Patricia Udaondo

Adalimumab Therapy for Refractory Uveitis: A Pilot Study

PURPOSE The aim of this study was to assess the efficacy and safety of adalimumab in treating refractory autoimmune uveitis. METHODS This work was a prospective, noncomparative, nonrandomized, clinical trial. Nineteen (19) patients meeting eligibility criteria received a 40-mg subcutaneous (s.c.) injection of adalimumab every other week during 1 year. RESULTS All patients underwent an outcome assessment at month 12. Visual acuity improved by -0.3 logMar in 12 (31%) eyes of 38, and worsened by +0.3 logMar in 1 (2.6%) eye. All patients had an active intraocular inflammation at baseline, and 12 patients (63%) achieved control of their inflammation with adalimumab at the end of follow-up. After optic coherence tomography, 33 eyes (86%) had cystoid macular edema (CME) at baseline, and at the end of follow-up there was a complete resolution of CME in 18 of these 33 eyes (54.54%). All patients were able to reduce at least 50% of the dose of the concomitant immunosuppressive drugs at the end of follow-up. Adalimumab was well tolerated in all patients, and only local minor side effects at the s.c. injection site were observed. Nevertheless, 8 patients (42.10%) had relapses during the follow-up period that were controlled with 1 periocular steroid injection. CONCLUSIONS Adalimumab seems to be an effective, safe therapy for the management of refractory uveitis and may provide the possibility to reduce the concomitant immunosuppressive drugs in these patients. Further long-term studies are warranted to determine the safety and efficacy of adalimumab in treating intraocular inflammation.

Consensus statement on indications for anti-angiogenic therapy in the management of corneal diseases associated with neovascularisation: outcome of an expert roundtable

The cornea is the clear window at the front of the eye and is the eyes main refractive medium. Its transparency is essential for vision. Corneal neovascularisation is a common clinical problem with serious consequences for vision; it can compromise corneal transparency and plays a major role in corneal graft rejection by breaching corneal immune privilege. In this review, we formulate a consensus on the unmet medical needs in the management of corneal neovascularisation and outline a framework for the clinical research that is needed to identify suitable agents to meet these needs.

Fusarium Keratitis 3 Weeks After Healed Corneal Cross-Linking

PURPOSE To report a case of Fusarium solani keratitis after corneal cross-linking (CXL) treatment. METHODS A 23-year-old woman presented with corneal ulcer 4 weeks following a CXL procedure. RESULTS Microbiological studies revealed Fusarium species as the etiological pathogen. CONCLUSIONS Fusarium species may cause infectious crystalline keratopathy after corneal CXL treatment.

INTRAVITREAL PLASMIN WITHOUT ASSOCIATED VITRECTOMY AS A TREATMENT FOR REFRACTORY DIABETIC MACULAR EDEMA

OBJECTIVE To determine the effectiveness of a low-dose intravitreal injection of autologous plasmin enzyme (APE), without the performance of a vitrectomy, as a treatment for refractory diffuse diabetic macular edema (DDME). DESIGN Prospective, comparative, interventional case series. PATIENTS Sixteen patients with bilateral DDME who had not responded to prior laser photocoagulation. All patients received an injection in 1 eye, while the other eye served as a control. INTERVENTION Intravitreal 0.2 mL APE injection under topical anesthesia. The APE was obtained using a simplified method. MAIN OUTCOME MEASURES Central macular thickness (CMT) at 1 and 6 months, determined by optical coherence tomography (OCT) and best corrected visual acuity (BCVA). RESULTS All patients underwent a 1-month follow-up. Prior to injection, CMT in the eye about to receive the injection was 541 +/- 79 microm (mean +/- standard deviation [SD]) versus 535 +/- 76 microm in the control eye. One month after injection, CMT was 241 +/- 47 microm in injected eyes and 530 +/- 85 microm in control eyes (P < 0.001, bilateral Wilcoxon test for paired samples). The macular edema (ME) improved in all injected eyes (100%), with complete resolution in 7 patients (44%). The mean BCVA of treated eyes was 0.618 +/- 0.27 (mean +/- SD) at baseline and 0.45 +/- 0.24 four weeks after injection (paired samples t-test, P < 0.001). No adverse effects were observed in any of the patients. BCVA and CMT were stable when evaluated at 6-month follow-up (0.43 +/- 0.242 and 244 +/- 46 microm, respectively). CONCLUSIONS Intravitreal APE injection effectively reduces macular thickening due to DDME in cases that fail to respond to conventional laser photocoagulation, and improves visual acuity in a short term, and this results remain stable in a medium term what is very important. Further investigation is warranted in order to assess long-term efficacy and safety.

Intravitreal plasmin without vitrectomy for macular edema secondary to branch retinal vein occlusion.

OBJECTIVES To evaluate the effects and safety of intravitreal injections of autologous plasmin enzyme (APE), without vitrectomy, as a treatment for macular edema secondary to branch retinal vein occlusion. DESIGN Prospective, comparative, interventional case series. METHODS Patients were recruited and enrolled consecutively from February 1 through October 31, 2008, at the Retina Unit of the Hospital General Universitario, Valencia, Spain. An eye from 8 patients diagnosed as having macular edema due to branch retinal vein occlusion received an injection, after having received topical anesthesia, of 0.2 mL of APE, which had been obtained using a simplified method. Best-corrected visual acuity and central macular thickness measured by optical coherence tomography constitute the main outcome measures of the study. RESULTS The mean (SD) central macular thickness decreased from 494.875 (68.82) to 226.375 (28.67) μm 1 month after APE injection and to 228.570 (21.53) μm after 6 months (P < .001). The best-corrected visual acuity (logarithm of the minimal angle of resolution) improved from a preoperative value of 0.552 (0.17) to 0.217 (0.087) (mean, 20/80-20/32, Snellen equivalent) at the end of follow-up (P < .01). No secondary effects were observed during 6 months of follow-up. CONCLUSION This pilot study suggests that intravitreal injection of APE as a treatment for macular edema secondary to branch retinal vein occlusion improves central macular thickness and best-corrected visual acuity and may be a safe and effective alternative therapy for this condition if confirmed in controlled trials compared with standard care with longer follow-up.

Treatment of Refractory Dry Eye Associated with Graft Versus Host Disease with 0.03% Tacrolimus Eyedrops

PURPOSE We investigate the efficacy of 0.03% topical tacrolimus eyedrops for the treatment of dry eye in graft versus host disease (GVHD) patients resistant/intolerant to 0.05% topical cyclosporine. METHODS Forty-three patients were enrolled in this prospective study. After completing a 1-year run-in period of using artificial tears, 50% autologous serum eyedrops, and punctal plug occlusion, all the symptomatic patients (n=29) were treated with 0.05% topical cyclosporine (Restasis(®); Allergan, Inc.). After 1 month, the patients who presented topical or systemic intolerance to cyclosporine were instructed to instill 0.03% topical tacrolimus once a day for 3 months (n=14). All the patients were allowed to continue with their basal dry eye treatment. Visual acuity, fluorescein staining, Schirmer test, fluorescein tear break-up time, and tear meniscus height measurement were evaluated fortnightly (minimum 3 months). Subjective assessments of symptoms were also reported at the beginning and at the end of the study. RESULTS Dry eye symptoms and signs improved statistically (P<0.05) and significantly with tacrolimus and cyclosporine topical treatment. No significant differences were observed between both the groups. The mean follow-up time was 12.14±2.69 months (range 10-18 months). CONCLUSION The findings of this prospective pilot study suggest that cyclosporine-intolerant patients with dry eye associated with GVHD can be effectively treated with topical tacrolimus.

Aqueous Humor Levels of Vascular Endothelial Growth Factor in Retinitis Pigmentosa

PURPOSE To determine the level of vascular endothelial growth factor A (VEGF-A) in aqueous humors of patients with retinitis pigmentosa (RP). METHODS A prospective, comparative control study. Aqueous humor was collected from 16 eyes of 16 patients with RP. The level of VEGF-A was determined with a commercially available enzyme-linked immunosorbent assay kit. The control group comprised 16 aqueous samples from 16 patients about to undergo cataract surgery and without any other ocular or systemic diseases. RESULTS The concentration of VEGF-A in aqueous humor was markedly lower in patients with RP than in control subjects (Mann-Whitney U test, P < 0.001). The level of VEGF-A was 94.9 +/- 99.8 (mean +/- SD) pg/mL in eyes with RP and 336.5 +/- 116.8 pg/mL in the eyes of the control group. CONCLUSIONS In patients with RP, the concentration of VEGF-A in aqueous humors is lower than in non-RP subjects. The lack of angiogenic actions attributed to VEGF-A may explain some of the clinical manifestations of this disease, such as narrowing and fibrotic degeneration of retinal blood vessels.

Acute endothelial failure after cosmetic iris implants (NewIris

We report a case of an acute endothelial failure after the implantation of a new cosmetic, colored, artificial iris diaphragm implant called NewIris®. A 21-year-old woman came to us complaining of progressive loss of vision and pain after NewIris lenses had been implanted. Decreased visual acuity, corneal edema, and increased intraocular pressure in both eyes appeared only 3 weeks after the surgery. The lenses were removed as soon as possible but had already severely affected the endothelial cell count. NewIris implants are an alternative to cosmetic contact lenses, but they are not as safe as other phakic anterior chamber intraocular lenses, nor are they a good option for the patient.

Prophylaxis of Macular Edema with Intravitreal Ranibizumab in Patients with Diabetic Retinopathy after Cataract Surgery: A Pilot Study

The purpose of this study was to evaluate the effectiveness of intravitreal ranibizumab (Lucentis, Genentech, South San Francisco, Calif, USA) combined with cataract surgery for the prevention of clinically significant macular edema (CSME) in patients with diabetic retinopathy (DR). This prospective interventional case series included fifty-four eyes of 54 patients with a previous diagnosis of nonproliferative diabetic retinopathy (NPDR) without macular edema preoperatively. Subjects were assigned in a 1 : 1 ratio to receive an intraoperative intravitreal ranibizumab injection (n = 27) or not (control group, n = 27) associated with standardised phacoemulsification surgery. The main outcome measure was the incidence of CSME one and three months after surgery. One month after surgery the incidence of CSME in the control group was 25.92% and 3.70% in the treatment group and at three months was 22.22% and 3.70%, respectively. Short-term results suggest that intravitreal ranibizumab immediately after phacoemulsification prevents CS ME in patients with NPDR.

Bilateral intraorbital abscesses and cavernous sinus thromboses secondary to Streptococcus milleri with a favorable outcome.

A 51-year-old woman with left proptosis, diplopia, headache, and nausea was found to have bilateral intraorbital abscesses, left superior ophthalmic vein thrombosis, bilateral cavernous sinus thromboses, and a left temporal lobe intracerebral abscess. Because the paranasal sinuses were unaffected, a dental origin was suspected and confirmed. The causative organism was Streptococcus milleri. Aggressive surgical intervention included bilateral orbital abscess drainage and dental extraction, and medical therapy included intravenous metronidazole, ceftriaxone, heparin, and methylprednisolone. A left sixth cranial nerve paresis was the only long-term sequela.