Risk factors for cystoid macular oedema in patients with uveitis

Frequency and Treatment Regimens of Macular Edema in 1946 Consecutive Patients with Noninfectious Uveitis at a Tertiary Ophthalmic Center in Shaanxi, China

INTRODUCTION

We investigated the frequency of uveitic macular edema (UME) in patients with different types of noninfectious uveitis and present the primary treatment methods for UME at a specialized eye center in Shaanxi Province, China.

METHODS

We conducted a retrospective, noninterventional, observational survey involving 1946 patients with noninfectious uveitis (2816 eyes). The collected data included sex, age of uveitis onset, age of UME onset, anatomical classification of uveitis, and the treatment administered to UME patients.

RESULTS

Of the 1946 patients with noninfectious uveitis, 929 (47.74%) were male and 1017 (52.26%) were female. The average age of all participants in the study was 42.19 ± 15.34 years, with average age at uveitis onset of 39.50 ± 15.52 years. Among the patients, 1003 (51.54%), 239 (12.28%), 410 (21.07%), and 294 (15.11%) had anterior uveitis, intermediate uveitis, posterior uveitis, and panuveitis, respectively. UME was observed in 134 (6.89%) of the uveitis patients. The average age of UME patients was 47.33 ± 17.17 years, with average age at uveitis onset of 45.78 ± 17.20 years. Out of the 134 UME patients, 3 (0.30%), 15 (6.28%), 47 (11.46%), and 69 (23.47%) had anterior uveitis, intermediate uveitis, posterior uveitis, and panuveitis, respectively. Among them, 37 were lost to follow-up, 44 received adalimumab (ADA) combined with low-dose prednisone and with or without conventional immunosuppressants, 19 received interferon-α2a therapy, 14 received intravitreal corticosteroid injections (such as dexamethasone implant or fluocinolone acetonide), 11 received low-dose corticosteroids combined with conventional immunosuppressants, 5 received only oral prednisone, and 4 received repeated peribulbar or subconjunctival injections of triamcinolone acetonide.

CONCLUSIONS

At our tertiary ophthalmic center in Shaanxi Province, China, only 6.89% of patients with noninfectious uveitis were diagnosed with UME. The primary treatment modality for UME in our center is ADA, in accordance with treatment guidelines and the Chinese medical insurance reimbursement system.

Risk factors for the development of macular edema in children with uveitis

Aim

To determine the risk factors for macular edema (ME) in children with uveitis.

Methods

A retrospective study was conducted of 150 pediatric patients (264 eyes) with uveitis attending 2 tertiary medical centers. Data were collected from the medical files on demographics, type of uveitis, etiology, clinical findings, treatment, and time to development of ME. Risk factors for the development of ME were identified.

Results

ME developed in 63 eyes (23.9%) over a mean period of 15.3 ± 2.95 months from diagnosis of uveitis, at a rate of 0.08 eyes per eye-year. On univariate analysis, risk factors for the development of ME were the non-anterior location of the inflammation (p=0.002), band keratopathy (p <0.0001), posterior synechiae (p=0.003), cataract (p=0.002), and vision impairment at presentation (p <0.0001). On multivariate analysis, non-anterior uveitis, which includes intermediate, pan, and posterior-uveitis, and vision impairment retained significance as independent risk factors of ME.

Conclusion

Within the pediatric population with uveitis, non-anterior location is associated with the highest risk of ME, followed by the presence of complications, such as band keratopathy and posterior synechiae. These findings indicate a need for close follow-up in children with uveitis for early detection of ME.

Medical Therapy of Uveitic Macular Edema: Biologic Agents

Introduction: Uveitic macular edema (UME) is a significant cause of visual impairment in all uveitis types. Methods: Reports that were cited in the MEDLINE database, that analyzed the effectiveness of biologics for UME in at least five patients, with a minimum follow-up of 3 months, published prior to April 1, 2019 were included. Reports that did not compare UME findings before and after the therapy, using either OCT or fluorescein angiography, were excluded. Results: Case series that analyzed the efficacy of intravitreal anti-VEGF agents showed modest, short-term benefit. Studies that investigated systemic anti-TNF agents in patients with noninfectious uveitis reported a therapeutic effect on UME. Anti-IL-6 antibodies have shown promising results for most severe cases of noninfectious UME. Interferon represents an option for patients with persistent UME in infectious and noninfectious uveitis. Conclusion: Multicenter, randomized controlled trials are needed to assess the effectiveness of each group of biologic agents in sufficient number of patients.

Characteristics of retinal layer thickness in acute anterior uveitis: an optical coherence tomography study

PURPOSE

To determine the changes in peripapillary retinal nerve fiber layer (pRNFL), macular and ganglion cell-inner plexiform layer (GC-IPL) thicknesses in patients with acute anterior uveitis (AAU).

METHODS

Patients diagnosed with unilateral non-infectious AAU and normal control were enrolled retrospectively. Optical coherence tomography scans were performed during the initial active phase and inactive phase of AAU. Patients were followed for at least 3 months after resolution of inflammatory activity.

RESULTS

Thirty-seven AAU patients and 40 controls were included. The average RNFL and central macular thickness (CMT) showed significant differences between patients and control groups during active phase (p < 0.001 and p = 0.022, respectively). The average pRNFL thicknesses of affected eyes and fellow eyes during the active phase were 109.4 ± 12.5 μm and 96.5 ± 8.0 μm, respectively (p < 0.001). During the inactive phase, the average thicknesses were 99.3 ± 8.9 μm and 97.0 ± 7.5, respectively; they were not significantly different (p = 0.236). The CMTs of affected and fellow eyes during the active phase were 261.6 ± 24.7 μm and 251.5 ± 17.3 μm, respectively; the difference was significant (p = 0.047). The average GC-IPL thicknesses of affected and fellow eyes were not significantly different (p = 0.061).

CONCLUSIONS

The pRNFL and central macula thickened during the active phase of AAU and decreased to a similar degree with fellow eyes during the inactive phase. Additionally, pRNFL thickness showed a sensitive response to the degree of inflammation in AAU. This suggests that pRNFL thickness may be useful in assessing disease activity.

Macular Abnormalities in Vogt-Koyanagi-Harada Disease

Purpose: To investigate the prevalence of macular abnormalities in Chinese Vogt-Koyanagi-Harada (VKH) patients.Methods: Clinical characteristics, therapeutic effectiveness and visual outcome were reviewed and analyzed.Results: The most common macular abnormality was macular edema (ME), followed by macular choroidal neovascularization (CNV). Macular abnormalities were associated with recurrent episodes, disease course and visual acuity ≤20/50 at first visit. The prevalence of macular abnormalities in patients who were not treated according to our regular treatment regimen with corticosteroids combined with immunosuppressive agents and who were followed-up for at least one year (13.1%) was significantly higher than in patients receiving the regular treatment (5.7%). Visual improvement was found in 66.7% of eyes with macular abnormalities after regular treatment.Conclusion: Macular abnormalities were associated with recurrent uveitis, course of disease and lower visual acuity at first visit. Regular treatment could prevent the development of macular abnormalities and improved visual outcome in most patients.

Uveitic Macular Edema: Treatment Update

The aim of this review is to summarize recent developments in the treatment of uveitic macular edema (ME). ME represent a major cause of visual loss in uveitis and adequate management is crucial for the maintenance of useful vision in patients with chronic uveitis.

Topical difluprednate monotherapy for uveitic macular edema

OBJECTIVE

To describe the use of topical difluprednate for the treatment of uveitic macular edema.

DESIGN

Retrospective review of 3 consecutive cases of uveitic macular edema.

METHODS

Patients were treated with topical difluprednate monotherapy.

RESULTS

All patients experienced complete resolution of uveitic macular edema within 2-4 weeks. We observed a statistically significant improvement in central subfield macular thickness (p = 0.04). There was an overall improvement in visual acuity, but this result was not statistically significant (p = 0.33).

CONCLUSIONS

Topical difluprednate can be effective for uveitic macular edema. Further investigation of this therapy in prospective randomized controlled trials is warranted.

Updates in uveitic macular edema

Macular edema is one of the most common vision-threatening complications of uveitis noted in one third of patients with uveitis. The release of a number of inflammatory mediators induces retinal vascular hyperpermeability leading to uveitic macular edema (UME) which most commonly is of cystoid shape. Fluorescein angiography and non-invasive spectral-domain optical coherence tomography are standard procedures for diagnosis and follow-up of UME with some innovations such as scanning laser ophthalmoscope retro-mode imaging. Effective management of UME requires thorough understanding of the individual case. Proper control of intraocular inflammation is mandatory before targeting macular edema itself. Mainstay of treatment is immunosuppressive therapy with various drug delivery routes including topical, local subconjunctival, peribulbar and sub-Tenon’s, intravitreal and systemic. Clinical trials with biologics are under way to study the efficacy of these agents in suppressing intraocular inflammation and resolution of UME. Visual prognosis in UME depends on numerous factors. Younger age and better visual acuity at baseline are associated with more favorable visual outcome in most studies

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.

Long-term follow-up of inflammatory cystoid macular edema

PURPOSE

To determine the long-term functional and anatomical outcome of idiopathic uveitic cystoid macular edema (UCME).

METHODS

A longitudinal retrospective study was undertaken of the medical records of patients with UCME. All individuals were examined in the uveitis Service at the Moorfields Eye Hospital. The main outcome measures were change in visual acuity and anatomical outcome of UCME at diverse time points.

RESULTS

A total of 109 eyes (92 patients) with UCME were included in the analysis. Mean follow-up was 60 ± 45 months (median, 48 months). Mean logarithm of the minimum angle of resolution visual acuity 1 month after the intervention improved significantly (P < 0.001) by 0.21 ± 0.27 and maintained at similar levels throughout the follow-up period. Visual acuity at the final follow-up improved in 75 eyes (69%), was deteriorated in 21 eyes (19%), and remained unchanged in 13 eyes (12%). Younger age and better visual acuity at baseline were associated with more favorable visual outcome (P < 0.001). Optical coherence tomography documentation of improvement or total resolution of UCME was observed in 84 eyes (77%) at the final follow-up.

CONCLUSION

Cystoid macular edema is a major complication in uveitis. Current management provides satisfactory long-term results for the majority of those individuals. Visual acuity 1 month after the intervention is usually indicative of the final functional outcome.

The impact of macular edema on visual function in intermediate, posterior, and panuveitis

PURPOSE

To evaluate the impact of macular edema on visual acuity and visual field sensitivity in uveitis.

DESIGN

This study utilized baseline data from the Multicenter Uveitis Steroid Treatment (MUST) Trial, a randomized, parallel treatment clinical trial comparing alternative treatments for intermediate, posterior and panuveitis.

PATIENTS & METHODS

255 patients (481 eyes with uveitis) recruited at 23 subspecialty centers. Visual acuity, optical coherence tomography and Humphrey 24-2 visual field testing.

RESULTS

Macular edema was associated with impaired visual acuity (p < 0.01). Different phenotypes of macular edema were associated with different degrees of visual impairment: cystoid changes without retinal thickening were associated with moderately impaired visual acuity (-5 ETDRS letters), but visual acuity was worse in eyes with retinal thickening (-13 letters) and with both cysts and thickening (-19 letters). Uveitis sufficient to satisfy the study's inclusion criteria was associated with impaired visual field sensitivity, but eyes with macular edema had even worse visual field sensitivity (p < 0.01).

CONCLUSIONS

The observation that macular edema substantially reduces visual function suggests macular edema itself is an important endpoint to study in the treatment of uveitis. As uveitis and macular edema both impair visual field sensitivity as measured by Humphrey 24-2 perimetry, both should be considered when evaluating patients with uveitis and raised intraocular pressure for glaucoma.

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.