Macular ischaemia in Behçet's disease

Macular Cone Abnormalities in Behçet's Disease Detected by Adaptive Optics Scanning Light Ophthalmoscope

BACKGROUND AND OBJECTIVE

Investigations of morphological changes in photoreceptors in Behçet's disease (BD) using adaptive optics scanning light ophthalmoscope (AOSLO) are lacking. The authors aimed to evaluate macular cone density and regularity in BD patients with or without a history of uveitis with good visual acuity (VA).

PATIENTS AND METHODS

The authors included 16 patients (29 eyes) with BD and 12 healthy volunteers (12 eyes) as controls. All subjects had VA of 20/20 or higher. Subjects underwent AOSLO to evaluate the photoreceptor status including cone density (numbers/mm²) and proportion of hexagonal Voronoi domains.

RESULTS

Hyporeflective patches that were not detected in color fundus photograph or optical coherence tomography were observed by AOSLO in BD patients both with and without past uveitis history; these were not detected in the control group. Cone density was significantly reduced in BD patients with a history of uveitis compared to controls (P = .002). The proportion of hexagonal Voronoi domains was significantly reduced in BD eyes both with and without history of uveitis relative to controls (P < .001).

CONCLUSION

Macular photoreceptor damage was observed in BD patients with and without a history of uveitis. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:218-225.].

The role of fundus autofluorescence imaging in the study of the course of posterior uveitis disorders

BACKGROUND

To evaluate the correlation of fundus autofluorescence (FAF) with indocyanine green angiography (ICGA) in patients with various posterior uveitis disorders.

METHODS

Interventional case series including 23 eyes of 15 patients with diagnosis of a specific type of retinochoroiditis, such as acute posterior multifocal placoid pigment epitheliopathy (APMPPE), serpiginous-like choroiditis, multifocal choroiditis (MFC), Harada disease, and syphilitic retinochoroiditis. Also, some cases with undefined retinochoroiditis were included. FAF and ICGA were performed and correlated at baseline and during follow-up after treatment.

RESULTS

In ICGA, early hypofluorescence was found to be the hallmark of acute choroidal inflammation, resolving in later stages and remaining in the late phase in areas with retinal pigment epithelium (RPE) damage. Poorly defined hyperautofluorescent areas correlated with acute choroidal lesions. Hypoautofluorescent delineation suggested the initiation of RPE healing processes, correlating well with the late phase of ICGA and delineating the RPE damage. Early hyperautofluorescence with late hypofluorescence in ICGA indicated the presence of primary RPE involvement.

CONCLUSION

FAF contributes to the interpretation of RPE disease and may be a useful tool for the follow-up of progressive inflammatory disorders. Comparative evaluation of FAF and ICGA allows a characterization of the sequence of inflammatory events and the level of tissue affected.

Macular involvement in patients with Behçet's uveitis

PURPOSE

The purpose of this study is to assess macular involvement in patients with Behçet's uveitis.

METHODS

The study included 65 patients (120 eyes) with Behçet's uveitis. All patients underwent detailed ophthalmic examination, including dilated biomicroscopic fundus examination, fundus photography, fluorescein angiography, and optical coherence tomography. Follow-up ranged from 6 to 46 months (mean 20 months).

RESULTS

At initial examination, 29 eyes (24.1 %) had macular involvement including macular edema (16 eyes, 13.3 %), serous retinal detachment (SRD; five eyes, 4.1 %), active retinitis (three eyes, 2.5 %), macular hole (three eyes, 2.5 %), macular atrophy (two eyes, 1.6 %), macular ischemia (one eye, 0.8 %), epiretinal membrane (one eye, 0.8 %), branch retinal vein occlusion involving the macula (three eyes, 2.5 %), and branch retinal artery occlusion involving the macula (two eyes, 1.6 %). During follow-up, 22 eyes (18.3 %) developed macular complications including macular edema (ten eyes, 8.3 %), SRD (four eyes, 3.3 %), active retinitis (two eyes, 1.6 %), severe macular atrophy (two eyes, 1.6 %), macular ischemia (three eyes, 2.5 %), macular hole (one eye, 0.8 %), epiretinal membrane (two eyes, 1.6 %), and subretinal fibrosis (one eye, 0.8 %). Branch retinal vein occlusion involving the macula developed in two eyes (1.6 %). Final best corrected visual acuity in patients with macular involvement ranged from 20/400 to 20/25 (mean 20/80).

CONCLUSIONS

Macular edema and other vision-threatening macular complications are common in Behçet's uveitis. Macular damage is often irreversible, causing permanent visual impairment. Early and appropriate treatment of Behçet's uveitis is mandatory to reduce the risk of visual impairment due to macular involvement.

Macular hole in Behçet's disease

Objective:

To investigate the clinical features, prevalence, role of surgical intervention and the visual prognosis of macular holes (MH) in patients with Behcet's disease (BD).

Materials and Methods:

Retrospective study of patients with BD and MH from January 1998 to November 2008.

Results:

Out of 159 patients, 21 eyes of 17 patients were identified with MH. The mean age was 38.59 (range 23-61) years and the mean follow-up period was 5.1 years (range 13-164 months). The prevalence of MH was 7%. Visual acuity (VA) at the time of presentation ranged from 20/70 to hand-motion. Optical coherence tomography (OCT) findings revealed intraretinal cysts at the edge of the MH. The mean size of MH was 983.6 um; 52% had elevated edges, 43% had flat edges and only one eye (5%) was closed postoperatively. Fluorescein angiography (FA) was consistent with macular ischemia in 76% of the cases. Human leukocyte antigen (HLA) B51 association was found in 14 of the 15 patients investigated. Six patients (out of 17) underwent pars plana vitrectomy. The final VA on their last follow-up ranged from 20/70 to 2/200. Surgical intervention for MH did not result in any visual improvement as compared to non-operated eyes. One patient lost vision completely due to elevated intraocular pressure post vitrectomy and silicon oil tamponade.

Conclusions:

MH in patients with BD may lead to significant visual disability. Surgical intervention does not seem to have any potential beneficial effect on the VA, probably due to significant macular ischemia and sequelae from the ocular inflammation.

Functional and morphological changes in the eyes of Behçet's patients with uveitis

PURPOSE

Behçet's disease (BD) is a chronic, recurrent, multisystem disorder, and serious ocular involvement may lead to blindness. In some BD patients, latent tissue damage caused by recurrent ocular inflammation is not reflected by visual acuity or ophthalmoscopic findings. In this study, we evaluated the morphological and functional changes of ocular features related to duration of uveitis from onset in BD patients, and analysed their association with visual acuity.

METHODS

Thirty-eight eyes of 20 patients with ocular BD were enrolled. Eyes with marked complications such as cataract, glaucoma, cystoid macular oedema, macular degeneration and optic atrophy were excluded from the study. During clinical remission of ocular inflammation, perimetric sensitivity and retinal thickness were measured by Micro Perimeter 1 (MP-1) and optical coherence tomography (OCT), respectively. The relationship between MP-1 and OCT findings, best-corrected visual acuity (BCVA) converted to logarithm of the minimum angle of resolution (logMAR) and duration from initial onset of uveitis were analysed statistically.

RESULTS

logMAR correlated with perimetric sensitivity measured with MP-1 at the fovea, inner macula and outer macula, but not with retinal thickness based on OCT. The duration of uveitis correlated significantly with logMAR and with OCT-based retinal thickness at the fovea, inner macular and outer macula, but not with MP-1-derived retinal perimetric sensitivity. No correlation was found between OCT-based retinal thickness and the corresponding MP-1-derived retinal sensitivity at the fovea, inner macula or outer macula.

CONCLUSION

These results demonstrate that visual acuity, retinal perimetric sensitivity and retinal thickness decrease with an increase in the duration of uveitis in BD patients, but that retinal perimetric sensitivity is relatively preserved among these factors.

Fluorescein and indocyanine green angiography for uveitis

In recent years enormous progress has been achieved in investigational procedures for uveitis. Imaging is one such example with the advent of new methods such as indocyanine green angiography, ultrasound biomicroscopy and optical coherence tomography to cite only the most important. This tremendous increase in precision and accuracy in the assessment of the level and degree of inflammation and its monitoring comes in parallel with the development of extremely potent and efficacious therapies. In view of these developments, our whole attitude in the appraisal and investigation of the uveitis patient has to be adapted and correctly reoriented integrating the recent developments and this is no different for ocular angiography.

ORIGINAL ARTICLE Indocyanine Green and Fundus Fluorescein Angiographic Findings in Patients with Active Ocular Behçet's Disease

PURPOSE

To define the indocyanine green (ICG) and fundus fluorescein angiographic (FFA) features of Behçet's disease.

METHODS

The study included 49 eyes of 25 patients (19 males, 6 females; mean age: 34.1 years; age range: 14-68 years) with Behçet's disease and active ocular involvement that fulfilled the criteria of the International Study Group for Behçet's Disease. In each patient, FFA and ICG angiography were performed consecutively in the same session using a TRC-50I/A fundus camera (Topcon, Tokyo, Japan) coupled to an Image Net digitizing system. All images were analyzed and FFA, ICG, and clinical findings summarized.

RESULTS

The mean duration of ocular involvement was 52.4 months (range: 2-240 months). FFA showed staining and dye leakage at the optic disc in 44 (89.8%) eyes and diffuse vasculitis in 36 (73.5%) eyes. Macular edema and ischemia were observed in 31 (63.3%) and 3 (6.1%) eyes, respectively. Eight (16.3%) eyes exhibited detectable retinal FFA alterations, but no abnormalities on ICG angiography. Disc ICG hyperfluorescence was observed in 23 (46.9%) eyes. ICG angiography revealed choroidal fuzziness in 16 (32.6%) eyes, hyperfluorescent spots in 13 (26.5%) eyes, and hypofluorescent plaques in 12 (24.5%) eyes. Eleven eyes (22.4%) showed no abnormal findings on ICG angiography.

CONCLUSION

ICG and FFA complement each other as tools for diagnosing patients with Behçet's disease. FFA often serves as a fairly reliable guide. Although some ICG findings cannot be demonstrated by FFA, they are not specific or pathognomonic. We do not recommend performing both procedures for Behçet's disease.

Uveitic foveal atrophy: clinical features and associations

OBJECTIVE

To characterize foveal atrophy in a heterogeneous group of patients with uveitis using clinical findings and high-definition (HD) optical coherence tomography (OCT).

DESIGN

Cross-sectional, retrospective case series.

RESULTS

The HD-OCT scans of 140 patients seen in a tertiary referral center were reviewed and 23 patients (33 eyes) with foveal atrophy were identified. All of the patients with foveal atrophy were diagnosed with intermediate uveitis, posterior uveitis, or panuveitis. The status of the photoreceptor layer as visualized with HD-OCT was associated with significant differences in mean visual acuity (P < .001). Clinical findings associated with foveal atrophy included atrophy of the retinal pigment epithelium and choroid (30 eyes [91%]), macular ischemia (13 eyes [39%]), cystoid macular edema (5 eyes [15%]), choroidal neovascularization (4 eyes [12%]), retinal detachment involving the macula (2 eyes [6%]), and serum antiretinal antibodies (2 eyes [6%]).

CONCLUSIONS

Foveal atrophy can be a complication of intraocular inflammation in a variety of uveitic syndromes. The cause of foveal atrophy is multifactorial and may include dysfunction and atrophy of the retinal pigment epithelium and choroid, cystoid macular edema, macular ischemia secondary to occlusive retinal vasculitis, choroidal neovascularization, retinal detachment, and possibly antibody-mediated damage directed against photoreceptors. Careful observation of the photoreceptor layer using HD-OCT may help to identify patients who are at risk for visual loss secondary to foveal atrophy.

Macular Hole in Behcet's Disease

Behcet's disease is an inflammatory disorder of unknown cause, characterized by recurrent oral aphthous ulcers, genital ulcers, uveitis, and skin lesions. Ocular involvement occurs in 60-80% of patients with Behcet's disease and presents as panuveitis in most cases. Posterior segment involvement may lead to irreversible alterations and significant vision loss. The development of a partial or full-thickness macular hole, though rarely reported, may cause serious vision loss. In this report, we present two cases of macular hole in the worse eye of bilateral cases of Behcet's disease, and discuss the possible mechanisms and management in such cases.

Aqueous humor nitric oxide levels in patients with Behçet disease

PURPOSE

The purpose of this study was to quantify aqueous humor nitric oxide levels in patients with Behçet uveitis and age-matched controls to assess how nitric oxide is involved in this ocular condition.

METHODS

Samples of aqueous humor were collected from 11 patients with Behçet uveitis who were undergoing cataract surgery. Sampling was done by paracentesis at the beginning of the operation. Similar samples were collected from 20 age-matched normal patients (controls). For each sample, we used the spectrophotometric method based on the Griess reaction to determine the amount of nitrite, which is the stable metabolite of nitric oxide.

RESULTS

The amount of nitrite in aqueous humor samples from patients with Behçet disease was above the detection limit in 8 of 11 cases; the mean level +/- SEM was 2.13 +/- 0.621 micromol/L. Levels in the control group were below the detection limit in all cases (<0.08 micromol/L). There was a statistically significant difference between the aqueous humor nitrite levels in patients with Behçet disease and those in controls (P = 0.00002).

CONCLUSIONS

Aqueous humor nitric oxide levels are elevated in patients with a history of Behçet disease.