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Chen CY, Kuo HT, Hsu AY, Lin CJ, Hsia NY, Tien PT, Lai CT, Chen HS, Tsai YY. Prevalence of uveitis in syphilis patients in Taiwan. Emerg Microbes Infect 2024; 13:2290836. [PMID: 38047718 PMCID: PMC10810637 DOI: 10.1080/22221751.2023.2290836] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/29/2023] [Indexed: 12/05/2023]
Abstract
Few population-based studies have looked at the risk of uveitis among syphilis patients. Our study addresses the knowledge gap by reporting on uveitis risk in syphilis patients through a retrospective cohort study. The Taiwan National Health Insurance database was used for this study, covering the period from January 1st, 2009, to December 31st, 2020. We created a 1:4 propensity score matched cohort between the syphilis patients and controls, which accounted for gender, age, and comorbidities. The primary endpoint was the incidence of newly recorded uveitis. The assessment of uveitis risk in syphilis patients included the use of the Kaplan-Meier method and multivariate Cox proportional hazard model. A total of 31,597 syphilis patients and 126,379 matched comparisons were recruited. The uveitis incidence rate from our syphilis patients was 1.25 per 1000 person-years. The uveitis incidence rate from our non-syphilis group was 0.8 per 1000 person-years. After matching, the syphilis group was found to have a higher risk of developing uveitis (adjusted hazard ratio (aHR) [95% CI]: 1.57 [1.36-1.81], P < .001). Among males and individuals aged 20-34 years, subgroup analysis showed an increased risk of uveitis in the presence of syphilis infection. The Kaplan-Meier survival curve showed a significant difference in uveitis incidence between syphilis and non-syphilis groups (log-rank test P < .001). In summary, our study revealed that Taiwanese syphilis patients were at a higher risk of developing uveitis. These results highlight the need for regular ocular monitoring and screening in individuals with syphilis.
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Affiliation(s)
- Chia-Yun Chen
- Department of General Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Hou-Ting Kuo
- Department of General Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Alan Y. Hsu
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chun-Ju Lin
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Optometry, Asia University, Taichung, Taiwan
| | - Ning-Yi Hsia
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Optometry, Asia University, Taichung, Taiwan
| | - Peng-Tai Tien
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Graduate Institute of Clinical Medical Science, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chun-Ting Lai
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Optometry, Asia University, Taichung, Taiwan
| | - Huan-Sheng Chen
- An-Shin Dialysis Center, NephroCare Ltd., Fresenius Medical Care, Taichung, Taiwan
| | - Yi-Yu Tsai
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Optometry, Asia University, Taichung, Taiwan
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Kochar A, Farooq S. Response to Letter to editor: HIV conundrum. Oman J Ophthalmol 2024; 17:156-157. [PMID: 38524334 PMCID: PMC10957050 DOI: 10.4103/ojo.ojo_210_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/21/2023] [Accepted: 11/24/2023] [Indexed: 03/26/2024] Open
Affiliation(s)
- Anju Kochar
- Department of Ophthalmology, SP Medical College, PBM and Associated Group of Hospitals, Bikaner, Rajasthan, India
| | - Shaheen Farooq
- Department of Ophthalmology, SP Medical College, PBM and Associated Group of Hospitals, Bikaner, Rajasthan, India
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Pasricha MV, Johnson RN, Agarwal A, Jumper JM, McDonald HR, Cunningham ET. A 48-YEAR-OLD CAUCASIAN MAN WITH UNILATERAL "SMUDGE" IN INFERIOR VISUAL FIELD. Retin Cases Brief Rep 2023; 17:S23-S26. [PMID: 36121815 DOI: 10.1097/icb.0000000000001355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 09/13/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE To report an increasingly prevalent fundoscopic manifestation of syphilitic uveitis. METHODS Case report of a patient with acute retinal necrosis secondary to syphilis. RESULTS A 48-year-old man presented with decreased vision, anterior segment inflammation, and a wedge-shaped retinal lesion in the superior periphery, with a diaphanous leading edge extending down toward the superior arcade. The patient was HIV+ and poorly compliant with therapy. The top three differential diagnoses were herpetic necrotizing retinitis, syphilis, and lymphoma. An extensive lab workup was positive for syphilis. The patient was treated with IV penicillin G and demonstrated improvement in visual acuity and examination. CONCLUSION There have been an increasing number of reports of syphilis patients, especially in the population of men who have sex with men, who present with fundus findings similar to acute retinal necrosis. These findings include a characteristic ground glass, translucent appearance of unifocal or multifocal lesions, primarily affecting the inner retina and sometimes associated with co-localizing occlusive vasculitis. Treatment with IV penicillin G is warranted and has demonstrated good visual recovery.
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Affiliation(s)
- Malini V Pasricha
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, California
- West Coast Retina Medical Group, San Francisco, California
| | - Robert N Johnson
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, California
- West Coast Retina Medical Group, San Francisco, California
| | - Anita Agarwal
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, California
- West Coast Retina Medical Group, San Francisco, California
| | - J Michael Jumper
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, California
- West Coast Retina Medical Group, San Francisco, California
| | - H Richard McDonald
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, California
- West Coast Retina Medical Group, San Francisco, California
| | - Emmett T Cunningham
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, California
- West Coast Retina Medical Group, San Francisco, California
- Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, California; and
- The Francis I. Proctor Foundation, UCSF School of Medicine, San Francisco, California
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Ling CJM, Zhang KY, Taubenslag KJ, Alexander N, Champ K, Murali N. The Mydriatic Red Eye as the Initial Presentation of Syphilis. J Emerg Med 2022; 63:296-299. [PMID: 36038437 DOI: 10.1016/j.jemermed.2022.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/09/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Syphilis is a sexually transmitted infection that has been increasing in prevalence since the early 2000s. Ocular involvement occurs in a minority of patients and must be in the differential diagnosis for patients who present with red eye and uveitis. CASE REPORT A 29-year-old woman presented to the emergency department with a painful, mydriatic red eye. Review of systems revealed a rash as well as a recent genital lesion and, on further questioning, she admitted to a history of intravenous drug use and high-risk sexual activity. Ophthalmology was consulted and the patient was diagnosed with bilateral uveitis. Serologic testing was positive for syphilis, and she was admitted and treated with intravenous penicillin, with resolution of her uveitis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Red eye is a common ocular symptom in patients presenting to the emergency department. The differential diagnosis of the red eye is broad and can range from benign etiologies, such as conjunctivitis, to life- and sight-threatening conditions, such as endogenous endophthalmitis. Systemic diseases such as syphilis may present with primarily ocular symptoms, and ocular syphilis must be identified and managed appropriately to prevent devastating sequelae.
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Affiliation(s)
- Carlthan J M Ling
- Department of Ophthalmology and Visual Sciences, University of Maryland Medical Center, Baltimore, Maryland
| | - Kevin Y Zhang
- Creighton University Medical School, Omaha, Nebraska
| | - Kenneth J Taubenslag
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nicole Alexander
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kathryn Champ
- Department of Internal Medicine, University of Maryland Medical Center, Midtown Campus, Baltimore, Maryland
| | - Neeraja Murali
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland.
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Abstract
Glaucoma is an intraocular pressure-related ophthalmic disease with multiple causes that results in an optic neuropathy and vision loss. Intraocular pressure elevation is among its strongest risk factors. While glaucoma is mostly primary in etiology, secondary glaucoma is not infrequent. Recognizing its cause is imperative, since treatment is often different depending on the pathophysiologic mechanism. Numerous clinically relevant ophthalmic infections can result in robust inflammatory responses that may result in pressure elevation or intraocular anatomic configurations that predispose to pressure elevation. Knowing the mechanisms by which these infections can lead to glaucoma is critical in treating, and we consolidate what is currently known in regards to how infectious diseases lead to glaucoma.
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Cunningham ET, Miserocchi E, Smith JR, Gonzales JA, Zierhut M. Intraocular Lymphoma. Ocul Immunol Inflamm 2021; 29:425-429. [PMID: 34296968 DOI: 10.1080/09273948.2021.1941684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Emmett T Cunningham
- The Department of Ophthalmology, California Pacific Medical Center, San Francisco, California, USA.,The Department of Ophthalmology, Stanford University School of Medicine, Stanford, California, USA.,The Francis I. Proctor Foundation, UCSF School of Medicine, San Francisco, California, USA
| | - Elisabetta Miserocchi
- The Department of Ophthalmology, San Raffaele Scientific Institute, University Vita-Salute, Milan, Italy
| | - Justine R Smith
- Flinders University College of Medicine & Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - John A Gonzales
- The Francis I. Proctor Foundation, UCSF School of Medicine, San Francisco, California, USA.,Department of Ophthalmology, UCSF School of Medicine, California, USA
| | - Manfred Zierhut
- Centre for Ophthalmology, University Tuebingen, Tuebingen, Germany
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Chen C, Du KF, Xie LY, Jiang TY, Kong WJ, Dong HW, Guo CG, Li XN, Wei WB. Clinical Features of Ocular Pathology in Patients with Acquired Immunodeficiency Syndrome and Syphilis. Adv Ther 2021; 38:3362-3372. [PMID: 34019246 DOI: 10.1007/s12325-021-01755-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 04/20/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The present study aimed to analyze the clinical features of ocular pathology in patients with acquired immunodeficiency syndrome (AIDS) combined with syphilis. METHODS A total of 129 patients with AIDS and syphilis who first visited the Department of Ophthalmology in Beijing YouAn Hospital between 2012 and 2019 were included in the study. All patients underwent ophthalmologic examinations, such as best-corrected visual acuity (BCVA), slit lamp, intraocular pressure, dilated fundus examination, and color fundus photography as well as systemic examinations related to AIDS and syphilis. The patients were divided into four groups according to fundus disease: a normal fundi group, an HIV-related microvascular retinopathy (MVR) group, a cytomegalovirus retinitis (CMVR) group, and a syphilis-related retinopathy group. RESULTS The incidence of fundus disease was 70.7%. There were 36 patients with normal fundi (29.3%), 40 with HIV-related MVR (31.0%), 25 with CMVR (19.4%) (including 11 cases of CMVR with syphilis-related retinopathy), 26 (20.2%) with syphilis-related retinopathy, 1 (0.78%) case with acute retinal necrosis, and 1 (0.78%) case with PORN. The median blood CD4 + T-cell count in the syphilis-associated retinopathy group was 357.5 cells/μl, which was significantly higher than in the other groups; this difference was statistically significant. In the CMVR group, 11 cases with concomitant syphilis-associated retinopathy had lower BCVA and 10 (90.9%) had active inflammatory manifestations in the anterior segment. CONCLUSION The incidence of ocular pathology was high in patients co-infected with AIDS and syphilis, which might manifest in a variety of ocular manifestations; some patients may also have multiple ocular changes, which should be given great clinical attention.
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Affiliation(s)
- Chao Chen
- Department of Ophthalmology, Beijing YouAn Hospital, Capital Medical University, Beijing, 100069, China
| | - Kui-Fang Du
- Department of Ophthalmology, Beijing YouAn Hospital, Capital Medical University, Beijing, 100069, China
| | - Lian-Yong Xie
- Department of Ophthalmology, Beijing YouAn Hospital, Capital Medical University, Beijing, 100069, China
| | - Tai-Yi Jiang
- Department of Infectious Diseases, Beijing YouAn Hospital, Capital Medical University, Beijing, 100069, China
| | - Wen-Jun Kong
- Department of Ophthalmology, Beijing YouAn Hospital, Capital Medical University, Beijing, 100069, China
| | - Hong-Wei Dong
- Department of Ophthalmology, Beijing YouAn Hospital, Capital Medical University, Beijing, 100069, China
| | - Chun-Gang Guo
- Department of Ophthalmology, Beijing YouAn Hospital, Capital Medical University, Beijing, 100069, China
| | - Xiao-Na Li
- Department of Ophthalmology, Beijing YouAn Hospital, Capital Medical University, Beijing, 100069, China
| | - Wen-Bin Wei
- Beijing Tongren Eye Center, Beijing key Laboratory of Intraocular Tumor Diagnosis and Treatment, Beijing Ophthalmology and Visual Sciences Key Lab, Medical Artificial Intelligence Research and Verification Key Laboratory of the Ministry of Industry and Information Technology, Beijing Tongren Hospital, Capital Medical University, No.1 Dongjiaomin Lane, Dongcheng District, Beijing, 100730, China.
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Abdalla Elsayed MEA, Kozak I. Pharmacologically induced uveitis. Surv Ophthalmol 2021; 66:781-801. [PMID: 33440194 DOI: 10.1016/j.survophthal.2021.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 12/26/2022]
Abstract
Treatments of numerous systemic and local diseases of different etiologies may be accompanied by an unwanted side effect in the form of uveitis. We inform readers about medications that have the potential to cause uveitis and analyze the strength of association of these medications with uveitis. Subsequently, cessation of medication or appropriate treatment can be individualized for each patient for the purpose of preventing further damage to tissue structure and function. Being aware of these associations, physicians may readily identify medications that may cause uveitis and avoid expensive and unnecessary clinical and laboratory testing.
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Affiliation(s)
| | - Igor Kozak
- Moorfields Eye Hospitals UAE, Abu Dhabi, United Arab Emirates.
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Iqbal KM, Hay MW, Emami-Naeini P. Medication-induced Uveitis: An Update. J Ophthalmic Vis Res 2021; 16:84-92. [PMID: 33520131 PMCID: PMC7841282 DOI: 10.18502/jovr.v16i1.8254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 12/04/2020] [Indexed: 01/21/2023] Open
Abstract
Drug-induced uveitis is an uncommon but important cause of ocular inflammation. Uveitis can be seen in association with various systemic, topical, and intraocular medications. In this article, we review common medications associated with uveitis. Most cases of drug-induced uveitis resolve with termination of the suspected medication with or without administration of topical or systemic steroids. It is important for clinicians to readily identify medications that may cause uveitis in order to provide rapid treatment, avoid consequences of longstanding inflammation, and prevent costly and excessive laboratory testing.
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Affiliation(s)
- Kashif M Iqbal
- (KM Iqbal and MW Hay contributed equally to this paper.)
| | - Madeline W Hay
- University of California Riverside School of Medicine, Riverside, CA
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de-la-Torre A, Gómez-Marín J. Disease of the Year 2019: Ocular Toxoplasmosis in HIV-infected Patients. Ocul Immunol Inflamm 2020; 28:1031-1039. [PMID: 32162993 DOI: 10.1080/09273948.2020.1735450] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Ocular toxoplasmosis (OT) may be an initial manifestation of acquired immunodeficiency syndrome (AIDS) in human immunodeficiency virus (HIV)-infected patients. OT has different clinical manifestations and can mimic other intraocular infections. Clinical findings may show single or multifocal retinochoroidal lesions or panuveitis. Atypical presentations are associated with extensive uni- or bilateral areas of retinal necrosis. OT lesions not associated with preexisting retinochoroidal scars are usually due to acquired rather than congenital infection. When CD4+ T cell counts are <100 c/uL, vitritis is frequently mild. Isolated anterior uveitis has been reported in single cases. Positive immunoglobulin M (IgM) antibodies are rare but their presence can support the diagnosis. As atypical presentations of OT are common, anterior chamber puncture for multiplex polymerase chain reaction amplification of infectious DNA should be considered, as early diagnosis and treatment can prevent massive tissue destruction and preserve vision. This review provides an overview of OT in HIV-infected patients.
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Affiliation(s)
- Alejandra de-la-Torre
- Grupo de Investigación en Neurociencia (Neuros), Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario , Bogotá, Colombia
| | - Jorge Gómez-Marín
- Gepamol. Centro de Investigaciones Biomédicas, Universidad del Quindío , Armenia, Q, Colombia
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Testi I, Agarwal A, Agrawal R, Mahajan S, Marchese A, Miserocchi E, Gupta V. Drug-induced Uveitis in HIV Patients with Ocular Opportunistic Infections. Ocul Immunol Inflamm 2019; 28:1069-1075. [PMID: 31850816 DOI: 10.1080/09273948.2019.1691240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose: To describe drug-induced uveitis in immunocompromised patients diagnosed with Human Immunodeficiency Virus (HIV) infection Methods: Narrative Review Results: Systemic and intraocular medications administered for the treatment of acquired immune deficiency syndrome (AIDS)-associated diseases in patients infected with HIV are a well-known cause of uveitis. Conclusions: Cidofovir and rifabutin, among other novel anti-retroviral therapies, are strongly associated with drug-induced uveitis. It is imperative to understand the pathogenesis, clinical findings, and management of HIV patients with uveitis induced by these agents.
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Affiliation(s)
- Ilaria Testi
- Medical Retina and Uveitis Service, Moorfields Eye Hospital, NHS Foundation Trust , London, UK
| | - Aniruddha Agarwal
- Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh, India
| | - Rupesh Agrawal
- Department of Ophthalmology, National Health Care Group Eye Institute, Tan Tock Seng Hospital , Singapore
| | - Sarakshi Mahajan
- School of Medicine, St Joseph Mercy Hospital , Oakland Pontiac, Michigan
| | - Alessandro Marchese
- Department of Ophthalmology, Scientific Institute San Raffaele, University Vita-Salute San Raffaele , Milan, Italy
| | - Elisabetta Miserocchi
- Department of Ophthalmology, Scientific Institute San Raffaele, University Vita-Salute San Raffaele , Milan, Italy
| | - Vishali Gupta
- Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh, India
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12
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Endogenous endophthalmitis and other ocular manifestations of injection drug use. Curr Opin Ophthalmol 2019; 30:506-512. [PMID: 31589187 DOI: 10.1097/icu.0000000000000606] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The United States has experienced a dramatic rise in opioid and injection drug use over the past 2 decades. A public health emergency was declared in 2017 and subsequently, there have been several new reports on the rise of endogenous endophthalmitis specifically associated with injection drug use. The purpose of this review is to provide a current perspective of the ocular harms posed by injection drug use. RECENT FINDINGS The opioid epidemic has prompted several new studies from New England, one of the US regions most heavily affected, that examine the trends and characteristics of injection drug use-associated endogenous endophthalmitis. Patients may delay seeking care and may be infected with a variety of rare and atypical microbes, and as a result clinical appearance may vary widely. Injection drug use also leads to embolic phenomena such as talc retinopathy and septic emboli from endocarditis. HIV is highly associated with injection drug use and although HAART has drastically reduced the morbidity and mortality of HIV-associated infections, a variety of ocular disease may accompany an immunocompromised patient. SUMMARY Healthcare providers must remain vigilant in the recognition of injection drug use patients with vision loss and ocular inflammation to ensure prompt medical and/or surgical treatment.
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Abstract
PURPOSE To describe the clinical characteristics, diagnosis, and treatment of VIAU in immunocompromised patients. METHODS A critical review of literature was performed. RESULTS Diagnosis and treatment of VIAU in immunocompromised patients may be a challenge due to atypical clinical-courses, severe presentations, and more frequent recurrences. A conclusive diagnosis can be made by aqueous-humour PCR-analysis. Visual prognosis depends on early diagnosis and prompt treatment. Frequent ocular examinations are recommended in HIV patients with CD-4-counts below 100 in order to rule out opportunistic ocular coinfections. It is essential to bear in mind the potential side-effects of therapeutic interventions and consider the possibility of Immune Recovery Uveitis (IRU) in eyes with treated viral retinitis after the initiation of HAART. CONCLUSIONS Early diagnosis and treatment of VIAU in immunocompromised patients can be achieved with high suspicion, recognizing clinical features, and obtaining specimens for molecular diagnostic testing in order to avoid usually severe ocular morbidity.
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Affiliation(s)
- Alejandra de-la-Torre
- a Grupo de Investigación en Neurociencias (NeURos), Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario , Bogotá , Colombia
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Krishna U, Ajanaku D, Denniston AK, Gkika T. Uveitis: a sight-threatening disease which can impact all systems. Postgrad Med J 2017; 93:766-773. [PMID: 28942431 DOI: 10.1136/postgradmedj-2017-134891] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 05/31/2017] [Accepted: 08/20/2017] [Indexed: 02/06/2023]
Abstract
Uveitis describes a group of conditions characterised by intraocular inflammation. The term uveitis technically describes inflammation of the uvea which comprises the iris, ciliary body and choroid, however now encompasses inflammation of adjacent intraocular structures such as the retina, vitreous and optic nerve. Uveitis is a significant cause of blindness worldwide, but its impact is generally underappreciated due to a lack of awareness and understanding of the condition among the public and most non-ophthalmic healthcare professionals. In this review, we provide an introduction to uveitis for the non-specialist, outlining the clinical presentations that should raise the suspicion of the disease, the signs that should be looked for and a framework in which to understand the condition. We show how a logical approach to classifying uveitis by aetiology and anatomical focus of disease provides the basis for treatment strategies (drug and route of administration) and clinical presentation and prognosis. We also show why understanding uveitis is helpful to clinicians working in almost every speciality due to the wide-ranging associations with systemic disease.
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Affiliation(s)
- Unnat Krishna
- Department of Ophthalmology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Deji Ajanaku
- Department of Ophthalmology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alastair K Denniston
- Department of Ophthalmology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
- Centre for Rare Diseases, Institute of Translational Medicine, Birmingham Health Partners, Birmingham, UK
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, UK
| | - Theodora Gkika
- Department of Ophthalmology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
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Lee JH, Agarwal A, Mahendradas P, Lee CS, Gupta V, Pavesio CE, Agrawal R. Viral posterior uveitis. Surv Ophthalmol 2017; 62:404-445. [PMID: 28012878 PMCID: PMC5654632 DOI: 10.1016/j.survophthal.2016.12.008] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 12/12/2016] [Accepted: 12/13/2016] [Indexed: 12/28/2022]
Abstract
The causes of posterior uveitis can be divided into infectious, autoimmune, or masquerade syndromes. Viral infections, a significant cause of sight-threatening ocular diseases in the posterior segment, include human herpesviruses, measles, rubella, and arboviruses such as dengue, West Nile, and chikungunya virus. Viral posterior uveitis may occur as an isolated ocular disease in congenital or acquired infections or as part of a systemic viral illness. Many viruses remain latent in the infected host with a risk of reactivation that depends on various factors, including virulence and host immunity, age, and comorbidities. Although some viral illnesses are self-limiting and have a good visual prognosis, others, such as cytomegalovirus retinitis or acute retinal necrosis, may result in serious complications and profound vision loss. Since some of these infections may respond well to antiviral therapy, it is important to work up all cases of posterior uveitis to rule out an infectious etiology. We review the clinical features, diagnostic tools, treatment regimens, and long-term outcomes for each of these viral posterior uveitides.
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Affiliation(s)
- Joanne H Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Aniruddha Agarwal
- Department of Vitreoretina and Uveitis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Cecilia S Lee
- Department of Uveitis, University of Washington, Seattle, Washington, USA
| | - Vishali Gupta
- Department of Vitreoretina and Uveitis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Carlos E Pavesio
- Department of Medical Retina, Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom
| | - Rupesh Agrawal
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Department of Medical Retina, Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom; Department of Ophthalmology, National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore.
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16
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Abstract
PURPOSE In this article, the authors describe multifocal choroiditis related to disseminated sporotrichosis in patients with HIV/AIDS. METHODS We conducted a retrospective observational study of three patients infected with HIV who presented with disseminated sporotrichosis characterized by cutaneous lesions, multifocal choroiditis, and other manifestations, including osteomyelitis and involvement of the bone marrow, larynx, pharynx, and nasal and oral mucosa. RESULTS Five eyes of three patients with HIV/AIDS showed multifocal choroiditis related to disseminated sporotrichosis. The CD4 counts ranged from 25 to 53 mm. All patients were asymptomatic visually. The ocular disease was bilateral in two patients. The lesion size ranged from 1/3 to 2 disc diameters. None of the patients had vitritis. Of the 12 lesions, 9 were localized in the posterior pole (Zone 1) and 3 were localized in the mild periphery (Zone 2). CONCLUSION Multifocal choroiditis due to disseminated sporotrichosis can occur in profoundly immunosuppressed patients with HIV/AIDS.
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Tsen CL, Chen SC, Chen YS, Sheu SJ. Uveitis as an initial manifestation of acquired immunodeficiency syndrome. Int J STD AIDS 2017; 28:1224-1228. [PMID: 28201950 DOI: 10.1177/0956462417694569] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) is a multisystem disease that can involve the human eyes. Using ophthalmic examination records from January 2006 to November 2015, we retrospectively reviewed all patients who were diagnosed with HIV/AIDS in our hospital. The study was performed at a tertiary referral center in southern Taiwan. Data included age, gender, ophthalmic examinations, systemic conditions, CD4 cell counts, course, and treatment. Eleven patients were identified as having AIDS with uveitis as their presenting manifestation. All were men, with a mean age of 39.5 ± 11.4 years (range 24-56). The mean CD4+ T-cell counts were 91.7 ± 50.3 cells/μl (range 27-169). Ocular diagnoses included cytomegalovirus (CMV) retinitis in five patients, ocular syphilis in four patients, and ocular toxoplasmosis in two patients. Uveitis resolved in all patients after medical treatment. However, a retinal detachment developed in two eyes in CMV retinitis and one eye in ocular syphilis. Ocular manifestations are among the most common clinical features in patients with HIV/AIDS who have varying clinical presentations that affect almost all ocular structures. This study demonstrated that ocular findings could be an initial manifestation of an underlying disease. Awareness of ocular lesions in HIV/AIDS is important for early recognition and management.
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Affiliation(s)
- Chui-Lien Tsen
- 1 Department of Ophthalmology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Shih-Chou Chen
- 1 Department of Ophthalmology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yao-Shen Chen
- 2 Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,3 School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shwu-Jiuan Sheu
- 1 Department of Ophthalmology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,3 School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Mashaghi A, Hong J, Chauhan SK, Dana R. Ageing and ocular surface immunity. Br J Ophthalmol 2017; 101:1-5. [PMID: 27378485 PMCID: PMC5583682 DOI: 10.1136/bjophthalmol-2015-307848] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 04/26/2016] [Accepted: 06/19/2016] [Indexed: 12/22/2022]
Abstract
The prevalence of ocular surface immunopathologies is enhanced in the elderly. This increased prevalence has been attributed to age-related dysregulation of innate and adaptive immune system responses. Age-related changes in ocular surface immunity have similar and distinct characteristics to those changes seen in other mucosal tissues. This mini review provides a brief outline of key findings in the field of ocular ageing, draws comparisons with other mucosal tissues and, finally, discusses age-related changes in the context of immunopathogenesis of infectious keratitis and dry eye disease, two of the most common inflammatory disorders of the ocular surface.
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Affiliation(s)
- Alireza Mashaghi
- Schepens Eye Research Institute, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Jiaxu Hong
- Schepens Eye Research Institute, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Sunil K Chauhan
- Schepens Eye Research Institute, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Reza Dana
- Schepens Eye Research Institute, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
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19
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Cheng WH, Chang CH, Lu PL, Lin HC. Bilateral uveitis associated with concurrent administration of rifabutin and nelfinavir. Taiwan J Ophthalmol 2015; 5:187-188. [PMID: 29018696 PMCID: PMC5602138 DOI: 10.1016/j.tjo.2014.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 06/27/2014] [Accepted: 08/18/2014] [Indexed: 11/17/2022] Open
Abstract
Rifabutin-associated uveitis has been recognized as a dosage-dependent side effect. Previous studies have reported that clarithromycin or fluconazole may elevate concentrations of rifabutin through inhibition of metabolism through the cytochrome P-450 pathway. Nelfinavir is a protease inhibitor widely used in the treatment of human immunodeficiency virus (HIV) infection. The interactions between protease inhibitors and rifabutin have not been reported in clinical practice. Therefore, we present a case of bilateral uveitis associated with coadministration of rifabutin and nelfinavir. Uveitis did not subside until discontinuation of rifabutin. To our knowledge, this is the first report of uveitis with concurrent administration of rifabutin and nelfinavir. Our finding reminds us that rifabutin dosage should be reduced when it is administered with protease inhibitors.
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Affiliation(s)
- Wen-Hsin Cheng
- Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Hsien Chang
- Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Liang Lu
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Hsien-Chung Lin
- Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Ophthalmology, Yuan's General Hospital, Kaohsiung, Taiwan
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20
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Carbonnière C, Couret C, Guillouzouic A, Lefebvre M, Lebranchu P, Weber M. [Ocular syphilis: A retrospective study of 27 cases in Nantes University Hospital (France) from 2000 to 2013]. Rev Med Interne 2015; 36:722-7. [PMID: 26387761 DOI: 10.1016/j.revmed.2015.07.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 06/15/2015] [Accepted: 07/27/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Syphilis may manifest as several distinct ophthalmological forms. The main objective of our study was to describe the diagnostic, therapeutic data and prognosis of ocular syphilis. PATIENTS AND METHODS We retrospectively analysed the cases of syphilitic uveitis diagnosed in the University Hospital of Nantes between 2000 and 2013. RESULTS Twenty-seven patients were included in our study. Their mean age was 53.1 years. Bilateral uveitis was the most frequent clinical presentation (67%). The average diagnostic delay after the first symptoms was 2.8 months. Three patients (11%) presented with an anterior uveitis and 24 (89%) with a posterior uveitis, panuveitis or papillitis. The most frequent clinical signs were papillar lesion (44%), multifocal choroiditis (33%) and chorio-retinitis (37%). Ninety-three percent of the patients were treated with benzathine penicillin intravenously, one patient was treated by intramuscular penicillin injections and another by ceftriaxone intramuscularly. Ocular manifestations alone were sufficient to make the diagnosis of syphilis in 25 patients (93%) and of HIV seroconversion in 3 patients (11%). Forty-one percent of the patients benefited from an adjuvant therapy with corticosteroids. The treatment allowed a visual improvement of -0.48 log MAR (P<0.0001) with an average reduction of retinal central thickness of 70.2 μm (P=0.33). CONCLUSION We did not find a significant difference neither in management nor in results between the HIV seropositive and HIV seronegative groups. Others studies remains controversial about this aspect. The increased frequency of ocular manifestation as well as the increase of syphilis makes systematic screening in uveitis of a great value.
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Affiliation(s)
- C Carbonnière
- Service d'ophtalmologie, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France.
| | - C Couret
- Service d'ophtalmologie, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - A Guillouzouic
- Service de bactériologie, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - M Lefebvre
- Service de maladies infectieuses, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - P Lebranchu
- Service d'ophtalmologie, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - M Weber
- Service d'ophtalmologie, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
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21
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Kempen JH, Sugar EA, Varma R, Dunn JP, Heinemann MH, Jabs DA, Lyon AT, Lewis RA. Risk of cataract among subjects with acquired immune deficiency syndrome free of ocular opportunistic infections. Ophthalmology 2014; 121:2317-24. [PMID: 25109932 PMCID: PMC4252252 DOI: 10.1016/j.ophtha.2014.06.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 02/14/2014] [Accepted: 06/11/2014] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To evaluate the risk of cataract in the setting of AIDS. DESIGN Prospective cohort study. PARTICIPANTS Subjects with AIDS free of ocular opportunistic infections throughout catamnesis. METHODS From 1998 through 2008, subjects 13 years of age or older were enrolled. Demographic characteristics and clinical characteristics were documented at enrollment and semiannually. MAIN OUTCOME MEASURES Cataract was defined as high-grade lens opacity observed by biomicroscopy judged to be the cause of a best-corrected visual acuity worse than 20/40. Eyes that underwent cataract surgery during follow-up were considered to have developed cataract before the first visit when pseudophakia or aphakia was observed. RESULTS Among 1606 participants (3212 eyes) at enrollment, 1.9% (95% confidence interval [CI]: 1.3%-2.7%) were observed to have cataract or prior cataract surgery. Among the 2812 eyes initially free of cataract and followed longitudinally (median follow-up, 4.6 years), the incidence of cataract was 0.37%/eye-year (95% CI: 0.26%-0.53%). In addition to age, significant cataract risk factors included prior cataract in the contralateral eye (adjusted hazard ratio [aHR], 21.6; 95% CI: 10.4-44.8), anterior segment inflammation (aHR, 4.40; 95% CI: 1.64-11.9), prior retinal detachment (aHR, 4.94; 95% CI: 2.21-11.0), and vitreous inflammation (aHR, 7.12; 95% CI: 2.02-25.0), each studied as a time-updated characteristic. Detectable human immunodeficiency virus RNA in peripheral blood was associated with lower risk of cataract at enrollment (adjusted odds ratio, 0.32; 95% CI: 0.12-0.80) but not of incident cataract (aHR, 1.58; 95% CI: 0.90-2.76). After adjustment for other factors, neither the then-current absolute CD4+ T-cell count nor antiretroviral therapy status showed consistent association with cataract risk, nor did an additive diagnosis of other comorbidities. Compared with the available population-based studies that used similar definitions of cataract, the age-specific prevalence of cataract in our cohort was higher than in 1 of 2 such studies, and the age-specific incidence of cataract surgery was higher. CONCLUSIONS Our results suggest cataract may occur earlier among patients with AIDS free of ocular opportunistic infections than in the general population. Cataract risk was associated most strongly with age and with other ocular morbidity in this population. With improved survival, the burden of cataract likely will increase for persons with the human immunodeficiency virus or AIDS.
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Affiliation(s)
- John H Kempen
- Department of Ophthalmology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
| | - Elizabeth A Sugar
- Department of Biostatistics, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Rohit Varma
- Doheny Eye Institute, Department of Ophthalmology, University of Southern California, Los Angeles, California
| | - James P Dunn
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Murk-Hein Heinemann
- Ophthalmic Oncology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Ophthalmology, Cornell University Medical College, New York, New York
| | - Douglas A Jabs
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alice T Lyon
- Department of Ophthalmology, Northwestern University, Chicago, Illinois
| | - Richard A Lewis
- Department of Ophthalmology, Baylor College of Medicine, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
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Patel N, Patel N, Khan T, Patel N, Espinoza LR. HIV Infection and Clinical Spectrum of Associated Vasculitides. Curr Rheumatol Rep 2011; 13:506-12. [DOI: 10.1007/s11926-011-0214-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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23
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Fonollosa A, Giralt J, Pelegrín L, Sánchez-Dalmau B, Segura A, García-Arumí J, Adan A. Ocular Syphilis—Back Again: Understanding Recent Increases in the Incidence of Ocular Syphilitic Disease. Ocul Immunol Inflamm 2009; 17:207-12. [DOI: 10.1080/09273940902741709] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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25
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Lin HC, Lu PL, Chang CH. Uveitis associated with concurrent administration of rifabutin and lopinavir/ritonavir (Kaletra). Eye (Lond) 2007; 21:1540-1. [DOI: 10.1038/sj.eye.6703016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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26
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Parc CE, Chahed S, Patel SV, Salmon-Ceron D. Manifestations and treatment of ocular syphilis during an epidemic in France. Sex Transm Dis 2007; 34:553-6. [PMID: 17667532 DOI: 10.1097/01.olq.0000253385.49373.1a] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To review cases of ocular syphilis presenting to a tertiary uveitis clinic during a syphilis epidemic in France between January 2001 and January 2004. STUDY DESIGN Retrospective chart and patient database review. RESULTS Ten patients who presented with symptoms and signs of uveitis tested positive for active syphilis. Some of the patients also presented with a rash or headache. Human immunodeficiency virus (HIV) antibody testing was positive in eight of the 10 patients, with CD4 cell counts >200 cells/mm3 in seven of the patients. Ocular inflammation resolved and visual acuity improved in all patients after treatment. CONCLUSIONS A diagnosis of ocular syphilis should be considered in any patient with visual loss associated with a rash or headache, irrespective of the patient's CD4 cell count. Ocular syphilis in HIV-positive patients should be treated as neurosyphilis, whereas ocular syphilis in non-HIV patients can be treated as secondary syphilis.
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Affiliation(s)
- Christine E Parc
- Department of Ophthalmology, Cochin Hospital, Paris V University, Paris, France.
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27
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Jeng BH, Holland GN, Lowder CY, Deegan WF, Raizman MB, Meisler DM. Anterior Segment and External Ocular Disorders Associated with Human Immunodeficiency Virus Disease. Surv Ophthalmol 2007; 52:329-68. [PMID: 17574062 DOI: 10.1016/j.survophthal.2007.04.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The eye is a common site for complications of human immunodeficiency virus (HIV) infection. Although cytomegalovirus retinitis remains the most prevalent of the blinding ocular disorders that can occur in individuals with the acquired immunodeficiency syndrome (AIDS), several important HIV-associated disorders may involve the anterior segment, ocular surface, and adnexae. Some of these entities, such as Kaposi sarcoma, were well described, but uncommon, before the HIV epidemic. Others, like microsporidial keratoconjunctivitis, have presentations that differ between affected individuals with HIV disease and those from the general population who are immunocompetent. The treatment of many of these diseases is challenging because of host immunodeficiency. Survival after the diagnosis of AIDS has increased among individuals with HIV disease because of more effective antiretroviral therapies and improved prophylaxis against, and treatment of, opportunistic infections. This longer survival may lead to an increased prevalence of anterior segment and external ocular disorders. In addition, the evaluation and management of disorders such as blepharitis and dry eye, which were previously overshadowed by more severe, blinding disorders, may demand increased attention, as the general health of this population improves. Not all individuals infected with HIV receive potent antiretroviral therapy, however, because of socioeconomic or other factors, and others will be intolerant of these drugs or experience drug failure. Ophthalmologists must, therefore, still be aware of the ocular findings that develop in the setting of severe immunosuppression. This article reviews the spectrum of HIV-associated anterior segment and external ocular disorders, with recommendations for their evaluation and management.
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Affiliation(s)
- Bennie H Jeng
- The Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Affiliation(s)
- Charles Huang
- Department of Ophthalmology and Visual Sciences, University of California at Davis, Sacramento, California, USA
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29
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Affiliation(s)
- Dhananjay Shukla
- Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
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30
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Affiliation(s)
- Shantan Reddy
- Department of Ophthalmology, New York University School of Medicine, New York, New York, USA
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Abstract
The purpose of this article is to outline the interaction between ophthalmologists and internists in the management of uveitis. Two issues will be addressed: 1) which strategies should the internist follow when asked to investigate a case of uveitis; and 2) in which systemic diseases should the internist order an ocular examination to rule out intraocular inflammation. The modern approach to the diagnosis of uveitis is based on the naming-meshing system popularized by Smith and Nozik. After a short history (ocular complaints, general health) an ophthalmic examination is carried out to determine the anatomic structures involved. Based on the results a uveitis is classified as anterior uveitis, intermediate uveitis, posterior uveitis, or panuveitis. Associated factors (eg, unilateral versus bilateral, acute versus chronic, granulomatous versus nongranulomatous, etc.) are also assessed. Based on this information the type of uveitis will be named (eg, acute, nongranulomatous, unilateral, anterior uveitis) and matched (meshing) to a potential list of etiologies (eg, viral iritis, HLA-B 27 associated iritis). Targeted questioning and selected medical and laboratory investigations based on the shortlist will then identify a possible cause for a particular patient's uveitis. In other words the ophthalmologist should never ask the internist to run the full battery of tests in a patient with uveitis. He rather should indicate which type of uveitis is present and what are the most likely diagnoses to be excluded. Many systemic diseases cause diffuse inflammation and are associated with uveitis. These include tuberculosis, spirochaetal diseases such as Lyme disease and syphilis, sarcoidosis, Behçet syndrome, juvenile idiopathic arthritis, and HIV infection amongst many others. Routine ophthalmic examination in patients with systemic disease may be indicated for diverse reasons: to prevent profound damage due to asymptomatic uveitis in JIA; to detect diagnostic clues in patients with febris e causa ignota; or to rule out opportunistic infections in HIV positive patients. It is clear that the information gained from routine examination in systemic disease will be greatly dependent on the prevalence of ocular involvement in a particular disease.
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Affiliation(s)
- P G Kestelyn
- Afdeling Oogheelkunde, Universitair Ziekenhuis, Gent.
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Ng WT, Versace P. Ocular association of HIV infection in the era of highly active antiretroviral therapy and the global perspective. Clin Exp Ophthalmol 2005; 33:317-29. [PMID: 15932540 DOI: 10.1111/j.1442-9071.2005.01001.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Ocular involvement is a common complication of HIV infection. Since the late 1990s, widespread use of highly active antiretroviral therapy (HAART) has altered the spectrum, and reduced the incidence of ocular involvement in developed countries. The incidence of the most common ocular opportunistic infection, cytomegalovirus retinitis, has decreased tremendously. However, immune recovery uveitis secondary to HAART has emerged as a frequent visually threatening condition. Early diagnosis and treatment with periocular steroids is helpful in minimizing visual loss. Clinicians should also be aware that certain antimicrobial agents used to treat opportunistic infections in HIV-positive patients are associated with potentially serious ocular side effects. In developing countries, where most of the world's 40 million HIV-positive patients live, the spectrum and incidence of ocular involvement differ from those in developed countries. The lack of HAART availability is among the many causes of these differences, which may include nutritional factors, basic medical care availability and the levels of exposure to different infectious agents. These factors add to the already challenging task of treating ocular complications and preventing blindness in HIV-positive patients in developing countries.
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Affiliation(s)
- Weng T Ng
- Department of Ophthalmology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.
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Tran THC, Cassoux N, Bodaghi B, Fardeau C, Caumes E, Lehoang P. Syphilitic uveitis in patients infected with human immunodeficiency virus. Graefes Arch Clin Exp Ophthalmol 2005; 243:863-9. [PMID: 16158310 DOI: 10.1007/s00417-005-1137-6] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2004] [Revised: 12/21/2004] [Accepted: 01/05/2005] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND This work investigates the incidence and clinical features of syphilitic uveitis in patients infected with human immunodeficiency virus (HIV). MATERIAL AND METHODS We retrospectively reviewed syphilitic uveitis in patients coinfected with HIV that presented at a referral center between July 2001 and November 2003. RESULTS Twelve patients (20 eyes) were included. The ocular manifestations of syphilis led to the discovery of HIV-1 seropositivity in three patients. All patients were male and homosexual. One patient has been previously treated for syphilis with benzathine penicillin G. One patient presented with anterior uveitis and 11 patients had panuveitis or posterior uveitis. Necrotizing retinitis was noted in seven eyes (35%), posterior placoid chorioretinitis in six eyes (30%) and optic nerve involvement in five eyes (25%). Of nine patients with available cerebrospinal fluid (CSF) studies, seven (77.8%) had CSF abnormalities. Eleven patients were treated with intravenous penicillin G and one with intravenous ceftriaxone sodium. One patient required a second course of antibiotics to control uveitis. Ocular inflammation decreased and visual acuity improved in all nine patients for whom follow-up was available after treatment. CONCLUSION Manifestations of syphilitic uveitis in HIV-infected patients are multiple, with high frequencies of posterior uveitis, posterior placoid chorioretinitis, necrotizing retinitis and optic nerve involvement. Syphilitic uveitis in HIV-infected patients seems to have a more severe course and may relapse despite high-dose intravenous penicillin therapy.
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Affiliation(s)
- Thi Ha Chau Tran
- Service d'Ophtalmologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
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Abstract
PURPOSE To evaluate the prevalence of the most common serious adverse events associated with intravitreous (IVT) injection. METHODS A systematic search of the literature via PubMed from 1966 to March 1, 2004, was conducted to identify studies evaluating the safety of IVT injection. Data submitted in New Drug Applications to the U.S. Food and Drug Administration for drugs administered into the vitreous were included where available. Serious adverse events reported in each study were recorded, and risk per eye and risk per injection were calculated for the following serious adverse events: endophthalmitis, retinal detachment, iritis/uveitis, intraocular hemorrhage, ocular hypertension, cataract, and hypotony. Rare complications also were noted. RESULTS Data from 14,866 IVT injections in 4,382 eyes were analyzed. There were 38 cases of endophthalmitis (including those reported as pseudoendophthalmitis) for a prevalence of 0.3% per injection and 0.9% per eye. Excluding cases reported specifically as pseudoendophthalmitis, the prevalence of endophthalmitis was 0.2% per injection and 0.5% per eye. Retinal detachment, iritis/uveitis, ocular hypertension, cataract, intraocular hemorrhage, and hypotony were generally associated with IVT injection of specific compounds and were infrequently attributed by the investigators to the injection procedure itself. Retinal vascular occlusions were described rarely in patients after IVT injection, and it was unclear in most cases whether these represented true injection-related complications or chance associations. CONCLUSION The risk of serious adverse events reported after IVT injection is low. Nevertheless, careful attention to injection technique and appropriate postinjection monitoring are essential because uncommon injection-related complications may be associated with permanent vision loss.
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Affiliation(s)
- Rama D Jager
- The Beetham Eye Institute, Joslin Diabetes Center and Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
HIV/AIDS affects millions of people worldwide. In the early stages of epidemic, eyes were affected because the CD4 T-lymphocytes count of HIV-infected patients dropped rapidly. Today, with the advent of highly active antiretroviral therapy, HIV-positive individuals live longer with a better quality of life. However, because a cure has not been found, many patients with HIV will develop ocular complications at some point. Ophthalmologists play an important role in the care of these patients. We must be prepared to work as part of a multidisciplinary staff, helping to understand the causes and try to achieve the best management of disease in order to prevent blindness. Most HIV-related ocular manifestations are discussed in this article, with a review of studies within the past 2 years. We hope government authorities, pharmaceutical industries, researchers and people from all nations stand together with two goals--less suffering and definitive cure.
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Affiliation(s)
- Haroldo V Moraes
- Uveitis Service, Department of Ophthalmology, Federal University of Rio de Janeiro, 11 Andar Ilha do Fundao, Rio de Janeiro-RJ, Brazil 21491-590.
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36
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Accorinti M, Ciapparoni V, Pirraglia MP, Pivetti-Pezzi P. Treatment of severe ocular hypotony in AIDS patients with cytomegalovirus retinitis and cidofovir-associated uveitis. Ocul Immunol Inflamm 2001; 9:211-7. [PMID: 11815890 DOI: 10.1076/ocii.9.3.211.3968] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe the medical treatment of severe ocular hypotony in HIV-seropositive patients with cytomegalovirus retinitis and cidofovir-associated uveitis. PATIENTS AND METHODS Two HIV-seropositive patients with cytomegalovirus retinitis and cidofovir-associated uveitis complicated by severe ocular hypotony were unresponsive to conventional therapy after treatment with cidofovir was stopped. They were subsequently treated successfully with ibopamine 2% eyedrops and dexamethasone 0.1% eyedrops. RESULTS In both cases, an increase in intraocular pressure to normal values was observed on average 18.5 days after starting treatment. Intraocular pressure remained stable while on therapy for a mean follow-up of 9.5 months. During the follow-up period, any attempt to stop treatment was followed by an intraocular pressure decrease; conversely, restoration of therapy increased intraocular pressure to normal values. No reactivation of cidofovir-associated uveitis or cytomegalovirus retinitis was observed during the follow-up period. CONCLUSIONS Ibopamine 2% eyedrops in combination with dexamethasone 0.1% eyedrops is a satisfactory therapy for severe ocular hypotony in patients with cytomegalovirus retinitis and cidofovir-associated uveitis.
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Affiliation(s)
- M Accorinti
- Servizio Speciale di Immunovirologia Oculare, Istituto di Oftalmologia, Università di Roma La Sapienza, Rome, Italy
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