous stimuli. This study was designed to evaluate inflammatory reactions in the diabetic eye through retinal leucocyte dynamics in the inflamed eyes of diabetic rats.

METHODS

Three weeks after diabetes induction in Long-Evans rats, endotoxin induced uveitis was produced by footpad injection of lipopolysaccharide (LPS). After LPS injection, leucocyte behaviour was evaluated in vivo by acridine orange digital fluorography.

RESULTS

The number of rolling leucocytes increased in a biphasic manner at 12 hours and 48 hours. The number of leucocytes accumulating in the retina reached a peak at 72 hours. The maximal numbers of rolling and accumulating leucocytes in the diabetic retina decreased by 56.3% (p<0.01) and 46.7% (p<0.0001), respectively, compared with the non-diabetic retina. The levels of mRNA expression of adhesion molecules in the retina, which were upregulated after LPS injection, were also lower in diabetic rats than in non-diabetic rats.

CONCLUSION

This study is the first to show that endotoxin induced inflammation is disturbed in the diabetic eye, based on evidence that the leucocyte-endothelial cell interactions stimulated by LPS were suppressed in the diabetic retina. These findings support the theory that ocular inflammatory reactions are impaired in diabetic patients.

Outcome of intravitreal triamcinolone in uveitis

PURPOSE

To report the short-term outcome of intravitreal triamcinolone acetate (TA) in the treatment of uveitic cystoid macular edema (CME).

DESIGN

Retrospective noncomparative (nonrandomized, uncontrolled) interventional case series.

PARTICIPANTS

Sixty-five eyes of 54 patients with uveitis-related CME inadequately responsive to treatment combinations of oral corticosteroid, periocular orbital floor corticosteroid injections, and second-line immunosuppressive agents.

INTERVENTION

Intravitreal injection of 4 mg/0.1 ml of TA.

MAIN OUTCOME MEASURES

Visual acuity (VA), intraocular pressure (IOP), levels of inflammation, and immunosuppressive therapy were assessed. Other potential complications, including cataract progression, vitreous hemorrhage, endophthalmitis, and retinal detachment (RD), were looked for.

RESULTS

The mean follow-up was 8.0 months (range, 3-51), and the mean improvement of VA after intravitreal TA was 0.26 (from 0.65 to 0.39 logarithm of the minimum angle of resolution; Snellen, 6/24-6/12, approximately). This occurred at a mean of 4 weeks (range, 1-30). The improvement in VA was more significant if the duration of CME before intravitreal TA was < or =12 months (P = 0.006) and if patients were < or =60 years old (P = 0.005). Patients with the worst vision before treatment also improved the least. The most important side effect was raised IOP (mean rise, 10.3 mmHg), with 28 eyes (43.1%) experiencing an IOP rise of >10 mmHg. Patients younger than 40 years were more likely to experience this IOP rise than those older than 40. Thirty-three eyes (51%) were treated with antiglaucoma medications, with a mean duration of treatment of 17.4+/-13.3 weeks, and no patient required trabeculectomy or lost vision. The dosage of oral corticosteroids and/or second-line immunosuppressive medication was reduced or stopped altogether in 18 of 33 eyes (54.5%) during the study period. There were no cases of injection-related vitreous hemorrhage, endophthalmitis, or RD.

CONCLUSIONS

In patients with uveitic CME, intravitreal TA can effectively reduce CME and improve VA and, in some eyes, allows the cessation and/or reduction of immunosuppressive therapy. The period of effectivity varies in different patients and, in some eyes, is limited. Treatment was associated in 43.1% with a rise in IOP, which was transient and treatable medically.

Low-dose intraocular triamcinolone injection for intractable macular oedema and inflammation in patients with uveitis

AIMS

To evaluate the efficacy and safety of low-dose (2 mg in 0.05 ml) intraocular triamcinolone injection for patients with uveitis-related cystoid macular oedema and/or intractable intraocular inflammation.

PATIENTS AND METHODS

Retrospective clinical case series.

RESULTS

Cystoid macular oedema was eliminated in 24/30 eyes (80%). Intractable intraocular inflammation was eliminated in 4/8 eyes (50%). Snellen visual acuity was improved by two lines or more after 14/36 injections (38.9%). Intraocular pressure rose to above 21 mmHg after 8/36 injections (22%). There were no major complications.

CONCLUSIONS

Low-dose (2 mg in 0.05 ml) intraocular triamcinolone acetonide injection is safe and effective for the management of refractory uveitic macular oedema. Its usefulness in controlling inflammation alone is questionable.

Uveitis in Gaucher disease

PURPOSE

Chronic uveitis has been previously reported in a patient with Gaucher's disease and improved with enzyme replacement therapy. This report describes the course of uveitis in two other patients with type I Gaucher's disease.

DESIGN

Observational case reports.

METHODS

Review of all patients in a large referral clinic for Gaucher's disease for incidence of uveitis.

RESULTS

Two patients with uveitis among 527 patients (0.4%) were found. Each had a different clinical outcome from the other and from the patient cited in the literature.

CONCLUSIONS

Both patients have mild Gaucher's disease, but one patient has uveitis well controlled for 10 years solely by local corticosteroids, whereas the other has suffered progression of uveitis despite enzyme replacement therapy.

The efficacy of sirolimus in the treatment of patients with refractory uveitis

AIMS

To determine the efficacy of sirolimus in the treatment of patients with severe non-infectious uveitis.

METHODS

Eight patients with severe non-infectious uveitis were recruited to an open study. Inclusion criteria were limited to patients whose disease was not controlled with at least two or more separate steroid sparing immunosuppressants (either because of unacceptable side effects or ineffectiveness of the drug) or who required regular doses of corticosteroids either as high dose systemic or orbital floor injections in order to control their disease. Intraocular inflammation, visual acuity, symptoms, corticosteroid burden, drug toxicity, and side effects were monitored.

RESULTS

Sirolimus therapy was effective in five of the eight patients, all of whom had their dose of corticosteroids reduced or discontinued. Treatment in three patients was considered a failure as it caused intolerable side effects and/or failed to control the uveitis. Side effects were common and were typically gastrointestinal or cutaneous in nature. The severity of symptoms was dose dependent in most cases and occurred at trough blood levels above 25 ng/ml.

CONCLUSION

Sirolimus is an effective and potent immunosuppressive treatment in the majority of patients with non-infectious uveitis and can reduce the need for long term supplementary corticosteroid therapy. Further studies are required to establish the long term efficacy and safety of sirolimus alone or in combination with other steroid sparing immunosuppressants.

Anti-TNF-alpha therapy for sight threatening uveitis

AIM

To describe the effect of additional treatment with anti-TNF-alpha therapy in a case series of 13 patients with serious sight threatening uveitis.

METHODS

13 patients with serious sight threatening uveitis were included, of whom six had Behçet's disease, five had idiopathic posterior uveitis, one had sarcoidosis, and one birdshot retinochoroiditis. Onset and course of ocular inflammation, inflammatory signs, and visual acuity were assessed. Patients were treated with 200 mg (approximately 3 mg/kg) infliximab infusion. Repeat infusions were given based on clinical response.

RESULTS

Infliximab treatment resulted in an effective suppression of ocular inflammation in all patients. In patients with non-Behcet's disease uveitis visual acuity in six out of eight improved or was stable. In patients with Behcet's disease visual acuity in five out of six improved or was stable.

CONCLUSION

Anti-TNF-alpha treatment may be of value in the treatment of uveitis, and in patients with Behçet's disease, leading to suppression of ocular inflammation, vasculitis, and improvement of vision in the majority. Based on these results a controlled masked study is warranted.

Visual outcome of juvenile rheumatoid arthritis-associated uveitis in adults

PURPOSE

Juvenile rheumatoid arthritis (JRA) is the systemic disease most frequently associated in childhood uveitis. The disease may cause several ocular complications, visual impairment, and blindness. Recent studies revealed a more favorable ocular prognosis. Our purpose was to analyze the long-term visual outcome of JRA-associated uveitis.

METHODS

Ocular complications and visual outcome in adult patients with JRA-associated uveitis were evaluated. Among 18 patients included in the study, uveitis was bilateral in 12 (66.7%) and unilateral in six (33.3%), for a total of 30 eyes with ocular involvement.

RESULTS

The mean durations of JRA and its associated uveitis were 24.9 and 20.5 years, respectively. All eyes (100%) had at least one ocular complication. The most frequently observed ocular complications were cataract (83.3%), band keratopathy (60%), posterior synechia (46.7%), glaucoma (33.3%), hypotony (16.7%), and macular pathology (13.3%). Final visual acuity was impaired in 40% of the eyes, poor in 20%, and totally lost in 10%. Therefore, 70% of the eyes were either visually handicapped or totally blind. Most eyes underwent at least one surgical procedure. Inflammation was active at last examination in 63.3% of eyes. All patients were still treated topically and with systemic NSAID. Sixty-one percent of the patients were using an immunosuppressive agent.

CONCLUSION

JRA-associated uveitis still has a severe course and blinding potential. Patients suffer from uveitis and its complications even during the adulthood period. However, because our series represents a more severe subset of the disease, the outcome may be poorer than that of some other outcome studies.

[Role of nitric oxide in ophthalmic diseases]

Nitric oxide is a unique molecule with simple chemical structure and sophisticated and heterogeneous functions in human organism. In this article, we reviewed possible participations of nitric oxide in physiological and pathological states inside the eye (eg. glaucoma, cataract, uveitis and retinal disorders).

[Acute, idiopathic, bilateral uveitis with periphlebitis--case report]

The purpose of this paper is to present the case of a 35 years old healthy male suffering from acute, bilateral uveitis with periphlebitis which despite broad ophthalmic and internal diagnosis remained of unknown origin. Despite anti-inflammatory treatment with acyclovir, ciprofloxacin and Encorton remission of inflammation was not achieved. Due to the failure of steroid treatment the decision of immunosuppressive therapy with Rapamycine and Endoxan was made. New therapeutic regimen caused the remission of inflammation and preserved patient's useful visual acuity.

The surgical management of chronic hypotony due to uveitis

PURPOSE

Evaluate surgery in chronic hypotony secondary to uveitis.

METHOD

Retrospective analysis of six patients operated for chronic hypotony (< or =5 mmHg) of at least 1 month's duration. Surgery involved removal of all traction and membranes on the ciliary processes. Use of oil was limited to patients with atrophic ciliary processes.

RESULTS

The average postoperative follow-up was 24 months (12-43). The average pressure increase was 7 mmHg at 6 months. Four of six uveitis patients had significantly increased vision.

CONCLUSION

Improved vision, and a sustained pressure rise are possible in hypotonous uveitis. The presence of ciliary processes is necessary. However, they do not need to be intact.

In vivo three-dimensional evaluation of leukocyte behavior in retinal microcirculation of mice

PURPOSE

To evaluate new physiologic and three-dimensional methods for monitoring leukocyte behavior in mouse retina.

METHODS

Endotoxin-induced uveitis (EIU) was produced in mice by footpad injection of lipopolysaccharide (LPS). Leukocytes were labeled with acridine orange (AO). Leukocyte rolling in the retinal microcirculation was evaluated in vivo with AO digital fluorography. The number of migrated leukocytes was counted in flatmounted retina. The behavior of leukocyte migration was observed three-dimensionally at the time of peak migration. After leukocytes were labeled with AO, the mice were perfused with rhodamine-labeled concanavalin A lectin to stain the vascular endothelium. Leukocyte migration into the retina was then monitored three-dimensionally with confocal microscopy, and the velocity of the migration was measured.

RESULTS

Both leukocyte rolling and migration peaked at 48 hours after LPS injection. Leukocytes were seen to extravasate from the deeper capillary layers and to migrate toward the outer layer of the retina. The traveling velocity of extravasated leukocytes in retinal tissue was 2.0 +/- 0.1 microm/h.

CONCLUSIONS

New methods have been demonstrated for the three-dimensional and quantitative evaluation of leukocyte behavior in mouse retina.

HLA-B27-associated uveitis: overview and current perspectives

PURPOSE OF REVIEW

To review current knowledge about the pathogenesis, clinical presentation, and treatment of HLA-B27-associated uveitis, which is the most commonly identified cause of uveitis in community-based practice and an important cause of ocular morbidity.

RECENT FINDINGS

Significant advances have been made in understanding the pathogenesis of HLA-B27-associated ocular and systemic disease, especially with regard to the genetic underpinning of these diseases. Increasing attention has also been focused on the use of alternative therapies in the treatment of HLA-B27-associated uveitis, with special attention to sulfa class antibiotics, historically have been used to treat the articular manifestations of the spondyloarthritides, and newer drugs that inhibit tumor necrosis factor-alpha.

SUMMARY

The next several years promise to yield exciting new advances in understanding of the genetic epidemiology and treatment of HLA-B27-associated uveitis.

Long-term results of cataract extraction with intraocular lens implantation in patients with uveitis

OBJECTIVE

To investigate the long-term visual results after cataract extraction in patients with uveitis, and to demonstrate the long-term viability of intraocular lenses.

DESIGN

In all, 61 patients (72 eyes), with update clinical examination, were retrospectively evaluated. Comparison of preoperative, postoperative, and latest visual function including best-corrected Snellen visual acuity, progression of uveitis and its complications, need for postoperative medical or surgical interventions.

RESULTS

After a minimum follow-up of 5 years (mean 7 years 7 months), 82% of eyes maintained a visual improvement of two Snellen lines, 74% maintained 6/9 or better, and 14% had 6/18 or worse. The mode acuity was better than 6/6. The prevalence of macular oedema or scarring was 24%, of posterior capsule opacification 96%, and of glaucoma drainage, 15%.

CONCLUSIONS

We report the long-term follow-up of cataract extraction and intraocular lens (IOL) implantation performed by a single surgeon on patients with uveitis attending a regional tertiary referral uveitis clinic. Using stringent perioperative and postoperative control of inflammation, patients with uveitis usually maintain high visual acuity over long-term follow-up. The incidence of sight-threatening postoperative complications is low and no ongoing complication has been attributed to IOL implantation.

[The hemodynamic condition in patients with uveitis of various etiologies]

Our research and comparison of the regional-dynamics condition in patients with ocular tuberculosis (OT) and uveitis of a non-specific etiology revealed the below signs typical of OT: a decreased (by 12% and more) maximum systolic blood-flow velocity (V max) and a decreased minimal diastolic blood-flow velocity (V min--by 53% and more) in the central retinal artery (CRA); as well as a decreased V max (by 34% and more) and a decreased V min (by 72%) in the posterior short ciliary arteries (PSCA). A higher resistance index was registered in the CRA (by 12%) and in the PSCA (by 11%). A higher maximum systolic and minimal diastolic velocity of blood flow in the CRA and PSCA is typical of uveitis of a non-specific etiology.

Choroidal Circulatory Disturbance in Ocular Sarcoidosis Without the Appearance of Retinal Lesions or Loss of Visual Function

BACKGROUND

Birdshot chorioretinopathy, acute posterior multifocal placoid pigment epitheliopathy, and retinal pigment epithelial detachment have been reported as rare manifestations associated with sarcoidosis, suggesting that ocular sarcoidosis may affect the choroidal circulation. We report a case of ocular sarcoidosis representing a choroidal circulatory disturbance without the appearance of retinal lesions or loss of retinal function.

CASE

A 20-year-old woman was referred with blurred vision in the left eye. Inflammatory change in the anterior segment of the eye was noted with multiple nodules on the iris.

OBSERVATIONS

Hematological examination revealed elevated lysozyme levels. Bilateral hilar lymphadenopathy was noted on chest X-ray. Specimens obtained by transbronchial lung biopsy revealed granuloma with Langhans giant cells, which led to the diagnosis of sarcoidosis. The eye was treated with topical steroid. The symptoms and the inflammatory change in the anterior segment disappeared within 10 days. However, despite the normal appearance of the ocular fundus, fluorescein angiography revealed multiple puncta of hyperfluorescence. In indocyanine green angiography, a filling delay was noted in the area corresponding to the punctate lesions. Static visual field testing and multifocal electroretinography showed no significant changes. At the last visit, 15 months after the left eye became asymptomatic, the choroidal lesions had disappeared with no residual alteration of the funduscopic appearance or visual function.

CONCLUSIONS

This case indicates that choroidal circulatory disturbance can underlie ocular sarcoidosis even in the absence of funduscopically detectable lesions and loss of visual function.

[Clinicopathological study on suprachoroidal and supraciliary hemorrhage during enucleation]

PURPOSE

To investigate the pathogenesis of suprachoroidal and supraciliary hemorrhage that might have been induced during enucleation.

METHODS

A histopathological examination of 392 enucleated eyeballs was carried out and 8 eyeballs with suprachoroidal and supraciliary hemorrhage were selected for further clinicopathological examination.

RESULTS

Among 14 eyeballs with severe acute intraocular inflammation, 7 eyeballs with suprachoroidal and supraciliary hemorrhage were found and one other such eyeball was seen among 53 with neovascular glaucoma. Among these 8, there was one case of prolapse of intraocular tissue with severe hemorrhage into the suprachoroidal and supraciliary spaces; 4 cases of severe hemorrhage into the suprachoroidal and supraciliary spaces without prolapse of intraocular tissue; and 3 cases of mild hemorrhage into the suprachoroidal or supraciliary spaces.

CONCLUSIONS

In the eyeballs with severe acute intraocular inflammation, intraocular pressure was elevated and the blood vessels were weakened by inflammatory cell infiltration. During enucleation external forces affected the blood vessel wall of the ciliary arteries and vortex veins, and the breakdown of vessel walls might have been the cause of the suprachoroidal and supraciliary hemorrhage.

Les uvéites virales

Viral eye diseases are common and associated with different well-known forms of uveitis. However, experimental models and clinical observations have led to an infectious, in particular a viral etiology in different autoimmune conditions. The use of molecular techniques is particularly informative, not only to characterize the previously well-known subgroup of presumed viral uveitis, but also to define the role of these agents or emerging viruses in atypical forms of autoimmune uveitis resistant to conventional therapy. PCR detection of viral DNA in patients with uveitis is a rapid, sensitive and accurate procedure. Therefore, aqueous humor could be analyzed when uveitis is unresponsive to anti-inflammatory molecules, in order to exclude a viral condition and dramatically modify the therapeutic management. Several new viral entities have recently been identified such as cytomegalovirus-associated chronic anterior uveitis and non-necrotizing herpetic retinopathies in immunocompetent hosts. Systemic antiviral drugs should be proposed rapidly in order to control viral replication before the use of corticosteroids. Maintenance therapy based on low-dose antivirals can reduce the rate of recurrence and should be considered.

The risk of complications of uveitis in a district hospital cohort

AIMS

To establish the frequency and risk factors for visual loss in a primary referral cohort of hospital patients with uveitis.

METHODS

561 consecutive uveitis patients attending three district hospitals were recruited and the acuity at the end of the study period recorded. A retrospective case-control study of risk factors for visual loss (permanent loss of acuity <6/9) was performed. Risk factors examined included type of uveitis, age at onset of uveitis, race, type of systemic inflammatory disease, length of follow up, and treatment variables.

RESULTS

Visual loss of at least 6/12 in one eye was found in 111 patients (19.9%). Only four patients (0.7%) suffered severe bilateral visual loss (6/36 or less). Visual loss was associated with age at onset >60 years (odds ratio 3.9, 95% confidence interval (CI) 2.2 to 7.0, long follow up 2.0 (1.2 to 3.3) and a history of cataract surgery 3.9 (2.1 to 7.2). It was less likely in patients with acute anterior uveitis 0.2 (0.1 to 0.3).

CONCLUSION

The frequency of visual loss associated with uveitis in a district hospital cohort is less than that found in referral centres and levels of legal blindness are low. Although acute anterior uveitis has a low frequency of visual loss it contributes significantly to the total burden. The ocular co-morbidity of the elderly may contribute to the increased visual loss of late onset uveitis.

PCR with the aqueous humor, blood leukocytes and vitreous of patients affected by cytomegalovirus retinitis and immune recovery uveitis

PURPOSE

To detect the cytomegalovirus (CMV) genome by PCR in the aqueous humor, blood leukocytes and vitreous of patients affected by retinitis and immune recovery uveitis (IRU).

METHODS

A PCR for CMV genome detection was carried out with the aqueous humor, vitreous and blood leukocytes of 54 patients with retinitis, including 25 HIV-infected patients presenting CMV retinitis in different stages (active lesion 6 cases, healed lesion 14 cases and IRU 5 cases), and 29 non-HIV-infected patients (retinitis unrelated to CMV) as negative controls.

RESULTS

The CMV genome was detected in the vitreous, aqueous humor and blood leukocytes of 3 out of 6 HIV-infected patients, presenting active lesions in the retina. No CMV genome was detected in the vitreous, aqueous humor and blood leukocytes of the 5 HIV-infected patients presenting IRU.

CONCLUSIONS

CMV genome detection by PCR in aqueous humor could be used as a specific and highly predictive technique for confirmation of this infection in the retina. The absence of CMV, based on the results of PCR done in clinical samples of the 5 IRU cases, does not confirm the hypothesis of a viral replication in the vitreous body and aqueous humor of these patients.

[Use of Doppler ultrasound study in the diagnosis of ocular tuberculosis]

The paper deals with the study of regional hemodynamics in patients with tuberculous uveitis. The comparative analysis has shown that the most significant microcirculatory changes occur in the central reticular and short posterior ciliary arteries in the presence of specific uveitis. The use of Doppler ultrasound study during tuberculin diagnosis has provided evidence that the most considerable decrease in hemodynamic parameters is detectable in patients with tuberculous uveitis. These data may be used for both the differential diagnosis of tuberculous and nonspecific uveitis and the objectivization of a focal response to the injection of tuberculin.

[Endogenous uveitis during pregnancy--a report of 4 cases]

PURPOSE

To estimate the influence of pregnancy on the clinical course of endogenous uveitis.

MATERIAL AND METHODS

Four pregnant women (6 eyes) aged 16-21 yrs with uveitis of unknown etiology were observed. In two cases uveitis was bilateral while other two patients developed unilateral intraocular inflammation. At the time when the pregnancy was diagnosed systemic steroids were discontinued. Ophthalmic examination was performed every 1-2 months and then 3-8 months after delivery.

RESULTS

In all cases, before pregnancy, the active stage of uveitis was observed; vitreous flare and vitreous cells were present in all cases (6 eyes). Iritis was present in one patient (1 eye), inflammatory chorioretinal lesions in 2 cases (3 eyes), while retinal vasculitis was observed in one case (1 eye). During pregnancy as well as within 3-8 months of follow-up after delivery, neither progression nor recurrences of uveitis were observed. In all patients gradual, total regression of intraocular inflammation with the improvement of visual acuity in 3 cases were noted.

CONCLUSIONS

Our observations can suggest positive influence of pregnancy on uveitis activity.

Methotrexate as a first-line corticosteroid-sparing therapy in a cohort of uveitis and scleritis

PURPOSE

To evaluate the clinical experience with methotrexate as a first-line corticosteroid-sparing drug in patients with resistant ocular inflammation.

METHODS

We retrospectively studied 39 consecutive patients with uveitis (n = 36) or scleritis (n = 3) who were treated with methotrexate following inadequate control with corticosteroids lasting five years. Criteria for initiating treatment with methotrexate and defining outcome were strictly defined.

RESULTS

The cohort included 21 females and 18 males, all Caucasians, with a mean age of 26.6 years (range: 3-73 years). Patients were followed up for 21.5 +/- 12.6 months. Treatment was discontinued due to side effects in 10 patients (26%). Of the remaining 29 patients, full or partial control of inflammation was achieved in 23 (79%). Response to treatment was observed after a mean of 2.4 +/- 0.8 months. Ten patients were fully controlled and discontinued methotrexate therapy after a mean of 20.9 +/- 9.2 months, with no recurrence of inflammation. Use of topical and systemic corticosteroids was markedly reduced in responsive patients.

CONCLUSIONS

Methotrexate is recommended as a first-line adjunct to or replacement of systemic corticosteroids in the treatment of ocular inflammation.

Application of classical and model-based spectral methods to ophthalmic arterial Doppler signals with uveitis disease

In this study, Doppler signals recorded from ophthalmic artery of 75 subjects were processed by PC-computer using classical and model-based methods. The classical method (fast Fourier transform) and three model-based methods (Burg autoregressive, moving average, least-squares modified Yule-Walker autoregressive moving average methods) were selected for processing ophthalmic arterial Doppler signals with uveitis disease. Doppler power spectra of ophthalmic arterial Doppler signals were obtained by using these spectrum analysis techniques. The variations in the shape of the Doppler spectra as a function of time were presented in the form of sonograms in order to obtain medical information. These Doppler spectra and sonograms were then used to compare the applied methods in terms of their frequency resolution and the effects in determination of uveitis disease.

Long-term progression, prognosis, and treatment of patients with recurrent ocular manifestations of Reiter's syndrome

PURPOSE

To investigate the spectrum of ocular involvement, to examine the clinical outcome, and to analyze the influence of treatment in patients with chronic ocular manifestations of Reiter's syndrome (RS) referred to a tertiary care ocular immunology service.

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

Twenty-five patients with RS evaluated at the Ocular Immunology and Uveitis Service of the Massachusetts Eye and Ear Infirmary from 1981 through 2001.

METHODS

Charts of patients were reviewed and data on age, gender, follow-up time, ocular symptoms, extraocular involvement, ocular complications, therapy, and visual acuities were recorded.

MAIN OUTCOME MEASURES

Visual acuity, ocular complications, disease progression, clinical outcome, and systemic treatment.

RESULTS

Twenty-five patients (20 male and 5 female) diagnosed with RS, with a mean age at presentation to our service of 37 years, were studied. The mean follow-up was 48.5 months. Eighty-five percent of patients tested were positive for human leukocyte antigen B27. Sixty-four percent of patients had a positive family history. All patients had oligoarthritis and enthesitis, most commonly affecting the back (56%), Achilles tendon (52%), and sacroiliac joint (24%). Eighty percent had a history of infection, most frequently urethritis (68%). Forty-four percent had a history of mucocutaneous lesions. All patients demonstrated ocular involvement at the time of diagnosis (68% with unilateral and 32% with bilateral disease), 84% had evidence of uveitis, 3% had scleritis, 2% had conjunctivitis, and 1% had pars planitis and iridocyclitis. During follow-up, the ocular complications included conjunctivitis (96%), anterior uveitis (92%), posterior uveitis (64%), keratitis (64%), cataract (56%), intermediate uveitis (40%), scleritis (28%), cystoid macular edema (28%), papillitis (16%), and glaucoma (16%). Systemic treatment for ocular inflammation was initiated in all patients. Ninety-six percent were treated with nonsteroidal anti-inflammatory agents. Eighty-eight percent were treated with corticosteroids, 64% requiring systemic prednisone. Immunosuppressive therapy was initiated in 52% of patients, with all receiving methotrexate. Seven patients required more than one immunosuppressive agent. The mean initial visual acuity was 20/25 in the right eye and 20/30 in the left eye. The mean final visual acuity was 20/25 in the right eye and 20/25 in the left eye.

CONCLUSIONS

Reiter's syndrome may be associated with chronic recurrent ocular inflammation. Systemic therapy (including immunosuppressive treatment) typically is required to control the ocular inflammation and to prevent progressive visual loss.