Effect of infliximab on sight-threatening panuveitis in Behçet's disease

Permanent loss of vision resulting from relapsing ocular inflammation occurs frequently in patients with Behçet's disease, despite intensive, chronic immunosuppressive therapy. Since tumour necrosis factor (TNF) might have an important pathogenetic role in Behçet's disease, we decided to give a single infusion of infliximab-a monoclonal antibody against TNF-to five patients with relapsing panuveitis, at the immediate onset of last relapse. Remission of ocular inflammation was evident within the first 24 h, and complete suppression was seen 7 days after treatment in all patients. No side-effects were noted. We suggest that infliximab is a rapid and effective new therapy for sight-threatening ocular inflammation in Behçet's disease.

Herpes simplex virus type 2: a cause of acute retinal necrosis syndrome

PURPOSE

To describe a case of herpes simplex virus type 2 (HSV-2) acute retinal necrosis syndrome (ARN) in a 13-year-old immunocompetent girl.

METHODS

Polymerase chain reaction (PCR), cultures, flow cytometry, and cytology were performed on the vitreous sample.

RESULTS

Both PCR studies and vitreous cultures revealed HSV-2 as the cause of ARN. Flow cytometry showed CD4+, CD8+, and natural killer cells. The visual outcome of the patient was 20/200.

CONCLUSION

Successful culture of HSV-2 from the vitreous specimen in a patient with ARN proved HSV-2 to be one of the causes of ARN. The successful culture of HSV-2 has not been previously reported.

Cystoid macular edema in a patient with acquired immunodeficiency syndrome and past ocular history of cytomegalovirus retinitis after initiation of protease inhibitors

PURPOSE

To describe a patient with acquired immunodeficiency syndrome (AIDS) who presented with cystoid macular edema (CME) which was not associated with active cytomegalovirus (CMV) retinitis or AIDS-related microvasculopathy.

METHOD

A 32-year-old man with AIDS and a past ocular history of inactive CMV retinitis was placed on protease inhibitors when his CD4+ T lymphocyte counts dropped to 8 cells/mm3. Three months later, after his CD4+ T lymphocyte counts had increased to 196 cells/mm3 he complained of micropsia and metamorphopsia in his right eye of 1 week duration. The patient had a complete ocular examination including fluorescein angiography (FA).

RESULTS

Visual acuity (VA) was 7/10 OD. Fundus examination revealed CME and inactive CMV retinitis, and FA demonstrated CME and a hot disc. Two transseptal injections of corticosteroids were administered 2 weeks apart in the right eye as treatment of the CME. The patient reported gradual visual improvement and 6 weeks later, his VA was 10/10(-2). CME had resolved clinically and angiographically.

CONCLUSIONS

CME in our case is associated with inactive CMV retinitis and gradually increasing number of CD4+ T lymphocytes after initiation of treatment with protease inhibitors. It may be amenable to regional administration of corticosteroids without reactivation of retinitis.

Medical treatment of macular edema in patients with uveitis

PURPOSE

To determine the efficacy of medical treatment of cystoid macular edema (CME) in patients with uveitis.

METHODS

Retrospective study of 40 patients (57 eyes) with uveitis and CME. Inclusion criteria were presence of CME with minimal and no macular pathology, or vascular disease which could account for CME. Patients who had undergone intraocular surgery or had visual acuity (VA) of > or = 20/40 were excluded. The diagnosis of CME was based on clinical and/or angiographic findings. Three treatment groups were defined: (1) transseptal injection of steroids (n=13 eyes); (2) systemic non steroidal anti-inflammatory drugs (NSAIDs) (n=11 eyes); both 1 and 2 (n=33 eyes).

RESULTS

Overall, 79% of eyes improved 3 or more lines of Snellen VA after treatment: 51% improved 4 or more lines. The average number of lines improved was 3.8 for eyes treated with transseptal injections of steroids, 2.9 for eyes treated with NSAIDs, and 4 for eyes treated with both. For all 3 treatment groups between 60-70% of eyes improving 2 or more lines reached best VA only after a minimum of 6 months of follow up.

CONCLUSIONS

CME, a vision threatening complication of uveitis, respond fairly well to medical treatment; however, the best VA is achieved after several months. The improvement in VA did not differ markedly among the three treatment groups.

Characteristics of uveitis presenting for the first time in the elderly

OBJECTIVE

This study aimed to describe the clinical characteristics of uveitis presenting de novo in the elderly.

DESIGN

The study design was a description of a retrospectively identified case series.

PARTICIPANTS

A population of 138 patients (209 eyes) with uveitis beginning after age 60 was analyzed.

RESULTS

Uveitis in the elderly accounted for 10.4% of the authors' uveitis population. The localization of uveitis was anterior in 56.5% of patients, intermediate uveitis was diagnosed in two patients (1.4%), posterior uveitis was found in 25.4%, while 16.7% of patients presented with panuveitis. Idiopathic uveitis accounted for the majority of cases (31.2%), whereas herpes zoster ophthalmicus (11.6%), herpes simplex virus (6.5%), presumed sarcoidosis (5.8%), syphilis (4.3%) ankylosing spondylitis (4.3%), and birdshot chorioretinopathy (3.6%) were the most frequent specific diagnostic entities. Secondary elevation of intraocular pressure was common (67 eyes, or 32%). The development of macular edema complicated 28.7% of cases (60 eyes). Two cases of intraocular lymphoma were identified in 19 diagnostic vitreous biopsy specimens. Fifty-two percent of eyes retained visual acuity of 20/40 or more; 32.6% had final visual acuity worse than 20/100.

CONCLUSIONS

Uveitis presenting for the first time in the elderly is not uncommon. Idiopathic uveitis accounts for the majority of cases, and herpes zoster ophthalmicus and herpes simplex virus are particularly prevalent. Intraocular lymphoma does not predominate in this age group. With adequate control of intraocular inflammation and its sequelae, the visual prognosis in patients in this age group with uveitis is relatively good.

Retinal perivasculitis in an immunocompetent patient with systemic herpes simplex infection

PURPOSE

To describe a case of retinal perivasculitis in an immunocompetent patient with systemic herpes simplex infection.

METHODS

Polymerase chain reaction amplifications were performed for aqueous and blood samples using primers specific for the following members of the herpesvirus family: cytomegalovirus, Epstein-Barr virus, herpes simplex virus (types 1 and 2), and varicella-zoster virus. The patient was placed on intravenous acyclovir and systemic corticosteroids.

RESULTS

A positive polymerase chain reaction signal was found only for herpes simplex virus type 1. Vision in the left eye improved from light perception to 20/25, and signs of retinal perivasculitis resolved.

CONCLUSION

The use of molecular diagnostic modalities in clinical practice may aid in determining infectious etiologies in patients with atypical clinical manifestations.