Phacoanaphylaxis in Behçet's disease

Risk factors, clinical features and treatment of Behçet's disease uveitis

Behçet's disease is a systemic vasculitis frequently associated with intraocular inflammation. Recent findings identified independent clinical clusters in Behçet's disease, each involving distinct combinations of affected organs. Ocular Behçet's disease, mainly manifested as uveitis, is characterized as an independent cluster with a low likelihood of association with other system involvements, such as intestinal, cardiovascular, or central nervous system. A prevailing theory suggests that the pathogenesis of the disease is multifactorial, where a variety of genetic and infectious agents may interact with each other to cause the disease. Among sporadic cases, the human leukocyte antigen (HLA) genes, including HLA-B51, HLA-A26, HLA-B15, and HLA-B5701, have been found to be a key component conferring genetic susceptibility. Outside the HLA region, a set of susceptibility variants are identified, closely related to interleukin (IL)-23/IL-17 pathway, tumor necrosis factor (TNF) signaling, and pattern recognition receptor systems. Microbial infections, such as Streptococcus sanguinis, Mycobacterium tuberculosis, and Herpes simplex virus (HSV), are linked to play the triggering of disease in immunogenetically predisposed individuals. Clinically, due to the notable relapsing-remitting course of ocular Behçet's disease, the prevention of recurrent attack would be the primary treatment goal. Combination of corticosteroids and immunomodulatory drugs, such as anti-TNF agents, interferon, and conventional immunosuppressants (e.g. cyclosporine, azathioprine), have been the mainstream regimen for the disease. Future research may focus on comparing the effectiveness of immunomodulatory drugs and identifying the most suitable subgroups for a specific drug on the basis of the knowledge of the molecular heterogeneity of the disease.

Coexisting Phacoanaphylaxis and Choroidal Melanoma: An Unusual Intraocular Inflammation

PURPOSE

To describe an unusual case of panuveitis in coexisting choroidal melanoma and phacoanaphylaxis.

METHODS

Clinical records of the patient with intraocular melanoma and pathologic findings of the affected eye were reviewed. Composition of inflammatory infiltrates involving the tumor and lens was evaluated immunohistochemically.

RESULTS

Histologically, tumor showed a choroidal mixed cell type malignant melanoma with infiltration of inflammatory cells. The globe also showed typical features of phacoanaphylaxis, characterized by disruptions of the lens capsule with zonal granulomatous inflammation. The inflammatory infiltration revealed the predominant presence of both cytotoxic T cells and histiocytes in phacoanaphylaxis and intra-tumoral inflammation.

CONCLUSIONS

The current clinico-pathologic case report suggests that a long standing intraocular melanoma can present with phacoanaphylaxis. The immunophenotype of the inflammatory infiltrates at both sites, lens and the tumor, is similar, cytotoxic T cells and histiocytes, favoring a common immune inflammatory process directed at the tumor and the lens.

Visual aspects of behçet’s disease

Behçet's disease is a systemic vasculitis characterized by recurrent oral and genital ulcers and ocular inflammation. The disease may also involve the joints, skin, central nervous system, the lungs, and gastrointestinal tract. Ocular manifestations include anterior uveitis, posterior uveitis, macular edema, retinal vasculitis, conjunctival ulcers, optic neuropathy, papilledema, secondary glaucoma, cataract, and neovascularization of iris or retina. The cause of Behçet's disease is unknown, but autoimmune and genetic factors are considered important in its pathogenesis. Promising new imaging techniques and treatments are available to provide better management for patients. This review focuses on recent data on visual aspects, pathogenesis, and the treatment of Behçet's disease.

Vitrectomy in the treatment of uveitis

PURPOSE

To assess the evidence that pars plana vitrectomy (PPV) is useful in improving vision, reducing disease activity, or ameliorating cystoid macular edema (CME) in patients with uveitis.

DESIGN

Review of the literature.

METHODS

A Medline search was conducted for relevant articles published in English, German, or French. Articles were analyzed for content and evidence level.

RESULTS

A total of 44 interventional case series published between 1981 and 2005 were identified that included 1575 patients (1762 eyes). Evidence level was grade CII-3 indicating possibly improved clinical outcomes with fair or poor evidence. The average age of patients was 36 years with a median duration of uveitis before surgery of 48 months and a median follow-up of 1.9 years. Intermediate uveitis was present in 841 eyes. Cystoid macular edema and cataract were common co-morbidities, and there were large numbers of additional surgical procedures. Visual outcomes in 39 articles were stated as improved in 708 eyes (68%), unchanged in 202 eyes (20%), and worsened in 124 eyes (12%). Reduction in systemic medication following PPV was reported in 25 studies. The median reported percentage of patients per study with CME was 36% preoperatively and 18% postoperatively.

CONCLUSIONS

Based on the evidence in the literature, PPV is possibly relevant to the outcomes of improving vision and reducing inflammation and CME. Randomized, controlled, collaborative trials or hypothesis-based case series with precise outcome measures that incorporate control groups would improve the quality of evidence supporting PPV as an adjunct to the medical treatment of uveitis.

Visual aspects of BehÇet’s disease

Behçet's disease is a systemic vasculitis characterized by recurrent oral and genital ulcers and ocular inflammation. The disease may also involve the joints, skin, central nervous system, the lungs, and gastrointestinal tract. Ocular manifestations include anterior uveitis, posterior uveitis, macular edema, retinal vasculitis, conjunctival ulcers, optic neuropathy, papilledema, secondary glaucoma, cataract, and neovascularization of iris or retina. The cause of Behçet's disease is unknown but autoimmune and genetic factors are considered important in its pathogenesis. Promising new imaging techniques and treatments are available to provide better management for patients. This review focuses on recent data on visual aspects, pathogenesis, and the treatment of Behçet's disease.

Trabeculectomy with Mitomycin-C in Uveitic Glaucoma Associated with Beh??et Disease

PURPOSE

To determine the effect of intraoperative application of Mitomycin-C (MMC) with trabeculectomy in uveitic glaucoma associated with Behçet disease.

MATERIALS AND METHODS

Twenty-six eyes of 26 patients with uveitic glaucoma associated with Behçet disease who underwent trabeculectomy with MMC between 1996 and 2001 were reviewed in this retrospective, noncomparative study. Trabeculectomy + MMC in concentration of 0.4 mg/mL for 3 minutes was performed to all patients. Main outcome measures were control of IOP, the number of antiglaucoma medications required to achieve the desired IOP, visual acuity and complications. The surgical success was defined as IOP less than 22 mm Hg and greater than 5 mm Hg without additional further glaucoma surgery or loss of light perception.

RESULTS

The cumulative probability of success was 83.3% at 1 year, 76.2% at 2 years, 70% at 3 years, 66.7% at 4 years and 62.5% at 5 years after surgery. The mean follow-up was 40.0+/-18.0 months. At last follow-up 23% of the patients required no antiglaucoma medications. Best-corrected visual acuity improved or remained within two lines of preoperative visual acuity in 19 eyes (73.1%). Glaucomatous (1 eye 3.8%) and nonglaucomatous optic atrophy (3 eyes 11.5%) was the most frequent reason for visual decrease (total 4 eyes 15.2%). The most common complications were cataract formation in 6 eyes (23.1%), bleb leakage in 4 eyes (15.3%) and choroidal effusion in 3 eyes (11.5%). Phthisis bulbi was found in one (3.8%) patient.

CONCLUSION

Trabeculectomy and intraoperative application of MMC appears to provide long term safety and effectiveness in uveitic glaucoma associated with Behçet disease.