Stephanie B Engelhard

Causes of uveitis in children without juvenile idiopathic arthritis

Background The purpose of this study was to report the demographics, disease characteristics, treatments, and visual outcomes of pediatric uveitis patients without juvenile idiopathic arthritis managed in a tertiary medical center. Methods A retrospective, observational study was performed in pediatric uveitis patients without juvenile idiopathic arthritis and aged 0–18 years, who were seen at the University of Virginia from 1984 to 2014. Results Thirty-nine pediatric uveitis patients (57 eyes) were identified. The patient population was 51.28% female, 51.28% Caucasian, and 33.33% African American. The mean age at diagnosis was 11.9 years. The mean duration of follow-up was 3.11 years. The mean number of visits to the clinic was 10.41. Of 57 eyes, 31 (54.39%) had anterior uveitis, 12 (21.05%) had intermediate uveitis, nine (15.79%) had posterior uveitis, and five (8.77%) had panuveitis. The leading diagnoses were traumatic uveitis (25.64%), undifferentiated anterior uveitis (17.95%), undifferentiated intermediate uveitis (15.38%), HLA-B27-associated anterior uveitis (7.69%), and herpetic anterior uveitis (7.69%). Systemic associations included sarcoidosis, ulcerative colitis, and psoriatic arthritis (n=3). The most common treatment modalities included local steroids (66.67%), systemic steroids (23.08%), and antimetabolites (20.51%). Ocular hypertension was found in five (12.82%) patients. Ocular surgery was performed in six (15.38%) patients. Mean best-corrected visual acuity (BCVA) at baseline across all anatomical locations was 0.458 logMAR, and was 0.411 logMAR at final follow-up. Mean BCVA improved during follow-up in all but the anterior uveitis group. The mean baseline intraocular pressure was 14.27 mmHg, and was 14.22 mmHg at final follow-up. Conclusion Uveitis in childhood is a vision-threatening group of inflammatory disorders arising from numerous etiologies that vary geographically and historically. Because of the high burden of disease, the difficulty of making precise etiologic diagnoses, and the complicated management, it is imperative that affected children be referred to and closely monitored by uveitis specialists to prevent devastating ocular damage. This study found that BCVA and intraocular pressure did not vary significantly during follow-up, suggesting that close management by an ophthalmologist may prevent adverse visual outcomes, and highlighted the high prevalence of traumatic uveitis in children, which tends to have good visual outcomes.

Intermediate uveitis, posterior uveitis, and panuveitis in the Mid-Atlantic USA.

Background The purpose of this study was to identify the causes, clinical features, and outcomes of intermediate uveitis, posterior uveitis, and panuveitis in patients managed in a mid-Atlantic tertiary care center. Methods This was a retrospective observational study of intermediate uveitis, posterior uveitis, and panuveitis patients seen at the University of Virginia from 1984 to 2014. Results One hundred and fifty-nine intermediate uveitis, posterior uveitis, and panuveitis patients (237 eyes) were identified. The patient population was 54.72% female; 67.30% of patients were Caucasian, and 22.01% were African–American. Mean age at diagnosis was 45.5 years. Mean duration of follow-up was 3.95 years. Mean number of visits to the clinic was 10.35. Of 491 uveitis patients, 26 (5.30%) had intermediate uveitis, 62 (12.60%) had posterior uveitis, and 71 (14.50%) had panuveitis. The leading diagnoses in the intermediate uveitis group were pars planitis (73.08%) and sarcoidosis (11.54%); toxoplasma uveitis (17.74%), multifocal choroiditis (14.52%), undifferentiated posterior uveitis (14.52%), and birdshot chorioretinitis (11.29%) in the posterior uveitis group; and undifferentiated panuveitis (29.58%), post-surgical panuveitis (18.31%), sarcoidosis (12.68%), acute retinal necrosis (12.68%), and toxoplasma uveitis (4.23%) in the panuveitis group. The most common treatment modalities included local steroids (57.23%) and systemic steroids (42.14%). Ocular hypertension was found in 38 patients (23.90%). Glaucoma surgery was performed in 18.24% of patients and cataract surgery in 21.38%. Mean best-corrected visual acuity was 0.66 logMAR at baseline across all anatomical locations and 0.57 logMAR at final follow-up. Best-corrected visual acuity improved or remained stable during follow-up in all groups. Conclusion The most common diagnoses in our series by anatomical location were pars planitis (intermediate uveitis), toxoplasmosis (posterior uveitis), and undifferentiated uveitis (panuveitis). Panuveitis had significantly worse visual outcomes and higher rates of complications than did intermediate or posterior uveitis, a finding that confirms earlier reports. In this series, unilateral disease, regardless of anatomical location, was associated with poorer visual outcome, in contrast with the findings of other reports.

Medical Malpractice in Uveitis: A Review of Clinical Entities and Outcomes.

ABSTRACT Purpose: To guide risk management in uveitis. Methods: Retrospective review of malpractice verdicts, rulings, and settlements. Results: The WestLaw® database was reviewed for lawsuits related to uveitis in the United States from 1930–2014. Twenty-five cases met inclusion criteria, and 48% of these were infectious. Overall, 64% of outcomes favored the defendant ophthalmologist. The most common diagnoses were viral retinitis (28%), iritis (12%), syphilis (8%), and toxoplasmosis (8%). Seven suits (28%) were resolved by settlement, with mean adjusted indemnities of

Infectious uveitis in Virginia

724,302 (median,

Traumatic uveitis in the mid-Atlantic United States.

409,390; range,

Malpractice Litigation in Pediatric Ophthalmology

127,837–2,021,887). Two cases (8%) resulted in plaintiff verdict, with adjusted awards of

Malpractice Litigation in Ocular Oncology

1,399,800 and

Ocular hypertension and hypotony as determinates of outcomes in uveitis.

630,799. Conclusions: Despite being a rare diagnosis, viral retinitis (especially acute retinal necrosis) is the most common clinical entity associated with litigation in uveitis and should be considered early. Educating patients about potential adverse events, early testing for syphilis, and maintaining a positive relationship may also minimize risk.

Malpractice Litigation in Cornea and Refractive Surgery: A Review of the WestLaw Database

Purpose To report the causes, clinical features, and outcomes of infectious uveitis in patients managed in a mid-Atlantic tertiary care center. Methods Retrospective, observational study of infectious uveitis patients seen at the University of Virginia from 1984 to 2014. Results Seventy-seven of 491 patients (15.7%) were diagnosed with infectious uveitis (mean age 58 years, 71.4% female, 76.6% Caucasian). The mean follow-up was 5 years. Anterior uveitis was the most common anatomic classification (39 patients, 50.6%) followed by panuveitis (20 patients, 26.0%) and posterior uveitis (18 patients, 23.4%). The most common infectious etiology was herpetic anterior uveitis (37 patients, 48.1%) followed by toxoplasma uveitis (14 patients, 18.2%). The most prevalent viral pathogen was varicella-zoster virus (21 patients, 27.3%) followed by herpes simplex virus (20 patients, 26.0%). Acute retinal necrosis (ARN) was diagnosed in 14 patients (18.2%). Aqueous humor yielded an etiologic diagnosis in seven (50%) of ARN patients, four of whom tested positive for cytomegalovirus and three for varicella-zoster virus. On presentation, 43 patients (55.8%) had a visual acuity (VA) better than 20/40 and 17 (22.1%) had a VA worse than 20/200. VA at the final follow-up was better than 20/40 in 39 patients (50.6%) and worse than 20/200 in 22 patients (28.6%). In all, 16 (20.8%) and 10 (13.0%) patients required cataract and vitrectomy surgery, respectively. A total of 14 patients (18.2%) were on glaucoma topical treatment and four (5.2%) required glaucoma surgery. Conclusion The most common type of infectious uveitis seen over the study period was herpetic anterior uveitis secondary to varicella-zoster virus or herpes simplex virus, found to be most prevalent in patients over 60 years of age. This finding is comparable to other American epidemiologic studies. Ocular toxoplasmosis and ARN were also common causes of infectious uveitis. In all, 50.6% of patients had a VA better than 20/40 at the final follow-up visit, indicating the importance of prompt referral and appropriate treatment.

Malpractice litigation in ocular oncology

Purpose The purpose of this study was to conduct an in-depth analysis of traumatic uveitis in patients managed in a mid-Atlantic tertiary care center with the goal of better characterizing the clinical features and outcomes of this large and important subset of uveitis patients. Methods This was a retrospective, observational study comparing traumatic uveitis patients with nontraumatic uveitis patients seen at the University of Virginia, Charlottesville, VA, USA, from 1984 to 2014. Results Fifty-four traumatic uveitis patients (55 eyes) were identified. The patient population was 70.4% male, 57.4% Caucasian, and 37.0% African American. Mean age at diagnosis was 31.2 years; mean duration of follow-up was 5.4 years; and mean number of visits to the clinic was 4. The most common treatment modality was local steroids (77.8%). Glaucoma was medically managed in eight patients (14.8%). Cataract surgery was performed in five patients (9.3%). Mean best-corrected visual acuity at baseline for traumatic uveitis patients was 0.33 logMAR (SD 0.42) at the initial visit and 0.16 logMAR (SD 0.33) at the final visit. Mean baseline intraocular pressure (IOP) in the traumatic uveitis group was 15.5 mmHg (SD 7.4) at the initial visit and 14.6 mmHg (SD 4.0) at the final visit. Patients in the traumatic uveitis cohort tended to have better visual outcomes than those in the nontraumatic uveitis cohort. Conclusion In our series, traumatic uveitis patients tended to be young and male and present with unilateral disease, all findings consistent with other reports. Despite relatively good visual outcomes, the traumatic uveitis patients still experienced a high burden of disease, measured both in the number of clinic visits and duration of follow-up. Due to the young mean age of patients, these disease burdens and decreased quality of life are nontrivial, emphasizing the importance of careful management and prompt treatment of this subset of uveitis patients.