Asima Bajwa

Epidemiology of uveitis in the mid-Atlantic United States

Purpose To demonstrate the demographic, anatomic, and diagnostic classification of patients with uveitis seen in a tertiary care center in central Virginia. Methods Retrospective chart review of patient demographics, disease characteristics, and disease severity-related outcomes (therapies, visual outcomes, and complications) from 1984 to 2014. Results There were 491 patients (644 eyes) with mean age of 46 years (±21.4 years) and mean duration of follow up of 4.8 years (±6.8 years). Of these, 278 patients were female (56.6%). Further, 60.5% were Caucasian, and 27.3% were African American. The anatomic types seen were anterior uveitis (67.3%), panuveitis (14.5%), posterior uveitis (12.6%), and intermediate uveitis (5.3%). The most common etiology was post-traumatic (12.2%), followed by post-procedural (10.0%), herpetic (7.9%), human leukocyte antigen (HLA)-B27-associated (6.7%), and sarcoidosis (6.7%). Herpetic uveitis was more common among Caucasians than African Americans (sex-adjusted odds ratio [OR]: 7.69, 95% confidence interval [CI] [2.12, 50.00]), and sarcoidosis was more common among African Americans than Caucasians (sex-adjusted OR: 6.54, 95% CI [2.98, 15.29]). Herpetic anterior uveitis was more common among females than males (race-adjusted OR: 3.03, 95% CI [1.32, 7.71]). Multifocal choroiditis was more common among males than females (race-adjusted OR: 9.09, 95% CI [1.47, 100.00]). Mean logMAR visual acuity was 0.18 at initial and final visit. A total 388 (79%) and 133 (27.3%) patients received local and systemic steroids, respectively. A total 52 patients (10.6%) received an antimetabolite. A total 116 patients (23.7%) were managed with topical glaucoma medication. A total 43 (8.8%), 129 (26.4%), and 46 patients (9.4%) underwent glaucoma surgery, cataract surgery, and vitrectomy, respectively. Conclusion Over the period of this study, Caucasian patients were more frequently seen than non-Caucasians, although African Americans constituted a considerable size of study population. The most common diagnoses were undifferentiated anterior uveitis, traumatic uveitis, post-procedural uveitis, herpetic disease, HLA-B27 associated uveitis, and sarcoidosis. Unlike previous reports, traumatic and post-procedural uveitis were frequently reported. Mean visual acuity remained stable from initial to final visit.

Causes of uveitis in children without juvenile idiopathic arthritis

Background The purpose of this study was to report the demographics, disease characteristics, treatments, and visual outcomes of pediatric uveitis patients without juvenile idiopathic arthritis managed in a tertiary medical center. Methods A retrospective, observational study was performed in pediatric uveitis patients without juvenile idiopathic arthritis and aged 0–18 years, who were seen at the University of Virginia from 1984 to 2014. Results Thirty-nine pediatric uveitis patients (57 eyes) were identified. The patient population was 51.28% female, 51.28% Caucasian, and 33.33% African American. The mean age at diagnosis was 11.9 years. The mean duration of follow-up was 3.11 years. The mean number of visits to the clinic was 10.41. Of 57 eyes, 31 (54.39%) had anterior uveitis, 12 (21.05%) had intermediate uveitis, nine (15.79%) had posterior uveitis, and five (8.77%) had panuveitis. The leading diagnoses were traumatic uveitis (25.64%), undifferentiated anterior uveitis (17.95%), undifferentiated intermediate uveitis (15.38%), HLA-B27-associated anterior uveitis (7.69%), and herpetic anterior uveitis (7.69%). Systemic associations included sarcoidosis, ulcerative colitis, and psoriatic arthritis (n=3). The most common treatment modalities included local steroids (66.67%), systemic steroids (23.08%), and antimetabolites (20.51%). Ocular hypertension was found in five (12.82%) patients. Ocular surgery was performed in six (15.38%) patients. Mean best-corrected visual acuity (BCVA) at baseline across all anatomical locations was 0.458 logMAR, and was 0.411 logMAR at final follow-up. Mean BCVA improved during follow-up in all but the anterior uveitis group. The mean baseline intraocular pressure was 14.27 mmHg, and was 14.22 mmHg at final follow-up. Conclusion Uveitis in childhood is a vision-threatening group of inflammatory disorders arising from numerous etiologies that vary geographically and historically. Because of the high burden of disease, the difficulty of making precise etiologic diagnoses, and the complicated management, it is imperative that affected children be referred to and closely monitored by uveitis specialists to prevent devastating ocular damage. This study found that BCVA and intraocular pressure did not vary significantly during follow-up, suggesting that close management by an ophthalmologist may prevent adverse visual outcomes, and highlighted the high prevalence of traumatic uveitis in children, which tends to have good visual outcomes.

LONG-TERM EFFICACY OF SYSTEMIC INFLIXIMAB IN RECALCITRANT RETINAL VASCULITIS.

Purpose: To evaluate the efficacy of systemic infliximab for the induction of remission in patients with retinal vasculitis, inadequately responsive to other immunomodulatory therapy, based on fluorescein angiography grading for retinal vasculitis evaluation. Methods: We analyzed 60 patients with retinal vasculitis, from the Massachusetts Eye Research and Surgery Institution in Cambridge, MA. Response to therapy was based on analysis of serial fluorescein angiography and fundus photography, including a baseline angiogram before initiation of infliximab. Results: Sixty patients received infliximab therapy between July 2007 and July 2012 at Massachusetts Eye Research and Surgery Institution for a diagnosis of retinal vasculitis. All had previously showed a poor clinical response to other immunomodulatory regimens, or ceased therapy due to intolerable side effects. The initial dose of infliximab was 5 mg/kg in all patients and remained at this dose for the extent of treatment in 57 (95%) patients. At 6 months, 45 of 51 (88.23%) patients were maintaining remission with therapy, 5 (9.8%) were in partial remission, and 1 patient had failed. At 12 months, 39 of 39 (100%) patients were maintaining remission with therapy. Conclusion: Infliximab is effective for the treatment of recalcitrant noninfectious retinal vasculitis, refractory to conventional immunomodulatory therapy.

Safety and efficacy of fluocinolone acetonide intravitreal implant (0.59 mg) in birdshot retinochoroidopathy.

Purpose: To report the treatment outcomes of the fluocinolone acetonide intravitreal implant (0.59 mg) in patients with birdshot retinochoroidopathy whose disease is refractory or intolerant to conventional immunomodulatory therapy. Methods: A retrospective case series involving 11 birdshot retinochoroidopathy patients (11 eyes). Eleven patients (11 eyes) underwent surgery for fluocinolone acetonide implant (0.59 mg). Treatment outcomes of interest were noted at baseline, before fluocinolone acetonide implant, and then at 6 months, 1 year, 2 years, 3 years, and beyond 3 years. Disease activity markers, including signs of ocular inflammation, evidence of retinal vasculitis, Swedish interactive threshold algorithm–short wavelength automated perimetry Humphrey visual field analysis, electroretinographic parameters, and optical coherence tomography were recorded. Data on occurrence of cataract and raised intraocular pressure were collected in all eyes. Results: Intraocular inflammation was present in 54.5, 9.9, 11.1, and 0% of patients at baseline, 6 months, 1 year, 2 years, 3 years, and beyond 3 years after receiving the implant, respectively. Active vasculitis was noted in 36.3% patients at baseline and 0% at 3 years of follow-up. More than 20% (47.61–67.2%) reduction in central retinal thickness was noted in all patients with cystoid macular edema at 6 months, 1 year, 2 years, and 3 years postimplant. At baseline, 54.5% patients were on immunomodulatory agents. This percentage decreased to 45.45, 44.4, and 14.28% at 1 year, 2 years, and 3 years postimplant, respectively. Adverse events included increased intraocular pressure (54.5%) and cataract formation (100%). Conclusion: The data suggest that fluocinolone acetonide implant (0.59 mg) helps to control inflammation in otherwise treatment-refractory cases of birdshot retinochoroidopathy. It is associated with significant side effects of cataract and ocular hypertension requiring treatment.

Infectious uveitis in Virginia

Purpose To report the causes, clinical features, and outcomes of infectious uveitis in patients managed in a mid-Atlantic tertiary care center. Methods Retrospective, observational study of infectious uveitis patients seen at the University of Virginia from 1984 to 2014. Results Seventy-seven of 491 patients (15.7%) were diagnosed with infectious uveitis (mean age 58 years, 71.4% female, 76.6% Caucasian). The mean follow-up was 5 years. Anterior uveitis was the most common anatomic classification (39 patients, 50.6%) followed by panuveitis (20 patients, 26.0%) and posterior uveitis (18 patients, 23.4%). The most common infectious etiology was herpetic anterior uveitis (37 patients, 48.1%) followed by toxoplasma uveitis (14 patients, 18.2%). The most prevalent viral pathogen was varicella-zoster virus (21 patients, 27.3%) followed by herpes simplex virus (20 patients, 26.0%). Acute retinal necrosis (ARN) was diagnosed in 14 patients (18.2%). Aqueous humor yielded an etiologic diagnosis in seven (50%) of ARN patients, four of whom tested positive for cytomegalovirus and three for varicella-zoster virus. On presentation, 43 patients (55.8%) had a visual acuity (VA) better than 20/40 and 17 (22.1%) had a VA worse than 20/200. VA at the final follow-up was better than 20/40 in 39 patients (50.6%) and worse than 20/200 in 22 patients (28.6%). In all, 16 (20.8%) and 10 (13.0%) patients required cataract and vitrectomy surgery, respectively. A total of 14 patients (18.2%) were on glaucoma topical treatment and four (5.2%) required glaucoma surgery. Conclusion The most common type of infectious uveitis seen over the study period was herpetic anterior uveitis secondary to varicella-zoster virus or herpes simplex virus, found to be most prevalent in patients over 60 years of age. This finding is comparable to other American epidemiologic studies. Ocular toxoplasmosis and ARN were also common causes of infectious uveitis. In all, 50.6% of patients had a VA better than 20/40 at the final follow-up visit, indicating the importance of prompt referral and appropriate treatment.

A comprehensive review and update on the biologic treatment of adult noninfectious uveitis: part II

Introduction: Treatment of adult, noninfectious uveitis remains a major challenge for ophthalmologists around the world, especially in regard to recalcitrant cases. It is reported to comprise approximately 10% of preventable blindness in the USA. The cause of uveitis can be idiopathic or associated with infectious and systemic disorders. The era of biologic medical therapies provides new options for patients with otherwise treatment-resistant inflammatory eye disease. Areas covered: This two-part review gives a comprehensive overview of the existing medical treatment options for patients with adult, noninfectious uveitis, as well as important advances for the treatment ocular inflammation. Part I covers classic immunomodulation and latest information on corticosteroid therapy. In part II, emerging therapies are discussed, including biologic response modifiers, experimental treatments and ongoing clinical studies for uveitis. Expert opinion: The hazard of chronic corticosteroid use in the treatment of adult, noninfectious uveitis is well documented. Corticosteroid-sparing therapies, which offer a very favorable risk–benefit profile when administered properly, should be substituted. Although nothing is currently approved for on-label use in this indication, many therapies, through either translation or novel basic science research, have the potential to fill the currently exposed gaps.

Traumatic uveitis in the mid-Atlantic United States.

Purpose The purpose of this study was to conduct an in-depth analysis of traumatic uveitis in patients managed in a mid-Atlantic tertiary care center with the goal of better characterizing the clinical features and outcomes of this large and important subset of uveitis patients. Methods This was a retrospective, observational study comparing traumatic uveitis patients with nontraumatic uveitis patients seen at the University of Virginia, Charlottesville, VA, USA, from 1984 to 2014. Results Fifty-four traumatic uveitis patients (55 eyes) were identified. The patient population was 70.4% male, 57.4% Caucasian, and 37.0% African American. Mean age at diagnosis was 31.2 years; mean duration of follow-up was 5.4 years; and mean number of visits to the clinic was 4. The most common treatment modality was local steroids (77.8%). Glaucoma was medically managed in eight patients (14.8%). Cataract surgery was performed in five patients (9.3%). Mean best-corrected visual acuity at baseline for traumatic uveitis patients was 0.33 logMAR (SD 0.42) at the initial visit and 0.16 logMAR (SD 0.33) at the final visit. Mean baseline intraocular pressure (IOP) in the traumatic uveitis group was 15.5 mmHg (SD 7.4) at the initial visit and 14.6 mmHg (SD 4.0) at the final visit. Patients in the traumatic uveitis cohort tended to have better visual outcomes than those in the nontraumatic uveitis cohort. Conclusion In our series, traumatic uveitis patients tended to be young and male and present with unilateral disease, all findings consistent with other reports. Despite relatively good visual outcomes, the traumatic uveitis patients still experienced a high burden of disease, measured both in the number of clinic visits and duration of follow-up. Due to the young mean age of patients, these disease burdens and decreased quality of life are nontrivial, emphasizing the importance of careful management and prompt treatment of this subset of uveitis patients.

Ocular Inflammatory Disease Observed in Rheumatology Clinic at a Tertiary-Care Hospital.

T aim of the study was to reconstruct the optical conditions inside the diabetic crystalline lens. Optical parameters of the crystalline lens were affected by homeostasis disorders associated with diabetes. The changes of optical parameters in subjects with diabetes are usually described with statistical methods (1) and the results of these statistical analyses rarely provide clear and unequivocal results. In the case of parameters that require high sensitivity measurements, the results often turn out to be located at the borderline of statistical significance. Thus, in such cases it is necessary to use more stable and predictable equivalents of these structures. For numerical simulations, a model of crystalline lens was constructed. The model was based on geometric parameters (2), physiological data (3) with gradient index (GRIN) of optical medium of the lens (4). The GRIN was modified according to our knowledge about changes of crystalline lens in diabetic patient (1). We examined refractive power and spherical aberration and their changes for possible disturbances. The present study has shown that the changes of gradient profile have the influence on the optical power of the lens and the value of spherical aberration as well. Furthermore, the study has proved the possible reduction of changes of optical parameters of the lens due to swelling by GRIN. When the lens swells, the focal length becomes shortened and spherical aberration is bigger. The results from simulation are clear because the mathematical model proves the relationship between the geometry of the lens and GRIN and image reproduction.B disease (BD) is a chronic inflammatory disease characterized by oral aphthous ulcers, genital ulcers, and skin lesions. It is an immune mediated vasculitis with unknown origin and systemic manifestation especially ocular involvement including post and anterior uveitis. BD affects both genders in the third or fourth decade of life. Recurrent oral/genital lesion and ocular manifestation are the cardinal signs of BD. In 20%of cases, ocular manifestation follow by the oral and genital ulcer can be the first presentations of the disease, seen in about 70% of patient. Retinal disease is the most serious complication of BD in which, several vasculitis may lead to thrombosis of vessels and secondary ischemic retinal damage. Pathogenesis of BD involves genetic, infections and immunological factor. Between 50 to 80% of BD patients are HLA-B51 positive while the frequency of HLA-B51 in the general US population is 7%. This review summarizes and crosslinks the recent progress on findings, challenges and novel treatment approaches in BD.Results: Among corneal donors, male (58%) is slightly more than female (42%) and the age span from 11 days to 95 years. The highest proportion being in 41-50 years age category and the most common cause of death was malignant tumor (54%). The donation corneas of Shenzhen local and other provinces has increased step by step then tends to stable situation. The main donation approach is based on the coordinators. Mean “death to enucleation time” and “preservation time” was 4.6 and 42.2 hours respectively. Using Optisol GS® media can significantly extend the preservation time.Introduction: Keratoconus is a non-inflammatory, progressive and usually bilateral corneal disorder that leads to considerable alterations in the shape, thickness and biomechanical properties of the cornea. The incidence varies globally depending upon the geographic location, the ethnic groups and diagnostic criteria used. Methods: Retrospective study, review the prevalence, demographic features and associated factors of the outpatients who have been diagnosed as keratoconus through the years 2010 2014. Results: Forty-Four eyes reviewed, the prevalence of keratoconus among ophthalmology department was 5-6 per 12,000 patients each year. The greatest age group affected was 20 29 years old (60.8%), slightly common in female compared to male (52.2%) with majority affected in both eyes (78.3%). The commonest presenting symptom was painless progressive decrease of vision (95.65%), itching (56.21%) and intolerance lenses (39.13%). Clinical profile started by visual acuity the greatest had 6/30 meter (29.3%) then count finger (14.9%), for K-reading mostly they had severe K-reading > 52 (56%), intraocular pressure was within normal (95.2%); high myopia > 6.00 for around half of the patients (41.7%) with absolute astigmatism in all patients. Slit Lamb examination the commonest found cunning (61%) then scaring of cornea (24.4%) and one case with acute bilateral hydro-drop. Discussion: To our knowledge, the current study is the first study of keratoconus in northern region of Saudi Arabia. Demographic features were parallel to the pervious published studies of keratoconus. Moreover, in this study was found a significant relationship between increasing in the age and the severity of the presenting features of keratoconus.Purpose: Age-related macular degeneration (AMD) is pathophysiologically linked to abnormal DNA repair and increased expression of vascular endothelial growth factor (VEGF). The BRCA1/2 gene is involved in maintaining genome stability and the increase in VEGF in tumors with a BCRA1/2 mutation. Therefore, we hypothesized that BRCA1/2 mutations may be associated with the development of exudative (wet) AMD and neovascularization together with age-related DNA damage.Methods: The medical records of 49 eyes of 36 patients who were diagnosed with DME and had received IVR treatment in the Chiba University Hospital from March to December in 2014 were re-viewed. The IVR had been injected pro re nata. The CMT and BCVA were measured at 1, 3, and 6 months after the IVR. Thirty-seven eyes were previously treated, with a Sub-Tenon’s injection of Triamcinolone Acetonide (STTA), 26 eyes had photocoagulation for microaneurysms, 16 eyes had panretinal photocoagulation, and 2 eyes had pars plana vitrectomy.Methods: 82 patients with PSS were randomly selected as study group and 106 healthy donors were randomly selected as control group from Guangdong Han population. All the blood samples were subjected to sequencing-based typing (PCR-SBT) at exon 2 of HLA-DPA1 and DPB1 genes in both directions. The allelic frequencies of HLA-DPA1 and DPB1 loci and the haplotype frequencies of HLA-DPAl-DPBl were respectively compared between the two groups by X2 test.

Incidental retinal vascular occlusions on hydroxychloroquine screening in patients with systemic lupus erythematosus

Objective The proportion of patients with systemic lupus erythematosus (SLE) who manifest retinal involvement increases many fold in patients with active systemic disease. The objective of this report is to stress upon the significance of comprehensive ophthalmic assessment of all SLE patients to prevent and manage blinding ocular manifestations of the disease. Methods Retrospective case review. Results Incidental retinal vascular complications seen in patients undergoing baseline hydroxychloroquine screening. Conclusion The purpose of comprehensive ophthalmic screening in SLE patients is twofold. It will aid in the diagnosis and treatment of blinding ocular complications of the disease and monitor hydroxychloroquine macular toxicity.

Clinical and visual outcomes of patients with uveitis in the mid-Atlantic United States

Purpose To report the clinical outcomes of uveitis patients at the University of Virginia. Methods Retrospective, observational study of uveitis patients seen at the University of Virginia from 1984 to 2014. Parametric and nonparametric methods were used to analyze the change in best-corrected visual acuity (BCVA) in relation to demographics, diagnoses, management, and complications. Results The study included 644 eyes of 491 patients. Patients with mild visual loss (logMAR <0.4) at presentation were younger than those with severe visual loss (SVL, logMAR >1.0) (P=0.002). Females were more likely to have mild visual loss as compared to males (P=0.025). Median overall BCVA was logMAR 0.18 at initial and final presentation (P=1.00). Vision loss at diagnosis was a predictor for moderate visual loss (MVL, logMAR 0.4 to <1.0) to SVL at last follow-up (P<0.001). Eyes with ocular hypertension were positively associated with MVL and SVL as compared to normotensive eyes (1.89 times at baseline, 2.62 times at last follow-up). Median BCVA was 0.18 logMAR for the anterior uveitis (AU) and 0.48 logMAR for the non-AU patients (P<0.001). AU patients were less likely to have SVL than non-AU group (P<0.001). AU group received local corticosteroids more frequently and systemic corticosteroids less commonly than non-AU patients (P<0.001). AU patients with MVL to SVL were more likely to have ophthalmic surgery (cataract, glaucoma or pars plana vitrectomy [PPV]) than those without MVL or SVL (P<0.001). Non-AU patients with MVL to SVL were more likely to have PPV than those without MVL or SVL (P=0.001). Conclusion Mean overall BCVA remained stable. Favorable visual results were associated with younger age, female gender, and AU. Poor visual prognosis was concomitant with SVL at presentation and ocular hypertension. Ocular surgery (cataract extraction and glaucoma filtration) was more frequently performed for AU patients with MVL to SVL than those AU patients who did not experience moderate to SVL. PPV was commonly performed for both AU and non-AU patients with MVL to SVL.