Richard Stawell

Syphilitic Punctate Inner Retinitis in Immunocompetent Gay Men

PURPOSE To describe the features of an unusual syphilitic uveitis syndrome in a cluster of homosexual patients. DESIGN Retrospective case series. PARTICIPANTS Five consecutive patients diagnosed with syphilitic retinitis in our Melbourne uveitis clinic over a period of 8 months. METHODS The case notes of patients diagnosed with syphilitic retinitis were reviewed and the clinical features are presented and discussed. MAIN OUTCOME MEASURES Description of retinal findings and documentation of any associated sequelae. RESULTS All patients were homosexual men. Two were human immunodeficiency virus positive. None of the patients had been previously diagnosed with syphilis, although 3 presented with systemic symptoms and signs of secondary syphilis. All patients had marked anterior uveitis and vitritis. All patients had acute retinal arteriolitis and inner retinitis, with distinctive, inner retinal and preretinal white dots. These retinal findings were remarkably similar in all patients, and resolved with little or no sequelae after standard systemic treatment for syphilis, combined with oral prednisolone. CONCLUSIONS Syphilitic retinitis may be an increasingly common clinical problem, reflecting the growing incidence of syphilis among homosexual men in Australia. Our patients showed stereotypical ocular and systemic features, which are useful in differentiating this condition clinically from other types of acute posterior uveitis, such as necrotizing viral retinitis. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Acute retinal necrosis: a case series with clinical features and treatment outcomes

Purpose:  To determine clinical features, viral aetiology and treatment outcomes of eyes with acute retinal necrosis (ARN).

Nd:YAG laser iridotomy in uveitic glaucoma

Purpose: To determine the survival of Nd:YAG laser peripheral iridotomy in those patients with angle closure glaucoma and iris bombé associated with uveitis.

Uveitis in Herpes zoster ophthalmicus

Background: Herpes zoster ophthalmicus (HZO) is a common condition occurring mostly in healthy people. Approximately 50% of HZO patients develop ocular complications, with iridocyclitis occurring in about 43%. This study aimed to identify the clinical features of uveitis secondary to HZO.

Toxocara canis: egg presence in Melbourne parks and disease incidence in Victoria.

Purpose: Toxocara canis can cause blinding eye disease. This study assessed the presence of T. canis eggs in soil from parks in Melbourne and also the incidence of presumed ocular toxocariasis in Victoria.

The course of uveitis in pregnancy and postpartum

Aim To examine the course of non-infectious uveitis during pregnancy. Methods This is a retrospective case series. The medical records of 47 subjects with a previous history of non-infectious uveitis pre-dating their pregnancy were reviewed. Uveitis activity during the periods 1 year before pregnancy, during pregnancy and 1 year postpartum, were recorded. Information on patient demographics, type of uveitis, medication use, sex of child and breastfeeding status were also collected. The main outcome measures were the events of flare-ups during the prepregnancy, pregnancy and postpartum periods. Results The rate of flare-up was 1.188 per person year prior to pregnancy, 0.540 per person year during pregnancy and 0.972 per person year in postpartum (p<0.001 for comparison between prepregnancy and pregnancy; p=0.009 for comparison between pregnancy and postpartum). Rates of flare-up only began to decrease in the second trimester. After delivery, rates of flare-up rebounded and within 6 months postpartum, flare-up rates were not significantly different from prepregnancy levels (p=0.306). Even so, 40% of subjects were found to have remained inactive within 1 year postpartum. Conclusions Uveitis activity decreased by mid-pregnancy, but returned to prepregnancy levels within 6 months postpartum. These findings may be used to adjust uveitis management during pregnancy and the postpartum period.

Familial amyloid polyneuropathy associated with the novel transthyretin variant Arg34Gly

We report a 57-year-old man with pathognomonic bilateral vitreo-lenticular amyloid opacities (pseudopodia lentis) in whom a novel transthyretin (TTR) mutation was identified. The patient presented due to bilateral floaters. The vitreous cavities of both eyes showed course, fibrilar opacities attached to the posterior lens surface with pseudopodia. There was a history of bilateral carpal tunnel syndrome. Nerve conduction studies showed upper and lower limb axonal polyneuropathy. Magnetic resonance imaging of the brain and spinal cord, renal and cardiac function were normal. Vitreous and conjunctival biopsies confirmed the diagnosis of TTR-related amyloidosis. Genetic analysis of exon 2 of the TTR gene revealed that the patient was heterozygous for a single nucleotide substitution c.160 A>G, resulting in replacement of arginine with glycine at position 34 of the mature protein (Arg34Gly). Five years later the patient developed increasing sensory and motor neuropathy of both lower limbs, and neovascular glaucoma in one eye. We hypothesize that the reason for his neovascular glaucoma was retinal ischaemia secondary to amyloid retinal vasculopathy.

Optical Coherence Tomography Evaluation in the Multicenter Uveitis Steroid Treatment (MUST) Trial

Purpose: To describe the evaluation of optical coherence tomography (OCT) scans in the Muliticenter Uveitis Steroid Treatment (MUST) trial and report baseline OCT features of enrolled participants. Methods: Time-domain OCTs acquired by certified photographers using a standardized scan protocol were evaluated at a reading center. Accuracy of retinal thickness data was confirmed with quality evaluation, and caliper measurement of centerpoint thickness (CPT) was performed when retinal thickness data were unreliable. Morphological evaluation included cysts, subretinal fluid, epiretinal membranes (ERMs), and vitreomacular traction. Results: Of the 453 OCTs evaluated, automated retinal thickness was accurate in 69.5% of scans, caliper measurement was performed in 26%, and 4% were ungradable. Intraclass correlation was.98 for reproducibility of caliper measurement. Macular edema (centerpoint thickness ≥ 240 μm) was present in 36%. Cysts were present in 36.6% of scans and ERMs in 27.8%, predominantly central. Intergrader agreement ranged from 78 to 82% for morphological features. Conclusion: Retinal thickness data can be retrieved in a majority of OCT scans in clinical trial submissions for uveitis studies. Small cysts and ERMs involving the center are common in intermediate and posterior/panuveitis requiring systemic corticosteroid therapy.

Methotrexate in inflammatory eye disease

Dr Richard J Stawell Ocular Immunology Clinic Royal Victorian Eye & Ear Hospital Locked Bag 8 East Melbourne Australia 3002 Tel: +61 3 9509 4233 Fax: +61 3 9500 9376 E-mail: rstawell@eyesurgery.com.au Methotrexate is now widely used in the management of uveitis as a steroid sparing and immunosuppressant drug. This is despite the lack of controlled trials to positively demonstrate its effectiveness.The basis for its use relies on a number of case series in inflammatory eye disease, and in the rheumatology literature where the drug’s use has been rigorously proven. Methotrexate’s mechanism of action is complex and not fully understood. It inhibits dihydrofolate reductase and folic acid metabolism thereby affecting the metabolism of actively proliferating cells such as lymphocytes. It has been shown to have a variety of effects at a molecular level. For example: TNF-a production is decreased by T cells in an arthritis model. It has been demonstrated in vitro that IL-4 and IL-10 expression are increased in rheumatoid arthritis patients treated with methotrexate. It suppresses the generation of some inflammatory mediators such as lipoxygenase products. The drug’s first reported use was by Farber in the treatment of acute leukaemia in children in 1948. This was followed a paper by Gubner in 1951 regarding a study in patients with psoriasis and rheumatoid arthritis. Rheumatologists have driven the research further with randomized double blind placebo controlled trials using methotrexate in rheumatoid arthritis. These studies have shown a significant reduction in the number of painful joints and that the toxicity of the drug was acceptable. Gastrointestinal side effects and hepatic toxicity are the most common problems. The latter is much reduced with low dose (10mgm to 25mg per week) oral treatment, compared with intravenous use. Bone marrow suppression, stomatitis, alopecia, headache and fever can also occur. Methotrexate is also teratogenic, so care must be taken with women of childbearing age. The toxic effects are probably due to the inhibition of dihydrofolate reductase, whilst the efficacy may be related to its other effects. Nausea, anorexia, stomatitis and diarrhoea can be minimized with the concomitant use of folic acid 1mgm daily. The data on methotrexate use in inflammatory eye disease is based on a number of small retrospective case series. Wong in 1965 was the

Corneal endotheliitis triggered by cataract surgery in a Chinese patient with cytomegalovirus anterior uveitis.

1. Hsuan KD, Selva D, McNab AA et al. Idiopathic sclerosing orbital inflammation. Arch Ophthalmol 2006; 124: 1244–50. 2. Rootman J, McCarthy M, White V et al. Idiopathic sclerosing inflammation of the orbit. A distinct clinicopathologic entity. Ophthalmology 1994; 101: 570–84. 3. Villarroel MC, Hidalgo M, Jimeno A. Mycophenolate mofetil: an update. Drugs Today 2009; 45: 521– 32. 4. Hatton MP, Rubin PAD, Foster CS. Successful treatment of idiopathic orbital inflammation with mycophenolate mofetil. Am J Ophthalmol 2005; 140: 916–8. 5. Thorne JE, Jabs DA, Qzi FA et al. Mycophenolate mofetil therapy for inflammatory eye disease. Ophthalmology 2005; 112: 1472–7. Corneal endotheliitis triggered by cataract surgery in a Chinese patient with cytomegalovirus anterior uveitis