Prevalence, clinical characteristics, and independent predictors of uveitic macular edema in an Asian population: a retrospective cohort study

BACKGROUND

To determine the prevalence, clinical characteristics, and independent predictors of uveitic macular edema (UME) in patients with intermediate, posterior and panuveitis.

METHODS

We retrospectively reviewed the records of patients with intermediate, posterior, and panuveitis who underwent macular assessment using optical coherence tomography between January 2015 and February 2020. The prevalence of UME and clinical characteristics of the patients were described. Predictors of UME were identified using multivariate regression analysis.

RESULTS

A total of 349 patients were included. The mean age was 41 years, female: male ratio was 1.3:1. The prevalence of UME was 51.9%. UME was found in 33.9%, 56.9%, and 54.1% of the intermediate, posterior, and panuveitis cases, respectively. Among patients with UME, 47% had infectious uveitis, 32.6% had idiopathic uveitis, and 20.4% had immune-mediated uveitis. Diffuse macular edema was the most frequently observed pattern (36.5%). Multivariate analysis showed that factors independently associated with UME included age at uveitis onset (adjusted odds ratio [aOR] 1.01, 95% confidence interval [CI] 1.00-1.03, P = 0.036), PU and panuveitis compared with intermediate uveitis (aOR 2.09, 95% CI 1.14-3.86, P = 0.018), and infectious uveitis compared with noninfectious uveitis (aOR 2.13, 95% CI 1.34-3.37, P = 0.001).

CONCLUSIONS

Increasing age at uveitis onset, posterior/panuveitis, and infectious etiology are predictive factors for UME in patients with intermediate, posterior and panuveitis.

Evaluation of Optical Coherence Tomography Angiography Findings in Pars Planitis and Multiple Sclerosis Associated Intermediate Uveitis in Remission

PURPOSE

To evaluate the microvasculature during remission in patients with pars planitis (PP-IU) and multiple sclerosis-associated intermediate uveitis (MS-IU) using optical coherence tomography angiography (OCT-A).

METHODS

Single-center, descriptive, case-control study was conducted. Adult patients (≥16 years) with IU in remission (PP-IU and MS-IU) and healthy age-sex matched healthy controls (HC) were enrolled to the study. Demographic/clinical features, best-corrected visual acuity (BCVA), ocular findings, neurological symptoms and preferred treatments were recorded. The presence of cystoid macular edema (CME) during follow-up was recorded. All IU patients in remission and HC subjects were scanned with OCT-A. Foveal avascular zone (FAZ) areas of superficial and deep capillary plexus (SCP/DCP) and vascular densities of SCP, DCP and choriocapillaris were obtained from OCT-A and compared between the groups.

RESULTS

Sixty-nine eyes of 37 IU patients in remission and 20 HC were included (44 eyes/23 patients in PP-IU, 25/14 in MS-IU, 40/20 in HC). No statistically significant differences were observed in terms of demographic or clinical characteristics of the patients. The vascular density in the SCP was significantly reduced in the PP-IU and MS-IU groups compared to the HC group (p < .05). Nevertheless, there were no significant changes in any of the OCTA parameters between the IU groups. Uveitis duration was found to be correlated with enlargement of the FAZ area in PP-IU (p = .039).

CONCLUSION

OCTA may not be useful in differentiating between PP-IU and MS-IU. Nevertheless, the primary implication in SCP potentially elucidates the pathogenesis of these two subtypes of IU, which are characterized by a shared pathogenesis. The monitoring of the FAZ area in the PP-IU group is valuable in terms of chronicity.

Pediatric Pars Planitis: A Review

PURPOSE

To provide an overview of pediatric pars planitis.

METHODS

Narrative literature review.

RESULTS

Pars planitis refers to the idiopathic subset of intermediate uveitis in which there is vitritis along with snowball or snowbank formation occurring in the absence of an associated infection or systemic disease. It is thought to be a T-cell mediated disease with a genetic predisposition. Pars planitis accounts for 5-26.7% of pediatric uveitis cases. Presentation is commonly bilateral but asymmetric, often with insidious onset of floaters and blurred vision. Although pars planitis is known to be a benign form of uveitis in most cases, severe complications secondary to chronic inflammation may arise, with cystoid macular edema being the most common cause of visual morbidity. Mild vitritis in the absence of symptoms, vision loss, or macular edema may be observed. Patients with severe vitritis and/or associated vision-threatening complications require prompt aggressive treatment. A stepladder approach including corticosteroids, immunosuppressive agents, anti‑tumor necrosis factor‑alpha and pars plana vitrectomy and/or laser photocoagulation is the most commonly used method for treatment of pars planitis.

CONCLUSION

Timely diagnosis and adequate treatment of pediatric pars planitis and associated complications are crucial in order to improve visual outcomes.

SER recommendations for the treatment of uveitis

OBJECTIVE

To develop evidence-based expert-consensus recommendations for the management of non-infectious, non-neoplastic, non-demyelinating disease associated uveitis.

METHODS

Clinical research questions relevant to the objective of the document were identified, and reformulated into PICO format (patient, intervention, comparison, outcome) by a panel of experts selected based on their experience in the field. A systematic review of the available evidence was conducted, and evidence was graded according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria. Subsequently, recommendations were developed.

RESULTS

Three PICO questions were constructed referring to uveitis anterior, non-anterior and complicated with macular edema. A total of 19 recommendations were formulated, based on the evidence found and/or expert consensus.

CONCLUSIONS

Here we present the first official recommendations of the Spanish Society of Rheumatology for the treatment of non-infectious and non-demyelinating disease associated uveitis. They can be directly applied to the Spanish healthcare system as a tool for assistance and therapeutic homogenisation.

Clinical characteristics of intermediate uveitis in adults according to criteria of the SUN working group

PURPOSE

To analyse the clinical characteristics of adult patients with pars planitis (PP-IU), non-pars planitis (NPP-IU) and multiple sclerosis-associated intermediate uveitis (MS-IU) and distinguish between groups.

METHODS

Seventy-three adult patients with intermediate uveitis (IU) reviewed retrospectively and divided as PP-IU, NPP-IU and MS-IU according to 'The standardization of uveitis nomenclature working group classification criteria.' Demographic and clinical characteristics, OCT and fluorescein angiography (FA) findings, complications and treatments were recorded.

RESULTS

A total of 134 eyes of 73 patients were included, and 42 of the patients were classified as PP-IU, 12 as NPP-IU, and 19 as MS-IU. If a patient presenting with blurred vision, or tent-shaped vitreous band/snowballs/snowbank on examination, or vascular leakage on FA and accompanying neurological symptoms, the frequency of demyelinating plaque detection on cranial MRI and the risk of MS-IU increased. Mean BCVA was increased from 0.22 ± 0.30 logMAR to 0.19 ± 0.31 logMAR (p = 0.021). Gender, initial BCVA, snowbank formation, disc oedema and periphlebitis on examination, and disc leakage/occlusion on FA were found predictive of decreased BCVA at final visit (p < 0.05).

CONCLUSIONS

The clinical features of these three groups are similar, some features that can guide the differential diagnosis. It may be recommended to periodically evaluate "suspicious" patients with MRI for MS.

Bilateral exudative retinal detachment, unusual pattern of uveitis with multiple sclerosis

MS (Multiple sclerosis) associated uveitis used to have limited phenotypes. Bilateral exudative retinal detachment has never been recognized as a pattern of MS-associated uveitis. We are reporting a patient with multiple sclerosis who presented initially with the usual pattern of intermediate uveitis and later developed bilateral exudative retinal detachment.

Anti-tumor necrosis factor-alpha treatment in pediatric patients with pars planitis: a single-center experience from Turkey

AIM

To evaluate the effectiveness and safety of anti-tumor necrosis factor-alpha (anti-TNF-alpha) treatment (Adalimumab [ADA]) combined with immunomodulatory agents (IMAs) in the treatment of pars planitis (PP).

METHODS

The patients with PP who were treated with anti-TNF-alpha agents for at least six months were qualified for the chart review. The outcome parameters were the steroid-free remission state, the best-corrected visual acuity (BCVA) and the central macular thickness (CMT) of the patients at the last visit.

RESULTS

After a mean total follow-up time of 15.5 ± 5.8 months (8-24 months), all the cases were in steroid-free remission at the last visit. The mean BCVA increased, and the mean CMT decreased significantly at the last visit (p < 0.001, p < 0.001, respectively).

CONCLUSION

ADA combined with IMAs offers effective and safe treatment modalities in the control of chronic intraocular inflammation in PP cases.

Macular vessel densities by optical coherence tomography angiography in patients with intermediate uveitis

Purpose

To evaluate the macular microvascular changes in patients with intermediate uveitis (IU) using optical coherence tomography angiography (OCT-A) and to determine the relationship of OCT-A measurements with disease duration and activity.

Methods

This cross-sectional study was performed at the uvea department of a tertiary hospital. Patients with IU (8 women, 8 men; mean age: 28.80 ± 12.80 years) were included in the study. The macular thickness measurements obtained by optical coherence tomography (OCT) (Heidelberg Spectralis, Heidelberg Engineering, Heidelberg, Germany) and macular superficial and deep vessel density (VD) parameters obtained by OCT-A (Avanti RTVue-XR; Optovue, Fremont, CA, USA) were compared with healthy subjects (12 men, 22 women; mean age: 28.40 ± 8.32 years). Eyes with pathology including marked obvious edema in the macula were not included in the study.

Results

The macular thickness was found to be higher in the patient group (p < 0.001). The deep and superficial VD measurements in almost all quadrants in both superficial and deep layers were significantly lower in the IU patient group (p < 0.05). Macular thickness was increased in the active state of IU (p = 0.03), however, none of the OCT-A parameters showed a significant difference between active and inactive IU patients (p > 0.05). No correlation was observed between OCT-A parameters and total IU disease duration.

Conclusion

Quantitative analyses of macular vascular structures demonstrate significantly reduced VD in both superficial and deep retinal layers in IU patients. Considering the importance of the macula in visual prognosis, OCT-A can provide crucial data for the monitoring and follow-up of IU patients.

Bilateral intermediate uveitis following treatment with paclitaxel in a patient with invasive ductal carcinoma of the breast

BACKGROUND

To report a case of bilateral intermediate uveitis without cystoid macular edema secondary to paclitaxel therapy, and its successful management with oral corticosteroids.

CASE PRESENTATION

A 66-year-old female developed bilateral intermediate uveitis with reduced best corrected visual acuity to 20/40 right and 20/200 left, following 12 cycles of paclitaxel therapy for breast carcinoma. Optical coherence tomography demonstrated no cystoid macular edema in either eye, and fundus fluorescein angiography showed localized retinal vascular leakage. Resolution of uveitis and improvement of visual acuity followed treatment with oral prednisolone for two months. Fourteen months after presentation, right and left visual acuities had returned to 20/32 and 20/40, respectively, and there was no recurrence of the uveitis.

CONCLUSIONS

This is the first reported case of bilateral intermediate uveitis in a patient treated with paclitaxel. Drug-induced uveitis should be considered in patients with visual symptoms in the setting of taxane chemotherapy, and oral corticosteroids are a safe and effective treatment.

Demography and clinical pattern of newly diagnosed uveitis patients in Malaysia

Introduction

Uveitis is one of the common causes of visual impairment in Malaysia. It remains a challenging entity to diagnose and manage due to variation in its clinical presentation. This study aims to observe the demographic and clinical pattern of cases from the participating ophthalmology units in Malaysia.

Methods

This study involved prospective and multicentered data collection for patients newly diagnosed with uveitis from 1^st January 2018 to 31^st December 2018. Variables collected and analyzed included age, gender, ethnicity, nationality, state of origin, laterality, granulomatous or non-granulomatous uveitis, and etiology of uveitis.

Results

A total of 1199 newly diagnosed uveitis patients were analyzed within the study period. There was a significant association between the anatomical location of uveitis with age at presentation. The percentage of patients with anterior uveitis was higher in the ‘40 to 60’ years and ‘above 60’ years age groups at 52.1% (n = 210) and 61.3% (n = 114) respectively. In contrast the percentage of patients with posterior and panuveitis was higher in the 1 to 20 and 20 to 40 years age groups at 51.4% (n = 54) and 48.7% (n = 246) respectively.

Sixty three percent of the patients presented with unilateral uveitis (n = 760, p < 0.001) vs bilateral. Non-granulomatous uveitis comprised 84.5% of all patients (n = 1013, p < 0.001) compared to granulomatous uveitis. Non-infectious etiology contributed to 65.7% of all patients (n = 788, p < 0.001) with the majority being unclassifiable uveitis (n = 686, 57.2%,). Specific inflammatory entities contributed to only 8.5% (n = 102) of the non-infectious causes with Vogt-Koyanagi-Harada (VKH) syndrome being the most common (n = 25, 2.1%,). Infectious uveitis comprised 34.3% (n = 411) with tubercular (TB) uveitis (n = 105, 8.8%) and viral uveitis (n = 107, 8.9%) contributing the most followed by ocular Toxoplasmosis (n = 93,7.8%).]

Conclusion

This study has highlighted the demographic data and common causes of uveitis in Malaysia.

Polymerase chain reaction confirmed mycobacterium tuberculosis intermediate uveitis - analysis of 22 eyes of 14 cases from a tertiary care centre in South India: a retrospective study

Background

To report the role of Polymerase Chain Reaction in confirming the diagnosis of presumed Mycobacterium Tuberculosis (MTB) Intermediate Uveitis.

Method

Retrospective analysis of 22 eyes of 14 cases of presumed tubercular intermediate uveitis wherein intraocular fluid was tested for MTB DNA by Nested & Real-time PCR, based on clinical suspicion of tubercular aetiology. QuantiFERON TB gold test and High-Resolution CT Chest were done. Patients were treated with anti-tubercular therapy with oral steroids & immunomodulators. In the study, eleven were male (79%) and three female (21%). The median age was 34 years. Nested PCR for both IS 6110 & MPB 64 was positive in 64% of the cases, IS 6110 positive in 23% and MPB 64 positive in 15%. Real-time PCR was positive in 48% of the cases. Vision improved in 33% of cases, maintained in 57%, and worsened in 10% of cases.

Conclusion

Presumed Tubercular intermediate uveitis can be confirmed by PCR of intraocular fluids. Anti-tubercular therapy with immunosuppression can improve vision and prevent recurrences in such cases.

Clinical course of HTLV-1 infection associated intermediate uveitis

OBJECTIVE

To describe the clinical features at presentation, delivered treatment and follow-up of a case series of human T-cell lymphotropic virus type 1 (HTLV-1) associated intermediate uveitis.

PATIENTS AND METHODS

Retrospective, descriptive and longitudinal study of patients with HTLV-1 associated intermediate uveitis treated at a reference ophthalmology facility in Lima, Peru, during the years 2012 to 2018.

RESULTS

A total of 18 patients (28 eyes) were included, the average age at presentation was 57.3 years, 66.6% were women, and the average follow-up time was 1,280 days. The most frequent symptoms were blurred or diminished vision (78.6%) and floaters (57.1%). Best corrected visual acuity was 20/40 or better in 53.6%. The mean initial intraocular pressure was 14.95 mmHg. Keratic precipitates were observed in 50% of eyes, 17.9% were of the stellate type. The most frequent treatment was periocular corticosteroid injections (53.6%). Complications such as epimacular membrane (50%), cataract (21.4%) and glaucoma (7.1%) occurred. At the end of follow-up, only 2 eyes lost one line of vision; the final best corrected visual acuity was 20/40 or better in 85.7%, and 20/70 or better in 96.4%. Patients with both eyes affected increased from 33% at presentation to 55.5%. The course of the disease was chronic in 60.7%.

CONCLUSION

HTLV-1 associated intermediate uveitis mainly occurred in patients in the second half of life, developing a chronic course and with good visual prognosis.

Clinical characteristics and treatment of pars planitis: an adalimumab experience

PURPOSE

This study aims to investigate the clinical and demographic characteristics, treatment outcomes and complications of patients with pars planitis.

METHODS

This retrospective study included patients diagnosed with pars planitis between 1998 and 2019 and followed for at least 6 months. Demographics, best-corrected visual acuity (BCVA), anterior segment and fundus examination findings, intraocular pressure (IOP) values at baseline and final examination, treatments used during the follow-up, surgeries and complications were noted from medical records of the patients. The percentage of patients given adalimumab (ADA), the reasons for treatment switch and response to ADA were investigated.

RESULTS

One hundred fifteen eyes of 59 patients were included in the study. Forty-seven percent of patients were female. The median age of the patients was 10 (4-44) years. The median follow-up time was 33 (6-252) months. The median BCVA at admission was 0.20 (0.00-2.00) logMAR. The most common complications were cystoid macular oedema, cataract, epiretinal membrane and inferior peripheral retinoschisis. Prophylactic laser photocoagulation for peripheral retinoschisis was the most common surgical intervention, followed by cataract surgery and pars plana vitrectomy. Approximately 80% of patients received immunosuppressive and corticosteroid therapy for initial treatment. ADA was initiated in 23 patients (38.9%) due to refractory uveitis and adverse effects to the corticosteroid and helped control intraocular inflammation and decrease the use of systemic steroids/immunosuppressives in 22 of 23 (95%) of patients who received ADA. The median BCVA at final examination increased to 0.00 (0.00-2.00) logMAR.

CONCLUSIONS

Pars planitis is a chronic, progressive and insidious disease with several ocular complications and requires early and aggressive treatment. ADA appeared to be effective especially in patients' refractory to conventional treatment.

The clinical presentation and treatment outcomes of ocular tuberculosis: a 5-year experience in an endemic area

PURPOSE

To report the clinical presentations of ocular tuberculosis infection (OTB) and the treatment regimen and outcome in an endemic area.

METHODS

This is a retrospective case series of patients with presumed OTB treated in a tertiary teaching hospital in Hong Kong in 2014-2019.

RESULTS

Among the nineteen patients recruited, the most common clinical presentation of OTB was retinal vasculitis (42.1%), followed by scleritis, intermediate uveitis, and choroidal tuberculoma (15.8% respectively). 94.7% and 94.4% of the subjects were treated with ATT and steroid, respectively, and 31.6% were put on systemic immunosuppressant prior to the initiation of ATT. Apart from those suffering from intermediate uveitis, most demonstrated good clinical response within 8 weeks of ATT initiation.

CONCLUSION

Ocular involvement of TB has been increasingly recognized, especially in endemic regions like Hong Kong. High index of suspicion is recommended for OTB in typical clinical phenotypes or recurrent/resistant ocular inflammation unresponsive to conventional therapy. TB retinal vasculitis was the most common presentation of OTB in this study and OTB generally requires treatment with either regional or systemic steroid together with ATT.

Effectiveness of the Dexamethasone Implant in Lieu of Oral Corticosteroids in Intermediate and Posterior Uveitis Requiring Immunosuppression

PURPOSE

To evaluate dexamethasone intravitreal implant effectiveness in lieu of high-dose oral prednisone for short-term treatment of noninfectious intermediate and posterior uveitis in patients requiring immunosuppression.

METHODS

This is a proof-of-concept, open-label, non-comparative clinical trial with 12-month follow-up. The primary outcome was uveitis control without additional prednisone at 6 and 12 months. Secondary outcomes were need for multiple implants or additional prednisone, and safety data.

RESULTS

20 patients (28 eyes) were enrolled- 16 eyes had control by 6 months; 20 by 12 months. No patients required high-dose prednisone. 6 patients enrolled on prednisone: 2 stopped; 4 tapered to 7.5 mg daily or less by 12 months. 16 eyes required multiple implants; five required cataract surgery; 12 required drops to control IOP; 2 underwent glaucoma surgery.

CONCLUSIONS

The dexamethasone implant was effective in lieu of high-dose prednisone although the majority required multiple implants. All patients decreased or discontinued prednisone during follow-up.

Recommendations statement on the immunosuppressive treatment of non-infectious, non-neoplastic, non-anterior uveitis

OBJECTIVE

To generate recommendations on the use of immunomodulators in patients with non-infectious, non-neoplastic intermediate uveitis (IU), posterior uveitis (PU) and panuveitis (PanU) based on best evidence and experience.

METHODS

A multidisciplinary panel of 5 experts was established, who defined the scope, users, and sections of the document. A systematic literature review (SLR) was performed to assess the efficacy and safety of immunomodulatory drugs in patients with non-infectious, non-neoplastic, non-anterior uveitis. The results of the SLR were presented and discussed during an expert meeting in which 34 recommendations were generated. The level of agreement with the recommendations was also tested in 25 additional experts following a Delphi process. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of the experts voted ≥7. The level of evidence and grade or recommendation were assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence.

RESULTS

The SLR included 33 articles. The 34 recommendations were accepted after 2 Delphi rounds (3 of them were modified after the first round). They include specific recommendations on patients with non-infectious, non-neoplastic, PU and PanU, as well as different treatment guidelines.

CONCLUSIONS

In patients with non-infectious, non-neoplastic, non-anterior uveitis these recommendations might help treatment decision making, due to the lack of robust evidence or other globally accepted algorithms.

Efficacy and safety of immunomodulatory drugs in patients with non-infectious intermediate and posterior uveitis, panuveitis and macular edema: A systematic literature review

BACKGROUND

Non-infectious non-anterior uveitis (NINA) is a sight-threatening condition that often requires immunomodulatory drugs (IMDs) for its management.

OBJECTIVES

To evaluate the published evidence regarding the use of IMDs in adult patients with NINA uveitis including intermediate (IU) and posterior uveitis (PU), panuveitis (PanU) and macular edema (ME).

METHODS

We performed a systematic literature review. Search strategies were designed for Medline, Embase, and Cochrane Libraries for articles up to 2019 to evaluate the efficacy and safety of the IMDs. A quality assessment was performed using the Jadad Scale.

RESULTS

Nineteen randomized clinical trials were selected from the 1,103 articles retrieved. Characteristics of patients, treatment dosages and outcome measures were heterogeneous. The outcomes most frequently analyzed were visual acuity (VA), macular thickness and vitreous haze (VH). Different IMDs were used at their usual dosages. Methotrexate (MTX), micophenolate mofetil, cyclosporine A (CsA), tacrolimus, adalimumab and sarilumab were effective in NINA uveitis. Rituximab combined with MTX was effective in PU. Interferon-β was superior to MTX, albeit with more adverse events in IU with ME. CsA was similar to cyclophosphamide (Cyc) in Behçet uveitis. Tacrolimus was safer and similar to CsA. Cyc was effective in serpiginoid choroiditis, but when combined with azathioprine in PU, but did not improve VA. Secukinumab did not prevent NINA uveitis recurrences, although intravenously it showed a higher response rate than when used subcutaneously. Daclizumab did not show any benefits in Behçet NINA uveitis.

CONCLUSION

Several IMDs and their combinations can be useful in treating NINA uveitis. The available studies were heterogeneous regarding patient characteristics and outcomes.

Implications of pars planitis-associated cystoid macular edema on visual outcome and management in children

PURPOSE

Pars planitis is a commonly observed type of pediatric uveitis. The aim of this study was to evaluate the implications of pars planitis-associated cystoid macular edema (CME) on visual outcome and treatment modalities.

METHODS

A retrospective review of medical records in a single center with academic practice.

RESULTS

Included were 33 children (mean age 8 years, 58 eyes). Eighteen eyes developed CME (31%): in 67% of them, CME was diagnosed at presentation and in 33%, it developed at a mean of 57 months after presentation. Anterior and posterior segment complications were more prevalent in eyes with CME. Papillitis was significantly associated with the development of CME (OR 12.4, 95% CI 2.3 to 65.6, p = 0.003). Patients with CME were 1.7 times more likely to be treated with systemic therapy. By the last follow-up, 50% of patients who never developed CME were without systemic therapy compared with 13% of patients who developed CME (p = 0.034). LogMAR visual acuity improvement between presentation and month 36 was 0.41 for eyes with CME compared with 0.14 for eyes that never developed CME (p = 0.009).

CONCLUSION

Pars planitis-associated CME entailed higher prevalence of ocular complications, more frequent use of immunomodulatory therapy, and a lower rate of remission.

Proteomic analysis of intermediate uveitis suggests myeloid cell recruitment and implicates IL-23 as a therapeutic target

Purpose

To profile vitreous protein expression of intermediate uveitis (IU) patients.

Observations

We identified a mean of 363 ± 41 unique proteins (mean ± SD) in IU vitreous and 393 ± 69 unique proteins in control samples using liquid chromatography-tandem mass spectrometry (LC-MS/MS) analysis of liquid vitreous biopsies collected during pars plana vitrectomy. A total of 233 proteins were differentially expressed among control and IU samples, suggesting a protein signature that could distinguish the two groups. Pathway analysis identified 22 inflammatory mediators of the interleukin-12 (IL-12) signaling pathway in IU vitreous. Upstream regulator analysis identified downstream mediators of IL-23 and myeloid differentiation primary response protein (MYD88), both of which are involved in the recruitment and differentiation of myeloid cells. Taken together, our results suggest the recruitment of myeloid cells as an upstream pathway in the pathogenesis of IU.

Conclusions

This study provides insights into proteins that will serve as biomarkers and therapeutic targets for IU. These biomarkers will help design future clinical trials using rational molecular therapeutics.

Inverted Flap Technique for Large Macular Hole Secondary to Chronic Uveitis

Macular hole is a defect in the neurosensory retina at the center of the fovea, seen in 8.3% of the postuveitic cases. In such cases, macular holes tend to be large and are associated with structural damage in the outer retinal layers. Here, we report a case of bilateral chronic intermediate uveitis treated with sub-Tenon steroids that developed a full-thickness macular hole in the right eye. We treated it surgically with inverted flap technique of internal limiting membrane peeling. Postoperatively, the patient showed Type-1 closure of the hole with visual improvement.

Disease Remission in Children and Adolescents with Intermediate Uveitis: A Survival Analysis

PURPOSE

To report the incidence rate (IR) of remission in pediatric noninfectious intermediate uveitis (IU).

METHODS

Longitudinal retrospective cohort study, including 19 patients (32 eyes) between 1985 and 2014, followed-up until loss or January 2016. Remission was defined following the Standardization of Uveitis Nomenclature workshop criteria, prolonged remission as a remission spanning 12 months and until the end of follow-up, and relapse as recurrence of inflammatory activity in an eye in remission.

RESULTS

Median follow-up time was 6.3 years. IRs (95% confidence interval) for remission, relapse, and prolonged remission were 18.6 (13.1-26.5), 32.3 (20.6-50.7), and 6.7 (3.8-11.9) episodes per 100 eye-years, respectively. 48% of eyes relapsed in the first year following remission. 25 and 50% of eyes achieved prolonged remission after 5 and 10 years of follow-up, respectively.

CONCLUSIONS

Inflammatory relapses may be frequent in noninfectious IU affecting children and adolescents, appearing early after remission. Also, prolonged remission seems infrequent, being achieved late during follow-up.

Intermediate uveitis: pattern of etiology, complications, treatment and outcome in a tertiary academic center

Background

Patients with intermediate uveitis (IU) represent a heterogenous group characterized by a wide spectrum of etiologies and regional differences. Aim of the study was to analyze the characteristics of patients with IU examined in an academic center in Germany.

Methods

We conducted a retrospective analysis of the clinical records of all patients with intermediate uveitis referred to the Eye Center, University of Freiburg from 2007 to 2014. Diagnosis followed the Standardization in Uveitis Nomenclature (SUN) criteria. Data analysis included: etiology of IU, demographics, complications, treatment and visual acuity.

Results

We identified 159 patients with intermediate uveitis during that period. Mean age at diagnosis was 35 years. Most are female (64%), and the mean duration of IU was 6.1 years (range 1 month – 35 years). Etiology of IU was idiopathic in 59%. Multiple sclerosis (MS) (20%) and sarcoidosis (10%) were frequent systemic causes of IU. Other etiologies including infectious diseases (tuberculosis, borreliosis) or immune-mediated conditions (eg, after vaccination) were present in 11%. The pattern of complications included macular edema (CME) (36%), cataract (24%), secondary glaucoma (7%), and epiretinal membrane formation (19%). Periphlebitis and optic neuritis were more frequent in conjunction with MS. Treatment comprised local and systemic steroids, immunosuppressive agents, biologics, and surgery. Best corrected visual acuity was better than 20/25 in 60% of the eyes after more than 10 years of follow-up.

Conclusions

In our German academic center, most IU cases were idiopathic or associated with MS or sarcoidosis. In contrast to other countries, infectious cases were rare. Patients’ overall visual prognosis is favorable even when the duration of IU has been long and and despite numerous complications.

Analysis of clinical features and visual outcomes of pars planitis

PURPOSE

To evaluate the demographic characteristics, clinical features, treatment and outcomes of patients with pars planitis in a tertiary referral center in Turkey.

METHODS

Medical records of patients with pars planitis were retrospectively reviewed. The data including demographic and ocular features and treatment outcomes were recorded. The distribution of clinical findings and complications were evaluated according to age and gender groups. The changes in final BCVA compared to the initial BCVA were noted. Statistical analysis was performed using SPSS software (Version 18.0, SPSS Inc., Chicago, USA).

RESULTS

Twenty-seven patients (54 eyes) were included in this study. 16 patients were male (59.3%), and 11 were female (40.7%). Mean age at diagnosis was 12.84 ± 8.26 (range 4-36) years. Mean follow-up period was 61.3 ± 52.15 (range 9-172) months. Mean BCVA was 0.58 ± 0.36 (range 0.03-1.00) (0.40 ± 0.45 logMAR) at presentation, and 0.81 ± 0.28 (range 0.10-1.00) (0.14 ± 0.27 logMAR) at final visit (P = 0.001). Vitreous inflammation (100%), vitreous haze (92.6%), snowballs (74.1%), snowbanks (66.7%), anterior chamber cells (66.7%) and peripheral retinal vascular sheathing (48.1%) were the most common presentations. Ocular complications included vitreous condensation (51.9%), cystoid macular edema (22.2%), cataract (18.5%), inferior peripheral retinal detachment (11.1%), glaucoma (5.6%) and vitreous hemorrhage (3.7%). Treatments included topical, periocular, intravitreal and systemic corticosteroids, immunosuppressives, peripheral laser photocoagulation and pars plana vitrectomy when needed.

CONCLUSIONS

Pars planitis is an idiopathic chronic intermediate uveitis mostly affecting children and adolescents. In spite of its chronic nature with high potential of causing ocular complications, adequate treatment and close follow-up lead to favorable visual outcomes.

Unilateral uveitis associated with IgA nephropathy

CASE REPORT

The case is presented of a 42 year-old man with episodes of unilateral uveitis in his right eye. Ophthalmic examination showed a granulomatous anterior uveitis with vitritis. Systemic investigations revealed non-nephrotic proteinuria and microhaematuria. A renal biopsy showed IgA nephropathy.

DISCUSSION

Uveitis and glomerulonephritis may have common immunological pathogenesis. IgA nephropathy should be a differential diagnosis in patients with uveitis and nephropathy.

[Sarcoidosis and uveitis : An update]

Ocular involvement in sarcoidosis is present in up to one third of patients and is frequently manifested before the underlying systemic disease has been diagnosed. With a view to the therapeutic consequences an early diagnosis of the underlying disease is advantageous. In cases of visual loss early diagnostic measures include invasive procedures, such as ultrasound-guided bronchoalveolar lavage and transbronchial biopsy, if nodular conjunctival or cutaneous manifestations which would confirm the diagnosis are not present. Sufficiently sensitive biomarkers of disease activity have not yet been identified. As elevated activity of angiotensin-converting enzyme (ACE) and lysozyme are associated with disease activity they may be supportive of but not specific for the diagnosis. Other indicators include calcemia, calciuria, augmented activity of hepatic enzymes, cutaneous anergy and hilar changes in the lungs. In patients with newly diagnosed anterior uveitis presenting with granulomatous mutton-fat corneal precipitates, snow balls and vitreous body base condensates with mild retinal periphlebitis in intermediate uveitis as well as multifocal choroiditis (creamy choroidal lesions at different stages of activity and approximately 500 µm in diameter), a diagnosis of sarcoidosis has to be considered and tuberculosis should be excluded, even in the absence of a known systemic disease. Anterior uveitis is frequently a self-limiting condition, which can be well-controlled with topical steroids. On the other hand, intermediate, posterior and panuveitis are typically associated with a chronic course and require systemic therapy to prevent severe loss of vision. If the response to systemic corticosteroids is insufficient, treatment with immunomodulatory agents and biologics is initiated at progressively earlier stages, with a view to averting permanent organ damage and frequently with a positive impact on the short and long-term outcomes, even in therapy-refractive cases.

Acute onset of fingolimod-associated macular edema

Purpose

Fingolimod is among the first oral disease-modifying agents for the treatment of relapsing-remitting multiple sclerosis (MS). Despite its favorable safety profile, fingolimod may cause macular edema, a significant adverse event, which occurs within the first 4 months of therapy. Macular edema usually resolves upon discontinuation of fingolimod; however, the time required for resolution of this condition is unknown.

Observations

A 42-year-old white male with a history of relapsing-remitting MS presented with blurring of vision in his left eye 24 h after the first dose of fingolimod. Dilated fundus examination of the left eye revealed an increased retinal thickness and mild optic disc pallor. Spectral domain optical coherence tomography (SD-OCT) confirmed the diagnosis of cystoid macular edema. Topical nonsteroidal anti-inflammatory drug (NSAID) was initiated immediately after the diagnosis, and fingolimod therapy was discontinued shortly thereafter. Seven weeks after the initial presentation, intermediate uveitis was noted in the inferior periphery of the left eye, and SD-OCT revealed worsening of macular edema. Acetazolamide therapy was added to the topical NSAID to control the edema. Three weeks after initiation of acetazolamide, macular thickness reduced significantly. The patient then stopped all medications, and 3 weeks later macular edema rebounded. Systemic steroid was employed to control both the intermediate uveitis and macular edema.

Conclusions and importance

We report a case of acute and very rapid onset of fingolimod-associated macular edema (FAME). Acetazolamide may have a beneficial effect on macular edema secondary to fingolimod. It is unclear if intermediate uveitis is associated with the rapid development of FAME.

A cross-sectional study of submacular thickening in intermediate uveitis and determination of treatment threshold

Background

The aim of this work is to refine understanding of anatomical and functional alterations in eyes with Intermediate Uveitis (IU), their natural history in mild cases not necessitating treatment and their response to treatment in severely affected eyes with macular edema.

Methods

61 consecutive patients with IU presenting over a 6-year period were prospectively recruited into the study. Two subgroups of patients with IU were identified on the basis of the need or not for systemic cortico-steroid treatment. A group of healthy volunteers was identified for determining normal average central foveal thickness (CFT) values. Statistical comparisons were sought between patient sub-groups and with the group of normal volunteers for CFT and Best Corrected Visual Acuity (BCVA) at baseline and after 6 months. In a post hoc analysis, a cut-off value of CFT for systemic treatment initiation in IU was statistically identified and its sensitivity and specificity determined.

Results

A statistically significant difference in mean CFT at baseline was observed between patients under systemic treatment and untreated patients (p = 0.0005) as well as between untreated patients and healthy volunteers. (p < 0.001) After six months difference in CFT between the two patients subgroups was no longer significant (p = 0.699). BCVA was worse for patients under systemic treatment. No statistically significant difference could be identified between the subgroup of untreated patients and the group of healthy volunteers either at baseline or after 6 months. Correlation between LogMAR visual acuity and central retinal thickness at baseline was strong (r = 0.7436, p < 0.0001, Pearson’s correlation coefficient). The cut-off value of CFT for initiating systemic treatment was determined at 215.5 μm in a post hoc analysis (sensitivity 62.5 %, specificity 96.4 %).

Conclusions

Subclinical retinal thickening of mildly inflamed eyes with IU can occur though bearing no functional clinical significance and spontaneously resolving within 6 months. A cut-off CFT value for treatment of macular edema in IU, in the presence of other relevant morphological features on Optical Coherence Tomography, seems to emerge from post hoc analysis of collected data demonstrating strong specificity and moderate sensitivity.

[Clinical course of pars planitis in patients treated with selective photocoagulation]

INTRODUCTION

Pars planitis is an intermediate uveitis with bilateral and asymmetric presentation. The etiology is unknown and pathogenesis is unclear. Treatment follows the algorithm of Foster, which includes selective photocoagulation. The mechanism of action of photocoagulation is still unknown.

MATERIAL AND METHODS

An observational, longitudinal, ambispective cohort study was performed with the objective of evaluating the course of inflammation in patients with pars planitis treated with a selective argon laser.

RESULTS

The study included 29 patients (10 female and 19 male) diagnosed with pars planitis and were treated with selective laser. The mean age of onset was 11.77 years. Eighteen (62.1%) patients were not immunosuppressed at the time of receiving the selective laser, and 11 (37.9%) were taking immunosuppressants. Indications for selective laser were; following the algorithm, 19 (65.55%), vitreous hemorrhage 7 (24.1%), vitrectomy 2 (6.98%), and neovascularization 1 (3.4%). The mean time for inflammation reduction was 5.9 months, and 17 patients (58.6%) had no relapse. Visual acuity showed improvement post-laser (OD P=.025 and OI P=.022). There was also an improvement in vitreous cells.

CONCLUSION

Selective laser was effective in 58.6%% of patients.