Nicholas P. Jones

The Manchester Uveitis Clinic: The First 3000 Patients—Epidemiology and Casemix

Abstract Purpose: To demonstrate the demography, anatomical, and diagnostic classification of patients with uveitis attending the Manchester Uveitis Clinic (MUC), a specialist uveitis clinic in the northwest of England, UK. Methods: Retrospective retrieval of data on a computerized database incorporating all new referrals to MUC from 1991 to 2013. Results: A total of 3000 new patients with uveitis were seen during a 22-year period. The anatomical types seen were anterior 46%; intermediate 11.1%; posterior 21.8%; and panuveitis 21.1%. The most common diagnoses were Fuchs heterochromic uveitis (11.5% of total), sarcoidosis-related uveitis (9.7%), idiopathic intermediate uveitis (7.9%), idiopathic acute anterior uveitis (7.0%), and toxoplasmosis (6.9%). Syphilis and tuberculosis-associated uveitis increased markedly in frequency during the study period. Conclusions: The uveitis casemix in this region reflects a predominantly white Caucasian population in a temperate country, but with changing characteristics owing to increasing immigration, enhanced diagnostic techniques, changes in referral pattern, and some real changes in disease incidence.

Phacoemulsification with intraocular lens implantation in patients with uveitis.

Purpose To investigate the safety and efficacy of phacoemulsification with intraocular lens implantation in eyes affected by uveitis.Methods A retrospective case series is presented including casenote review and update patient examinations. Patient data were withdrawn from the Uveitis Clinic database. All uveitis patients undergoing phacoemulsification with intraocular lens implantation from August 1995 to November 2000 were included. A pre-operative preparation protocol was used. Operative and post-operative complications, degree of postoperative inflammation, best-corrected and final visual acuity were the main outcome measures.Results Eighty-six eyes of 75 patients underwent surgery, which in 11 cases was combined with trabeculectomy. Mean follow-up was 24.1 months. Eight eyes (10%) had severe or fibrinous uveitis post-operatively. The mean delay between surgery and return to baseline treatment was 8.6 weeks. Posterior capsule opacification occurred in 42% of eyes and Nd-YAG capsulotomy was required in 21%. Cystoid macular oedema was seen in 2 eyes. Seventy-two per cent of eyes retain a visual acuity of 6/9 or better, and 87% of eyes retain a post-operative improvement of 2 or more lines of Snellen acuity.Conclusions With careful patient selection, appropriate pre-operative preparation, diligent surgery and close post-operative supervision, phacoemulsification with intraocular lens implantation is safe and effective in the great majority of eyes with uveitis.

Massive proliferation of lens epithelial remnants after Nd-YAG laser capsulotomy.

Eight eyes exhibited massive proliferation of lens epithelial remnants following Nd-YAG posterior capsulotomy. All eyes had pre-existing retinal pathology. Six had undergone vitrectomy (four for proliferative diabetic retinopathy) before extracapsular cataract extraction with posterior chamber intraocular lens implantation. The other two eyes had familial exudative vitreoretinopathy or retinopathy of prematurity, respectively. Five eyes required removal of the lens proliferations via a pars plana approach. High levels of growth factors in the posterior segment associated with proliferative disorders of the retina may play a role in lens cell proliferation.

Extracapsular cataract surgery with and without intraocular lens implantation in Fuchs' heterochromic uveitis

The results of extracapsular cataract extraction, with or without posterior chamber intraocular lens (IOL) implantation, in Fuchs Heterochromic Uveitis, are reported. Twenty-nine patients underwent 30 operations. Twenty-two patients (73%) obtained a visual acuity of 6/12 or better. Post-operative uveitis or glaucoma were encountered in 13 eyes, including 11 of 20 eyes with IOL implantation (55%), and two often eyes without IOL implantation (20%). IOL implantation is a significant additional factor in cataract surgery in patients with FHU. Preoperative risk factors include severe iris atrophy, secondary glaucoma, and severe abnormalities of iris vasculature. IOL implantation is not recommended in these eyes. The routine postoperative use of anti-glaucoma medication is recommended. Long-term postoperative follow-up is important.

Eye Injury in Sport

SummaryEye injury sustained during sport is increasing in incidence worldwide, reflecting the rise in popularity of sport as recreation. It can account for up to 25% of severe eye injuries. This paper considers the historical context and demography of sports injuries, and the physical mechanisms and results of various types of ocular trauma in relation to sport. It reviews the specific problems associated with the sports considered to be most important in the epidemiology of eye injuries today.Certain sports, such as boxing, have an intrinsic risk of injury so high that some consider the sport should be banned. The risk of injury in many sports can be mitigated by changes in rules, such as the prevention of high sticking in ice hockey. Other sports with high risk of trauma could be made far safer with the widespread introduction of eye protection, and this applies especially to squash and badminton.The various types of eye protection are discussed. There is an urgent need to increase awareness of the risk of eye injury, to teach safe techniques, and to encourage the use of appropriate ocular protective wear in those at high risk of injury, especially the one-eyed.

One Year of Severe Eye Injuries in Sport

A one year prospective study was undertaken to assess all sports injuries requiring inpatient treatment at Manchester Royal Eye Hospital. (1 January to 31 December 1987.) Fifty two patients were admitted (25.1% of all admissions due to trauma). Racquet sports accounted for 51.9% of these cases. Eight patients required 12 surgical procedures and there were 3 perforating injuries. Sport is becoming an increasingly important cause of severe eye injury and the encouragement of adequate ocular protection is now a matter of urgency.

Serpiginous-like choroiditis as a marker for tuberculosis in a non-endemic area

Aim To describe the increasing incidence of multifocal outer retinal and inner choroidal inflammation as a marker for intraocular tuberculosis in the UK, a non-endemic area. Patients and methods Retrospective case series. Results 14 patients presented with serpiginous-like choroiditis over 10 years (seven within the last 2 years). Seven of 14 patients showed evidence of exposure to tuberculosis and received antituberculous treatment. 17 of 23 eyes showed stable or improved visual acuity. All with decreased acuity had direct macular involvement at presentation. Conclusions Multifocal outer retinal and inner choroidal inflammation is a marker for intraocular tuberculosis of increasing importance, even in a non-endemic area. Originally described as ‘serpiginous-like choroiditis’, the lesions are multifocal, irregular in shape, very numerous, widespread, often asymmetrical and often demonstrating both active and resolved lesions simultaneously. Active lesions show contiguous extension. We recommend that every patient with SLC should undergo testing for previous exposure to tuberculosis, and undergo antituberculous treatment if lesions are progressive and sight-threatening.

Outcomes and complications of trabeculectomy enhanced with 5-fluorouracil in adults with glaucoma secondary to uveitis.

Purpose:To analyze the long-term clinical outcomes of 5-fluorouracil (5FU)-enhanced trabeculectomy in patients with glaucoma secondary to uveitis (UG), to compare outcomes with those achieved elsewhere by primary mitomycin C-enhanced trabeculectomy and primary glaucoma drainage implant (GDI) surgery and to consider the optimal surgical approach in this group of patients. Methods:A retrospective analysis of a single-surgeon series of 31 eyes of 25 patients with UG attending the Manchester Uveitis Clinic who had undergone 5FU-enhanced trabeculectomy between October 2002 and August 2010. Main outcome measures were an intraocular pressure (IOP)<21 mm Hg with medications (unqualified success) and with medications (qualified success). Secondary outcome measures were IOP⩽66% of initial IOP. Other risk factors and postoperative complications were also examined. Results:The mean follow-up was 5.1 years. Qualified success for postoperative IOP control of <21 was achieved in 90.3% at 1 year and 76.5% at 5 years. IOP<66% of initial IOP was achieved in 93.5% at 1 year and 82.3% at 5 years. No patients developed long-term hypotony. Patients under 30 years of age at surgery were at a higher risk for bleb failure and 50% in this age group went on to require GDI surgery. Conclusions:This study demonstrates good long-term survival rates of 5FU-enhanced trabeculectomy in patients with UG, comparable with results for primary open-angle glaucoma. The results also compare favorably with those of mitomycin C-enhanced trabeculectomy and GDIs in patients with UG, with a lower risk of complications. We conclude that for patients over 30 years, 5FU-enhanced trabeculectomy is appropriate first-line surgery, whereas GDI surgery should be used as the primary procedure for those under 30 years.

Lymphopenia as a predictor of sarcoidosis in patients with uveitis

Aims To investigate the hypothesis that lymphopenia is an independent predictor of sarcoidosis in new patients presenting with uveitis. Patients and methods Retrospective case–control study of 112 patients with sarcoidosis-associated uveitis (SAU) against 398 controls with other forms of uveitis. Results Of the patients with SAU, 30/112 (26.8%) had significant lymphopenia (<1.0×109/L), compared with 24/398 (6.0%) for other uveitis (p≤0.0001, OR 5.7 (95% CI 3.2 to 10.3)). The mean lymphocyte count for patients with SAU was 1.43 vs 2.04 for other uveitis (p≤0.0001). Logistic regression modelling using diagnosis of SAU as the independent variable identified age, ACE levels and lymphocyte count as independent predictors of SAU. A new patient with uveitis with significant lymphopenia has a risk of sarcoidosis (from this parameter alone) of 31.6%. Conclusions Significant lymphopenia (<1.0×109/L) is an independent predictor of sarcoidosis in new patients presenting with uveitis. We recommend that diagnostic criteria for SAU should be modified to include this phenomenon.

Very Severe HLA B27-associated Panuveitis Mimicking Endophthalmitis: A Case Series

Purpose: To report rare but important instances of very severe, hyperacute HLA B27-associated panuveitis, mimicking infective endophthalmitis and providing challenges to both diagnosis and management. Design: Retrospective case review. Methods: Four patient records were reviewed. Demographic features, clinical findings, course of uveitis, diagnostic/therapeutic measures, and outcomes are reported. Results: All cases presented with severe panuveitis with visual acuities below 6/60 and poor fundal views. Three patients underwent intraocular fluid sampling for microbiology. All required systemic high-dose corticosteroid treatment, and two also needed oral immunosuppression. All eventually required cataract extraction. Final visual acuity varied from 6/12 to 6/6. Conclusions: HLA B27-associated uveitis may be unusually severe and may cause a panuveitis, mimicking infective endophthalmitis. The course may be prolonged and difficult with frequent complications including cataract.