Anthony J. Hall

Syphilitic uveitis: a review of clinical manifestations and treatment outcomes of syphilitic uveitis in human immunodeficiency virus‐positive and negative patients

The incidence of syphilis and syphilitic uveitis in our community is increasing. The prevalence of associated neurosyphilis is unknown, and it remains unclear whether syphilitic uveitis should be treated as secondary syphilis with intramuscular penicillin or neurosyphilis with intravenous penicillin. The (English language) literature was reviewed for all unique cases of syphilitic uveitis reported from 1984 to June 2008. For each case the following data were recorded: the clinical features of the syphilis, the uveitis and any associated neurosyphilis, the human immunodeficiency virus (HIV) status, lumbar puncture findings, treatment and follow up. We identified 143 patients in 41 original reports of syphilitic uveitis (93 HIV‐positive and 50 HIV‐negative). Posterior uveitis was reported in 79 patients (55.2%); panuveitis was reported in 36 patients (25.2%); anterior/intermediate uveitis was reported in only 28 patients (19.6%). Lumbar puncture findings were abnormal in 82 patients (57%), and the majority of these patients (76%, 62 out of 82) were HIV‐positive. One hundred and ten (77%) patients were treated with intravenous therapy, usually penicillin. Most recovered from the syphilis, however, a proportion did not recover full vision. There were 13 (9%) treatment failures, which tended to occur in patients who were HIV‐positive (n = 11), had abnormal lumbar puncture findings (n = 8) and/or were treated (n = 11) intravenously. There is a high incidence of abnormal lumbar puncture findings in patients with syphilitic uveitis and a strong association with HIV infection. Most received appropriate therapy with a low relapse rate, which was not related to the type of therapy.

Leber's hereditary optic neuropathy triggered by antiretroviral therapy for human immunodeficiency virus

AbstractPurpose To describe the clinical features of two cases of Lebers hereditary optic neuropathy (LHON) precipitated by antiretroviral treatment for human immunodeficiency virus (HIV) infection.Methods Two cases of LHON (from an expected four new cases a year throughout Australia) were identified in men on treatment for HIV infection.Results Two HIV-infected men were receiving combination antiretroviral therapy that included nucleoside analogues. Both patients carried the 14 484 mitochondrial DNA mutation and were distantly related (seventh cousins). Although both men presented with sequential visual loss typical of LHON and one had a known close relative affected by LHON, the correct diagnosis was delayed in both cases. The final visual outcome was profoundly reduced in both instances and cessation of antiretroviral therapy did not result in recovery of vision in one patient.Conclusion Patients with a family history of LHON who require antiretroviral treatment should be warned of the high risk of severe visual loss. The underlying mechanism of antiretroviral side effects may help characterize the other trigger factors for LHON.

Predictors of Poor Follow-up in Children that had Cataract Surgery

Background: Centers for high quality cataract surgery for children have been developed in a number of sub-Saharan African countries. Surgery, however, is only the first stage of a long, often complex, rehabilitation program. There are indications that follow-up in these settings is poor. In a setting with a high quality surgical service an active program to identify and manage children with cataract and a newly developed low vision program, we sought to measure routine follow-up and to determine the factors associated with good or poor follow-up. Methods: This prospective study included all children (under the age of 16 years) having surgery for congenital, developmental, or traumatic cataract at KCMC Hospital between March 2003 and October 2004. Standardized data was collected pre-, intra-, and postoperation. Follow-up was assessed at two weeks and ten weeks. Results: Among the 154 children included 35.1% had congenital cataract, 32.5% had developmental cataract, and 31.8% had traumatic cataract. Overall, 66.9% attended two-week follow-up and 42.9% attended ten-week follow-up. Multivariate analysis revealed that sex (being a boy), close proximity to a hospital, and minimal delay in presentation for surgery all independently predicted good follow-up at two weeks. Only distance from a hospital and preoperative vision (not blind in operative eye) predicted good ten-week follow up. Discussion: Current follow-up practices are inadequate. Significant investment in surgical interventions may not lead to improved visual rehabilitation or quality of life, if investments in follow-up are not increased. Linking individual children, their families, and the hospital needs to be approached systematically, if follow-up is to be improved. Improved hospital-based counseling should focus on families who bring their child late for surgery and with girls.

Syphilitic Punctate Inner Retinitis in Immunocompetent Gay Men

PURPOSE To describe the features of an unusual syphilitic uveitis syndrome in a cluster of homosexual patients. DESIGN Retrospective case series. PARTICIPANTS Five consecutive patients diagnosed with syphilitic retinitis in our Melbourne uveitis clinic over a period of 8 months. METHODS The case notes of patients diagnosed with syphilitic retinitis were reviewed and the clinical features are presented and discussed. MAIN OUTCOME MEASURES Description of retinal findings and documentation of any associated sequelae. RESULTS All patients were homosexual men. Two were human immunodeficiency virus positive. None of the patients had been previously diagnosed with syphilis, although 3 presented with systemic symptoms and signs of secondary syphilis. All patients had marked anterior uveitis and vitritis. All patients had acute retinal arteriolitis and inner retinitis, with distinctive, inner retinal and preretinal white dots. These retinal findings were remarkably similar in all patients, and resolved with little or no sequelae after standard systemic treatment for syphilis, combined with oral prednisolone. CONCLUSIONS Syphilitic retinitis may be an increasingly common clinical problem, reflecting the growing incidence of syphilis among homosexual men in Australia. Our patients showed stereotypical ocular and systemic features, which are useful in differentiating this condition clinically from other types of acute posterior uveitis, such as necrotizing viral retinitis. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Nd:YAG laser iridotomy in uveitic glaucoma

Purpose: To determine the survival of Nd:YAG laser peripheral iridotomy in those patients with angle closure glaucoma and iris bombé associated with uveitis.

Toxocara canis: egg presence in Melbourne parks and disease incidence in Victoria.

Purpose: Toxocara canis can cause blinding eye disease. This study assessed the presence of T. canis eggs in soil from parks in Melbourne and also the incidence of presumed ocular toxocariasis in Victoria.

Compliance with Eye Screening Examinations among Diabetic Patients at a Tanzanian Referral Hospital

Background: Sub-Saharan Africa faces an epidemic of diabetes with its attendant complications. Early treatment of diabetic retinopathy prevents visual impairment and blindness. However, very little has been done to establish diabetic retinopathy screening in Africa. We aimed to measure current use of the eye department by diabetics and the increase in eye examinations following education about diabetic eye disease by a dedicated nurse counselor and the offer of a free eye examination. Methods: In a prospective study over 6 months we enrolled all diabetics over the age of 18 attending the diabetic clinic at KCMC. Data was collected on whether patients had had a previous dilated eye exam and whether they knew this was necessary. Education on diabetic eye disease and a referral form to the eye clinic for a free examination were given to the patient. Findings: Three-hundred sixteen patients were enrolled in the study. 187 (59.1%) of the patients reported that they had undergone dilated fundus exam at some point since their diagnosis. 91 (28.8%) had undergone fundus examination within the past 12 months. Of the 316 patients, 114 (36%) came to the eye clinic with the referral form. 106 had not been examined in the last year. 65 of these had never been examined before. A logistic regression model demonstrated that knowledge that diabetes damages the eye (OR = 7.34, 95%CI = 4.66–11.57) and age (OR = 1.02, 95%CI = 1.01–1.03) but not duration of diabetes were independently associated with ever having had a dilated fundus exam and with having had an exam in the past year. Interpretation: Only 29% of diabetics had had an eye examination in the previous year. After the intervention this increased to 47% of those who had not been examined. In the short term we achieved a reasonable, albeit less than optimal, increase in use of eye care services among diabetic patients. It is essential that we continue to strive to find ways to improve eye care for diabetic patients in Africa to avoid an increase in visual impairment.

The course of uveitis in pregnancy and postpartum

Aim To examine the course of non-infectious uveitis during pregnancy. Methods This is a retrospective case series. The medical records of 47 subjects with a previous history of non-infectious uveitis pre-dating their pregnancy were reviewed. Uveitis activity during the periods 1 year before pregnancy, during pregnancy and 1 year postpartum, were recorded. Information on patient demographics, type of uveitis, medication use, sex of child and breastfeeding status were also collected. The main outcome measures were the events of flare-ups during the prepregnancy, pregnancy and postpartum periods. Results The rate of flare-up was 1.188 per person year prior to pregnancy, 0.540 per person year during pregnancy and 0.972 per person year in postpartum (p<0.001 for comparison between prepregnancy and pregnancy; p=0.009 for comparison between pregnancy and postpartum). Rates of flare-up only began to decrease in the second trimester. After delivery, rates of flare-up rebounded and within 6 months postpartum, flare-up rates were not significantly different from prepregnancy levels (p=0.306). Even so, 40% of subjects were found to have remained inactive within 1 year postpartum. Conclusions Uveitis activity decreased by mid-pregnancy, but returned to prepregnancy levels within 6 months postpartum. These findings may be used to adjust uveitis management during pregnancy and the postpartum period.

Changing trends in sympathetic ophthalmia.

Sympathetic ophthalmia is a rare and potentially visually devastating bilateral panuveitis, typically following non‐surgical penetrating injury to one eye. Three patients are presented where sympathetic ophthalmia developed after repeated vitreoretinal surgery. Prompt and effective management with systemic immunosuppressive agents permitted control of their disease and retention of good visual acuity in their remaining eye. Vitreoretinal surgery is an important risk factor in sympathetic ophthalmia. Informed consent for vitreoretinal surgery (especially in the re‐operation setting) should now include the risk of sympathetic ophthalmia (approximately 1 in 800). Diverse clinical presentations are possible in sympathetic ophthalmia and any bilateral uveitis following vitreoretinal surgery should alert the surgeon to the possibility of sympathetic ophthalmia. Modern immunosuppressive therapy with systemic steroids and steroid‐sparing agents such as cyclosporin A and azathioprine have improved the prognosis. This is particularly so in cases where early diagnosis is made and prompt and suitable immunotherapy is commenced.

Prevalence of Antiviral Drug Resistance in Untreated Patients with Cytomegalovirus Retinitis

The purpose of this study was to determine the prevalence of UL97 resistance mutations in cytomegalovirus (CMV) DNA amplified from the eyes of patients with AIDS and newly diagnosed CMV retinitis. Relevant segments of the CMV UL97 gene were amplified from vitreous humor, after which restriction digest screening was performed for resistance mutations at codons 460, 520, 591, 592, 594, 595, and 603. Mutations were confirmed by DNA sequencing. Vitreous from 21 eyes with AIDS-related non-CMV viral retinitis served as negative controls. CMV DNA was successfully amplified from 195 of 204 eyes. A resistance mutation was found in only a single eye, a T-->G mutation at base 1774, predicting a cysteine to glycine mutation at codon 592. The prevalence of UL97 resistance mutations in the eyes of patients with newly diagnosed CMV retinitis is very low.