Laura Pelegrín

Multicenter study of intravitreal dexamethasone implant in noninfectious uveitis: indications, outcomes, and reinjection frequency.

PURPOSE To identify clinical outcomes and treatment patterns of intravitreal dexamethasone implant (Ozurdex; Allergan, Inc) in noninfectious uveitis in the clinical setting. DESIGN Multicenter retrospective cohort study. METHODS Eighty-two eyes (63 patients) receiving 142 implant injections over 35 months were included. Treatment indication, uveitis diagnosis, visual acuity, intraocular pressure, vitreous haze score, central retinal thickness by optical coherence tomography, phakic status, number of injections, time to reinjection, systemic treatments, and complications data were collected. Time to visual acuity and vitreous haze score improvement as per the Standardization of Uveitis Nomenclature guidelines were also determined. RESULTS The probability of visual acuity improvement (≥0.3 logarithm of the minimal angle of resolution units improvement) was 39% at 1 month, 49% at 3 months, 52% at 6 months, and 58% at 12 months. Eyes with baseline vitritis (vitreous haze score ≥+0.5, n = 45) had a probability of vitreous haze score improvement (2-step decrease or change from +0.5 to 0) at 2 weeks of 41%, at 1 month 63%, at 3 months 73%, at 6 months 79%, and at 12 months 88%. In eyes that completed 12-month follow-up (n = 54), 40.7% underwent 2 injections (mean time to second injection of 6.6 ± 1.9 months) and 11.2% required ≥3 injections (mean time to third injection of 11 ± 1.5 months). CONCLUSIONS Dexamethasone implant use in uveitis provides favorable visual acuity and vitreous haze score outcomes but requires repeated injections, an important consideration when choosing intraocular treatment as a route to controlling uveitis.

Dexamethasone intravitreal implant for treatment of uveitic persistent cystoid macular edema in vitrectomized patients.

Purpose: To evaluate the safety and efficacy of Ozurdex (dexamethasone intravitreal implant) 0.7 mg in the treatment of uveitic macular edema in vitrectomized eyes. Methods: Data from 13 patients (17 eyes) with persistent uveitic cystoid macular edema and a history of pars plana vitrectomy in the study eyes that were treated with intravitreal injection of 0.7-mg dexamethasone implant were reviewed retrospectively. Main outcome measures were changes in central retinal thickness measured by optical coherence tomography and changes in best-corrected visual acuity. Results: The median age of patients was 61 years (range, 19–81 years). The median duration of uveitic macular edema was 12 months (range, 2–72 months). The mean baseline central retinal thickness (95% confidence interval) was 461.6 &mgr;m (403.8–519.4), decreased to 277.2 &mgr;m (244.6–309.8) at 4 weeks (P < 0.01), remained low at 349.9 &mgr;m (281.8–418.0) at 3 months (P = 0.01), and then reached 394.1 &mgr;m (328.3–459.8) at 6 months (P = 0.14). After 3 months, there was a median improvement of 2 lines of best-corrected visual acuity, with 52.9% of eyes gaining 2 lines or more (P < 0.01). At 6 months, there were 5 eyes that maintained the 2 lines gain and none had lost >1 line from baseline (P = 0.03). In 8 eyes (47.1%), reinjection of the implant was performed at a mean of 6.5 months. Ocular hypertension (47.1%), hypotony (11.8%), anterior chamber displacement of the implant (5.9%), and glaucoma, which required filtration surgery (5.9%), were the most common adverse events. Mean follow-up was 9.6 months (range, 6–17 months). Conclusion: In this small case series of eyes with limited follow-up, treatment with dexamethasone intravitreal implant injection for uveitic macular edema in vitrectomized eyes was associated with favorable visual outcomes and had an acceptable safety profile.

Behçet Disease-associated Uveitis Successfully Treated with Golimumab

Abstract Over the past decade, the off-label use of biologic agents such as TNF-α antagonists, including infliximab and adalimumab, has improved the treatment armamentarium for refractory immune-mediated uveitis, with particular success in Behçet disease-associated uveitis. Golimumab is a novel fully human anti-TNF-α monoclonal antibody that has been approved for the treatment of rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, with very promising results. Herein, the authors present the use of GLM in a case of Behçet uveitis refractory to other TNF-α blockers. There are only two reports in the literature about the use of GLM in uveitis, describing four patients with JIA-associated uveitis and a case of idiopathic retinal vasculitis. To the authors’ knowledge, this is the first report about the use of GLM in Behçet uveitis.

Ocular syphilis--back again: understanding recent increases in the incidence of ocular syphilitic disease.

Purpose: The clinical findings and outcomes of 12 cases of luetic uveitis are reported. Methods: Review of clinical records. Results: Patients included 10 men and 2 women; 7 were homosexual, 9 HIV-positive. Six patients presented a medical history suggestive of syphilis. All patients presented with iritis and vitritis. Visual acuity improved in 11 patients after treatment. Conclusions: Syphilis has reemerged in developed countries. This may be related to the post-AID S/HAART era, with a growing pool of HIV-positive men who oftenly practice unsafe sex. We underscore the importance of a high index of suspicion of ocular syphilis in patients with these characteristics.

Indirect supportive evidence for diagnosis of tuberculosis-related uveitis: from the tuberculin skin test to the new interferon gamma release assays.

Purpose:  To evaluate clinical and paraclinical parameters for the indirect diagnosis of tuberculosis‐related uveitis (TRU).

Tocilizumab treatment for recalcitrant uveitic macular edema.

Dear Editor, Cystoid macular edema (CME) is the most frequent structural complication of uveitis, and is responsible for a significant amount of visual morbidity. Treatments for uveitic CME include corticosteroids, administered systemically, periocularly, or intravitreal, systemic immunosuppressive medications, anti-tumor necrosis factor alpha (TNF-α) drugs, and vitreous surgery. Despite these treatment options, a number of patients remain that do not respond to any of these treatment modalities. Tocilizumab (TCZ), a fully humanized antibody that binds both to soluble and membrane-bound IL-6 receptors, is currently approved for the treatment of rheumatoid arthritis refractory to one or more anti-TNF-α drugs [1]. Herein, we report one case of idiopathic panuveitis with severe CME refractory to systemic and local treatments who favourably responded to TCZ. A 56-year-old-woman diagnosed with idiopathic panuveitis had been treated with prednisone (7.5 mg daily) in combination with cyclosporine A (CsA) (150 mg bid) and methotrexate (MTX) (15 mg weekly) for 12 years. In 2001, a total three-port pars plana vitrectomy with lensectomy was performed in both eyes. In 2009, her inflammatory condition relapsed with severe bilateral CME, and intravenous infusion with 5 mg/kg of infliximab was given. She developed an hypersensitivity reaction and therapy was switched from infliximab to 40 mg every 2 weeks of adalimumab, trying to get her uveitis and macular edema under control. Nevertheless, CME remained in both eyes. In 2011, an intravitreal injection of dexamethasone implant was performed in her left eye, but the implant migrated into the anterior chamber and Descemet’s folds with corneal edema developed. In April 2012, anterior segment examination disclosed 2+ cells in anterior chamber, and on fundus biomicroscopy 1+ vitreous cells and CME were observed in her right eye. Central retinal thickness (CRT) measured by optic coherence tomography (OCT) was 896 μm in her right eye (Fig. 1). OCT was not performed in the left eye due to corneal edema. Her visual acuity was counting fingers at 1 m in the right eye and light perception in the left eye. We then initiated intravenous TCZ 8 mg/Kg monthly with oral prednisone at a daily dose of 7.5 mg. Adalimumab was stopped 4 weeks prior starting TCZ. After six infusions of TCZ the patient remained asymptomatic, and ophthalmic examination revealed no sign of active inflammation; the CRT decreased from 896 to 182 μm on the OCT (Fig. 2a, b). Visual acuity improved to 20/400 in the right eye. No remarkable side-effects after 6 months of follow-up have been reported. IL-6 is a pleiotropic, proinflammatory cytokine mainly produced by T cells and monocytes/macrophages, inducing proliferation and differentiation of T cells as well as the terminal differentiation of B cells. Antiinterleukin 6 receptor (anti-IL-6R) antibodies have been effective in experimental models of autoimmune arthritis, encephalomyelitis, and also uveitis [2]. IL-6 is present in the vitreous of patients with active intermediate A. Adán (*) :V. Llorenç :M. Mesquida : L. Pelegrín Department of Ophthalmology, Hospital Clinic of Barcelona, Calle Sabino de Arana, 1, 08036 Barcelona, Spain e-mail: amadan@clinic.ub.es

Explantation of intraocular lenses in children with juvenile idiopathic arthritis–associated uveitis

We report the outcome in 2 eyes of 2 patients with juvenile idiopathic arthritis-associated uveitis who had intraocular lens (IOL) explantation. The primary reason for explantation was persistent and uncontrolled inflammation with secondary cystoid macular edema.

Predictive Value of Selected Biomarkers, Polymorphisms, and Clinical Features for Oligoarticular Juvenile Idiopathic Arthritis-associated Uveitis

Abstract Purpose: Uveitis is the most common extra-articular manifestation of juvenile idiopathic arthritis (JIA) and is associated with considerable morbidity. The aim of this study was to examine the risk factors associated with uveitis in oligoarticular JIA. Methods: We conducted a chart review of 86 patients with oligoarticular JIA to assess if antinuclear antibody (ANA) status, gender, and age at JIA onset were associated with the development of uveitis. Biomarkers such as cytokine gene polymorphisms, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level were also assessed. Results: Twenty-seven patients exhibited oligoarticular JIA-associated uveitis. Only the ESR at arthritis onset and the patients age at arthritis onset were related to uveitis development in our patient sample. Conclusions: An age-associated risk of uveitis was observed in children younger than 3 years at the time of JIA onset. ESR values at arthritis onset higher than 22 mm/h were also related to uveitis development.

Long-term evaluation of dexamethasone intravitreal implant in vitrectomized and non-vitrectomized eyes with macular edema secondary to non-infectious uveitis

PurposeTo compare dexamethasone (DEX) intravitreal implant effect in non-vitrectomized (non-PPV) vs vitrectomized (PPV) eyes with macular edema (ME) secondary to non-infectious uveitis.MethodsMedical records of patients with uveitic ME treated with DEX-intravitreal implant were reviewed. Main outcome measures were changes in central retinal thickness (CRT), best corrected visual acuity (BCVA), intraocular pressure (IOP), vitreous haze and adverse events. Statistical analysis was performed by Longitudinal Linear model using the General Estimating Equation methodology.ResultsForty-two eyes of 32 patients were included. Median follow-up time was 18 months (interquartile range (IQR): 12–24). Median CRT showed its maximum decrease at the first month in non-PPV and PPV eyes without statistically significant differences between both groups (P=NS). Median Snellen BCVA, converted to logarithm (LogMAR), showed its maximum improvement at third month in both groups without statistically significant differences between them (P=NS). Median IOP was higher in non-PPV eyes than in PPV eyes from third (P=0.025) to 12th month (P=0.013). Vitreous haze score improved in both groups since first month and showed no differences (P=0.706). Reinjection was performed in 45.2% of eyes at a median time of 5 months IQR: (5–6). Ocular hypertension (47.6%) was the most common adverse event.ConclusionsDEX-intravitreal implant for uveitic ME has similar long-term safety profile and good response measured in terms of CRT decrease, BCVA, and vitreous haze improvement in both groups. Non-PPV eyes following DEX-intravitreal implant showed higher IOP increase than PPV eyes, showing the need for close IOP monitoring.

Conjunctival resection with and without amniotic membrane graft for the treatment of superior limbic keratoconjunctivitis.

Purpose: To compare the efficacy of conjunctival resection versus conjunctival resection with amniotic membrane graft (AMG) in patients with superior limbic keratoconjunctivitis not responsive to medical therapies. Methods: In a retrospective and comparative study, 16 eyes of 9 patients with long-lasting superior limbic keratoconjunctivitis who were refractory to medical treatment were included. Conjunctival resection was performed in 8 cases, and conjunctival resection with AMG was performed in 8 cases. Subjective symptoms, biomicroscopic signs, and impression cytology were evaluated both pre- and postoperatively. Results: The mean follow-up period was 46 months, ranging from 1.5 to 6 years. After surgery, all cases undergoing conjunctival resection and 7 of 8 cases undergoing conjunctival resection with AMG remained asymptomatic. One case undergoing conjunctival resection with AMG experienced recurrence, requiring reoperation 2 years later (conjunctival resection without AMG). In this patient, complete disappearance of symptoms and signs was achieved during a 4-year period of follow-up after the second surgery. No intra- or postoperative complications were observed in either group. Preoperative impression cytology disclosed severe squamous metaplasia, and goblet cells were markedly decreased in all patients. Postoperative impression cytology 3 months after surgery did not show any significant improvement in squamous metaplasia in either of the groups. Conclusions: Conjunctival resection and conjunctival resection with AMG are effective and safe surgical procedures. Despite the potential benefits of the AMG, this procedure did not provide additional advantages in our study.