Narciss Okhravi

Assessment of visual outcome after cataract surgery in patients with uveitis

OBJECTIVE To assess the outcome of cataract surgery in eyes of patients with uveitis. DESIGN Prospective, noncomparative case series. PARTICIPANTS A total of 90 eyes of 76 patients fulfilled the enrollment criteria. INTERVENTION All patients had their surgery performed using standard cataract extraction techniques. Unless contraindicated, preoperative systemic steroids were administered to all patients with posterior disease, chronic anterior uveitis, with known macular edema, and those in whom outcome of cataract surgery on the fellow eye had been poor. RESULTS Patients were divided into those with anterior disease (n = 53) and those with posterior disease (n = 37). Overall, 81 (90%) of 90 eyes showed improvement in vision (median +4 Snellen lines). In those with anterior disease, the development of severe uveitis in the first week postsurgery was associated with a greater incidence of macular edema (P = 0.014). The single largest diagnosis in those with posterior disease was that of panuveitis (n = 24). This group showed the poorest visual outcomes in this study. The majority of patients, however, were noted to have visual loss secondary to conditions present before surgery. CONCLUSION Cataract surgery in eyes with uveitis leads to an improvement of vision in the majority of cases. Severe postoperative uveitis is the most common postoperative complication and is associated with a significant risk of macular edema in those with anterior disease. In the posterior group, poor visual outcome after surgery is most commonly the result of preoperative vision-limiting conditions.

Skills Acquisition and Assessment after a Microsurgical Skills Course for Ophthalmology Residents

OBJECTIVE To assess the impact of a skills course on microsurgical skills acquisition and to investigate the validity of a video-based modified Objective Structured Assessment of Technical Skill (OSATS) assessment tool that has not previously been applied to ophthalmic surgery. DESIGN Prospective longitudinal cohort study. PARTICIPANTS Fourteen residents were recruited from 20 attendees at the Moorfields Eye Hospital microsurgical skills course for residents. METHODS Each resident performed a standardized microsurgical task consisting of the placement of a 10-0 nylon corneal suture into a model eye using an operating microscope with standardized equipment in a standardized environment. Objective measurements were made using the Imperial College Surgical Assessment Device (ICSAD). This is a motion-tracking device returning 3 parameters for economy of movement: total path length, time, and number of individual hand movements. A concurrent video recording was made of each task by 2 independent observers who were masked to the time of the recording relative to the course and the identity of the resident. Video footage was marked in accordance with the OSATS video scoring template. MAIN OUTCOME MEASURES Each resident had motion-tracking analysis performed during corneal suturing before and after the course (total path length, time, and number of individual hand movements), along with concurrent OSATS video scores. RESULTS Skills improvement after the course was found to be statistically significant for all 3 ICSAD economy of movement parameters: path length, P = 0.001; hand movements, P = 0.012; and time, P = 0.009. Differences in the combined OSATS scores of the 2 raters before and after the course were found to be significant (P = 0.039). Interrater reliability of OSATS scorers was 0.78 (alpha Cronbach). Correlations between the OSATS scores and each of the ICSAD parameters were found to be significant (P<0.001). CONCLUSIONS A video-based OSATS scoring system has significant correlation with the ICSAD motion-tracking parameters, demonstrating concurrent validity between the 2 assessment tools. These data also demonstrate that surgical skill, as measured by a validated motion-tracking system, is significantly improved after a 1-day microsurgical skills course. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Cystoid macular edema in uveitis.

Cystoid macular edema (CME) can cause profound visual loss and is one of the major causes of legal blindness in patients with uveitis. It can complicate virtually any type of acute or chronic, anterior or posterior uveitis. When mild and of short duration, CME may respond to treatment used to control the intraocular inflammation. However, patients may need more aggressive treatment with local and systemic steroid therapy and other immunosuppressive drugs. Unfortunately, CME may become refractory to all currently available therapies and result in severe visual loss.

Intraoperative use of intravitreal triamcinolone in uveitic eyes having cataract surgery: Pilot study

PURPOSE: To report the outcomes of cataract extraction with intraoperative intravitreal triamcinolone (IVTA) in eyes with a history of posterior uveitis. SETTING: Moorfields Eye Hospital Uveitis Service, London, United Kingdom. METHODS: Nineteen eyes of 17 patients with posterior uveitis thought to require systemic corticosteroid prophylaxis for cataract surgery were included. The use of systemic corticosteroids at the time of surgery would have been problematic in 7 of the patients, who had a history of systemic hypertension. Three of the 7 patients were also diabetic. All patients were not happy about using oral corticosteroids. RESULTS: Median visual acuity 1 day after surgery was 20/40 (range 20/20 to counting fingers). At final follow‐up (mean 25.2 months; range 7 to 41 months), 17 eyes (89.5%) eyes achieved visual acuity of 20/40 or better; 2 eyes failed to achieve a final visual acuity of 20/40 or better, 1 as a result of optic atrophy and the other as a result of macular edema. No patient lost acuity and no eye developed macular edema within 4 months of surgery. Intraocular pressure elevation occurred after surgery in 3 eyes; all were controlled by topical medication that was discontinued after 3 months. One patient developed severe intraocular inflammation after surgery that resolved with intensive topical corticosteroid therapy within 1 week. CONCLUSIONS: Cataract extraction by phacoemulsification with concurrent IVTA appears a useful treatment option. Targeted delivery of corticosteroid is achieved without the risks of systemic corticosteroid prophylaxis. The incidence of postoperative macular edema was markedly reduced. Levels of visual acuity after cataract surgery, similar to those in eyes without uveitis, were achieved in eyes with posterior uveitis.

Lack of Consensus in the Diagnosis and Treatment for Ocular Tuberculosis among Uveitis Specialists

Abstract Purpose: To assess the approach of specialists to ocular tuberculosis (TB). Methods: The American Uveitis Society (AUS) Listserv was surveyed using two clinical cases and general questions. Results: Of 196 members, 87 responded (44.4%), of whom 64 were affiliated with practices in North America, while 23 were outside of North America. The survey provided normative data on how physicians evaluate patients with uveitis as well as opinions about ocular TB. Responses varied widely on such issues as (1) the pretest probability that a patient with granulomatous panuveitis had TB uveitis (range 1–75%) or that a patient with a risk factor for TB had ocular TB (range 0–90%); (2) the optimal duration of anti-TB therapy; and (3) whether therapy should be discontinued after 2 months in nonresponders. Conclusions: Consensus is lacking among uveitis specialists for the diagnosis or management of ocular TB.

“Low-tech” simulation of corneal foreign body removal

To describe a new, low-tech simulation model for corneal foreign body (CFB) removal and present the results of a comparison between different simulation models for CFB removal.

Inflammatory vascular disease

Henry Eales, a British ophthalmologist, described this condition almost 125 years ago [14, 15]. Eales’ original description was of recurring retinal and vitreous hemorrhages along with epistaxis, headaches, variation in peripheral circulation, dyspepsia, and chronic constipation in young men. He felt it was a vasomotor neurosis, wherein constriction of the alimentary vessels resulted in compensatory dilatation of the vessels in the head, leading to bleeding. Though Eales was honored with the eponym for this disease, Wadsworth was the first to describe the presence of retinal inflammation, 5 years later [37]. Duke Elder considered Eales’ disease to be a clinical manifestation of many diseases.

Comment on 'Clinical features and outcomes of HLA B27 positive and HLA B27 negative acute anterior uveitis in a Turkish patient population'.

Narciss Okhravi Moorfields Eye Hospital, UK Anterior uveitis is the commonest from of intraocular inflammation seen by the ophthalmologist, whether as a primary care provider or a tertiary care center. HLA B27 acute anterior uveitis (AAU) is the most common identifiable form of AAU, accounting for up to 40% of anterior uveitis cases in Western countries. HLA B27 testing is an important part of the systemic workup of patients with recurrent anterior uveitis, not only because HLA B27 patients have a particular course/type of ocular disease, but also because of its associated systemic manifestations. For example, 90% of patients with Ankylosing spondylitis are HLA B27 positive, and of these, up to a third develop AAU.1 Also, HLA B27 positive uveitis is much more likely to be associated with hypopyon (12–15%) and fibrin (25–56%) at presentation, but unlikely to be associated with Mutton fat KPs (0–3%), as compared with HLA B27 negative uveitis.1 Tuncer et al. report than in their study HLA B27 negative patients required more aggressive therapy than those who were HLA B27 positive, whereas other authors have reported a greater use of immunosuppressive agents in HLA B27 positive patients.2,3 A recent review by Chang et al. has extensively investigated these conflicting findings, which are probably explainable by different diagnostic criteria and length of follow-up.1 Uveitis associated with ulcerative colitis, Crohns, Reiters, and possibly also those who have associated psoriatic disease, may have posterior segment signs but AAU associated with HLA B27, rarely requires systemic immunosuppression. Most studies agree that greater number of AAU recurrences are seen in HLA B27 positive patients, and as such it would be reasonable to expect these patients to demonstrate a greater propensity for ocular complications and a worse prognosis. Of course, in the initial phase of a patient’s presentation, when the ophthalmologist is faced with a hypopyon uveitis, these blood results are not available, and management depends on detailed history, clinical examination, severity of clinical signs, bilaterality of disease, and presence of systemic disease. The management of such patients must first include a detailed history to exclude posssibility of infectious endophthalmitis/panuveitis, especially if the patient