Ian Pearce

Abatacept: a potential therapy in refractory cases of juvenile idiopathic arthritis-associated uveitis

BackgroundJuvenile idiopathic arthritis (JIA) is the most common of all systemic conditions associated with childhood uveitis. Visual impairment has been shown to be as high as 40% of which 10% being blind (6/60 or worse). Due to the lack of well-designed randomized control trials for paediatric uveitis and arthritis there are limited comparative data regarding the efficacy of single or combination treatments. Recently, abatacept was shown to control ocular inflammation in a case of psoriatic arthritis- associated uveitis, seven cases of JIA- associated uveitis and in JIA. We present two cases with JIA-associated uveitis who have responded dramatically to abatacept therapy following unsuccessful therapy with other immunosuppressants. Control of arthritis still represents a challenge with this treatment.MethodsProspective review of two patients with refractory JIA- associated uveitis not responding to maximum conventional treatment. Patients were regularly reviewed in the ophthalmology and rheumatology clinics. Assessment of their ocular condition was characterized according to the Standardization of Uveitis Nomenclature (SUN) group.ResultsIn case 1, ocular inflammation was brought under control after repeated abatacept infusions. Case 2 showed complete resolution of cystoids macular edema CME and improvement of 5 Snellen’s lines in best corrected visual acuity. After 9 months, the ocular condition of both patients remains in remission with steroid sparing. Joint disease was brought to clinical remission in case 2, but not in case 1.ConclusionsAbatacept is a promising alternative treatment in refractory cases of JIA uveitis but may not be as successful in controlling joint disease. Larger series with long term follow up of biological therapies in paediatric uveitis are essential to assess the efficacy and cost effectiveness.

Visual loss following removal of intraocular silicone oil

Aim: To investigate the cause of visual loss following removal of intraocular silicone oil in patients who underwent vitrectomies for retinal detachment or giant retinal tear. Methods: The clinical records of three cases with visual loss following removal of silicone oil were reviewed. Investigations carried out included fundus fluorescein angiogram, optical coherence tomography, and electrophysiological studies. Results: Visual acuities dropped from 6/9 to 6/36 in two cases and 6/24 to 3/24 in the third. None of the three cases had macula detachment at any stage. Fundus fluorescein angiogram and optical coherence tomography were normal in all cases. Pattern electroretinogram showed reduced amplitudes of the P50 and N95 components. Multifocal electroretinogram indicated a selective damage to the central part of the macula. Conclusions: The results suggest that the abnormality arises predominantly in the central part of the macula, especially the outer and middle layers. However, the exact mechanism still remains obscure.

Peel and peel again

Aim: To determine if the internal limiting membrane (ILM) was present in the epiretinal membrane (ERM) when we deliberately tried to perform a “double peel” for macular pucker. Methods: Pars-plana vitrectomy and a “double peel” were carried out. The ERM and ILM were stained with Trypan Blue and peeled separately over the same area. The amount of ERM present in ILM specimens and the amount of ILM present in ERM specimens were evaluated by histological examination. Results: Seventeen eyes in 17 patients were included. It was possible to double peel in all cases. Five of 17 ERM specimens (29%) contained ILM fragments. When ILM was present on the ERM, it represented less than 50% of the sample. One ILM specimen was lost as result of an administrative error; of the remaining 16 specimens, residual ERM was found in six, and cellular remnants were observed on the vitreous surface in a further six of the ILMs. Clinically, no recurrence of ERM was found. Conclusion: ILM was present in some ERM specimens seemingly over the same area that an intact ILM was subsequently peel. We speculate that the ILM in the ERM represent a secondary basement membrane and that the surgical plane of dissection for most ERM peel is between the ERM and the native ILM, making it feasible to double peel routinely.

Heavy tamponade 2 Densiron 68® in routine clinical practice: anatomical and functional outcomes of a consecutive case series

PurposeTo evaluate the safety and efficacy of Densiron 68® in the clinical management of complex vitreoretinal cases with inferior retinal pathology.MethodsWe present a prospective interventional non-comparative case series of 122 eyes of 121 consecutive patients. The primary end point was anatomical re-attachment of the retina, defined as retinal re-attachment in the absence of any tamponade agent. The secondary end point was to record the visual function and surgical complications. Inclusion criteria were proliferative vitreoretinopathy, posterior or inferior retinal breaks, and the patients inability to posture.ResultsPatients were 59.9 years (±19.6), (m/f=72:49), (R/L=65:57). Seventy-seven (63.1%) had previous unsuccessful retinal surgery and 45 had Densiron 68 at first procedure. The extent of the detachments was 2.21 quadrants (±1.07) with macular involvement in 66 cases (54%). Eighty-seven (71.3%) patients achieved retinal re-attachment with one retinal operation and ultimately no tamponade, 102 (83.6%) achieved retinal re-attachment with more than one operation and ultimately no tamponade, and 112 (91.3%) patients achieved flat retina with tamponade in situ. Visual acuity rose from 1.38 LogMar (±0.87) to 1.06 (±0.83) (P=0.007). Densiron was removed after 135 days (±73.2; range 35–405)ConclusionNo tamponade agent can provide simultaneous support for the superior as well as the inferior retina; therefore, a tamponade agent that ‘sinks’ is a welcome new tool at the surgeons disposal. The sequential use of heavy silicone oil followed by conventional silicone oil may be an acceptable management strategy in recurrent detachment.

Visual function and patient satisfaction after macular hole surgery

Purpose Over recent years success in macular hole surgery has increased in terms of anatomical closure. However, debate still continues on the benefit to the patient in terms of visual outcome. We designed a prospective study to investigate the outcome of full thickness macular hole (FTMH) surgery in terms of anatomical closure, visual outcome, incidence of complications and patient satisfaction.Methods Thirty eyes of 30 consecutive patients with FTMH were prospectively studied (stage 2 = 2; stage 3 = 23; stage 4 = 5). All cases had surgery involving vitrectomy, injection of an autologous platelet aggregate over the hole and gas tamponade. At 3 months post-operatively all cases were assessed for closure of the FTMH, Snellen acuity and the incidence of complications. At this stage all patients completed a patient satisfaction questionnaire.Results Anatomical closure of the hole was achieved in 83% of cases (25/30). Visual improvement of 2 Snellen lines or more occurred in 50% of cases (15/30). A vision of 6/12 or better was achieved in 27% of cases (8/30). A post-operative lens opacity was present in 46% (13/28) of phakic patients and a temporal, peripheral wedge-shaped field defect occurred in 17% (5/30) of cases. In this study, 53%, 70%, 57% and 67% of patients gave a positive response to specific questions about satisfaction with near, intermediate and distance vision and overall visual function respectively.Conclusions Although the anatomical success of FTMH surgery is high the functional outcome in terms of Snellen acuity is less rewarding. Analysis of patient satisfaction suggests that the arbitrary visual outcome measures presently used may underestimate the functional benefit to the patient. Improved objective measures of visual outcome are required to assess the benefit of surgery in these cases.

Ranibizumab 0.5 mg for Diabetic Macular Edema with Bimonthly Monitoring after a Phase of Initial Treatment 18-Month, Multicenter, Phase IIIB RELIGHT Study

PURPOSE To evaluate ranibizumab 0.5 mg using bimonthly monitoring and individualized re-treatment after monthly follow-up for 6 months in patients with visual impairment due to diabetic macular edema (DME). DESIGN A phase IIIb, 18-month, prospective, open-label, multicenter, single-arm study in the United Kingdom. PARTICIPANTS Participants (N = 109) with visual impairment due to DME. METHODS Participants received 3 initial monthly ranibizumab 0.5 mg injections (day 0 to month 2), followed by individualized best-corrected visual acuity (BCVA) and optical coherence tomography-guided re-treatment with monthly (months 3-5) and subsequent bimonthly follow-up (months 6-18). Laser was allowed after month 6. MAIN OUTCOME MEASURES Mean change in BCVA from baseline to month 12 (primary end point), mean change in BCVA and central retinal thickness (CRT) from baseline to month 18, gain of ≥10 and ≥15 letters, treatment exposure, and incidence of adverse events over 18 months. RESULTS Of 109 participants, 100 (91.7%) and 99 (90.8%) completed the 12 and 18 months of the study, respectively. The mean age was 63.7 years, the mean duration of DME was 40 months, and 77.1% of the participants had received prior laser treatment (study eye). At baseline, mean BCVA was 62.9 letters, 20% of patients had a baseline BCVA of >73 letters, and mean baseline CRT was 418.1 μm, with 32% of patients having a baseline CRT <300 μm. The mean change in BCVA from baseline to month 6 was +6.6 letters (95% confidence interval [CI], 4.9-8.3), and after institution of bimonthly treatment the mean change in BCVA at month 12 was +4.8 letters (95% CI, 2.9-6.7; P < 0.001) and +6.5 letters (95% CI, 4.2-8.8) at month 18. The proportion of participants gaining ≥10 and ≥15 letters was 24.8% and 13.8% at month 12 and 34.9% and 19.3% at month 18, respectively. Participants received a mean of 6.8 and 8.5 injections over 12 and 18 months, respectively. No new ocular or nonocular safety findings were observed during the study. CONCLUSIONS The BCVA gain achieved in the initial 6-month treatment period was maintained with an additional 12 months of bimonthly ranibizumab PRN treatment.

Incidence of neovascularization in the fellow eye of patients with unilateral retinal angiomatous proliferation.

AimsThe aim of this study is to describe the incidence and characteristics of neovascularization in the fellow eye of patients with retinal angiomatous proliferation (RAP).MethodsThis is a retrospective study conducted on all patients with a diagnosis of unilateral RAP commencing treatment in a single centre between November 2002 and January 2010. Clinical biomicroscopic examination, fluorescein angiography, and if required, indocyanine green angiography, and optical coherence tomography were used to evaluate all patients.ResultsIn all, 37 patients had a follow-up of ⩾1 year, 28 ⩾2 years, and 11 ⩾3. Patients who developed RAP in the fellow eye were: 2 of 37 (5.4%) within 1 year of follow-up, 4 of 28 (14.2%) within 2 years, and 4 of 11 (36.3%) within 3 years.ConclusionIn our case series, the risk of neovascularization in the fellow eye of patients with unilateral RAP increased with time. Approximately one-third of patients with a 3-year follow-up developed a bilateral disease. Our findings warrant further large-scale investigation.

Ranibizumab in retinal vein occlusion: treatment recommendations by an expert panel

Retinal vein occlusion (RVO) is a common cause of retinal vascular disease, resulting in potentially irreversible loss of vision despite the existence of several therapeutic options. The humanised monoclonal antibody fragment ranibizumab binds to and inhibits vascular endothelial growth factor, a key driver of macular oedema in RVO. In 2010, ranibizumab was approved in the USA for the treatment of macular oedema in RVO and, in 2011, ranibizumab was approved in the European Union for the treatment of visual impairment caused by macular oedema secondary to RVO in branch and central RVO. Ranibizumab provides an additional therapeutic option for this complex disease: an option that was not fully considered during the preparation of current international guidelines. An expert panel was convened to critically evaluate the evidence for treatment with ranibizumab in patients with visual impairment caused by macular oedema secondary to RVO and to develop treatment recommendations, with the aim of assisting physicians to optimise patient treatment.

Use of Staurenghi lens angiography in the management of posterior uveitis

Purpose:  Retinal vasculitis is an important component of posterior uveitis. It may be difficult to detect either clinically or with conventional angiography. We assessed the role of Staurenghi lens angiography (SLA) in the diagnosis and management of patients with posterior uveitis.

Does cryotherapy before drainage increase the risk of intraocular haemorrhage and affect outcome? A prospective, randomised, controlled study using a needle drainage technique and sustained ocular compression

AIMS/BACKGROUND A prospective, randomised, controlled clinical trial was conducted to investigate the effect of performing cryotherapy before drainage of subretinal fluid (SRF) on the incidence of intraocular haemorrhage (IOH) in the management of retinal detachment. METHODS Eighty eyes of 80 patients with rhegmatogenous retinal detachment requiring SRF drainage were recruited. Thirty four cases were randomised to receive drainage before cryotherapy (drainage, air injection, cryotherapy, and explant = DACE group) while 46 cases had drainage after cryotherapy (cryotherapy, drainage, air injection, and explant = CDAE group). All cases had trans-scleral drainage of SRF using a 27 gauge hypodermic needle combined with prolonged, intraocular hypertension. RESULTS There was a low incidence of IOH associated with drainage in both groups with no statistically significant difference between the groups (DACE group = 2.9%; CDAE group = 4.3%; p = 0.43). There was no significant difference between the groups in the rate of anatomical success with a single operation (DACE group = 82.4%; CDAE group = 86.9%; p = 0.38). There was no significant difference between the groups in the visual outcome. An improvement of two Snellen lines or more occurred in 52.9% of the DACE group and in 56.5% of the CDAE group (p = 0.93). CONCLUSION It was concluded that the surgical sequence of applying cryotherapy before drainage of SRF can be safely and effectively performed. The sequences CDAE and CDE, when air injection is not required, along with DACE should all be part of the surgical repertoire for the management of retinal detachments.