Alfredo Adán

Multicenter study of intravitreal dexamethasone implant in noninfectious uveitis: indications, outcomes, and reinjection frequency.

PURPOSE To identify clinical outcomes and treatment patterns of intravitreal dexamethasone implant (Ozurdex; Allergan, Inc) in noninfectious uveitis in the clinical setting. DESIGN Multicenter retrospective cohort study. METHODS Eighty-two eyes (63 patients) receiving 142 implant injections over 35 months were included. Treatment indication, uveitis diagnosis, visual acuity, intraocular pressure, vitreous haze score, central retinal thickness by optical coherence tomography, phakic status, number of injections, time to reinjection, systemic treatments, and complications data were collected. Time to visual acuity and vitreous haze score improvement as per the Standardization of Uveitis Nomenclature guidelines were also determined. RESULTS The probability of visual acuity improvement (≥0.3 logarithm of the minimal angle of resolution units improvement) was 39% at 1 month, 49% at 3 months, 52% at 6 months, and 58% at 12 months. Eyes with baseline vitritis (vitreous haze score ≥+0.5, n = 45) had a probability of vitreous haze score improvement (2-step decrease or change from +0.5 to 0) at 2 weeks of 41%, at 1 month 63%, at 3 months 73%, at 6 months 79%, and at 12 months 88%. In eyes that completed 12-month follow-up (n = 54), 40.7% underwent 2 injections (mean time to second injection of 6.6 ± 1.9 months) and 11.2% required ≥3 injections (mean time to third injection of 11 ± 1.5 months). CONCLUSIONS Dexamethasone implant use in uveitis provides favorable visual acuity and vitreous haze score outcomes but requires repeated injections, an important consideration when choosing intraocular treatment as a route to controlling uveitis.

Dexamethasone intravitreal implant for treatment of uveitic persistent cystoid macular edema in vitrectomized patients.

Purpose: To evaluate the safety and efficacy of Ozurdex (dexamethasone intravitreal implant) 0.7 mg in the treatment of uveitic macular edema in vitrectomized eyes. Methods: Data from 13 patients (17 eyes) with persistent uveitic cystoid macular edema and a history of pars plana vitrectomy in the study eyes that were treated with intravitreal injection of 0.7-mg dexamethasone implant were reviewed retrospectively. Main outcome measures were changes in central retinal thickness measured by optical coherence tomography and changes in best-corrected visual acuity. Results: The median age of patients was 61 years (range, 19–81 years). The median duration of uveitic macular edema was 12 months (range, 2–72 months). The mean baseline central retinal thickness (95% confidence interval) was 461.6 &mgr;m (403.8–519.4), decreased to 277.2 &mgr;m (244.6–309.8) at 4 weeks (P < 0.01), remained low at 349.9 &mgr;m (281.8–418.0) at 3 months (P = 0.01), and then reached 394.1 &mgr;m (328.3–459.8) at 6 months (P = 0.14). After 3 months, there was a median improvement of 2 lines of best-corrected visual acuity, with 52.9% of eyes gaining 2 lines or more (P < 0.01). At 6 months, there were 5 eyes that maintained the 2 lines gain and none had lost >1 line from baseline (P = 0.03). In 8 eyes (47.1%), reinjection of the implant was performed at a mean of 6.5 months. Ocular hypertension (47.1%), hypotony (11.8%), anterior chamber displacement of the implant (5.9%), and glaucoma, which required filtration surgery (5.9%), were the most common adverse events. Mean follow-up was 9.6 months (range, 6–17 months). Conclusion: In this small case series of eyes with limited follow-up, treatment with dexamethasone intravitreal implant injection for uveitic macular edema in vitrectomized eyes was associated with favorable visual outcomes and had an acceptable safety profile.

Anti-TNF-α therapy in patients with refractory uveitis due to Behçet’s disease: a 1-year follow-up study of 124 patients

OBJECTIVE The aim of this study was to assess the efficacy of anti-TNF-α therapy in refractory uveitis due to Behçets disease (BD). METHODS We performed a multicentre study of 124 patients with BD uveitis refractory to conventional treatment including high-dose corticosteroids and at least one standard immunosuppressive agent. Patients were treated for at least 12 months with infliximab (IFX) (3-5 mg/kg at 0, 2 and 6 weeks and then every 4-8 weeks) or adalimumab (ADA) (usually 40 mg every 2 weeks). The main outcome measures were degree of anterior and posterior chamber inflammation, visual acuity, macular thickness and immunosuppression load. RESULTS Sixty-eight men and 56 women (221 affected eyes) were studied. The mean age was 38.6 years (s.d. 10.4). HLA-B51 was positive in 66.1% of patients and uveitis was bilateral in 78.2%. IFX was the first biologic agent in 77 cases (62%) and ADA was first in 47 (38%). In most cases anti-TNF-α drugs were used in combination with conventional immunosuppressive drugs. At the onset of anti-TNF-α therapy, anterior chamber and vitreous inflammation was observed in 57% and 64.4% of patients, respectively. In both conditions the damage decreased significantly after 1 year. At baseline, 50 patients (80 eyes) had macular thickening [optical coherence tomography (OCT) >250 μm] and 35 (49 eyes) had cystoid macular oedema (OCT>300 μm) that improved from 420 μm (s.d. 119.5) at baseline to 271 μm (s.d. 45.6) at month 12 (P < 0.01). The best-corrected visual acuity and the suppression load also showed significant improvement. After 1 year of follow-up, 67.7% of patients were inactive. Biologic therapy was well tolerated in most cases. CONCLUSION Anti-TNF-α therapy is effective and relatively safe in refractory BD uveitis.

Intravitreal Bevacizumab in Inflammatory Ocular Neovascularization

PURPOSE To assess the role of bevacizumab in inflammatory ocular neovascularization. DESIGN Retrospective, multicenter, consecutive case series of inflammatory ocular neovascularization. METHODS Patients with inflammatory ocular neovascularization of varying causes for whom standard therapy failed were treated with intravitreal injection of bevacizumab. Main outcome measures included improvement of best-corrected visual acuity (BCVA) expressed in logarithm of minimum angle of resolution units, response of inflammatory ocular neovascularization by funduscopy and angiography, and decrease in central foveal thickness as measured by optical coherence tomography at the three-month follow-up. RESULTS At the three-month follow-up, 84 eyes of 79 patients had been treated with a mean of 1.3 injections (range, one to three). Thirty-four eyes showed juxtafoveal choroidal neovascularization (CNV), 34 eyes showed subfoveal CNV, eight eyes showed peripapillary CNV, and 11 eyes showed neovascularization of the disc (NVD) or neovascularization elsewhere (NVE). BCVA improved 2.4 lines from 0.68 (6/28 or 20/94) to 0.44 (6/17 or 20/55) (P < .001). BCVA improved by one to three lines in 34.5% of the eyes, by four to six lines in 16.7% of the eyes, and by more than six lines in 14.2% of the eyes. Function was unchanged in 23.8% of the eyes. BCVA worsened in 10.7% (zero to three lines in 7.1%, more than four lines in 3.6%). Central foveal thickness decreased from baseline 346 to 252 microm (P < .001). For CNV, 32 eyes (43.2%) had complete regression after the injection, 27 (36.5%) had partial regression, five (6.8%) had no response, and 10 eyes (13.5%) were not evaluated by the contributors. For NVD or NVE, seven eyes (63.6%) had complete regression of new vessels and four eyes (36.4%) had partial regression after the injection. CONCLUSIONS Intravitreal bevacizumab led to short-term significant visual improvement and regression of inflammatory ocular neovascularization in a wide variety of inflammatory ocular diseases.

Intravitreal bevacizumab (avastin) injection as primary treatment of inflammatory choroidal neovascularization.

Objective: To assess the effects of intravitreal bevacizumab injection as primary treatment of inflammatory choroidal neovascularization (CNV). Methods: Data for nine consecutive patients with newly diagnosed inflammatory CNV who were treated with intravitreal bevacizumab (1.25 mg) injection were reviewed retrospectively. Main outcome measures were best-corrected visual acuity, foveal thickness measured by optical coherence tomography (OCT), and complete resolution of CNV. Results: CNV resolved completely in 9 (100%) of 9 affected eyes. At the last examination, visual acuity was improved in 8 eyes (88.8%), stable in 1 (11.2%), and worse in 0. Over a mean follow-up of 7.1 months (range, 6–10 months), 7 eyes received 1 injection, 1 eye developed CNV recurrence and required a second injection, and 1 eye required a third injection. Foveal thickness by OCT decreased significantly (P = 0.049) after treatment. Conclusion: In this small case series of eyes with limited follow-up, intravitreal bevacizumab injection for treatment of inflammatory CNV was found to be safe and was associated with favorable visual outcomes for both subfoveal and juxtafoveal or extrafoveal inflammatory CNV.

Epidemiology of uveitis in a Western urban multiethnic population. The challenge of globalization

To report the anatomical pattern and etiological spectrum of uveitis in an urban multi‐ethnic population from Barcelona, Spain. General and specific epidemiological data for the most prevalent aetiologies are also calculated.

Behçet Disease-associated Uveitis Successfully Treated with Golimumab

Abstract Over the past decade, the off-label use of biologic agents such as TNF-α antagonists, including infliximab and adalimumab, has improved the treatment armamentarium for refractory immune-mediated uveitis, with particular success in Behçet disease-associated uveitis. Golimumab is a novel fully human anti-TNF-α monoclonal antibody that has been approved for the treatment of rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, with very promising results. Herein, the authors present the use of GLM in a case of Behçet uveitis refractory to other TNF-α blockers. There are only two reports in the literature about the use of GLM in uveitis, describing four patients with JIA-associated uveitis and a case of idiopathic retinal vasculitis. To the authors’ knowledge, this is the first report about the use of GLM in Behçet uveitis.

Amniotic membrane implantation as a therapeutic contact lens for the treatment of epithelial disorders.

Purpose. To evaluate the efficacy and safety of amniotic membrane implantation as a therapeutic contact lens in the treatment of different epithelial defects without stromal ulceration. Methods. We used amniotic membrane implantation as a therapeutic contact lens in 20 consecutive patients with epithelial defects. Group 1 included 10 patients with persistent epithelial defects that did not respond to medical treatment. Group 2 included 10 patients with surgically induced epithelial defects. Results. No intra-or postoperative complications were observed. The amniotic membrane implant remained in place for a mean of 12.5 days (range, 3–34). In 11 of the 20 patients, the amniotic membrane implant became detached within the first 8 days. When the corneal implant was postoperatively covered with a soft contact lens, this time increased. In group 1, complete epithelialization was achieved in three of the four cases in which the amniotic membrane remained in place for 2 or more weeks. There were no cases of complete epithelialization in which the implant remained in place for less than 1 week. In group 2, epithelialization was achieved in all cases, regardless of the time that the implant remained in place. Conclusion. Amniotic membrane implanted as a therapeutic contact lens can be an effective and safe option for the treatment of different epithelial defects. In patients with persistent epithelial defects, the number of cases with complete postoperative epithelialization was higher when the amniotic membrane remained in place longer. The early detachment of the amniotic membrane implant remains a major problem, even with the use of multiple fixation sutures.

Ocular syphilis--back again: understanding recent increases in the incidence of ocular syphilitic disease.

Purpose: The clinical findings and outcomes of 12 cases of luetic uveitis are reported. Methods: Review of clinical records. Results: Patients included 10 men and 2 women; 7 were homosexual, 9 HIV-positive. Six patients presented a medical history suggestive of syphilis. All patients presented with iritis and vitritis. Visual acuity improved in 11 patients after treatment. Conclusions: Syphilis has reemerged in developed countries. This may be related to the post-AID S/HAART era, with a growing pool of HIV-positive men who oftenly practice unsafe sex. We underscore the importance of a high index of suspicion of ocular syphilis in patients with these characteristics.

Long-Term Effects of Tocilizumab Therapy for Refractory Uveitis-Related Macular Edema

OBJECTIVE To report the long-term efficacy and safety of the interleukin-6 receptor antagonist tocilizumab for refractory uveitis-related macular edema (ME). DESIGN Retrospective cohort study. PARTICIPANTS Eyes with uveitis seen at a single tertiary referral center for which ME was the principal cause of reduced visual acuity. METHODS Data were obtained by standardized chart review. MAIN OUTCOME MEASURES Central foveal thickness (CFT) measured by optical coherence tomography, degree of anterior and posterior chamber inflammation (Standardization of Uveitis Nomenclature Working Group criteria), and visual acuity (logarithm of the minimum angle of resolution [logMAR]) were recorded during tocilizumab therapy at months 1, 3, 6, and 12. RESULTS Eleven eyes from 7 patients (all women) were included. Mean age was 43.4 years. Mean duration of ME was 14.2 years. Mean follow-up with tocilizumab therapy was 15.2 months (range, 12-18 months). Before tocilizumab therapy, conventional immunosuppressive therapy and 1 or more biologic agents failed in all patients. Uveitis diagnoses were birdshot chorioretinopathy (n = 3), juvenile idiopathic arthritis-associated uveitis (n = 3), and idiopathic panuveitis (n = 1). Mean CFT was 550 ± 226 μm at baseline, 389 ± 112 μm at month 1 (P = 0.007), 317 ± 88 μm at month 3 (P = 0.01), 292 ± 79 μm at month 6 (P = 0.006), and 274 ± 56 μm at month 12 of follow-up (P = 0.002). Mean logMAR best-corrected visual acuity improved from 0.67 ± 0.53 at baseline to 0.4 ± 0.56 at month 12 (P = 0.008). Tocilizumab therapy was withdrawn in 2 patients because of sustained remission at month 12. In both patients, ME relapsed 3 months after tocilizumab withdrawal. Reinitiation of tocilizumab therapy led to good uveitis control and ME resolution. Tocilizumab generally was well tolerated and no serious adverse events were reported. CONCLUSIONS In this study, tocilizumab was effective in the treatment of refractory inflammatory ME. No serious adverse events were observed.