Yan Guex-Crosier

Bacterial keratitis: a prospective clinical and microbiological study

AIM To define the clinical and microbiological profile of bacterial keratitis at the Jules Gonin Eye Hospital and to test the in vitro bacterial resistance. METHODS Patients presenting with bacterial keratitis were prospectively followed; clinical features (age, risk factors, visual acuity) and response to therapy were analysed. Bacteriological profile was determined and the sensitivity/resistance of isolated strains were tested towards 12 ocular antibiotics (NCCLS disc diffusion test). RESULTS 85 consecutive patients (mean age 44.3 (SD 20.7) years) were prospectively enrolled from 1 March 1997 to 30 November 1998. The following risk factors were identified: contact lens wear, 36%; blepharitis, 21%; trauma, 20%; xerophthalmia, 15%; keratopathies, 8%; and eyelid abnormalities, 6%. The most commonly isolated bacteria wereStaphylococcus epidermidis, 40%;Staphylococcus aureus, 22%;Streptococcus pneumoniae, 8%; othersStreptococcus species, 5%;Pseudomonas, 9%;Moraxella andSerratia marcescens, 5% each;Bacillus,Corynebacterium, Alcaligenes xyloxidans, Morganella morganii, andHaemophilus influenza, 1% each. 1–15% of strains were resistant to fluoroquinolones, 13–22% to aminoglycosides, 37% to cefazolin, 18% to chloramphenicol, 54% to polymyxin B, 51% to fusidic acid, and 45% to bacitracin. Five of the 85 patients (5.8%) had a poor clinical outcome with a visual loss of one or more lines of visual acuity. CONCLUSION Fluoroquinolones appear to be the therapy of choice for bacterial keratitis, but, based upon these in vitro studies, some strains may be resistant.

Posterior sub-Tenon's steroid injections for the treatment of posterior ocular inflammation: indications, efficacy and side effects.

PURPOSE Posterior sub-Tenons steroid injections (PSTSI) are a standard drug delivery method used for the treatment of chronic uveitis of the posterior segment. The aim of this study was to analyse the indications, efficacy and complications of PSTSI in the treatment of chronic uveitis. METHODS During the period 1990-1994, 53 (9.5%) of 558 patients (58 eyes) followed up in the uveitis clinic received a total of 162 PSTSI of triamcinolone acetonide 40 mg in the superior quadrants. Indications for treatment were vision inferior or equal to 0.7 and/or intolerable visual disturbance. Only patients in whom PSTSI were the only treatment parameter changed were analysed. Among the main parameters analysed were visual acuity, aqueous laser flare photometry, intraocular pressure (IOP) and complications. RESULTS Anatomical location of uveitis was as follows: anterior HLA-B27-related uveitis with CME (1 patient/1 eye), intermediate uveitis (28/32), posterior uveitis (10/10) and panuveitis (14/15). Mean duration of follow-up was 448+/-57 days. Visual acuity improved significantly from 0.40+/-0.03 to 0.79+/-0.07, with 59.4% of eyes having a gain of 2-5 Snellen lines and 18.7% a gain of >5 lines. Mean aqueous flare photometry decreased significantly from 29.6+/-3.5 to 13.6+/-2.2 photons/ms. Mean IOP increased significantly from 13.6+/-0.5 to 18.5+/-0.8 mm Hg with a rise of pressure >8 mm Hg in 23 cases (36%), transient in 16 cases, but chronic in 6 cases, needing filtering surgery. Partial superior ptosis was seen in two cases and cataract progressed in seven cases. CONCLUSION PSTSI are very effective in restoring visual acuity in chronic uveitis of the posterior segment, without systemic complications, but at the expense of intraocular hypertension, a complication that was found more frequently than expected.

Necrotizing herpetic retinopathies a spectrum of herpes virus-induced diseases determined by the immune state of the host

PURPOSE Necrotizing herpetic retinopathies (NHR), a new spectrum of diseases induced by viruses of the herpes family (herpes simplex virus, varicella-zoster virus and cytomegalovirus), includes acute retinal necrosis (ARN) occurring in apparently immunocompetent patients and progressive outer retinal necrosis (PORN) described in severely immuno-compromised patients. Signs of impaired cellular immunity were seen in 16% of ARN patients in a review of 216 reported cases, indicating that immune dysfunction is not only at the origin of PORN but might also be at the origin of ARN. The aim of this study was to correlate clinical findings in NHR patients with their immunologic parameters. METHODS Charts from patients with the diagnosis of ARN or PORN seen from 1990 to 1995 were reviewed. Clinical characteristics and disease patterns were correlated with immunological parameters taking into account CD4 lymphocyte rate in AIDS patients and blood-lymphocyte subpopulation determination by flow cytometry, cutaneous delayed type hypersensitivity testing and lymphocytic proliferation rate to seven antigens in HIV-negative patients. RESULTS During the period considered, 11 patients and 7 patients fulfilled the criteria of ARN and PORN respectively. Immune dysfunctions were identified in most patients. Mild type of ARN and classical ARN were associated with discrete immune dysfunctions, ARN with features of PORN was seen in more immunodepressed patients and classical PORN was always seen in severely immunodepressed HIV patients. CONCLUSION Our findings suggest that NHR is a continuous spectrum of diseases induced by herpes viruses, whose clinical expression depends on the immune state of the host going from mild or classical ARN at one end in patients with non-detectable or slight immune dysfunction to PORN in severely immunodepressed patients at the other end and with intermediary forms between these extremes.

Use of Laser Flare Photometry to Assess and Monitor Inflammation in Uveitis

PURPOSE Laser flare photometry (LFP) is a new quantitative method for the evaluation of aqueous flare, making flare the only inflammatory parameter that can be evaluated precisely and objectively. The aim of this study was to characterize the inflammatory pattern of acute human leukocyte antigen-B27 (HLA-B27)-related anterior uveitis and to determine further clinical use and limitations of LFP in posterior inflammation. METHODS In the first part of the study, 78 episodes of HLA-B27-related acute anterior uveitis were analyzed to determine mean pretreatment (initial) flare, mean flare evolution, need for additional periocular steroids, and mean duration of an episode. In the second part of the study, the use of LFP was further tested in posterior inflammation, first by analyzing the predictive value of a subclinical LFP-detected flare increase for disease recrudescence in posterior scleritis, and then by exploring clinical applications for LFP in posterior uveitis, where LFP was essential either in the establishment of a diagnosis or in guiding therapeutic decisions. RESULTS Mean initial flare in HLA-B27-related acute anterior uveitis was 160 +/- 22 photons/msec, and mean duration of an episode was 18.5 +/- 15 days. A 50% and 90% flare reduction occurred after 2 and 8 days, respectively. In posterior scleritis, LFP was accurate in monitoring response to systemic steroid therapy and a small flare increase was predictive for disease recrudescence in five of six cases (predictive value 0.83, sensitivity 100%). In posterior uveitis, LFP was sensitive to monitor systemic treatments and to establish a diagnosis in unclear cases by measuring the effect of a selective therapy (therapeutic trial) on the flare level. CONCLUSION In acute anterior HLA-B27-associated uveitis, LFP represented a potential improvement in management by allowing precise adjustment of therapy. In uveitis of the posterior segment, our data confirm the validity of LFP to monitor response and adjust systemic therapy and to detect disease recurrence in patients with a sufficient pretreatment level of associated blood-aqueous barrier disruption (flare).

Sensitivity of Laser Flare Photometry to Monitor Inflammation in Uveitis of the Posterior Segment

PURPOSE Laser flare photometry is a new quantitative method for evaluating aqueous flare, making flare the only inflammatory parameter that can be evaluated precisely and objectively. The validity of the method already has been demonstrated in anterior segment inflammation. The aim of this study is to assess the validity and limitations of the method to quantify and monitor inflammation in uveitis with predominant involvement of the posterior segment. METHODS Five well-defined conditions with uveitis predominant in the posterior segment were analyzed in this study: Behçet uveitis, pars planitis, posterior sarcoidosis, posterior pole toxoplasmosis, and birdshot chorioretinopathy. (1) Mean initial (pretreatment) flare was determined; (2) in the patients needing systemic steroid therapy, introduction of therapy was correlated with evoluting laser flare photometry; and (3) in patients with quiescent disease, the predictive value of a defined subclinical photometry-detected flare rise for disease recrudescence was analyzed. RESULTS Initial pretreatment flare was 331.8 +/- 47.7 photon counts per millisecond (ph/msecond) (mean +/- standard error of the mean) for Behçet uveitis, 15.6 +/- 1.3 ph/msecond for pars planitis, 26.9 +/- 4.6 ph/msecond for posterior sarcoidosis, 7.5 +/- 1.0 ph/msecond for posterior pole toxoplasmosis, 5.8 +/- 0.7 ph/msecond for birdshot chorioretinopathy, and 4.7 +/- 0.1 ph/msecond for a group of 88 control eyes. A significant flare reduction after start of steroid therapy was seen in Behçet uveitis (78% reduction), sarcoidosis (44.8%), and pars planitis (51%), but not in toxoplasmosis or in birdshot. A small flare rise had a predictive value for disease recrudescence in 27/35 patients (predictive value, 0.77; sensitivity rate, 100%). The level of associated blood-aqueous barrier disruption for reliable follow-up of posterior uveitis was empirically determined to be 13 to 15 ph/msecond. CONCLUSION Laser flare photometry was found to be very sensitive to monitor inflammation in uveitis of the posterior segment as long as a sufficient level of associated blood-aqueous barrier disruption (flare) was present.

Anti-TNF-α Therapy in Patients with Chronic Non-Infectious Uveitis: The Experience of Jules Gonin Eye Hospital

BACKGROUND The purpose of this study is to describe the experience of Jules Gonin Eye Hospital on the long-term outcome of anti-TNF-alpha therapy in chronic non-infectious uveitis. PATIENTS AND METHODS We identified and followed those patients with chronic non-infectious uveitis who received systemic anti-TNF-alpha therapy. Anti-TNF-alpha therapy was administered when no response had been obtained with classical immunosuppressive therapies or in the presence of severe rheumatoid disease. RESULTS Fifteen patients (28 eyes), 7 male and 8 female (mean age, 43 years; range: 7 to 70 years) were identified. Diagnoses included HLA-B27-associated anterior uveitis (n = 4), sarcoidosis (n = 2), juvenile idiopathic arthritis (n = 2), idiopathic retinal vasculitis with uveitis (n = 2), pars planitis (n = 2), Adamantiades-Behçet disease (n = 1), birdshot retinochoroidopathy (n = 1), and Crohns disease (n = 1). Mean duration of ocular disease was 8 years (range: 1 to 29 years). Treatment with infliximab (n = 11), etanercept (n = 2), or adalimumab (n = 2) was initiated. One patient with etanercept was switched to infliximab due to lack of clinical response. Clinical and angiographic regression of uveitis was observed within the first two months of therapy in all patients, and was maintained throughout the entire follow-up period (mean 18 months; range: 3 - 72 months). Recurrence was observed in 3 patients, and resolved after adjustment of therapy. Adverse events were recorded in only one patient (arterial hypotension). CONCLUSIONS In this series of patients with chronic non-infectious uveitis, anti-TNF-alpha therapy was effective and safe. Further clinical studies are needed to determine an adequate duration of therapy.

Prolonged retinal arterio-venous circulation time by fluorescein but not by indocyanine green angiography in birdshot chorioretinopathy

PURPOSE To compare retinal arterio-venous circulation time by fluorescein (FA) and indocyanine green angiography (ICGA) in birdshot chorioretinopathy. METHODS We analyzed prolonged retinal arterio-venous fluorescein transit time, a known feature in birdshot chorioretinopathy and correlated it with ICGA findings in four consecutive patients. RESULTS Mean retinal arterio-venous fluorescein circulation time was 31.1 +/- 5.2 seconds, a transit time significantly longer than in a group of ten patients with sarcoidosis (9.45 +/- 3.36 sec., p < 0.0001) and in a group of three cases with Vogt-Koyanagi-Harada disease (7.0 +/- 1.1 sec., p < 0.0001). CONCLUSION Prolonged fluorescein arterio-venous transit time seems to be a characteristic feature of birdshot chorioretinopathy that does however not reflect the actual intravascular hemodynamic situation but diffuse blood-retinal barrier damage allowing exudation, slow gradual tissue impregnation and delayed venous reabsorption of small molecules like fluorescein.

Viral Retinitis following Intraocular or Periocular Corticosteroid Administration: A Case Series and Comprehensive Review of the Literature

Abstract Purpose: To describe viral retinitis following intravitreal and periocular corticosteroid administration. Methods: Retrospective case series and comprehensive literature review. Results: We analyzed 5 unreported and 25 previously published cases of viral retinitis following local corticosteroid administration. Causes of retinitis included 23 CMV (76.7%), 5 HSV (16.7%), and 1 each VZV and unspecified (3.3%). Two of 22 tested patients (9.1%) were HIV positive. Twenty-one of 30 (70.0%) cases followed one or more intravitreal injections of triamcinolone acetonide (TA), 4 (13.3%) after one or more posterior sub-Tenon injections of TA, 3 (10.0%) after placement of a 0.59-mg fluocinolone acetonide implant (Retisert), and 1 (3.3%) each after an anterior subconjunctival injection of TA (together with IVTA), an anterior chamber injection, and an anterior sub-Tenon injection. Mean time from most recent corticosteroid administration to development of retinitis was 4.2 months (median 3.8; range 0.25–13.0). Twelve patients (40.0%) had type II diabetes mellitus. Treatments used included systemic antiviral agents (26/30, 86.7%), intravitreal antiviral injections (20/30, 66.7%), and ganciclovir intravitreal implants (4/30, 13.3%). Conclusions: Viral retinitis may develop or reactivate following intraocular or periocular corticosteroid administration. Average time to development of retinitis was 4 months, and CMV was the most frequently observed agent. Diabetes was a frequent co-morbidity and several patients with uveitis who developed retinitis were also receiving systemic immunosuppressive therapy.

Indocyanine green angiography anomalies in ocular syphilis.

Objective: To report indocyanine green (ICG) angiography anomalies in ocular syphilis. Design: A noncomparative, interventional case series. Participants: Eight patients (16 eyes) affected by ocular syphilis. Methods: All patients presenting with a diagnosis of active ocular syphilis between January 1994 and December 2001 were evaluated by a standard fluorescein and ICG angiography protocol. ICG angiography was repeated after completion of systemic antitreponemal and antiinflammatory treatment. Results: ICG angiography anomalies were detected in 12 (75%) of 16 eyes. Two types of anomalies were observed: late-phase scattered hyperfluorescent spots (11 eyes) and persistent staining of retinal vessels (1 eye). Of these 12 eyes, 4 had no alteration by concomitant fluorescein angiography. When ICG angiography was repeated (5 ± 1 weeks after the beginning of treatment), ICG angiography anomalies disappeared. Conclusions: ICG angiography may be a valuable tool in the assessment of patients with active ocular syphilis. Retinal and choroidal vascular anomalies can be determined that would otherwise go undetected by funduscopy and/or fluorescein angiography. It can also be useful in monitoring antitreponemal therapy.

Treatment Strategies in Primary Vitreoretinal Lymphoma: A 17-Center European Collaborative Study

IMPORTANCE The best treatment option for primary vitreoretinal lymphoma (PVRL) without signs of central nervous system lymphoma (CNSL) involvement determined on magnetic resonance imaging or in cerebrospinal fluid is unknown. OBJECTIVE To evaluate the outcomes of treatment regimens used for PVRL in the prevention of subsequent CNSL. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted at 17 referral ophthalmologic centers in Europe. We reviewed clinical, laboratory, and imaging data on 78 patients with PVRL who did not have CNSL on presentation between January 1, 1991, and December 31, 2012, with a focus on the incidence of CNS manifestations during the follow-up period. INTERVENTIONS The term extensive treatment was used for various combinations of systemic and intrathecal chemotherapy, whole-brain radiotherapy, and peripheral blood stem cell transplantation. Therapy to prevent CNSL included ocular radiotherapy and/or ocular chemotherapy (group A, 31 patients), extensive systemic treatment (group B, 21 patients), and a combination of ocular and extensive treatment (group C, 23 patients); 3 patients did not receive treatment. A total of 40 patients received systemic chemotherapy. MAIN OUTCOMES AND MEASURES Development of CNSL following the diagnosis of PVRL relative to the use or nonuse of systemic chemotherapy and other treatment regimens. RESULTS Overall, CNSL developed in 28 of 78 patients (36%) at a median follow-up of 49 months. Specifically, CNSL developed in 10 of 31 (32%) in group A, 9 of 21 (43%) in group B, and 9 of 23 (39%) in group C. The 5-year cumulative survival rate was lower in patients with CNSL (35% [95% CI, 50% to 86%]) than in patients without CNSL (68% [95% CI, 19% to 51%]; P = .003) and was similar among all treatment groups (P = .10). Adverse systemic effects occurred in 9 of 40 (23%) patients receiving systemic chemotherapy; the most common of these effects was acute renal failure. CONCLUSIONS AND RELEVANCE In the present series of patients with isolated PVRL, the use of systemic chemotherapy was not proven to prevent CNSL and was associated with more severe adverse effects compared with local treatment.