Nikolas London

The epidemiology of uveitis in developing countries.

Uveitis represents a major cause of ocular morbidity worldwide. In the western world, uveitis affects approximately 200 per 100,000 in the population, resulting in an estimated annual incidence of 20 per 100,000 person-years. More than half of all patients with uveitis develop complications related to their disease, and up to 35% of patients suffer severe visual impairment. Uveitis is believed to account for 5% to 10% of all causes of legal blindness in the United States and Europe. Uveitis and its complications are even more common in the developing world, in which the condition occurs in up to 714 per 100,000 in the population, and accounts for up to 25% of all blindness. The causes of uveitis are numerous, and include infection, trauma, noninfectious systemic or ocular disease, and masquerade syndromes. To generate a differential, clinicians must consider all available information, including the anatomic location, character (granulomatous vs. nongranulomatous), laterality, and chronicity of inflammation. Moreover, the frequency and pattern of uveitis in a given population must be considered. This is particularly important in resource-poor settings, in which avoiding costly and unnecessary diagnostic tests is a priority. Numerous studies have examined the pattern of uveitis around the world. Many are from western countries, including the United States and countries in Europe, whereas data from developing countries are less common. In general, developing countries see a larger proportion of infectious causes of uveitis, including tuberculosis,

Pars plana vitrectomy and scleral buckle versus pars plana vitrectomy alone for patients with rhegmatogenous retinal detachment at high risk for proliferative vitreoretinopathy.

Purpose: To compare using pars plana vitrectomy (PPV) combined with a scleral buckle versus primary vitrectomy alone in patients with rhegmatogenous retinal detachment at high risk for postoperative proliferative vitreoretinopathy (PVR). Methods: Six hundred and seventy-eight patients were identified from billing data as having rhegmatogenous retinal detachment between April 1, 2010 and August 1, 2012. Patients were considered at high risk for PVR if they presented with retinal detachment in 2 or more quadrants, retinal tears >1 clock hour, preoperative PVR, or vitreous hemorrhage. Results: Of the 678 patients with rhegmatogenous retinal detachment, 65 were identified as high risk for PVR. Thirty-six patients were treated with simultaneous PPV–scleral buckle and 29 patients were treated with PPV alone, with an overall success rate of 63.1%. The use of PPV–scleral buckle was associated with significantly higher single surgery anatomical success compared with patients treated with PPV alone (odds ratio, 3.24; 95% confidence interval, 1.12–9.17; P = 0.029). Visual acuity at 3 months postprocedure or final follow-up was no different between the treatment groups. Overall, 23.1% of patients developed postoperative PVR with no difference between surgical approaches. Conclusion: For patients at high risk for PVR, PPV–scleral buckle was associated with significantly higher rates of anatomical success compared with PPV alone.

Drug-induced uveitis.

Purpose of review Although more than 50% of all uveitis cases have no identifiable cause, certain medications can cause ocular inflammation and are often overlooked. Drug-induced ocular inflammation has increased in frequency with the advent of new bisphosphonates, antitumor necrosis factor biologic agents, and intravitreal triamcinolone and antivascular endothelial growth factor medications. Identification of these inciting drugs will simplify work-up and management of patients with uveitis and improve visual outcomes. Recent findings This review briefly focuses on the drugs that have long been known to be strongly associated with uveitis and emphasize new observations about these associations. It will also highlight the newest medications associated with uveitis and scleritis. The strength of the association between each drug and uveitis will be quantified and categorized into definite, probable, possible, and unlikely causes of uveitis utilizing Naranjos classification criteria. Summary Drug-induced uveitis has become increasingly recognized in association with a number of commonly used systemic, intraocular, and topical medications. A detailed history is often all that is needed to identify these important, often overlooked, and readily curable causes of uveitis. Most cases of drug-induced uveitis respond promptly to discontinuation of the suspected agent in conjunction with topical corticosteroid and cycloplegic therapy.

Leukemia presenting as serous retinal detachment.

BACKGROUND To describe a patient who presented with bilateral serous retinal detachments without the other retinal vascular or ocular inflammatory signs, and who was ultimately diagnosed with acute leukemia. METHODS Case report and review of the literature. RESULTS This patient presented with isolated bilateral serous retinal detachments as the initial manifestation of hematologic malignancy. CONCLUSION Acute leukemia may present with serous retinal detachments without the signs of other retinopathy or ocular inflammation. Incorrect diagnosis may delay detection and proper management of the malignancy. Leukemia should be considered in the differential diagnosis of isolated serous retinal detachments.

HIV/AIDS in the developing world.

This article reviews information available from developing countries including those in Africa Asia Eastern Europe Latin American and the Caribbean regarding the current state of the HIV/AIDS epidemic. It also discusses the common ocular manifestations associated with HIV/AIDS including: HIV microvasculopathy cytomegalovirus (CMV) retinitis ocular toxoplasmosis non-CMV herpetic retinitis neuro-ophthalmic complications herpes zoster ophthalmicus and ocular neoplasia.

Effect of topical aqueous suppression on intraocular gas duration after pure perfluoropropane injection in nonvitrectomized eyes with retinal detachment.

Purpose: To determine whether topical aqueous suppressants affect the duration of pure expansile intraocular gas in nonvitrectomized eyes. Methods: A prospective randomized controlled trial was performed on nonvitrectomized patients undergoing retinal detachment repair with scleral buckle or pneumatic retinopexy using 0.3 mL of 100% perfluoropropane (C3F8) gas tamponade. Eyes were randomly assigned to receive topical dorzolamide 2% and timolol 0.5% twice daily postoperatively until gas dissolution or to observation. Results: Twenty-one patients met all inclusion and exclusion criteria. Twelve were randomized to the control group and nine to the dorzolamide–timolol group. In the dorzolamide–timolol group, mean intraocular pressure was 17.4 on postoperative Day 1 and 12.5 on postoperative Week 1 (P = 0.03). In the control group, mean intraocular pressure was 14.5 on postoperative Day 1 and 15.1 on postoperative Week 1 (P = 0.73). The mean duration of C3F8 was 37.8 days in the dorzolamide–timolol group and 40.4 days in the control group (P = 0.70). Conclusion: Topical aqueous suppression does not seem to have a significant effect on the duration of pure expansile intraocular C3F8 in nonvitrectomized eyes after pneumatic retinopexy or scleral buckling.

Drugs, Inflammation, and the Eye

California Pacific Medical Center, San Francisco, California, USA, The Department of Ophthalmology, Stanford University School of Medicine, Stanford, California, USA, The Francis I. Proctor Foundation, UCSF School of Medicine, San Francisco, California, USA, West Coast Retina Medical Group, San Francisco, California, USA, Retina Consultants San Diego, La Jolla, California, USA, Associated Vitreoretinal and Uveitis Consultants, Indiana University School of Medicine, Indianapolis, Indiana, USA, MidAtlantic Retina, The Retina Service of Wills Eye Hospital, Philadelphia, Pennsylvania, USA, and Centre for Ophthalmology, University Tuebingen, Tuebingen, Germany

Mortality in Patients With AIDS-Related Cytomegalovirus Retinitis in Myanmar

To the Editor—Retinitis is the most common clinical manifestation of human immunodeficiency virus (HIV)–related cytomegalovirus (CMV) disease, but there is irrefutable clinical [1] and autopsy [2] evidence that AIDS-related CMV retinitis is only part of a systemic infection. By virtue of this association with systemic disease, CMV retinitis both predicts and contributes to mortality [3], and systemic anti-CMV therapy improves patient survival [4]. In high-income countries, systemic anti-CMV treatment has always been the standard of care, but in middle- and low-income countries, systemic anti-CMV treatment is rarely available because of cost. In the few settings that provide diagnosis, patients with retinitis receive local anti-CMV treatment (ganciclovir eye injection), combined with antiretroviral therapy (ART) [5]. This approach can prevent blindness in the involved eye, but ignores systemic disease. We investigated all-cause mortality of HIV patients with active CMV retinitis in Yangon, Myanmar, where trained HIV clinicians diagnose CMV retinitis by indirect ophthalmoscopy and provide intraocular ganciclovir injections, but where systemic anti-CMV treatment was not available. Consecutive patients with active CMV retinitis were retrospectively analyzed for all-cause mortality. All patients were offered complete medical care including ART. An ophthalmologist with expertise in CMV retinitis regularly visited and monitored diagnostic accuracy. Twenty-six of 94 (28%) patients with CMV retinitis died. In 19 patients for whom information was available, 13 of 19 (68%) died within 3 months of diagnosis of CMV retinitis, and all 19 died within 6 months. Sixteen of 94 (17%) patients were lost to follow-up. Cytomegalovirus was one of the 3 unusual infections that occurred in all 5 patients in the 5 June 1981 Centers for Disease Control and Prevention report marking the beginning of the AIDS epidemic. That report established that CMV infection is a systemic disease: 1 patient died with CMV pneumonia; another had biopsy proven CMV esophagitis [6]. At this time there is a substantial burden of CMV retinitis in Southeast Asia, no apparent reduction over the past decade, little information about mortality, and virtually none about extraocular CMV disease [7]. We document a 28% mortality rate associated with a diagnosis of CMV retinitis, similar to cryptococcal meningitis mortality [8], and believe that the actual mortality rate in our CMV retinitis cohort was higher as most patients lost to follow-up in this setting are likely to have died. Where information is available, patients with CMV retinitis who did not survive typically died within months (13 of 19 patients died within 3 months), also consistent with prior data showing early mortality in patients with CMV retinitis [9]. To improve management of CMV retinitis, we must provide early diagnosis by indirect ophthalmoscopy screening for all new patients who first enter the healthcare system with a CD4 count <100 cells/µL as part of the initial physical examination; in addition, treatment for all patients with CMV retinitis must include systemic therapy with valganciclovir for at least 3 months, combined with intraocular ganciclovir injection for the first 2 weeks to promptly stop progression of retinitis, as well as to preserve this technique for patients who may become cytopenic from valganciclovir or otherwise require an alternative therapy [10].

Spectral-Domain Optical Coherence Tomography of White Dot Fovea

White dot fovea is thought to be a benign condition and was originally recognized in 1997 by Yokotsuka and associates. It is characterized by the appearance of multiple tiny, white dots on the surface of the foveola that typically are arranged in a ringlike pattern at the foveal margin; the appearance can simulate a macular hole. In that early report, nearly all (28 of 30) cases described were bilateral, and all patients were Japanese. Fekrat and Humayun also identified the same condition in an African American patient with an asymptomatic, single, ringlike, white macular lesion in the right eye. To our knowledge, white dot fovea has not been described using optical coherence tomography (OCT). Herein, we present 3 patients with asymptomatic findings in both maculae identical to those presented by Yokotsuka and associates and Fekrat and Humayun and show spectral-domain OCT (SDOCT) images through the foveal abnormalities.

Retinal and Choroidal Manifestations of HIV/AIDS

The human immunodeficiency virus (HIV) pandemic has continued despite the advent of new antiviral therapies; this is responsible for an increase in the number of patients with this entity and its survival. The majority of ocular manifestations of HIV infection involve the posterior segment of the eye. Prior to the introduction of highly active antiretroviral therapy (HAART), retinal microvasculopathy and cytomegalovirus (CMV) retinitis accounted for more than 80% of the ocular complications in HIV-positive patients. To date, HIV disease and CMV retinitis have become chronic diseases. Many challenges remain to be addressed. HAART has indeed decreased the incidence of some ophthalmic problems, such as CMV retinitis, and it has brought with it new challenges, such as immune recovery uveitis (IRU). Ocular disorders associated with HIV disease remain important problems in the world, despite HAART, and increasingly are more significant and frequent. The approach to diagnosis and management of different pathological presentations at the posterior pole is very important.