A Glimpse into Uveitis in the Aging Eye: Pathophysiology, Clinical Presentation and Treatment Considerations

Uveitis describes a group of inflammatory conditions of the eye that have various underlying causes and clinical presentations. Susceptibilities to uveitis in the elderly may be attributed to age-related risk factors such as immunosenescence, increased immunological inflammatory mediators, and autoimmunity. Overall, anterior uveitis is more common than posterior and panuveitis in the general population and also in the elderly. Some causes of uveitis in the elderly are herpes simplex virus, ocular ischemic syndrome, sarcoidosis, and central nervous system lymphoma, and these will be discussed in detail herein. Eye care professionals need to consider the wide differential for uveitis, obtain the appropriate history, conduct a detailed clinical examination, and tailor management to the clinical presentation and underlying cause of disease. The challenges of polypharmacy and nonadherence in the elderly impact patient outcomes and must be taken into consideration when considering treatment.

Multiple myeloma masquerading as panuveitis in a middle-aged woman

Panuveitis secondary to masquerade syndrome is uncommon. A middle-aged woman presented to the ophthalmology clinic with panuveitis associated with anaemia, joint pain, and renal impairment. An incidental finding of a lytic lesion over her left scapula following a chest x-ray prompted further skeletal survey and revealed further lytic lesions over the skull and pelvic bone. Bone marrow aspiration was performed and this confirmed the diagnosis of multiple myeloma. Her left eye vision and intraocular inflammation improved after commencement of chemotherapy. A detailed history is important to elucidate the aetiology of masquerade syndrome and to prevent any delayed diagnosis of underlying malignancy.

Outcomes of Vogt-Koyanagi-Harada Disease: A Subanalysis From a Randomized Clinical Trial of Antimetabolite Therapies

PURPOSE

To report outcomes of Vogt-Koyanagi-Harada (VKH) disease from a clinical trial of antimetabolite therapies.

DESIGN

Subanalysis from an observer-masked randomized clinical trial for noninfectious intermediate, posterior, and panuveitis.

METHODS

setting: Clinical practice at Aravind Eye Hospitals, India.

PATIENT POPULATION

Forty-three of 80 patients enrolled (54%) diagnosed with VKH.

INTERVENTION

Patients were randomized to either 25 mg oral methotrexate weekly or 1 g mycophenolate mofetil twice daily, with a corticosteroid taper.

MAIN OUTCOME MEASURES

Primary outcome was corticosteroid-sparing control of inflammation at 5 and 6 months. Secondary outcomes included visual acuity, central subfield thickness, and adverse events. Patients were categorized as acute (diagnosis ≤3 months prior to enrollment) or chronic (diagnosis >3 months prior to enrollment).

RESULTS

Twenty-seven patients were randomized to methotrexate and 16 to mycophenolate mofetil; 30 had acute VKH. The odds of achieving corticosteroid-sparing control of inflammation with methotrexate were 2.5 times (95% CI: 0.6, 9.8; P = .20) the odds with mycophenolate mofetil, a difference that was not statistically significant. The average improvement in visual acuity was 12.5 Early Treatment Diabetic Retinopathy Study (ETDRS) letters. On average, visual acuity for patients with acute VKH improved by 14 more ETDRS letters than those with chronic VKH (P < .001), but there was no difference in corticosteroid-sparing control of inflammation (P = .99). All 26 eyes with a serous retinal detachment at baseline resolved, and 88% achieved corticosteroid-sparing control of inflammation.

CONCLUSIONS

The majority of patients treated with antimetabolites and corticosteroids were able to achieve corticosteroid-sparing control of inflammation by 6 months. Although patients with acute VKH gained more visual improvement than those with chronic VKH, this did not correspond with a higher rate of controlled inflammation.

Quality of Life and Risks Associated with Systemic Anti-inflammatory Therapy versus Fluocinolone Acetonide Intraocular Implant for Intermediate Uveitis, Posterior Uveitis, or Panuveitis: Fifty-four-Month Results of the Multicenter Uveitis Steroid Treatment Trial and Follow-up Study

PURPOSE

To evaluate the risks and quality-of-life (QoL) outcomes of fluocinolone acetonide implant versus systemic therapy with corticosteroid and immunosuppression when indicated for intermediate uveitis, posterior uveitis, and panuveitis.

DESIGN

Additional follow-up of a randomized trial cohort.

PARTICIPANTS

Two hundred fifty-five patients with intermediate uveitis, posterior uveitis, or panuveitis, randomized to implant or systemic therapy.

METHODS

Randomized subjects with intermediate uveitis, posterior uveitis, or panuveitis (479 eyes) were followed up over 54 months, with 79.2% completing the 54-month visit.

MAIN OUTCOME MEASURES

Local and systemic potential complications of the therapies and self-reported health utility and vision-related and generic health-related QoL were studied prospectively.

RESULTS

Among initially phakic eyes, cataract and cataract surgery occurred significantly more often in the implant group (hazard ratio [HR], 3.0; P = 0.0001; and HR, 3.8; P < 0.0001, respectively). In the implant group, most cataract surgery occurred within the first 2 years. Intraocular pressure elevation measures occurred more frequently in the implant group (HR range, 3.7-5.6; all P < 0.0001), and glaucoma (assessed annually) also occurred more frequently (26.3% vs. 10.2% by 48 months; HR, 3.0; P = 0.0002). In contrast, potential complications of systemic therapy, including measures of hypertension, hyperlipidemia, diabetes, bone disease, and hematologic and serum chemistry indicators of immunosuppression toxicity, did not differ between groups through 54 months. Indices of QoL initially favored implant therapy by a modest margin. However, all summary measures of health utility and vision-related or generic health-related QoL were minimally and nonsignificantly different by 54 months, with the exception of the 36-item Short-Form Health Survey physical component summary score, which favored implant by a small margin at 54 months (3.17 on a scale of 100; P = 0.01, not adjusted for multiple comparisons). Mean QoL results were favorable in both groups.

CONCLUSIONS

These results suggest that fluocinolone acetonide implant therapy is associated with a clinically important increased risk of glaucoma and cataract with respect to systemic therapy, suggesting that careful monitoring and early intervention to prevent glaucoma is warranted with implant therapy. Systemic therapy subjects avoided a significant excess of toxicities of systemic corticosteroid and immunosuppressive therapies in the trial. Self-reported QoL measures initially favored implant therapy, but over time the measures converged, with generally favorable QoL in both groups.

Randomized comparison of systemic anti-inflammatory therapy versus fluocinolone acetonide implant for intermediate, posterior, and panuveitis: the multicenter uveitis steroid treatment trial

OBJECTIVE

To compare the relative effectiveness of systemic corticosteroids plus immunosuppression when indicated (systemic therapy) versus fluocinolone acetonide implant (implant therapy) for noninfectious intermediate, posterior, or panuveitis (uveitis).

DESIGN

Randomized controlled parallel superiority trial.

PARTICIPANTS

Patients with active or recently active uveitis.

METHODS

Participants were randomized (allocation ratio 1:1) to systemic or implant therapy at 23 centers (3 countries). Implant-assigned participants with bilateral uveitis were assigned to have each eye that warranted study treatment implanted. Treatment-outcome associations were analyzed by assigned treatment for all eyes with uveitis.

MAIN OUTCOME MEASURES

Masked examiners measured the primary outcome: change in best-corrected visual acuity from baseline. Secondary outcomes included patient-reported quality of life, ophthalmologist-graded uveitis activity, and local and systemic complications of uveitis or therapy. Reading Center graders and glaucoma specialists assessing ocular complications were masked. Participants, ophthalmologists, and coordinators were unmasked.

RESULTS

On evaluation of changes from baseline to 24 months among 255 patients randomized to implant and systemic therapy (479 eyes with uveitis), the implant and systemic therapy groups had an improvement in visual acuity of +6.0 and +3.2 letters (P = 0.16, 95% confidence interval on difference in improvement between groups, -1.2 to +6.7 letters, positive values favoring implant), an improvement in vision-related quality of life of +11.4 and +6.8 units (P = 0.043), a change in EuroQol-EQ5D health utility of +0.02 and -0.02 (P = 0.060), and residual active uveitis in 12% and 29% (P=0.001), respectively. Over the 24 month period, implant-assigned eyes had a higher risk of cataract surgery (80%, hazard ratio [HR] = 3.3, P < 0.0001), treatment for elevated intraocular pressure (61%, HR=4.2, P < 0.0001), and glaucoma (17%, HR=4.2, P = 0.0008). Patients assigned to systemic therapy had more prescription-requiring infections than patients assigned to implant therapy (0.60 vs 0.36/person-year, P=0.034), without notable long-term consequences; systemic adverse outcomes otherwise were unusual in both groups, with minimal differences between groups.

CONCLUSIONS

In each treatment group, mean visual acuity improved over 24 months, with neither approach superior to a degree detectable with the study's power. Therefore, the specific advantages and disadvantages identified should dictate selection between the alternative treatments in consideration of individual patients' particular circumstances. Systemic therapy with aggressive use of corticosteroid-sparing immunosuppression was well tolerated, suggesting that this approach is reasonably safe for local and systemic inflammatory disorders.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Vitrectomy for Persistent Panuveitis in Behçet's Disease

PURPOSE

To determine whether vitrectomy is safe and effective for the management of vitreoretinal complications in Behçet's patients with persistent panuveitis.

METHODS

Patients who had undergone therapeutic vitrectomy for Behçet's panuveitis were reviewed retrospectively. Those patients who had shown persistent uveitis despite maximum medical therapy were included. Surgical outcomes were measured by an improvement in vision of 0.3 logarithm of minimum angle of resolution, acute relapse rates, and postoperative complications.

RESULTS

Twenty-one patients with a mean postoperative follow-up of 30 months were identified. For almost all patients visual acuity and inflammatory control were significantly improved after vitrectomy. However, patients with optic disc neovascularization (NVD) showed no improvement in their vision or inflammatory control. The postoperative rise of intraocular pressure was frequently associated with intravitreal triamcinolone acetonide injections.

CONCLUSIONS

Our study suggests that vitrectomy may be both safe and effective for the management of vitreoretinal complications in Behçet's patients with persistent uveitis. Patients with NVD, however, may have poor outcomes.

[Vogt-Koyanagi-Harada syndrome]

INTRODUCTION

Vogt-Koyanagi-Harada syndrome is a rare, inflammatory disease with manifestations affecting the ocular, central nervous, audito-vestibular, and integumentary systems. Vogt-Koyanagi-Harada syndrome is more frequent in Asia but is also described in Europe. We report three new non asiatic cases of this syndrome.

OBSERVATIONS

The three patients had bilateral panuveitis and hypoacusia. Two of them had peripheral facial palsy, two of them had vestibular syndrome and one of them lymphocytic meningitis. In each case we found characteristic HLA II typing and in one case we discovered the simultaneous presence of three auto-antibodies: anti-retina (anti-Arrestin type), anti-choroid and anti-cochlea. These patients were treated by corticosteroids but required an additional treatment by cyclophosphamide (0.8g/m2). The clinical course was favorable with visual sequelae for two and auditory one for one.

DISCUSSION

These biological and therapeutic elements and a review of the recent literature are in favor of an autoimmune origin of this syndrome.

[Biphosphonates and intraocular inflammation]

PURPOSE/MATERIAL AND METHOD: A 67 year old woman had been taking oral alendronate in a single weekly dose of 70 mg. She developed panuveitis in her right eye and anterior uveitis in the left. The uveitis was resolved with steroids and discontinuation of alendronate. Three weeks later alendronate was reinstituted and this produced a recurrence. Her past medical history revealed that she had a temporal arteritis but her past ocular history was unremarkable.

RESULTS/CONCLUSION

Disodium alendronate can cause intraocular inflammation (panuveitis and anterior uveitis), which requires discontinuing the treatment.

Visual outcome of vitrectomy in seasonal hyperacute pan uveitis

INTRODUCTION

Seasonal Hyper Acute Panuveitis (SHAPU) is a sight threatening condition often affecting children. Its management as yet is a challenge in ophthalmic practice. Most of the eyes even after treatment end up in pthisis bulbi.

MATERIALS AND METHODS

A retrospective hospital based analysis of 18 patients with SHAPU managed with vitrectomy at Himalaya Eye Hospital (HEH) Pokhara over a period of two years was carried out.

RESULTS

Out of 18 patients 10 were males. Majority of them were below the age of 15 years. Best corrected visual acuity (BCVA) at presentation was less then 3/60 in 72% of them. BCVA was better then 6/60 in 7 (50%) out of 14 patients, who underwent vitrectomy.

CONCLUSION

Vitrectomy is a useful procedure in management of SHAPU.

Syphilitic panuveitis and asymptomatic neurosyphilis: a marker of HIV infection

Co-existing human immunodeficiency virus (HIV) infection can alter the course and presentation of syphilis. Severe ocular manifestations and accelerated natural course of syphilis along with neurosyphilis may be associated with HIV infection. A 30-year-old man is described in whom syphilitic panuveitis and asymptomatic neurosyphilis served as a marker for HIV infection.

Intravitreal sustained-release dexamethasone device in the treatment of experimental uveitis

PURPOSE

Uveitis often runs a chronic course requiring long-term therapy. Topical treatment results in poor intravitreal penetration, and systemic therapy is associated with significant side effects. The authors investigated whether an intravitreal sustained-release dexamethasone device was effective in the treatment of severe panuveitis in a rabbit model.

METHODS

Twenty New Zealand white rabbits were immunized twice subcutaneously with 10 mg of Mycobacterium tuberculosis H37Ra antigen. Twelve days later, sustained-release dexamethasone devices were implanted into the vitreous of the right eye of 10 rabbits. Ten control rabbits received a sham device. One day later, rabbits were challenged with an intravitreal injection of 33 micrograms of antigen. Three animals in each group were sacrificed on post-challenge days 7 and 13 for aqueous white blood cell (WBC) count, protein determination, and histologic examination. To simulate chronic inflammation with exacerbations, the eight remaining eyes were rechallenged with intravitreal antigen on day 15 and were observed for 3 1/2 months. Inflammation was graded clinically by two masked observers. Retinal function was evaluated by electroretinography (ERG). Light microscopy was used to evaluate the eyes histopathologically. The amount of residual drug in the devices was measured on day 13 and at the end of the experiment.

RESULTS

By all clinical criteria measured--anterior chamber cells, flare, and vitreous opacity--treated eyes had significantly less inflammation than untreated eyes (P < 0.05). Clinical examination correlated well with objective data. Both protein concentration (P < 0.05) and aqueous WBCs (P < 0.02) were approximately 10-fold higher, and ERGs were significantly depressed (P < 0.05) in untreated eyes compared to treated eyes. Histopathologic examination showed marked inflammation and tissue disorganization in the untreated compared to the treated eyes. After antigen rechallenge, inflammation in experimental eyes was still less than in control eyes. Late complications such as corneal neovascularization, cataract, and hypotony were also less in the treated eyes than in the untreated eyes. At the end of the experiment (99 days after device implantation), approximately 30% of drug remained in the devices.

CONCLUSIONS

The intravitreal sustained-release dexamethasone device is highly effective in suppressing inflammation and preventing complications after two episodes of experimental uveitis in a rabbit model for at least 3 1/2 months. This device may be useful in the management of patients with severe chronic posterior uveitis who cannot tolerate systemic or periocular therapy.