Khalid F. Tabbara

Infliximab Effects Compared to Conventional Therapy in the Management of Retinal Vasculitis in Behçet Disease

PURPOSE To assess the outcome of retinal vasculitis in patients with Behçet disease treated with infliximab compared to treatment with conventional therapy. DESIGN Nonrandomized, retrospective comparative clinical study. METHODS Patients with Behçet disease with all four major criteria were included in this study. Patients had recurrent episodes of uveitis and retinal vasculitis. Thirty-three patients (Group 1) were treated with oral prednisone, cyclosporine, and azathioprine or methotrexate for a minimum period of three months. Ten patients (Group 2) who failed to respond to conventional therapy were given infliximab at a dose of 5 mg/kg in a single intravenous infusion on day 1 and every two weeks for a total of six doses. Patients were given the same treatment during each subsequent relapse. The main outcome measures were the number of relapses, visual outcome, and ocular complications. RESULTS The mean follow-up period was 36 months in Group 1 and 30 months in Group 2. The mean number of relapses was significantly reduced and the duration of remission was longer in the infliximab therapy group compared to conventional therapy group (P < .0001). The visual acuity at 24 months follow-up was significantly better in patients treated with infliximab (Group 2) when compared to conventional therapy (Group 1) (P = .0059). CONCLUSIONS Patients with Behçet disease had significant decrease in inflammation, improvement of visual acuity, and reduced ocular complications following infliximab when compared to conventional therapy. The number of relapses was less in the infliximab treatment group than the conventional therapy group.

Ocular Findings after Allogeneic Hematopoietic Stem Cell Transplantation

OBJECTIVE To study the incidence, causes, and outcome of major ocular complications in patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT). DESIGN Retrospective, noncomparative, observational clinical study. PARTICIPANTS The study included a total of 620 patients who underwent allogeneic HSCT in the period from 1997 to 2007 at King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. INTERVENTION Allogeneic HSCT. MAIN OUTCOME MEASURES Patients with ocular complications were referred to the ophthalmology division for complete ophthalmologic examination, including visual acuity, tonometry, Schirmer test, biomicroscopy, and dilated ophthalmoscopy. Laboratory investigations were performed whenever indicated. The incidence and causes of major ocular complications after allogeneic HSCT were determined. Visual acuity at 1 year after allogeneic HSCT was recorded. RESULTS Major ocular complications occurred in 80 (13%) of 620 patients who underwent allogeneic HSCT. There were 36 male patients (45%) and 44 female patients (55%) with a mean age of 29 years and an age range of 9 to 65 years. Prophylaxis for graft-versus-host disease (GVHD) consisted of cyclosporine and methotrexate in 69 patients, and cyclosporine, methotrexate and corticosteroids, or mycophenolate mofetil in 11 patients. The most frequently encountered ocular complications were chronic GVHD, dry eye syndrome without GVHD, corneal ulcers, cataract, glaucoma, cytomegalovirus retinitis, fungal endophthalmitis, and acquisition of allergic conjunctivitis from atopic donors. There was no correlation between the pattern of ocular complications and the transplanted stem cell source. Best-corrected visual acuity (BCVA) at 1 year after transplantation was less than 20/200 in 13 patients (16%), less than 20/50 in 17 patients (21%), and better than 20/50 in 50 patients (63%). CONCLUSIONS Ocular complications are common in patients undergoing allogeneic HSCT. Early recognition and prompt treatment are important. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Clinics of Ocular Tuberculosis

Abstract Purpose: Ocular tuberculosis is an extrapulmonary tuberculous condition and has variable manifestations. The purpose of this review is to describe the clinical manifestations of ocular tuberculosis affecting the anterior and posterior segments of the eye in both immunocompetent and immunocompromised patients. Methods: Review of literature using Pubmed database. Results: Mycobacterium tuberculosis may lead to formation of conjunctival granuloma, nodular scleritis, and interstitial keratitis. Lacrimal gland and orbital caseating granulomas are rare but may occur. The intraocular structures are also a target of insult by M. tuberculosis and may cause anterior granulomatous uveitis, anterior and posterior synechiae, secondary glaucoma, and cataract. The bacillus may involve the ciliary body, resulting in the formation of a localized caseating granuloma. Posterior segment manifestations include vitritis, retinal vasculitis, optic neuritis, serpiginous-like choroiditis, choroidal tubercules, subretinal neovascularization, and, rarely, endophthalmitis. Conclusions: The recognition of clinical signs of ocular tuberculosis is of utmost importance as it can provide clinical pathway toward tailored investigations and decision making for initiating anti-tuberculosis therapy.

Causes of Uveitis at a Referral Center in Saudi Arabia

Purpose: The main purpose of this study was to determine the causes of uveitis at the Eye Center in Saudi Arabia. Methods: A retrospective review. The causes of uveitis were analyzed according to various patient characteristics. Results: A total of 488 cases were encountered. The age range was 3 to 99 years (mean age: 38 years). The most common causes of uveitis included anterior uveitis 60%, panuveitis 24%, posterior uveitis 11%, and intermediate uveitis 6%. Conclusions: The authors found a high prevalence of acute anterior nongranulomatous uveitis. The most commonly encountered infectious uveitis included herpes virus, tuberculosis, and toxoplasmosis.

Uveitis survey in children

Background/aims: This is a retrospective cohort uveitis survey to determine the clinical features of uveitis in children and assess the rate of complications at two referral centres in Saudi Arabia. Methods: All children under the age of 16 years presenting with uveitis for the first time between 1997 and 2007 to The Eye Center and King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia were included. Clinical features of uveitis entities were described. Last follow-up visual acuity and ocular complications were analysed. Results: A total of 163 cases of uveitis in children were included. The age range was 1–16 years with a mean age of 10 years. The most frequent clinical type of uveitis in children included acute anterior non-granulomatous uveitis 26%, intermediate uveitis 20%, Vogt–Koyanagi–Harada (VKH) disease 16% and juvenile idiopathic arthritis (JIA) 15%. Anterior uveitis accounted for 42%, intermediate for 20%, posterior for 7%, and panuveitis for 31%. Immune-mediated uveitis was present in 144 (88%) patients, while infectious causes manifested in 19 (12%) patients. Conclusions: The most common cause of uveitis in children was anterior non-granulomatous uveitis of undetermined aetiology. There was a high prevalence of intermediate uveitis, VKH and JIA. Infectious causes of uveitis were uncommon.

Topical ganciclovir in the treatment of acute herpetic keratitis

Herpetic keratitis is caused by herpes simplex virus (HSV) and is a common cause of corneal blindness. Following a primary ocular herpetic infection, latency of the virus occurs, followed by subsequent recurrences of herpetic keratitis. Such recurrences may lead to structural damage of the cornea. Recurrent herpetic keratitis is a common indication for corneal transplantation. Recurrences of herpetic keratitis in the corneal graft may lead to corneal graft rejection. Several antiviral agents for HSV are available, including the thymidine analogs. Prolonged use of thymidine analogs may lead to toxicity of the ocular surface, including epithelial keratitis, corneal ulcers, follicular conjunctivitis, and punctal occlusions. Availability of topical antiviral agents that are safe and effective in the treatment and prophylaxis of herpetic keratitis is highly desirable. Ganciclovir is a potent inhibitor of members of the herpes virus family. The drug has been used systemically for the treatment of cytomegalovirus (CMV) retinitis. Its hematologic toxicity secondary to systemic administration led to its limited use in herpetic infections. On the other hand, topical ganciclovir has been shown to be as safe and effective as acyclovir in the treatment of herpetic epithelial keratitis. Furthermore, topical ganciclovir can reach therapeutic levels in the cornea and aqueous humor following topical application. Several clinical trials have shown that topical ganciclovir 0.15% ophthalmic gel is safe and effective in the treatment and prophylaxis of herpetic epithelial disease. Long-term use of ganciclovir ophthalmic gel in patients with penetrating keratoplasty following herpetic keratitis has prevented recurrences of the disease. Topical ganciclovir ophthalmic gel is well tolerated, does not cause toxic effects on the ocular surface, and does not cause hematologic abnormalities. Clinical studies have underscored the potential role of ganciclovir ophthalmic gel in the treatment and prophylaxis of herpetic epithelial keratitis. Future randomized, controlled, multicenter, prospective clinical trials are needed to assess the long-term safety and efficacy of topical ganciclovir in the treatment and prevention of herpetic keratitis and uveitis.

Complications of presumed ocular tuberculosis

Acta Ophthalmol. 2010: 88: 905–909

Ocular manifestations of graft-versus-host disease

Allogeneic hematopoietic stem cell transplantation (HSCT) has evolved over the past two decades to become the standard of care for hematologic and lymphoid malignancies. Major ocular complications after allogeneic HSCT have been increasing in number and severity. Graft-versus-host disease (GVHD) remains a major cause of ocular morbidity after allogeneic HSCT. The main objective of this review is to elucidate the ocular complications in patients developing GVHD following HSCT. Ocular complications secondary to GVHD are common and include dry eye syndrome, acquisition of ocular allergy from donors with allergic disorders. Eyelid changes may occur in GVHD leading to scleroderma-like changes. Patients may develop poliosis, madarosis, vitiligo, lagophthalmos, and entropion. The cornea may show filamentary keratitis, superficial punctate keratitis, corneal ulcers, and peripheral corneal melting which may lead to perforation in severe cases. Scleritis may also occur which can be anterior or posterior. Keratoconjunctivis sicca appears to be the most common presentation of GVHD. The lacrimal glands may be involved with mononuclear cell infiltration of both the major and accessory lacrimal glands and decrease in tear production. Severe dry eye syndrome in patients with GVHD may develop conjunctival scarring, keratinization, and cicatrization of the conjunctiva. Therapy of GVHD includes systemic immunosuppression and local therapy. Surgical treatment in refractory cases includes surgical intervention to improve the manifestation of GVHD of the eye. This may include tarsorrhapy, prose lenses, punctal occlusions and corneal transplantation.

Childhood Blindness at a School for the Blind in Riyadh, Saudi Arabia

Purpose: To determine the major causes of eye diseases leading to visual loss and blindness among children attending a school for the blind in Riyadh, Saudi Arabia. Methods: A total of 217 school children with visual disabilities attending a school for the blind in Riyadh were included. All children were brought to The Eye Center, Riyadh, and had complete ophthalmologic examinations including visual acuity testing, biomicroscopy, ophthalmoscopy, tonometry and laboratory investigations. In addition, some patients were subjected to electroretinography (ERG), electrooculography (EOG), measurement of visual evoked potentials (VEP), and laboratory work-up for congenital disorders. Results: There were 117 male students with an age range of 6–19 years and a mean age of 16 years. In addition, there were 100 females with an age range of 6–18 years and a mean age of 12 years. Of the 217 children, 194 (89%) were blind from genetically determined diseases or congenital disorders and 23 (11%) were blind from acquired diseases. The major causes of bilateral blindness in children were retinal degeneration, congenital glaucoma, and optic atrophy. The most common acquired causes of childhood blindness were infections and trauma. Conclusion: The etiological pattern of childhood blindness in Saudi Arabia has changed from microbial keratitis to genetically determined diseases of the retina and optic nerve. Currently, the most common causes of childhood blindness are genetically determined causes. Consanguineous marriages may account for the autosomal recessive disorders. Public education programs should include information for the prevention of trauma and genetic counseling. Eye examinations for preschool and school children are mandatory for the prevention and cure of blinding disorders.

Proteomic analysis of climatic keratopathy droplets

PURPOSE To identify the proteins in the corneal droplets of climatic droplet keratopathy (CDK), a disease that results in the formation of droplets on the cornea. Progressive accumulation of droplets in CDK leads to visual loss. METHODS Proteomic mass spectrometry of the CDK specimens was performed after fractionation of proteins in 4% to 20% SDS-polyacrylamide gels. Droplets were derived from two human donors. Immunohistochemistry with antibodies was performed to confirm the presence of identified proteins on donor tissues from patients with CDK and control subjects. RESULTS Proteomic analyses revealed identification of 105 proteins in CDK specimens. Immunohistochemical analyses confirmed localization of annexin A2 and glyceraldehyde 3-dehydrogenase (GAPDH), proteins identified by proteomic analyses in CDK specimens. The proteins were subjected to analyses with the Kyoto Encyclopedia of Genes and Genomes (KEGG) Database which showed that a few biochemical pathways were more frequent for the identified proteins. CONCLUSIONS Approximately 105 proteins were identified in CDK specimens, and a subset of them was confirmed by immunohistochemistry. Several of these may play a role in fibril or deposit formation.