Panagiota Stavrou

Degree, duration, and causes of visual loss in uveitis

Background/aims: Uveitis is a major cause of visual morbidity in the working age group. The authors investigated the duration, degree, and causes of visual loss in uveitis patients with the aim of better defining the visual morbidity and identifying potential risk factors. Methods: A retrospective, non-interventional, observational survey of 315 consecutive patients attending a tertiary referral uveitis service. Results: The mean duration of follow up was 36.7 months. Reduced vision (⩽6/18) was found in 220/315 (69.95%) of the patients with a subset of 120 patients having vision ⩽6/60. Unilateral visual loss occurred in 109 (49.54%), while 111 (50.45%) had bilateral loss. The mean duration of visual loss was 21 months. Of the 148 patients with pan-uveitis, 125 (84.45%) had reduced vision, with 66 (53%) having vision ⩽6/60. Main causes of visual loss were cystoid macular oedema (CMO) (59/220, 26.8%), cataract (39/220, 17.7%), and combination of CMO and cataract (44/220, 20%). The following were predictive of a poorer visual prognosis: pan-uveitis (p = 0.0005), bilateral inflammation (p = 0.0005), increasing duration of reduced vision (p = 0.0005), an Indian or Pakistani ethnic background (p = 0.004), and increasing patient age (p = 0.02). Conclusion: Prolonged visual loss occurred in two thirds of uveitis patients, with 70 (22%) patients meeting the criteria for legal blindness at some point in their follow up. Older patients with bilateral inflammation and an increasing duration of reduced vision are at the greatest risk of severe visual loss (⩽6/60). CMO and cataract were responsible for visual loss in 64.5% of patients.

Evaluation of foldable intraocular lenses in patients with uveitis

OBJECTIVE To evaluate various foldable posterior chamber intraocular lenses (IOLs) after phacoemulsification in patients with uveitis. DESIGN A prospective, noncomparative, interventional case series. PARTICIPANTS Forty-nine consecutive patients (60 eyes) with various types of uveitis (anterior, n = 20; posterior, n = 1; panuveitis, n = 37, intermediate, n = 2). INTERVENTION All patients underwent phacoemulsification with foldable posterior chamber IOL implantation. All eyes were free of active inflammation at the time of surgery. A variety of IOL biomaterials were implanted: acrylic (n = 30), silicone (n = 17), and hydrogel (n = 13). MAIN OUTCOME MEASURES Detailed examination was performed by one masked observer. Several parameters were compared for each implant biomaterial, including level of best corrected Snellen visual acuity at final follow-up, presence of posterior synechiae, anterior capsular phimosis, posterior capsule opacification, and the degree of cellular deposits on the IOL optic. RESULTS There were 26 males and 23 females, aged 9 to 83 years (mean, 48 years). Follow-up ranged from 1 to 33 months (mean, 17.03 months). At final follow-up, 56 eyes (93.3%) had an improvement in visual acuity compared with preoperative levels as follows: 34 eyes (56.6%) achieved an improvement of four or more Snellen lines, and 44 eyes (73.3%) achieved 20/30 or better. Giant cells, observed on the IOL optic in 19 eyes (31.7%), were most often seen on the acrylic biomaterial at the 1-month follow-up, although this was not found to be statistically significant. Scratch marks produced by the lens-introducing forceps were seen in 24 eyes (40.0%), mainly on the acrylic and hydrogel optics. Posterior capsule opacification (PCO) occurred in 49 eyes (81.7%), with only 5 eyes requiring laser capsulotomy. There was no association between PCO and the various lens biomaterials. Other causes for reduced visual acuity included glaucomatous optic neuropathy (n = 5) and cystoid macular edema (n = 8). CONCLUSIONS The use of foldable IOLs in eyes with uveitis is safe, but the optimal biomaterial has yet to be found.

Long-term follow-up of trabeculectomy without antimetabolites in patients with uveitis.

Abstract PURPOSE: To determine the long-term success rate after trabeculectomy without antimetabolites in patients with uveitis. METHODS: Review of data from all patients with uveitis who underwent trabeculectomy for uncontrolled intraocular pressure secondary to intraocular inflammation between May 1990 and December 1994. Results were compared with those from a group of patients with primary open-angle glaucoma matched for sex and surgeon. RESULTS: The uveitis group consisted of 32 eyes (20 patients). Maximum control of intraocular inflammation was achieved for a minimum of 2 months before surgery. Mean (± SD) age was 40.0 ± 12.5 years (range, 14 to 67 years), with a median (± SE) follow-up of 53.0 ± 1.8 months (range, 33 to 84 months). The primary open-angle glaucoma group consisted of 33 eyes (23 patients), with a mean age of 62.0 ± 13.7 years (range, 26 to 81 years) and a median follow-up of 63.0 ± 12.0 months (range, 34 to 299 months). The overall 5-year success rate (intraocular pressure ≤ 21 mm Hg with or without topical medication) for the uveitis group was 78% compared with 82% for the primary open-angle glaucoma group ( P = .7). The absolute 5-year success rate (intraocular pressure ≤ 21 mm Hg with no medication) for the uveitis group was 53% compared with 67% for the primary open-angle glaucoma group ( P = .87). CONCLUSIONS: In the absence of other risk factors, such as Afro-Caribbean race and previous intraocular surgery, and with adequate preoperative control of inflammation, trabeculectomy without antimetabolites may be considered the primary surgical procedure for increased intraocular pressure in patients with uveitis.

Detection of varicella-zoster virus DNA in ocular samples from patients with uveitis but no cutaneous eruption

Herpes zoster ophthalmicus is a well-recognised cause of intraocular inflammation, which may become recurrent or chronic after the acute phase has elapsed. Although it commonly presents with the typical rash, cases of ocular zoster with no cutaneous eruption have been well documented. We present two patients with unilateral anterior uveitis complicated by cataract, in whom molecular techniques based on the polymerase chain reaction detected varicella-zoster virus DNA in intraocular material obtained during cataract surgery. Neither patient gave a history of cutaneous eruption.

Clinical diagnosis of ocular sarcoidosis

Purpose: To assess the value of raised serum angiotensin converting enzyme (ACE) levels in making a clinical diagnosis of ocular sarcoidosis in patients with intraocular inflammation, compatible with sarcoidosis, in whom tissue biopsy is either not practical or not possible.Methods: The ocular manifestations and clinical course of 22 patients with intraocular inflammation compatible with sarcoidosis and elevated ACE level (including 11 patients with abnormal chest radiograph) were compared with those of a group of 18 patients with intraocular inflammation due to biopsy-proven sarcoidosis. The mean follow-up (± SD) was 4.5 ± 3.4 years in the presumed ocular sarcoidosis group and 7.8 ± 5.3 years in the biopsy-proven sarcoidosis group.Results: There was no difference in sex, race and age distribution between the two groups. No statistically significant difference could be found between the ocular manifestations seen in each group. The most common finding was retinal vasculitis with panuveitis, seen in 86.4% of the presumed ocular sarcoidosis group and in 83.3% of the biopsy-proven sarcoidosis group.Conclusions: These results suggest that intraocular inflammation compatible with sarcoidosis in conjunction with raised ACE levels would be accordant with a diagnosis of sarcoidosis in patients in whom histological diagnosis is either not practical or not possible.

Electrophysiological findings in Stargardt's-fundus flavimaculatus disease

Purpose To determine the incidence of electrophysiological abnormalities in patients with Stargardts-fundus flavimaculatus (STGD/FFM) disease.Methods A retrospective review was carried out of the hospital records of 46 patients who had undergone a scotopic, single flash photopic and 30 Hz electroretinogram (ERG), pattern ERG (PERG) and electro-oculogram (EOG).Results Patients were classified in two groups: those with flecks (n = 26) and those without flecks (n = 20). The incidence of abnormalities (amplitude and/or latency) for the two groups was: PERG, 90% and 98%; 30 Hz ERG, 55.8% and 50%;scotopic ERG, 38.5% and 27.5%;and single flash photopic ERG, 26% and 16%, respectively. EOG abnormalities occurred significantly more frequently in the group with flecks compared with the group without flecks: 69% and 42.5% respectively (p < 0.025). Furthermore, in the group with flecks the group mean scotopic ERG b-wave, 30 Hz ERG b-wave and PERG (P50) amplitude were significantly lower than in the group without flecks (p < 0.01).Conclusions The most consistent electrophysiological abnormality in STGD/ FFM is the reduction of the PERG. However, EOG, 30 Hz ERG, scotopic and photopic ERG abnormalities can also frequently occur. ERG and EOG abnormalities occur more often in the presence of flecks.

Trabeculectomy in uveitis Are antimetabolites necessary at the first procedure

A retrospective study was undertaken analysing the results of trabeculectomy without antimetabolites in 33 eyes with uveitis compared to 33 eyes with primary open angle glaucoma (POAG). Both groups were matched for surgeon with a median follow-up of 19 months (range 2-44 months) for the uveitis group and 24 months (range 6-92 months) for the POAG group. The overall one and two year success (IOP ± 21 mmHg with or without medication) was 92% and 83% respectively for the uveitis group and 96% for both years for the POAG group (p = 0.241, Mantel-Haenszel test). These results indicate that the success of trabeculectomy in patients with inflammatory glaucoma compares well with that of the POAG group. In the absence of other risk factors, primary trabeculectomy without the use of antimetabolites should be considered as the first choice of surgical treatment for raised intraocular pressure in patients with intraocular inflammatory disease.

Heparin surface modified intraocular lenses in uveitis.

A retrospective analysis of the results of cataract surgery using heparin surface modified intraocular lenses (HSM-IOL) performed on patients with uveitis between August 1989 and July 1993 was undertaken. In total, 32 eyes of 28 patients with various types of uveitis underwent extracapsular cataract extraction and implantation of a posterior chamber HSM-IOL. In four patients, cataract extraction was combined with trabeculectomy. The post-operative follow-up period ranged from two to 51 months (average 16 months). The visual acuity improved in 31 of 32 eyes (96.8%) with 28 eyes (87.5%) seeing 6/18 or better. In four eyes (12.5%), the visual acuity was only 6/60 due to longstanding, pre-operative cystoid macular oedema. Posterior synechiae developed in eight eyes (25%), inflammatory deposits were noticed on the IOL surface in five eyes (15.6%), and three eyes (9.3%) required YAG laser posterior capsulotomy. These results suggest that HSM lenses are associated with minimal post-operative complications and appear safe to be used in human uveitic eyes.

Clinical Features of Patients with Diabetes Mellitus Presenting with Their First Episode of Uveitis

Purpose: Little is known about uveitis in patients with diabetes mellitus (DM). The authors studied diabetic patients with their first episode of uveitis. Methods: Cross-sectional, case note study documenting the uveitis, underlying cause/syndrome, treatment, type of DM and treatment, and any diabetic retinopathy. Results: There were 34 patients (M/F: 17/17, 48 eyes) with their first uveitis episode (33 had type 2 DM). Mean age of onset of DM 49 years and uveitis 56 years. Uveitis was bilateral in 14 (45%), with most having idiopathic anterior uveitis. Visual acuity 6/18–6/60 in 15 eyes, and worse than 6/60 in 11 eyes. There was 3–4+ flare in 16 eyes, 3–4+ anterior chamber cells in 13 eyes. Diabetic retinopathy was seen in 20 (42%) eyes, and mean blood glucose was 13.64 mmol/L in 11 patients. Conclusions: Diabetic patients presenting with uveitis, whatever the aetiology, may have severe inflammation, reduced vision, and poor glycaemic control.

Indocyanine green angiography in systemic lupus erythematosus-associated uveitis

Purpose: To report indocyanine green (ICG) angiography findings in a patient with systemic lupus erythematosus-associated uveitis. Methods: Review of the patient’s clinical records. Results: ICG angiography revealed dilatation of individual choroidal vessels in the early phase. Furthermore, two types of hypofluorescent areas became visible from the intermediate up to the late phase: the first type was small, round, and better defined, while the second type consisted of larger, ill-defined areas seen around fixation in the right eye and temporal to fixation in the left eye. These hypofluorescent areas were not visible on either clinical examination or fluorescein angiography. Conclusions: The results of ICG angiography suggest choroidal involvement in patients with systemic lupus erythematosus-associated uveitis.