Pitipol Choopong

Daclizumab for treatment of birdshot chorioretinopathy.

OBJECTIVEnTo report the outcomes for daclizumab in the treatment of birdshot chorioretinopathy (BSCR) refractory to traditional immunomodulatory therapy (IMT).nnnMETHODSnWe retrospectively reviewed medical records of 8 patients with BSCR whose disease was refractory to or who were intolerant of traditional IMT. All patients received 1 mg/kg of daclizumab intravenously at 2-week intervals initially at 1 referral uveitis practice. Main outcome measures were changes in visual acuity, vitreous inflammation, fluorescein angiographic pathologic features, electroretinography (ERG) parameters, concomitant IMT requirements, and adverse events.nnnRESULTSnOver a mean follow-up of 25.6 months, 7 patients had either stabilization or improvement in visual acuity of both eyes and complete resolution of vitreous inflammation. Six patients had resolution of vasculitis on fluorescein angiography. The ERG 30-Hz implicit times and the bright scotopic amplitudes worsened in some patients despite abolition of clinically evident inflammation. Four patients were able to discontinue all other IMT and remain inflammation free while receiving only daclizumab treatment. Two patients developed adverse effects that led to daclizumab treatment discontinuation.nnnCONCLUSIONSnDaclizumab therapy was effective in stabilizing vision and decreasing inflammation in most patients with BSCR. The ERG parameters continued to decline in some patients despite adequate inflammatory control. Regular serologic monitoring is critical to detect adverse events.

Melanocytic Lesions of the Conjunctiva

CONTEXTnMelanocytic proliferations are among the most common neoplasms of the conjunctiva. They often represent challenging lesions for pathologists unfamiliar with unique histologic features of melanocytic proliferations in this location and with nomenclature used by ophthalmologists.nnnOBJECTIVEnTo comprehensively review clinical aspects, pathologic features, and management of melanocytic proliferations of the conjunctiva.nnnDATA SOURCESnReview of the literature and personal experience of the authors.nnnCONCLUSIONSnClassification, state of the art, and practical aspects of pathology of melanocytic proliferations of the conjunctiva are discussed.

Clinical Manifestations of Cytomegalovirus-Associated Posterior Uveitis and Panuveitis in Patients Without Human Immunodeficiency Virus Infection

IMPORTANCEnLittle attention has been paid to clinical features of cytomegalovirus (CMV) infections in individuals without human immunodeficiency virus (HIV).nnnOBJECTIVEnTo describe the clinical manifestations and comorbidities of patients without HIV infection who have CMV-associated posterior uveitis or panuveitis.nnnDESIGN AND SETTINGnRetrospective observational case series in an academic research setting.nnnPARTICIPANTSnThe medical records were reviewed of 18 patients (22 affected eyes) diagnosed as having posterior uveitis or panuveitis who had aqueous positive for CMV by polymerase chain reaction techniques.nnnMAIN OUTCOME MEASURESnDemographic data, clinical manifestations, and associated systemic diseases were recorded.nnnRESULTSnOcular features included focal hemorrhagic retinitis (n = 13) and peripheral retinal necrosis (n = 7). Two eyes had no focal retinal lesions but manifested vasculitis and vitritis. All patients exhibited vitreous inflammation. Inflammatory reactions in anterior segments developed in 14 of 22 eyes (64%). Retinal vasculitis was observed in 16 of 22 eyes (73%) and included mostly arteries (in 13 of 16 eyes [81%]). Eleven of 18 patients were taking immunosuppressive medications (5 for hematologic malignant diseases, 4 for systemic autoimmune diseases, and 2 following organ transplants). One additional patient was diagnosed as having non-Hodgkin lymphoma 3 months after the onset of CMV-associated panuveitis, and another patient had primary immunodeficiency disorder. Of the remaining 5 patients, 2 had diabetes mellitus, and 3 had no associated systemic diseases and exhibited no evidence of immune deficiency.nnnCONCLUSIONS AND RELEVANCEnCytomegalovirus-associated infections of posterior eye segments can develop in patients without HIV infection who have compromised immune function of variable severity but may occur also in individuals who have no evidence of immune insufficiency. Cytomegalovirus infections located in posterior eye segments in patients without HIV infection caused intraocular inflammatory reaction in all cases and demonstrated more variable clinical presentation than classic CMV retinitis observed in patients with HIV infection.

Frosted branch angiitis as a result of immune recovery uveitis in a patient with cytomegalovirus retinitis

BackgroundSince the introduction of Highly Active Antiretroviral Therapy (HAART), AIDs related morbidity and mortality have declined. However, the advent of HAART brought the new problem of immune recovery inflammatory syndrome. Cytomegalovirus retinitis remains the most common cause of visual loss in AIDs patients. Some patients with cytomegalovirus retinitis who experienced immune recovery as a consequence of HAART develop worsening of visual symptoms from immune recovery uveitis (IRU).FindingsWe report a case of cytomegalovirus retinitis and AIDs who developed an unusual presentation of IRU after the initiation of HAART. A 40-year-old woman presented with a history of blurry vision in the right eye. She was diagnosed with human immunodeficiency virus infection and cytomegalovirus retinitis, treated with intravitreal injections of ganciclovir. The retinitis improved. One week after HAART initiation, she developed IRU, characterized by increased intraocular inflammation, extensive frosted branch angiitis and cystoid macular edema. The CD4+ T lymphocyte count increased from 53 to 107 cells/mm3. Systemic prednisolone with continuation of HAART and intravitreal injections of ganciclovir were given with significant improvement.ConclusionAtypical presentation of IRU, characterized by extensive frosted branch angiitis and increased intraocular inflammation may occur in immunocompromised patients with cytomegalovirus retinitis who experienced immune recovery. The time from HAART initiation to develop IRU may vary from days to months. This case demonstrated a very rapidly developed IRU which should be recognized and appropriately managed to avoid permanent damage of the eye.

Crystallization after intravitreal ganciclovir injection.

Purpose: To report crystal formation as a complication of intravitreal ganciclovir injection. Patients and methods: A 73-year-old female patient with unilateral cytomegalovirus retinitis was treated with intravitreous ganciclovir (4 mg/0.04 mL). Results: After the intravitreal injection, sudden crystallization was observed in the vitreous humor. The patient experienced marked reduction in visual acuity and increased intraocular pressure. Despite aqueous paracenthesis and pars plana vitrectomy, optic atrophy was observed and her visual acuity remained unimproved after 12 months. Conclusion: Crystal formation can occur as a complication of intravitreal ganciclovir injection. Associated retinal and optic nerve damage was found which results in permanent visual morbidity.

Eosinophil activation in Wegener's granulomatosis: a harbinger of disease progression?

Purpose: To investigate the relation between eosinophil activation in tissue from patients with an active, limited form of Wegeners granulomatosis (WG) affecting the eye and subsequent systemic disease activity. Methods: Analysis of ocular specimens obtained from 10 patients was performed. Sections were probed with antibodies to assess the presence of major basic protein (MBP) and eosinophil cationic protein (ECP). Results: Four of the 10 specimens demonstrated the presence of MBP and ECP. WG progressed to the complete form in two of these patients, who received no or inadequate treatment. The other two, treated with cyclophosphamide for one year, did not progress to the complete form of WG during observation after therapy. Conclusions: Activated eosinophils in sclera or conjunctiva of patients with ocular limited WG may predict progression to complete WG.

Solitary myofibroma of the sclera.

Purpose: To report a novel case of solitary myofibroma involving the sclera. Methods: Case report and review of the literature. Results: A 19-year-old woman had an expanding and painful epibulbar mass clinically diagnosed as nodular scleritis that did not respond to anti-inflammatory therapy. A biopsy showed a proliferation of spindle-shaped cells that reacted strongly positively with immunoperoxidase stains for vimentin and smooth-muscle actin. The diagnosis of solitary myofibroma was made. Six months postoperatively, the patient was well, and the lesion had not recurred. Conclusions: Myofibroma should be considered in the differential diagnosis of an epibulbar mass, especially in the setting that would mimic nodular scleritis.

Treatment outcomes of reduced-dose intravitreal ganciclovir for cytomegalovirus retinitis

BackgroundCytomegalovirus retinitis (CMVR) is one of the most common opportunistic infection in immunocompromised individuals. Intravitreal ganciclovir injection has been used successfully but no standard regimen was established. Risks of drug toxicity, endophthalmitis, and injection-related complications increased with number and frequency of injection. The aim of this study is to evaluate the outcomes of reduced-dose intravitreal ganciclovir (2xa0mg/0.04xa0mL) for the treatment of CMVR.MethodsA prospective observational cohort study involving 67 eyes of 49 patients with CMVR was performed. Induction therapy involved intravenous ganciclovir (10xa0mg/kg/day) for 2xa0weeks unless contraindicated or patients refused. Patients were then treated with reduced-dose intravitreal ganciclovir every week for 4xa0weeks, and then every other week until the lesion healed. The patients’ demographic data were recorded, and vision parameters were examined every visit.ResultsTwenty eyes (29.9xa0%) presented with initial visual acuities less than 6/60. The majority of patients were diagnosed with CMVR in zones 1 or 2 (63 eyes, 94xa0%), and, at least, one quadrant of the retina was involved (56 eyes, 83.6xa0%). Forty-one eyes (61.2xa0%) completely resolved after treatment within the 6-month follow-up. There was no significant difference in healing time, whether or not patients received induction treatment with intravenous ganciclovir (111.00u2009±u200912.96 vs 105.00u2009±u200928.32xa0days, pu2009=u20090.8). Five eyes (12.2xa0%) of patients with healed CMVR had visual acuities less than 6/60.ConclusionsReduced-dose intravitreal ganciclovir is a safe and effective treatment option. It provides comparable results to other weekly regimens. Induction with intravenous ganciclovir is not crucial in a resolution of retinitis, although it may be necessary to reduce systemic cytomegalovirus loads and mortality rates.Trial registrationThe trial was registered with Thai Clinical Trials Registry (TCTR) on 16 March 2016 – TCTR20160316001.

Uveitis in Siriraj Hospital: pattern differences between immune-related uveitis and infectious uveitis in a university-based tertiary care hospital

PurposeTo describe a proportion of uveitis and to analyse differences between immune-related uveitis and infectious uveitis groups.MethodsA retrospective study of 458 uveitis patients were categorized into immune-related uveitis, infectious uveitis, masquerade, and undetermined groups. The pattern of inflammation was described. Subgroup analysis was performed to compare pattern differences between immune-related uveitis and infectious uveitis groups.ResultsThe most common location of inflammation was the anterior eye segment. Vogt-Koyanagi-Harada disease was the most common identifiable cause. From multivariate analysis, variables found to be significantly different between immune-related uveitis group and infectious uveitis group were age of onset, presence of systemic autoimmune diseases, HIV infection, and laterality.ConclusionsIdiopathic anterior uveitis was the most prevalent diagnosis. Vogt-Koyanagi-Harada disease was the most common identifiable uveitis. Most immune-related uveitis patients were young and presented with chronic bilateral panuveitis, with most patients in the infectious uveitis group presenting with chronic unilateral posterior uveitis.

Late-onset postoperative Mycobacterium haemophilum endophthalmitis masquerading as inflammatory uveitis: a case report

BackgroundAlthough atypical mycobacteria had been increasingly found in various ocular infections in the past decades, a slow-growing Mycobacterium haemophilum (M. haemophilum) was scarcely reported. Similar to tuberculous infection, the presentation can masquerade as low-grade granulomatous intraocular inflammation with partial response to corticosteroids. Besides, the special requirements for culture make this pathogen difficult to diagnose. The study aims to report the clinical presentation and notify the awareness of NTM endophthalmitis among clinicians. This is the first case report of late-onset, postoperative M. haemophilum endophthalmitis in the literature.Case presentationA 66-year-old man with non-insulin-dependent diabetes mellitus (NIDDM) manifested chronic granulomatous inflammation in the left eye after multiple glaucoma surgeries. With a diagnosis of noninfectious panuveitis, he was treated with systemic corticosteroids. The inflammation initially responded to therapy although it subsequently worsened and became purulent endophthalmitis. The vitreous cultures grew M. haemophilum. Intraocular and systemic antimicrobial treatments were administered early, but the patient eventually turned blind.ConclusionsM. haemophilum endophthalmitis is a rare but serious intraocular complication leading to loss of vision or eyeball. Awareness of atypical mycobacterial infections is necessary especially in patients with impaired immune function, previous intraocular surgery, and corticosteroid resistance. Proper laboratory investigations and treatments should be performed. However, due to the rarity of the disease, the development of guidelines for its investigation and therapy is still challenging.