Acute Retinal Necrosis Presenting as Central Retinal Artery Occlusion with Cilioretinal Sparing

Purpose

To report a case of acute retinal necrosis presenting as central retinal artery occlusion with cilioretinal sparing.

Methods

Single inter ventional case report. The findings of the ophthalmic examination, MRI, blood parameters, biopsy results and clinical course are reported.

Results

A forty two year old gentleman reporting sudden loss of sight, ophthalmic examination revealing uveitis, central retinal artery occlusion with cilioretinal sparing and peripheral necrotizing retinitis.

Conclusions

Central retinal artery occlusion can be an early feature of acute retinal necrosis (ARN).

A low balance between microparticles expressing tissue factor pathway inhibitor and tissue factor is associated with thrombosis in Behçet's Syndrome

Thrombosis is common in Behçet's Syndrome (BS), and there is a need for better biomarkers for risk assessment. As microparticles expressing Tissue Factor (TF) can contribute to thrombosis in preclinical models, we investigated whether plasma microparticles expressing Tissue Factor (TF) are increased in BS. We compared blood plasma from 72 healthy controls with that from 88 BS patients (21 with a history of thrombosis (Th+) and 67 without (Th-). Using flow cytometry, we found that the total plasma MP numbers were increased in BS compared to HC, as were MPs expressing TF and Tissue Factor Pathway Inhibitor (TFPI) (all p < 0.0001). Amongst BS patients, the Th+ group had increased total and TF positive MP numbers (both p ≤ 0.0002) compared to the Th- group, but had a lower proportion of TFPI positive MPs (p < 0.05). Consequently, the ratio of TFPI positive to TF positive MP counts (TFPI/TF) was significantly lower in Th+ versus Th- BS patients (p = 0.0002), and no patient with a TFPI/TF MP ratio >0.7 had a history of clinical thrombosis. We conclude that TF-expressing MP are increased in BS and that an imbalance between microparticulate TF and TFPI may predispose to thrombosis.

Visual loss and falls: a review

Falls are an important health issue. They cause significant morbidity and mortality particularly in older people, and also have marked psychological effects on the individual. The literature focuses particularly on older adults, an age group in which both visual impairment and falls are more prevalent, as is the associated morbidity. In this review, we summarise the current literature and point to further studies which need to be undertaken. The consequences of falls are well recognised, and there has been considerable work into identifying risk factors. Changes in visual components such as visual field, acuity, contrast sensitivity and stereopsis all have a part and the co-existence of other sensory impairments certainly increases the risk of falls. However there remain considerable gaps in our knowledge of the relationship between visual loss and falls, for example in patients with diabetic eye disease. Furthermore, there is also conflicting data as to the importance of different visual components. Various interventions, such as programmed inter-disciplinary involvement, have shown promise, however these need further confirmation of their efficacy and cost effectiveness. An added confounder may be that an intervention (eg, cataract extraction) paradoxically affects an individual's future activity level and behaviour, thereby increasing the risk of falling. With an ageing population the importance of this topic is likely to increase, as will the potential benefits of optimising our assessment and management of these patients.

Treating ocular toxoplasmosis: current evidence

The current treatment of ocular toxoplasmosis is controversial. The mainstay of treatment has been pyrimethamine and sulphonamides with or without systemic corticosteroids, but the actual evidence that antibiotics have a beneficial effect in recurrent toxoplasmic retinochoroiditis is unsupported by randomised placebo controlled trials. Thus far there have only been three studies looking at the efficacy of antibiotic treatment, all of which were methodologically weak and two of which were perfomed more than 30 years ago. All studies reported adverse effects from treatment. There is an urgent need for further randomised, double blind, placebo controlled studies for lesions in all parts of the retina and to test the efficacy of adjunctive corticosteroid treatment.

Immunity and Toxoplasma retinochoroiditis

Toxoplasma infection accounts for up to 50% of all cases of posterior uveitis worldwide. In this review the control of Toxoplasma infection generally, and specific in the eye, by the immune system is discussed.

Management of Behçet disease: a systematic literature review for the European League Against Rheumatism evidence-based recommendations for the management of Behçet disease

OBJECTIVES

To present and analyse the literature sources regarding the management of Behçet disease (BD) identified during the systematic literature research, which formed the basis for the European League Against Rheumatism (EULAR) evidence-based recommendations for the management of BD.

METHODS

Problem areas and related keywords regarding the management of BD were determined by the multidisciplinary expert committee commissioned by EULAR for developing the recommendations. A systematic literature research was performed using MedLine and Cochrane Library resources through to December 2006. Meta-analyses, systematic reviews, randomised controlled trials (RCTs), open studies, observational studies, case control studies and case series' involving > or = 5 patients were included. For each intervention the effect size and number needed to treat were calculated for efficacy. Odds ratios and numbers needed to harm were calculated for safety issues of different treatment modalities where possible.

RESULTS

The literature research yielded 137 articles that met the inclusion criteria; 20 of these were RCTs. There was good evidence supporting the use of azathioprine and cyclosporin A in eye involvement and interferon (IFN)alpha in mucocutaneous involvement. There were no RCTs with IFNalpha or tumour necrosis factor (TNF)alpha antagonists in eye involvement. Similarly controlled data for the management of vascular, gastrointestinal and neurological involvement is lacking.

CONCLUSION

Properly designed, controlled studies (new and confirmatory) are still needed to guide us in managing BD.

Systematic review of ethnic variation in the phenotype of Behcet's disease

OBJECTIVE

To systematically review the strength of evidence that supports the premise that there are different expressions in the clinical phenotype of Behcet's disease (BD) in different ethnic groups.

METHODS

The hierarchy of evidence and inclusion criteria were decided prior to the search for relevant literature. We searched Medline and Embase databases between 1966 and March 2005 for publications related to epidemiology of Behcet's disease or syndrome. Relevant papers were extracted in hard copy and the references of all these papers were then hand searched for further articles.

RESULTS

Four population-based studies, of which two were from Turkey, and seven non-population-based comparative studies were found. The majority of literature identified were case series and were not included in the review. There were insufficient cross-sectional studies from different populations to be able to compare phenotypic differences. None of the comparative studies found evidence of a difference in the clinical expression of BD between ethnic groups.

CONCLUSIONS

There is insufficient evidence to support the premise that there are different expressions in the clinical phenotype of BD in different ethnic groups. Population-based, cross-sectional surveys or case-control studies using standardized criteria and clear ethnic definitions are suggested to investigate this hypothesis further.

Toxoplasmic retinochoroiditis presenting in childhood: clinical findings in a UK survey

AIM

To compare the clinical findings in children with symptomatic toxoplasmic ocular lesions attributable to infection acquired before or after birth.

METHODS

Cases were prospectively ascertained for 24 months through national surveillance units and reference laboratories in the British Isles. Age and presenting symptoms, site of lesion and visual impairment in children who were classified as acquiring infection either before or after birth on the basis of clinical and serological findings were compared.

RESULTS

31 children had toxoplasmic retinochoroiditis, 15 had congenital infection and all but three of these presented before the age of 4 years. The remaining 16 children acquired toxoplasmosis postnatally, and 14 of 16 presented after the age of 10 years. A further four children had retinochoroiditis due to other causes. The presence of bilateral, multiple or posterior pole lesions did not distinguish between the two groups, but most children (16/19; 84%) presenting with acute ocular symptoms had postnatally acquired infection. Unilateral visual impairment (Snellen < or =6/18) was equally prevalent in the two groups (4/9 before birth v 7/16 after birth; p>0.5). Only two children had bilateral visual impairment, both of whom had congenital infection. No child was blind.

CONCLUSIONS

About 50% of children with ocular lesions due to toxoplasmosis had postnatal infection. Retinochoroidal lesions due to infection before and after birth were indistinguishable. The prognosis for bilateral visual function was good, regardless of when infection was acquired.

Low-dose intra-venous cyclophosphamide therapy in a patient with neurological complications of Behçet’s disease

Behçet's disease (BD) is a chronic relapsing-remitting inflammatory disorder of unknown origin, affecting multiple organs. Neurological involvement is one of the most devastating manifestations of BD and may be fatal. We report a 36-year-old woman with neuro-Behçet who was treated with low-dose pulse cyclophosphamide (St. Thomas' protocol) and methylprednisolone, with almost complete clinical remission.

Expression analysis of immune response genes of Müller cells infected with Toxoplasma gondii

PURPOSE

To investigate changes in immune response genes following Toxoplasma gondii infection of Müller cells.

METHODS

Human Müller cells were infected or mock infected with two strains of T. gondii (RH and Prugniaud). RNA and supernatants were collected from infected and uninfected cells at 2 and 24 h. RNA from the two time points were compared using a custom made DNA microarray. Real time PCR or human cytokine antibody array was used to confirm up-regulation of immune molecules.

RESULTS

Gene expression in infected cells showed up-regulation of CCL2, IL-6, CXCL8, and CXCL2. CCL2 and CXCL2 gene expression was confirmed by real time PCR. IL-6 and CXCL8 protein production was confirmed by a cytokine antibody array. IL-4 production was observed by cytokine antibody array but not by DNA microarray. In contrast, infection with T. gondii did not induce interferon-gamma (IFNgamma) and IL-12 expression, molecules conventionally associated with the inter-conversion of tachyzoite to bradyzoite.

CONCLUSION

These results indicate that while in vitro infected Müller cells may be capable of inducing an immune response by attracting blood-borne leucocytes, they do not appear able to directly control the proliferation of T. gondii.

Associations of major histocompatibility complex class I chain-related molecule polymorphisms with Behcet's disease in Caucasian patients

HLA-B*51 is known to be associated with Behcet's disease (BD) in many ethnic groups. The pathogenic gene, however, may lie close to the HLA-B locus and therefore be in linkage disequilibrium with HLA-B*51. On the basis of the proximity of MIC genes to HLA-B, their expression pattern and their affinity for the activating NKG2D receptor on natural killer (NK) cells and gammadelta T cells, these molecules have been postulated as susceptibility factors in BD. DNA from 56 western European Caucasians with BD and 90 Caucasian controls were analysed by polymerase chain reaction using allele-specific primers for MICA and MICB alleles. An increased allele frequency of MICA*009 was found in the BD patient group (25.0%) when compared with the controls (7.2%). This was associated with a corresponding decrease in MICA*008 in the BD patients (36.6%) compared with the controls (46.7%), which was not significant. MICA*009 was strongly associated with the presence of HLA-B*51 in patients and controls. No significant difference in frequency of MICB alleles was found between patients and controls. Both HLA-B*51 and MICA*009 are strongly associated with BD in a pure Caucasian BD patient group, and the two alleles are in linkage disequilibrium. No MICB allele was found to associate significantly with the disease, an unexpected finding considering the close proximity of the MICA and MICB loci. Our results suggest that while MICB does not influence the development of BD, polymorphisms in MICA may be pathogenic, perhaps through the interaction with NK and gammadelta T cells.

Intravitreal triamcinalone acetonide for refractory uveitic cystoid macular oedema: longterm management and outcome

PURPOSE

To establish the role of intravitreal triamcinalone acetonide (TA) in the long term management of refractory uveitic cystoid macular oedema (CMO) and to determine the long term visual outcome in these patients.

METHOD

This is a retrospective observational case series. All patients had resistant CMO and active inflammation. The primary outcome measure was complete resolution of CMO on ocular coherence tomography. Visual acuity and intraocular pressure were also monitored. Twelve eyes of twelve patients received 2 (n = 10) to 4 (n = 2) mg of intravitreal TA. All had previously been unresponsive to orbital floor steroids. Fluorescein angiography was performed where indicated.

RESULTS

There was complete resolution of CMO in all patients. Nine patients had improvement in acuity at there final follow up (mean follow up 40.5 months). Seven had improved by 2 lines (58%). In 3 patients there was no visual improvement. These 3 failed to respond to re-treatment. Five other patients were re-treated because of recurring CMO and deteriorating VA (median time to re-treatment 4 mths). The mean number of re-treatments for this group with orbital floor TA was three. 41.6% of patients developed ocular hypertension (33.8 mhg mean). One required a trabeculectomy.

CONCLUSIONS

2 mg of intravitreal TA is effective even in cases of resistant uveitic CMO. Although re-treatment is often required, the initial response to treatment can be maintained by subsequent orbital floor steroid injections.

The visual field in toxoplasmic retinochoroiditis

AIMS

To document loss of central field in patients with scars from toxoplasmic retinochoroiditis close to the disc after resolution of disease.

METHODS

Patients with a clinical diagnosis of toxoplasmic retinochoroiditis were enrolled from four centres. Automated central visual field testing was performed when their disease had settled and retinal photographs of the lesions were taken. The type of central field defect (whether absolute or relative) and whether it broke out to the periphery were correlated with the size of the retinochoroidal scar and its proximity to the optic nerve head.

RESULTS

69 eyes were enrolled; 16 (26%) were discarded because of poor field performance. Of the 53 remaining eyes, 31 showed absolute defects and 20 relative defects. Scars within one disc diameter of the disc were more likely to be associated with absolute defects breaking out to the periphery.

CONCLUSION

The scarring induced by toxoplasmic retinochoroiditis is associated with considerable field loss when it occurs close to the optic nerve head. Current treatment is unlikely to ameliorate this situation. The degree of visual field loss should be an outcome measure for future trials of the efficacy of treatment trials for the disease.

Are cytokine gene polymorphisms associated with outcome in patients with idiopathic intermediate uveitis in the United Kingdom?

BACKGROUND/AIM

Competing levels of cytokines, either locally within the eye or systemically, may influence the eventual outcome of ocular inflammation. Polymorphism in the promoter part of the genes controlling cytokine production may result in either higher or lower production of the relevant cytokine to a given stimulus. The authors hypothesised that such polymorphisms may relate to visual outcome in patients with idiopathic intermediate uveitis.

METHODS

DNA was obtained from 125 patients with idiopathic intermediate uveitis and analysed for the interleukin 10 IL-10-1082G/Alpha and IL-10-819C/T, and interferon gamma IFNgamma 874T/A gene polymorphisms. Associations with disease were calculated by both allelic frequency and haplotype analysis, and associations between ocular disease outcomes and the presence of polymorphisms were identified. A bad outcome was defined as loss of vision <6/12 Snellen in both eyes at 5 years from presentation when the eyes were quiet.

RESULTS

An initial screen showed that the 874T allele of the IFNgamma gene was more prevalent in patients than controls (chi2= 7.9; p = 0.004 OR 1.7; 95% CI 1.2 to 2.6 (Pc = 0.02), whereas the IL-10-1082/-819 AT haplotype of the interleukin 10 (IL-10) gene was not. Analysis of disease outcome showed an association between IL-10-1082 AA homozygosity and bad outcome (chi2= 13; p = 0.0003). Moreover, the two cytokine polymorphisms taken together showed that up to 75% of patients with a poor visual outcome had the combined IFNgamma 874TA or TT genotype together with the IL-10-1082AA genotype (chi2= 13.2 p = 0.0008 OR 6.4; 95% CI 1.85 to 23.6 Pc = 0.1).

CONCLUSION

These results show that disease outcome in intermediate uveitis may be partly determined by a complex interplay between cytokine genes and these results may have implications for future treatment with biological agents that target these cytokines.

The effect of Toxoplasma gondii infection on expression of chemokines by rat retinal vascular endothelial cells

Cells infected by Toxoplasma gondii undergo up-regulation of proinflammatory cytokines, organelle redistribution, and protection from apoptosis. During infection in man, the parasite encysts within the retina, a process that results in retinochoroiditis which can lead to permanent loss of sight. The reasons for the parasite to infect retinal tissue and the mechanisms by which it encysts are not clearly understood. We studied the effect of infection with T. gondii of retinal vascular endothelial cells using the Clontech Atlastrade mark array system in order to elucidate changes in gene expression. We compared hybridization of RNA to the array from infected and uninfected cells at two time points; 2 and 24 h. Exposure to T. gondii after 2 h resulted in change of expression of approximately 6% of genes on the array, including those involved in cell structure, protein and vesicle trafficking, cell-cycle regulation, transcriptional and translational machinery, and apoptosis. Among the genes involved in the inflammatory response, chemokine genes such as GRO1 (Growth Regulated Oncogene 1), MCP-1 (Monocyte Chemotactic Protein-1), FKN (Fractalkine) and RANTES (Regulated upon Activation, Normal T Cell Expressed and Secreted) were found to be up-regulated and protein production was confirmed by ELISA. However after 24 h of infection, GRO1, MCP-1 and FKN were down-regulated, confirmed by RT-PCR. Thus, invasion of retinal vascular endothelium (RVE) cells by T. gondii leads to the production of chemokines important in directing the traffic of inflammatory cells to the infected area.

Chemokine gene polymorphisms associate with gender in patients with uveitis

Uveitis is an inflammatory condition of ocular tissue characterized by leukocyte infiltration, tissue damage, and decreased visual acuity. Chemokines have been implicated in the pathogenesis of uveitis. Polymorphisms in the genes encoding chemokines have been described as affecting chemokine production or function. We analyzed the frequency of single-nucleotide polymorphisms (SNPs) in genes encoding CCL2 (-2518 and -2076) and CCL5 (-403 and -28) in patients with Behçet's disease (BD), a systemic form of uveitis, and patients with retinal vasculitis (RV), an organ-specific form of disease. We report that there was no association between any SNP and disease. However, when segregated on the basis of gender the CCR5 -403 AA genotype was only found in male patients with BD. Similarly, CCL2 genotypes 1/2 were predominant in males, while genotype 4 was significantly associated with disease in female patients with BD. Differences in disease symptoms and severity between males and females have been described in BD and gender-specific genetic differences in chemokine gene function may be involved.

Steroid prophylaxis in eyes with uveitis undergoing phacoemulsification

AIM

To compare the efficacy of two preoperative steroid regimens for cataract surgery in patients with uveitis.

METHODS

40 uveitis patients with cataract underwent phacoemulsification and intraocular lens (IOL) implantation. Preoperatively they were randomised into two groups: group 1 (20 patients) received a single dose of intravenous methylprednisolone (15 mg/kg) half an hour before surgery, and group 2 (20 patients) received a 2 week course of oral prednisolone (0.5 mg/kg) which was tapered postoperatively. Preoperatively patients had aqueous flare and cells measured with the Kowa laser flare meter. On days 1, 7, 28, and 90 aqueous flare and cells were measured, and on days 7 and 90 fluorescein angiography was performed to determine the incidence of cystoid macular oedema (CMO).

RESULTS

At all postoperative visits the mean increase in flare was greater for group 1 (intravenous steroid). Patients with posterior synechiae had greater blood-aqueous barrier damage (BAB) postoperatively. There were no statistically significant differences in logMAR visual acuity and incidences of CMO between the two groups at 7 and 90 days.

CONCLUSION

A 2 week course of oral prednisolone, tapered postoperatively, produced a better recovery of the BAB than a single dose of intravenous methylprednisolone and is thus the recommended preoperative regimen.

Analysis of the CC chemokine receptor 5 (CCR5) Delta32 polymorphism in Behcet's disease

Chemokines are important determinants of the early inflammatory response. The CC chemokine receptor 5 (CCR5) Delta32 variant results in a non-functional form of the chemokine receptor, and has been implicated in a variety of immune-mediated diseases. To investigate its role in the pathogenesis of Behçet's disease, we studied 350 patients and 519 healthy controls from three ethnic groups. While significant inter-ethnic variation in allele frequency was observed, no association was identified with disease, even when data were stratified by the known susceptibility gene HLA-B*51.

Behçet's disease: from Hippocrates to the third millennium

Behçet's disease (BD) is characterised by recurrent episodes of orogenital aphthae, systemic vasculitis, and systemic and retinal venous thrombosis. An association between HLA-B51 and BD was first identified over 20 years ago, but recently identified gene associations implicate regions both within and without the MHC in the immunological events underlying the lesions in BD. These include allelic variants within the tumour necrosis factor gene region and within the MHC class I chain related gene region, the factor V Leiden mutation, which is associated with retinal vascular occlusion, and alleles of the intercellular adhesion molecule gene. No single causative gene for BD has emerged; the evidence indicates that the underlying immune events in BD are triggered by a microbial antigen and subsequently driven by genetic influences which control leucocyte behaviour and the coagulation pathways. Knowledge of these risk factors may permit a more accurate prognosis for a given patient, and identify new pathways for more targeted intervention than is currently available.

Behçet's disease in patients of west African and Afro-Caribbean origin

AIM

To report the presence of Behçet's disease with ocular involvement in patients of west African or Afro-Caribbean origin.

METHODS

Case series of eight patients reporting to a tertiary uveitis service.

RESULTS

Eight patients with typical features of the disease are presented. Six of the eight patients were tested and found to be HLA-B51 negative.

CONCLUSION

Behçet's disease has only been reported in sporadic case reports in the indigenous west African and Afro-Caribbean populations, in whom the incidence of HLA B51 is also very low. A series of patients from the London region presented with the typical symptoms and signs of disease, most of whom were also HLA B51 negative. The presence of disease in this population, when absent in the indigenous population, suggests either that ascertainment of disease is poor in the indigenous population or that acquired factors may be important in the aetiology of the disease.

Corticosteroid-induced osteoporosis in patients with uveitis

AIMS

To estimate the prevalence of low bone density and osteoporosis in a population of patients with uveitis taking systemic steroid treatment; to clarify the risks of steroid-induced fracture and to suggest a protocol for the prevention and management of bone loss in patients with ophthalmic inflammatory disease.

METHODS

Bone densitometry was performed on 129 adult patients with prednisolone-treated uveitis from four centres. Information on uveitis diagnosis, associated risk factors, steroid dosage and treatment duration, prophylaxis and management, was collected. Juveniles, patients with scleritis and those who had used deflazacort, were excluded.

RESULTS

Steroid treatment time varied from 13 weeks to 31 years, and the total dosage from 1.29 g to 166.5 g. Twenty-six percent of patients also used one or more immunosuppressives. Forty-eight percent had additional risk factors for bone loss. Bone density was abnormally low in 44.2%, and 15.5% had osteoporosis. Osteoporosis was substantially more common in males (20.6%, all under 60 yrs) than in females (9.8%). Seven symptomatic fractures occurred in patients on treatment. Bone loss correlated with total steroid dose, mean dose, duration of treatment and the presence of pre-existing risk factors.

CONCLUSIONS

The prevalence of steroid-induced osteoporosis and fracture is low for patients with uveitis but young males are at risk. Patients at high risk should be identified, and prophylaxis and treatment should be used as required. The guideline of the National Osteoporosis Society is recommended as a management protocol.

Reliability of expert interpretation of retinal photographs for the diagnosis of toxoplasma retinochoroiditis

AIMS

To measure agreement and estimate sensitivity and specificity of uveitis experts' interpretation of retinal photographs for the diagnosis of toxoplasma retinochoroiditis.

METHODS

The authors collated 96 retinal photographs from patients presenting with symptomatic posterior uveitis to ophthalmology clinics within a defined geographical area. Five uveitis experts independently ranked each photograph as definite, probable, possible, or not toxoplasma retinochoroiditis. They measured interobserver agreement based on an intraclass correlation coefficient and estimated sensitivity and specificity for each observer using a maximum likelihood model.

RESULTS

The intraclass correlation coefficient for all five observers was 0.62 (95% CI: 0.54 to 0.69). Estimates of sensitivity and specificity for individual observers ranged from 71% to 96% and 58% to 100% respectively when appearances were dichotomised as definite or probable toxoplasma retinochoroiditis, versus possible or not.

CONCLUSION

Agreement between uveitis experts on the interpretation of retinal photographs was moderate to good, but the estimates of sensitivity and specificity of their interpretation for the diagnosis of toxoplasma retinochoroiditis were highly variable. Assuming that interpretation of photographs is similar to real time ophthalmoscopy, clinicians need to beware that treatment decisions made on the basis of a single assessment will include patients without toxoplasma retinochoroiditis and will miss patients with the disease.

Acute retinal necrosis in children caused by herpes simplex virus

PURPOSE

To report the diagnosis, management, and outcome of acute retinal necrosis syndrome in children.

METHOD

Case series of three consecutive children aged 11 years and younger who were diagnosed with acute retinal necrosis. In addition to full ocular and systemic examinations, the children underwent vitreous biopsy (Patients 1 and 2) or aqueous tap (Patient 3) for polymerase chain reaction analysis.

RESULTS

All patients had unilateral retinitis that was associated with preexisting chorioretinal scars, and two patients (Patients 1 and 3) had concurrent extraocular central nervous system abnormalities. Intraocular herpes simplex virus was detected in all three children: Type 1 in Patient 1 and Type 2 in Patients 2 and 3. In addition, all three children had a history of extraocular herpes simplex virus infection.

CONCLUSIONS

Retinitis associated with preexisting chorioretinal scars and detectable intraocular herpes simplex virus on polymerase chain reaction was common to all three children with acute retinal necrosis.

Hypopyon uveitis and iris nodules in non-Hodgkin's lymphoma: ocular relapse during systemic remission

We report the case history of a patient with peripheral non-Hodgkin's lymphoma in systemic remission, who presented with a pseudohypopyon and iris nodules. Iris biopsy confirmed the presence of intraocular tumour, which subsequently responded to orbital radiation. Ocular remission, however, was soon followed by a systemic relapse, suggesting that the eye may act as a sanctuary site for tumour cells during chemotherapy, and that cells may metastasize from the eye back to the periphery during systemic remission.

Intravitreal triamcinolone for uveitic cystoid macular edema: an optical coherence tomography study

PURPOSE

To investigate the use of intravitreal injection of triamcinolone acetonide (TA) for the treatment of refractory uveitic cystoid macular edema (CME).

DESIGN

Prospective, nonrandomized, self-controlled comparative trial.

PARTICIPANTS

Six patients with chronic CME resistant to treatment with systemic steroids, orbital floor steroids, and cyclosporine A. Three patients were followed for more than 1 year, and the other three for between 3 and 9 months.

INTERVENTION

Injection of 2 mg of TA into the vitreous cavity.

TESTING

Optical coherence tomography scanning of the fovea before and after injection and logarithmic minimal angle of resolution visual acuity.

MAIN OUTCOME MEASURES

Visual acuity, retinal thickness, cystoid space height, and intraocular pressure.

RESULTS

There was complete anatomic resolution of CME in five of the six cases within 1 week after injection. Cystoid spaces began to return between 6 weeks and 3 months after injection. Two patients with longer term follow-up responded to further orbital floor steroid injection and had no CME 1 year later. One patient had raised intraocular pressure develop, requiring a trabeculectomy. Mean improvement in visual acuity after 12 months was 0.27 (range, 0.14-0.42).

CONCLUSIONS

Complete anatomic and, to some extent, functional recovery can be induced by intravitreal TA despite long-term refractory inflammatory CME. Optical coherence tomography aids in the management of these cases.

Urinary neopterin in idiopathic retinal vasculitis

AIMS

To determine whether urinary neopterin:creatinine (UNC) ratios relate to disease activity in idiopathic retinal vasculitis (RV).

METHODS

18 patients with RV were prospectively recruited into a year long longitudinal study. Patients collected first morning urine samples on a weekly basis and on the same day completed a diary which documented their subjective view of RV activity and any concurrent infection. They were examined in clinic on a 6-8 weekly basis and an objective assessment was made of RV disease activity. 14 healthy controls collected urine samples in the same way.

RESULTS

UNC ratios were significantly higher in patients than in controls (p=0.004, Mann-Whitney U test). UNC ratios were significantly higher when, according to their diaries, the patients had a subjective flare up of RV (p=0.001, Mann-Whitney U test). Subjective increased RV activity occurred more often when the patients had a concurrent infection (p<0.0001, chi(2) test). There was no significant difference in the UNC ratio between objective clinical relapse and non-relapse of RV. There was moderate agreement between the clinical assessment and patients' subjective impression of RV activity (kappa=0.48).

CONCLUSIONS

Higher neopterin levels reflect cell mediated disease that occurs in RV, but UNC ratios are not recommended as a means of monitoring clinical disease activity in RV.

Detection of retinal lesions after telemedicine transmission of digital images

PURPOSE/BACKGROUND

To assess whether loss of image resolution or colour and subsequent telemedicine transmission of digital images affects the accuracy of retinal lesion detection by ophthalmologists when compared with the original transparencies.

METHODS

Fifteen ophthalmologists of different experience independently scored 11 retinal images for pathological signs. The images were presented as either transparencies or colour and monochrome digital images, which had been transmitted via telephone lines to a geographically remote location. One patient's eye was also imaged using scanning laser ophthalmosocopy (SLO) which produced a dynamic black and white digital image. ANOVA analysis was performed.

RESULTS

Total scores were higher for transparencies than colour (p = 0.0003) or black and white digital images (p = 0.00006). Expert observers (n = 5) considered separately showed no significant difference of accuracy between transparencies and either colour digital (p = 0.09) or monochrome digital images (p = 0.11). Experts were better than trainees at detecting pathology from less familiar images: total score (p = 0.02), colour digital (p = 0.03), monochrome digital (p = 0.02) and SLO images (p = 0.004).

CONCLUSION

Experienced observers can identify sight-threatening retinal pathology from poorer-resolution digital images that have been transmitted by telemedicine. They can also adapt to viewing less familiar images such as black and white digital or SLO images.