Raul N. G Vianna

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.

Combination of azathioprine and corticosteroids in the treatment of serpiginous choroiditis

BACKGROUNDnAlthough therapy with immunosuppressive agents is currently accepted as the best option for treating active serpiginous choroiditis (SC), there is no consensus on the most effective immunosuppressive drug to use. In this paper, we describe the clinical course of patients with active SC treated with azathioprine (AZA) in combination with corticosteroids.nnnMETHODSnThis retrospective study included 4 patients (5 eyes) with active, vision-threatening SC who received systemic immunosuppression with AZA at 1.5 to 2.0 mg/kg per day. In combination with oral AZA, patients also received 1 mg/kg oral prednisone per day. Information collected included Snellen visual acuity (VA), clinical disease activity, duration of follow-up, rate of inflammation recurrence, and side effects of AZA.nnnRESULTSnWithin 3 weeks of treatment, all patients experienced decreased ocular inflammation and improved VA. One patient, however, had a recurrence in both eyes while oral prednisone was being tapered. In this case, once the dosage of oral prednisone was increased and methotrexate was added to the therapeutic scheme, inflammation was controlled within 1 month. The other 3 patients presented no further visual loss while on AZA and were able to taper and then discontinue oral prednisone. Nevertheless, SC recurred in 1 of these patients 40 months after the initial treatment. AZA was reintroduced but the patient complained of gastrointestinal problems, and it was then successfully replaced by mycophenolate mofetil. None of the 4 patients presented serious systemic side effects secondary to AZA.nnnINTERPRETATIONnThis study suggests that when AZA is used in combination with corticosteroids it is a safe and acceptable option for treating patients with active SC. Side effects and recurrences while on AZA therapy can occur, requiring either replacement of the drug or addition of another immunosuppressive agent.

Late-stage diffuse unilateral subacute neuroretinitis: photocoagulation of the worm does not improve the visual acuity of affected patients.

Background and objective: To evaluate the visual outcome following direct laser photocoagulation of the worm in patients with late-stage diffuse unilateral subacute neuroretinitis (DUSN). Patients and methods: The study reports on 22 DUSN patients diagnosed in its late stage, in whom the worm was identified and subsequently destroyed by laser photocoagulation. Information gathered included initial and final visual acuities and length of follow-up. Statistical analysis was performed with the Paired Student’s t-Test. A pvalue of less than 0.05 was considered significant. Results: After a mean follow-up of 13.1xa0months, visual acuity improved in 2 patients, remained unchanged in 19 patients and decreased in one patient. Comparison of the visual outcome before and after laser treatment was not statistically significant (p = 0.302). Conclusion: Destruction of the worm by laser photocoagulation in eyes with late-stage DUSN does not improve the visual acuity of affected patients.

Indocyanine-green angiography in acute idiopathic exudative polymorphous vitelliform maculopathy.

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

PURPOSEnTo report a patient with Crohns disease and acute decreased vision in one eye secondary to multifocal choroiditis and serous retinal detachment.nnnMETHODSnA complete ocular examination, including fluorescein angiography, was performed.nnnRESULTSnFundus 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.nnnCONCLUSIONSnChorioretinal 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).

The role of ultrasound biomicroscopy in predicting the result of temporal artery biopsy in temporal arteritis patients: a preliminary study.

Purpose Temporal artery biopsy is considered the gold standard for the diagnosis of temporal arteritis (TA). However, complications following this procedure may occur. The goal of this study is to evaluate if ultrasound biomicroscope (UBM) findings are useful in predicting the result (positive or negative) of temporal artery biopsy in patients with TA. Methods Twenty-six consecutive patients with clinical diagnosis of TA seen at the Department of Ophthalmology, Royal Victoria Hospital, Montreal, Canada, were involved in this study. All patients were submitted to UBM before temporal artery biopsy. Eight patients presented histopathologic findings consistent with the diagnosis of TA. Thus, UBM findings of these patients were compared with those from 18 patients with negative biopsy. On UBM we searched for the presence of a hypoechoic effect surrounding the walls of the temporal arteries, the so-called halo sign, as well as an intra-arterial middle reflexive filling, the so-called intra-arterial filling. Results The halo sign and/or the intra-arterial filling were found in 8 (100%) of 8 patients with biopsy-proven TA. However, 10 (55.5%) of 18 patients with a negative biopsy presented one or both of these two UBM findings. On the other hand, the absence of these two parameters on the UBM of a patient with TA strongly suggests that the temporal artery biopsy will be negative (negative predictive value=100%). Conclusions This preliminary work suggests that UBM may play a role in predicting a negative result of the temporal artery biopsy in patients with TA. In the present series approximately 30% of the patients could be spared this surgical procedure and its possible complications.

Oncocytoma of the Caruncle: A Clinicopathologic Case Report

Background: Oncocytoma is an uncommon, relatively benign tumor, composed of transformed epithelial cells of the ducts. We report a case of oncocytoma of the caruncle. Methods Case report. Results: A 51-year-old woman with a 2xa0years history of a mass located in the caruncle of her right eye was presented. Surgical excision was then performed, and the histological diagnosis of oncocytoma was established. Conclusion: The oncocytoma should be considered in the differential diagnosis of a caruncular mass in elderly people, particularly in female patients.

Cyclooxygenase-2 expression in human irradiated uveal melanomas

AimPrevious studies have shown that radiotherapy is a stimulus for cyclooxygenase-2 (COX-2) expression and that use of COX-2 inhibitors enhances the radio sensitivity of tumor cells. The objective of this study was to evaluate COX-2 expression, and its correlation with tumor regrowth after irradiation, in enucleated eyes with uveal melanomas.MethodsFifteen tissue samples from patients who underwent enucleation after radiotherapy between 1988 and 2001 were used. Nine cases (60%) were enucleated because of tumor regrowth and six (40%) because of severe complications of radiotherapy. Specimens were immunostained for COX-2, and tumor cells were evaluated for specific cytoplasmic and granular immunostaining. COX-2 expression for these cases was compared with that in the previous study including 40 non-irradiated uveal melanoma cases. COX-2 expression was also correlated with tumor regrowth after radiotherapy.ResultsTwo cases (13.3%) were positive and thirteen (86.7%) were negative for COX-2 expression. One of the positive cases had been enucleated because of tumor regrowth and one because of radiotherapy complications. There was no relationship between tumor regrowth and COX-2 expression. COX-2 expression was significantly lower in irradiated cases than in non-irradiated cases in the previous study (pxa0<xa00.001).ConclusionsIn contrast with studies showing an increase of COX-2 expression in other irradiated malignancies, irradiation was not a factor inducing COX-2 in uveal melanomas. Radiotherapy may, moreover, be a factor that reduces COX-2 expression in uveal melanomas.

Extração da catarata pela técnica de facoemulsificação em pacientes com uveíte

PURPOSEnTo report outcomes of cataract extraction by phacoemulsification in patients with uveitis.nnnMETHODSnWe retrospectively reviewed the charts of 189 patients (242 eyes) with uveitis who underwent cataract extraction by phacoemulsification at the Uveitis and Ocular Immunology Unit of McGill University Health Centre, Montreal, Quebec, Canada.nnnRESULTSnAverage follow-up was 46 +/- 31.2 months. Average preoperative visual acuity was 20/100 and average postoperative visual acuity was 20/40. Hundred and forty-six eyes (59.9%) attained visual acuity better than 20/40. Visual loss occurred in 26 eyes. The most common peroperative complication was posterior capsule rupture with vitreous loss seen in 7 eyes (3%). Recurrence of uveitis was the most common postoperative complication seen in 73 eyes (30.16%). Other postoperative complications included iris atrophy (28.51%), ocular hypertension (28.09%), epiretinal membrane (26.44%), posterior capsule opacification (19%), cystoid macular edema (13.63%), ocular hypotony (12.80%), optic disc atrophy (8.67%) and posterior synechiae (6.61%).nnnCONCLUSIONSnCataract extraction by phacoemulsification is safe in patients with uveitis. Successful visual results are observed in long-term follow-up despite the prevalence of recurrence of uveitis, posterior capsule opacification and macular abnormalities. To the best of our knowledge this is the largest series presented to date.

Scleral buckling surgery and eye pain: assessment of chronic eye pain during the postoperative period of scleral buckling surgery.

Purpose: To assess the progression of eye pain after scleral buckling surgery to treat rhegmatogenous retinal detachment and to investigate the occurrence and characteristics of chronic eye pain. Methods: This was a longitudinal, prospective, and observational study. Eye pain was measured according to a numerical analog scale (range, 0–10) for 6 months after scleral buckling surgery. The sample was divided into two groups, with or without chronic eye pain, to perform statistical analyses. For this study, chronic eye pain was defined as postoperative pain beyond 30 days. The following variables were assessed to investigate the etiology of chronic eye pain: age, gender, ethnicity, degree of myopia, visual acuity, intraocular pressure, and degree of scleral indentation. Results: A total of 100 patients were assessed in this study. One particular sequence of levels on the pain analog scale, specifically 3–2–1–0–0 (intensity of eye pain on postoperative Days 1, 14, 30, 60, and 180, respectively), was identified more frequently during the progression of eye pain in the 180-day follow-up period. The pain resolved for 72% of patients within 30 days. Chronic eye pain occurred in 18% of the patients. Scleral indentation was the only statistically significant variable investigated relative to the etiology of chronic eye pain (P < 0.05). Conclusion: Chronic eye pain correlated significantly with large scleral indentation. Patients with more intense pain at the onset of the postoperative period tended to develop chronic eye pain.