Pinar Ozdal

ORIGINAL ARTICLE Visual Outcome of Juvenile Rheumatoid Arthritis-Associated Uveitis in Adults

Purpose: Juvenile rheumatoid arthritis (JRA) is the systemic disease most frequently associated in childhood uveitis. The disease may cause several ocular complications, visual impairment, and blindness. Recent studies revealed a more favorable ocular prognosis. Our purpose was to analyze the long-term visual outcome of JRA-associated uveitis. Methods: Ocular complications and visual outcome in adult patients with JRA-associated uveitis were evaluated. Among 18 patients included in the study, uveitis was bilateral in 12 (66.7%) and unilateral in six (33.3%), for a total of 30 eyes with ocular involvement. Results: The mean durations of JRA and its associated uveitis were 24.9 and 20.5 years, respectively. All eyes (100%) had at least one ocular complication. The most frequently observed ocular complications were cataract (83.3%), band keratopathy (60%), posterior synechia (46.7%), glaucoma (33.3%), hypotony (16.7%), and macular pathology (13.3%). Final visual acuity was impaired in 40% of the eyes, poor in 20%, and totally lost in 10%. Therefore, 70% of the eyes were either visually handicapped or totally blind. Most eyes underwent at least one surgical procedure. Inflammation was active at last examination in 63.3% of eyes. All patients were still treated topically and with systemic NSAID. Sixty-one percent of the patients were using an immunosuppressive agent. Conclusion: JRA-associated uveitis still has a severe course and blinding potential. Patients suffer from uveitis and its complications even during the adulthood period. However, because our series represents a more severe subset of the disease, the outcome may be poorer than that of some other outcome studies.

Comparison of autofluorescence and optical coherence tomography findings in acute and chronic central serous chorioretinopathy.

AIM To discuss and compare the fundus autofluorescence (FAF) and optical coherence tomography (OCT) in acute or chronic central serous chorioretinopathy (CSCR). METHODS Medical records of 100 cases of CSCR were reviewed. Acute and chronic cases were evaluated according to the duration of decreased visual acuity, serous retinal detachment (RD) and focal leakage on fluorescein angiography (FA). Chi-square test was used for statistical analysis. RESULTS Forty cases had acute and 60 cases had chronic CSCR. FAF showed focal hypo-autofluorescence in 34 (85%) and iso-autofluorescence in 6 (15%) of acute cases and hypo-autofluorescence in 51 (85%), hyper-autofluorescence in 6 (10%) and iso-autofluorescence in 3 (5%) of chronic cases. OCT showed serous RD with distinct borders correlated with FAF findings (hypo-autofluorescence) in all acute CSCR cases. In chronic CSCR group, OCT showed serous RD with indistinct borders correlated with FAF findings. The differences between the OCT and FAF findings of the two groups were significant (P=0.000). CONCLUSION OCT and FAF findings can support the clinical observations in differential diagnosis of acute and chronic CSCR and help clinicians to evaluate retinal pigment epithelium, outer segments of photoreceptors and the components of serous RD.

Safety and Efficacy of Gevokizumab in Patients with Behçet’s Disease Uveitis: Results of an Exploratory Phase 2 Study

ABSTRACT Purpose: To evaluate the safety and efficacy of gevokizumab for the treatment of Behçet’s disease uveitis in a prospective, open-label, randomized phase 2 trial. Methods: Behçet’s disease patients with new acute ocular exacerbation or at risk of exacerbation received 30 or 60 mg gevokizumab every 4 weeks intravenously or subcutaneously, on top of a stable regimen of immunosuppressives and corticosteroids (≤20 mg/day equivalent prednisolone). Patients withdrew in cases of ocular exacerbation. Results: A total of 21 patients were included (17 acute and 4 at-risk; mean duration of uveitis 45.6 ± 37.4 months). There were no serious adverse events related to gevokizumab. Recorded adverse events were mostly associated with exacerbation of uveitis or its complications. Response was evaluated for 14 acute patients and all showed rapid control of acute ocular exacerbation, mostly within 1 week, without any increase in corticosteroid dosage. Conclusions: Gevokizumab was well tolerated and rapidly controlled acute ocular exacerbations of Behçet’s disease uveitis without the need for high-dose corticosteroid.

Factors influencing treatment results in pseudophakic endophthalmitis.

Purpose To evaluate risk factors, therapeutic approaches and factors associated with the poor visual outcome in pseudophakic endophthalmitis. Methods Data related to 28 cases with the diagnosis of endophthalmitis after cataract surgery and IOL implantation were gathered retrospectively. Results Preceding surgery was extracapsular cataract extraction (ECCE) in 18, phacoemulsification in 8 and scleral fixated intraocular lens implantation in two cases. Posterior capsule rupture and diabetes mellitus were considered to contribute to the development of endophthalmitis because of their high incidences (50% and 25%) in the study group. Microbiological studies from aqueous and vitreous humour were done in 85% of the cases and 58% were positive. S. Epidermidis was the most common organism, accounting for 50% of the isolates. All cases were given topical and systemic antibiotics. Inflammation was controlled by addition of subconjunctival antibiotics to this regimen in two, intravitreal antibiotic injection in 14, pars plana vitrectomy, total capsular and lens extraction and intravitreal antibiotic injection in three, lens exchange, intracapsular and intravitreal antibiotic injection in three cases. Six (21%) cases eventually needed evisceration. Visual acuity of 20/40 or better was achieved in 25%, and 20/100 or better in 64%. Conclusions Treatment delay (p=0.039), capsular rupture complicating cataract surgery, especially with extracapsular cataract extraction (p=0.015), and initial visual acuity worse than hand motion (p=0.003) were strong predictors of poor visual outcome. The risk of endophthalmitis was not different for planned ECCCE (0.26%) and phacoemulsification (0.27%) but the prognosis was better with the latter.

Ultrasound biomicroscopy of pseudophakic eyes with chronic postoperative inflammation

Purpose: To evaluate the ultrasound biomicroscopy (UBM) findings in pseudophakic eyes with chronic noninfectious postoperative inflammation and discuss the use of the technique in these cases. Setting: Uveitis Service, Department of Ophthalmology, McGill University, Montréal, Québec, Canada. Methods: Fifty‐four eyes of 51 patients with chronic noninfectious postoperative inflammation were prospectively evaluated between January 1998 and September 2001. Patients with aphakia, a dislocated intraocular lens (IOL) in the posterior segment, and endophthalmitis were excluded. All patients had a UBM examination that comprised locating the IOL position, investigating the presence of lens remnants, and evaluating the anterior segment of the eye. Results: Ultrasound biomicroscopic examination revealed IOL misplacement in 37 eyes (68.5%). Of these, 23 (62.2%) had a sulcus‐implanted posterior chamber IOL (PC IOL), 9 (24.3%) an in‐the‐bag PC IOL, and 5 (13.5%) an anterior chamber IOL. Haptic misplacement was significantly higher with sulcus‐implanted PC IOLs than with in‐the‐bag PC IOLs (P<.01). Other UBM findings included edematous ciliary body processes and hypoechogenic and/or thickened ciliary bodies in 11 eyes (20.4%), peripheral anterior synechias in 8 eyes (14.8%), a significant number of lens remnants (graded as severe) in 6 eyes (11.1%), a thick cyclitic membrane in 3 eyes (5.6%), and an early cyclitic membrane in 2 eyes (3.7%). Conclusions: Irritation of ocular tissues by an IOL was the main cause of chronic postoperative noninfectious inflammation in pseudophakic eyes. Therefore, detecting the IOL position and its relationships to ocular tissues is very important in planning the treatment. Ultrasound biomicroscopy is a practical method that accurately provides this information.

Benign ocular adnexal tumours of a ocrine eccrine or hair follicle origin

BACKGROUND The differential diagnosis of malignant eyelid tumours, particularly basal cell carcinoma (BCC), includes tumours of skin appendages. The incidence of these adnexal tumours has not been well established. This study aimed to determine the incidence and review the main clinicopathological features of benign tumours arising from skin appendages of the eyelid with apocrine, eccrine or hair follicle differentiation. METHODS The histopathological diagnoses of 7751 ophthalmic specimens retrieved from 6967 patients between September 1993 and March 2002 at the Henry C. Witelson Ophthalmic Pathology Laboratory and Registry, McGill University, Montreal, were retrospectively reviewed. Clinical data and histopathological diagnoses were obtained for 228 benign adnexal tumours of apocrine, eccrine or hair follicle origin. New histopathological slides were made from the paraffin-embedded specimens and stained with hematoxylin-eosin and periodic acid-Schiffs reagent. RESULTS Of the 228 benign adnexal tumours, 182 were diagnosed as apocrine or eccrine hydrocystoma (79.8%), 12 pilomatrixoma (5.3%), 12 syringoma (5.3%), 11 trichilemmoma (4.8%), 5 syringocystadenoma papilliferum (2.2%), 3 trichoepithelioma (1.3%) and 3 trichofolliculoma (1.3%). Discrepancies between clinical and histopathological diagnoses were noted in 22 cases (9.6%). INTERPRETATION Benign tumours originating from skin appendages of the eyelid are rare and frequently have apocrine or eccrine differentiation. These tumours, particularly those originating from the hair follicle, should be considered in the differential diagnosis of BCC of the eyelid.

Vogt-Koyanagi-Harada Syndrome in Children: Report of a Case and Review of the Literature

This article reviews the therapeutic approaches in children with Vogt-Koyanagi-Harada (VKH) syndrome, and reports on a 9-year-old girl with progressive visual loss due to VKH syndrome in spite of treatment. In previous reports, corticosteroids were found to be the most effective agents in the treatment of VKH syndrome, while combination therapies with cyclosporine, methotrexate, or azathioprine were used with favorable results in refractory cases. In the current case, none of the treatments sufficiently stabilized the vision, but triple combination of corticosteroids, cyclosporine, and methotrexate suppressed the relapses of intraocular inflammation. Treatment of children with VKH syndrome is challenging. Various treatment modalities have been reported with various responses, but there is still no definite treatment regimen, and the treatment is usually individualized in pediatric VKH cases.

Trimethoprim/Sulfamethoxazole and Azithromycin Combination Therapy for Ocular Toxoplasmosis

Purpose: To evaluate the efficacy and safety of trimethoprim/sulfamethoxazole and azithromycin combination for the treatment of ocular toxoplasmosis. Methods: Nineteen ocular toxoplasmosis patients treated with trimethoprim/sulfamethoxazole and azithromycin ± corticosteroid combination were retrospectively reviewed. Demographic data, clinical findings, the time interval until resolution of inflammation, recurrences, and drug side effects were collected. Results: The mean follow-up time of the patients was 25.0 ± 22.5 (range; 6 –66) months. Final visual acuity improved with a mean of 6 ± 4 lines in 15 patients (78.9%). Inflammatory findings began to subside within 14.8 ± 10.0 days. Three patients (15.8%) had recurrent attack. Only 1 patient (5.3%) had side effects from therapy. Conclusions: Trimethoprim/sulfamethoxazole and azithromycin combination is an effective and safe treatment modality for the treatment of ocular toxoplasmosis.

The risk of other primary cancer in patients with uveal melanoma: a retrospective cohort study of a Canadian population.

BACKGROUND The incidence of second primary malignant tumours has doubled during the last 2 decades. These tumours now represent the sixth most common group of cancers. Many authors have described the presence of multiple primary cancers in patients with uveal melanoma. However, no studies have been performed using Canadian data. The purpose of this study was to describe the occurrence of other primary cancers diagnosed before or after uveal melanoma and to calculate the incidence of subsequent primary cancer in a Canadian cohort with uveal melanoma. METHODS We conducted a retrospective study of a cohort of patients with uveal melanoma diagnosed between 1990 and 2002 at a university-affiliated centre in Montreal. We reviewed medical records to identify patients in whom other, unrelated primary malignant disease had been diagnosed. We used the standardized incidence ratio to calculate the risk of development of a second, unrelated cancer following the diagnosis of uveal melanoma. RESULTS A total of 129 cases of uveal melanoma were diagnosed. Eighteen patients (14%) also had a diagnosis of an unrelated primary cancer. In nine patients the other cancer had been diagnosed first, and in nine patients the other tumour had been diagnosed after the uveal melanoma. There was no increased risk of development of any particular form of cancer studied for females or males. INTERPRETATION In our Canadian cohort, statistical analysis showed no increased risk of a second cancer, overall or by organ site, in male or female patients with uveal melanoma. As uveal melanoma is a rare type of cancer, analyses of a much larger cohort may be needed to accurately estimate the risk of development of a second primary cancer in patients with uveal melanoma.

Multifocal choroiditis--an unusual finding in Crohn's disease.

PURPOSE To report a patient with Crohns disease and acute decreased vision in one eye secondary to multifocal choroiditis and serous retinal detachment. METHODS A complete ocular examination, including fluorescein angiography, was performed. RESULTS Fundus biomicroscopy disclosed multifocal, deep, discretely elevated yellowish lesions at the posterior pole of the affected eye. Fluorescein angiographic study of these lesions revealed early hypofluorescence followed by late yperfluorescence. Subtenonian injection of corticosteroids rapidly induced remission of the choroidal lesions. CONCLUSIONS Chorioretinal involvement in patients with Crohns disease may or may not be related to reactivation of this disorder. Therefore, even patients without gastrointestinal symptoms who present with posterior segment inflammation must be informed of this. The chorioretinal inflammatory lesions do seem to respond promptly to periocular injection of corticosteroids. (Eur J Ophthalmol 2004; 14: 345-9).