Charles Stephen Foster

Management of coincident cataract and uveitis

Cataract surgery in a patient with uveitis is more complex than senile cataract extraction, because it involves multiple considerations related to the cause of uveitis, prospects of visual rehabilitation, appropriate surgical timing and technique, and the type and material of the intraocular lens used. Establishing the diagnosis, thorough eye examination, careful patient selection and meticulous control of perioperative inflammation are key elements to a successful visual outcome. Our aims in this article are to review the literature on this subject over the past year and highlight the behavior of intraocular lenses of various biomaterials in the uveitic eye. In addition, we also reemphasize the idea of a model of zero tolerance to intraocular inflammation to minimize the incidence of irreversible damage to ocular structures essential to good vision.

Intravitreal bevacizumab in refractory uveitic macular edema: one-year follow-up.

Purpose Uveitis is a major cause of ocular morbidity in developed countries. It has been demonstrated that macular edema is a significant cause of decreased visual acuity and macular edema in these patients. In this article, we evaluate the long-term outcome of intravitreal bevacizumab in the treatment of refractory uveitic macular edema. Methods In this retrospective, noncomparative, interventional case series, uveitic patients with macular edema who were refractory to conventional therapy and who were treated with intravitreal bevacizumab were identified and assessed. Best-corrected visual acuity and optical coherence tomography central macular thickness measurements were collected and analyzed with correlative statistical analysis, including the use of Student paired t-test, Kaplan-Meier, and linear regression analysis. Results Twenty-nine eyes of 27 patients with diverse uveitic etiologies were analyzed and followed up at 1 year. Thirteen patients received a single intravitreal bevacizumab injection. Six patients required a second intravitreal bevacizumab injection, while 10 patients received combination therapy of intravitreal bevacizumab and triamcinolone acetonide. Baseline mean logMAR visual acuity was −0.59. At 1 year, the mean logMAR visual acuity was −0.42± 0.36 (p=0.0045). Baseline mean central macular thickness was 383.66 μm. At 1 year, the mean thickness was 294.32±110.87 (p=0.0007). Conclusions Intravitreal bevacizumab is a useful and therapeutically beneficial agent in the treatment of refractory uveitic macular edema. Some patients will require adjunctive intravitreal bevacizumab injections or the use of combination therapy with intravitreal triamcinolone acetonide.

Cataracts and uveitis.

Purpose of review To describe recent evidence from the literature regarding cataract surgery and lens implantation in patients with uveitis. Recent findings Most uveitic patients enjoy good vision despite potentially sight-threatening complications, including cataract development. In those patients who develop cataracts, successful surgery stems from educated patient selection, careful surgical technique, and aggressive preoperative and postoperative control of inflammation. Although commonly accepted in the adult patient population, recent investigations reflect the increased tolerance for primary intraocular lens placement in the pediatric cohort. The role of absolute control of inflammation continues with greater focus on immunomodulatory therapies. However, these agents bear their own side effect and complication profiles, including recent evidence of increased mortality. As a result, localized treatment with not only these agents but also with corticosteroids offers a potential balance. Summary Cataract extraction with intraocular lens implantation in the setting of meticulous control of inflammation can optimize visual outcome in adults and children with uveitis.PURPOSE OF REVIEWnTo describe recent evidence from the literature regarding cataract surgery and lens implantation in patients with uveitis.nnnRECENT FINDINGSnMost uveitic patients enjoy good vision despite potentially sight-threatening complications, including cataract development. In those patients who develop cataracts, successful surgery stems from educated patient selection, careful surgical technique, and aggressive preoperative and postoperative control of inflammation. Although commonly accepted in the adult patient population, recent investigations reflect the increased tolerance for primary intraocular lens placement in the pediatric cohort. The role of absolute control of inflammation continues with greater focus on immunomodulatory therapies. However, these agents bear their own side effect and complication profiles, including recent evidence of increased mortality. As a result, localized treatment with not only these agents but also with corticosteroids offers a potential balance.nnnSUMMARYnCataract extraction with intraocular lens implantation in the setting of meticulous control of inflammation can optimize visual outcome in adults and children with uveitis.

Road to remission: a comprehensive review of therapy in uveitis

Introduction: Although uveitis remains the third leading cause of preventable blindness in the US, the care and management of patients with uveitis and ocular inflammatory disease sit poised to make evolutionary if not revolutionary changes in the years ahead. This review serves to highlight important advances in the pharmacologic options available for the treatment of uveitis and ocular inflammation. Areas covered: Advances in steroid therapy (both topical and extended delivery), updates in the clinical safety of systemic immune modulation, and the emerging therapies for uveitis and ocular inflammatory disease are some of the areas covered in this review. Expert opinion: Corticosteroids have been the mainstay in the care of patients with ocular inflammatory disorders for many years. Indeed, some physicians still use only steroids for treating inflamed eyes. However, the mission is remission of all corticosteroids in order to prevent the complications associated with long-term corticosteroid use. The goal is to achieve quiescence through aggressive use of corticosteroids to extinguish the fire and then move along to achieve steroid-free remission through immunosuppressant agents.

Outcome of tocilizumab treatment in refractory ocular inflammatory diseases

To report the outcomes of tocilizumab treatment for refractory ocular inflammatory diseases.

Vitreous evaluation: a diagnostic challenge.

PURPOSEnTo categorize vitrectomy cytologic diagnoses and ancillary tests to address appropriate processing of low-volume vitreous samples.nnnDESIGNnRetrospective case series.nnnPARTICIPANTSnFive thousand seven hundred thirty-six vitreous samples.nnnMETHODSnCytologic diagnoses of therapeutic and diagnostic vitrectomy samples and their processing protocols from 3 teaching institutions were reviewed.nnnMAIN OUTCOME MEASURESnDiagnostic results were categorized as negative for malignancy, suspicious for malignancy, and positive for malignancy. All ancillary studies performed were documented, including special stains, immunohistochemistry analysis, cytokine levels, and polymerase chain reaction (PCR) analysis.nnnRESULTSnOf the 5736 vitreous samples analyzed, 4683 (81.64%) were from Tufts Medical Center (TMC), 955 (16.65%) were from Boston Medical Center (BMC), and 98 (1.70%) were from Massachusetts Eye Research and Surgery Institution (MERSI). Cases from TMC and BMC were therapeutic and diagnostic vitrectomies, and MERSI cases were diagnostic vitrectomies. Most vitrectomies showed negative results for malignancy: 99.47% of TMC cases, 99.89% of BMC cases, and 79.6% of MERSI cases. These included vitreous hemorrhage and inflammatory or infectious findings. Ancillary studies performed in this category included Periodic Acid-Schiff staining for fungi, PCR analysis for toxoplasmosis, cytomegalovirus, Epstein-Barr virus (EBV), herpes simplex virus I and II, and vitreous cultures for infections (coagulase-negative Staphylococcus, Candida, Fusarium, and Propionibacterium species). Interleukin (IL) 10-to-IL-6 ratios were performed on 38.7% of cases from MERSI. Fourteen cases from TMC were suspicious for malignancy based on cytologic evaluation. Eleven cases from TMC, 1 case from BMC, and 20 cases from MERSI showed positive results for malignancy and included B-cell lymphoma, retinoblastoma, melanoma, and metastatic adenocarcinoma. The ancillary testing included PCR for heavy chain immunoglobulin gene rearrangements, immunohistochemistry for EBV, in situ hybridization for κ and λ light chains, and cytogenetics.nnnCONCLUSIONSnThis is the largest data pool of reported cytologic diagnoses of diagnostic and therapeutic vitrectomy samples. Cytologic evaluation of therapeutic vitrectomy samples provides a valuable baseline of nonpathologic findings that assist in differentiation between malignancy, infections, and inflammatory conditions. Allocation of small-volume vitreous samples to select ancillary testing from the plethora of available diagnostic tests requires preoperative communication between surgeons and pathologists to ensure appropriate and timely treatment methods.

Ocular involvement in systemic lupus erythematosus.

Purpose of review Many patients suffer from the ocular manifestations associated with systemic lupus erythematosus (SLE). Retinal vasculitis and optic neuritis are two of the most vision-threatening complications that can be associated with the disease. Ocular manifestations are often associated with wide-spread systemic inflammation which can be fatal. Thus, immediate recognition and treatment is vital for a positive outcome. Recent findings There is an array of medications available to ophthalmologists for treating the ocular manifestations of SLE. Treating the underlying systemic disease is crucial, as well as treating the active ocular complications. Recently, more attention has been placed on evaluating biologic agents’ efficacy in treating the systemic condition. New therapies continue to emerge that have the potential to provide benefit to patients suffering from SLE. Summary SLE is a serious systemic condition that may first present with ocular manifestations. Thus, it is crucial for ophthalmologists to be equipped with the knowledge to detect and adequately treat the disorder to avoid vision/life-threatening complications. More research is needed to determine which therapy provides the best outcome for patients with limited side-effects.

Comparison of Two Different Combination Immunosuppressive Therapies in the Treatment of Vogt-Koyonagi-Harada Syndrome

Purpose: To compare the efficacy and safety of cyclosporine/mycophenolate mofetil (CSA/MMF) and cyclosporine/azathioprine (CSA/AZT) in Vogt-Koyonagi-Harada (VKH) patients. Methods: Retrospective comparative case series with follow-up period of at least 1 year. Outcomes include remission rate and corticosteroid-sparing effect. Results: A total of 10 patients were included (5 patients in CSA/MMF, 5 patients in CSA/AZT). The remission rates for CSA/MMF and CSA/AZT were 5.3 and 5.6, respectively (p = .96). The median time to remission was 15 months for CSA/MMF group and 7 months for CSA/AZT group (p = .6419). The rates of corticosteroid-sparing effect were 7.9 and 5.0 for the CSA/MMF and CSA/AZT groups, respectively (p = .65). The median time to corticosteroid-sparing effect was faster in the CSA/AZT group (2 months) compared to the CSA/MMF group (13 months) (p = .9625). Approximately 50% of patients failed with the presented IMT combination regimens. Conclusions: No statistically significant difference was found in the two regimens from the study as presented, although the median time to remission and to corticosteroid-sparing effect was shorter for the CSA/AZT combination.

Immunohistochemical differences between normal and chronically inflamed conjunctiva: diagnostic features.

Purpose:There is widespread misinterpretation of normal conjunctival fibrinogen. In differentiating between normal conjunctiva and cicatrizing conjunctivitis, including ocular cicatricial pemphigoid, atopic keratoconjunctivitis, and lichen planus, it is important to properly evaluate and characterize the histologic appearance of the structures seen and not base a diagnosis on just the presence or absence of certain features. One feature of conjunctival histology prone to misinterpretation and misdiagnosis is the presence of subepithelial fibrinogen, particularly when the diagnosis of lichen planus is being considered. Although the presence of subepithelial fibrinogen in oral mucous membranes and in skin can be indicative of lichen planus, such is not the case for conjunctiva. An erroneous diagnosis of lichen planus based on the presence of conjunctival subepithelial fibrinogen can initiate prolonged treatment with topical steroids leading to avoidable, blinding, complication, and further, delay therapy for the real cause of the conjunctivitis. We conducted a cross sectional, controlled, blinded and prospective Institutional Review Board–approved study on the occurrence and pattern of fibrinogen at the epithelial basement membrane zone (BMZ) of normal and inflamed conjunctiva. Methods:Bulbar conjunctiva was obtained from 10 cases of undiagnosed chronic conjunctivitis of at least 6 months duration and 8 patients with normal conjunctiva. Immunofluorescent staining with antifibrinogen antibodies, periodic acid-schiff stain (PAS), and Giemsa staining were performed. Results:BMZ fibrinogen was found in all cases. This layer was linear, smooth, and continuous in normal conjunctiva and 7 cases of chronic conjunctivitis. It was fragmented and lumpy in 1 case of ocular cicatricial pemphigoid (OCP) and showed spikes and spurs in 2 cases of lichen planus. Conclusions:BMZ fibrinogen is a normal component of the conjunctiva and its morphological features rather than its mere presence should be assessed as a diagnostic tool.

Update on ocular cicatricial pemphigoid and emerging treatments

Mucous membrane pemphigoid is a systemic disorder that primarily affects mucous membranes. When localized to the conjunctiva, it is known as ocular cicatricial pemphigoid, a potentially blinding disease. Ocular cicatricial pemphigoid is an indication for systemic immunosuppressive treatment to achieve adequate remission. Immunosuppressive agents are selected with a stepladder approach, commencing with medications having the fewest side effects. We provide an update of the literature on immunomodulatory agents since 2011 as additional treatment modalities have been explored in the last 4 years.