Stefanos Baltatzis

Methotrexate therapy for chronic noninfectious uveitis: analysis of a case series of 160 patients.

PURPOSE To evaluate the outcomes of patients with chronic noninfectious uveitis unresponsive to conventional antiinflammatory therapy who were treated with methotrexate. DESIGN Retrospective noncomparative interventional case series. PARTICIPANTS All patients with chronic noninfectious uveitis treated with methotrexate at a single institution from 1985 to 1999. METHODS Charts of patients seen on the Ocular Immunology & Uveitis Service at the Massachusetts Eye & Ear Infirmary were reviewed. Patients with chronic uveitis of noninfectious origin treated with methotrexate were included in the study. MAIN OUTCOME MEASURES Control of inflammation, steroid-sparing effect, visual acuity, adverse reactions. RESULTS A total of 160 patients met the inclusion criteria. Control of inflammation was achieved in 76.2% of patients. Steroid-sparing effect was achieved in 56% of patients. Visual acuity was maintained or improved in 90% of patients. Side effects requiring discontinuation of medication occurred in 18% of patients. Potentially serious adverse reactions occurred in only 8.1% of patients. There was neither long-term morbidity nor mortality caused by methotrexate. CONCLUSIONS Methotrexate is effective in the treatment of chronic noninfectious uveitis that fails to respond to conventional steroid treatment. It is an effective steroid-sparing immunomodulator, is a safe medication, and is well tolerated.

Gas-permeable scleral contact lens therapy in ocular surface disease

PURPOSE To describe the therapeutic benefits of nonfenestrated gas-permeable scleral contact lenses in the management of patients with ocular surface disease. METHODS The charts of 49 consecutive patients (76 eyes) with ocular surface disease whose management included the use of gas-permeable scleral contact lenses were reviewed. We also developed a questionnaire to assess the impact of lens wear on subjective aspects of activities of daily living. RESULTS The mean age of the 49 patients was 44.6 years (range, 3 to 87 years); 31 patients were female and 18 were male. The most common indication for fitting of the lenses was Stevens-Johnson syndrome (54 [71%] of the 76 eyes). Other indications included ocular cicatricial pemphigoid, exposure keratitis, toxic epidermal necrolysis, postherpetic keratitis, congenital deficiency of meibomian glands, superior limbal keratoconjunctivitis, Sjögren syndrome, and inflammatory corneal degeneration. The mean follow-up was 33.6 months (range, 2 to 144 months). Improvement in best-corrected visual acuity (defined as a gain of 2 or more Snellen lines) was observed in 40 (53%) of the eyes. In eight (53%) of the 15 eyes with active corneal epithelial defects at the time of lens fitting, the defects healed, whereas in the remaining seven eyes the corneal epithelial defects remained unchanged. Forty-five (92%) of the 49 patients reported improvement in their quality of life as a result of reduction of photophobia and discomfort. The mean wearing time of the gas-permeable scleral contact lenses was 13.7 hours per day (range, 4 to 18 hours). Many patients had preparatory surgical procedures before lens fitting (for example, punctal occlusion or mucous membrane grafting), and some had visual rehabilitation surgical procedures (for example, keratoplasty and/or cataract surgery) after lens fitting. CONCLUSIONS Gas-permeable scleral contact lens wear provides an additional effective strategy in the surface management and visual rehabilitation of patients with severe ocular surface disease.

Mycophenolate mofetil as an immunomodulatory agent in the treatment of chronic Ocular inflammatory disorders

PURPOSE To evaluate the outcomes of patients with chronic ocular inflammatory disease treated with mycophenolate mofetil as an immunosuppressive and steroid-sparing agent. DESIGN Retrospective noncomparative interventional case series. PARTICIPANTS All patients with ocular inflammatory disease treated with mycophenolate mofetil at a single institution between 1998 and 2001. METHODS Charts of patients seen on the Ocular Immunology and Uveitis Service at the Massachusetts Eye and Ear Infirmary were reviewed. Patients with chronic ocular inflammatory disease were included in the study. MAIN OUTCOME MEASURES Control of inflammation, steroid-sparing effect, visual acuity, and adverse reactions were measured. RESULTS A total of 54 patients were evaluated. Control of ocular inflammation with mycophenolate mofetil as monotherapy was achieved in 35 patients (65%) and in 67 eyes (62%), and a steroid-sparing effect was achieved in 29 (54%) patients. Visual acuity was maintained or improved in 51 patients (94%) and in 97 eyes (90%). Side effects requiring discontinuation of medication occurred in 10 patients (18%). There was neither long-term morbidity nor mortality due to mycophenolate mofetil. CONCLUSIONS Mycophenolate mofetil is effective in the treatment of patients with steroid-dependent or -resistant chronic ocular inflammatory disorders that fail to respond to conventional steroid treatment. It is a safe and effective steroid-sparing immunomodulatory agent and can be considered an important addition to our armamentarium in the care of patients with ocular inflammatory disease.

Limbal stem cell transplantation in chronic inflammatory eye disease.

OBJECTIVE The goal of this study was to describe the outcome of limbal stem cell transplantation (LSCT) in patients with severe ocular surface disease caused by underlying chronic inflammatory eye disease. DESIGN Retrospective noncomparative case series. PARTICIPANTS Nine patients with limbal stem cell deficiency caused by an underlying ocular inflammatory disease who underwent LSCT. METHODS The authors reviewed the records of 11 eyes of 9 patients with immunologically mediated ocular surface disease that underwent LSCT. MAIN OUTCOME MEASURES The main outcome measures were reepithelialization of the corneal surface, restoration of corneal surface, and improvement in visual acuity. RESULTS A total of 11 eyes underwent either autologous (n = 1) or HLA-matched living related donor (n = 10) LSCT for ocular surface disease secondary to inflammatory disease. Reepithelialization of the corneal surface in the immediate postoperative period occurred in 10 eyes (91%) within an average of 10 days (range, 3-21 days). Long-term restoration of the corneal surface was achieved in six (55%) eyes. Visual acuity improved in six eyes (55%). Reasons for poor outcomes included microbial infection, limbal stem cell graft rejection, and corneal ulceration. No donor eyes had complications. CONCLUSIONS Patients with underlying immunologically mediated diseases, such as Stevens-Johnson syndrome, toxic epidermal necrolysis, or ocular cicatricial pemphigoid, who undergo LSCT have lower success rates than do those patients with noninflammatory ocular surface diseases.

The effect of treatment and its related side effects in patients with severe ocular cicatricial pemphigoid

PURPOSE To determine the clinical outcome of patients with ocular-cicatricial pemphigoid (OCP) and the influence of systemic treatment on clinical progression. DESIGN Noncomparative interventional case series. PARTICIPANTS Sixty-one patients with biopsy-proven OCP. METHODS Patients with documented disease progression treated with chemotherapy and/or corticosteroids were followed between 1985 and 2000. The parameters evaluated were ocular stage at presentation, visual acuity, ocular complications, disease progression, control of ocular inflammation, and presence of extraocular involvement. Systemic treatment and related side effects were analyzed. MAIN OUTCOME MEASURES Visual acuity, ocular complications, extraocular involvement, disease progression, clinical outcome, systemic treatment, and related side effects. RESULTS Sixty-one patients (32 female; 29 male) with a mean age of 67 years were studied. Extraocular involvement was present in 50% of patients. Sixty percent of eyes were initially seen with stage III (advanced cicatrizing) disease at first evaluation. Seven percent of involved eyes at first visit and 21% at the end of follow-up were legally blind. The most common ocular complications encountered were dry eye, corneal abnormalities, and glaucoma. Dapsone was the most commonly used drug (51 patients), followed by methotrexate (24 patients), azathioprine (23 patients), and cyclophosphamide (15 patients); prednisone, always given as adjunctive treatment, was used in 17 patients. Control of ocular inflammation (total or partial) was achieved in 90% of patients, but 46% of them needed continuation of systemic treatment to avoid disease recurrences, and 10% progressed despite different drugs used. Two agents were required in 32% of cases to control disease activity. The most common treatment-related side effects were hematologic complications (n = 34) followed by gastrointestinal (n = 17), cardiovascular (n = 15), and urinary complications (n = 11). Dapsone was responsible for the greatest number of side effects (n = 43); methotrexate caused the least trouble (n = 6). Corticosteroid-related complications (n = 34) were mostly cardiovascular and endocrinologic. CONCLUSIONS Ocular-cicatricial pemphigoid is an autoimmune disease that, untreated, progresses to conjunctival scarring and blindness; systemic immunosuppression is required to control it. Long-term systemic treatment and more than one drug are frequently necessary to avoid recurrences, exposing elderly patients to a higher risk of drug toxicity. The most frequently encountered treatment-related side effects were anemia, leukopenia, liver toxicity, and hypertension.

Efficacy and safety of Chlorambucil in intractable noninfectious uveitis: The Massachusetts eye and ear infirmary experience

PURPOSE To report our experience with the use of chlorambucil for otherwise treatment-resistant uveitis and to assess its safety and efficacy. DESIGN Noncomparative interventional case series. PARTICIPANTS Twenty-eight patients with intractable noninfectious uveitis. METHODS We reviewed the records of 28 patients (56 eyes) with chronic noninfectious uveitis who were treated with chlorambucil from 1987 to 2000. Diagnoses included Adamantiades-Behçets disease (ABD) (7 patients), juvenile rheumatoid arthritis (JRA)-associated uveitis (10 patients), pars planitis (2 patients), sympathetic ophthalmia (1 patient), idiopathic uveitis (6 patients), Crohns disease (1 patient), and HLA-B27-associated uveitis (1 patient). All patients were refractory to other immunomodulatory therapy and systemic steroids. The median duration of treatment with chlorambucil was 12 months (range, 4-50 months), whereas the median daily dosage was 8 mg (range, 4-22 mg). Patients were followed for a median follow-up period of 46 months (range, 4-166 months) after chlorambucil treatment was begun and continued to be followed for relapse after cessation of therapy. MAIN OUTCOME MEASURES Visual outcome, response to treatment, treatment-related side effects, drug dosage, previous and final treatment, discontinuation of systemic corticosteroids. RESULTS Chlorambucil was discontinued in seven patients because of side effects: two females had temporary amenorrhea develop, two patients had unacceptable gastrointestinal intolerance, one patient had infection, and 2 patients had progressive leukopenia. Nineteen patients (68%) showed positive clinical response to the treatment, four (14%) initially responded then relapsed after discontinuation of the drug, three patients with ABD had improvement of ocular disease but worsening of systemic symptoms, and two had persistent inflammation. Visual acuity was improved in 24 eyes (43%), stable in 22 (39%), and worsened in 10 eyes (18%). Systemic prednisone was successfully discontinued in 19 of the 28 patients (68%), and 14 patients were free of inflammation at the end of follow-up without any systemic medication. CONCLUSIONS Chlorambucil can be a safe and effective alternative for preserving vision in patients with otherwise treatment resistant uveitis.

Multifocal choroiditis and panuveitis: Immunomodulatory therapy

PURPOSE To report our analysis of the efficacy of immunomodulatory therapy on the course of 19 patients with multifocal choroiditis and panuveitis (MCP). DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS Nineteen patients with multifocal choroiditis with panuveitis evaluated on the Ocular Immunology and Uveitis Service of the Massachusetts Eye and Ear Infirmary from 1978 to 2000. METHODS Fifteen patients were treated with systemic immunomodulatory therapy; 4 patients (who refused therapy) were treated with systemic steroids. All patients were analyzed for control of inflammation, visual acuity outcome, and tolerance of immunomodulatory therapy. MAIN OUTCOME MEASURES Control of inflammation and visual acuity. RESULTS Nineteen patients with bilateral MCP with a mean follow-up of 72.7 months were studied. Fifteen were treated with immunomodulatory agents, whereas 4 patients received only systemic steroids; these 4 developed serious systemic steroid-related complications, and 12 others had cataract and/or glaucoma related to chronic topical, regional, or systemic steroid use before immunomodulatory therapy. Two patients who refused immunomodulatory therapy lost considerable vision in three of their four eyes. Of the 15 patients treated with immunomodulatory drugs, 7 patients lost considerable vision in one eye on steroid therapy but maintained good vision in the other eye once immunomodulatory therapy was instituted. No patient lost vision in any eye once he or she was treated with immunomodulatory treatment. CONCLUSIONS Immunomodulatory therapy controls inflammation and preserves vision in patients with multifocal choroiditis and panuveitis.

Topical versus sub-Tenon’s anesthesia without sedation in cataract surgery

Purpose: To compare pain control using topical anesthesia with that using sub‐Tenons anesthesia for clear corneal phacoemulsification cataract surgery and foldable intraocular lens (IOL) implantation. Setting: Departments of Ophthalmology, General Hospital Asklepeion Voulas and General Hospital of Athens, University of Athens, Athens, Greece. Methods: One hundred consecutive patients scheduled for bilateral cataract surgery 1 to 2 months apart were prospectively randomized to receive topical anesthesia (100 eyes) or sub‐Tenons anesthesia (100 eyes). The randomization was stratified so that one half of first‐eye surgeries and one half of second‐eye surgeries were assigned to each anesthesia group, with each patient receiving each type of anesthesia once. All patients had clear corneal phacoemulsification with foldable IOL implantation. Patients were asked to rate their pain level on a 10‐point scale for 4 periods: during the administration of the anesthetic agent, during surgery, immediately after surgery, and 24 hours postoperatively. The surgeon recorded his subjective assessment of ease of surgery and surgical complications using a standardized template. Results: Eighty‐one percent of patients who received topical anesthesia and 8% of patients who received sub‐Tenons anesthesia reported no pain during delivery of the anesthetic agent. The mean pain score was 0.19 ± 0.39 (SD) in the topical group and 1.35 ± 0.63 in the sub‐Tenons group. The difference between groups was statistically significant (P < .001). Seventy‐two percent of patients in the topical anesthesia group and 86% in the sub‐Tenons anesthesia group reported no pain or slight discomfort during surgery (mean score 1.13 ± 1.57 and 0.57 ± 1.28, respectively) (P < .001). Ninety percent of topical anesthesia patients and 100% of sub‐Tenons anesthesia patients reported no pain or slight discomfort 30 minutes postoperatively (mean score 0.80 ± 0.93 and 0.12 ± 036, respectively) (P < .001). All patients in the topical anesthesia group and 77% in the sub‐Tenons group reported no pain 24 hours postoperatively (mean pain 0.00 ± 0.00 and 0.23 ± 0.40, respectively) (P < .001). Complications including prolonged akinesia of the globe, chemosis, and conjunctival hemorrhage occurred significantly more frequently in the sub‐Tenons than in the topical group (P < .001). Conclusions: Patients having cataract surgery under topical anesthesia had more intraoperative and postoperative discomfort than patients receiving sub‐Tenons anesthesia. However, patients having topical anesthesia reported less pain during its administration and had fewer complications. Both anesthesia methods provided high levels of pain control without additional sedation.

Ocular features associated with anticardiolipin antibodies: A descriptive study

PURPOSE To evaluate ocular features in patients presenting with inflammation in the presence of anticardiolipin antibodies. METHODS A descriptive study of 13 patients presenting with idiopathic ocular inflammation involving anterior and posterior segment was performed. Patients were followed for a mean follow-up of 22 months (range, 1 to 125). A comprehensive report of ocular involvement, including visual symptoms, visual acuity, clinical characteristics, funduscopic and fluorangiographic features, was reported. Systemic associated symptoms were analyzed. Laboratory investigations included anticardiolipin antibody titers and isotypes, presence of other autoantibodies, and markers of immune system activation. RESULTS The most common ocular symptom at presentation was blurred vision (eight patients) followed by redness and pain(three patients) and visual loss(two patients). Anterior segment abnormalities, including iritis (eight patients) scleritis (two patients) and filamentary keratitis (one patient), were present in 76% of patients, whereas the most represented feature of posterior involvement was retinal vasculitis (60%) followed by vitritis (38%), retinal detachment (15%), posterior scleritis (7%), and central retinal artery occlusion (7%). All patients had abnormal titers of anticardiolipin antibodies, predominantly IgG isotype; six had markers of immune system activation. CONCLUSIONS Although posterior pole disease is more commonly associated with anticardiolipin antibodies, the anterior segment can also be involved with a wide spectrum of features. Scleritis has never been previously described as associated with anticardiolipin antibodies. Systemic symptoms are frequently present in association with ocular disease.

Orbital cellulitis, orbital subperiosteal and intraorbital abscess. Report of three cases and review of the literature

INTRODUCTION Orbital cellulitis is usually a complication of paranasal sinus infection. Either the infection may dissect under the periosteum and lead to subperiosteal abscess (SPA) or intraorbital abscess may be formed secondary to a progressive and localized cellulitis. Without appropriate treatment orbital infection may lead to serious complications, even death. REPORT OF CASES Three cases are described, one of orbital cellulitis, one of SPA and one of intraorbital abscess and the literature is being reviewed. CONCLUSION Prompt treatment is mandatory to avoid visual loss or intracranial complications. Initially, IV antibiotics may be administered, but if no improvement appears within 48h, surgical drainage of the orbit and the affected sinuses must be performed. In medial or medial-inferior SPA a transnasal approach is used, but in superior orbital abscess an external incision is required.