Unraveling the Spectrum of Uveitis: Insights from an Epidemiological Study in a National Referral Center in Northern Italy

PURPOSE

Uveitis embraces a heterogeneous group of vision-threatening inflammatory conditions. Understanding uveitis epidemiology, etiology, and clinical findings is fundamental for a prompt diagnosis and optimal patient management. The aim of the study is to report the epidemiology of uveitis in a national referral center in Northern Italy and investigate the visual prognosis.

METHODS

This retrospective study was conducted at Uveitis Service (Ospedale San Raffaele) between June 2016 and May 2023. Demographic data, clinical characteristics, and etiological diagnoses of uveitis patients were collected, and visual prognosis was longitudinally explored.

RESULTS

1105 patients with uveitis were included in the study, while 47 patients presented neoplastic masquerade syndrome and have been excluded. The population had a slight majority of females (M/F ratio = 0.76), mean age was 47 years. 25% presented infectious uveitis, primarily due to herpetic etiology, toxoplasmosis, and tuberculosis. Non-infectious uveitis was the most prevalent diagnosis (38%), with sarcoidosis, HLA-B27-associated uveitis, and Fuch's uveitis as prominent causes. Anatomically, anterior segment was most frequently involved (41%). Significant improvement in visual acuity was observed at follow-up, particularly in patients with infectious uveitis.

CONCLUSIONS

Our study sheds light into the epidemiological landscape of uveitis in Northern Italy, reflecting changing patterns due to factors such as migration and changing sexual habits. In particular, higher percentages of syphilis have been observed, compared to other European reports. The distribution of non-infectious uveitis reflects other epidemiological European series. Higher percentages of neoplastic masquerade syndromes support the need of early recognition. Our findings offer precious insights for uveitis epidemiology and daily clinical practice.

Peripapillary Retinal Nerve Fiber Layer Thickness as a Predictor of Visual Outcomes in Patients with Acute Nonarteritic Anterior Ischemic Optic Neuropathy

Objective

To evaluate the utility of peripapillary retinal nerve fiber layer thickness (pRNFLT) for the prediction of visual outcomes, including visual acuity (VA) and visual field (VF), in subjects with acute nonarteritic anterior ischemic optic neuropathy (NAION).

Materials and Methods

We performed a retrospective study of data relating to 60 eyes of 60 subjects with acute NAION. Of these, reliable VF values were obtained at both the initial and at 6-month follow-up visits for 30 eyes, which were included in the VF analysis. The pRNFLT was measured globally and separately in all four quadrants (superior, inferior, nasal, and temporal) using optical coherence tomography at the initial visit. Multivariate analysis and the area under the curve (AUC) were used to evaluate the utility of pRNFLT for the prediction of visual outcomes, including favorable VA (VA better than or equal to 20/25) and favorable VF (visual field index (VFI) ≥90%), at the 6-month follow-up visit.

Results

The median VA and mean VFI at the initial visit were 0.40 (interquartile range (IQR): 0.40, 0.54; logarithm of the minimum angle of resolution (logMAR)) and 73.07% ± 6.73%, respectively. The median VA and mean VFI at the 6-month follow-up visit were 0.30 (IQR: 0.00, 0.70) logMAR and 69.27% ± 28.94%, respectively. Thinner temporal-quadrant pRNFLT was associated with favorable VA (odds ratio 0.98; p = 0.042) with a cut-off value of 128 µm (AUC 0.839, 95% CI: 0.732-0.947, sensitivity 77.27%, specificity 84.21%). Thinner nasal-quadrant pRNFLT was associated with favorable VF (odds ratio 0.97; p = 0.047) with a cut-off value of 105 µm (AUC 0.780, 95% CI: 0.612-0.948, sensitivity 90.00%, specificity 70.00%).

Conclusions

The pRNFLT is clinically useful for the prediction of visual outcomes in patients with acute NAION. A temporal-quadrant pRNFLT ≤128 µm and a nasal-quadrant pRNFLT ≤105 µm predict favorable VA and VF at the 6-month follow-up visit, respectively.

Clinical Features of Pediatric Uveitis at a Tertiary Referral Center in the Western Region of Japan

PURPOSE

This study aimed to assess the clinical features of pediatric uveitis at a tertiary referral center in Western Japan.

METHODS

One hundred forty eyes of 80 patients aged <20 years at the time of uveitis onset, who visited Kyushu University Hospital between January 2010 and December 2019 were included in this study. Clinical records were retrospectively reviewed. Demographics, clinical findings, treatments, and visual prognoses were compared between the disease groups.

RESULTS

Of 80 patients, 32 were males and 48 were females. The average age of onset was 12.5 ± 4.8 (0-19) years. Tubulointerstitial nephritis and uveitis (TINU) and juvenile idiopathic arthritis (JIA) were the most frequent causes, accounting for 11.3% and 10% of cases, respectively, followed by sarcoidosis (5%), Behçet's disease, acute anterior uveitis, Vogt-Koyanagi-Harada disease, and juvenile chronic iridocyclitis (3.8% each). Infectious uveitis accounted for 7.6% of the cases: cytomegalovirus was the most frequent agent. Of these cases, 43.8% were unclassified. Systemic therapies were administered to 87.5% of the patients with JIA, 33.3% of those with TINU, and 28.6% of the other diagnostic groups. In the unclassified group, 80% of the patients were followed up with only topical corticosteroids. LogMAR visual acuity of 0 or less accounted for more than 80% in the final examination.

CONCLUSION

TINU and JIA were the most common causes of pediatric uveitis. Although each required systemic therapy, most unclassified cases of pediatric uveitis were managed by topical corticosteroids alone with good visual prognosis. Accurate diagnosis is important for pediatric uveitis management.

Severe Macular Ischemia Is Associated with a Poor Visual Prognosis and Serious Complications in Eyes with Central Retinal Vein Occlusion

PURPOSE

This study aims to investigate the factors influencing post-treatment visual acuity (VA) in patients with central retinal vein occlusion (CRVO) with macular edema (ME).

METHODS

The subjects of this study were patients who visited our clinic from May 2013 to July 2019 and who could be followed up with for at least 12 months. Cases with hemi CRVO were excluded from this study. Factors considered in the evaluation of visual prognosis at the 12 months included initial best-corrected VA, central subfoveal thickness, CRVO subtype (nonischemic, ischemic, or converted from nonischemic to ischemic), time taken for the first treatment, number of anti-vascular endothelial growth factor agent injections, structural changes in the inner and outer retinal layers, and the presence of macular ischemia in a multiple regression analysis.

RESULTS

There were 41 patients with 41 eyes, 27 males and 14 females. The mean age of the patients was 70.5 ± 12.2 (mean ± standard deviation) years. The mean VA was 0.544 ± 0.576, 0.456 ± 0.568, and 0.586 ± 0.665 at the initial visit, 12 months later, and time of last observation, respectively. There were no significant differences in VAs observed between the baseline, month 12, and final visit. Multiple regression analysis revealed that the external limiting membrane score at month 12 (p = 0.030), the VA at initial visit (p < 0.001), and the presence of severe macular ischemia (p < 0.001) were the key factors associated with VA at month 12. Moreover, severe macular ischemia was identified as the only factor affecting decimal VA less than 20/200 at the last observation (p = 0.0092).

CONCLUSIONS

Severe macular ischemia is strongly linked to a poor visual prognosis in patients with ME associated with CRVO.

Early and Late Complications after Cataract Surgery in Patients with Uveitis

Background and Objectives: Uveitis, a prevalent eye disorder characterized by inflammatory processes, often leads to cataract formation and significant visual impairment. This study aimed to evaluate preoperative conditions and postoperative outcomes following cataract surgery in uveitis patients. Materials and Methods: A retrospective study was conducted at the University Hospital Center Rebro Zagreb, Croatia, involving uveitis patients who underwent cataract surgery between 2013 and 2022. Eligible patients had uveitic cataracts affecting visual acuity or posterior segment visualization in a "quiet eye" and were disease-inactive for at least three months. Patients with certain pre-existing ocular conditions were excluded. The data collected included patient demographics, uveitis type, preoperative therapy, preexisting lesions, and postoperative outcomes such as visual acuity, intraocular pressure, central macular thickness, and complications. Statistical analysis was performed to identify risk factors associated with complications. Results: This study included 105 patients. The most common uveitis types were idiopathic uveitis, HLA-B27-associated uveitis, and JIA uveitis. After cataract surgery, there was a significant improvement in visual acuity at various time points, with 90% of eyes showing improvement. Intraocular pressure decreased over time. Central macular thickness increased at three months post-surgery but remained stable thereafter. Early and late complications were observed in 52.4% and 63.8% of eyes, respectively. The most common complications were posterior capsular opacification (53.3%), macular edema (26.6%), and epiretinal membrane formation (9.52%). The factors associated with complications varied between early and late stages but included age, age at the onset of uveitis, and the uveitis type. Conclusions: In patients with quiescent uveitis undergoing cataract surgery, significant visual improvement was achieved. This study highlights the importance of careful patient selection, preoperative and postoperative inflammation management, and precise surgical techniques. Although complications were common, the risk of capsular opacification, macular edema, and epiretinal membrane formation after surgery increased. However, future investigations should address this study's limitations and further refine perioperative strategies.

Characteristics of fundus autofluorescence imaging at 795 nm and its correlations with postoperative outcomes for idiopathic macular hole

BACKGROUND

Vitrectomy combined with internal limiting membrane (ILM) peeling or ILM inverted flap greatly improves hole closure and vision prognosis for idiopathic macular holes (IMH). The application of indocyanine green (ICG) in MH surgery increases the visibility of ILM and the safety of surgery. However, the area of ILM peeling and the state of the flap and a closed hole has not been well observed.

AIM

Fundus autofluorescence at 7935nm can show the range of ILM peeling and the state of the hole site and ILM flap by monitoring residual ICG postoperatively. However, the characteristics of fundus autofluorescence especially the site of the closed hole, and its relationship with vision prognosis have not been explored. The aim of this project was to find the autofluorescence features of the closed hole and their relation with vision.

OBJECTIVE

To investigate the characteristics of fundus autofluorescence imaging after ICG-assisted vitrectomy for IMH and to evaluate the correlations of fluorescence patterns at the MH site with visual acuity and macular anatomic outcomes.

METHODS

We retrospectively evaluated 33 IMH patients (33 eyes) who underwent a 25G pars plana vitrectomy (follow-up, 6-14.5 months). ICG staining (2.5 mg/mL) was either used to remove the internal limiting membrane (ILM) or the inverted ILM flap was overlaid on the hole. After surgery, fluorescence imaging of the fundus was obtained using a scanning laser ophthalmoscope at 795 nm.

RESULTS

On fluorescence imaging, the area of ILM peeling in all eyes showed hypofluorescence with no changes over time. The inverted ILM flap (performed in 18 eyes) was positioned on the inferior retina and exhibited early mild hyperfluorescence with blurred edges. This was gradually enhanced up to 3-6 months postoperatively and was then attenuated. MHs showed two distinct patterns on optical coherence tomography: granular (21 eyes) and patchy hyperfluorescence (12 eyes). Best-corrected visual acuity improved postoperatively in all cases (p<0.001, Z=-4.744). VA was worse in the patchy (vs. granular) hyperfluorescence cases (p=0.011, Z=-2.548).

CONCLUSION

The status of the ILM peeling area, ILM flap, and closed MH can be clearly observed using autofluorescence imaging at 795 nm. Fluorescence may be due to ICG staining of the ILM and accumulation in retinal pigment epithelium cells during ICG-assisted surgery. Granular hyperfluorescence at the MH site may indicate good anatomic and visual prognoses.

Neovascular Glaucoma Complicating Central Retinal Artery Occlusion Despite Cilioretinal Artery Sparing

This case report aims to describe a case of unilateral central retinal artery occlusion (CRAO) with cilioretinal artery sparing, which was complicated by neovascular glaucoma (NVG). A 75-year-old Indian woman with underlying normal tension glaucoma presented with the sudden onset of painless generalized blurring of the right eye's vision for a week. Her right eye vision was hand motion with the presence of a right relative afferent pupillary defect. Fundus examination revealed retinal whitening over the macula sparing the papillomacular bundle with generalized retinal arteriolar attenuation, which was suggestive of right CRAO with cilioretinal artery sparing. Systemic examination revealed high blood pressure (175/75 mmHg) without ocular bruit or audible murmur on auscultation. Optical coherence tomography of the macula showed inner retinal thickening over the temporal macula. Ultrasound carotid Doppler and computed tomography angiography of the carotid showed more than 75% stenosis over the right distal internal carotid artery. Unfortunately, she developed rubeosis iridis over her right eye two weeks after her presentation, which required pan-retinal photocoagulation. She subsequently progressed to NVG, requiring maximum anti-glaucoma medications to stabilize intraocular pressure. In conclusion, CRAO is a sight-threatening medical emergency. Thorough investigations are required to determine the underlying cause so that early intervention can be done to reduce the risk of a similar attack in the fellow eye and the risk of a cerebrovascular event or cardiac ischemia, which could be life-threatening. The presence of a cilioretinal artery does not prevent ocular neovascularization in CRAO. Hence, patients should also be closely monitored after the initial diagnosis to prevent devastating complications such as NVG.

Ellipsoid Zone and External Limiting Membrane-Related Parameters on Spectral Domain-Optical Coherence Tomography and Their Relationships With Visual Prognosis After Successful Macular Hole Surgery

Purpose: To compare structural diameters of the ellipsoid zone (EZ) and external limiting membrane (ELM) bands on spectral domain-optical coherence tomography (SD-OCT) images between vision-improved (group A) and vision-unimproved (group B) patients, and investigate the connection between these parameters and visual prognosis.

Materials and Methods: Forty-five eyes of 43 patients with idiopathic full-thickness macular hole closed after vitrectomy were retrospectively reviewed. Best-corrected visual acuity (BCVA) and SD-OCT were conducted preoperatively and at 1 week, 1 month and 6 months postoperatively. Structural and functional parameters were then measured using ImageJ software.

Results: Among structural and functional parameters, the relative reflectivity of EZ and the ratio of continuous ELM and EZ in group A were significantly higher than in group B from the 1-month postoperative visit. At the 6-month follow-up, the diameter of EZ disruption in group A was significantly smaller than in group B, and the relative reflectivity of ELM/EZ was significantly higher than group B. At 6-months, BCVA was statistically significantly correlated with baseline BCVA, basal diameter (BD), macular hole index (MHI), and diameter of ELM/EZ disruption. Change in BCVA from baseline was found to be significantly correlated with axial length and diameter hole index (DHI).

Conclusions: Postoperative BCVA outcome was significantly correlated with integrity, thickness and reflectivity of the EZ band. Patients with smaller diameter of EZ disruption and higher reflectivity of EZ band tended to have better visual outcomes. Given that the EZ band reflects the recovery of mitochondria in photoreceptors, it is a promising parameter for their functional evaluation.

Characterization of Risk Profiles for Diabetic Retinopathy Progression

Diabetic retinopathy (DR) is a frequent complication of diabetes and, through its vision-threatening complications, i.e., macular edema and proliferative retinopathy, may lead to blindness. It is, therefore, of major relevance to identify the presence of retinopathy in diabetic patients and, when present, to identify the eyes that have the greatest risk of progression and greatest potential to benefit from treatment. In the present paper, we suggest the development of a simple to use alternative to the Early Treatment Diabetic Retinopathy Study (ETDRS) grading system, establishing disease severity as a necessary step to further evaluate and categorize the different risk factors involved in the progression of diabetic retinopathy. It needs to be validated against the ETDRS classification and, ideally, should be able to be performed automatically using data directly from the examination equipment without the influence of subjective individual interpretation. We performed the characterization of 105 eyes from 105 patients previously classified by ETDRS level by a Reading Centre using a set of rules generated by a decision tree having as possible inputs a set of metrics automatically extracted from Swept-source Optical Coherence Tomography (SS-OCTA) and Spectral Domain- OCT (SD-OCT) measured at different localizations of the retina. When the most relevant metrics were used to derive the rules to perform the organization of the full pathological dataset, taking into account the different ETDRS grades, a global accuracy equal to 0.8 was obtained. In summary, it is now possible to envision an automated classification of DR progression using noninvasive methods of examination, OCT, and SS-OCTA. Using this classification to establish the severity grade of DR, at the time of the ophthalmological examination, it is then possible to identify the risk of progression in severity and the development of vision-threatening complications based on the predominant phenotype.

The Effect of Secondary Intraocular Lens Implantation Time on Visual Prognosis in Aphakia Cases After Open Globe Injury

Purpose

We investigated the effect of the time of secondary intraocular lens (IOL) implantation on final visual acuity and other causes affecting visual prognosis in cases left aphakic after open globe injury.

Methods

The study included 62 eyes of 62 patients left aphakic after the repair of open globe injury between 2012-2019. Demographic characteristics, trauma zone, ocular trauma score (OTS), type of injury, time of secondary IOL implantation, final best corrected visual acuity (BCVA), and complications were recorded for each patient.

Results

The mean follow-up time of 62 patients was 25.05 ± 12.59 months. The preoperative BCVA was found to be 2.40±0.86 LogMAR, while the postoperative final BCVA was found to be 0.53±0.70 LogMAR (p<0.01). The mean interval timing of secondary sulcus foldable IOL implantation was determined to be 3.79 ± 4.04 months. No correlation was observed between secondary IOL implantation time and final BCVA (r= 0.140, p=0.319). Furthermore, when only pediatric patients were taken, an excellent positive correlation was found between the secondary IOL implantation time and final BCVA LogMAR (r=0.895, p<0.01). Multiple linear regression on final BCVA with age, revealed a significant model explaining 48.0% of the variability with younger age and better final BCVA with as significant coefficients (p= 0.007).

Conclusion

Although time interval between primary repair and secondary IOL implantation to correct aphakia does not effect final BCVA in adult patients, earlier surgery should be considered for amblyopia management in pediatric patients.

Correlation Between Electroretinogram and Visual Prognosis in Metallic Intraocular Foreign Body Injury

Purpose: This study aims to investigate the correlation between electroretinogram (ERG) and visual outcome in eyes with metallic intraocular foreign body (IOFB) injury.

Methods: Cases with metallic IOFB injuries with preoperative ERG from January 2008 to May 2020 were reviewed retrospectively. Five ERG responses were recorded, including rod response, maximal response, oscillatory potentials, cone response, and 30-Hz flicker. The results were compared between the affected and the contralateral eyes. All patients received surgery to remove IOFBs. The correlation between amplitudes, implicit times, and grades of ERG with final best-corrected visual acuity (BCVA) was analyzed.

Results: A total of 33 eyes of 33 patients were included. The eyes with IOFB had generally delayed implicit time and reduced amplitude in all waves. The maximum change was found in oscillatory potentials S3 and N1 (0.42 ± 0.42 and 1.95 ± 1.97 of the fellow eyes, respectively, p < 0.05). All amplitudes were negatively correlated with the final BCVA (rs: −0.676 to −0.459, all p < 0.05). In contrast, all implicit times were positively correlated with final BCVA, although, some of them were not statistically significant (rs: 0.035 to 0.687). Among them, oscillatory potential P3 has the highest correlation coefficient (rs = 0.687, p < 0.001). All grades of ERG waves were statistically correlated with the final BCVA (rs: −0.596 to −0.664, all p < 0.001).

Conclusions: ERG can be used to assess visual outcome in metallic IOFB injury after surgery. Oscillatory potentials provided the most significant responses.

Indicators of Visual Prognosis in Diabetic Macular Oedema

Diabetic macular oedema (DMO) is an important cause of moderate vision loss in people with diabetes. Advances in imaging technology have shown that a significant proportion of patients with DMO respond sub-optimally to existing treatment options. Identifying associations and predictors of response before treatment is initiated may help in explaining visual prognosis to patients and aid the development of personalized treatment strategies. Imaging features, such as central subfoveal thickness, photoreceptor integrity, disorganization of retinal inner layers, choroidal changes, and macular perfusion, have been reported to be prognostic factors of visual acuity (VA) in DMO. In this review we evaluated each risk factor to understand their relative importance in visual prognostication of DMO eyes post-treatment. Although individually, some of these factors may not be significant predictors, in combination they may form phenotypes that can inform visual prognosis. Stratification based on these phenotypes needs to be developed to progress to personalized medicine for DMO.

Clinical Characteristics Associated with the Development of Cystoid Macular Edema in Patients with Cytomegalovirus Retinitis

We evaluated the incidence and characteristics of eyes with cytomegalovirus (CMV) retinitis according to the occurrence of cystoid macular edema (CME) and identified the risk factors of its occurrence. Patients diagnosed with CMV retinitis and examined using optical coherence tomography were classified according to the development of CME. The CME group was further divided according to the presence of active retinitis at the time of CME development. The demographics, serologic findings, ophthalmic presentations, ocular treatments, and visual prognosis were compared. CME was identified in 25 eyes (17 eyes with active retinitis and 8 eyes with inactive retinitis) out of the 67 eyes with CMV retinitis. Visual acuity was worse in the CME group than in the non-CME group. The CME group had longer CMV viremia duration, zone 1 involvement, and larger extent of CMV retinitis. While CME with concurrent active retinitis developed in eyes with direct foveal involvement of retinitis in the acute phase and required more ganciclovir injections after CME development, CME without active retinitis developed in eyes with larger extents of involvement and more intravitreal ganciclovir injections before CME development. Zone 1 involvement and longer CMV viremia duration were independently associated with the occurrence of CME. CME, which caused visual deterioration, developed in considerable patients with CMV retinitis and had different characteristics according to the presence of active retinitis.

Surgical management and outcomes of pediatric open globe injuries requiring vitrectomy

PURPOSE

To describe surgical management and establish visual outcomes of open globe injury (OGI) in pediatric patients requiring vitrectomy.

METHODS

Forty-eight eyes of 48 pediatric patients underwent vitrectomy for OGI with secondary vitreoretinal complications in the eye center of Jilin University were included. Characteristics of patients, details of ocular examination and operation, presenting and final visual acuity were recorded.

RESULTS

Presenting visual acuity less than 20/400 was found in 44 eyes (91.7%), which included no light perception (NLP) in four eyes. At last visit, there was no eyes with visual acuity of NLP, and 19 eyes (39.6%) had a vision recovery to 20/400 or better. Mechanisms of injury, intraocular contents prolapse, presence of hyphema, intraocular foreign body, vitreous hemorrhage, retinal detachment, and total time from injury to PPV > 2 weeks were significant predictors of visual prognosis. Logistic regression analysis showed that hyphema was a significant predictive factor for poor visual outcome.

CONCLUSION

Visual acuity was improved in most of the patients with OGI in this study. Hyphema is an important presenting ocular sign in estimating the post-vitrectomy visual outcome for OGI in children. Proper timing of vitrectomy is suggested, and in this study patients may benefit more with early vitrectomy as less proliferative vitreoretinopathy (PVR) was found together with a better visual acuity.

Retained visual function in a subset of patients with long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD)

Introduction: LCHADD causes retinopathy associated with low vision, visual field defects, nyctalopia and myopia. We report a retrospective long-term single-center study of 6 LCHADD patients trying to clarify if early diagnosis has an impact on the course and outcome of chorioretinal degeneration. Methods: Long-term follow-up of visual acuity and staging of chorioretinal degeneration by fundus photography, optical coherence tomography (OCT) and autofluorescence (AF) in all six patients. Three patients (2 m/1 f; age 8-14.8 years) were diagnosed by newborn screening, a single patient early within the first year of life and treated promptly while the other two (1 m/1 f; age 23-24 years) were diagnosed later after developing symptoms. All carried HADHA variants; five were homozygous for the common p.E510Q variant, in one from the symptomatically diagnosed group p.[E510Q]; [R291*] was detected. Results: All patients showed retinal alterations, but early diagnosis was associated with a milder phenotype and a longer preservation of visual function. Among symptomatic patients, only one showed mild retinal involvement at the time of diagnosis. Conclusion: Despite the small number our study suggests that early diagnosis does not prevent retinopathy but might contribute to a milder phenotype with retained good visual acuity over time. OCT and AF are reliable non-invasive diagnostic tools to estimate the progression of early-stage retinal changes in LCHADD patients.

Rapid Administration of High-Dose Intravenous Methylprednisolone Improves Visual Outcomes After Optic Neuritis in Patients With AQP4-IgG-Positive NMOSD

Objective: The purpose of this study was to elucidate the rapid impact of high-dose intravenous methylprednisolone pulse therapy (1,000 mg/day for 3 days) on the eventual visual prognosis in patients with serum anti-aquaporin-4 immunoglobulin G (AQP4-IgG)–positive neuromyelitis optica spectrum disorders (NMOSDs) who had an attack of optic neuritis (ON).

Methods: Data from 32 consecutive NMOSD patients (1 male and 31 female) with at least one ON attack, involving a total of 36 ON-involved eyes, were evaluated. The following variables at ON onset were evaluated: sex, age at the first ON episode, visual acuity at nadir, visual acuity after 1 year, duration from ON onset to treatment for an acute ON attack, cycles of high-dose intravenous methylprednisolone pulse therapy for the ON attack, and cycles of plasmapheresis for the ON attack. Among the 36 ON-involved eyes, 27 eyes were studied using orbital MRI with a short-T1 inversion recovery sequence and gadolinium-enhanced fat-suppressed T1 imaging before starting treatment in the acute phase.

Results: In univariate analyses, a shorter duration from ON onset to the initiation of high-dose intravenous methylprednisolone pulse therapy favorably affected the eventual visual prognosis 1 year later (Spearman's rho = 0.50, p = 0.0018). The lesion length on orbital MRI was also correlated with the eventual visual prognosis (rho = 0.68, p < 0.0001). Meanwhile, the days to steroid pulse therapy and lesion length on orbital MRI did not show a significant correlation. These findings suggest that the rapidness of steroid pulse therapy administration affects the eventual visual prognosis independent of the severity of ON. In multivariate analysis, a shorter time from ON onset to the start of acute treatment (p = 0.0004) and a younger age at onset (p = 0.0071) were significantly associated with better visual outcomes.

Conclusions: Rapid initiation of high-dose intravenous methylprednisolone pulse therapy is essential to preserve the eventual visual acuity in patients with serum AQP4-IgG-positive NMOSD. Once clinicians suspect acute ON with serum AQP4-IgG, swift administration of steroid pulse therapy before confirming the positivity of serum AQP4-IgG would be beneficial for preserving visual function.

Higher aqueous levels of matrix metalloproteinases indicated visual impairment in patients with retina vein occlusion after anti-VEGF therapy

PURPOSE

To investigate the levels of matrix metalloproteinases (MMPs) in aqueous humour of patients with retinal vein occlusion (RVO) and the relationship between intraocular MMP levels and retinal lesion and visual prognosis.

MATERIALS AND METHODS

52 RVO patients, including 23 with central retinal vein occlusion (CRVO) and 29 with branch retinal vein occlusion (BRVO) and 20 participants with senile cataract were enrolled in this study. Retinal lesions were examined by fundus colour photography, fluorescein fundus angiography and optical coherence tomographic angiography. Sixty microliters of aqueous humour were collected during intravitreal anti-Vascular Endothelial Growth Factor (VEGF) injection or cataract surgery. The aqueous levels of MMP-1, MMP-2, MMP-7, MMP-9 and MMP-10 were measured using the Luminex xMAP multiplex assay. The relationship between MMP levels and clinical presentations was analysed by Pearson correlation test.

RESULTS

The aqueous humour levels of MMP-1, MMP-2, MMP-7 and MMP-9, but not MMP10 in RVO patients were significantly higher than those in people with cataract after adjusting for age. Further analysis of RVO subgroups showed that the aqueous humour level of MMP2 in CRVO was significantly higher than that in BRVO. The aqueous humour levels of MMP-1 and MMP-2 were positively correlated with superficial capillary plexus vessel density (SVD), whereas the aqueous humour levels of MMP-1 and MMP-7 were negatively correlated with visual improvement following treatment. No correlation between aqueous humour levels of MMP and disease duration and central retinal thickness was observed.

CONCLUSIONS

RVO eyes had significantly higher intraocular levels of MMP-1, MMP-2, MMP-7 and MMP-9 than cataract eyes and the level of MMP2 appears to be related to the area of occlusion. Intraocular levels of MMP may positively affect SVD and negatively impact visual function in RVO.

Prognostic Factors of Cytomegalovirus Infection Associated Retinitis in HIV-Negative Patients: A Retrospective Cohort Study

Purpose: To summarize the prognostic factors of cytomegalovirus (CMV) retinitis (CMVR) in HIV-negative patients treated with multiple intravitreal injections (IVs) of ganciclovir.Methods: A retrospective cohort study (70 eyes) was conducted. Clinical signs, initial and final best corrected visual acuity (BCVA), initial aqueous load of CMV DNA, course of treatment, and occurrence of complications were recorded and analyzed.Results: A positive correlation was found between the baseline and the final best corrected visual acuity (P < .001) and between the initial aqueous CMV DNA load and the number of IVs (P = .01). A lesion close to the posterior pole (P < .001) and a larger retinal lesion (P = .002) remarkably led to worse visual prognosis.Conclusions: Poor visual prognosis was significantly associated with poor initial visual acuity, proximity of lesion to the posterior pole, and an extensive CMV lesion. The treatment duration was positively correlated with the initial aqueous CMV DNA load.

[Idiopathic intracranial hypertension: a rare case related to pregnancy]

We report the case of a 25-year old primipara whose pregnancy was complicated by idiopathic intracranial hypertension (ICHT) associated with visual impairment in the first quarter. She underwent lumboperitoneal shunt without obstetric consequences. This study aimed to determine the features of this rare pathological entity whose pathophysiological mechanism is poorly elucidated. It would be caused by poor absorption of cerebrospinal fluid (CSF) through the arachnoid granulations. Major risk factors are: obesity, polycystic ovary syndrome, thrombophilia and hyperfibrinolyse. Diagnosis is based on modified Dandy criteria after negative clinico-biological and radiological assessment. Visual prognosis is compromised, as in the case of « classical » ICHT. However, there is no risk for cerebral involvements which could be life-threatening. In addition, this disease does not influence pregnancy outcome. This said, rapid and effective treatment should be implemented in order to preserve visual function in these patients.

Ocular Behçet's Disease: Changing Patterns Over Time, Complications and Long-Term Visual Prognosis

PURPOSE

To investigate demographic, clinical features and complications of Italian patients with ocular Behçet's disease (BD) over time.

METHODS

Retrospective study of 385 patients examined from 1968 to 2011, 265 of whom had follow-up ≥ 12 months.

RESULTS

A significant increase in the proportion of females (p = 0.03) and anterior uveitis (p < 0.001), and a decrease in the complete type of BD in all patients (p = 0.003) and in males (p = 0.002), and in hypopyon (p = 0.024) were observed over time. Optic neuropathy (p < 0.0001), maculopathy (p = 0.002), retinal detachment, and retinal neovascularization (p = 0.02) decreased over time, with no difference between genders, concomitant with an increase in the use of immunosuppressive drugs (p = 0.003). Visual acuity ≤1/10 was detected more often in males than females (p = 0.003).

CONCLUSIONS

A significant shift in clinical manifestations of BD patients was observed over 44 years. Immunosuppressive therapy succeeded in lowering ocular complications. The incidence of ocular BD is increasing in females, but visual prognosis is still worse in males.

Relationship between variations in posterior vitreous detachment and visual prognosis in idiopathic epiretinal membranes

PURPOSE

To clarify the relationship between variations in posterior vitreous detachments (PVDs) and visual prognoses in idiopathic epiretinal membranes (ERMs).

METHODS

In this retrospective, observational, and consecutive case series, we observed variations in PVDs in 37 patients (mean age, 65.7±11.0 years) with ERMs and followed them for 2 years. Three PVD types were found biomicroscopically: no PVD, complete PVD with collapse (C-PVD with collapse), and partial PVD without shrinkage, with persistent vitreous attachment to the macula through the premacular hole of the posterior hyaloid membrane (P-PVD without shrinkage [M]). The best-corrected visual acuity (BCVA) was measured and converted to the logarithm of the minimum angle of resolution (logMAR) BCVA at the first visit and 2 years later.

RESULTS

No PVD was observed in 16 of the 37 eyes (mean age, 61.3±11.3 years), C-PVD with collapse in 11 of the 37 eyes (mean age, 69.1±9.9 years), and P-PVD without shrinkage (M) in 10 of the 37 eyes (mean age, 69.3±10.9 years). The logMAR BCVA at the first visit was the worst in the P-PVD without shrinkage (M) group (0.22±0.35) compared with the no-PVD group (-0.019±0.07; P<0.01) and the C-PVD group (0.029±0.08; P<0.05). The logMAR BCVA 2 years later was also worst in the P-PVD without shrinkage (M) group (0.39±0.35) compared with the no-PVD group (0.04±0.13) and the C-PVD with collapse group (0.03±0.09; P<0.05 for both comparisons). The change in the logMAR BCVA over the 2-year follow-up period was worst in the P-PVD without shrinkage (M) group (0.17±0.23) compared with the no-PVD group (0.06±0.14) and the C-PVD with collapse group (0.0009±0.09; P<0.05 for both comparisons).

CONCLUSION

Cases with an ERM with a P-PVD without shrinkage (M) had a worse visual prognosis than those with an ERM with no PVD and C-PVD with collapse.

Visual Prognosis and Ocular Complications in Herpetic versus HLA-B27- or Ankylosing Spondylitis-associated Anterior Uveitis

PURPOSE

To investigate the visual prognosis and ocular complications in patients with herpetic versus HLA-B27 associated anterior uveitis (AU).

METHODS

This was a retrospective, observational study conducted at the ophthalmology department of the University Medical Center of Groningen. Sixty-two herpetic and 113 HLA-B27-associated AU patients were included. The main outcome measures were visual acuity and ocular complications.

RESULTS

Visual acuity over time was significantly lower in herpetic as compared to HLA-B27 AU, mainly due to corneal scarring. The incidence rate of any ocular complication was higher in herpetic AU compared to HLA-B27-associated AU (0.140/EY versus 0.076/EY, p = <0.001), which was mainly due to glaucoma (0.033/EY versus 0.004/EY, p < 0.001) and cataract (0.059/EY versus 0.023/EY, p < 0.001).

CONCLUSIONS

The most prominent finding was a worse visual prognosis in herpetic AU, which is probably related to higher prevalence of corneal scarring and glaucoma. In addition, herpetic AU patients have more ocular complications overall.

Changes in Ocular Manifestations of Behçet Disease in Korean Patients over Time: A Single-center Experience in the 1990s and 2000s

PURPOSE

To analyze chronological changes in ocular manifestations of Behçet's disease (BD) in Korean patients.

METHODS

Ocular findings were retrospectively analyzed from medical records of patients diagnosed with BD between 1994 and 2010 and divided into two groups according to the date of their first visit to our ophthalmology department. Group A began care between 1994 and 2000, and Group B between 2004 and 2010.

RESULTS

Fifty-six patients (83 eyes) were included in analyses. There was a significant decrease in the number of complete BD cases in Group B compared to Group A, and fewer patients had genital lesions in Group B. Mean visual acuity was better, and more patients had good vision in Group B than in Group A at the one and two year follow-up.

CONCLUSIONS

The severity of BD has decreased over the past two decades, allowing BD patients with ocular involvement to have better visual prognoses.

Branch retinal vein occlusion: pathogenesis, visual prognosis, and treatment modalities

In branch retinal vein occlusion (BRVO), abnormal arteriovenous crossing with vein compression, degenerative changes of the vessel wall and abnormal hematological factors constitute the primary mechanism of vessel occlusion. In general, BRVO has a good prognosis: 50-60% of eyes are reported to have a final visual acuity (VA) of 20/40 or better even without treatment. One important prognostic factor for final VA appears to be the initial VA. Grid laser photocoagulation is an established treatment for macular edema in a particular group of patients with BRVO, while promising results for this condition are shown by intravitreal application of steroids or new vascular endothelial growth factor inhibitors. Vitrectomy with or without arteriovenous sheathotomy combined with removal of the internal limiting membrane may improve vision in eyes with macular edema which are unresponsive to or ineligible for laser treatment.