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Beltrán Catalán E, Brito García N, Pato Cour E, Muñoz Fernández S, Gómez Gómez A, Díaz Valle D, Hernández Garfella M, Francisco Hernández FM, Trujillo Martín MDM, Silva Fernández L, Villanueva G, Suárez Cuba J, Blanco R. SER recommendations for the treatment of uveitis. REUMATOLOGIA CLINICA 2023; 19:465-477. [PMID: 37839964 DOI: 10.1016/j.reumae.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/12/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVE To develop evidence-based expert-consensus recommendations for the management of non-infectious, non-neoplastic, non-demyelinating disease associated uveitis. METHODS Clinical research questions relevant to the objective of the document were identified, and reformulated into PICO format (patient, intervention, comparison, outcome) by a panel of experts selected based on their experience in the field. A systematic review of the available evidence was conducted, and evidence was graded according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria. Subsequently, recommendations were developed. RESULTS Three PICO questions were constructed referring to uveitis anterior, non-anterior and complicated with macular edema. A total of 19 recommendations were formulated, based on the evidence found and/or expert consensus. CONCLUSIONS Here we present the first official recommendations of the Spanish Society of Rheumatology for the treatment of non-infectious and non-demyelinating disease associated uveitis. They can be directly applied to the Spanish healthcare system as a tool for assistance and therapeutic homogenisation.
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Affiliation(s)
| | - Noé Brito García
- Unidad de Investigación, Sociedad Española de Reumatología, Madrid, Spain.
| | | | - Santiago Muñoz Fernández
- Servicio de Reumatología, Hospital Universitario Infanta Sofía. Universidad Europea de Madrid, Madrid, Spain
| | | | - David Díaz Valle
- Unidad de Inflamación Ocular, Hospital Clínico San Carlos, Madrid, Spain
| | | | | | | | - Lucía Silva Fernández
- Servicio de Reumatología, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | | | - Julio Suárez Cuba
- Servicio de Reumatología, Hospital Universitario Príncipe de Asturias, Madrid, Spain
| | - Ricardo Blanco
- Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Cantabria, Spain
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Schmickl CN, Owens RL, Orr JE, Edwards BA, Malhotra A. Side effects of acetazolamide: a systematic review and meta-analysis assessing overall risk and dose dependence. BMJ Open Respir Res 2021; 7:7/1/e000557. [PMID: 32332024 PMCID: PMC7204833 DOI: 10.1136/bmjresp-2020-000557] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 02/22/2020] [Accepted: 02/29/2020] [Indexed: 02/04/2023] Open
Abstract
Introduction Acetazolamide (AZM) is used for various conditions (eg, altitude sickness, sleep apnoea, glaucoma), but therapy is often limited by its side effect profile. Our objective was to estimate the risk of commonly reported side effects based on meta-analyses. We hypothesised that these risks are dose-dependent. Methods We queried MEDLINE/EMBASE (Medical Literature Analysis and Retrieval System Online/Excerpta Medica dataBASE) up until 04/10/2019, including any randomised placebo-controlled trial in which adults received oral AZM versus placebo reporting side effects. Eligibility assessment was performed by two independent reviewers. Data were abstracted by one reviewer who verified key entries at a second time point. For side effects reported by >3 studies a pooled effect estimate was calculated, and heterogeneity assessed via I2; for outcomes reported by >5 studies effect modification by total daily dose (EMbyTDD; <400 mg/d, 400–600 mg/d, >600 mg/d) was assessed via meta-regression. For pre-specified, primary outcomes (paraesthesias, taste disturbances, polyuria and fatigue) additional subgroup analyses were performed using demographics, intervention details, laboratory changes and risk of bias. Results We included 42 studies in the meta-analyses (Nsubjects=1274/1211 in AZM/placebo groups). AZM increased the risk of all primary outcomes (p<0.01, I2 ≤16% and low-to-moderate quality of evidence for all)—the numbers needed to harm (95% CI; nStudies) for each were: paraesthesias 2.3 (95% CI 2 to 2.7; n=39), dysgeusia 18 (95% CI 10 to 38, n=22), polyuria 17 (95% CI 9 to 49; n=22), fatigue 11 (95% CI 6 to 24; n=14). The risk for paraesthesias (beta=1.8 (95% CI 1.1 to 2.9); PEMbyTDD=0.01) and dysgeusia (beta=3.1 (95% CI 1.2 to 8.2); PEMbyTDD=0.02) increased with higher AZM doses; the risk of fatigue also increased with higher dose but non-significantly (beta=2.6 (95% CI 0.7 to 9.4); PEMbyTDD=0.14). Discussion This comprehensive meta-analysis of low-to-moderate quality evidence defines risk of common AZM side effects and corroborates dose dependence of some side effects. These results may inform clinical decision making and support efforts to establish the lowest effective dose of AZM for various conditions.
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Affiliation(s)
- Christopher N Schmickl
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Robert L Owens
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Jeremy E Orr
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Clayton, Victoria, Australia.,School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Clayton, Victoria, Australia
| | - Atul Malhotra
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
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Pepple KL, Nguyen MH, Pakzad-Vaezi K, Williamson K, Odell N, Lee C, Leveque TK, Van Gelder RN. RESPONSE OF INFLAMMATORY CYSTOID MACULAR EDEMA TO TREATMENT USING ORAL ACETAZOLAMIDE. Retina 2019; 39:948-955. [PMID: 29346240 PMCID: PMC6047935 DOI: 10.1097/iae.0000000000002044] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE To determine the treatment effect of oral acetazolamide on refractory inflammatory macular edema. METHODS A retrospective review of identified patients with uveitic or pseudophakic macular edema treated using acetazolamide between 2007 and 2014. Visual acuity and central macular subfield thickness was determined at baseline and at first follow-up. Baseline optical coherence tomography features were analyzed as predictors of acetazolamide response. RESULTS Sixteen patients (19 eyes) of 61 screened met all criteria. Mean age was 57.9 years (19.7-81.1). The most common diagnosis was idiopathic uveitis (n = 6, 31.6%). Mean uveitis duration was 4.4 years (0.2-27.5). Average central macular subfield thickness decreased significantly (from 471.8 ± 110.6 μm to 358.3 ± 50.4 μm) (P < 0.0001). Average visual acuity (logarithm of the minimum angle of resolution) improved significantly from 20/54 (0.43 ± 0.25) to 20/37 (0.27 ± 0.16) (P = 0.003). Pretreatment optical coherence tomographies demonstrated intraretinal fluid (n = 19, 100%), subretinal fluid (n = 8, 42.1%), epiretinal membrane (n = 13, 68.3%), and vitreomacular traction (n = 1, 5.2%). No optical coherence tomography characteristic was predictive of a response to therapy. CONCLUSION There is a significant benefit to vision and central macular subfield thickness after acetazolamide treatment in patients with inflammatory macular edema. In patients with refractory inflammatory macular edema, treatment using acetazolamide can provide anatomical and visual benefit without corticosteroid-related adverse effects.
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Affiliation(s)
- Kathryn L. Pepple
- University of Washington, Department of Ophthalmology, Seattle, Washington, USA
| | - Macklin H. Nguyen
- University of Washington, Department of Ophthalmology, Seattle, Washington, USA
| | - Kaivon Pakzad-Vaezi
- University of Washington, Department of Ophthalmology, Seattle, Washington, USA
| | - Kathleen Williamson
- University of Washington, Department of Ophthalmology, Seattle, Washington, USA
| | - Naomi Odell
- University of Washington, Department of Ophthalmology, Seattle, Washington, USA
| | - Cecilia Lee
- University of Washington, Department of Ophthalmology, Seattle, Washington, USA
| | - Thellea K. Leveque
- University of Washington, Department of Ophthalmology, Seattle, Washington, USA
| | - Russell N. Van Gelder
- University of Washington, Department of Ophthalmology, Seattle, Washington, USA
- University of Washington, Department of Biological Structure, Seattle, Washington USA
- University of Washington, Department of Pathology, Seattle, Washington USA
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Tallouzi MO, Moore DJ, Barry RJ, Calvert M, Mathers J, Murray PI, Denniston AK. The Effectiveness of Pharmacological Agents for the Treatment of Uveitic Macular Edema (UMO): A Systematic Review. Ocul Immunol Inflamm 2019; 27:658-680. [PMID: 30811272 DOI: 10.1080/09273948.2019.1569243] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Purpose: To conduct a systematic review of effectiveness of pharmacological therapies for treatment of Uveitic Macular Edema (UMO). Method/Design: Comparative studies of pharmacological therapies in patients with UMO were identified in Cochrane CENTRAL/MEDLINE/EMBASE/CINAHL/trials registers (February 2017). PROSPERO registration: CRD42015019170. Results: Thirty-one studies were included. Corticosteroids were the most frequently studied (n = 20). Corticosteroids (all forms) were consistently of greater/equal efficacy to active comparators; for anti-VEGF (n = 4) improvement, best-corrected visual acuity (BCVA) and central macular thickness (CMT) were mostly less than local corticosteroid injection; for interferon (n = 1) improvement BCVA and CMT were greater than the comparator of methotrexate; for topical indomethacin (n = 1) improvement, BCVA and CMT were greater than placebo. Non-steroidal anti-inflammatory drugs, carbonic anhydrase inhibitors, and vitamin E (n = 5) were not effective for these outcomes. Conclusion: The review highlights areas where the evidence base is still lacking, and appropriately focused trials are needed to inform best treatment to tackle this sight-threatening condition.
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Affiliation(s)
- Mohammad O Tallouzi
- a Academic Unit of Ophthalmology, Institute of Applied Health Research, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK.,b Centre for Patient Reported Outcome Research, Institute of Applied Health Research, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK
| | - David J Moore
- c Institute of Applied Health Research, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK
| | - Robert J Barry
- d Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK
| | - Melanie Calvert
- b Centre for Patient Reported Outcome Research, Institute of Applied Health Research, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK.,c Institute of Applied Health Research, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK
| | - Jonathan Mathers
- b Centre for Patient Reported Outcome Research, Institute of Applied Health Research, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK.,c Institute of Applied Health Research, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK
| | - Philip I Murray
- d Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK
| | - Alastair K Denniston
- b Centre for Patient Reported Outcome Research, Institute of Applied Health Research, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK.,e Department of Ophthalmology, Queen Elizabeth Hospital Birmingham , University Hospitals Birmingham NHS Foundation Trust , Birmingham , UK
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Koronis S, Stavrakas P, Balidis M, Kozeis N, Tranos PG. Update in treatment of uveitic macular edema. DRUG DESIGN DEVELOPMENT AND THERAPY 2019; 13:667-680. [PMID: 30858697 PMCID: PMC6387597 DOI: 10.2147/dddt.s166092] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Macular edema (ME) represents the most common cause for visual loss among uveitis patients. The management of uveitic macular edema (UME) may be challenging, due to its often recalcitrant nature. Corticosteroids remain the mainstay of treatment, through their capability of effectively controlling inflammation and the associated ME. Topical steroids may be effective in milder cases of UME, particularly in edema associated with anterior uveitis. Posterior sub-Tenon and orbital floor steroids, as well as intravitreal steroids often induce rapid regression of UME, although this may be followed by recurrence of the pathology. Intra-vitreal corticosteroid implants provide sustained release of steroids facilitating regression of ME with less frequent injections. Topical nonsteroidal anti-inflammatory drugs may provide a safe alternative or adjuvant therapy to topical steroids in mild UME, predominantly in cases with underlying anterior uveitis. Immunomodulators including methotrexate, mycophenolate mofetil, tacrolimus, azathioprine, and cyclosporine, as well as biologic agents, notably the anti-tumor necrosis factor-α monoclonal antibodies adalimumab and infliximab, may accomplish the control of inflammation and associated ME in refractory cases, or enable the tapering of steroids. Newer biotherapies have demonstrated promising outcomes and may be considered in persisting cases of UME.
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Squires H, Poku E, Bermejo I, Cooper K, Stevens J, Hamilton J, Wong R, Denniston A, Pearce I, Quhill F. A systematic review and economic evaluation of adalimumab and dexamethasone for treating non-infectious intermediate uveitis, posterior uveitis or panuveitis in adults. Health Technol Assess 2018; 21:1-170. [PMID: 29183563 DOI: 10.3310/hta21680] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Non-infectious intermediate uveitis, posterior uveitis and panuveitis are a heterogeneous group of inflammatory eye disorders. Management includes local and systemic corticosteroids, immunosuppressants and biological drugs. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of subcutaneous adalimumab (Humira®; AbbVie Ltd, Maidenhead, UK) and a dexamethasone intravitreal implant (Ozurdex®; Allergan Ltd, Marlow, UK) in adults with non-infectious intermediate uveitis, posterior uveitis or panuveitis. DATA SOURCES Electronic databases and clinical trials registries including MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and the World Health Organization's International Clinical Trials Registry Platform were searched to June 2016, with an update search carried out in October 2016. REVIEW METHODS Review methods followed published guidelines. A Markov model was developed to assess the cost-effectiveness of dexamethasone and adalimumab, each compared with current practice, from a NHS and Personal Social Services (PSS) perspective over a lifetime horizon, parameterised with published evidence. Costs and benefits were discounted at 3.5%. Substantial sensitivity analyses were undertaken. RESULTS Of the 134 full-text articles screened, three studies (four articles) were included in the clinical effectiveness review. Two randomised controlled trials (RCTs) [VISUAL I (active uveitis) and VISUAL II (inactive uveitis)] compared adalimumab with placebo, with limited standard care also provided in both arms. Time to treatment failure (reduced visual acuity, intraocular inflammation, new vascular lesions) was longer in the adalimumab group than in the placebo group, with a hazard ratio of 0.50 [95% confidence interval (CI) 0.36 to 0.70; p < 0.001] in the VISUAL I trial and 0.57 (95% CI 0.39 to 0.84; p = 0.004) in the VISUAL II trial. The adalimumab group showed a significantly greater improvement than the placebo group in the 25-item Visual Function Questionnaire (VFQ-25) composite score in the VISUAL I trial (mean difference 4.20; p = 0.010) but not the VISUAL II trial (mean difference 2.12; p = 0.16). Some systemic adverse effects occurred more frequently with adalimumab than with placebo. One RCT [HURON (active uveitis)] compared a single 0.7-mg dexamethasone implant against a sham procedure, with limited standard care also provided in both arms. Dexamethasone provided significant benefits over the sham procedure at 8 and 26 weeks in the percentage of patients with a vitreous haze score of zero (p < 0.014), the mean best corrected visual acuity improvement (p ≤ 0.002) and the percentage of patients with a ≥ 5-point improvement in VFQ-25 score (p < 0.05). Raised intraocular pressure and cataracts occurred more frequently with dexamethasone than with the sham procedure. The incremental cost-effectiveness ratio (ICER) for one dexamethasone implant in one eye for a combination of patients with unilateral and bilateral uveitis compared with limited current practice, as per the HURON trial, was estimated to be £19,509 per quality-adjusted life-year (QALY) gained. The ICER of adalimumab for patients with mainly bilateral uveitis compared with limited current practice, as per the VISUAL trials, was estimated to be £94,523 and £317,547 per QALY gained in active and inactive uveitis respectively. Sensitivity analyses suggested that the rate of blindness has the biggest impact on the model results. The interventions may be more cost-effective in populations in which there is a greater risk of blindness. LIMITATIONS The clinical trials did not fully reflect clinical practice. Thirteen additional studies of clinically relevant comparator treatments were identified; however, network meta-analysis was not feasible. The model results are highly uncertain because of the limited evidence base. CONCLUSIONS Two RCTs of systemic adalimumab and one RCT of a unilateral, single dexamethasone implant showed significant benefits over placebo or a sham procedure. The ICERs for adalimumab were estimated to be above generally accepted thresholds for cost-effectiveness. The cost-effectiveness of dexamethasone was estimated to fall below standard thresholds. However, there is substantial uncertainty around the model assumptions. In future work, primary research should compare dexamethasone and adalimumab with current treatments over the long term and in important subgroups and consider how short-term improvements relate to long-term effects on vision. STUDY REGISTRATION This study is registered as PROSPERO CRD42016041799. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Hazel Squires
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Edith Poku
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Inigo Bermejo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Katy Cooper
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Stevens
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Ian Pearce
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Fahd Quhill
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Abstract
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.
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Affiliation(s)
- Raquel Goldhardt
- Assistant Professor of Clinical Ophthalmology, University of Miami Miller School of Medicine, Bascom Palmer Eye Institute
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Bilateral Subretinal Fluid Mimicking Subretinal Neovascularization Within 24 Hours After Selective Laser Trabeculoplasty. J Glaucoma 2016; 25:e110-4. [DOI: 10.1097/ijg.0000000000000259] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Turan-Vural E, Halili E, Serin D. Assessing the effects of ketorolac and acetazolamide on macular thickness by optical coherence tomography following cataract surgery. Int Ophthalmol 2015; 34:525-31. [PMID: 24022643 DOI: 10.1007/s10792-013-9847-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 08/14/2013] [Indexed: 11/28/2022]
Abstract
We aimed to evaluate the efficacy of topical ketorolac 0.5 % solution and oral acetazolamide 250 mg/day delivery during the first month after uneventful phacoemulsification surgery by measuring the macular thickness using optical coherence tomography. Our nonmasked randomized prospective study comprised 87 eyes of 80 patients. Complete follow-up was achieved on 84 eyes of 77 eligible patients. Postoperatively, the patients were divided into three groups. One group received ketorolac 0.5 %, the other group received acetazolamide 250 mg/day, and the control group was given no agent. Macular thickness and volume were measured at 1 week and 1 month after surgery by optical coherence tomography. Foveal thickness, parafoveal thickness, and perifoveal thickness were determined to be significantly elevated at postoperative 1 week and 1 month in the control group. Foveal, perifoveal, and parafoveal volumes were also significantly high at postoperative week 1 and month 1 in the control group. There was no significant difference between the ketorolac and acetazolamide groups. The correlation analysis between best-corrected visual acuity, and volume and thickness revealed a negative correlation in the acetazolamide group. Use of acetazolamide after cataract surgery is as effective as ketorolac on macular thickness and volume.
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Karim R, Sykakis E, Lightman S, Fraser-Bell S. Interventions for the treatment of uveitic macular edema: a systematic review and meta-analysis. Clin Ophthalmol 2013; 7:1109-44. [PMID: 23807831 PMCID: PMC3685443 DOI: 10.2147/opth.s40268] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Uveitic macular edema is the major cause of reduced vision in eyes with uveitis. Objectives To assess the effectiveness of interventions in the treatment of uveitic macular edema. Search strategy Cochrane Central Register of Controlled Trials, Medline, and Embase. There were no language or data restrictions in the search for trials. The databases were last searched on December 1, 2011. Reference lists of included trials were searched. Archives of Ophthalmology, Ophthalmology, Retina, the British Journal of Ophthalmology, and the New England Journal of Medicine were searched for clinical trials and reviews. Selection criteria Participants of any age and sex with any type of uveitic macular edema were included. Early, chronic, refractory, or secondary uveitic macular edema were included. We included trials that compared any interventions of any dose and duration, including comparison with another treatment, sham treatment, or no treatment. Data collection and analysis Best-corrected visual acuity and central macular thickness were the primary outcome measures. Secondary outcome data including adverse effects were collected. Conclusion More results from randomized controlled trials with long follow-up periods are needed for interventions for uveitic macular edema to assist in determining the overall long-term benefit of different treatments. The only intervention with sufficiently robust randomized controlled trials for a meta-analysis was acetazolamide, which was shown to be ineffective in improving vision in eyes with uveitic macular edema, and is clinically now rarely used. Interventions showing promise in this disease include dexamethasone implants, immunomodulatory drugs and anti-vascular endothelial growth-factor agents. When macular edema has become refractory after multiple interventions, pars plana vitrectomy could be considered. The disease pathophysiology is uncertain and the course of disease unpredictable. As there are no clear guidelines from the literature, interventions should be tailored to the individual patient.
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Affiliation(s)
- Rushmia Karim
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia
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Suzuki T, Hayakawa K, Nakagawa Y, Onouchi H, Ogata M, Kawai K. Topical dorzolamide for macular edema in the early phase after vitrectomy and epiretinal membrane removal. Clin Ophthalmol 2013; 7:549-53. [PMID: 23620653 PMCID: PMC3633550 DOI: 10.2147/opth.s42188] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background The purpose of this study was to evaluate prospectively the efficacy of a topical carbonic anhydrase inhibitor in macular edema after vitrectomy. Methods Forty patients were included, all of whom had undergone vitrectomy combined with phacoemulsification and intraocular lens implantation for epiretinal membrane. Twenty eyes from 40 patients received topical 2% dorzolamide three times a day. The patients were followed up for at least 3 months. In this study, we evaluated the effect of dorzolamide on visual acuity, intraocular pressure, central macular thickness, and aqueous flare. Results Mean logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity preoperatively and 2 weeks, 1 month, and 3 months after surgery was 0.48 ± 0.23, 0.60 ± 0.16, 0.40 ± 0.29, and 0.24 ± 0.32, respectively, in the treatment group, and 0.40 ± 0.09, 0.44 ± 0.12, 0.32 ± 0.10, and 0.16 ± 0.09, respectively, in the control group. No statistically significant difference was observed between the two groups. Mean central macular thickness preoperatively and at 2 weeks and 3 months after surgery was 572.6, 427.2, and 333.4 μm, respectively, in the treatment group, and 571.4, 485.2, and 388.4 μm, respectively, in the control group. Mean aqueous flare preoperatively, and 1 month and 3 months after surgery was 8.6, 34.2, and 23.5 photon counts per millisecond (pc/ms), respectively, in the treatment group, and 9.7, 24.7, and 23.4 pc/ms, respectively, in the control group. No statistically significant differences were observed between data from the two groups. However, statistically significant (P < 0.05) differences in mean central macular thickness at 1 month and mean aqueous flare at 2 weeks after surgery were found between the treatment group (358.8 μm, 36.8 pc/ms) and the control group (467.8 μm, 64.0 pc/ms). Differences in mean intraocular pressure preoperatively and at 2 weeks, 1 month, and 3 months after surgery were not statistically significant between the two groups. Intraocular pressure never exceeded 21 mmHg. Conclusion Topical dorzolamide significantly reduced mean central macular thickness at 1 month and mean aqueous flare at 2 weeks after surgery for epiretinal membrane compared with controls. Although further investigation of more cases and longer follow-up are needed, this study suggests that topical dorzolamide can be efficacious in reducing macular edema in the early phase after vitrectomy via its anti-inflammatory effect.
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Affiliation(s)
- Takahiro Suzuki
- Department of Ophthalmology, Tokai University School of Medicine, Isehara, Japan
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Suttorp-Schulten MS, Jager MJ, Kijlstra A. Recent developments in the treatment of posterior uveitis. Ocul Immunol Inflamm 2012; 4:207-17. [PMID: 22827460 DOI: 10.3109/09273949609079654] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Uveitis is an intraocular inflammation that can be caused by infection, autoimmune disease, trauma or malignancy. It is a serious cause of visual handicap and therapy is targeted at: removal of possible infectious agents, the immunological processes that lead to or sustain the inflammation and finally to prevent or treat the destructive effects of the inflammation on the delicate ocular structures. In this review the latest developments concerning the treatment of posterior uveitis are illuminated, e. g., new approaches concerning the treatment of infectious uveitis including the therapy of herpes virus (VZV, HSV and CMV), bacterial and toxoplasma infections of the eye. Several new ways to influence the immune response and inflammation are described including the use of interferons, modulation of cytokines, soft steroids, other new immunosuppressive drugs and treatment of autoimmune uveitis by oral tolerization. An overview is given to illustrate new ways to administer drugs into eyes, such as intravitreal devices. Finally new developments in the field of the treatment of the various complications of uveitis (cystoid macular edema) are described.
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Koo NK, Kim YC. A case of paclitaxel-induced maculopathy treated with methazolamide. KOREAN JOURNAL OF OPHTHALMOLOGY 2012; 26:394-7. [PMID: 23060729 PMCID: PMC3464326 DOI: 10.3341/kjo.2012.26.5.394] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 03/02/2011] [Indexed: 11/23/2022] Open
Abstract
A 54-year-old female patient who had been undergoing anti-cancer chemotherapy and radiotherapy for seven years after surgery for left breast cancer visited our clinic for visual disturbance in the right eye at nine months after paclitaxel administration. The best-corrected visual acuity was 0.5 in the right eye and 1.0 in the left eye. The patient was diagnosed with maculopathy due to paclitaxel administration based on the finding of cystoid macular edema in the right eye on fundus examination and optical coherence tomography; however, no leakage was detected on fluorescein angiography. Thus, drug replacement was planned. On the other hand, no abnormal finding was observed in the left eye. However, as the anti-cancer effect of paclitaxel is significant, replacing paclitaxel with another agent was not warranted; therefore, maintenance therapy with methazolamide was performed before and after administering the anti-cancer agent. Aggravation of cystoid macular edema was prevented, and vision improvement was achieved by oral maintenance therapy with methazolamide. In addition, the same fundus findings as shown in the right eye were detected in the left eye at 16 months after paclitaxel administration. After administering methazolamide, macular thickness was reduced, and vision was improved in the left eye. Paclitaxel administration was discontinued due to cutaneous metastasis from the breast cancer, and another anti-cancer agent was then administered. No subsequent cystoid macular edema has occurred.
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Affiliation(s)
- Nam Kyun Koo
- Department of Ophthalmology, Dongkang Hospital, Ulsan, Korea
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Koo NK, Kim YC. Resolution of macular edema after systemic treatment with furosemide. KOREAN JOURNAL OF OPHTHALMOLOGY 2012; 26:312-5. [PMID: 22870034 PMCID: PMC3408540 DOI: 10.3341/kjo.2012.26.4.312] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Accepted: 11/15/2010] [Indexed: 11/24/2022] Open
Abstract
We report two cases of macular edema treated with the oral administration of furosemide. The first case presented here was a 78-year-old male patient with visual disturbance of the left eye. He had been taking an oral agent for diabetes and had chronic renal failure for 7 years. From 10 days prior to the visit, he had visual disturbance of the left eye accompanied by systemic edema. There were no specific findings in the anterior segment, but sub-retinal fluid was observed in the left fundus. Macular edema was observed on fluorescein angiography and optical coherence tomography; therefore, the oral administration of furosemide was initiated. After seven days, the sub-retinal fluid disappeared. The second case was a 43-year-old female patient with visual disturbance of the left eye who had been taking hypoglycemic agents for diabetes for 13 years. There were no specific findings in the anterior segment, but flame-shaped retinal hemorrhages were scattered over both posterior poles, neovascularization was observed in the left eye, and, of particular note, sub-retinal fluid was detected in the macula of the left eye. Macular edema was also observed on fluorescein angiography and optical coherence tomography, and oral administration of furosemide was initiated. After 3 weeks, the macular edema had significantly decreased.
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Affiliation(s)
- Nam Kyun Koo
- Department of Ophthalmology, Dongkang Hospital, Ulsan, Korea
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Pato E, Muñoz-Fernández S, Francisco F, Abad MA, Maese J, Ortiz A, Carmona L. Systematic Review on the Effectiveness of Immunosuppressants and Biological Therapies in the Treatment of Autoimmune Posterior Uveitis. Semin Arthritis Rheum 2011; 40:314-23. [DOI: 10.1016/j.semarthrit.2010.05.008] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Revised: 05/17/2010] [Accepted: 05/20/2010] [Indexed: 12/14/2022]
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Genead MA, Fishman GA, McAnany JJ. Efficacy of topical dorzolamide for treatment of cystic macular lesions in a patient with enhanced S-cone syndrome. Doc Ophthalmol 2010; 121:231-40. [PMID: 20842519 DOI: 10.1007/s10633-010-9247-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Accepted: 08/20/2010] [Indexed: 12/15/2022]
Abstract
The purpose of this study was to evaluate the efficacy of topical dorzolamide 2% eye drops on macular function and thickness in a case of enhanced S-cone syndrome (ESCS). A 24-year-old Asian man with enhanced S-cone syndrome treated with topical dorzolamide in the left eye participated in the study. Examinations performed before and during treatment were included visual acuity (VA), contrast sensitivity measured with briefly presented grating targets (grating CS) and the Pelli-Robson chart (P-R CS), microperimetry (MP), and spectral-domain optical coherence tomography (SD-OCT). Following 4 months of treatment, the mean thickness of the central 1-mm foveal subfield of the left eye, as measured by SD-OCT, decreased from 551 to 242 μm. Mean MP sensitivity within the central 12 degrees (28 points) increased from 9.4 dB at baseline to 11.2 dB. Although Pelli-Robson contrast sensitivity improved only minimally in the left eye, grating contrast sensitivity improved by more than a factor of two. Mean log MAR VA was 0.22 OD and 1.00 OS (at baseline), which improved to 0.10 OD and 0.66 OS after 4 months of treatment. The results indicate that in our patient with enhanced S-cone syndrome, treatment with topical dorzolamide was effective in improving macular thickness, VA, microperimetry sensitivity, and grating contrast sensitivity. These measures of retinal structure and function are sensitive tools for evaluating the effects of treatment in enhanced S-cone syndrome patients with cystoid macular edema. Further investigation is warranted to assess the relationships among visual performance for daily activities, visual sensitivity, and macular thickness.
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Affiliation(s)
- Mohamed A Genead
- Department of Ophthalmology and Visual Sciences (MC 648), University of Illinois at Chicago, Room 3.85, Eye and Ear Infirmary, 1855 W Taylor Street, Chicago, IL 60612-7234, USA
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19
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Abstract
Pseudophakic cystoid macular edema (PCME) is the most common complication following cataract surgery. In 1-3% of cases it is associated with a decrease in visual acuity. However, PCME has a good prognosis, persisting in only 10% of the patients beyond 2 years. The prophylactic therapy of eyes without additional disease with non-steroidal antiphlogistic drugs or steroids does not influence the final visual acuity. Under certain circumstances, prophylaxis can be a reasonable option. Risk factors that promote the formation of PCME are discussed. The course of acute or chronic PCME can be influenced by drug treatment, but in general the level of evidence for the treatment of this widespread problem is low. We would therefore like to present the Freiburg treatment scheme for PCME for discussion.
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Bonilha VL, Rayborn ME, Bhattacharya SK, Gu X, Crabb JS, Crabb JW, Hollyfield JG. The retinal pigment epithelium apical microvilli and retinal function. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2007; 572:519-24. [PMID: 17249618 PMCID: PMC2748829 DOI: 10.1007/0-387-32442-9_72] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Vera L Bonilha
- Cole Eye Institute, Cleveland Clinic Foundation, OH 44195, USA
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21
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Gutfleisch M, Spital G, Mingels A, Pauleikhoff D, Lommatzsch A, Heiligenhaus A. Pars plana vitrectomy with intravitreal triamcinolone: effect on uveitic cystoid macular oedema and treatment limitations. Br J Ophthalmol 2007; 91:345-8. [PMID: 17005547 PMCID: PMC1857663 DOI: 10.1136/bjo.2006.101675] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2006] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate the effect of pars plana vitrectomy (PPV) in combination with intraoperative intravitreal triamcinolone acetonide injection on the course of cystoid macular oedema (CME) in patients with uveitis. METHODS Patients with uveitis with CME (n = 19) not responding to systemic corticosteroids and/or immunosuppression combined with acetazolamide were retrospectively studied after PPV with additional intravitreal injection of 4 mg triamcinolone acetonide. Patients had chronic anterior uveitis (n = 4), intermediate uveitis (n = 9), posterior uveitis (n = 3) or panuveitis (n = 3). Visual acuity tests, tonometry, fluorescein angiographic appearance and postoperative complications were analysed. Mean follow-up was 14 months (SD 4.6). RESULTS CME improved in 58% of the patients within the first 6 weeks postoperatively. After 12 months, CME was further improved in 44% and worsened in another 12%. Improvement of visual acuity was noted in 42% after 3 months and in 28% after 12 months. Cataract progressed in 85% of the phacic patients postoperatively. Increased intraocular pressure was detected in 27% at 2 weeks and in 11% at 12 months after surgery. CONCLUSION Uveitic CME that is unresponsive to systemic immunosuppression and acetazolamide may improve after PPV with additional intravitreal triamcinolone application. The effect seems to be transient in many of the patients. Frequent complications were cataract formation and ocular hypertension.
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Affiliation(s)
- Matthias Gutfleisch
- Department of Ophthalmology, St Franziskus Hospital, Hohenzollernring, Muenster, Germany
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22
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Sivaprasad S, McCluskey P, Lightman S. Intravitreal steroids in the management of macular oedema. ACTA ACUST UNITED AC 2007; 84:722-33. [PMID: 17083528 DOI: 10.1111/j.1600-0420.2006.00698.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The use of intravitreal corticosteroids in the management of macular oedema has recently gained widespread acceptance. New long-acting steroid preparations and methods of delivery have facilitated the use of these new modalities. This review describes the various types of macular oedema for which this therapeutic option is used and the results.
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Affiliation(s)
- Sobha Sivaprasad
- Department of Clinical Ophthalmology, Institute of Ophthalmology, Moorfields Eye Hospital, London, UK
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Androudi S, Letko E, Meniconi M, Papadaki T, Ahmed M, Foster CS. Safety and efficacy of intravitreal triamcinolone acetonide for uveitic macular edema. Ocul Immunol Inflamm 2005; 13:205-12. [PMID: 16019680 DOI: 10.1080/09273940590933511] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND To evaluate the safety and efficacy of intravitreal triamcinolone acetonide (TA) for treating macular edema secondary to non-infectious uveitis. METHODS Retrospective review of sixteen patients (20 eyes) with chronic cystoid macular edema (CME) as a consequence of controlled intermediate uveitis, posterior uveitis, or panuveitis who received at least one intravitreal injection of TA. Main outcome measures were visual acuity (VA), intraocular pressure (IOP), formation or progression of an existing cataract, and CME resolution during the follow-up period. RESULTS At last follow-up, VA showed improvement (compared to baseline) in 11 eyes (55%), deterioration in three eyes (15%), remained completely unchanged in one eye (5%), and showed improvement initially but returned to baseline levels in five eyes (25%). At last follow-up, CME had relapsed or was still present in 10 of the eyes (50%). The remaining eyes showed complete resolution of the CME, without evidence of recurrence during the follow-up time. Mean VA at last follow-up showed statistically significant improvement (p = 0.02) in nonvitrectomized eyes (mean baseline VA: 1.14 +/- 0.58; mean final VA: 0.96 +/- 0.66) compared to the almost unaltered mean visual acuity for vitrectomized eyes (mean baseline VA: 0.76 +/- 0.41; mean final VA: 0.71 +/- 0.48)(p = 0.40, paired samples t-test). Elevation of IOP was transient in all cases and responded well to topical medications, except for one patient who required placement of an Ahmed valve. Preexisting cataract progressed in three of the 15 phakic eyes (20%). One patient developed a retinal detachment and required additional surgery to reattach it. Patients were followed for a mean of 34 weeks (median: 32 weeks; range: 19-56 weeks). CONCLUSIONS Intravitreal TA may play a role in the treatment of uveitis-related CME. Further controlled studies are necessary to test this hypothesis.
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Affiliation(s)
- Sofia Androudi
- Ocular Immunology and Uveitis Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, and the Massachusetts Eye Research and Surgery Institute (MERSI), Boston, 02114, USA
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Kok H, Lau C, Maycock N, McCluskey P, Lightman S. Outcome of intravitreal triamcinolone in uveitis. Ophthalmology 2005; 112:1916.e1-7. [PMID: 16171868 DOI: 10.1016/j.ophtha.2005.06.009] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2004] [Accepted: 06/15/2005] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To report the short-term outcome of intravitreal triamcinolone acetate (TA) in the treatment of uveitic cystoid macular edema (CME). DESIGN Retrospective noncomparative (nonrandomized, uncontrolled) interventional case series. PARTICIPANTS Sixty-five eyes of 54 patients with uveitis-related CME inadequately responsive to treatment combinations of oral corticosteroid, periocular orbital floor corticosteroid injections, and second-line immunosuppressive agents. INTERVENTION Intravitreal injection of 4 mg/0.1 ml of TA. MAIN OUTCOME MEASURES Visual acuity (VA), intraocular pressure (IOP), levels of inflammation, and immunosuppressive therapy were assessed. Other potential complications, including cataract progression, vitreous hemorrhage, endophthalmitis, and retinal detachment (RD), were looked for. RESULTS The mean follow-up was 8.0 months (range, 3-51), and the mean improvement of VA after intravitreal TA was 0.26 (from 0.65 to 0.39 logarithm of the minimum angle of resolution; Snellen, 6/24-6/12, approximately). This occurred at a mean of 4 weeks (range, 1-30). The improvement in VA was more significant if the duration of CME before intravitreal TA was < or =12 months (P = 0.006) and if patients were < or =60 years old (P = 0.005). Patients with the worst vision before treatment also improved the least. The most important side effect was raised IOP (mean rise, 10.3 mmHg), with 28 eyes (43.1%) experiencing an IOP rise of >10 mmHg. Patients younger than 40 years were more likely to experience this IOP rise than those older than 40. Thirty-three eyes (51%) were treated with antiglaucoma medications, with a mean duration of treatment of 17.4+/-13.3 weeks, and no patient required trabeculectomy or lost vision. The dosage of oral corticosteroids and/or second-line immunosuppressive medication was reduced or stopped altogether in 18 of 33 eyes (54.5%) during the study period. There were no cases of injection-related vitreous hemorrhage, endophthalmitis, or RD. CONCLUSIONS In patients with uveitic CME, intravitreal TA can effectively reduce CME and improve VA and, in some eyes, allows the cessation and/or reduction of immunosuppressive therapy. The period of effectivity varies in different patients and, in some eyes, is limited. Treatment was associated in 43.1% with a rise in IOP, which was transient and treatable medically.
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Affiliation(s)
- Howesen Kok
- Department of Clinical Ophthalmology, Institute of Ophthalmology, Moorfields Eye Hospital, London, United Kingdom
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Schilling H, Heiligenhaus A, Laube T, Bornfeld N, Jurklies B. Long-term effect of acetazolamide treatment of patients with uveitic chronic cystoid macular edema is limited by persisting inflammation. Retina 2005; 25:182-8. [PMID: 15689809 DOI: 10.1097/00006982-200502000-00011] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE To assess the long-term effect of acetazolamide treatment on patients with cystoid macular edema (CME) in the course of intermediate or posterior chronic uveitis and to define those patients who may particularly benefit from the drug. METHODS Fifty-two eyes (45 patients) with chronic uveitic CME were treated with acetazolamide at an initial dosage of 500 mg/d. The effect of treatment was assessed by fluorescein angiography, ophthalmoscopy, visual acuity, and Amsler testing. Therapy was withdrawn when CME did not improve at 3 weeks. In cases with CME improvement, the dosage was gradually tapered. RESULTS The mean follow-up was 3.1 years (minimum, 1.5 years). Two subgroups were identified: group 1, quiescence of uveitis with acetazolamide as the single therapeutic agent (33 eyes); and group 2, chronically active uveitis requiring additional systemic antiinflammatory drugs (19 eyes). In both groups, visual acuity improvement was statistically significant (group 1, P = 0.012; group 2, P = 0.025). In 12 patients with a stable visual acuity gain, the medication dose could be tapered off completely without any recurrent edema shown by fluorescein angiography after a minimum follow-up of 1 year. Sixteen patients required a maintenance dosage, ranging from 125 to 500 mg daily. No major adverse effects of the medication were observed. CONCLUSIONS During long-term follow-up, low-dose acetazolamide can be a useful therapeutic option for chronic CME in uveitis. The effect was better in patients with quiescence of uveitis than in those with chronically active uveitis. Permanent therapy is not imperative in every case.
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Chams H, Lashei A, Sadeghi-Tari A, Karkhaneh R, Davatchi F, Shahram F, Chams C, Abazari A. Origin and outcome of macular edema in Behçet's disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2003; 528:349-53. [PMID: 12918722 DOI: 10.1007/0-306-48382-3_71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Affiliation(s)
- H Chams
- Behcet's Research Center, Shariati Hospital, Tehran University for Medical Sciences, Tehran, Iran
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Lashay AR, Rahimi A, Chams H, Davatchi F, Shahram F, Hatmi ZN, Khalkhali H, Beigi B. Evaluation of the effect of acetazolamide on cystoid macular oedema in patients with Behcet's disease. Eye (Lond) 2003; 17:762-6. [PMID: 12928692 DOI: 10.1038/sj.eye.6700464] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
AIM To study the effect of acetazolamide on cystoid macular oedema (CMO) in patients with Behcet's disease. PATIENTS AND METHODS A total of 67 eyes of 35 Behcet's patients with chronic, but well-controlled uveitis, and CMO were randomised into a double-masked, crossover trial comparing the effect of acetazolamide vs placebo. The patients received an initial 4-week course of either 250 mg acetazolamide twice daily (b.i.d.) or placebo, followed by a 4-week washout period. They then received a 4-week course of the reverse study medication. An improvement in visual acuity and fundus fluorescein angiographic findings was assessed. RESULTS In total, 29 patients (55 eyes) completed the trial and were available for analysis. Of the 29, 16 men and 13 were women. The age range was 13-50 years (mean 33.6 years). Patients on acetazolamide showed a slightly better improvement of angiographic signs (at least by one grade improvement) over that of placebo (12 vs five eyes). They also had less deterioration of angiographic signs over that of placebo (three vs seven eyes). However, these findings were not statistically significant (P=0.99). Acetazolamide had no statistically significant effect (P=0.53) on the improvement of visual acuity of patients over that of placebo (13 vs eight eyes), nor on the deterioration of visual acuity (three vs 11 eyes). CONCLUSION Despite seemingly favourable results, the 4-week course of acetazolamide (250 mg b.i.d.) has no statistically significant effect on the improvement of the visual acuity and the fluorescein angiographic findings in Behcet's patients with CMO.
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Affiliation(s)
- A R Lashay
- Department of Ophthalmology Tehran Medical Sciences University Tehran, Iran
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Giusti C, Forte R, Vingolo EM, Gargiulo P. Is acetazolamide effective in the treatment of diabetic macular edema? A pilot study. Int Ophthalmol 2002; 24:79-88. [PMID: 12201348 DOI: 10.1023/a:1016354517304] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AIM To investigate whether acetazolamide, already found to be helpful in decreasing cystoid macular edema in patients with retinitis pigmentosa, was also effective in the treatment of diabetic macular edema in nonproliferative retinopathy. METHODS Two randomized age- and sex-matched groups (cases and controls) of 12 diabetics (five Type 1 and seven Type 2) were selected for this pilot study and graded for retinopathy (Early Treatment of Diabetic Retinopathy Study-Airlie House Classification). Cases were treated with acetazolamide for three months according to a standard protocol. The Early Treatment of Diabetic Retinopathy Study chart was used for assessing far-best corrected visual-acuity, and fluorescein angiography was performed using the Heidelberg Retina Angiograph. The Amsler grid-test and computerized-perimetry (Octopus 2000R) were also performed. RESULTS Fluorescein-angiographic findings and perimetric data improved significantly (p < 0.01) in the acetazolamide-treated cases compared to the controls while visual-acuity varied only slightly (p > 0.01). The Amsler grid-test resulted insignificant in our study (p > 0.05). No adverse effects or significant variations in laboratory tests were recorded. CONCLUSION Further clinical investigations involving larger numbers of patients and a longer follow-up are required to confirm these preliminary results. However, the present study seems to suggest that acetazolamide could be effective in reducing fluorescein-angiographic findings and improving perimetric data in diabetics with macular edema, even though the mechanism of action remains obscure. Visual-acuity varied only slightly.
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Affiliation(s)
- C Giusti
- University La Sapienza , Rome, Italy.
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Takahashi J, Mori F, Hikichi T, Yoshida A. Effect of acetazolamide on outward permeability of blood-retina barrier using differential vitreous flyorophotometry. Curr Eye Res 2001; 23:166-70. [PMID: 11803477 DOI: 10.1076/ceyr.23.3.166.5461] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE To measure fluorescein (F) and fluorescein monoglucuronide (FG) concentrations in the vitreous and evaluate the effect of acetazolamide (AZM) on the outward permeability of the blood-retina barrier (BRB) using differential vitreous fluorophotometry (DVF). METHODS DVF was performed 180 minutes after intravenous injection of AZM (5 mg/kg) and 50 mg of sodium fluorescein in six rabbits (AZM group). DVF also was performed in six rabbits injected intravenously with only 50 mg of sodium fluorescein (control group). The F/FG ratio was calculated based on the concentrations of F and FG obtained by DVF. DVF also was performed 180 minutes after 50 mg of intravenous injection of sodium fluorescein in five rabbits given probenecid (150 mg/kg) intraperitoneally (probenecid group). RESULTS The average F/FG ratio was 0.36 +/- 0.17 (range, 0.22-0.66) in the AZM group, which was significantly smaller than the control value of 0.74 +/- 0.22 (range, 0.50-1.60). The average F/FG ratio at 180 minutes after injection was 1.51 +/- 0.46 (range, 0.94-2.00) in the probenecid group, which was significant higher (p < 0.05) than that of the AZM or control group. CONCLUSIONS This study showed that the F/FG ratio might be a good indicator of the estimated outward permeability of the BRB using DVF and that AZM may accelerate the outward active transport function of the BRB.
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Affiliation(s)
- J Takahashi
- Department of Ophthalmology, Asahikawa Medical College, Asahikawa, Japan
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Young S, Larkin G, Branley M, Lightman S. Safety and efficacy of intravitreal triamcinolone for cystoid macular oedema in uveitis. Clin Exp Ophthalmol 2001; 29:2-6. [PMID: 11272779 DOI: 10.1046/j.1442-9071.2001.00360.x] [Citation(s) in RCA: 239] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To report the safety and efficacy of intravitreal triamcinolone in the treatment of inflammatory cystoid macular oedema (CMO) in six patients who were resistant to other forms of therapy. METHODS An open-label unmasked prospective nonrandomized pilot study of six patients with idiopathic uveitis and visually significant macular oedema, resistant to periocular and/or systemic corticosteroid treatment, was carried out. Baseline examination and investigations were performed, including fundus fluorescein angiography, and the patients were given a single intravitreal injection of triamcinolone (4 mg/0.1 mL). The primary outcome measure was angiographic resolution of CMO. Patients were reviewed at intervals of 2-4 weeks for 12 months. RESULTS A single intravitreal injection of triamcinolone induced clinical and angiographic resolution of inflammatory macular oedema in all patients for varying periods of time up to 6 months. Five patients experienced increased intraocular pressure to 30 mmHg or greater which required treatment. Two patients developed posterior subcapsular cataract. CONCLUSION One injection of intravitreal triamcinolone was an effective short-term treatment for resistant CMO in uveitis. As with steroids given by other routes, raised intraocular pressure and cataract may occur. As it was so effective in these eyes with resistant CMO, a larger study is warranted to evaluate this form of therapy.
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Affiliation(s)
- S Young
- Department of Clinical Ophthalmology, Institute of Ophthalmology, Moorfields Eye Hospital, London, UK
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Abstract
Most papers on the subject of CMO associated with uveitis are retrospective, combine patients with different disease aetiologies, at different stages of evolution, and often describe patients who were previous treatment failures with other therapies besides the one under consideration. There are almost no prospective randomised double-masked controlled studies. This is perhaps in part due to the relative sparsity of uveitis patients seen by many uveitis centres. At the moment, treatment is largely empirical, based in large part on the studies, and others, quoted above. The need to regularly repeat courses of therapy, loss of efficacy of certain form of therapy after repeated use, and cumulative side-effects, all need to be taken into consideration when interpreting results and deciding upon the best approach to be adopted. The risks to the patient's well-being increase with the addition of systemic medication, and long-term steroid use can cause hypertension, induce or exacerbate diabetes, cause premature osteoporosis, cushingoid features, peptic ulceration and aseptic necrosis of the femoral head. Immunosuppressive drugs can be nephrotoxic, hepatotoxic, cause hypertension, gastric disturbances and excessive hair growth. The assessment of macular changes, both structurally and functionally, is the key aspect in understanding visual loss in CMO and also in predicting potential visualrecovery. The combined use of the various tools mentioned here, such as SLO, OCT and electrodiagnostic tests, may give us some of the necessary answers in this process. However, all these tests will need to be validated. A prospective analysis of CMO in cases of uveitis, especially if coupled with therapeutic intervention, will give us the opportunity to achieve this objective.
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Wolfensberger TJ. The role of carbonic anhydrase inhibitors in the management of macular edema. Doc Ophthalmol 2000; 97:387-97. [PMID: 10896355 DOI: 10.1023/a:1002143802926] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Medical treatment of cystoid macular edema (CME) with carbonic anhydrase inhibitors has been known for over a decade. Initial observations were based on experimental data which suggested that acetazolamide can increase fluid absorption across the retinal pigment epithelium. Carbonic anhydrase inhibitors (CAI) have also been shown to have other direct effects both on retinal and retinal pigment epithelial cell function by inducing an acidification of the subretinal space, a decrease of the standing potential as well as an increase in retinal adhesiveness. It is thought that acidification of the subretinal space is finally responsible for the increase in fluid resorption from the retina through the RPE into the choroid. Several clinical studies have suggested that patients with cystoid macular edema due to retinitis pigmentosa and uveitis may react more favorably to CAI treatment than other etiologies such as diabetic maculopathy or macular edema after retinal vein occlusion. The present working hypothesis is that diffuse leakage from the RPE responds more readily to CAI treatment than leakage from retinal vessels. This may be due to the modulation of membrane- bound CA IV in the RPE which may have lost its polarised distribution in the presence of macular edema. A normal clinical starting dose of CAI is 500 mg/day which should be continued for at least one month to see an effect. This dose may be reduced by the patients over the course of therapy. Metaphylaxis to the drug may occur with a rebound of the edema despite continuation of treatment.
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Affiliation(s)
- T J Wolfensberger
- Hôpital Ophtalmique Jules Gonin, University of Lausanne, Switzerland.
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Affiliation(s)
- M Zierhut
- Department of General Ophthalmology, University Eye Clinic, Tübingen, Germany
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Abstract
AIMS To report a series of patients requiring treatment for falling visual acuity associated with immune recovery vitritis, a recently described syndrome of a predominantly vitreous inflammatory reaction in patients with AIDS and cytomegalovirus (CMV) retinitis. METHODS The medical records of all patients requiring treatment for falling visual acuity associated with immune recovery vitritis were reviewed between March 1996 and March 1998. RESULTS Nine eyes in seven patients required treatment for falling visual acuity. All patients had inactive CMV retinitis and had received highly active antiretroviral treatment including a protease inhibitor. Vitreous inflammation developed at a mean of 5.5 months (range 1-14) after starting a protease inhibitor. The onset of inflammation correlated with a mean rise in CD4(+) lymphocyte levels of 83 x 10(6)/l (range 30-128). The visual acuity fell by a mean of 2.8 Snellen lines (range 1-4) before treatment, and rose by a mean of 1.9 Snellen lines (range 0-4) after treatment with orbital floor steroids. The mean time interval between treatment with orbital floor steroids and improvement in visual acuity was 3.5 weeks (range 1-8). Following treatment the visual acuity improved or remained stable in all nine eyes, eight eyes returning to within one line of their preinflammation Snellen visual acuity. No eyes developed reactivation or progression of CMV retinitis after treatment, and none developed any other pathology. CONCLUSIONS Orbital floor steroids appear to be have a useful role in the treatment of persistent immune recovery vitritis where the visual acuity is compromised.
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Affiliation(s)
- H W Henderson
- St Stephen's Centre, Chelsea and Westminster Hospital, London
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Flach AJ. The incidence, pathogenesis and treatment of cystoid macular edema following cataract surgery. TRANSACTIONS OF THE AMERICAN OPHTHALMOLOGICAL SOCIETY 1998; 96:557-634. [PMID: 10360304 PMCID: PMC1298410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Affiliation(s)
- A J Flach
- Department of Ophthalmology, University of California, San Francisco Medical Center, USA
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Pfeiffer N. Dorzolamide: development and clinical application of a topical carbonic anhydrase inhibitor. Surv Ophthalmol 1997; 42:137-51. [PMID: 9381367 DOI: 10.1016/s0039-6257(97)00053-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Systemic carbonic anhydrase inhibitors are among the most powerful agents to lower intraocular pressure. Unfortunately, their use is frequently accompanied by undesired side effects. Some are due to the relatively large amounts of drug that have to be systemically administered to inhibit the carbonic anhydrase in the ciliary processes. Recently, dorzolamide, a topical carbonic anhydrase inhibitor, has become commercially available for clinical use. This article reviews the development of topical carbonic anhydrase inhibitors with special reference to dorzolamide. When administered three-times daily, dorzolamide lowers intraocular pressure in a clinically useful manner. Ocular side-effects include frequent stinging and burning and allergy can develop. Systemic side effects have not been observed that could definitively be related to inhibition of extraocular carbonic anhydrase. Blood dyscrasias have not yet been observed. Absence of cardiovascular and pulmonary side effects, as can occur with beta adrenergic antagonists, and lack of pupillary and accommodative stimulation, as occur with cholinergic agonists, might make dorzolamide first-line medical treatment for elevated intraocular pressure.
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Affiliation(s)
- N Pfeiffer
- Department of Ophthalmology, University Hospital, Mainz, Germany
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Whitcup SM. Author's reply. Ophthalmology 1996. [DOI: 10.1016/s0161-6420(96)30543-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Whitcup SM, Csaky KG, Podgor MJ, Chew EY, Perry CH, Nussenblatt RB. A randomized, masked, cross-over trial of acetazolamide for cystoid macular edema in patients with uveitis. Ophthalmology 1996; 103:1054-62; discussion 1062-3. [PMID: 8684794 DOI: 10.1016/s0161-6420(96)30567-8] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PURPOSE To study the effect of acetazolamide on cystoid macular edema in patients with uveitis. METHODS Forty patients with chronic intermediate, posterior, or panuveitis associated cystoid macular edema were randomized into a masked, cross-over trial comparing acetazolamide versus placebo. Patients received an initial 4-week course of either acetazolamide or placebo (course A) followed by a 4-week washout period. They then received a 4-week course of the opposite study medication (course B). Primary endpoints included area of cystoid macular edema measured on late-phase views of fluorescein angiography and visual acuity. RESULTS Thirty-seven patients completed the trial and were available for analysis; 17 (46%) were randomized to receive acetazolamide and 20 (54%) to receive placebo during course A. Acetazolamide resulted in a 0.5-disc area (25%) decrease in cystoid macular edema over that of placebo (P = 0.01; estimated treatment effect = -0.5 disc areas; 95% confidence interval, -0.9 to -0.1). However, there was no statistically significant effect of acetazolamide on visual acuity (P = 0.61; estimated treatment effect = 0.6 letters; 95% confidence interval, -2 to 3). CONCLUSIONS A 4-week course of acetazolamide therapy results in a statistically significant but small decrease in cystoid macular edema in patients with chronic uveitis, and does not improve visual acuity. In contrast to previous studies in the literature, acetazolamide may have a more limited clinical benefit in patients with long-standing cystoid macular edema associated with chronic uveitis.
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Affiliation(s)
- S M Whitcup
- National Eye Institute, National Institutes of Health, Bethesda, MD 20892-1858, USA
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Suttorp-Schulten MS, Feron E, Postema F, Kijlstra A, Rothova A. Macular grid laser photocoagulation in uveitis. Br J Ophthalmol 1995; 79:821-4. [PMID: 7488600 PMCID: PMC505267 DOI: 10.1136/bjo.79.9.821] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
AIMS/BACKGROUND The aim of this study was to evaluate whether grid laser photocoagulation of the macula is beneficial in the treatment of cystoid macular oedema in patients with uveitis. METHODS Six eyes of five patients with long standing cystoid macular oedema due to chronic uveitis were treated by grid laser photocoagulation of the macula. RESULTS In the first weeks after treatment a temporary increase of oedema and paracentral scotomas were observed. At the long term follow up of more than 18 months in all patients, macular oedema had been reduced significantly or disappeared in all eyes treated. One eye had a significant increase in Snellen acuity, three eyes more or less stabilised, and two eyes deteriorated. CONCLUSION The beneficial effect of laser treatment on visual acuity in patients with uveitis might be more favourable if performed at an earlier stage of the disease.
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