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Shekhar M, Chaudhary S, Pai A, Rajesh V, Balakrishnan L, Nagu K, Wijesinghe HK. Visual outcomes and risk factors of uveitis cataract eyes after phacoemulsification and manual small-incision cataract surgery. J Cataract Refract Surg 2024; 50:257-263. [PMID: 37885121 PMCID: PMC10878458 DOI: 10.1097/j.jcrs.0000000000001354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/17/2023] [Accepted: 10/21/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE To examine the visual outcomes and risk factors of uveitis cataract eyes after phacoemulsification and manual small-incision cataract surgery (MSICS). SETTING Tertiary-care eye hospital in southern India. DESIGN Retrospective interventional case series. METHODS Of the uveitis eyes operated for cataract surgery between 2017 and 2020, eyes with a minimum of 6 months postoperative follow-up were included. Eyes with ocular trauma, lens subluxation, lens-induced uveitis, or retinal detachment-induced uveitis were excluded. Demography, visual acuity, intraoperative and postoperative records, and surgical outcomes were analyzed. RESULTS 191 eyes of 191 patients with a mean age of 51.7 ± 14.4 years were included. Phacoemulsification was performed in 134 eyes, and 57 eyes underwent MSICS. Synechiolysis and pupil-expanding maneuvers were required in 74 eyes (38.7%). No differences were noted in the rates of complications between phacoemulsification and MSICS eyes, except at 1 year, where higher rates of posterior capsular opacification and vitritis were noted in MSICS eyes ( P = .018). The visual outcomes of eyes that underwent MSICS and phacoemulsification were comparable ( P = .463). In 12 eyes (13.5%), improvement in vision was not significant. CONCLUSIONS This study shows phacoemulsification may be a preferred technique in uveitis cataracts, given the lesser incidence of postoperative complications. Patients should be counseled for realistic expectations.
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Affiliation(s)
- Madhu Shekhar
- From the Cataract Services, Aravind Eye Hospital, Madurai, India (Shekhar, Chaudhary, Pai, Wijesinghe); Uveitis Services, Aravind Eye Hospital, Madurai, India (R, Wijesinghe); Medical Research Foundation, Aravind Eye Hospital, Madurai, India (Balakrishnan, Nagu)
| | - Sushmita Chaudhary
- From the Cataract Services, Aravind Eye Hospital, Madurai, India (Shekhar, Chaudhary, Pai, Wijesinghe); Uveitis Services, Aravind Eye Hospital, Madurai, India (R, Wijesinghe); Medical Research Foundation, Aravind Eye Hospital, Madurai, India (Balakrishnan, Nagu)
| | - Aruna Pai
- From the Cataract Services, Aravind Eye Hospital, Madurai, India (Shekhar, Chaudhary, Pai, Wijesinghe); Uveitis Services, Aravind Eye Hospital, Madurai, India (R, Wijesinghe); Medical Research Foundation, Aravind Eye Hospital, Madurai, India (Balakrishnan, Nagu)
| | - Vedhanayaki Rajesh
- From the Cataract Services, Aravind Eye Hospital, Madurai, India (Shekhar, Chaudhary, Pai, Wijesinghe); Uveitis Services, Aravind Eye Hospital, Madurai, India (R, Wijesinghe); Medical Research Foundation, Aravind Eye Hospital, Madurai, India (Balakrishnan, Nagu)
| | - Logesh Balakrishnan
- From the Cataract Services, Aravind Eye Hospital, Madurai, India (Shekhar, Chaudhary, Pai, Wijesinghe); Uveitis Services, Aravind Eye Hospital, Madurai, India (R, Wijesinghe); Medical Research Foundation, Aravind Eye Hospital, Madurai, India (Balakrishnan, Nagu)
| | - Kamatchi Nagu
- From the Cataract Services, Aravind Eye Hospital, Madurai, India (Shekhar, Chaudhary, Pai, Wijesinghe); Uveitis Services, Aravind Eye Hospital, Madurai, India (R, Wijesinghe); Medical Research Foundation, Aravind Eye Hospital, Madurai, India (Balakrishnan, Nagu)
| | - Hiruni Kaushalya Wijesinghe
- From the Cataract Services, Aravind Eye Hospital, Madurai, India (Shekhar, Chaudhary, Pai, Wijesinghe); Uveitis Services, Aravind Eye Hospital, Madurai, India (R, Wijesinghe); Medical Research Foundation, Aravind Eye Hospital, Madurai, India (Balakrishnan, Nagu)
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Abdallah M, Al-Hussaini AK, Soliman W, Saleh MGA. Outcome of cataract surgery in children with presumed trematode-induced granulomatous anterior uveitis. BMC Ophthalmol 2024; 24:21. [PMID: 38225542 PMCID: PMC10789070 DOI: 10.1186/s12886-023-03273-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 12/20/2023] [Indexed: 01/17/2024] Open
Abstract
PURPOSE To examine the 6-month visual outcomes and complications following cataract surgery in patients with persumed trematode induced granulomatous anterior uveitis. SETTING Assiut university hospital, Assiut, Egypt. DESIGN This is a retrospective non comparative case series study. METHODS Patients presenting with significant cataract secondary to uveitis caused by trematode induced anterior chamber granuloma were included in this study. Cases with active anterior uveitis, within the last 3 months preceding surgery, and those with a history of trauma, were excluded from this study. Data collected included demographic characteristics, history of the condition including when uveitis started, treatment received and history of other health conditions that may be relevant to uveitis.Complete opthalmologic examination including assessment of best corrected visual acuity (BCVA) and OCT macula, if possible, were done. These was repeated 1 week, 1 month, 3 months and 6 months after surgery. Specular microscopy was performed preoperatively and 3 months after surgery. Patients underwent cataract surgery with posterior chamber intra ocular lens and statistical analysis was performed to compare preoperative and postoperative BCVA and corneal endothelial cell counts. Postoperative complications were recorded. RESULTS Five eyes of 5 patients were included in the study. All study eyes showed improvement in the post-operative visual acuity. A statistically significant improvement was observed in VA in the sixth postoperative month compared to the baseline measurements (p = 0.004). No statistically significant difference was observed between the preoperative and postoperative endothelial cell counts (p = 0.696). Cystoid macular edema did not occur as a postoperative complication. CONCLUSION Visual outcomes of cataract surgery in eyes with persumed trematode induced granulametous anterior uveitis are favorable. No sight threatening complication was observed in our series.
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Affiliation(s)
- Mona Abdallah
- Department of Ophthalmology, Faculty of Medicine, Assiut University, Assiut, 71515, Egypt.
| | - Ashraf K Al-Hussaini
- Department of Ophthalmology, Faculty of Medicine, Assiut University, Assiut, 71515, Egypt
| | - Wael Soliman
- Department of Ophthalmology, Faculty of Medicine, Assiut University, Assiut, 71515, Egypt
| | - Mohamed G A Saleh
- Department of Ophthalmology, Faculty of Medicine, Assiut University, Assiut, 71515, Egypt
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Cataract Surgery in Uveitis: Risk Factors, Outcomes, and Complications. Am J Ophthalmol 2022; 244:117-124. [PMID: 36002071 DOI: 10.1016/j.ajo.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 08/11/2022] [Accepted: 08/12/2022] [Indexed: 01/30/2023]
Abstract
PURPOSE To determine the outcomes of cataract surgery in eyes with uveitis, including the rates of intraoperative and postoperative complications, as well as predictors of visual outcomes. DESIGN Retrospective observational cohort study. METHODS Setting: Tertiary public hospital setting in Auckland, New Zealand, between 2008 and 2020. STUDY POPULATION Patients who underwent cataract surgery following a diagnosis of uveitis.Main observation Procedures: Additional intraoperative procedures, intraoperative and postoperative complications, and postoperative visual outcomes and complications. RESULTS 471 eyes of 371 subjects were included. Median duration of uveitis prior to cataract surgery was 3.0 years (interquartile range [IQR] 5.2) and median period of quiescence prior to surgery was 1.0 years (IQR 1.5). Additional procedures (posterior synechiae peel [32.3%] and vision blue [18.1%]) were common. Intraoperative complications occurred in 32 eyes (6.8%). Consultants were the primary surgeons in the majority (82.5%) of operations. By 12 months, visual acuity was 20/50 or better in 248 eyes (79.7%). The most common postoperative complication was uveitis flare, occurring in 56.5%. On Cox proportional hazards analysis, time quiescent was associated with reduced risk of flare (HR 0.794, P = .003). Postoperative cystoid macular edema (CME) developed in 45 eyes (9.6%), with no significant predictors identified on multivariate analysis. CONCLUSIONS Cataract surgery in uveitis is complex. In the hands of the surgically experienced, rates of intraoperative complications are low. The primary challenge is managing postoperative care as we report a high rate of uveitis relapse and CME. Careful monitoring is important as complications can be unpredictable and occur later than expected.
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Kolli H, Evers C, Murray PI. Nd:YAG Laser Posterior Capsulotomy in Adult Patients with Uveitis. Ocul Immunol Inflamm 2020; 29:1537-1539. [PMID: 32255718 DOI: 10.1080/09273948.2020.1738500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Purpose: To study the complication rate of Nd:YAG laser posterior capsulotomy in patients with uveitis.Method: Retrospective case note analysis of pseudophakic uveitis patients having undergone Nd:YAG laser posterior capsulotomy between January 2016 and December 2018. Complications documented included uveitis flare, raised intraocular pressure, intraocular lens damage/displacement, cystoid macular edema, and retinal detachment.Results: There were 39 eyes of 38 patients (20M, 18F; age 27-89 years). Mean interval between cataract surgery and laser was 55 months (range 8-286 months). Mean laser energy was 79 mJ (range 33-207 mJ). At 3 months 62% of eyes achieved a 2-5 Snellen line improvement that was maintained at 12 months. Vision was unchanged in 21% of eyes due to preexisting pathology, with no eyes having worse vision. No post-laser complications were documented.Conclusions: Nd:YAG laser posterior capsulotomy is a safe procedure in uveitis patients, resulting in a good improvement in vision.
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Affiliation(s)
- Hema Kolli
- Birmingham and Midland Eye Centre, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Charlotte Evers
- Birmingham and Midland Eye Centre, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Philip I Murray
- Birmingham and Midland Eye Centre, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.,Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Ozates S, Berker N, Cakar Ozdal P, Ozdamar Erol Y. Phacoemulsification in patients with uveitis: long-term outcomes. BMC Ophthalmol 2020; 20:109. [PMID: 32183739 PMCID: PMC7079372 DOI: 10.1186/s12886-020-01373-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 03/06/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND To assess the long-term outcomes of phacoemulsification and intraocular lens (IOL) implantation in eyes with uveitis. METHODS One hundred and five eyes of 81 patients, who underwent phacoemulsification and IOL implantation between January 2009 and July 2016, were included in this study. The demographic data, preoperative clinical findings, postoperative outcomes, and intraoperative and postoperative complications were recorded. All collected data and risk factors with regard to visual prognosis were analyzed with the help of the Statistical Package for the Social Sciences version 20.0 software program (IBM Corp., Armonk, NY, USA). RESULTS During follow-up (mean: 35.2 ± 22.2 months), corrected distance visual acuity (CDVA) improved in 87.7% of all eyes and reached a level of 0.3 LogMAR or greater in 61.3% of eyes. Postoperative complications included posterior capsule opacification (50.9%), posterior synechiae (21.7%), cystoid macular edema (16%), epiretinal membrane (13.2%), glaucoma (11.3%), increased intraocular pressure (8.5%), and severe inflammation (6.6%). Uveitis recurred in 55.7% of all eyes. The risk for the development of cystoid macular edema was found to be associated with recurrence in the early postoperative period. Low visual acuity risk was 11.1-fold higher with macular scarring (p = 0.001) and 14-fold higher with optic atrophy (p < 0.001), respectively. CONCLUSIONS With appropriate management during the pre- and postoperative periods, phacoemulsification and IOL implantation surgery can be safe and effective in eyes with uveitis. However, great caution must be taken to prevent complications both before and after the surgery.
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Affiliation(s)
- Serdar Ozates
- Department of Ophthalmology, Kars Harakani State Hospital, Yenişehir Mahallesi, İsmail Aytemiz Blv. No:55, 36200, Merkez, Kars, Turkey.
| | - Nilufer Berker
- Department of Ophthalmology, Ulucanlar Eye Training and Research Hospital, Ankara, Turkey
| | - Pinar Cakar Ozdal
- Department of Ophthalmology, Ulucanlar Eye Training and Research Hospital, Ankara, Turkey
| | - Yasemin Ozdamar Erol
- Department of Ophthalmology, Ulucanlar Eye Training and Research Hospital, Ankara, Turkey
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Lu LM, McGhee CN, Sims JL, Niederer RL. High rate of recurrence of herpes zoster–related ocular disease after phacoemulsification cataract surgery. J Cataract Refract Surg 2019; 45:810-815. [DOI: 10.1016/j.jcrs.2019.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 12/28/2018] [Accepted: 01/02/2019] [Indexed: 02/09/2023]
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Abstract
The visual outcome of uveitic cataract surgery depends on the underlying uveitic diagnosis, the presence of vision-limiting pathology and perioperative optimization of disease control. A comprehensive preoperative ophthalmic assessment for the presence of concomitant ocular pathology, with particular emphasis on macula and optic nerve involvement, is essential to determine which patients will benefit from improved vision after cataract surgery. Meticulous examination in conjunction with adjunct investigations can help in preoperative surgical planning and in determining the need for combined or staged procedures. The eye should be quiescent for a minimum of 3 months before cataract surgery. Perioperative corticosteroid prophylaxis is important to reduce the risk of cystoid macular edema and recurrence of the uveitis. Antimicrobial prophylaxis may also reduce the risk of reactivation in eyes with infectious uveitis. Uveitic cataracts may be surgically demanding due to the presence of synechiae, membranes, and pupil abnormalities that limit access to the cataract. This can be overcome by manual stretching, multiple sphincterotomies or mechanical dilation with pupil dilation devices. In patients <2 years of age and in eyes where the inflammation is poorly controlled, intraocular lens implantation should be deferred. Intensive local and/or oral steroid prophylaxis should be given postoperatively if indicated. Patients must be monitored closely for disease recurrence, excessive inflammation, raised intraocular pressure, hypotony, and other complications. Complications must be treated aggressively to improve visual rehabilitation. With proper patient selection, improved surgical techniques and optimization of peri- and post-operative care, patients with uveitic cataracts can achieve good visual outcomes.
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Affiliation(s)
| | - Seng-Ei Ti
- Singapore National Eye Centre, Singapore 168751, Singapore
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Abstract
Uveitis is a leading causes of blindness worldwide, and the development of cataracts is common due to both the presence of intraocular inflammation and the most commonly employed treatment with corticosteroids. The management of these cataracts can be very challenging and often requires additional procedures that can compromise surgical results. The underlying disease affects a relatively young population at higher risk of complications. Preoperative control of inflammation/quiescent disease for at least three months is generally accepted as the minimum amount of time prior to surgical intervention. Phacoemulsification with intraocular lens is the preferred method for surgery, with some studies showing improvement in visual acuity in over 90% of patients. The most common postoperative complications include macular edema, posterior capsule opacification, recurrent or persistent inflammation, glaucoma, epiretinal membrane and IOL deposits, or dislocation. Despite the potential complications, cataract surgery in uveitis patients is considered a safe and successful procedure.
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Affiliation(s)
- Stephanie M Llop
- a Uveitis and Ocular Immunology Service , Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School , Boston , MA , USA
| | - George N Papaliodis
- a Uveitis and Ocular Immunology Service , Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School , Boston , MA , USA
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Pålsson S, Andersson Grönlund M, Skiljic D, Zetterberg M. Phacoemulsification with primary implantation of an intraocular lens in patients with uveitis. Clin Ophthalmol 2017; 11:1549-1555. [PMID: 28860705 PMCID: PMC5572992 DOI: 10.2147/opth.s143886] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE To evaluate the outcome of cataract surgery in adult patients with uveitis. MATERIALS AND METHODS In this retrospective cohort study, medical charts of patients with uveitis and matched control patients without uveitis who underwent cataract surgery at the Eye Clinic, Sahlgrenska University Hospital, Mölndal, between January 2005 and December 2009 were analyzed. RESULTS The study included 58 eyes with and 283 eyes without uveitis. The most common etiologies were idiopathic anterior uveitis and Fuchs' heterochromic uveitis. Postoperative visual acuity at 4 weeks was ≥0.5 decimal (0.3 logMAR) in 48 eyes with uveitis (87.3%) compared to 180 non-uveitic eyes (86.1%). Four eyes with uveitis (7.1%) and one eye without uveitis (0.5%) developed postoperative intraocular hypertension/glaucoma. Posterior capsule opacification developed in 11 eyes (19.0%) with and 28 eyes (12.4%) without uveitis. CONCLUSION With appropriate perioperative anti-inflammatory regimen and surveillance, modern cataract surgery using phacoemulsification and primary intraocular lens implantation can be performed in patients with uveitis without greater risk of complications, yielding similar visual outcome as in patients without uveitis.
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Affiliation(s)
- Sara Pålsson
- Department of Clinical Neuroscience/Ophthalmology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Marita Andersson Grönlund
- Department of Clinical Neuroscience/Ophthalmology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Dragana Skiljic
- Department of Clinical Neuroscience/Ophthalmology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Madeleine Zetterberg
- Department of Clinical Neuroscience/Ophthalmology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal, Sweden
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Abstract
To evaluate the visual outcomes of cataract surgery in patients with uveitis, and to determine risk factors for the recurrence of uveitis and postoperative complications.Eighty patients with uveitis who underwent phacoemulsification with intraocular lens (IOL) implantation were included in this retrospective study. We analyzed the following data: patient characteristics, medications used, visual acuity, and complications of cataract surgery.The mean ± standard deviation time from cataract surgery to the last visit was 20.8 ± 10.4 months. Best-corrected visual acuity improved significantly after surgery (P < .001). The visual outcome was worse in patients with Behçet disease than in patients with other etiologies of uveitis. Gender (P = .018) and IOL type (P = .020) were significantly associated with recurrent uveitis after surgery. The incidence of recurrent inflammation was not significantly different between patients who did or did not receive systemic therapy (P = .43). Perioperative systemic therapies (P = .011) and recurrent uveitis within 3 months of surgery (P = .043) were associated with posterior capsular opacification. Perioperative systemic therapies (P = .026) and recurrent uveitis after surgery (P = .006) were also significantly associated with cystoid macular edema.Patients with uveitis could benefit from cataract surgery. Patients with Behçet disease had worse postoperative prognosis than patients with other etiologies of uveitis. A heparin-surface-modified IOL may reduce the incidence of recurrent inflammation.
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Affiliation(s)
- Yinglei Zhang
- Department of Ophthalmology, Eye, Ear, Nose, and Throat Hospital of Fudan University
- Key Laboratory of Myopia, Ministry of Health
- Shanghai Key Laboratory of Visual Impairment and Restoration of Shanghai, Fudan University, Shanghai, China
| | - Xiangjia Zhu
- Department of Ophthalmology, Eye, Ear, Nose, and Throat Hospital of Fudan University
- Key Laboratory of Myopia, Ministry of Health
- Shanghai Key Laboratory of Visual Impairment and Restoration of Shanghai, Fudan University, Shanghai, China
| | - Wenwen He
- Department of Ophthalmology, Eye, Ear, Nose, and Throat Hospital of Fudan University
- Key Laboratory of Myopia, Ministry of Health
- Shanghai Key Laboratory of Visual Impairment and Restoration of Shanghai, Fudan University, Shanghai, China
| | - Yongxiang Jiang
- Department of Ophthalmology, Eye, Ear, Nose, and Throat Hospital of Fudan University
- Key Laboratory of Myopia, Ministry of Health
- Shanghai Key Laboratory of Visual Impairment and Restoration of Shanghai, Fudan University, Shanghai, China
| | - Yi Lu
- Department of Ophthalmology, Eye, Ear, Nose, and Throat Hospital of Fudan University
- Key Laboratory of Myopia, Ministry of Health
- Shanghai Key Laboratory of Visual Impairment and Restoration of Shanghai, Fudan University, Shanghai, China
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Balta O, Sungur G, Acar MA, Kosker M, Yakin M, Ornek F. Long-term results of cataract surgery in patients with anterior uveitis. Int Ophthalmol 2017; 38:1399-1407. [PMID: 28602016 DOI: 10.1007/s10792-017-0598-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 06/05/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE This study was aimed to assess the long-term results of phacoemulsification and posterior chamber intraocular lens implantation in patients with anterior uveitis. METHODS Patients with complicated cataract secondary to anterior uveitis who underwent phacoemulsification and posterior chamber intraocular lens implantation were included in this study. Long-term results and all complications were evaluated throughout the postoperative 4 years. RESULTS A total of 55 eyes of 48 patients were identified in this study. Cases with anterior uveitis were categorised into four aetiologic groups. Of the 55 eyes, 22 (19 patients) had idiopathic anterior uveitis, 10 (9 patients) had viral anterior uveitis, 10 (9 patients) had Fuchs' anterior uveitis and 13 (11 patients) had anterior uveitis associated with collagen vascular diseases. Preoperative macular oedema was more frequent (63.6%) in the idiopathic group than in the other groups (p < 0.001). The success rates of the best corrected visual acuity of 20/40 or better ranged from 80.0 to 100.0% in the groups. While postoperative increased intraocular pressure rate was statistically significantly higher in the Fuchs' group (p = 0.047), there was no statistically significant difference in other complication rates between the groups. CONCLUSIONS The long-term outcomes of phacoemulsification with intraocular lens implantation in patients with uveitic cataract were satisfactory with excellent visual acuity and relatively low complication rates.
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Affiliation(s)
- Ozgur Balta
- Department of Ophthalmology, Dr. Nafiz Korez Sincan State Hospital, Ankara, Turkey.
| | - Gulten Sungur
- Department of Ophthalmology, Ankara Training and Research Hospital, Ankara, Turkey
| | - Mehmet Akif Acar
- Department of Ophthalmology, Ankara Training and Research Hospital, Ankara, Turkey
| | - Mustafa Kosker
- Department of Ophthalmology, Ankara Diskapi Training and Research Hospital, Ankara, Turkey
| | - Mehmet Yakin
- Department of Ophthalmology, Ankara Training and Research Hospital, Ankara, Turkey
| | - Firdevs Ornek
- Department of Ophthalmology, Ankara Training and Research Hospital, Ankara, Turkey
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12
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Fry M, Aravena C, Yu F, Kattan J, Aldave AJ. Long-term outcomes of the Boston type I keratoprosthesis in eyes with previous herpes simplex virus keratitis. Br J Ophthalmol 2017; 102:48-53. [DOI: 10.1136/bjophthalmol-2017-310186] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/29/2017] [Accepted: 04/09/2017] [Indexed: 11/04/2022]
Abstract
PurposeTo report the long-term outcomes of the Boston type I keratoprosthesis (Kpro) in eyes with prior herpes simplex virus (HSV) keratitis.MethodsRetrospective review of all Kpro procedures performed by a single surgeon from 1 May 2004 to 1 January 2015.Results13 of 173 Kpro procedures were performed in 11 eyes with prior HSV keratitis. There was not a significant difference in the percentage of eyes with and without prior HSV keratitis with preoperative (9% vs 8%, p=1.00) or postoperative (57% vs 60%, p=1.00) corrected distance visual acuity (CDVA) ≥20/200 or in the percentage of contralateral eyes with preoperative CDVA ≥20/50 (55% vs 30%, p=0.18). While several postoperative complications occurred approximately twice as often in eyes with prior HSV keratitis, including persistent epithelial defect (63.6% vs 34.1%; p=0.10), corneal infiltrate (27.3% vs 12.3%; p=0.17) and sterile vitritis (18.2% vs 9.4%; p=0.31), only cystoid macular oedema (45.5% vs 12.3%; p=0.01) was significantly more common. Similarly, while the Kpro retention failure rate in eyes with prior HSV keratitis was twice than that in eyes without it (0.15 vs 0.07 per year), the difference was not statistically significant (p=0.09).ConclusionAs greater than half of patients with unilateral HSV keratitis undergoing Kpro implantation have CDVA ≥20/50 in the contralateral eye, and as the Kpro retention failure rate in eyes with prior HSV keratitis is twice than that in eyes without prior HSV keratitis, caution should be exercised when considering Kpro implantation in these patients.
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Rashid W, Lone I, Mir AM, Rashid A, Latif M. Fuchs Heterochromic Iridocylitis: Clinical Characteristics and Outcome of Cataract Extraction with Intra Ocular Lens Implantation in a Kashmiri Population- A Hospital Based Study. J Clin Diagn Res 2017; 10:NC13-NC16. [PMID: 28208900 DOI: 10.7860/jcdr/2016/21244.9111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 10/19/2016] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Fuchs Heterochromic Iridocylitis (FHI) is a rare form of uveitis which is frequently complicated by cataract and glaucoma, but it does not show typical features of uveitis like pain, redness and posterior synechia. AIM To study the clinical characteristics and outcome of cataract extraction with Intra Ocular Lens (IOL) implantation in patients with FHI. MATERIALS AND METHODS The present prospective study was carried out in the Postgraduate Department of Ophthalmology, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Bemina from March 2012 to January 2015. The study included 33 eyes of 32 patients of FHI who underwent thorough clinical examination and cataract surgery with IOL implantation and were evaluated based on their visual outcome and intra and post-operative complications. Post-operative follow-up was done on 1st day, one week, one month, two month, six month and at twelve months. RESULTS Mean age of our study group was 33.9 years (Range 18 to 65 years). No male or female preponderance was seen. There was bilateral involvement of eyes in only one case. Cataract and stellate keratic precipitates were present in all cases whereas, heterochromia was present in only six eyes (18.75%). Best Corrected Visual Acuity (BCVA) showed a significant improvement following cataract surgery (p<0.001). Post-operatively, 26 eyes (78.78%) showed an improvement of four lines or more (BCVA of > 6/12). Most common causes of decreased vision post-operatively were vitreous opacities in nine eyes (27.27%) followed by glaucoma in eight eyes (24.24%) and posterior capsular opacification in six eyes (18.18%). CONCLUSION Cataract extraction with IOL lens implantation in FHI is a safe procedure associated with good visual prognosis and few complications. However, glaucoma is one of the main concerns and should be closely monitored both pre and post-operatively.
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Affiliation(s)
- Wasim Rashid
- Senior Resident, Department of Ophthalmology, SKIMS, Medical College , Bemina, Srinagar, India
| | - Imtiyaz Lone
- Assistant Professor, Department of Opthalmology, SKIMS, Medical College , Bemina, Srinagar, India
| | - Adil Majid Mir
- Fellow Paediatric Ophthalmology, LVPEI , Hyderabad, India
| | - Aamir Rashid
- Post Doctoral Fellow Paediatric Cardiology, SCTIMST , Trivenderum, Kerela, India
| | - Mehreen Latif
- Tutor Demonstrator, Department of Forensic Medicine, SKIMS, Medical College , Bemina, Srinagar, India
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Intravitreal dexamethasone implant for recurrent cystoid macular edema due to Irvine-Gass syndrome: a prospective case series. Eye (Lond) 2016; 30:1549-1557. [PMID: 27858937 DOI: 10.1038/eye.2016.205] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 06/15/2016] [Indexed: 11/08/2022] Open
Abstract
PurposeTo determine the preliminary efficacy and safety of off-label dexamethasone implant for treatment of recurrent cystoid macular edema (CME) secondary to Irvine-Gass syndrome (IGS).Patients and methodsThis study was set in Raghudeep Eye Clinic, Ahmedabad and LV Prasad Eye Institute, Hyderabad (India). It is a Prospective Case Series. Prospective case series comprising of patients with uncomplicated pseudophakia and CME due to IGS who recurred after one course of topical steroids with NSAIDS and a sub-Tenon corticosteroid injection. A complete ocular and systemic exam, fluorescein angiography, and central subfield thickness (CST) on optical coherence tomography scans were performed. Follow-up visits were on days 1, 15, and 30 and then monthly for a year. Appropriate statistical analysis was done. The primary outcome measure was the change in CDVA at months 1, 6, and 12. Secondary outcome measures were recurrence of CME and complications if any as noted at months 1, 2, 6, and 12.ResultsAbout 27 patients (27 eyes) with 16 males were included. Median age: 63.24±5.62 years. At 1 month, the CDVA improved to 0.04±0.02 (20/25) logMAR from 0.52±0.12 logMAR (20/70) (P=0.001) with a reduction in CST from 454.2±45.3 to 218.32±38.15 microns(P=0.013). The CDVA was 0.04±0.03 logMAR(P<0.001) at month 6 and 0.05±0.02 logMAR(P<0.001) at month 12. The CST was 221±35.2 microns (P=0.013) at month 6 and 214±43.34 microns (P=0.0124) at month 12. All improvements were maintained for a year. Only one patient required a second injection. No complications were noted.ConclusionThe implant is safe and effective for the treatment of recurrent CME due to IGS.
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Bhargava R, Kumar P, Sharma SK, Arora Y. Phacoemulsification Versus Manual Small Incision Cataract Surgery in Patients With Fuchs Heterochromic Iridocyclitis. Asia Pac J Ophthalmol (Phila) 2016; 5:330-4. [PMID: 26939115 DOI: 10.1097/apo.0000000000000191] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To compare the safety and efficacy of phacoemulsification and manual small incision cataract surgery (SICS) to treat cataract in patients with Fuchs heterochromic iridocyclitis (FHI). DESIGN A randomized, double-masked, prospective, multicenter study. METHODS Consecutive patients with cataract after FHI were randomly assigned to have phacoemulsification or manual SICS by 1 of 2 surgeons experienced in both techniques. Complications (intraoperatively and postoperatively), operative time, visual acuities, endothelial cell counts, and surgically induced astigmatism were compared. RESULTS At 6 months, 65 (92.8%) patients in the phacoemulsification group and 70 (92.1%) in the manual SICS group had a corrected distance visual acuity of 20/63 or better (P = 0.974). Surgical time was significantly shorter in the SICS group (11.2 ± 2.4 minutes) than in the phacoemulsification group (14.2 ± 3.1 minutes) (P < 0.001). The mean surgically induced astigmatism was 0.8 ± 0.2 diopters (D) in the phacoemulsification group and 1.16 ± 0.2 D in the SICS group (P < 0.001). Endothelial cell counts at 1 week and at 6 months did not differ significantly in the phacoemulsification and SICS groups (t test; P = 0.133 and P = 0.032, respectively). Intraoperatively, 2 (3%) eyes randomized to receive phacoemulsification and 4 (5.3%) eyes randomized to receive SICS had posterior capsular rent (P = 0.465). CONCLUSIONS Both techniques achieved good visual outcomes with low rates of complications. Manual SICS may be a viable alternative for cataract management in patients with FHI in settings with limited access to phacoemulsification.
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Affiliation(s)
- Rahul Bhargava
- From the Departments of *Ophthalmology and †Pathology, School of Medical Sciences and Research, Sharda University, Greater Noida; and ‡Department of Ophthalmology, Rotary Eye Hospital, Maranda, Palampur, India
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Liu X, Zhao C, Xu T, Gao F, Wen X, Wang M, Pei M, Zhang M. Visual Prognosis and Associated Factors of Phacoemulsification and Intraocular Lens Implantation in Different Uveitis Entities in Han Chinese. Ocul Immunol Inflamm 2016; 25:349-355. [PMID: 26902289 DOI: 10.3109/09273948.2015.1125512] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To address the visual prognosis and associated predictors of phacoemulsification and intraocular lens implantation in different uveitis entities in Han Chinese. METHODS A retrospective review of the uveitis patients who underwent phacoemulsification and intraocular lens implantation in our center between 2004 and 2014. RESULTS The 158 patients (226 eyes) included anterior uveitis (45 eyes), posterior/pan-uveitis (61 eyes), Vogt-Koyanagi-Harada disease (79 eyes) and Behçet disease (41 eyes). At 6 months after surgery, best-corrected visual acuity (BCVA) significantly improved (p < 0.001) in all uveitis groups with 134 (59.3%) eyes achieving 20/40 or better. The anterior uveitis and Behçet disease groups had significantly better and worse visual outcomes than other groups, respectively. Poor preoperative BCVA, macular lesions, and secondary glaucoma were independent variables that predicted a poor visual outcome. CONCLUSIONS Our current study revealed a generally favorable outcome and associated predictors of phacoemulsification and intraocular lens implantation in uveitic cataracts in Han Chinese.
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Affiliation(s)
- Xinshu Liu
- a Department of Ophthalmology, Peking Union Medical College Hospital , Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Chan Zhao
- a Department of Ophthalmology, Peking Union Medical College Hospital , Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Tao Xu
- b Department of Epidemiology and Statistics , Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College , Beijing , China
| | - Fei Gao
- a Department of Ophthalmology, Peking Union Medical College Hospital , Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Xin Wen
- c Department of Ophthalmology, Sun Yat-sen Memorial Hospital , Sun Yat-sen University , Guangzhou , China
| | - Min Wang
- a Department of Ophthalmology, Peking Union Medical College Hospital , Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Minghang Pei
- a Department of Ophthalmology, Peking Union Medical College Hospital , Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Meifen Zhang
- a Department of Ophthalmology, Peking Union Medical College Hospital , Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
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Bhargava R, Kumar P, Sharma SK, Kumar M, Kaur A. Phacoemulsification versus small incision cataract surgery in patients with uveitis. Int J Ophthalmol 2015; 8:965-70. [PMID: 26558210 DOI: 10.3980/j.issn.2222-3959.2015.05.20] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 09/28/2014] [Indexed: 11/02/2022] Open
Abstract
AIM To compare the safety and efficacy of phacoemulsification and small incision cataract surgery (SICS) in patients with uveitic cataract. METHODS In a prospective, randomized multi-centric study, consecutive patients with uveitic cataract were randomized to receive phacoemulsification or manual SICS by either of two surgeons well versed with both the techniques. A minimum inflammation free period of 3mo (defined as less than 5 cells per high power field in anterior chamber) was a pre-requisite for eligibility for surgery. Superior scleral tunnel incisions were used for both techniques. Improvement in visual acuity post-operatively was the primary outcome measure and the rate of post-operative complications and surgical time were secondary outcome measures, respectively. Means of groups were compared using t-tests. One way analysis of variance (ANOVA) was used when there were more than two groups. Chi-square tests were used for proportions. Kaplan Meyer survival analysis was done and means for survival time was estimated at 95% confidence interval (CI). A P value of <0.05 was considered statistically significant. RESULTS One hundred and twenty-six of 139 patients (90.6%) completed the 6-month follow-up. Seven patients were lost in follow up and another six excluded due to either follow-up less than six months (n=1) or inability implant an intraocular lens (IOL) because of insufficient capsular support following posterior capsule rupture (n=5). There was significant improvement in vision after both the procedures (paired t-test; P<0.001). On first postoperative day, uncorrected distance visual acuity (UDVA) was 20/63 or better in 31 (47%) patients in Phaco group and 26 (43.3%) patients in SICS group (P=0.384). The mean surgically induced astigmatism (SIA) was 0.86±0.34 dioptres (D) in the phacoemulsification group and 1.16±0.28 D in SICS group. The difference between the groups was significant (t-test, P=0.002). At 6mo, corrected distance visual acuity (CDVA) was 20/60 or better in 60 (90.9%) patients in Phaco group and 53 (88.3%) in the manual SICS group (P=0.478). The mean surgical time was significantly shorter in the manual SICS group (10.8±2.9 versus 13.2±2.6min) (P<0.001). Oral prednisolone, 1 mg/kg body weight was given 7d prior to surgery, continued post-operatively and tapered according to the inflammatory response over 4-6wk in patients with previously documented macular edema, recurrent uveitis, chronic anterior uveitis and intermediate uveitis. Rate of complications like macular edema (Chi-square, P=0.459), persistent uveitis (Chi-square, P=0.289) and posterior capsule opacification (Chi-square, P=0.474) were comparable between both the groups. CONCLUSION Manual SICS and phacoemulsification do not differ significantly in complication rates and final CDVA outcomes. However, manual SICS is significantly faster. It may be the preferred technique in settings where surgical volume is high and access to phacoemulsification is limited, such as in eye camps. It may also be the appropriate technique for uveitic cataract under such circumstances.
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Affiliation(s)
- Rahul Bhargava
- Department of Ophthalmology, Laser Eye Clinic, Noida 201301, India
| | - Prachi Kumar
- Department of Pathology, Santosh medical College and Hospital, Ghaziabad 201301, India
| | - Shiv Kumar Sharma
- Department of Ophthalmology, Rotary Eye Hospital, Maranda, Palampur 176102, India
| | - Manoj Kumar
- Department of Ophthalmology, Laser Eye Clinic, Noida 201301, India
| | - Avinash Kaur
- Department of Ophthalmology, Rotary Eye Hospital, Maranda, Palampur 176102, India
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Abbouda A, Tortorella P, Restivo L, Santoro E, De Marco F, La Cava M. Follow-Up Study of Over Three Years of Patients with Uveitis after Cataract Phacoemulsification: Outcomes and Complications. Semin Ophthalmol 2015; 31:532-41. [PMID: 25700154 DOI: 10.3109/08820538.2015.1009554] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To evaluate the rate and onset of intraoperative and postoperative complications post-phacoemulsification. METHODS One hundred sixty-two eyes of 145 patients with uveitis who underwent phacoemulsification between 2006 and 2009 were identified through surgical record review. Fifty-nine eyes of 46 patients met the inclusion criteria. Hazard ratio (HR) and Kaplan-Meier survival probability were calculated for each class of uveitis. RESULTS Macular edema (ME) resulted to be associated to chronic postoperative inflammation (r = 0.6; p = 0.00) and mostly related to patients who presented more than one postoperative relapse/year (r = 0.2; p = 0.02). Fuchs uveitis resulted to be a risk factor for posterior capsule opacification (PCO) (HR 3.36 IC95%1.0-10.5; p = 0.03). Hypotony and elevated intraocular pressure (IOP) were detected in the anterior uveitis group (0.02 EY). CONCLUSION The HR to develop ME was significantly related to chronic anterior uveitis. PCO and elevated IOP are most frequent in Fuchs uveitis. The postoperative visual acuity result was good among all the uveitis groups.
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Affiliation(s)
- Alessandro Abbouda
- a Department of Ophthalmology , University of Rome "Sapienza" , Rome , Italy
| | - Paolo Tortorella
- a Department of Ophthalmology , University of Rome "Sapienza" , Rome , Italy
| | - Lucia Restivo
- a Department of Ophthalmology , University of Rome "Sapienza" , Rome , Italy
| | - Elisa Santoro
- a Department of Ophthalmology , University of Rome "Sapienza" , Rome , Italy
| | - Federica De Marco
- a Department of Ophthalmology , University of Rome "Sapienza" , Rome , Italy
| | - Maurizio La Cava
- a Department of Ophthalmology , University of Rome "Sapienza" , Rome , Italy
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Kim DH, Cho BJ, Chung H, Heo JW. Intravitreal Injection of Dexamethasone Implant during Cataract Surgery in Patients with Noninfectious Uveitis. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2015. [DOI: 10.3341/jkos.2015.56.5.721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Dong Hyun Kim
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea
| | - Bum Joo Cho
- Department of Ophthalmology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Hum Chung
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea
| | - Jang Won Heo
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea
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Bucolo C, Marrazzo G, Platania CBM, Romano GL, Drago F, Salomone S. Effects of topical indomethacin, bromfenac and nepafenac on lipopolysaccharide-induced ocular inflammation†. J Pharm Pharmacol 2014; 66:954-60. [DOI: 10.1111/jphp.12224] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 01/01/2013] [Indexed: 01/22/2023]
Abstract
Abstract
Objectives
To evaluate the effects of topical non-steroidal anti-inflammatory drugs (NSAIDs) on retinal vascular leakage, and inflammatory markers in endotoxin-induced uveitis (EIU) in rats.
Methods
EIU was induced in rats by lipopolysaccharide (LPS). Topical 0.5% indomethacin, 0.09% bromfenac and 0.1% nepafenac were given before and after LPS. Twenty-four hours after LPS, the animals were euthanized and plasma along with retina were collected to assess prostaglandin-E2 (PGE2) and C-reactive protein (CRP) levels using enzyme-linked immunosorbent assay. Retinal vascular leakage was assessed by Evans blue. Molecular modelling was used to evaluate interaction of compounds with cyclooxygenase-2 (COX-2).
Key findings
All NSAIDs tested significantly prevented PGE2 production with higher effect of indomethacin and bromfenac in comparison with nepafenac. The three drugs did not affect plasma CRP levels. The analysis of retinal vascular leakage revealed a significant (P < 0.01) decrease after treatment with indomethacin, but no significant changes were observed after treatment with bromfenac and nepafenac. Indomethacin had a different interaction with COX-2 in comparison with bromfenac and amfenac (active metabolite of nepafenac).
Conclusions
Topical treatment with indomethacin, bromfenac and nepafenac has significant anti-inflammatory effects. However, only indomethacin was able to prevent retinal vascular leakage in LPS-injected rats, likely due to the distinctive molecular mechanism.
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Affiliation(s)
- Claudio Bucolo
- Department of Clinical and Molecular Biomedicine, Section of Pharmacology and Biochemistry, Medical School, University of Catania, Catania, Italy
| | | | - Chiara Bianca Maria Platania
- Department of Clinical and Molecular Biomedicine, Section of Pharmacology and Biochemistry, Medical School, University of Catania, Catania, Italy
| | - Giovanni Luca Romano
- Department of Clinical and Molecular Biomedicine, Section of Pharmacology and Biochemistry, Medical School, University of Catania, Catania, Italy
| | - Filippo Drago
- Department of Clinical and Molecular Biomedicine, Section of Pharmacology and Biochemistry, Medical School, University of Catania, Catania, Italy
| | - Salvatore Salomone
- Department of Clinical and Molecular Biomedicine, Section of Pharmacology and Biochemistry, Medical School, University of Catania, Catania, Italy
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Kosker M, Sungur G, Celik T, Unlu N, Simsek S. Reply: To PMID 23692885. J Cataract Refract Surg 2013; 40:166-7. [PMID: 24355738 DOI: 10.1016/j.jcrs.2013.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Indexed: 10/25/2022]
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Intracameral steroids versus subconjunctival and systemic steroids: prevention of postoperative inflammation in cataract with anterior uveitis. J Cataract Refract Surg 2013; 40:166. [PMID: 24355739 DOI: 10.1016/j.jcrs.2013.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Indexed: 11/23/2022]
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