Bryn M. Burkholder

Clinical Features and Incidence Rates of Ocular Complications in Patients With Ocular Syphilis

PURPOSE To describe the clinical outcomes of ocular syphilis. DESIGN Retrospective chart review. METHODS The charts of patients with ocular syphilis (regardless of human immunodeficiency virus [HIV] status) seen in a uveitis referral center between 1984 and 2014 were reviewed. RESULTS The study included 35 patients (61 eyes). Panuveitis was the most common type of ocular inflammation (28 eyes), independent of HIV status. Thirty-three of 35 patients received systemic antibiotics with 24 patients treated with intravenous (IV) penicillin only. When compared to the HIV-positive patients, HIV-negative patients with ocular syphilis were older (P < .001), were more likely to be female (P = .004), and had poorer visual acuity at presentation (P = .01). During follow-up, the incidence rates of visual impairment were 0.29 per eye-year (EY; 95% confidence interval [CI]: 0.06/EY-0.86/EY) and 0.12/EY (95% CI: 0.01/EY-0.42/EY) among the HIV-negative and the HIV-positive patients, respectively. The incidence of blindness was 0.07/EY (95% CI: 0.009/EY-0.27/EY) and 0.06/EY (95% CI: 0.002/EY-0.35/EY) among the HIV-negative and the HIV-positive patients, respectively. Longer duration of uveitis prior to diagnosis and chorioretinitis in the macula at presentation were associated with ≥ 2 Snellen lines of visual loss (P < .01) and visual acuity loss to 20/50 or worse (P = .03) in HIV-negative patients, respectively. CONCLUSIONS Syphilis is an uncommon cause of ocular inflammation in both HIV-negative and HIV-positive patients. Visual loss and ocular complications were common among HIV-negative patients even with systemic antibiotic treatment. Delay of diagnosis and chorioretinitis in the macula were associated with visual loss in these patients.

Clinical features and incidence rate of ocular complications in punctate inner choroidopathy

Purpose: To study the clinical features and incidence rate of ocular complications in patients with punctate inner choroidopathy. Methods: This is a retrospective cohort study conducted in a single-center academic practice setting. Patients diagnosed with punctate inner choroidopathy at the Wilmer Eye Institute, Johns Hopkins University from 1984 to 2012 were identified. Demographics and clinical features including the presence of choroidal neovascularization (CNV) and structural complications were collected. Main outcome measures, including visual impairment and incidence rate of ocular complications, were analyzed. Results: Thirty-one patients (59 eyes) were included in the study. Follow-up data were available for 24 patients (47 eyes) with a mean follow-up time of 3.4 years (range, 2 months to 8.7 years). In the affected eyes with follow-up, the incidence rate of visual impairment to 20/50 or worse was 0.06 per eye-year (EY) (95% confidence interval, 0.022/EY–0.114/EY). The incidence rate of visual loss to 20/200 or worse was 0.006/EY (95% confidence interval, 0.0001/EY–0.034/EY). Thirty-six eyes (77%) had an ultimate visual acuity of 20/40 or better. All of the 13 patients with more than ≥3 years of follow-up had a visual acuity of ≥20/40 in at least 1 eye at 3 years after presentation. Two thirds of the follow-up patients (67%) on immunomodulatory drug therapy did not have new or recurrent CNV. However, this was not a statistically significant difference. Three eyes with follow-up had recurrence of CNV for an incidence rate of 0.04/EY (95% confidence interval, 0.008/EY–0.12/EY). Two eyes developed new CNV during follow-up for an incidence rate of 0.02/EY (95% confidence interval, 0.002/EY–0.066/EY). Conclusion: The visual prognosis in most cases of punctate inner choroidopathy is very good. The incidence rate of new CNV and recurrent CNV was 0.02/EY and 0.04/EY, respectively.

Spectral domain optical coherence tomography findings in acute syphilitic posterior placoid chorioretinitis

BackgroundWe describe the spectral domain optical coherence tomography (SD-OCT) findings in three patients with acute syphilitic posterior placoid chorioretinitis (ASPPC). The SD-OCT images demonstrate the pathologic changes in ASPPC with a high level of anatomic detail and may provide information about the pathophysiology of the disease.FindingsWe report a series of three consecutive patients seen at the Wilmer Eye Institute in 2012 and 2013 who presented with clinical and laboratory findings consistent with a diagnosis of unilateral ASPPC. Two of the three patients had HIV co-infection with good immune recovery. SD-OCT images from their initial (pre-treatment) presentation demonstrated thickening and hyperreflective nodularity of the choroid-retinal pigment epithelium (RPE) complex, with focal disruption of the overlying photoreceptor inner segment-outer segment junction in the areas corresponding to the retinal lesions seen on clinical examination. These changes improved with intravenous antibiotic treatment over a 3-month period of follow-up.ConclusionsSD-OCT imaging in ASPPC demonstrates reversible, focal thickening, and nodularity of the RPE with disruption of the overlying photoreceptor inner segment-outer segment junction. We believe that these SD-OCT images support the concept that ASPPC involves an inflammatory process at the level of the choroid-RPE with resultant structural and functional changes in the retinal photoreceptors. Further study with OCT imaging may be helpful in better understanding this disease.

Postoperative outcomes after fluocinolone acetonide implant surgery in patients with birdshot chorioretinitis and other types of posterior and panuveitis

Purposes: To evaluate outcomes after placement of fluocinolone acetonide (FA) implants in eyes with birdshot chorioretinitis and to compare these outcomes with eyes with posterior and panuveitis. Methods: This is a retrospective cohort study of 48 eyes from patients with posterior and panuveitis treated with FA implants from 2006 to 2010. Outcome measures include visual acuity, intraocular pressure, need for glaucoma surgery, postoperative complications, and control of inflammation. Results: All eyes treated with FA implants achieved improved control of inflammation and decreased reliance on adjunctive therapy. Birdshot chorioretinitis eyes had a statistically significant increase in intraocular pressure in the first 4 months after FA implantation (P = 0.04) compared with baseline intraocular pressure. A higher percentage of eyes with birdshot chorioretinitis required glaucoma surgery and after a shorter time period after FA implantation than did eyes with other forms of posterior and panuveitis (0.42/eye-year vs. 0.11/eye-year; median time to glaucoma surgery: 15.5 months vs. 31.5 months respectively, hazard ratio, 3.4; 95% confidence interval, 1.0–10.8, P = 0.04). Conclusion: Although the FA implant is effective in controlling inflammation and reducing the need for systemic immunosuppressive therapy, eyes of patients with birdshot chorioretinitis tend to have a more robust intraocular pressure response to the FA implant than eyes with other types of posterior and panuveitis.

The Dexamethasone Intravitreal Implant for Noninfectious Uveitis: Practice Patterns Among Uveitis Specialists

ABSTRACT Purpose: To describe the practice patterns and perceptions of uveitis specialists regarding the use of the intravitreal dexamethasone (DEX) implant for the treatment of noninfectious uveitis. Methods: We invited uveitis specialists to participate in an anonymous online survey. Results: Among the 45 respondents, 76.5% identified uveitic macular edema as the most common clinical finding for which they use the DEX implant. The most common contraindications to DEX implantation were aphakia and glaucoma requiring >2 medications. Nearly two-thirds (64.3%) felt that the advent of the DEX implant did not change the frequency with which they used the fluocinolone acetonide (FA) implant, and about one-third (32.3%) preferred to use at least one DEX implant, before committing a patient to an FA implant. Conclusions: Uveitis physicians use the DEX implant for a wide range of clinical findings and uveitic diagnoses. There was no clear consensus on preferences regarding the use of DEX versus FA implants.

Inadvertent trypan blue posterior capsule staining during cataract surgery

PURPOSE To report 5 cases of inadvertent posterior capsule staining with trypan blue during phacoemulsification. DESIGN Retrospective, observational case series. METHODS Five cases of posterior capsule staining with trypan blue were identified from cataract surgeries performed at an academic institution. All 5 eyes underwent phacoemulsification with use of iris retractors. The surgical videos from each case were reviewed to better understand the mechanisms and risk factors for posterior capsule staining with trypan blue and techniques to avoid this complication. RESULTS No eyes had clinical evidence of zonular pathology during their preoperative examination. Only 1 patient reported a possible childhood history of trauma to both eyes. One eye had uveitis, requiring posterior synechialysis. All 5 cases involved the use of iris retractors. No other intraoperative complications occurred, and the intraocular lens was successfully placed in the capsular bag in all cases. All eyes had resolution of posterior capsule staining by postoperative day 8. CONCLUSIONS Inadvertent posterior capsule staining with trypan blue can occur in eyes that appear structurally normal. The use of iris retractors may facilitate posterior capsule staining by allowing the posterior flow of trypan blue under the iris and through the zonules to the posterior capsule. Surgeons should consider techniques to minimize the risk of posterior capsule staining, particularly in cases involving the use of iris retractors.

Occurrence of and Risk Factors for Ocular Hypertension and Secondary Glaucoma in Juvenile Idiopathic Arthritis-associated Uveitis.

ABSTRACT Purpose: To describe the incidence of ocular hypertension (OHT) and secondary glaucoma (SG) in JIA-associated uveitis, identify risk factors for development of these complications, and describe their effect on visual outcomes. Methods: A retrospective cohort of 108 patients (196 eyes) with JIA-associated uveitis seen over 30 years at an academic practice. Results: Of examined eyes, 40% had OHT or SG at presentation. These eyes had a nearly three-fold higher incidence of legal blindness during follow-up, compared with eyes without OHT or SG. An additional 41 eyes developed OHT or SG during follow-up. Presenting with anterior uveitis, active inflammation, and using systemic corticosteroids were risk factors for developing OHT, while use of immunosuppressive medication at presentation reduced this risk. Risk factors for developing SG included anterior uveitis and use of systemic corticosteroids. Conclusions: OHT and SG were common in patients with JIA-associated uveitis. Use of immunosuppressive drugs may decrease the risk of developing OHT.

Sclerouveitis Associated with Rosai-Dorfman Disease in an HIV-infected Patient

ABSTRACT Purpose: To describe a case of Rosai-Dorfman-associated sclerouveitis in an HIV-infected patient. Design: Case report. Methods: A 49-year-old man with HIV had bilateral eye pain, redness, photophobia, and multiple systemic complaints. He underwent serial ocular examinations, abdomen/pelvis CT scan, and lymph node biopsy. Results: Ophthalmologic evaluation revealed bilateral, nongranulomatous anterior uveitis and anterior scleritis. Biopsy of a retroperitoneal lymph node identified on CT revealed mixed inflammatory infiltrate composed of histiocytes, lymphocytes, and plasma cells involving fibroadipose tissue, indicating Rosai-Dorfman disease. Conclusions: This is the first report of sclerouveitis in Rosai-Dorfman disease. Rosai-Dorfman is typically self-limiting, occurring rarely in HIV.

Multiple sclerosis-associated uveitis

Uveitis is uncommon in patients with multiple sclerosis (MS), but the link between the two entities is clearly established. While a common etiology or pathologic process remains unknown, shared human leukocyte antigens suggest a genetic predisposition. The treatment for MS‑associated uveitis is not distinct from treatment of other types of noninfectious uveitis, but interferons may serve as a common therapeutic avenue for both CNS and eye disease. Further study is needed to better understand MS-associated uveitis and its link to demyelinating CNS disease.

Iluvien Implantation for Uveitis and Uveitic Macular Edema.

The Iluvien (Alimera Science, Alpharetta, GA) implant was approved by the Food and Drug Administration (FDA) for the management of diabetic retinopathy in 2014 and is the only injectable, extended-release fluocinolone acetonide implant available in the United States. We report off-label use of the Iluvien implant in the management of chronic, non-infectious uveitis with associated macular edema.