Risk of Ocular Hypertension in Adults with Noninfectious Uveitis

Subconjunctival injection of rapamycin-loaded polymeric microparticles for effective suppression of noninfectious uveitis in rats

Noninfective uveitis is a major cause of vision impairment, and corticosteroid medication is a mainstay clinical strategy that causes severe side effects. Rapamycin (RAPA), a potent immunomodulator, is a promising treatment for noninfective uveitis. However, because high and frequent dosages are required, it is a great challenge to implement its clinical translation for noninfective uveitis therapy owing to its serious toxicity. In the present study, we engineered an injectable microparticulate drug delivery system based on biodegradable block polymers (i.e., polycaprolactone-poly (ethylene glycol)-polycaprolactone, PCEC) for efficient ocular delivery of RAPA via a subconjunctival injection route and investigated its therapeutic efficacy in an experimental autoimmune uveitis (EAU) rat model. RAPA-PCEC microparticles were fabricated using the emulsion-evaporation method and thoroughly characterized using scanning electron microscopy, fourier transform infrared spectroscopy, X-ray diffraction, and differential scanning calorimetry. The formed microparticles exhibited slow in vitro degradation over 28 days, and provided both in vitro and in vivo sustained release of RAPA over 4 weeks. Additionally, a single subconjunctival injection of PCEC microparticles resulted in high ocular tolerance. More importantly, subconjunctival injection of RAPA-PCEC microparticles significantly attenuated the clinical signs of EAU in a dose-dependent manner by reducing inflammatory cell infiltration (i.e., CD45+ cells and Th17 cells) and inhibiting microglial activation. Overall, this injectable microparticulate system may be promising vehicle for intraocular delivery of RAPA for the treatment of noninfective uveitis.

Characteristics of ocular hypertension and uveitic glaucoma among patients with noninfectious uveitis

OBJECTIVE

Ocular hypertension and uveitic glaucoma are important downstream sequela of noninfectious uveitis (NIU). Herein, we describe the clinical outcomes of NIU cases with ocular hypertension and uveitic glaucoma.

DESIGN

Retrospective cohort study.

PARTICIPANTS

All adults (≥18 years) with NIU under the care of uveitis subspecialty tertiary care clinics between 2010 and 2021 were included.

METHODS

The primary outcomes were baseline and final visual acuity.

RESULTS

A total of 216 patients out of 914 (23.6%) cases with NIU had ocular hypertension or uveitic glaucoma over the study period. Of all patients with ocular hypertension or uveitic glaucoma, 46% were corticosteroid responders. Baseline and last median visual acuities were better for the ocular hypertension patients compared with patients with uveitic glaucoma (p < 0.001). A higher proportion of patients with uveitic glaucoma than patients with ocular hypertension required glaucoma surgery (p < 0.001). The regression analyses suggested that baseline visual acuity and anatomical classification are significant predictors of last visual acuity, whereas diagnosis of ocular hypertension versus uveitic glaucoma were significant predictors of requirement for glaucoma surgery (p < 0.001).

CONCLUSION

A quarter of patients with NIU in this study developed ocular hypertension or uveitic glaucoma. Approximately half of the patients with ocular hypertension or uveitic glaucoma were deemed to be corticosteroid responders. Baseline and last visual acuity outcomes are better amongst ocular hypertension patients compared with those with uveitic glaucoma. Poor baseline visual acuity and panuveitis are predictors of worse vision at last follow-up. Additionally, diagnosis of uveitic glaucoma was a significant predictor of requirement for glaucoma surgery.

Update on Diagnosis and Treatment of Uveitic Glaucoma

Glaucoma is a common and potentially blinding complication of uveitis. Many mechanisms are involved alone or in combination in the pathogenesis of uveitic glaucoma (UG). In terms of diagnostic evaluation, the effects of inflammatory activity in the retinal nerve fiber layer may be a source of bias in the interpretation of optical coherence tomography measurements. For the successful treatment of UG, the control of intraocular inflammation specific to the cause or anti-inflammatory treatment, combined with IOP management, is mandatory. The early institution of specific treatment improves the prognosis of UG associated with CMV. The young age of UG patients along with increased failure rates of glaucoma surgery in this group of patients warrants a stepwise approach. Conservative and conjunctival sparing surgical approaches should be adopted. Minimally invasive surgical approaches were proved to be effective and are increasingly being used in the management of UG along with the traditionally used techniques of trabeculectomy or tubes. This review aims to summarize the progress that recently occurred in the diagnosis and treatment of UG.

De Novo Uveitis in the Colombian Elderly Population: Characteristics and Comparison with Patients Under 60 Years of Age

PURPOSE

To describe the differences between de novo uveitis in elderly patients (≥60 years of age) and younger patients (< 60 years of age) in Colombia.

METHODS

Observational, analytic, cross-sectional study.

RESULTS

In the elderly group, idiopathic was the most common type of uveitis, followed by immune-mediated and infectious uveitis.No masquerade syndromes were diagnosed. Elderly patients had worse average visual acuities than young. Significant differences between both groups were observed in corneal edema, macular edema, cataract, glaucoma, and epiretinal membrane. Additionally, there were differences in the drugs used, such as topical hypotensive drugs, ocular lubricants, topical steroids, methotrexate, hydroxychloroquine, and adalimumab.

CONCLUSION

The present study demonstrated significant differences between elderly and young Colombian patients with de novo uveitis. The ophthalmologists should be aware of these patterns of presentation, which would help reach an adequate diagnosis and prevent complications based on the characteristics of each group.

Incidence of and Risk Factors for Cataract in Anterior Uveitis

PURPOSE

To estimate the incidence/risk factors for cataract in noninfectious anterior uveitis.

DESIGN

Retrospective multicenter cohort study (6 US tertiary uveitis sites, 1978-2010).

METHODS

Data were harvested by trained expert reviewers, using protocol-driven review of experts' charts. We studied cataract incidence-newly reduced visual acuity worse than 20/40 attributed to cataract; or incident cataract surgery-in 3923 eyes of 2567 patients with anterior uveitis.

RESULTS

Cataract developed in 507 eyes (54/1000 eye-years, 95% CI 49-59). Time-updated risk factors associated with cataract included older age (≥65 vs <18 years: adjusted hazard ratio [aHR] 5.04, 95% CI 3.04-8.33), higher anterior chamber cell grade (P(trend)=0.001), prior incisional glaucoma surgery (aHR 1.86, 95% CI 1.10-3.14), band keratopathy (aHR 2.23, 95% CI 1.47-3.37), posterior synechiae (aHR 3.71, 95% CI 2.83-4.87), and elevated intraocular pressure ≥30 vs 6-20 mm Hg (aHR 2.57, 95% CI 1.38-4.77). Primary acute (aHR 0.59, 95% CI 0.30-1.15) and recurrent acute (aHR 0.74, 95% CI 0.55-0.98) had lower cataract risk than chronic anterior uveitis. Higher-dose prednisolone acetate 1%-equivalent use (≥2 drops/day) was associated with >2-fold higher cataract risk in eyes with anterior chamber cell grades 0.5+ or lower but was not associated with higher cataract risk in the presence of anterior chamber cells of grade 1+ or higher.

CONCLUSIONS

Cataract complicates anterior uveitis in ∼5.4/100 eye-years. Several fixed and modifiable risk factors were identified, yielding a point system to guide cataract risk minimization. Topical corticosteroids only were associated with increased cataract risk when anterior chamber cells were absent or minimally present, suggesting their use to treat active inflammation (which itself is cataractogenic) does not cause a net increase in cataract incidence.

Predictors of glaucoma in patients with uveitis and scleritis

BACKGROUND

To examine risk factors for development of glaucoma in a large cohort of subjects with uveitis and scleritis.

METHODS

Retrospective review of subjects diagnosed with uveitis or scleritis between 2006 and 2019 at Auckland District Health Board. Subjects were excluded if they had glaucoma due to another cause. Main outcome measure was development of glaucoma. Data for local steroid use was not available.

RESULTS

3462 eyes of 2414 subjects were included in the study. Mean follow-up was 5.7 years (total follow-up time 19,897 eye years). Median age was 44.3 years and 1189 (49.3%) were female. Glaucoma developed in 222 eyes (6.3%) during the follow-up. Five-year cumulative risk of glaucoma was 6.2% (CI 5.0-7.5%) for anterior uveitis, 5.4% (CI 3.2-9.0%) for intermediate uveitis, 1.6% (CI 0.4-6.7%) for posterior uveitis, 8.7% (CI 6.5-11.7%) for panuveitis, and 3.2% (CI 1.0-9.5%) for scleritis. Five-year cumulative risk of glaucoma was lowest in HLA-B27 uveitis at 0.9% (CI 0.4-2.1%) and highest in viral uveitis 15.1% (CI 10.1-22.3%), sarcoidosis 9.9% (CI 6.1-15.9%) and tuberculosis 9.7% (CI 5.4-17.0%). On multivariate analysis, risk factors for development of glaucoma were older age at presentation, higher presenting intraocular pressure, chronic inflammation, and cystoid macular oedema.

CONCLUSIONS

Glaucoma is a common complication of uveitis and scleritis and was more frequent in older subjects, high presenting IOP, chronic inflammation and those with cystoid macular oedema. Local steroid therapy contributes to this, but is not quantifiable in this study. Targeted screening is required to avoid irreversible progression of glaucomatous optic neuropathy.

Relationship between ultra-widefield optical coherence tomography and ophthalmoscopy for detecting posterior inflammation in posterior uveitis and panuveitis

PURPOSE

To confirm the utility of ultra-widefield optical coherence tomography (W-OCT) for diagnosing uveitis.

METHOD

We retrospectively studied patients who had been diagnosed with uveitis and had undergone W-OCT. All patients had visited at Osaka Metropolitan University between January 2019 and January 2022. On W-OCT, vitreous opacity ("W-OCT VO") and the presence of vitreous cells ("W-OCT Cells") were identified by three specialists. We compared findings from ophthalmoscopy ("Ophthalmoscopic findings") and fluorescein angiography ("FAG findings") with those from W-OCT.

RESULTS

This study investigated 132 eyes from 68 patients (34 males, 34 females; mean age, 53.97±22.71 years). Vitreous cells in posterior uveitis and panuveitis differed significantly between "W-OCT Cells" and "Ophthalmoscopic findings" for all cases (P = 0.00014). Vitreous opacities in posterior uveitis and panuveitis did not differ significantly between "W-OCT VO" and "Ophthalmoscopic findings" (P = 0.144) for all cases. Compared to "Ophthalmoscopic findings", "W-OCT Cells" offered 51.1% sensitivity and 66.7% specificity for all cases (p<0.01). Compared to "Ophthalmoscopic findings", "W-OCT VO" offered 78.6% sensitivity and 30% specificity for all cases (p = 0.19). In addition, "W-OCT Cells" did not differ significantly from "FAG findings" for all cases (P = 0.424).

CONCLUSION

W-OCT was shown to offer significantly greater sensitivity than ophthalmoscopy for detecting vitreous cells. The results of this study may add an option for the evaluation of uveitis.

Features of hemodynamic and immunological parameters in patients with recurrent uveitis complicated by hypertension, Fuchs heterochromic uveitis and Posner-Schlossman syndrome

Introduction: Uveitis is a disease that manifests with increased vascular permeability and occlusion, with some ischemia and inflammatory mediators. It is characterized by a wide range of pathological processes, including inflammation, increased vascular permeability and occlusion, local ischemia and cell alteration by inflammatory mediators, and is characterized by the presence of complications. Aim: To study the state of ocular hemodynamics by rheoophthalmography, as well as the immune status in patients with idiopathic recurrent anterior uveitis complicated by intraocular hypertension, Fuchs heterochromic uveitis, Posner-Schlossman syndrome, during the relapse period. Materials and methods: 93 patients with idiopathic recurrent anterior uveitis were included in this study, 8 patients with Fuchs' uveitis, and 6 patients with Posner-Schlossman syndrome. According to clinical signs, relapse and remission were considered. The control group (healthy volunteers of the same age) consisted of 27 people. In this regard, 5 groups of subjects were formed. The mean age of the patients was (M ± SD) 39.2 ± 14.6 years. According to the Median (range), the duration of the disease in patients was 2033 (350-3285) days, intraocular hypertension being recorded at P0 > 20 mm Hg. Statistical analysis was carried out in spreadsheets using STATISTICA 8.0 (StatSoft.Inc) program. Quantitative indicators were evaluated according to the correspondence to the normal distribution and to the Kolmogorov-Smirnov criterion. With a normal distribution, arithmetic means (M) and standard deviations (SD), limits of the 95% confidence interval (95% CI) and Student's t-test were calculated. Results: The volumetric blood filling of the eye according to the rheoophthalmographic indicator RQ during the period of remission of uncomplicated and complicated by hypertension anterior uveitis was reduced by 32.4%-40.5%, respectively, compared with the norm. During the period of relapse, RQ was significantly higher by 28% (p<0.05) than in remission, in the group of uncomplicated uveitis, and in the group of uveitis with increased IOP, no significant differences between the periods of remission and relapse were observed, which reflected the ischemic process in the relapse period. Volumetric blood filling in Fuchs and Posner-Schlossman syndromes in the acute period did not differ from the norm. Cellular immunity in the groups of uncomplicated and complicated by intraocular hypertension idiopathic uveitis, as well as with Fuchs and Posner-Schlossman syndromes, had a higher level of CD4 helper lymphocytes and a lower level of CD8 suppressor lymphocytes, which reflected higher values of the immunoregulatory index. The increase in the immunoregulatory index is most pronounced in Fuchs and Posner-Schlossman syndromes. Discussion: In the presented study, the incidence of idiopathic recurrent anterior uveitis complicated by intraocular hypertension was 9,9% among all cases of idiopathic recurrent anterior uveitis in one-time period. According to literature, this complicated form of uveitis occurs in 11,5%-46,1% of cases. Most often (up to 92% of cases), the anterior chamber angle was open. Conclusions: Different activity of the mechanisms regulating the balance of cellular and humoral immunity, sensitivity of T-cells to eye antigens in idiopathic anterior uveitis, Fuchs and Posner-Schlossman syndromes was assumed. Peculiarities of eye hemodynamics in these forms of uveitis were also revealed. Abbreviations: IOP = intraocular pressure, IOHS = inflammatory ocular hypertension syndrome, HSV = herpes simplex virus, CMV = cytomegalovirus, OCT = optical coherence tomography, OD = right eye, OS = left eye.

Topical Anti-Inflammatory Agents for Non-Infectious Uveitis: Current Treatment and Perspectives

Non-infectious uveitis represents a heterogenous group of immune-mediated ocular diseases, which can be associated with underlying systemic disease. While the initial choice of treatment of non-infectious uveitis depends on a number of factors such as anatomical location and degree of inflammation, topical therapies often remain the initial choice of non-invasive therapy. In this narrative review, we aim to describe the literature on non-infectious uveitis, with specific focus on the current perspective on topical anti-inflammatory therapy.

Outcomes of Kahook Dual Blade Goniotomy for Uveitis Associated Open Angle Glaucoma or Ocular Hypertension

PRCIS

Kahook Dual Blade (KDB) goniotomy can successfully lower intraocular pressure in some patients with uveitis-associated ocular hypertension or glaucoma.

PURPOSE

The purpose of this study was to report a case series of patients that underwent KDB goniotomy at a single institution for uveitis-associated ocular hypertension or glaucoma with an open angle.

METHODS

We performed a retrospective chart review of all patients with uveitis-associated ocular hypertension or glaucoma who underwent KDB goniotomy with trabecular meshwork excision alone or in combination with phacoemulsification cataract surgery at a single center between August 2017 and February 2020. The case series included 45 eyes of 37 patients. All eyes developed ocular hypertension refractory to maximum-tolerated medical therapy and required surgical intervention. Two eyes were excluded as they were lost to follow-up before 5 months postoperatively. Surgical success was defined as reaching the goal intraocular pressure or lower for each patient, including ongoing medical therapy.

RESULTS

At most recent follow-up, 25 (55.6%) of 45 eyes had an intraocular pressure that was at goal. Mean follow-up time was 15.2±12.1 months ranging from 0.5 to 36 months postoperatively, considering that patients were eliminated from the data analysis once they required a second surgery. The mean number of preoperative medications, including oral carbonic anhydrase inhibitors was 3.7±1.2 medications. The mean number of postoperative medications through the last clinic visit was 2.5±1.9 medications for a mean reduction of 1.2±1.6 medications ( P -value <0.0001*).

CONCLUSIONS

This larger case series shows that some patients with uveitis-associated ocular hypertension or glaucoma with an open angle may have success with KDB goniotomy.

Risk factors for secondary Glaucoma in patients with Vogt-Koyanagi-Harada disease

BACKGROUND/PURPOSE

Identify the prevalence and risk factors for secondary glaucoma among Mexican-mestizo patients with Vogt-Koyanagi-Harada Disease (VKH).

METHODS

Retrospective cohort study analyzing the demographic, clinical, and epidemiological variables. Risk estimates were calculated using a Cox proportional hazards regression model.

RESULTS

One hundred eyes of 50 patients, 44 (88%) women and 6 men (12%) with a median age of 35.5 years (IQR 29-46) and a median follow-up time of 72 months (IQR 13.7-126.7) were analyzed. The prevalence of glaucoma was 20%, with angle-closure accounting for 70% of all cases. Significant clinical risk factors for glaucoma development were a chronic recurrent stage at presentation (RR 2.88, 95% CI 1.11-12.63, p = 0.037), ≥ 2 episodes of recurrent anterior uveitis (RR 8.52, 95% CI 2.02-35.92, p < 0.001), angle-closure disease (ACD, RR 7.08, 95% CI 2.44-20.48, p < 0.001), iris bombé (RR 5.0, 95% CI 2.10-11.90, p < 0.001), and peripapillary atrophy (RR 3.56, 95% CI 1.43-8.85, p < 0.001). Exposure to > 24 months of oral (RR 9.33, 95% CI 2.21-39.28, p < 0.001) or > 12 months of topical corticosteroids (RR 3.88, 95% CI 1.31-11.46, p = 0.007) were associated with an increased likelihood for secondary glaucoma development.

CONCLUSION

Glaucoma is a frequent complication of VKH, often attributed to mixed pathogenic mechanisms. Chronic disease at presentation, recurrent inflammation, angle-closure mechanisms, iris bombé, and peripapillary atrophy represent clinically significant risk factors for developing secondary glaucoma. Prompt and aggressive steroid-spearing immunosuppressive therapy for adequate inflammation control may lower the risk of glaucoma in VKH.

Outcomes of Microhook ab Interno Trabeculotomy in Consecutive 36 Eyes with Uveitic Glaucoma

Microhook trabeculotomy (μLOT), recently developed by Tanito belongs to minimally invasive glaucoma surgery and contributes to intraocular pressure (IOP) control in eyes with glaucoma resistant to medical therapy. In this study, we aimed to investigate the effectiveness and safety of μLOT for uveitic glaucoma. The medical records of consecutive 36 eyes from 30 patients who underwent μLOT and were followed up over post-operative 1 year were reviewed. The surgical success (IOP = 5–20 mmHg and ΔIOP ≥ 20% with additional anti-glaucoma drugs) was achieved in 67% of eyes at post-operative 12 months. The median IOP significantly decreased from 30.5 mmHg pre-operatively to 15 mmHg at 12 months post-operatively (p = 0.001), and the median glaucoma drug score changed from 5 pre-operatively to 2.5 at 12 months post-operatively (p = 0.301). Intraocular inflammation scores at post-operative 6 weeks did not show a significant worsening as compared to pre-operatively, and 8 (22%) eyes exhibited exacerbation of inflammation during the 12-month follow-up period. Post-operative complications were confirmed in 58% of eyes, but most of them were mild and transient or successfully managed. With its favorable benefit–risk profile, μLOT would be an option worth considering as the first glaucoma surgery for uveitic glaucoma.

Risk of Elevated Intraocular Pressure With Difluprednate in Patients With Non-Infectious Uveitis

PURPOSE

To evaluate the risk factors associated with clinically important intraocular pressure (IOP) elevation with topical difluprednate treatment in patients with non-infectious uveitis.

DESIGN

Retrospective cohort study.

METHODS

Fifty-four eyes of 54 patients with non-infectious uveitis treated with topical difluprednate at the current institution were included. Demographics and clinical characteristics of uveitis patients were collected. The main outcome measure was development of clinically important IOP elevation defined as IOP ≥21 mmHg and an increase of ≥10 mmHg from baseline.

RESULTS

A clinically important IOP elevation was observed in 17 patients (31.5%). The mean time to clinically important IOP elevation was 7.4±4.8 weeks (range 3-19). Statistically significant risk factors for incident clinically important IOP elevation were being a child (adjusted hazard ratio [aHR] 7.85 [95% CI 1.48-41.56], P = .02) and concurrent use of systemic steroids (aHR 5.31 [95% CI 1.18-24.00], P = .03). Patients with concurrent systemic corticosteroids developed clinically important IOP elevation earlier than those without systemic corticosteroid (mean 5.7±3.4 [range 3-14] vs 10.4±5.7 [range 4-19] weeks, P = .05). Incident IOP ≥30 mmHg occurred in 7 patients (13.0%). All patients responded well to the cessation of difluprednate and/or use of topical antiglaucomatous agents and no eyes required glaucoma surgery.

CONCLUSIONS

This study demonstrated that clinically important IOP elevation is common in uveitis patients with topical difluprednate treatment. Children and patients with concurrent systemic corticosteroids are at substantial risk of developing clinically important IOP elevation.

Gonioscopy-assisted transluminal trabeculotomy is an effective surgical treatment for uveitic glaucoma

BACKGROUND

To assess the efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in uveitic glaucoma (UG).

METHODS

A retrospective interventional case series in which 33 eyes of 32 patients with UG underwent GATT with or without concomitant cataract extraction and intraocular lens implantation (CE/IOL) at three Canadian treatment centres from October 2015 to 2020. The main outcome measure was surgical success defined as an intraocular pressure (IOP) ≤18 mm Hg and at least one of the following: IOP within one mm Hg of baseline on fewer glaucoma medications as compared with baseline or a 30% IOP reduction from baseline on the same or fewer medications. Secondary outcome measures were IOP, medication usage and surgical complications.

RESULTS

Mean patient age (mean±SD) was 49±16 years (range: 18-79) and 44% were female. GATT was performed as a standalone procedure in 52% of cases and the remainder were combined with CE/IOL. Surgical success was achieved in 71.8% (SE: 8.7%) of cases. Mean preoperative IOP (±SD) was 31.4±10.8 mm Hg on a median of 4 medications. 59% of patients were on oral carbonic anhydrase inhibitors (CAIs) prior to surgery. After 1 year, average IOP was 13.8 mm Hg on a median 1 medication, with 6% of patients being on oral CAIs. No sight threatening complications occurred during surgery or follow-up.

CONCLUSION

GATT is an effective surgical strategy in the management of UG. This microinvasive conjunctival-sparing procedure should be considered early in these patients.

Elevated Cytokine Levels in Aqueous Humor Are Associated with Peripheral Anterior Synechiae after Penetrating Keratoplasty

Peripheral anterior synechiae (PAS) after corneal transplantation leads to refractory glaucoma and permanent loss of vision. However, the exact mechanism remains elusive. This study aimed to evaluate the association between cytokine levels in the aqueous humor (AqH) and the progression of PAS after penetrating keratoplasty (PKP). We measured 20 cytokine levels in AqH and assessed the correlation with PAS progression after PKP in 85 consecutive patients who underwent PKP. We also evaluated age-dependent alterations in PAS and cytokine levels in DBA2J mice. PAS developed in 38 (44.7%) of 85 eyes after PKP. The incidence of intraocular pressure increase after PKP was significantly greater in eyes with PAS (26.3%) than in those without PAS (2%, p = 0.0009). The PAS area at 12 months after PKP was significantly positively correlated with the preoperative levels of interleukin (IL)-6, interferon (IFN)-γ and monocyte chemotactic protein (MCP)-1 (p ≤ 0.049). In the DBA2J mice, an experimental glaucoma model that developed PAS at 50 weeks, the AqH levels of IL-2, IL-6, IL-10, IFN-γ, tumor necrosis factor-α, MCP-1 and granulocyte-macrophage colony-stimulating factor (GM-CSF) significantly increased at 50 weeks compared to 8 weeks (p ≤ 0.021). In conclusion, inflammatory alterations in the AqH microenvironment, such as high preoperative specific cytokine levels, can lead to PAS formation and glaucoma.

Aqueous Cytokine Levels Are Associated With Progression of Peripheral Anterior Synechiae After Descemet Stripping Automated Endothelial Keratoplasty

Purpose

To evaluate the association between total protein and cytokine levels in aqueous humor (AqH) and the progression of peripheral anterior synechiae (PAS) after Descemet stripping automated endothelial keratoplasty (DSAEK).

Methods

This prospective study included 146 consecutive patients who underwent DSAEK. Preoperative levels of total protein and 20 cytokines in AqH were measured. Using three-dimensional anterior segment optical coherence tomography, we assessed the iridotrabecular contact (ITC) area before and at 3, 6, and 12 months after DSAEK. Correlations between the total protein and cytokine levels in the AqH and ITC area were analyzed.

Results

ITC was observed in 47 eyes (32.2%) after DSAEK. The ITC area increased from 2.00 ± 4.42 mm² preoperatively to 3.00 ± 6.85 mm² at 12 months. The total protein level in AqH was significantly higher in eyes with ITC progression than in those without (1.45 ± 1.03 mg/mL vs. 1.00 ± 0.57; P = 0.04) and was significantly positively correlated with the progression of ITC area after DSAEK (at 6 months, r = 0.311 and P = 0.005; at 12 months, r = 0.342 and P = 0.0004). The ITC area at 12 months was significantly correlated with the preoperative AqH levels of interleukin-8 (r = 0.252; P = 0.021), interferon-γ (r = 0.318; P = 0.009), and soluble intercellular adhesion molecule-1 (r = 0.292; P = 0.004). Multivariate analyses showed that the total protein levels in AqH and the presence of preoperative ITC were significant risk factors for increased ITC area after DSAEK (β = 0.193–0.574; all P < 0.02).

Conclusions

Higher preoperative total protein and specific cytokine levels in AqH were associated with ITC formation after DSAEK.

Translational Relevance

Our findings indicate that chronic pathological changes in AqH can cause PAS progression and glaucoma after DSAEK.

High rate of conversion from ocular hypertension to glaucoma in subjects with uveitis

AIMS

To examine presentation, management and long-term sequelae of ocular hypertension and uveitic glaucoma.

METHODS

Retrospective observational study of all subjects with uveitic glaucoma or ocular hypertension seen in Auckland uveitis clinics over the last 10 years.

RESULTS

A total of 188 eyes of 139 subjects with uveitic glaucoma or ocular hypertension were included for analysis. Total follow-up was 1854.5 eye years (mean 9.9 years). The mean age at uveitis diagnosis was 49.3 years. 52.5% of subjects were male. The most common diagnoses were idiopathic uveitis (29.3%), sarcoidosis (13.3%), herpes zoster (6.9%), HLA-B27 uveitis (6.9%), tuberculosis (5.9%) and Posner-Schlossmann or cytomegalovirus (CMV) uveitis (5.3%). Median intraocular pressure (IOP) at diagnosis was 35 mm Hg (IQR 29-45). 144 eyes (77.0%) developed glaucoma during the follow-up period, of whom 41 lost some central vision due to glaucoma. Oral acetazolamide was required for IOP control in 64.5%, 50 eyes underwent trabeculectomy, 18 eyes required a tube and 6 underwent minimally invasive glaucoma surgery.

CONCLUSION

Rapid progression was observed from ocular hypertension to uveitic glaucoma. Uveitic glaucoma is aggressive, with high likelihood of requiring surgical management and high risk of central vision loss. Close collaboration between uveitis and glaucoma specialists is required to maximise outcomes for these patients.

Characterization of Peripheral Anterior Synechiae Formation After Microhook Ab-interno Trabeculotomy Using a 360-Degree Gonio-Camera

Purpose

To investigate the prevalence, locations, and characteristics of peripheral anterior synechiae (PAS) formation after microhook ab-interno trabeculotomy (µLOT), a minimally invasive glaucoma surgery, using a 360-degree gonio-camera, gonioscope GS-1 (NIDEK Co., Gamagori, Japan).

Subjects and Methods

A total of 105 consecutive eyes of 75 subjects with open-angle glaucoma were analyzed. The eyes had undergone µLOT or combined µLOT and cataract surgery as an initial glaucoma surgery. Postoperative PAS formation was evaluated in 16 iridocorneal angle images with the best focus covering 360 degrees in each eye.

Results

Compared to baseline, at 225±226 days postoperatively, the intraocular pressure and number of antiglaucoma medications decreased significantly (p<0.01, respectively). PAS developed in 86% of eyes. The mean number of iridocorneal angle images that showed PAS in all eyes was 4.1 (26%) in the total circumference, 3.1 (39%) within the µLOT incision, and 1.0 (13%) outside of the µLOT incision; the rate was significantly (p<0.0001) higher within the incision than outside of the incision. Moreover, the higher total PAS rate and that within the incision may be associated with later postoperative days (p=0.01 and 0.004, respectively), that outside of the incision with µLOT alone rather than the combined surgery, and with shallower preoperative central anterior chamber depth (p=0.048 and 0.04, respectively), calculated by the mixed-effect model.

Conclusion

The current results showed the characteristics of PAS formation after µLOT using 360-degree gonio-images, and the formation rate was significantly higher within the µLOT incision. The PAS within and outside of the incision had different causes.

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.

Incidence and Outcome of Uveitic Glaucoma in Eyes With Intermediate, Posterior, or Panuveitis Followed up to 10 Years After Randomization to Fluocinolone Acetonide Implant or Systemic Therapy

PURPOSE

To evaluate long-term risk and outcomes of glaucoma in eyes with intermediate, posterior, and panuveitis managed with systemic or fluocinolone acetonide (0.59 mg, "implant") therapy.

DESIGN

Prospective Follow-up of the Multicenter Uveitis Steroid Treatment (MUST) Clinical Trial Cohort.

METHODS

Patients with intermediate, posterior, or panuveitis randomized to implant or systemic therapy (corticosteroid plus immunosuppression in >90%) were followed prospectively for glaucoma incidence and outcome.

RESULTS

Among 405 uveitic at-risk eyes of 232 patients (median follow-up = 6.9 years), 40% (79/196) of eyes assigned and treated with implant and 8% (17/209) of eyes assigned and treated with systemic therapy (censoring eyes receiving an implant on implantation) developed glaucoma (hazard ratio [HR] = 5.9, 95% confidence interval [CI] 3.2, 10.8; P < .001). Adjustment for intraocular pressure (IOP) elevation during follow-up only partially mitigated the association of implant treatment with glaucoma incidence: HR = 3.1 (95% CI 1.6, 6.0); P = .001. Among 112 eyes of 83 patients developing glaucoma, the 5-year cumulative incidence following diagnosis of sustained (2 or more consecutive visits) worsening of mean deviation by ≥6 dB was 20% (95% CI 12%, 33%); 5-year cumulative incidence of sustained worsening of cup-to-disc ratio by ≥0.2 was 26% (95% CI 17%, 39%).

CONCLUSIONS

The implant has substantially higher risk of glaucoma than systemic therapy, a difference not entirely explained by posttreatment IOP elevation. Management of IOP elevation was effective in preventing worsening of glaucoma for the large majority of cases, but even under expert clinical management, some glaucoma worsened. Uveitis cases should be monitored carefully for IOP elevation and glaucoma indefinitely.

Prevalence, risk factors and management of ocular hypertension or glaucoma in patients with Vogt-Koyanagi-Harada disease

BACKGROUND/AIMS

This study was performed to examine the prevalence, risk factors and treatment outcome of OHT/glaucoma in Chinese patients with Vogt-Koyanagi-Harada (VKH).

METHODS

Retrospective non-interventional case series were conducted on a total of 2281 patients with VKH referred from April 2008 to April 2019. Of these cases, 1457 had a minimum follow-up period of 3 months and were included for this study. Medical records were reviewed for demographic, ocular and treatment data.

RESULTS

Among 2914 eyes of 1457 patients with VKH, 695 (23.9%) eyes of 425 patients (29.2%) developed OHT/glaucoma. The risk factors of OHT/glaucoma included initial BCVA of 20/200 or worse (OR=4.826), final best-corrected visual acuity (BCVA) of 20/50-20/100 (OR=5.341) and final BCVA of 20/200 or worse (OR=4.235), the interval between uveitis attack and referral time interval being 2 months or more (OR=3.318), more than three recurrent episodes (OR=4.177) and posterior synechiae (OR=1.785). The main possible mechanisms of OHT/glaucoma were inflammatory factor-induced open-angle OHT/glaucoma in 277 eyes (39.9%) and pupillary block arising from complete posterior synechiae in 201 eyes (28.9%). In these 695 eyes with OHT/glaucoma, normalised intraocular pressure (IOP) was achieved in 389 eyes (56.0%) following medical treatment. In the remaining 306 eyes, various surgical interventions were performed and a normalised IOP could be achieved in 249 eyes (81.4%).

CONCLUSION

OHT/glaucoma is a common complication in Chinese patients with VKH. Risk factors of OHT/glaucoma included worse acuity at first and final visits, the longer interval between uveitis attack and referral, more recurrent episodes and posterior synechiae.

Outcome and risk of ocular complications of managing children with chronic anterior uveitis with topical rimexolone 1

PURPOSE

To investigate the efficacy and safety of 1% rimexolone ophthalmic suspension in children with chronic anterior uveitis under real-life conditions in a tertiary center.

METHODS

This is a retrospective longitudinal study. Medical records were analyzed at baseline, 1, 3, 6 and 12 months before and after switching to rimexolone for best-corrected visual acuity (BCVA), oral steroid use, number of flares, IOP and anti-glaucoma management.

RESULTS

Twenty-four patients (41 eyes) diagnosed with either anterior uveitis (n = 25, 60.0%) or panuveitis (n = 16, 40%) were enrolled. The mean age was 10.5 years (4-16 years). The number of patients requiring oral prednisolone reduced from 8 patients (32.0%) at baseline to 3 patients (20.0%) at 12 months (P < 0.001). Following baseline, the median number of uveitis flares reduced from 2.0 (inter-quartile range (IQR) 1.0-2.75) to 1.0 (IQR 0.0-1.0) compared to the 12 months before baseline (P < 0.001). The mean IOP reduced from baseline (22.0 ± 7.3 mmHg) to 1 month (18.8 ± 8.7 mmHg, P = 0.01) and remained stable up to 12 months (15.9 ± 5.0 mmHg, P < 0.001). Average BCVA, dose of oral prednisolone and anti-glaucoma treatments did not change compared to the baseline. The development for IOP ≥ 30 mmHg was associated with a known corticosteroid response [odds ratio (OR) 6.8, P = 0.003] and a dose > 7.5 mg/day oral prednisolone (OR 4.4, P = 0.033).

CONCLUSIONS

Rimexolone 1% ophthalmic suspension is an effective and safe topical steroid for pediatric anterior uveitis.

Aqueous Humor Dynamics in Uveitic Eyes

PURPOSE

To investigate aqueous humor dynamics in uveitic eyes.

DESIGN

Cross-sectional study.

PARTICIPANTS

Patients with recurrent (≥3 attacks) anterior uveitis (now quiescent) and being treated for glaucoma or ocular hypertension (OHT) (Group 1), previous recurrent anterior uveitis (≥3 attacks) without glaucoma or OHT (Group 2), and normal subjects with no ocular problems and IOP < 21 mm Hg at screening (control group; Group 3).

METHODS

Patients had one-off measurements. Group 1 patients who were on antihypertensives were washed out for a 4-week period, prior to their study measurements. Main outcome measures were tonographic outflow facility, aqueous humor flow rate, and uveoscleral outflow.

RESULTS

One hundred and one patients were screened between February 2014 and February 2017. Nine patients did not meet the inclusion criteria. Groups 1 and 3 each included 30 patients, and Group 2 included 32 patients. The mean intraocular pressure was higher in Group 1 compared to the others (25 ± 10.2 mm Hg in Group 1 vs 16 ± 2.7 mm Hg in Group 2 vs 16 ± 2.2 mm Hg in Group 3, P < .001). The tonographic outflow facility was lower in Group 1 compared to the others (0.18 ± 0.1 μL/min/mm Hg in Group 1 vs 0.25 ± 0.1 μL/min/mm Hg in Group 2 vs 0.27 ± 0.1 μL/min/mm Hg in Group 3, P = .005). However, aqueous humor flow rate was not statistically different (2.47 ± 0.9 μL/min in Group 1 vs 2.13 ± 0.9 μL/min in Group 2 vs 2.25 ± 0.7 μL/min in Group 3, P = .3). There was also no significant difference in calculated uveoscleral outflow.

CONCLUSION

This is the first aqueous humor dynamics study in patients with uveitic glaucoma/OHT and recurrent anterior uveitis compared with age-matched controls. We have demonstrated that the elevated intraocular pressure seen in the uveitic glaucoma/OHT eyes (3-6 attacks) was due to reduced tonographic outflow facility. The aqueous humor flow rate was not detectibly different, nor did the calculated uveoscleral outflow demonstrate any discernible difference. However, the exact mechanism remains to be elucidated.

[Registry-based research in ophthalmology]

Medical registries and registry studies are frequently used for health services research as they represent a valuable means of capturing real-life data. Registry studies are particularly suitable for rare diseases for which epidemiological population-based or randomized controlled clinical studies are difficult. The are many examples of successful medical registries that have not only contributed to both epidemiological and clinical research, but which have also improved health service delivery. Only few ophthalmological medical registries are currently available. For non-infectious uveitis in children and adolescents with juvenile idiopathic arthritis (JIA), a rare disease entity, there is a need for data on, e.g., treatment, long-term outcomes, and risk factors for progression. The advantages for this disease of a registry with uveitis module from which numerous scientific publications and guidelines have been derived has been proven. Thus, we use the example of non-infectious uveitis to discuss the benefits of registries for other areas of ophthalmology.