Risk of hypotony in noninfectious uveitis

Effect of Early Aqueous Suppression After Valved Tube Shunt Surgery for Uveitic Glaucoma

PURPOSE

To compare outcomes of early aqueous suppression (EAS) and standard therapy (ST) after Ahmed Glaucoma Valve (AGV) implantation for uveitic glaucoma.

DESIGN

Retrospective comparative cohort study.

PARTICIPANTS

All patients with uveitic glaucoma underwent AGV implantation from January 2010 to October 2020 at Northwestern Medicine.

METHODS

Excluding the first postoperative day 1 (POD1), only eyes with IOP 10-15 mmHg at their first visit with IOP ≥ 10 mmHg were included in the main analysis. Early aqueous suppression (EAS) was defined as initiation of ocular hypotensive therapy when IOP was first 10-15 mmHg. Standard therapy was initiation of therapy at any later time. Failure was defined as IOP > 21 mmHg, < 5 mmHg, or < 20% reduction in IOP from baseline after 3 months, for 2 consecutive study visits. Hypotony was defined as IOP ≤ 5 mmHg for ≥ 2 visits. Hypertensive phase was defined as IOP > 21 mmHg for 2 consecutive visits in the first 3 months.

MAIN OUTCOME MEASURES

Proportion achieving overall success; incidence of hypotony and hypertensive phase.

RESULTS

Twenty-eight eyes of 26 patients were in the EAS group and 20 eyes of 19 patients were in the ST group, with a mean follow-up of 17.7 and 28.2 months, respectively. Baseline IOP was similar in the EAS (31.2 ± 10.1 mmHg) and ST (34.6 ± 12.2 mmHg) groups; P = 0.18. Final IOP was lower in the EAS group (12.9 ± 4.6 mmHg) than the ST group (16.4 ± 5.7 mmHg; P = 0.02) on 2.6 ± 0.9 medications in the EAS group and 1.8 ± 1.5 in the ST group (P = 0.07). Overall success was achieved in 87% of EAS eyes and 74% of ST eyes (P = 0.43). There were no statistically significant differences in the occurrence of additional glaucoma surgery (4% for EAS, 20% for ST; P = 0.11), hypotony (7% for EAS, 0% for ST; P = 0.50), or hypertensive phase (4% for EAS, 21% for ST; P = 0.09).

CONCLUSIONS

EAS was associated with a lower final IOP after AGV in uveitic glaucoma eyes; however, more medications were in use at the final visit. No statistically significant differences in overall success or the incidence of adverse events were observed.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Recent advances of smart materials for ocular drug delivery

Owing to the variety and complexity of ocular diseases and the natural ocular barriers, drug therapy for ocular diseases has significant limitations, such as poor drug targeting to the site of the disease, poor drug penetration, and short drug retention time in the vitreous body. With the development of biotechnology, biomedical materials have reached the "smart" stage. To date, despite their inability to overcome all the aforementioned drawbacks, a variety of smart materials have been widely tested to treat various ocular diseases. This review analyses the most recent developments in multiple smart materials (inorganic particles, polymeric particles, lipid-based particles, hydrogels, and devices) to treat common ocular diseases and discusses the future directions and perspectives regarding clinical translation issues. This review can help researchers rationally design more smart materials for specific ocular applications.

A Novel Tube Insertion Technique for Glaucoma Drainage Device Implantation

PURPOSE

Early hypotony after non-valved glaucoma drainage device (GDD) implantation for complex glaucomatous eyes with labile aqueous production can lead to significant visual morbidity. We therefore sought to report the early postoperative outcomes of a novel surgical technique that allows atraumatic insertion of non-valved GDDs through a much smaller 25-gauge scleral track, to minimize entry site leakage and improve safety.

METHODS

Retrospective case series of 15 consecutive cases undergoing non-valved GDD insertion into the anterior chamber using a previously unreported technique.

RESULTS

All eyes underwent successful GDD insertion using our novel technique, with no intraoperative complications. The mean preoperative intraocular pressures (IOP), at day 1, week 1 and week 3 were 31.4, 22.4, 23.7, and 25.6 mm Hg, respectively. A statistically significant IOP reduction was achieved at day 1, week 1 and week 3 postoperatively ( P <0.05) without any observed leakage at the scleral entry site. One eye (6.7%) with complex panuveitic glaucoma developed early hypotony (5 mm Hg) with shallow choroidal detachments on day 1. This was successfully managed with 1 intracameral ophthalmic viscoelastic device injection given at the slit-lamp and no further intervention.

CONCLUSIONS

This novel single needle-docking intraocular insertion manoeuvre is an easily adoptable technique to make GDD insertion through a smaller 25-gauge water-tight scleral track more efficient and less traumatic. The technique reduces scleral distortion and therefore improves surgical safety particularly in eyes with complex secondary glaucoma.

Suprachoroidal injection of polyzwitterion hydrogel for treating glaucoma

Glaucoma is the primary cause of irreversible blindness worldwide. The current treatments are primarily based on drug usage or surgical operation to reduce intraocular pressure (IOP). However, it is expensive and requires patients to insist on taking the medicine for a long time. The suprachoroidal space (SCS) is the space between the choroid and the sclera, which forms part of the uveovortex pathway in the circulation of aqueous humor. So far, it is still challenging to realize the injection of hydrogels into the SCS with long-term duration. In this work, an in situ-forming polyzwitterionic polycarboxybetaine hydrogel is designed and injected to expand SCS to increase the drainage of aqueous humor from the eye via the uveovortex pathway, thus reducing IOP for at least 6 weeks, while commercial hyaluronic acid hydrogel can only last for about 4 weeks. The clinical ophthalmological safety assessment examination shows that the treatment of polyzwitterion hydrogel is well-tolerated that leads to minimal inflammatory reaction, and histopathology assessment demonstrates that the SCS is expanded after injection of the hydrogel. Further analysis of ultrasound biomicroscopy reveals that there is a strong correlation between IOP reduction and SCS expansion. In short, the polyzwitterion hydrogel developed in this work can prolong the period of IOP reduction by expanding SCS, thus treating ocular hypertension and glaucoma without resorting to drugs or regular surgery.

COMPARING VITRECTOMY, SILICONE OIL ENDOTAMPONADE WITH/WITHOUT CYCLOPEXY TO TREAT CYCLODIALYSIS CLEFTS WITH SEVERE OCULAR TRAUMA

PURPOSE

Comparing the anatomical and functional outcomes of vitrectomy, silicone oil endotamponade without cyclopexy (VEWOC) and with cyclopexy (VEWC) in patients with traumatic cyclodialysis clefts and severe ocular comorbidities.

METHODS

A total of 55 patients (55 eyes) with traumatic cyclodialysis clefts were divided into VEWOC and VEWC groups according to the surgery undergone. Besides the cyclodialysis clefts, all study eyes had one or more additional conditions caused by severe ocular trauma: cataract, lens dislocation, vitreous hemorrhage, retinal detachment, choroidal detachment, maculopathy, suprachoroidal hemorrhage, subretinal hemorrhage, or proliferative vitreoretinopathy. The minimum postoperative follow-up period for all patients was six months. The main measures of outcome were rate of successful anatomical repair, intraocular pressure, and best-corrected visual acuity.

RESULTS

Both the VEWOC group (33 eyes) and the VEWC group (22 eyes) showed significant improvement in postoperative best-corrected visual acuity and intraocular pressure at the final follow-up. The groups had no significant differences in terms of anatomical success rates (VEWOC 29/33 vs. VEWC 20/22, P = 1.000), final best-corrected visual acuity (VEWOC 1.60 ± 0.76 [median Snellen acuity: counting fingers, range: light perception to 20/20] vs. VEWC 1.46 ± 0.66 [median Snellen acuity: 20/800, range: light perception to 20/32], P = 0.485), and final intraocular pressure (VEWOC 13.40 [8.20-17.80] vs. VEWC 11.40 [6.65-14.00] mmHg, P = 0.311). However, the intraocular pressure on postoperative Day 1 was significantly different between the groups (VEWOC 10.40 [6.40-14.60] vs. VEWC 6.40 [4.70-7.98] mmHg, P = 0.002).

CONCLUSION

This study showed that both surgical approaches were equally effective in treating cyclodialysis clefts secondary to severe ocular trauma. Therefore, it may be unnecessary to perform cyclopexy in addition to the vitrectomy procedure in such cases.

Remission of Non-Infectious Anterior Scleritis: Incidence and Predictive Factors

PURPOSE

To assess how often non-infectious anterior scleritis remits and identify predictive factors.

METHODS

Our retrospective cohort study at four ocular inflammation subspecialty centers collected data for each affected eye/patient at every visit from center inception (1978, 1978, 1984, 2005) until 2010. Remission was defined as inactivity of disease off all suppressive medications at all visits spanning at least three consecutive months or at all visits up to the last visit (to avoid censoring patients stopping follow-up after remission). Factors potentially predictive of remission were assessed using Cox regression models.

RESULTS

During 1,906 years' aggregate follow-up of 832 affected eyes, remission occurred in 214 (170 of 584 patients). Median time-to-remission of scleritis = 7.8 years (95% confidence interval [CI]: 5.7, 9.5). More remissions occurred earlier than later during follow-up. Factors predictive of less scleritis remission included scleritis bilaterality (adjusted hazard ratio [aHR] = 0.46, 95% CI: 0.32-0.65); and diagnosis with any systemic inflammatory disease (aHR = 0.36, 95% CI: 0.23-0.58), or specifically with Rheumatoid Arthritis (aHR = 0.22), or Granulomatosis with Polyangiitis (aHR = 0.08). Statin treatment (aHR = 1.53, 95% CI: 1.03-2.26) within ≤90 days was associated with more remission incidence.

CONCLUSIONS

Our results suggest scleritis remission occurs more slowly in anterior scleritis than in newly diagnosed anterior uveitis or chronic anterior uveitis, suggesting that attempts at tapering suppressive medications is warranted after long intervals of suppression. Remission is less frequently achieved when systemic inflammatory diseases are present. Confirmatory studies of whether adjunctive statin treatment truly can enhance scleritis remission (as suggested here) are needed.

Contemporaneous Risk Factors for Visual Acuity in Non-Infectious Uveitis

INTRODUCTION

We evaluated the associations of clinical and demographic characteristics with visual acuity (VA) with over 5 years in a subspecialty noninfectious uveitis population.

METHODS

Retrospective data from 5,530 noninfectious uveitis patients were abstracted by expert reviewers, and contemporaneous associations of VA with demographic and clinical factors were modeled.

RESULTS

Patients were a median of 41 years old, 65% female, and 73% white. Eyes diagnosed ≥5 years prior to cohort entry had worse VA (-1.2 lines) than those diagnosed <6 months prior, and eyes with cataract surgery performed prior to entry had worse VA (-5.9 lines) than those performed during follow-up. Vitreous haze (-4.2 lines for 3+ vs quiet), hypotony (-2.5 lines for ≤5 mm Hg vs 6-23 mm Hg), and CNV (-1.8 lines) all were strongly associated with reduced VA.

CONCLUSION

Factors associated with reduced VA included well-known structural complications, and lack of subspecialty care during cataract surgery.

Drug-Free, Nonsurgical Reduction of Intraocular Pressure for Four Months after Suprachoroidal Injection of Hyaluronic Acid Hydrogel

Glaucoma is the leading cause of irreversible blindness. Current treatments use drugs or surgery to reduce intraocular pressure (IOP). In this study, a drug-free, nonsurgical method is developed that lowers IOP for 4 months without requiring daily patient adherence. The approach involves expanding the suprachoroidal space (SCS) of the eye with an in situ-forming hydrogel injected using a microneedle. This study tests the hypothesis that SCS expansion increases the drainage of aqueous humor from the eye via the unconventional pathway, which thereby lowers IOP. SCS injection of a commercial hyaluronic acid (HA) hydrogel reduces the IOP of normotensive rabbits for more than 1 month and an optimized HA hydrogel formulation enables IOP reduction for 4 months. Safety assessment by clinical ophthalmic examinations indicate the treatment is well tolerated. Histopathology shows minor hemorrhage and fibrosis at the site of injection. Further analysis by ultrasound biomicroscopy demonstrates a strong correlation of IOP reduction with SCS expansion. Outflow facility measurements show no difference in pressure-dependent outflow by the conventional pathway between treated and untreated eyes, supporting the hypothesis. In conclusion, SCS expansion with an in situ-forming hydrogel can enable extended IOP reduction for treating ocular hypertension and glaucoma without drugs or surgery.

Pattern of Uveitis in Iran: A Systematic Review

PURPOSE

Uveitis is the third leading cause of blindness worldwide. This study aimed to summarize the pattern of uveitis in Iran through a systematic review.

METHODS

This review was conducted according to the guidelines for systematic reviews in the following four steps: literature search, study selection and assessment, inclusion and exclusion criteria, and statistical analysis.

RESULTS

One hundred and fifteen articles were identified by an encyclopedic literature search, and three independent investigators examined them according to the defined inclusion and exclusion criteria. Eventually, 109 manuscripts were retrieved and six cross-sectional studies covering 3,567 patients were included and reviewed. According to the results, the mean age of patients was 40 years, and sex was not a statistically significant predisposing factor. The most common anatomical pattern of involvement was anterior uveitis, and the prevalence of the other three types of uveitis, including middle, posterior, and pan-uveitis, were almost equal. Overall, the most common etiologies of uveitis in the Iranian population were idiopathic uveitis, toxoplasmosis, Behcet's syndrome, and Fuchs heterochromic iridocyclitis.

CONCLUSION

This study depicted the pattern of uveitis in the Iranian society; this can help physicians in the diagnostic approach, management, and treatment of patients.

Severe Hypotony Maculopathy in Anterior Uveitis Associated with Hodgkin Lymphoma

Purpose: To describe the clinical course and management of anterior uveitis complicated by ocular hypotony associated with Hodgkin lymphoma.Design: Case report.Methods: Chart and multimodal imaging review, including ultrasound biomicroscopy, widefield fundus pictures, fundus autofluorescence, fluorescein angiography, and indocyanine green angiography.Results: A 44-year-old female with progressive visual deterioration and history of low-grade fever developed bilateral granulomatous anterior uveitis complicated by severe hypotony maculopathy, not improving with systemic and topical steroids. After starting ibopamine 2% eye drops, ocular hypotony progressively resolved with visual recovery. Histologic examination of a biopsied enlarged lymph node of the neck revealed the presence of Hodgkin lymphoma, for which the patient underwent systemic chemotherapy.Conclusion: Severe hypotony maculopathy complicating anterior uveitis can be associated with Hodgkin lymphoma. Topical ipobamine 2% was safe and effective in the treatment of ocular hypotony in this case.

Ocular hypotony: A comprehensive review

Ocular hypotony is an infrequent, yet potentially vision-threatening, entity. The list of differential causes is extensive, involving any condition that may compromise aqueous humor dynamics or the integrity of the globe and sometimes following medical treatments or procedures. Depending on the cause and the clinical impact, treatment options aim to correct the underlying pathology and to reestablish anatomical integrity, as well as visual function. We review the pathophysiology, clinical presentation, different causes, and associated therapeutic options of ocular hypotony.

Long-term results of pars plana vitrectomy as an anti-inflammatory therapy of pediatric intermediate uveitis resistant to standard medical treatment

PURPOSE

To evaluate the efficacy of pars plana vitrectomy (PPV) as an anti-inflammatory therapy in pediatric recurrent intermediate uveitis.

METHODS

A retrospective study evaluated the long-term results of PPV indicated for intermediate uveitis with a mean observation period of 10.3 years (range 7-15.6 years) in 6 children (mean age 8 years, range 6-12 years). Pars plana vitrectomy was performed on 10 eyes in the standard manner and was initiated by vitreous sampling for laboratory examination. Data recorded were perioperative or postoperative vitrectomy complications, anatomic and functional results of PPV, and preoperative and postoperative best-corrected Snellen visual acuity.

RESULTS

No perioperative or postoperative complications were observed. Bacteriologic, virologic, mycotic, and cytologic analysis of the vitreous was negative in all tested children. Five eyes were subsequently operated on for posterior subcapsular cataracts. An average preoperative visual acuity of 0.32 improved to an average postoperative visual acuity of 0.8.

CONCLUSIONS

In the case of systemic immunosuppressive treatment failure in pediatric uveitis, particularly in eyes with cystoid macular edema, we recommend PPV relatively early.

Risk of Ocular Hypertension in Adults with Noninfectious Uveitis

PURPOSE

To describe the risk and risk factors for ocular hypertension (OHT) in adults with noninfectious uveitis.

DESIGN

Retrospective, multicenter, cohort study.

PARTICIPANTS

Patients aged ≥18 years with noninfectious uveitis seen between 1979 and 2007 at 5 tertiary uveitis clinics.

METHODS

Demographic, ocular, and treatment data were extracted from medical records of uveitis cases.

MAIN OUTCOME MEASURES

Prevalent and incident OHT with intraocular pressures (IOPs) of ≥21 mmHg, ≥30 mmHg, and increase of ≥10 mmHg from documented IOP recordings (or use of treatment for OHT).

RESULTS

Among 5270 uveitic eyes of 3308 patients followed for OHT, the mean annual incidence rates for OHT ≥21 mmHg and OHT ≥30 mmHg are 14.4% (95% confidence interval [CI], 13.4-15.5) and 5.1% (95% CI, 4.7-5.6) per year, respectively. Statistically significant risk factors for incident OHT ≥30 mmHg included systemic hypertension (adjusted hazard ratio [aHR], 1.29); worse presenting visual acuity (≤20/200 vs. ≥20/40, aHR, 1.47); pars plana vitrectomy (aHR, 1.87); history of OHT in the other eye: IOP ≥21 mmHg (aHR, 2.68), ≥30 mmHg (aHR, 4.86) and prior/current use of IOP-lowering drops or surgery in the other eye (aHR, 4.17); anterior chamber cells: 1+ (aHR, 1.43) and ≥2+ (aHR, 1.59) vs. none; epiretinal membrane (aHR, 1.25); peripheral anterior synechiae (aHR, 1.81); current use of prednisone >7.5 mg/day (aHR, 1.86); periocular corticosteroids in the last 3 months (aHR, 2.23); current topical corticosteroid use [≥8×/day vs. none] (aHR, 2.58); and prior use of fluocinolone acetonide implants (aHR, 9.75). Bilateral uveitis (aHR, 0.69) and previous hypotony (aHR, 0.43) were associated with statistically significantly lower risk of OHT.

CONCLUSIONS

Ocular hypertension is sufficiently common in eyes treated for uveitis that surveillance for OHT is essential at all visits for all cases. Patients with 1 or more of the several risk factors identified are at particularly high risk and must be carefully managed. Modifiable risk factors, such as use of corticosteroids, suggest opportunities to reduce OHT risk within the constraints of the overriding need to control the primary ocular inflammatory disease.

Risk of Hypotony in Juvenile Idiopathic Arthritis-Associated Uveitis

OBJECTIVE

To describe risk factors for hypotony in patients with juvenile idiopathic arthritis (JIA)-associated uveitis.

DESIGN

Retrospective cohort study.

METHODS

All patients with JIA-associated uveitis (N = 108; affected eyes = 196) evaluated and followed at the Wilmer Eye Institute from July 1984 through June 2014 were included in this study. Prevalence and incidence of hypotony (intraocular pressure [IOP] <5 mm Hg) and low IOP (5 mm Hg ≤ IOP < 8 mm Hg) and risk factors for developing hypotony were analyzed.

RESULTS

At presentation, 9.3% of patients (7.1% of affected eyes) had hypotony. During a median follow-up of 5.3 years, the rate of developing hypotony and low IOP were 0.04 per eye-year (/EY; 95% confidence interval [CI]: 0.02/EY, 0.05/EY) and 0.06/EY (95% CI: 0.04/EY, 0.08/EY), respectively. Risk factors for development of hypotony during follow-up appeared to be associated with more severe uveitic disease, such as the presence of panuveitis (adjusted hazard ratio [aHR], 43.1; P = .004), anterior chamber cells or flare ≥ 3+ (aHR, 25.6, P < .001), posterior synechiae (aHR, 5.9, P = .02), and the use of oral corticosteroid (aHR 28.9; P = .003) at the presenting examination. Receiving immunosuppressive drug therapy at the time of presentation was associated with a lower risk of development of hypotony (aHR, 0.02; P = .002).

CONCLUSIONS

Hypotony affects a small but significant proportion of patients with JIA-associated uveitis and is associated with signs of active and severe uveitis. Immunosuppression was associated with significantly lower risk of hypotony, suggesting that aggressive control of the inflammation may reduce risk of hypotony in JIA-associated uveitis.

Nuclear cataract as an early predictive factor for recalcitrant juvenile idiopathic arthritis-associated uveitis

PURPOSE

To analyze factors predictive of having treatment-resistant uveitis in patients with juvenile idiopathic arthritis (JIA)-associated uveitis.

METHODS

The medical records of patients diagnosed with JIA-associated uveitis treated at a single tertiary referral center from October 2005 to March 2013 were reviewed retrospectively. The main outcome measures were demographic characteristics, ocular comorbidity, clinical course, treatments, and baseline risk factors associated with poor response to first-line therapies.

RESULTS

A total of 96 patients (175 eyes) were included. Of these, 58 patients (108 eyes) required biologic disease-modifying antirheumatic drugs or alkylating agents for their uveitis during follow-up (recalcitrant group), and 38 patients (67 eyes) did not (nonrecalcitrant group). Eyes of the recalcitrant group tended to have a higher incidence of cataract at baseline (49%; P < 0.0001). In the nonrecalcitrant group, the most frequent complications were cataract (20.9%) and secondary glaucoma (20.9%). The mean number of flares in the recalcitrant group was significantly reduced from 3.7/eye/year prior to cataract surgery to 1.6/eye/year after (P < 0.0001). Nuclear cataract was found to be an independent predictor for a severe course of JIA-associated uveitis. Any other type of cataract, posterior synechiae, male sex, or active uveitis at baseline were not found to be independently associated with recalcitrant uveitis.

CONCLUSIONS

Nuclear cataract at baseline evaluation is a risk factor for poor response to first-line therapies in JIA-associated uveitis patients.

Ocular hypertension and hypotony as determinates of outcomes in uveitis

Purpose

To assess ocular hypertension (OHT) and hypotony as outcomes of uveitis in patients managed in a mid-Atlantic tertiary care center.

Methods

Retrospective, observational study of uveitis patients seen at the University of Virginia from 1984 to 2014.

Results

A total of 442 patients (582 eyes) with uveitis were identified and included in the study. The patient population was 57.0% female. Overall, 61.9% were Caucasian and 26.6% were African American. Mean age was 46.8 years. Overall, 11.5% of the eyes had OHT at initial visit, and 7.9% had OHT at final visit (P=0.035). For each additional decade of life, the odds that an eye had OHT were elevated by a factor of 1.15 (95% confidence interval [CI]: [1.02, 1.30], P=0.027) at initial visit and by a factor of 1.15 (95% CI: [1.00, 1.32], P=0.055) at final visit. The odds that an anterior uveitis eye had OHT were greater by a factor of 2.50 (95% CI: [1.22, 5.14], P=0.013) than the odds for a nonanterior uveitis eye at initial visit and greater by a factor of 2.61 (95% CI: [1.24, 5.50], P=0.011) at final visit. For each additional 0.5 logarithm of the minimum angle of resolution increase in initial visual acuity, the odds that an affected eye had OHT were elevated by a factor of 1.18 (95% CI: [1.00, 1.39], P=0.047) at initial visit and 1.23 (95% CI: [0.99, 1.54], P=0.065) at final visit. Overall, 21 of 582 eyes (3.6%) were hypotonous initially, while 24 of 582 eyes (4.1%) were hypotonous at final follow-up (P=0.631).

Conclusion

OHT was associated with increasing age, anterior uveitis, and poor presenting visual acuity. Ocular hypotony was more common in anterior uveitis than in nonanterior uveitis. Fluctuations in intraocular pressure are an important cause of visual impairment in patients with uveitis. Careful monitoring of all uveitis patients, and especially those most at risk for fluctuations in intraocular pressure, can preserve vision and improve patient outcomes.

Cataract Surgery Outcomes in Uveitis: The Multicenter Uveitis Steroid Treatment Trial

PURPOSE

To assess the visual outcomes of cataract surgery in eyes that received fluocinolone acetonide implant or systemic therapy with oral corticosteroids and immunosuppression during the Multicenter Uveitis Steroid Treatment (MUST) Trial.

DESIGN

Nested prospective cohort study of patients enrolled in a randomized clinical trial.

PARTICIPANTS

Patients that underwent cataract surgery during the first 2 years of follow-up in the MUST Trial.

METHODS

Visual outcomes of cataract surgery were evaluated 3, 6, and 9 months after surgery using logarithmic visual acuity charts. Change in visual acuity over time was assessed using a mixed-effects model.

MAIN OUTCOME MEASURES

Best-corrected visual acuity.

RESULTS

After excluding eyes that underwent cataract surgery simultaneously with implant surgery, among the 479 eyes in the MUST Trial, 117 eyes (28 eyes in the systemic, 89 in the implant group) in 82 patients underwent cataract surgery during the first 2 years of follow-up. Overall, visual acuity increased by 23 letters from the preoperative visit to the 3-month visit (95% confidence interval [CI], 17-29 letters; P < 0.001) and was stable through 9 months of follow-up. Eyes presumed to have a more severe cataract, as measured by inability to grade vitreous haze, gained an additional 42 letters (95% CI, 34-56 letters; P < 0.001) beyond the 13-letter gain in eyes that had gradable vitreous haze before surgery (95% CI, 9-18 letters; P < 0.001) 3 months after surgery, making up for an initial difference of -45 letters at the preoperative visit (95% CI, -56 to -34 letters; P < 0.001). Black race, longer time from uveitis onset, and hypotony were associated with worse preoperative visual acuity (P < 0.05), but did not affect postsurgical recovery (P > 0.05, test of interaction). After adjusting for other risk factors, there was no significant difference in the improvement in visual acuity between the 2 treatment groups (implant vs. systemic therapy, 2 letters; 95% CI, -10 to 15 letters; P = 0.70).

CONCLUSIONS

Cataract surgery resulted in substantial, sustained, and similar visual acuity improvement in the eyes of patients with uveitis treated with the fluocinolone acetonide implant or standard systemic therapy.

Profound hypotony maculopathy in a first episode of bilateral idiopathic acute anterior uveitis

Background

We report a case of a HLA-B27 negative patient presenting with severe, bilateral, idiopathic acute anterior uveitis with acute hypotony and hypotony maculopathy as their first uveitic episode.

Case presentation

Within a week of onset of her first episode of acute anterior uveitis, a 45 year-old Caucasian lady developed profound ocular hypotony with unrecordable intraocular pressures, reduced vision and choroidal folds. All investigations were negative. Uveitic hypotony responded slowly to corticosteroids – intravenous, oral and topical – with normalization of intraocular pressure and resolution of choroidal folds after two months. Anterior uveitis and hypotony have not returned with six months of follow-up.

Conclusion

Bilateral, profound hypotony maculopathy may present acutely in idiopathic acute anterior uveitis, may be slow to respond to treatment and should be considered as a cause of vision loss in patients with this condition.

The Risk of Intraocular Pressure Elevation in Pediatric Noninfectious Uveitis

PURPOSE

To characterize the risk and risk factors for intraocular pressure (IOP) elevation in pediatric noninfectious uveitis.

DESIGN

Multicenter retrospective cohort study.

PARTICIPANTS

Nine hundred sixteen children (1593 eyes) younger than 18 years at presentation with noninfectious uveitis followed up between January 1978 and December 2007 at 5 academic uveitis centers in the United States.

METHODS

Medical records review by trained, certified experts.

MAIN OUTCOME MEASURES

Prevalence and incidence of IOP of 21 mmHg or more and 30 mmHg or more and incidence of a rise in IOP by 10 mmHg or more. To avoid underascertainment, outcomes were counted as present when IOP-lowering therapies were in use.

RESULTS

Initially, 251 (15.8%) and 46 eyes (2.9%) had IOP ≥21 mmHg and ≥30 mmHg, respectively. Factors significantly associated with presenting IOP elevation included age of 6 to 12 years (versus other pediatric ages), prior cataract surgery, pars plana vitrectomy, duration of uveitis ≥6 months, contralateral IOP elevation, presenting visual acuity worse than 20/40, and topical corticosteroid use (in a dose-response relationship). The median follow-up was 1.25 years (interquartile range, 0.4-3.66). The estimated incidence of any observed IOP elevation to ≥21 mmHg, to ≥30 mmHg, and increase in IOP by ≥10 mmHg was 33.4%, 14.8%, and 24.4%, respectively, within 2 years. Factors associated with IOP elevation included pars plana vitrectomy, contralateral IOP elevation (adjusted hazard ratio [aHR], up to 9.54; P < 0.001), and the use of topical (aHR, up to 8.77 that followed a dose-response relationship; P < 0.001), periocular (aHR, up to 7.96; P < 0.001), and intraocular (aHR, up to 19.7; P < 0.001) corticosteroids.

CONCLUSIONS

Intraocular pressure elevation affects a large minority of children with noninfectious uveitis. Statistically significant risk factors include IOP elevation or use of IOP-lowering treatment in the contralateral eye and local corticosteroid use that demonstrated a dose-and route of administration-dependent relationship. In contrast, use of immunosuppressive drug therapy did not increase such risk. Pediatric eyes with noninfectious uveitis should be followed up closely for IOP elevation, especially when strong risk factors such as the use of local corticosteroids and contralateral IOP elevation are present.

Two percent ethylenediaminetetraacetic acid chelation treatment for band-shaped keratopathy, without blunt scratching after removal of the corneal epithelium

Background

The purpose of this study was to assess the effectiveness of 2% ethylenediaminetetraacetic acid (EDTA) for the treatment of band-shaped keratopathy.

Methods

We studied 24 eyes of 16 patients with band-shaped keratopathy who underwent EDTA chelation treatment from April 1, 2011 to December 31, 2012. We compared preoperative and 1 month postoperative logarithm of the minimum angle of resolution (logMAR) best corrected visual acuity, intraocular pressure, and corneal curvature radius (K1, horizontal meridian; K2, vertical meridian; Km, average of K1 and K2). The Mann-Whitney U-test was used to determine the significance of differences.

Results

There was a significant difference in preoperative and postoperative logMAR best corrected visual acuity (P=0.01). There were no significant differences in preoperative and postoperative intraocular pressure (P=0.24) or corneal curvature radius (K1, P=0.54; K2, P=0.49; Km, P=0.45).

Conclusion

After 2% EDTA chelation treatment, post-operative logMAR best corrected visual acuity improved significantly. Moreover, since there was no significant difference in corneal curvature radius, there was little influence on corneal surface form. We believe that the results of our 2% EDTA chelation treatment were comparable with results obtained with 3.75% EDTA chelation treatment in previous reports. Two percent EDTA chelation is an effective treatment for band-shaped keratopathy and a useful method for any institution.

A case of herpetic keratitis after subconjunctival triamcinolone acetonide injection

Purpose

We report a case of herpetic epithelial keratitis that developed after subconjunctival triamcinolone acetonide injection (STI).

Methods

A 65-year-old female with anterior uveitis and hypotony in her right eye was given a STI (2 mg/0.5 ml). After the injection, she developed redness and an ocular discharge. A clinical examination was performed and real-time polymerase chain reaction (PCR) was used to amplify the viral DNA in a corneal scraping.

Results

Slit-lamp biomicroscopy revealed a severe purulent discharge, conjunctival injection, and a geographic corneal ulcer in the right eye. Herpes simplex virus 1 DNA was identified in the corneal scraping using real-time PCR. Herpetic keratitis was diagnosed and topical acyclovir ointment as well as systemic valacyclovir were started. The inflammation subsided with this medication.

Conclusion

We encountered a case of herpetic epithelial keratitis after a STI.

Incidence of visual improvement in uveitis cases with visual impairment caused by macular edema

PURPOSE

Among cases of visually significant uveitic macular edema (ME), to estimate the incidence of visual improvement and identify predictive factors.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Eyes with uveitis, seen at 5 academic ocular inflammation centers in the United States, for which ME was documented to be currently present and the principal cause of reduced visual acuity (<20/40).

METHODS

Data were obtained by standardized chart review.

MAIN OUTCOME MEASURES

Decrease of ≥ 0.2 base 10 logarithm of visual acuity decimal fraction-equivalent; risk factors for such visual improvement.

RESULTS

We identified 1510 eyes (of 1077 patients) with visual impairment to a level <20/40 attributed to ME. Most patients were female (67%) and white (76%), and had bilateral uveitis (82%). The estimated 6-month incidence of ≥ 2 lines of visual acuity improvement in affected eyes was 52% (95% confidence interval [CI], 49%-55%). Vision reduced by ME was more likely to improve by 2 lines in eyes initially with poor visual acuity (≤ 20/200; adjusted hazard ratio [HR] 1.5; 95% CI, 1.3-1.7), active uveitis (HR, 1.3; 95% CI, 1.1-1.5), and anterior uveitis as opposed to intermediate (HR, 1.2), posterior (HR, 1.3), or panuveitis (HR, 1.4; overall P = 0.02). During follow-up, reductions in anterior chamber or vitreous cellular activity or in vitreous haze each led to significant improvements in visual outcome (P <0.001 for each). Conversely, snowbanking (HR, 0.7; 95% CI, 0.4-0.99), posterior synechiae (HR, 0.8; 95% CI, 0.6-0.9), and hypotony (HR, 0.2; 95% CI, 0.06-0.5) each were associated with lower incidence of visual improvement with respect to eyes lacking each of these attributes at a given visit.

CONCLUSIONS

These results suggest that many, but not all, patients with ME causing low vision in a tertiary care setting will enjoy meaningful visual recovery in response to treatment. Evidence of significant ocular damage from inflammation (posterior synechiae and hypotony) portends a lower incidence of visual recovery. Better control of anterior chamber or vitreous activity is associated with a greater incidence of visual improvement, supporting an aggressive anti-inflammatory treatment approach for ME cases with active inflammation.

Juvenile idiopathic arthritis-associated uveitis at an Italian tertiary referral center: clinical features and complications

PURPOSE

To describe the frequencies and risk factors of ocular complications and poor visual outcomes in children with juvenile idiopathic arthritis (JIA).

METHODS

Retrospective cohort study, including 69 consecutive children (116 eyes) affected by JIA-associated uveitis managed at a tertiary uveitis clinic.

RESULTS

The incidence of visual loss to the 20/50 or worse threshold was 0.04/eye-year (EY) and to the 20/200 or worse threshold was 0.02/EY. The most common complications at baseline were posterior synechiae (52%), band keratopathy (38%), and cataract (12%). Risk factor for a visual acuity threshold of 20/50 or worse included hypotony (p = 0.01; hazard ratio [HR] 3.7; 95% CI 1.3-10.4); anterior chamber flare >1 (p = 0.04; HR 1.3; 95% CI 0.5-3.4); a positive antinuclear antibody (ANA) (p = 0.02; HR1.4; 95% CI 0.8-2.4). Hypotony and positive ANA are also associated to the 20/200 or worse threshold (p = 0.03; HR 5.1; 95% CI 1.1-23.9 and p = 0.04; HR 1.0; 95% CI 0.4-2.3; respectively). Use of immunosuppressive drugs was associated with a reduced risk of visual loss of 20/200 or worse (odds ratio 0.14, 95% CI, 0.02-1.29; p = 0.04).

CONCLUSIONS

Loss of vision and ocular complications still occur among children with JIA-related uveitis. Prompt diagnosis and a strict follow up associated to immunosuppressive therapy may decrease the poor visual outcome.

Research in Uveitis and Ocular Inflammation, 2011 to 2012

PURPOSE

This study was aimed to provide ophthalmologists with an update of recent research and developments in the areas of ocular immunology and uveitis.

DESIGN

This is a literature review.

METHODS

A 1-year search (July 1, 2011, to June 30, 2012) of the English language literature on PubMed was conducted using the search terms ocular immunology, ocular inflammation, uveitis, iritis, iridocyclitis, intermediate uveitis, posterior uveitis, panuveitis, pediatric uveitis, scleritis, choroiditis, retinitis, uveitic glaucoma, uveitic cataract, hypotony, immunomodulators, immunosuppressive therapy, corticosteroids, drug-induced uveitis, sarcoidosis, toxoplasmosis, tuberculosis, syphilis, herpes simplex virus, herpes zoster virus, cytomegalovirus, optical coherence tomography, mucous membrane pemphigoid, experimental autoimmune uveitis, and endotoxin-induced uveitis. Approximately 10% of articles studied were included in this article.

RESULTS

This review incorporates original articles encompassing new insights and updates to the field of uveitis and ocular immunology. Particular consideration was given to randomized, controlled clinical trials as well as analyses of larger cohorts; however, smaller studies and case reports involving new aspects of treatment/diagnosis or expanding the understanding of disease processes were also included.

CONCLUSIONS

Review of the literature reflected an improved understanding of uveitic disease and treatments, especially in the areas of immunomodulatory therapy, uveitic cystoid macular edema, toxoplasmosis, and sarcoidosis. Results from the Systemic Immunosuppressive Therapy for Eye Diseases Study and the Multicenter Uveitis Steroid Treatment trial, especially, yielded useful information in a number of areas. By its nature, this review cannot be all inclusive but is meant to focus on the literature and results most relevant to ophthalmologists in practice.

Infliximab counteracts tumor necrosis factor-α-enhanced induction of matrix metalloproteinases that degrade claudin and occludin in non-pigmented ciliary epithelium

Infliximab, a monoclonal antibody directed against human tumor necrosis factor-alpha (TNF-α), effectively treats anterior uveitis, which can accompany Behçet's disease. Here, we investigated the underlying mechanism of this action. We examined human, non-pigmented ciliary epithelial cells (HNPCECs), which make up the blood-aqueous barrier (BAB) in the uvea. We measured the expression levels of matrix metalloproteinases (MMPs) and tissue inhibitors of MMPs in the presence or absence of TNF-α using quantitative, real-time polymerase chain reaction and enzyme-linked immunosorbent assays. The expression of MMP-1, MMP-3, and MMP-9 increased in the presence of TNF-α, and the addition of infliximab reversed the increase. The TNF-α effects were more attenuated when infliximab was added before than when it was added after TNF-α exposure. Gelatin zymography demonstrated that the protease activity of these MMPs was also increased in the presence of TNF-α and attenuated with infliximab. Immunostaining showed that MMP-1, MMP-3, and MMP-9 degraded claudin-1 and occludin in HNPCECs and in non-pigmented ciliary epithelial cells of the swine ciliary body. In a monolayer of HNPCECs, we found that permeability was significantly increased with MMP treatment. Thus, TNF-α increased levels of MMPs in cells that form the BAB, and MMPs degraded components of the tight junctions in the BAB, which increased permeability through the cellular barrier. Furthermore, infliximab effectively attenuated the TNF-α-induced increases in MMP expression in cells that make up the BAB. These findings might suggest a basis for the clinical prevention of anterior uveitis.