Ocular manifestations of liver disease: an important diagnostic aid

PURPOSE

This review examined existing literature to determine various ocular manifestations of liver pathologies, with a focus on metabolic deficiencies as well as viral and immune liver conditions.

METHODS

Recent data were compiled from PubMed from 2000 to 2020 using keywords that were relevant to the assessed pathologies. Ocular presentations of several liver pathologies were researched and then summarized in a comprehensive form.

RESULTS

Several ocular manifestations of liver disease were related to vitamin A deficiency, as liver disease is associated with impaired vitamin A homeostasis. Alcoholic liver cirrhosis can result in vitamin A deficiency, presenting with Bitot spots, xerosis, and corneal necrosis. Congenital liver diseases such as mucopolysaccharidoses and peroxisomal disorders are also linked with ocular signs. Viral causes of liver disease have associations with conditions like retinal vasculitis, keratoconjunctivitis sicca, retinopathies, Mooren's ulcer, and Sjogren's syndrome. Autoimmune hepatitis has been linked to peripheral ulcerative keratitis and uveitis.

CONCLUSIONS

Building strong associations between ocular and liver pathology will allow for early detection of such conditions, leading to the early implementation of management strategies. While this review outlines several of the existing connections between hepatic and ophthalmic disease, further research is needed in the area in order to strengthen these associations.

Atopic Dermatitis Associated Retinal Detachment and Retinal Vasculitis: A Case Report

Atopic dermatitis is usually associated with various ocular complications. We report a 21-year-old Chinese male who presented to our ophthalmology clinic with bilateral retinal detachment and cataracts. The patient had a clear medical history of atopic dermatitis, which had been diagnosed eight years earlier and had been treated with loratadine and pimecrolimus. Cataract surgery was performed for both eyes, combined with scleral buckling for the right eye and pars plana vitrectomy for the left eye. During postoperative follow-up, fundus fluorescein angiography showed retinal vasculitis in both eyes and macular edema in the left eye, which coincided with an exacerbation of atopic dermatitis. Macular edema improved after four months of regular dupilumab treatment in the dermatology department. The ocular condition remained stable three years postoperatively.

Characteristics, Etiology, and Clinical Outcome of Retinal Vasculitis in Tertiary Hospital in Thailand

OBJECTIVE

To analyze characteristics, etiology, and outcome of retinal vasculitis in Central Thailand.

METHODS

A retrospective cohort study.

RESULTS

Retinal vasculitis was found in 10% of uveitis, 74 from 741 uveitis, noninfectious (64.9%) and infectious group (35.1%). The most common cause was Behcet's disease (48.6%). Behcet's disease was the most common cause of all types of vascular leakage on angiography, including capillary (80.4%), venous (56.3%), and arterial leakage (56%). Final visual acuity was 0.86 ± 0.97 logMAR. Cataract was the most frequent complication (42.5%). Acute clinical course (p = .025) and retinal neovascularization (p = .031) were associated with infectious group. Forty-three percent of vasculitis complicated by ischemia required photocoagulation (33%) and anti-VEGF injection (17%). Furthermore, 17% of vasculitis underwent vitrectomy.

CONCLUSION

One-half of the retinal vasculitis in Central Thailand were Behcet's disease. Acute onset and retinal neovascularization may suggest infectious etiology. Retinal ischemia should be cautious and undergo early interventions to prevent sight-threatening complications.

[Diagnostic modalities of a Behçet uveitis]

Behçet disease is a chronic multisystemic inflammatory condition. The ocular disease mainly manifests as a bilateral, non-granulomatous, posterior uveitis or panuveitis, associated with occlusive retinal vasculitis. Uveitis is frequent in Behçet disease, it may be severe, and visually threatening. Early diagnosis and aggressive treatment are mandatory to preserve visual function. Therefore, the goal of this review is to describe the new diagnosis tools and therapeutic guidelines allowing for a significant improvement of the visual prognosis.

CLINICOPATHOLOGICAL ANALYSIS OF SECONDARY RETINAL VASOPROLIFERATIVE TUMOR/REACTIVE RETINAL ASTROCYTIC TUMOR SUCCESSFULLY TREATED BY ENDORESECTION

PURPOSE

To report the clinicopathological findings of retinal vasoproliferative tumor/reactive retinal astrocytic tumor (VPT/RRAT) with retinal vasculitis, treated by tumor resection.

METHODS

A retrospective single case report.

PATIENT

A 29-year-old Japanese woman was referred with cystoid macular edema and retinal vasculitis in the right eye. Best-corrected visual acuity was 0.9. Results of fundus examination, optical coherence tomography, and fluorescein angiography demonstrated VPT/RRATs in the temporal retina surrounded by a subretinal exudate, serous retinal detachment and macular edema, and retinal vasculitis. Despite 3 months of oral prednisolone treatment, a full-thickness macular hole developed. Pars plana vitrectomy and endoresection of the VPT/RRATs were performed. Pathologic and immunohistochemical analyses with anti-CD34 antibody, antiglial fibrillary acidic protein antibody, anti-Ki67 antibody, and anti-vascular endothelial growth factor antibody were performed on the excised tissue. Inflammation was evaluated by immunohistological staining with leukocyte common antigen (LCA), anti-CD3 antibody, and anti-CD20 antibody.

RESULTS

After surgery, the macular hole closed, best-corrected visual acuity improved to 1.2, retinal vasculitis was ameliorated, and retinal exudate disappeared. There was no recurrence of VPT/RRAT or retinal vasculitis. Pathologic examination showed that antiglial fibrillary acidic protein and anti-vascular endothelial growth factor were widely expressed, irrespective of the distribution of blood vessels. Ki67-positive proliferating cells were detected in the perivascular area. Leukocyte common antigen-positive leukocytes and CD3-positive T cells were detected throughout the samples, whereas CD20-positive B cells were rarely detected.

CONCLUSION

Endoresection of VPT/RRAT could be a good treatment option for secondary VPT/RRAT accompanied by retinal vasculitis. Pathologic findings revealed for the first time that inflammatory cells infiltrate the tissue in secondary VPT/RRAT.

Bilateral Retinal Vasculitis as Initial Presentation of Systemic Lupus Erythematosus with Secondary Antiphospholipid Syndrome

BACKGROUND Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease of undefined etiology with a relapsing and remitting course. Lupus retinopathy is reported in around 10% of patients with SLE; however, it is rarely the initial presenting feature of the disease. We report a unique case of bilateral retinal vasculitis as the initial presentation of SLE with secondary antiphospholipid syndrome (APS). CASE REPORT A 34-year-old man, previously healthy, presented to the eye clinic for the first time with painless reduced vision for 3 weeks. A review of systems revealed generalized fatigue, myalgia, arthralgias, and weight loss of around 10 kg in the last 3 months. On ophthalmic examination, his visual acuity was reduced bilaterally, more in the right eye. A fundus exam revealed bilateral diffuse multiple cotton-wool spots, dot and blot hemorrhage covering the posterior pole, and venous congestion and beading. In addition, there was cystoid macular edema (CME) in the fovea of both eyes, and fundus fluorescein angiography (FFA) showed bilateral areas of peripheral and macular hypo-fluorescence, multiple hyper-fluorescent knob-like aneurysmal dilatations, and vascular leaking and staining. He was diagnosed with SLE by the rheumatology team based on the clinical presentations and laboratory investigations. The patient was managed with intravenous methylprednisolone and discharged on oral prednisone with a tapering regimen. Eighteen months after, he reported significant improvement in his vision with regular follow-ups. CONCLUSIONS Ocular manifestations can be the initial presentation of SLE and can lead to serious ocular complications. Early diagnosis and proper management are essential and require cooperation between rheumatologists and ophthalmologists.

OPHTHALMIC ARTERY OCCLUSION AS THE PRESENTING SIGN OF ACQUIRED IMMUNODEFICIENCY SYNDROME

BACKGROUND/PURPOSE

The purpose of this study was to describe a case of severe occlusive vasculitis that led to a diagnosis of AIDS in a previously healthy middle-aged man.

METHODS

Multimodal imaging including widefield fundus photography, spectral domain optical coherence tomography, and widefield fluorescein angiography was performed.

RESULTS

A healthy 46-year-old man presented with sudden onset vision loss in his left eye with an afferent pupillary defect. His examination revealed signs of retinal vascular disease in both eyes, with an ophthalmic artery occlusion in his affected left eye and a hemiretinal vein occlusion in his asymptomatic right eye. An extensive medical workup was significant for HIV positivity; he was ultimately diagnosed with AIDS, and ocular findings were attributed to an associated occlusive vasculitis. He developed anterior segment neovascularization in the left eye for which he received intravitreal bevacizumab and panretinal photocoagulation. He ultimately required cyclophotocoagulation in the left eye for poorly controlled intraocular pressure in the setting of neovascular glaucoma.

CONCLUSION

Although HIV is most classically associated with a retinal microangiopathy, testing should be considered in cases of occlusive retinal vasculitis because it is a rare cause of such findings.

[Association of the different forms of uveitis with inflammatory rheumatic diseases and their treatment]

The etiology of uveitis greatly varies worldwide, whereby in industrial nations noninfectious causes occur relatively more frequently. In Germany, 44% of all cases of uveitis are due to systemic diseases. In rheumatology, uveitis or other kinds of ocular inflammation, such as scleritis or retinal vasculitis, most commonly occur in spondylarthritis, vasculitis and sarcoidosis. Vice versa, ophthalmologists often ask rheumatologists about an underlying rheumatic disease in patients with uveitis. It is of utmost importance to differentiate between the different forms of uveitis. This review article presents the associations with inflammatory rheumatic diseases as well as treatment options from the point of view of both ophthalmologists and rheumatologists.

Diagnosis of Eales disease from a macular epiretinal membrane

Macular involvement is a common finding in patients with Eales disease. The purpose of this communication is to describe the diagnosis of Eales disease from the finding of a macular epiretinal membrane in a young patient. The case is presented of a 38-year-old man referred to this medical service unit with blurred vision developed over the past 3 months, and was associated with vitreoretinal traction and a macular epiretinal membrane. After an ophthalmological examination including the retinal periphery, optical coherence tomography, tuberculin test, interferon gamma release assay (IGRA), and a systemic study, the patient was diagnosed with Eales disease. Macular oedema or epiretinal membranes due to Eales disease are relatively common. Sd-OCT is recommended in all patients with Eales disease. On the other hand, the presence of epiretinal membranes in young patients usually suggests a non-idiopathic aetiology.

Association of Meniere's disease and retinal vascular calibre: a prospective observational study in China

OBJECTIVE

It is believed that Meniere's disease (MD) is associated with vascular disorders, but few studies have reported the relationship between retinal vascular disorders and MD. We evaluated and compared the retinal vascular calibres in patients with MD with healthy subjects matched for age, sex and vascular risk factors using retinal photographs to explore the association between MD and retinal vascular calibre.

STUDY DESIGN

A prospective study.

SETTING

Tertiary referral centre.

PARTICIPANTS

Sixty patients with MD and 62 healthy subjects matched for age, sex and vascular risk factors were enrolled in this study. Twenty-four patients with MD had migraines, and 36 patients with MD did not have migraines.

MAIN OUTCOME MEASURE

Retinal vascular calibres were calculated and compared not only between patients with MD and healthy subjects but also between subgroups of patients with MD.

RESULTS

Compared with healthy subjects, patients with MD had a slightly larger retinal artery calibre (126.30±10.45vs 119.61±15.86, p=0.006) and a higher retinal artery/vein ratio (0.79±0.09vs 0.75±0.10, p=0.005). Among patients with MD, those with migraines had a larger retinal artery calibre (130.73±11.55vs 123.35±8.61, p=0.006) than those without migraines. Moreover, the presence of migraines and the high frequency of vertigo attacks appeared to increase the retinal artery calibre.

CONCLUSIONS

Our study suggests that a relationship exists between retinal vascular calibre and MD. Although the pathophysiological relationship between migraine and MD remains unclear, the presence of migraine attacks may aggravate endolymphatic hydrops (EH) and accelerate the outflow of EH in patients with MD. More extensive studies are required to explore the association between retinal vascular calibre and MD.

A new perspective for analyzing clinical characteristics of idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome

PURPOSE

We aimed to analyze the clinical characteristics of idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome. Furthermore, we aimed to correlate the number and location of retinal aneurysms with the size of retinal non-perfusion area and neovascularization.

METHODS

Six patients with IRVAN syndrome (1 male and 5 females, age 5-38 years) were enrolled in this study. Fundus fluorescein angiography (FFA) was used to determine the total number of retinal aneurysms, number of aneurysms within the first branch of the retinal artery, minimum distance between the non-perfusion margin and the optic disc, and the number of retinal aneurysms in each quadrant, as well as the type of neovascularization.

RESULTS

The size of the non-perfusion area was positively correlated with the total number of retinal aneurysms, the number of aneurysms within the first branch of the retinal artery, and the number of retinal aneurysms in each quadrant (P < 0.05). During the 5-year follow-up, one patient exhibited a dynamic change in the number and location of retinal aneurysms.

CONCLUSIONS

In IRVAN syndrome, the number and location of retinal aneurysms correlate with the size of retinal non-perfusion area and type of neovascularization.

Bilateral Parry-Romberg Syndrome Associated with Retinal Vasculitis

PURPOSE

To describe an unusual case of bilateral progressive facial hemiatrophy (Parry-Romberg syndrome (PRS)) associated with retinal vasculitis.

METHODS

In a 37-year-old man with bilateral PRS, retinal vasculitis of the right eye was evident on fundus examination and fluorescein angiography. Right temporalis muscle biopsy and needle electromyography of the masseter muscles were performed. The patient underwent immunosuppressive therapy and retinal laser photocoagulation.

RESULTS

Biopsy specimens showed large fibrosis with focal lymphohistiocytic infiltration of the muscle fibers. Electromyographic findings are consistent with a primary muscle disease. Visual acuity improved from 20/25 to 20/20 in the right eye with a follow-up of one year.

CONCLUSIONS

The evidence of retinal vasculitis and the histologic findings of facial changes observed in this PRS case could support the pathogenetic model of a chronic inflammatory process as a plausible explanation for progressive facial hemiatrophy.

Therapeutic Effects of Laser Photocoagulation and/or Vitrectomy in Eales' Disease

PURPOSE

To determine visual outcomes and regression of retinal neovascularization following laser photocoagulation and/or vitrectomy in eyes with Eales' disease.

METHODS

In a retrospective noncomparative study, the authors reviewed the existing data of 67 eyes of 54 patients with a diagnosis of Eales' disease who had undergone laser photocoagulation and/or vitrectomy based on their clinical presentations. Main outcome measures were visual acuity changes and regression of retinal neovascularization of the eyes following treatment.

RESULTS

Both laser therapy and vitrectomy improved visual acuity and induced regression of retinal neovascularization. Forty-three eyes had undergone laser therapy; their rate of visual acuity 320/30 improved from 53% before treatment to 60% after treatment. Twenty-four eyes had undergone vitrectomy; rate of visual acuity 320/30 improved from 13% before surgery to 38% after surgery. In eyes that had undergone laser therapy, additional laser therapy controlled recurrent neovascularization in 47% of the eyes, but ultimately, 12% of them required vitrectomy. In the primary vitrectomized group, additional required treatment was repeat vitrectomy in 21%, and/or laser therapy in 29% of the eyes.

CONCLUSIONS

Although laser photocoagulation should be the first line of treatment in Eales' disease, it cannot always induce regression of retinal neovascularization. In such cases vitrectomy may further enhance therapeutic success.

INTRAVITREAL TRIAMCINOLONE IN SUSAC SYNDROME

PURPOSE

To report the use of intravitreal triamcinolone for Susac Syndrome in one patient.

METHODS

Case report.

RESULTS

A 23-year-old woman presented with presented with sudden visual loss in the left eye with associated neurologic symptoms. Ophthalmic examination and fluorescein angiography showed multiple areas of branch retinal artery occlusion, bilaterally. Magnetic resonance imaging showed dot-like, diffusion-restricted lesions in the corpus callosum, and audiometry showed low-frequency sensory hearing loss, compatible with Susac Syndrome. The patient received a single intravitreal injection of triamcinolone (4 mg) in the left eye. One week later, before beginning systemic corticosteroids, all signs and symptoms resolved in the left eye only.

CONCLUSION

In cases of delayed systemic corticosteroid therapy, intravitreal triamcinolone resolves the ocular manifestations of Susac Syndrome.

Hemorrhagic Occlusive Retinal Vasculitis After First Eye Cataract Surgery Without Subsequent Second Eye Involvement

A case of monocular postoperative hemorrhagic occlusive retinal vasculitis (HORV) after uncomplicated bilateral cataract surgery is described. HORV is a severe syndrome that leads to painless visual loss after uncomplicated cataract surgery. The same surgical procedure was adopted in both eyes except for the use of intracameral vancomycin, which was injected only in the eye that developed HORV. Diffuse retinal ischemia with vascular sheathing and intraretinal hemorrhages were detected during the fourth postoperative day. Despite treatment, the patient developed severe neovascular glaucoma. This case supports the causative role of vancomycin in the pathogenesis of HORV and suggests avoiding it for chemoprophylaxis. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:764-766.].

[Ocular manifestations of syphilitic uveoretinitis in patients co-infected with human immunodeficiency virus]

OBJECTIVE

To investigate the clinical manifestations of syphilitic uveoretinitis in patients co-infected with human immunodeficiency virus (HIV).

METHODS

Uveoretinitis patients presenting between January 2008 and December 2014 at Eye and ENT Hospital of Fudan University were collected. Patients were selected with positive serologic tests, including rapid plasma regain titer (RPR) > 1:8, treponema pallidum particle agglutination assay (TPPA) and human immunodeficiency virus (HIV). Other causes of uveoretinitis were excluded. Each patient underwent complete ophthalmologic examination including best-corrected visual acuity (BCVA), slit-lamp biomicroscopy, ophthalmoscopy, applanation tonometry and B-scan ultrasonography. Fundus fluorescein angiography were obtained in each case except for patients whose fundus was blurred with dense vitritis. Optical coherence tomography (OCT) was performed in selected patients. Thorough physical examination was performed simultaneously.

RESULTS

Twenty six patients were included in this study including 24 male (92.3%) and 2 female (7.7%). The mean age at presentation was 39.3 ± 13.2 (range 20 to 63 years). RPR titres ranged from 1:32 to 1:512. There were 49 eyes altogether and ocular involvement was bilateral in 23 patients (88.5%) and unilateral in 3 patients (11.5%). Panuveitis was the most common ophthalmic presentation (n = 39, 79.6%). Only two eyes were anterior uveitis (4.1%) and 8 eyes were posterior uveitis (16.3%). Anterior chamber cells+++ and mild to severe vitreous opacities were observed. Sixteen eyes presented with neuroretinitis (32.7%), 27 eyes had vitritis (55.1%), 5 eyes had retinochoroiditis (10.2%), 5 eyes had optic neuritis (10.2%), 5 eyes had retinitis (10.2%) including 2 eyes with necrotizing retinitis (4.1%), 4 eyes had retinal vasculitis (8.2%). Two eyes (11.5%) presented with posterior placoid chorioretinitis (4.1%) and multifocal choroiditis (4.1%). Systemic manifestations were detected. Five patients had a history of skin rash (19.2%), five (19.2%) had genital ulcers, three (11.5%) had chancre, two (7.7%) suffered from headache, two (7.7%) had a fever, one (3.8%) had oral ulcers and one patient (3.8%) lost his hair.

CONCLUSIONS

The clinical features are protean and lack of specificity. The most common manifestations was neuroretinitis, ususlly with vitritis.

Surgical outcomes of minimally invasive vitrectomy surgery in Eales' disease

INTRODUCTION

The results of surgical outcomes of 20 gauge pars plana vitrectomy in Eales' disease are available in the scientific literature. However, all these studies have been done using the 20 gauge vitrectomy systems and most studies have been conducted in a retrospective manner.

OBJECTIVE

To evaluate the outcomes and safety of 23 gauge vitrectomy in complications of Eales' disease.

MATERIALS AND METHODS

STUDY DESIGN

Consecutive interventional case series.

PARTICIPANTS

Seventy-six eyes of 72 nonconsecutive patients undergoing 23-gauge vitrectomy for complications of Eales' disease were enrolled. The participants were followed up for a minimum of one year.

INTERVENTION

The participants underwent a complete demographic, medical and ophthalmic evaluation. A 23-gauge vitrectomy was performed. Endotamponade was used when necessary. Perioperative and postoperative events were recorded. Primary outcome measures were visual acuity and complications arising due to surgery.

RESULTS

Indication for surgery was non-clearing vitreous hemorrhage in 89.4% (68/76) and secondary retinal detachment in 10.6% (8). Visual acuity improved from Log Mar 1.80 ± 0.19 units preoperatively to Log Mar 0.47±0.59. Best-corrected visual acuity equivalent to Snellen 6/9 was achieved in 77. 6% of eyes. . Surgical failure was seen in 6.5% cases. Four cases were lost due to progression to neovascular glaucoma and 1 case was lost to severe residual retinal detachment. Iatrogenic portside retinal breaks occurred in 3.9% (3), post-vitrectomy retinal detachment 2.6% ( 2), hypotony 1.3% (1) and cataract in 38.1% (28) cases.

CONCLUSION

23-gauge sutureless vitrectomy in patients with Eales' disease is a safe and effective technique with acceptable level of risk and complications.

[A case of atypical serpiginous choroiditis with chorioretinal lesions along retinal blood vessels]

BACKGROUND

Serpiginous choroiditis, a chronic disease affecting the choroid and retinal pigment epithelium, is characterized by acute lesions located adjacent to atrophic scars initiated from the peripapillary region. This report describes a chorioretinal disease accompanied with retinal phlebitis finally diagnosed as serpiginous choroiditis by the characteristic extension of the lesions.

CASE

A 68-year-old man was referred to our hospital with blurred vision in his both eyes. A small amount of cells infiltrating the vitreous, partial vitreous opacity, retinal phlebitis, grayish-white lesions around the optic disc and retinal phlebitis, and cystoid macular edema were observed in the both eyes. Since active lesions were found at the border of the inactive lesions and appeared in an interlocking polygonal pattern that spread out continuously, the condition was diagnosed as serpiginous choroiditis with retinal phlebitis. Systemic administration of predonisolone was initiated, which resolved the retinal phlebitis, and the active lesions were turned to scars. No recurrence has been observed since.

CONCLUSION

Atypical serpiginous choroiditis accompanied with retinal phlebitis responds to systemic steroid administration.

Secondary rhegmatogenous retinal detachment following intravitreal bevacizumab in patients with vitreous hemorrhage or tractional retinal detachment secondary to Eales' disease

BACKGROUND

To report the occurrence of secondary rhegmatogenous retinal detachment (RRD) after intravitreal bevacizumab injection in patients with Eales' disease.

METHODS

This is a retrospective, non-controlled, comparative case series. We reviewed 14 eyes of 14 patients with Eales' disease who had received pretreatment with intravitreal bevacizumab (1.25 mg/0.05 ml) and subsequently undergone a pars plana vitrectomy for non-resolving vitreous hemorrhage and/or tractional retinal detachment. Clinical records were reviewed. The primary outcome measure was the occurrence of secondary RRD after intravitreal bevacizumab injection.

RESULTS

Four patients had developed secondary RRD, with retinal breaks that were localized to the base of tractional retinal bands, within 1 week of receiving intravitreal bevacizumab. On comparative analysis, median age of patients who had developed secondary RRD was 26.5 years, significantly less than the median age of 33.5 years in the rest (P = 0.022). Median post-operative best-corrected visual acuity (BCVA) in patients who developed secondary RRD was logMAR 0.7 (0.3-0.8), significantly worse than the BCVA of logMAR 0.3 (0.0-0.5) in the rest (P = 0.015). None of the patients who developed secondary RRD had a complete posterior vitreous detachment (PVD) at presentation.

CONCLUSION

Intravitreal bevacizumab injections may be associated with the serious complication of secondary RRD in patients of Eales' disease within 7 days of injection.

Impact of interleukin-6 promoter polymorphism and serum interleukin-6 level on the acute inflammation and neovascularization stages of patients with Eales' disease

PURPOSE

To evaluate the role of interleukin-6 (IL-6) in the inflammatory and proliferative stages of Eales' disease (ED) and to determine the influence of IL-6-174G/C polymorphism in the IL-6 and IL-6-regulated protein expression, as well as the development of ED.

METHODS

One hundred and twenty-one patients diagnosed with ED, 223 matched healthy controls, and 16 control patients with macular holes were recruited from the eastern Indian population. Serum and vitreous levels of IL-6 and vascular endothelial growth factors (VEGF) were measured by enzyme-linked immunosorbent assay. Serum levels of high-sensitivity C-reactive protein (hsCRP) were measured by enzyme immunoassay. Subjects were genotyped for the IL-6-174G/C polymorphism (rs1800795) by a custom TaqMan single-nucleotide polymorphism (SNP) Genotyping Assays system.

RESULTS

Serum IL-6 (p<0.0001), hsCRP (p<0.0001), and VEGF (p=0.0031) levels were significantly higher in the inflammatory stage of ED than in healthy controls. Serum IL-6 also significantly correlated with hsCRP (Spearman's correlation coefficient; r=0.4992, p=0.0009), but not with VEGF in this stage in ED patients. At the proliferative stage of ED, significantly higher levels of vitreous IL-6 (p=<0.0001) and VEGF (p=<0.0001) were found compared with the vitreous of patients with macular holes. A significant correlation was observed between vitreous IL-6 and VEGF in ED patients (Spearman's correlation coefficient; r=0.5834, p=0.0087). A statistically significant association was found between the -174GG genotype (p=0.006) and occurrence of ED. Mean serum and vitreous concentrations of IL-6 were also higher in the subjects with the GG genotype than in those with the GC or CC genotype in this population.

CONCLUSIONS

IL-6 expression, regulated by the allelic distribution of -174 loci and the enhanced level of IL-6, modulates CRP and VEGF concentration depending respectively on the acute inflammatory stimulation at the initial stage and angiogenic stimulation at the advanced stage of ED.

[A case of frosted branch angiitis associated with retinal vein occlusion as a complication of familial Mediterranean fever]

BACKGROUND

Familial Mediterranean fever (FMF) is characterized by recurrent episodes of fever and serositis caused by autosomal recessive inheritance MEFV gene mutations. It is reported that the onset of angiitis is high among patients with this disease, but no reports were found in the field of ophthalmology in Japan. In this paper, we report one case that developed from optic disc vasculitis to frosted branch angiitis associated with retinal vein occlusion.

CASE

A 39 year old male. Fever, abdominal pain and chest pain were continued from childhood. In 2006, an idiopathic fever was reported with a renal disorder. Based on the results of laboratory examinations, he was diagnosed with FMF and started oral colchicines to stabilize the symptoms. In October 2007, he complained of blurry vision in his left eye that lasted for about one week prior to his visit and decided to visit our department for an examination. Visual acuity was right 1.5 and left 1.2. Although no abnormalities were found in the anterior chamber or optic media of either eye, the left eye papilla was reddish and swollen, and varicose enlargement of the retinal veins and a small retinal hemorrhage were found. Four days later, a white vascular infiltration spread to all branches of the retinal veins at the upper-half of the left eye papilla, the hemorrhage increased in the entire retina and the visual acuity decreased to 0.1. He was hospitalized and systemic administration of an antiviral agent, an antibacterial agent and a steroidal agent (prednisolone 60 mg/day) was started. Subsequently, the left eye ocular fundus findings slowly improved and he was cured 7 months later with a visual acuity of 1.0.

CONCLUSION

Frosted branch angiitis may occur with systemic gene abnormalities as an underlying condition and it is important in the future to consider FMF as a causative disease.

[Diagnosis and treatment of eye diseases associated with HIV infection and AIDS]

OBJECTIVE

To investigate the manifestations and treatment principles of ocular diseases associated with human immunodeficiency virus infection (HIV) and acquired immunodeficiency syndrome (AIDS).

METHODS

It was a retrospective case series. One hundred and ten patients were recruited. Two hundred and twenty eyes underwent ophthalmologic examination that included vision acuity, anterior segment and fundus examinations with papillary dilation and fundus fluorescein angiography. CD(4)(+)T-lymphocyte was counted in peripheral blood of 110 patients. Intravitreal injection of ganciclovir 400 microg was performed in 4 eyes (2 patients) with cytomegalovirus (CMV) retinitis associated with AIDS. All statistical analyses were performed using SPSS 13.0 software. The association between the age, duration of HIV infection and HIV/AIDS related ocular manifestations was analyzed by Pearson Correlation Analysis. The association between the gender and HIV/AIDS related ocular manifestations was analyzed by Pearson Chi-Square test. For comparison of the CD(4)(+)T cells counts of the patients with normal fundus, HIV retinopathy, CMV retinitis, Kruskal-Wallis Test for Several Independent Samples was used.

RESULTS

Baseline visual acuity: no light perception (NLP) 5 eyes; light perception (LP) to 0.04, 10 eyes; 0.05 to 0.2, 14 eyes; 0.3 to 0.7, 62 eyes and >/= 0.8, 129 eyes. Small grayish keratin precipitates or pigment keratin precipitates were present in 25 eyes, 22 eyes had positive aqueous flare, 4 eyes had posterior synechia of the iris, 28 eyes had cataract. HIV retinopathy was present in 34 eyes. Cotton-wool spots, retinal hemorrhages, and retinal microaneurysms were found in eyes with HIV retinopathy. CMV retinitis was present in 32 eyes. The fundus manifestations of CMV retinitis included retinal vasculitis; dense, full-thickness, yellow-white lesions along vascular distribution with irregular granules at the border, and hemorrhage on the retinal surface in 26 eyes. Late stage retinopathy was demonstrated in 3 eyes characterized as atrophic retina, sclerotic and attenuated vessels, and optic nerve atrophy. Retinal detachment was found in 3 eyes. The median of CD(4)(+)T-lymphocyte counts of the patients with normal fundus was 100.0/mm(3). The median of CD(4)(+)T-lymphocyte counts of the patients with HIV retinopathy was 41.0/mm(3). The median of CD(4)(+)T-lymphocyte counts of the patients with CMV retinitis was 18.0/mm(3). The difference of CD(4)(+)T-lymphocyte counts between patients with normal fundus and HIV retinopathy was statistically significant (chi(2) = 4.848, P = 0.028). The difference of CD(4)(+)T-lymphocyte counts between patients with normal fundus and CMV retinitis was statistically significant (chi(2) = 15.696, P = 0.000). The difference of CD(4)(+)T-lymphocyte counts between patients with CMV retinitis and HIV retinopathy was statistically significant (chi(2) = 4.860, P = 0.027). Four eyes (2 patients) with CMV retinitis underwent intravitreal injection of ganciclovir 400 microg. After intravitreal injection of ganciclovir, visual acuity was improved and fundus lesions disappeared in 4 eyes.

CONCLUSIONS

HIV retinopathy is a common intraocular complication in HIV-infected patients. CMV retinitis is the severest intraocular complication in patients with AIDS. Highly active anti-retroviral therapy allows immune reconstitution. Intravitreal injection of ganciclovir can effectively control CMV retinitis and save the vision.

Primary Vascular Occlusion in IRVAN (Idiopathic Retinal Vasculitis, Aneurysms, Neuroretinitis) Syndrome

IRVAN is a rare retinal vascular disease characterized by the presence of aneurysmal dilations along the retinal arteriolar tree. Visual loss occurs from sequelae to proliferative changes or due to severe macular exudation and rarely from secondary vascular occlusion following laser photocoagulation of the aneurysms. We herein report a patient with a primary vascular occlusion in a patient with IRVAN and suggest that such patients may already have a natural predisposition to develop a vascular occlusion.

An unusual case of acute unilateral uveitis with retinal capillaritis

We report an unusual case of unilateral uveitis with retinal capillaritis showing spontaneous recovery in a 23-year-old female who underwent complete ophthalmological examination. Retinal capillary dilation and leakage was observed of the left eye without systemic manifestations and spontaneously resolved without treatment in 2 months. Unilateral uveitis with retinal capillaritis is an unusual disease in young age and fluorescein angiography is useful for the correct diagnosis and follow-up.

[Vasculitis of retinal vessels in lung tuberculosis--a case report]

The authors examined during the period 2003-2004 in an eye practice 652 patients who were hospitalized due to active lung tuberculosis. All patients were treated with combination of 3-4 antituberculotic drugs and the examination was performed to observe the possible side effects of ethambutol to the optic nerve. The most interesting was the ocular finding in a young man treated due to acute lung tuberculosis in whom during the antituberculotic therapy with combination of 4 antituberculotics, the acute retinal vasculitis developed. This type of vasculitis is rare demonstration of ocular tuberculosis. The ocular finding resolved after starting the systemic corticoid therapy.

Longterm visual prognosis of patients with ocular Adamantiades-Behçet's disease treated with interferon-alpha-2a

OBJECTIVE

Relapsing ocular involvement is one of the major manifestations in Adamantiades-Behçet's disease (ABD). Combining systemic corticosteroids with cyclosporin A is currently the treatment of choice. Interferon-alpha (IFN-alpha) has proven to be effective in mucocutaneous ABD and has been reported to improve ocular lesions. We examined the longterm effects of IFN-alpha-2a in a case series of 45 patients with ocular involvement.

METHODS

Since 1988, 45 patients (79 eyes of 90 eyes) with ocular involvement in ABD have been treated with IFN-alpha (3 x 6-9 Mio IU per wk). In the initial acute phase of the disease, patients additionally received short-term corticosteroids (oral prednisolone 100 mg/day), tapered to a maintenance dose of 10 mg/day within 2 weeks. IFN-alpha-2a was administered as longterm therapy with a mean duration of 30 months (range 1.1-101 mo).

RESULTS

IFN-alpha-2a/prednisolone treatment was effective against vasculitis, optic nerve neuropathy, and iritis. Sixty-four eyes had no recurrence under therapy. To date, recurrences have been seen in 26 eyes under IFN-alpha treatment. Flu-like symptoms were recorded in nearly all patients (n = 43). Further side effects were dose-dependent reversible thrombocytopenia (n = 1), psychosis (n = 3), depression (n = 13), thyroiditis (n = 1), and reversible diffuse alopecia (n = 7). In our series, 92% of all eyes showed stable or improved visual acuity in longterm followup.

CONCLUSION

Longterm remission of ocular inflammation can be achieved with the combination of IFN-alpha and low-dose corticosteroids.

Endothelial dysfunction and low-grade inflammation and the progression of retinopathy in Type 2 diabetes

AIMS

To study whether microalbuminuria, endothelial dysfunction and low-grade inflammation are associated with the presence and progression of diabetic retinopathy.

METHODS

Patients with Type 2 diabetes (n = 328) attending a diabetes clinic were followed for 10 years and examined annually during the last 7 years. Retinopathy was assessed after pupillary dilatation by direct ophthalmoscopy (baseline) and two-field 60 degrees fundus photography (follow-up). Urinary albumin excretion, and markers of endothelial function (von Willebrand factor, tissue-type plasminogen activator, soluble E-selectin (sE-selectin), and soluble vascular cell adhesion molecule 1) and inflammatory activity (C-reactive protein and fibrinogen) were determined.

RESULTS

The prevalence of retinopathy was 33.8%. The median diabetes duration at baseline was 7 years (interquartile range 2-12 years). The highest tertiles of baseline urinary albumin excretion and glycated haemoglobin (HbA(1c)) were associated with prevalent retinopathy: odds ratio (OR) 95% confidence interval (CI) 2.80 (1.44-5.46) and 2.19 (1.11-4.32), respectively. Progression of retinopathy occurred in 188 patients. The second and third tertiles of baseline sE-selectin were associated with progression of retinopathy [1.44 (1.04-2.01) and 1.61 (1.19-2.18)] but not independently of HbA(1c). None of the other markers was significantly associated with the presence or progression of retinopathy. High baseline HbA(1c) was significantly associated with progression of retinopathy: 1.65 (1.21-2.25).

CONCLUSIONS

In this population of patients with Type 2 diabetes who attended a diabetes clinic, there was some evidence for a role of endothelial dysfunction in the progression of retinopathy. We could not demonstrate a role for low-grade inflammation. Our study emphasizes the importance of glycaemic control in the development and progression of retinopathy.

Idiopathic retinitis, vasculitis, aneurysms, and neuroretinitis (IRVAN): new observations and a proposed staging system

PURPOSE

To review the clinical features, disease progression, and effects of treatment on idiopathic retinitis, vasculitis, aneurysms, and neuroretinitis (IRVAN).

DESIGN

Retrospective interventional case series.

PARTICIPANTS

Ten patients with IRVAN originally reported in 1995 and 12 additional patients identified since the original series.

INTERVENTION

Patients in the series had testing that may have included fluorescein angiography, indocyanine green angiography, and systemic evaluation. Treatments included panretinal laser photocoagulation, cryotherapy, vitrectomy surgery, and injection of periocular or intravitreal steroids.

MAIN OUTCOME MEASURES

Initial visual acuity (VA), initial stage at diagnosis, clinical course, surgical intervention, final VA, and complications of disease.

RESULTS

A total of 44 eyes of 22 patients were studied; 9 eyes had reached stage 1 or 2 disease at last follow-up, 17 had reached stage 3, and 12 had reached stage 4 or 5. At the time of last follow-up, 14 eyes had maintained 20/20 vision, 15 had between 20/40 and 20/200 vision, and 9 had 20/300 vision or worse. Later stages of retinal ischemia are associated with worse VA. Thirty-two of 38 followed eyes were treated. Twenty-five were treated initially with panretinal laser photocoagulation. The clinical course of each eye after initiation of panretinal laser photocoagulation was evaluated with respect to the final VA and stage of ischemic retinopathy at the initiation of treatment. Panretinal laser photocoagulation was initiated in 3 eyes at stage 2, 16 at stage 3, 5 at stage 4, and 1 at stage 5. Seven eyes underwent grid laser retinal photocoagulation of the macula for macular edema.

CONCLUSIONS

Idiopathic retinitis, vasculitis, aneurysms, and neuroretinitis is an isolated retinal vascular disease that can progress rapidly to severe vision loss due to ischemic sequelae despite treatment with panretinal laser photocoagulation. Based on our review of the largest cohort of IRVAN patients, early panretinal laser photocoagulation should be considered when angiographic evidence of widespread retinal nonperfusion is present, and before (or shortly after) the development of neovascularization. A functional staging system is proposed to improve treatment paradigms.

Acute idiopathic frosted branch angiitis

This is a case of acute idiopathic frosted branch angiitis in a 4-year-old African American girl with history of sickle cell trait. She developed bilateral, subacute vision loss attributed to acute idiopathic frosted branch angiitis and was treated with systemic corticosteroids with a good recovery of vision. Acute idiopathic frosted branch angiitis is a rare disease, usually with a good prognosis. This is, to our knowledge, the 10th reported case in the United States.

Surgical outcomes for vitrectomy in Eales' disease

AIM

To present and analyse the anatomical and functional outcomes for vitrectomy in Eales' disease.

METHODS

This retrospective case series enrolled 63 patients (71 eyes) who underwent pars plana vitrectomy (PPV) for the complications of Eales' disease. Indications included nonclearing vitreous haemorrhage (VH) with/without epiretinal membranes in 49 (69%) eyes, and retinal detachments (RD) involving/threatening macula in 22 (31%). Additional procedures (scleral buckling; gas/oil tamponade) were performed at surgeon's discretion. Minimum follow-up was 6 months. The primary outcome measures were change in best-corrected visual acuity (BCVA) and posterior segment status.

RESULTS

The mean age of the patients was 29.6 years (range: 15-70 years); 60 were male (95%). Preoperatively, posterior vitreous detachment (PVD) existed in 28 (39.4%) eyes. Forty (56.3%) eyes underwent only PPV; the rest required additional surgical procedures (q.v.). The mean baseline BCVA (1/60) improved to 6/24 postoperatively (P<0.0001). Fifty-four eyes of 50 patients (76%) showed an improvement of > or =2 equivalent Snellen lines; six eyes (four patients) remained stable (+/-1 line); visual acuity worsened in 11 eyes (nine patients). The mean final BCVA was similar in eyes operated for VH and RD (P=0.08); but the magnitude of change from baseline was greater in the VH group (P=0.009). PVD had a borderline association with final BCVA (P=0.056); but did not influence the functional/anatomical improvement. Thirteen eyes required repeat interventions; 11 (15.49%) eyes experienced surgical failure.

CONCLUSIONS

Although surgical outcomes in Eales' disease depend on preoperative PVD/RD to some extent; good results are possible in the presence of incomplete PVD and tractional sequelae.

Linear scleroderma 'en coup de sabre' associated with cerebral and ocular vasculitis

Linear scleroderma 'en coup de sabre' (LSCS) has been reported in association with intracranial abnormalities. We report the case of an 11-year-old boy with LSCS who presented with recurrent headaches. Cranial magnetic resonance imaging (MRI) and angiography were consistent with the diagnosis of a cerebral vasculitis. In addition, retinal examination showed an exudative inflammatory lesion consistent with vasculitis.

Functional outcome and prognostic factors in 304 eyes managed by retinectomy

BACKGROUND

This study was undertaken to relate the anatomic and functional results of patients who underwent retinectomy for complex retinal detachment (RD) to preoperative prognostic variables.

METHODS

Three hundred and four eyes of 302 patients whose surgery involved retinectomy were included in the analysis. All eyes had established proliferative vitreoretinopathy (PVR grade C). The main outcome measures were (1) postoperative visual acuity of 6/24 or better, (2) status of the retina at the end of follow-up, and (3) incidence of hypotony whilst under review.

RESULTS

PVR was secondary to rhegmatogenous RD in 237 eyes (78%), posterior trauma in 51 eyes (16.8%), tractional RD in vasoproliferative vasculitides in 12 eyes (4%), acute retinal necrosis in 2 eyes and endophthalmitis in 2 eyes. Complete reattachment rate after one operation was 51%, with final complete reattachment success rate of 72%. The visual acuity improved in 138 eyes (45%), remained the same in 73 eyes (24%) and became worse in 89 cases (29%). Postoperative visual acuity of 6/24 or better was significantly associated with preoperative vision, the duration of silicone oil tamponade, silicone oil removal and retinectomy size. There was also some evidence of association between visual outcome and the number of clock hours of retinal detachment. Final retinal attachment was significantly associated with silicone oil removal and preoperative vision, and final hypotony was significantly associated with silicone oil removal. The incidence of sympathetic ophthalmia in our study was 0.09% (one case).

CONCLUSIONS

Good functional outcome is possible following retinectomy surgery despite advanced pathology and often multiple surgical procedures. Retinal redetachment as a result of reproliferation and hypotony appear to be the main reasons for anatomical and functional failure. The clinical features we have identified as good indicators for improved final visual acuity such as shorter tamponade duration, removal of silicone oil, smaller retinectomy size, fewer previous operations and better preoperative vision are surrogate markers of less advanced PVR and should prompt retinal surgeons to consider retinectomy at an earlier stage in the process of PVR development. Clinicians should be aware of the small risk of sympathetic ophthalmia from complex retinal surgery.

Unusual clinical cases that mimic MS

Diseases which are associated with relapses and disability accumulation that mimic MS may be effectively treated if they are appropriately diagnosed. Unfortunately, however, it can be easy to assume that a patient is presenting with unusual symptoms of MS rather than establish unequivocally that there is no other cause. This article illustrates five short cases from a selection presented at the MS Forum Interactive Symposium at the LACTRIMS Congress, Brazil, 2004. These cases feature the differential diagnosis of MS and illustrate the importance of early and accurate diagnosis. Each case has clinical features suggestive of MS, together with diagnostic findings that are discordant with this disease. Clinical features that can easily be interpreted as unusual MS presentations, but which indicate the need to undertake additional investigation, are included.

[Bilateral retinal vasculitis with arterial aneurysms]

The authors reported unusual and rare condition of bilateral retinal vasculitis primarily affecting the central retinal artery at the nerve head and its 4 main branches. The most striking feature was the presence of the diffuse vitreous cells, occlusion of branch retinal artery, segmental periarterial infiltration, arterial sheating, retinal arterial aneurysms, disc swelling, peripheral retinal non perfusion and their complications. During 13 year's observation and treatment one eye went blind 3 years after initial examination. Second eye started the same clinical course two years after beginning of the disease. To avoid similar devastating course of the disease we started systemic steroids and immunosuppressive therapy, followed by photocoagulation of nonperfused peripheral retina and vitreoretinal surgery. We achieved stabilization of the disease with decreased visual functions. Comprehensive systemic work-up was unrevealing, no clear etiology was identified and diagnosis of idiopathic retinal vasculitis was made.

Retinal vasculitis

Retinal vasculitis represents a group of diseases characterized by inflammation affecting the retinal vasculature. It is an uncommon disorder that may occur as an isolated disease or more commonly in association with other ocular diseases or a variety of systemic diseases. With a wide variety of disease associations, a search for an underlying etiology should be undertaken based on a meticulous history, review of systems, and physical examination. The laboratory evaluation of patients with retinal vasculitis is an essential component of the work-up to facilitate detection of any underlying disease or to establish a limited differential diagnosis. The management of infectious causes of retinal vasculitis consists of antimicrobial therapy while noninfectious retinal vasculitis is managed with corticosteroids and/or immunosuppressive agents. Because retinal vasculitis is an uncommon disease, there are only a limited number of publications over the past year related to this topic.

[Eales' disease with bilateral brain strokes and jaw-closing dystonia]

Eales' disease is an idiopathic occlusive vasculopathy of the retina, which is characterized by extensive peripheral non-perfusion, perivascular sheathing, and neovascularization. It is associated with recurrent vitreous hemorrhages. Both eyes are affected consecutively in 80% to 90% of the patients. In spite of the multiple theories that have been proposed, it continues to have unknown origin and its diagnosis relies on exclusion of other causes of retinal vasculopathy. In some occasions, these patients develop complications of the central nervous system, above all brain infarcts. We present the case of a 38 year old woman with Eales' disease who developed bilateral brain infarcts associated with occlusion or stenosis of the middle cerebral arteries. The cerebral angiography showed beading of the Silvian arteries, suggestive of an underlying inflammatory disorder. Early corticosteroid therapy could avoid contralateral retinal involvement and neurological complications. The patient also presented delayed jaw closing dystonia secondary to basal ganglia infarct which followed a benign course with spontaneous resolution in a few days.