Nikos N. Markomichelakis

Cytomegalovirus as a cause of anterior uveitis with sectoral iris atrophy

OBJECTIVE To report two cases of recurrent anterior uveitis with sectoral iris atrophy and ocular hypertension during attacks caused by cytomegalovirus (CMV). DESIGN Two observational case reports. PARTICIPANTS Two immunocompetent patients with a history of recurrent unilateral hypertensive anterior uveitis with sectoral iris atrophy were referred to us with the presumptive diagnosis of herpetic uveitis. MAIN OUTCOME MEASURES Comprehensive ophthalmic examination, aqueous humor polymerase chain reaction (PCR), and peripheral blood serologic studies were performed on both patients. RESULTS Examination of aqueous humor by PCR was positive for CMV and negative for herpesvirus. Serum IgG/IgM titers disclosed past CMV infection. Both patients responded well to antiviral therapy with ganciclovir. The final visual acuity level was 20/20 in both eyes of both patients. CONCLUSIONS CMV infection can produce recurrent attacks of anterior uveitis with clinical characteristics indistinguishable from those previously considered highly suggestive or even pathognomonic for herpetic infection. This observation has implications for the therapeutic management of such patients.

Intravitreal Infliximab for Sight-Threatening Relapsing Uveitis in Behçet Disease: A Pilot Study in 15 Patients

PURPOSE To assess the safety and to conduct a preliminary assessment of efficacy of intravitreal infliximab, an anti-tumor necrosis factor antibody, for sight-threatening relapsing uveitis in Behçet disease. DESIGN Prospective, noncomparative, interventional pilot study. METHODS A single intravitreal injection of infliximab (1 mg/0.05 mL) was given to 15 patients with relapsing posterior uveitis at the onset of a unilateral attack. Best-corrected visual acuity, anterior chamber cells, vitreous haze, and posterior eye segment inflammation were assessed at baseline and at 1, 7, 14, and 30 days after treatment. RESULTS Ocular or extra-ocular side effects were not observed. Baseline best-corrected visual acuity (mean logarithm of minimal angle of resolution, 0.74; range, 0.15 to 1.7) improved significantly by day 7 and continued to improve through day 30 after infliximab (mean, 0.30; P < .0001). Profound decreases in anterior chamber cells and vitreous haze (both P < .0001), as well as beneficial effects in retinal vasculitis (P = .0001) and retinitis (P = .001) were evident through day 30. Cystoid macular edema persisted in 9 of 11 eyes affected, but central macular thickness decreased from a baseline mean of 434 to 309 mm at the end of follow-up (P < .0001). Lack of systemic treatment at baseline in 4 patients or background immunosuppressive medications, which remained unchanged during follow-up, did not influence significantly these responses; additional treatment was not required. CONCLUSIONS These findings suggest that intraocularly produced or acting tumor necrosis factor, or both, is crucial in Behçet disease-associated relapsing uveitis and that intravitreal infliximab should be considered when systemic administration is not feasible or contraindicated. Further studies may identify patients for whom intravitreal infliximab is preferable to systemic treatment.

Intermediate Uveitis and Retinal Vasculitis as Manifestations of Cat Scratch Disease

PURPOSE To study the ocular manifestations of systemic Rochalimaea infection. METHODS We examined a healthy 21-year old woman who had floaters in both eyes. A bilateral mild vitreitis and multiple foci of retinal vasculitis were found; during the ensuing two weeks, exudates appeared over the inferior pars plana. The patient owned five kittens but had no history of cat bites or scratches. Serum levels of antibodies to Rochalimaea were elevated. RESULT The retinal vasculitis and vitreitis resolved after three weeks of therapy with ciprofloxacin hydrochloride without concomitant anti-inflammatory therapy. CONCLUSION Rochalimaea infection should be considered in the differential diagnosis of intermediate uveitis and retinal vasculitis.

Course of Macular Edema in Uveitis under Medical Treatment

Objective: To describe the response of uveitic macular edema to various treatment methods using optical coherence tomography (OCT). Methods: This is a prospective study of consecutive uveitis patients with macular edema in at least one eye. The patients received medical treatment. Best corrected Snellen Visual Acuity (BCVA) and tomographic features of the macula, including macular thickness measurement, were obtained at one, three, six, and 12 months after commencing treatment. Results: Eighty-one eyes of 58 patients were analyzed. Complete resolution of macular edema occurred in 38 eyes (47%). The average BCVA was 20/34 logarithm of minimum angle of resolution (-logMAR, 0.2 ± 0.3) upon study entry and 20/27 (-logMAR, 0.13 ± 0.29) upon study completion. The difference was statistically significant (p = 0.04). The corresponding mean retinal thickness at the central fovea was 319 ± 150 μm at the beginning of the study compared to 241 ± 125 μm at 12 months (p < 0.001). A weak but statistically significant correlation between the reduction of macular thickness and the improvement of BCVA (r = 0.3, p = 0.01) was found. Thirteen of the 43 eyes (30%) with persistent macular edema had a more than 15% reduction of macular thickness compared to baseline, whereas 10 eyes (23, 3%) had a more than 15% increase in macular thickness. Statistical analysis indicated that the presence of an epiretinal membrane and an OCT pattern of diffuse macular edema was a significant factor associated with medical treatment failure. Conclusion: This study demonstrates the overall favorable visual prognosis of uveitic macular edema under medical treatment. The presence of an epiretinal membrane is an important factor associated with medical treatment failure.

Medical treatment of macular edema in patients with uveitis.

Purpose: To determine the efficacy of medical treatment of cystoid macular edema (CME) in patients with uveitis. Methods: Retrospective study of 40 patients (57 eyes) with uveitis and CME. Inclusion criteria were presence of CME with minimal and no macular pathology, or vascular disease which could account for CME. Patients who had undergone intraocular surgery or had visual aucity (VA) of ≥20/40 were excluded. The diagnosis of CME was based on clinical and/or angiographic findings. Three treatment groups were defined: (1) transseptal injection of steroids (n=13 eyes); (2) systemic non steroidal anti-inflammatory drugs (NSAIDs) (n=11 eyes); both 1 and 2 (n=33 eyes). Results: Overall, 79% of eyes improved 3 or more lines of Snellen VA after treatment: 51% improved 4 or more lines. The average number of lines improved was 3.8 for eyes treated with transseptal injections of steroids, 2.9 for eyes treated with NSAIDs, and 4 for eyes treated with both. For all 3 treatment groups between 60–70% of eyes improving 2 or more lines reached best VA only after a minimum of 6 months of follow up. Conclusions: CME, a vision threatening complication of uveitis, respond fairly well to medical treatment; however, the best VA is achieved after several months. The improvement in VA did not differ markedly among the three treatment groups.

Intravenous Pulse Methylprednisolone Therapy for Acute Treatment of Serpiginous Choroiditis

Purpose: To evaluate the safety and efficacy of high-dose intravenous steroid therapy (HDIST) for the acute treatment of vision-threatening serpiginous choroiditis. Methods: Retrospective review of the records of five patients with serpiginous choroiditis who were treated with HDIST (1 g methylprednisolone for three days) in addition to their standard immunosuppressive treatment. The visual acuities and improvement of ocular signs after HDIST were evaluated. Results: Twelve episodes of macula-threatening choroiditis in five patients with serpiginous choroiditis were treated during a seven-year period. All patients responded to HDIST with evidence of a decrease in intraocular inflammation immediately after and complete restoration of visual acuity within 10 days of commencing treatment. In one patient, medical intervention was required because of gastric distress. During the follow-up, three out of five patients experienced new attacks and two patients developed subretinal neovascularization. Conclusion: HDIST is effective in controlling severe vision-threatening serpiginous choroiditis and in improving visual function in a short period of time. However, the effect of this treatment in long-term disease control is uncertain.

Human mast cell subtypes in conjunctiva of patients with atopic keratoconjunctivitis, ocular cicatricial pemphigoid and Stevens-Johnson syndrome

Purpose: Investigate mast cell (MC S ) subtypes in atopic keratoconjunctivitis (AKC), ocular cicatrical pemphigoid (OCP), and Stevens-Johnson Syndrome (SJS). Methods: MC S subtypes were determined by immunohistochemistry of conjunctiva (obtained from 34 patients – 9 AKC, 9 OCP, 9 SJS and 7 normal) using monoclonal antibodies directed against chymase (MC C ) and tryptase (MC T ). Double staining was used to distinguish MC S as positive for both chymase and tryptase (MC TC ). Results: The number of MC S was significantly increased in AKC, OCP and SJS patients, compared to normal subjects. MC C were especially high in AKC, and moderately high in OCP. MC T and MC TC were similar in each disease group. Conclusions: While the AKC findings were not surprising, the result in OCP and SJS suggests that MC S play an underappreciated role in the inflammatory process of these disorders. Disparate proportions of MC S subtypes in these diseases may imply differential functions of MC S in these disorders.

Herpes simplex virus type 2: a cause of acute retinal necrosis syndrome

PURPOSE: To describe a case of herpes simplex virus type 2 (HSV-2) acute retinal necrosis syndrome (ARN) in a 13-year-old immunocompetent girl. METHODS: Polymerase chain reaction (PCR), cultures, flow cytometry, and cytology were performed on the vitreous sample. RESULTS: Both PCR studies and vitreous cultures revealed HSV-2 as the cause of ARN. Flow cytometry showed CD4+, CD8+, and natural killer cells. The visual outcome of the patient was 20/200. CONCLUSION: Successful culture of HSV-2 from the vitreous specimen in a patient with ARN proved HSV-2 to be one of the causes of ARN. The successful culture of HSV-2 has not been previously reported.

Macular hole closure after peribulbar steroid injection.

PURPOSE To report the closure of a macular hole after a peribulbar corticosteroid injection in a patient with anterior uveitis associated with human leukocyte antigen B*27. DESIGN Interventional case report.The patient was evaluated by comprehensive ophthalmic check-up and optical coherence tomography. RESULTS A healthy 50-year-old woman presented to our service with active human leukocyte antigen B*27-associated anterior uveitis, macular hole in the right eye and macular edema in the left eye. Visual acuity was 20/200 in both eyes. Peribulbar injections of triamcinolone acetonide were administered in both eyes. Three months later, visual acuity improved to 20/50 in both eyes, and the uveitis was in complete remission. Optical coherence tomography verified that the macular hole in the right eye was closed. CONCLUSIONS Inflammation and macular edema might be contributing factors in macular hole formation in patients with uveitis. This case indicates that treatment of inflammation and macular edema might lead to macular hole closure in similar cases.

Evaluation of Single-dose Azithromycin Versus Standard Azithromycin/Doxycycline Treatment and Clinical Assessment of Regression Course in Patients with Adult Inclusion Conjunctivitis

Abstract Background: Single-dose azithromycin (AZT) has been proved efficient in treating various human Chlamydia infections. However, it has not been thoroughly tested in patients with adult inclusion conjunctivitis (AIC). It is the aim of this study to perform a comparative evaluation of efficacy and safety of one-day AZT with long-term AZT and doxycycline (DOX) regimens in AIC and to present a clinical profile of regression course of the disease. Materials: Eighty-three consecutive adults, with symptoms and signs of chronic conjunctivitis and positive Polymerase Chain Reaction (PCR) for chlamydia, were randomly assigned in four treatment groups; AZT 1-day 1000 mg orally, AZT 500 mg daily 9 and 14 days and DOX 200 mg 21 days orally. Follow-up visits were scheduled 1 and 2 weeks, 1, 3 and 6 months after treatment completion. PCR was repeated at the 2nd post-treatment week to confirm elimination of infectious agent. Detailed record of subjective symptoms and objective signs was performed at all visits. Retreatment rate among groups was evaluated as primary outcome. Regression rate of symptoms/signs among groups was recorded as secondary outcomes. Results: All treatment groups provided statistically equivalent results of retreatment rate. Statistically significant regression of symptoms/signs was documented, initially from the 1st post-treatment week in general, but 1 month was required for complete patients’ relief. Follicles were the most common clinical sign with the earliest regression after successful treatment. Conclusion: Single-dose azithromycin should be considered as equally reliable treatment option, comparing to long-term alternative regimens for AIC. Patients should wait for one week, until first signs of significant regression become obvious and should consider approximately one month to total relief. Follicles could be reasonably used as a key sign for clinical assessment of treatment success.