Henry A. Leder

Ocular tolerability and efficacy of intravitreal and subconjunctival injections of sirolimus in patients with non-infectious uveitis: primary 6-month results of the SAVE Study

BackgroundThe purpose of this study is to evaluate the ocular tolerability and efficacy of sirolimus administered as subconjunctival or intravitreal injections in patients with non-infectious uveitis. Sirolimus as a Therapeutic Approach for Uveitis (SAVE) is a prospective, randomized, open-label, interventional study. Thirty patients were enrolled and randomized in 1:1 ratio to receive either intravitreal injections of 352 μg sirolimus or subconjunctival injections of 1,320 μg at days 0, 60, and 120, with primary endpoint at month 6.ResultsAt month 6, all subjects with active uveitis at baseline showed reduction in vitreous haze of one or more steps. Forty percent of subjects showed reduction of two steps or more of vitreous haze (four in each group), and 60% showed a reduction of one-step vitreous haze (seven in group 1 and five in group 2). Changes in the inflammatory indices were statistically significant (p < 0.05) in both study groups. Thirty percent of patients gained one or more lines of visual acuity, 20% lost one or more lines, and 50% maintained the same visual acuity. There were no statistically significant differences between the two study groups at month 6. No serious adverse events were found to be related to the study drug.ConclusionLocal administration of sirolimus, either intravitreally or subconjunctivally, appears to be safe and tolerable. No drug-related systemic adverse events or serious adverse events were noted. Sirolimus delivered as either an intravitreal or subconjunctival injection has demonstrated bioactivity as an immunomodulatory and corticosteroid-sparing agent in reducing vitreous haze and cells, improving visual acuity, and in decreasing the need for systemic corticosteroids.

Wide-field Retinal Imaging in the Management of Noninfectious Posterior Uveitis

PURPOSE To determine whether the use of ultra wide-field imaging changes the management or determination of disease activity in patients with noninfectious posterior uveitis. DESIGN Prospective, observational case series. METHODS setting: Divisions of Retina and Ocular Immunology at single academic medical center. patient population: Total of 43 patients with noninfectious posterior uveitis seen by 4 investigators at the Wilmer Eye Institute. procedures: Each patient underwent standard clinical examination, followed by ultra wide-field scanning laser ophthalmoscope (SLO) imaging and angiography. Investigators successively determined disease activity and management decisions based on clinical examination, examination plus simulated 30- or 60-degree fluorescein angiography (FA) (obtained by physically narrowing the field of view of the wide-field images), examination plus ultra wide-field SLO images, and examination plus wide-field FA. main outcome measures: The primary outcome was the percentage of patients whose management changed based on the availability of wide-field imaging, compared with standard examination and imaging. The secondary outcome was detection of disease activity with and without wide-angle imaging. RESULTS Management was altered in 7 of 43 patients (16%) based on examination and limited FA, whereas 21 of 43 patients (48%) had management change with the use of the ultra wide-field imaging and angiography (P < .001). Disease activity was detected in 22 of 43 patients (51%) based on examination and simulated conventional imaging, and in 27 of 43 (63%) with wide-field imaging (P = .27). CONCLUSIONS The index study, with several design limitations, has suggested that ultra wide-field imaging may alter management decisions compared to standard-of-care imaging and clinical examination. Additional studies, including longitudinal evaluations, are needed to determine whether these findings, or the subsequent management alterations, may improve patient outcomes.

Ultra-wide-field retinal imaging in the management of non-infectious retinal vasculitis.

BackgroundThe purpose of this study is to describe and quantify the benefit of ultra-wide-field imaging and fluorescein angiography (FA) in the management of non-infectious retinal vasculitis. In this prospective observational cohort series, patients with non-infectious retinal vasculitis were evaluated and enrolled by four investigators from the Divisions of Retina and Ocular Immunology at the Wilmer Eye Institute. In each patient, disease activity and the need for management changes were assessed, based on clinical examination with or without standard (60°) imaging and then with the addition of ultra-wide-field pseudo-color scanning laser ophthalmoscope (SLO) images and FA using the Optos ultra-wide-field SLO (Optos Panoramic 200MA™, Optos PLC, Dunfermline, Scotland, UK). A standardized questionnaire was completed by each investigator at the time of the clinical evaluation.The primary outcome was the percentage of patients whose management was changed by clinical examination and standard FA, compared with clinical examination plus ultra-wide-field imaging. The secondary outcome was the percentage of patients whose disease was determined to be active based on each modality.ResultsSeventy-one visits from 23 patients were reviewed and analyzed. Based on examination plus ultra-wide-field imaging and ultra-wide-field angiography, disease activity was detected in 48/71 (68%) compared with 32/71 (45%) based on examination and standard FA (P = 0.0095). Based on the clinical examination alone, the decision to alter management was made in 4 of 71 visits (6%), and an additional 3 of 71 (4%) based on simulated standard FA. The addition of ultra-wide-field SLO pseudo-color images altered management in an additional 10/71 visits (14%), and 36/71 (51%) with the addition of ultra-wide-field FA.ConclusionsUltra-wide-field fluorescein imaging and angiography can provide additional information that may be important and relevant in the management of retinal vasculitis.

Periocular Triamcinolone Acetonide Injections for Cystoid Macular Edema Complicating Noninfectious Uveitis

PURPOSE To describe the effectiveness of periocular corticosteroid injections in the treatment of cystoid macular edema (CME) complicating noninfectious uveitis. DESIGN Retrospective cohort study. METHODS A total of 126 patients (156 eyes) were evaluated for presence of CME, visual acuity, intraocular pressure, degree of intraocular inflammation, and the presence of ocular complications. Main outcome measures included resolution of CME and visual acuity at the 1- and 3-month visits, failure of periocular injection therapy, and side effects. RESULTS Twenty-eight percent of the 156 eyes had anterior uveitis, 22% intermediate uveitis, and 31% panuveitis. Of these eyes, 53% demonstrated clinical resolution of CME at 1 month and 57% at 3 months after a single periocular corticosteroid injection. Forty eyes were treated with >1 periocular injection because the CME persisted 1 month after the first injection (1 additional injection in 21 eyes; 2 additional injections in 14 eyes; >2 additional injections in 5 eyes). For the 21 eyes treated with a second periocular corticosteroid injection, 81% had no CME 1 month after the second injection and 48% had no CME 3 months after the second injection. Twenty-three eyes (15%) failed periocular corticosteroid therapy. Of eyes initially responding to periocular injection, CME recurred in 53% (median time to recurrence = 20.2 weeks). A halving of the visual angle was observed in 52% and 57% at the 1- and 3-month visits after injection, respectively. CONCLUSIONS Fifty-three percent of eyes treated with a single periocular corticosteroid injection had clinical resolution of CME 1 month after the injection.

Disappearance of classic birdshot spots after immunosuppression with tacrolimus and mycophenolate mofetil

Birdshot chorioretinopathy is commonly diagnosed by characteristic choroidal spots on funduscopic exan. These spots are particularly prominent on indocyanine angiography and can resolve with treatment. The clinical significance of this is not clear. We present a case of birdshot chorioretinopathy with classic spots which resolved after immunosupression with mycophenolate mofetil, tacrolimus and prednisone. A 35-year-old white woman with a 1-year history of birdshot chorioretinopathy (BSCR) complicated by choroidal neovascular …

Resolution of conjunctival Kaposi sarcoma after institution of highly active antiretroviral therapy alone.

We present a case of conjunctival Kaposi sarcoma that resolved after treatment with highly active antiretroviral therapy alone. A 53-year-old man from Ghana was diagnosed with human immunodeficiency virus in July 2005 and presented on March 2006 with a 2-week history of itching, redness and pain in the right eye. His examination showed a large, mobile, slightly tender lesion of the conjunctiva, not involving caruncle (fig 1). At that time his CD4+ T cell count was 38 cells/μl. He had simultaneous lesions on his feet consistent with Kaposi sarcoma. Biopsy of his foot …

Periocular Triamcinolone Acetonide Injections for Control of Intraocular Inflammation Associated with Uveitis

Purpose: To describe the effectiveness of periocular corticosteroid injections for the control of intraocular inflammation associated with noninfectious uveitis. Methods: A total of 81 patients (109 eyes) who received a periocular injection were evaluated for active inflammation, visual acuity, intraocular pressure, degree of intraocular inflammation, and the presence of ocular complications, including macular edema. Results: Of all eyes, 36% (95%CI: 25%, 45%) demonstrated clinical resolution of inflammation at the 1-month visit after first injection, and 48% (95%CI: 37%, 59%) at 3 months. For multiple injections, 50% (95%CI: 28%, 72%) demonstrated resolution of inflammation at 1 month after the last injection, and 41% (95%CI: 20%, 63%) resolution of inflammation at 3 months after the last injection. Of the 49 eyes that initially responded, the estimated median time to recurrence was 7.6 months. Conclusions: Approximately half of the treated eyes had resolution of intraocular inflammation at 3 months after corticosteroid injection.

Papillary conjunctivitis associated with kikuchi disease

Purpose: To describe a case of papillary conjunctivitis associated with Kikuchi-Fujimoto disease (KFD). Methods: Case report. Results: A 35-year-old black man developed bilateral eye redness before developing high fevers and cervical lymphadenopathy. Mediastinoscopy confirmed the diagnosis of KFD. The eye redness resolved on a regimen of prednisone 60 mg daily and recurred after corticosteroids were discontinued. The patient was found to have bilateral papillary conjunctivitis that resolved with topical prednisolone acetate. Conclusions: Papillary conjunctivitis may be associated with KFD.

Transient band keratopathy associated with ocular inflammation and systemic hypercalcemia

Purpose To report a case of visually significant band keratopathy associated with ocular inflammation and systemic hypercalcemia which markedly decreased in severity after treatment of these underlying factors. Methods Retrospective case report. Results A 53-year-old Asian female with granulomatous panuveitis in the left eye presented with diffuse band keratopathy through the central cornea. The serum calcium was elevated. The patient was treated with topical prednisolone acetate 1% and oral prednisone with marked improvement in inflammation. The band keratopathy lessened in severity with clearing of the central cornea and improvement in visual acuity. Conclusions Early medical treatment of underlying factors may allow reversal of band keratopathy.

Ocular complications of HIV/AIDS in the era of HAART

Mortality associated with AIDS has declined after the introduction of highly active antiretroviral therapy (HAART) with fewer patients progressing to severe infections. This has affected the incidence and management of HIV complications to a great extent. The natural history, incidence, management and sequelae of a wide range of HIV-associated retinopathies, especially cytomegalovirus retinitis, have also drastically changed. The reduction in the incidence of ocular opportunistic infections due to HAART has been accompanied by a rise in the number of new HAART-associated syndromes such as immune recovery uveitis. Immune recovery uveitis is a HAART-dependent inflammatory response that may occur in patients with regressed cytomegalovirus retinitis and elevated CD4 count and has emerged as an important cause of ocular and visual morbidity.