Zohar Habot-Wilner

Intraocular Methotrexate in the Treatment of Uveitis and Uveitic Cystoid Macular Edema

OBJECTIVE A pilot study to evaluate the use of intravitreal methotrexate (MTX) for the treatment of uveitis and uveitic cystoid macular edema (CME). DESIGN Prospective, consecutive, interventional case series. PARTICIPANTS Fifteen eyes of 15 patients with a unilateral exacerbation of noninfectious intermediate, posterior uveitis, or panuveitis and/or CME such that visual acuity (VA) was 20/40 or worse, together with a history of increased intraocular pressure (IOP) in response to corticosteroid administration. INTERVENTION Intravitreal injection of 400 microg in 0.1 ml MTX. MAIN OUTCOME MEASURES The primary outcome measure was VA (using the Early Treatment Diabetic Retinopathy Study chart). Other outcome measures included ocular inflammation scores, time to relapse, levels of systemic corticosteroid and immunosuppressive therapy, and ocular coherence tomography. Potential complications of intravitreal MTX injection, including cataract progression, vitreous hemorrhage, retinal detachment, and corneal epitheliopathy, were assessed. RESULTS VA improved at all time points and was statistically significant at the 3- and 6-month follow-up examinations. The mean visual improvement was 4 lines at 3 months and 4.5 lines at 6 months, with no statistical difference between the best VA obtained after MTX injection and after previous corticosteroid treatment, including intravitreal triamcinolone acetate injection. Five patients relapsed after a median of 4 months; a similar improvement was seen after re-injection. Ocular inflammation scores improved at all time points, and systemic immunosuppressive medication was reduced in 3 of 7 patients taking this at the start of the trial. CONCLUSIONS In patients with uveitis and uveitic CME, intravitreal MTX can improve VA and reduce CME and, in some patients, allows the reduction of immunosuppressive therapy. Relapse occurs at a median of 4 months in some patients, but reinjection has similar efficacy.

Outcome of Raised Intraocular Pressure in Uveitic Eyes with and without a Corticosteroid-Induced Hypertensive Response

PURPOSE To compare the management and outcome of raised intraocular pressure (IOP) in uveitis patients with a corticosteroid hypertensive response and those who are noncorticosteroid responders and to determine the impact of intraocular corticosteroid use on IOP in uveitic eyes. DESIGN Retrospective study. METHODS Eight hundred and ninety-one uveitis patients were observed in a specialized clinic over 3 months. The main outcome measures were frequency, characterization, management, and outcome of uveitis-related ocular hypertension and glaucoma. RESULTS Of 891 patients with uveitis, 191 (275 eyes) had IOP elevation (21.4%). Of these, 95 (34.5%) eyes had glaucoma. IOP elevation attributed to corticosteroid-response (61.1%) was controlled more easily than that resulting from other causes (38.9%), requiring fewer eye drops (mean, 2.06 vs 2.52; P = .009) and less filtration surgery (8.9% vs 22.4%). Among eyes with uveitis and raised IOP, elevated IOP developed in 18 eyes (6.5%) after intravitreal triamcinolone, including 64.7% to 30 to 39 mm Hg and 35.3% to 40 mm Hg or more. Prostaglandin analogs were used in 49.2% of 246 eyes; no increase in inflammation was seen in these eyes. CONCLUSIONS In this tertiary center series, most instances of raised IOP were attributable to corticosteroid response. Raised IOP induced by corticosteroid response was controlled more easily and less often resulted in optic nerve or visual field changes of glaucoma. Although intravitreous triamcinolone was associated with substantial risk of corticosteroid-response IOP elevation, all cases were controlled medically without experiencing glaucomatous injury. Prostaglandin-induced uveitis was not observed despite extensive use of prostaglandin IOP-lowering agents.

Refractive results with secondary piggyback implantation to correct pseudophakic refractive errors

PURPOSE: To assess the efficacy and safety of implanting a second intraocular lens (IOL) to correct pseudophakic refractive errors. SETTING: Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel. METHODS: This prospective noncomparative case series included 10 pseudophakic eyes, 5 with a myopic residual refractive error and 5 with a hyperopic residual refractive error. All eyes had secondary piggyback IOL implantation with the IOL placed in the ciliary sulcus. Five types of IOLs were used to correct the residual refractive error. RESULTS: The mean preoperative myopia was −6.6 diopters ± 3.3 (SD), and the refractive outcome was within 0.5 ± 0.7 D of the desired refraction (range –1.5 [undercorrected] and +1.0 D [overcorrected]). The mean preoperative hyperopia was +3.8 ± 0.8 D, and the refractive outcome was within 0.46 ± 0.4 D of the desired refraction (range 0 and 1.0 D overcorrected). All patients showed visual acuity improvement. Best spectacle‐corrected visual acuity improved from 20/44 to 20/30 (P<.05). CONCLUSION: An IOL type that is appropriate for implantation in the ciliary sulcus is a viable option for correcting pseudophakic refractive error using the piggyback technique.

Vitreal, retinal, and choroidal findings in active and scarred toxoplasmosis lesions: a prospective study by spectral-domain optical coherence tomography.

BackgroundThe aim of our study was to investigate vitreal, retinal, and choroidal morphologic changes in active and scarred toxoplasmosis lesions using spectral-domain optical coherence tomography (SD-OCT).MethodsIn this prospective study, 19 eyes of 15 consecutive patients with ocular toxoplasmosis were included. Complete ophthalmologic examination and SD-OCT were done at the initial visit and during follow-up. Retina and choroid SD-OCT protocols directed to macular area and lesions observed on clinical examination were used.ResultsSeventeen active lesions and 56 retinochoroidal scars were studied. In the acute phase, disruption, thickening, and hyper-reflectivity of the neurosensory retina with photoreceptor (PR) interruption and retinal pigment epithelial (RPE) elevation were found. The choroid became thickened and hyporeflective. During follow-up, neurosensory retinal layers thinning and disorganization, PR interruption, and RPE elevation and/or atrophy were demonstrated. The choroid returned to normal thickness and became more hyperreflective. Five active lesions presented with hyperreflective oval deposits within the vitreoretinal interface, adjacent to or far away from the lesions. During follow-up, the deposits became smaller, entered into the inner retina layers and faded with time until complete resolution. Multiple hyperreflective dots in the vitreous cavity, compatible with vitritis, and posterior hyaloid thickening were demonstrated in the acute phase, with complete resolution and detachment of the posterior hyaloid during follow-up. Four types of scars were specified according to outer retina–choroid interface changes; atrophic, elevated, deep, and combined (atrophic & elevated). Epiretinal membrane segments were found over active and scarred lesions.ConclusionsSD-OCT imaging showed toxoplasmic retinochoroidal lesions and scars to be complex and characterized acutely by thickening and disorganization of both the retina and underlying choroid, and following scar formation by varying degrees of thinning, often in conjunction with irregularity of the outer retinal layers.

The inhibitory effect of different concentrations of topical bevacizumab on corneal neovascularization

Acta Ophthalmol. 2010: 88: 862–867

Repeat intravitreal triamcinolone acetonide injections in uveitic macular oedema

retreatment only after the sixth month. The design of this compassionate program study provided for retreatment from the fourth month on a PRN basis. Our results show that a sustained effect can be obtained for both functional and anatomical aspects. It is worth remarking that our patients displayed older CRVO forms, with longer ME duration in comparison with the GENEVA trial (13 versus 5 months, respectively), lower mean BCVA at baseline (20 ⁄ 320, versus 20 ⁄ 80, respectively) and higher CFT (620 versus 550 lm, respectively) (Haller et al. 2010). Although obvious limitations include small number of patients and absence of a control group, this study illustrates, with all due caution, the positive effect of dexamethasone implant for ME secondary to CRVO in a clinical setting, demonstrating a sustained effect if a PRN basis is followed. Further studies are needed to ascertain the best therapeutic approach and the most appropriate timing of the treatment.

Intravitreal triamcinolone acetonide as adjunctive treatment with systemic therapy for uveitic macular edema.

Purpose. TO report the outcome of a single intravitreal triamcinolone acetonide (IVTA) injection as an adjunctive treatment with systemic medication for refractory uveitic cystoid macular edema (CME). Methods. This was a retrospective, noncomparative, interventional case series. Medical records of 25 patients (35 eyes) with quiescent uveitic CME who were treated with oral immunosuppressive therapy and underwent 4 mg/0.1 mL IVTA injection were reviewed. Data was collected 6 months post-injection and included details of uveitis, best-corrected visual acuity (BCVA), CME, systemic therapy required, and potential complications of IVTA injection. Results. Thirty eyes (85%) responded with improvement in vision. The mean BCVA improvement was 0.33 (from 0.67 to 0.34 logarithm of the minimum angle of resolution; Snellen equivalent, between 2 and 3 lines) (p<0.001), at a mean time of 6.2 weeks (range 2–16). Resolution of CME was achieved in 31 (88%) of the treated eyes. Following initial response to IVTA, CME relapsed in 8 eyes (26%) after a mean time of 4.2 months (range 2.5–5.5). The dosage of oral corticosteroids and/or second-line immunosuppressive agents was able to be reduced or stopped in 22 patients, 29 of 35 eyes (82.8%). The most common adverse effect was increased intraocular pressure, in 17 (49%) of the treated eyes. Steroid-induced cataract was observed in 6 eyes (17%). Conclusions. Intravitreal triamcinolone acetonide appears to be an effective supplementary tool in the management of CME refractory to systemic immunosuppressive therapy. Retreatment might be required in some and may be associated with elevated intraocular pressure and cataract.

Spectral domain optical coherence tomography classification of acute posterior multifocal placoid pigment epitheliopathy.

Purpose: To study the retinal morphologic changes occurring in acute posterior multifocal placoid pigment epitheliopathy using spectral domain optical coherence tomography. Methods: Prospective observational case series of 12 eyes (6 consecutive patients) diagnosed with acute posterior multifocal placoid pigment epitheliopathy. All patients underwent complete ophthalmologic examination, fundus photography, fluorescein angiography, and spectral domain optical coherence tomography at the initial visit. During follow-up, ophthalmologic examination and spectral domain optical coherence tomography scans were performed. The scans were directed to the lesions observed on the clinical examination and fluorescein angiography. Results: Spectral domain optical coherence tomography classification containing four distinct stages for acute posterior multifocal placoid pigment epitheliopathy is proposed. Stage 1 demonstrates a dome-shaped elevation with disruption of the photoreceptor junction that flattens shortly after. Stage 2, occurring 2 weeks later, demonstrates distinct separation between the photoreceptor junction and the retinal pigment epithelium (RPE). Stage 3, visible 6 weeks post disease initiation, demonstrates accentuated RPE hyperreflectivity and union of the RPE and photoreceptor junction. Stage 4, the resolution phase, starts at 3 months demonstrating reformation of 2 distinct visible layers of photoreceptors and RPE. Conclusion: The morphologic retinal findings in acute posterior multifocal placoid pigment epitheliopathy visible by the spectral domain optical coherence tomography occur in the outer retina, mainly the photoreceptors and RPE. Most findings reached nearly complete resolution and were correlated with improvement in visual acuity.

Effect of Amniotic Membrane Transplantation on the Healing of Bacterial Keratitis

PURPOSE To study, with the use of an animal model, the efficacy of amniotic membrane (AM) transplantation as adjunctive treatment in corneal healing after bacterial keratitis. METHODS Staphylococcus aureus keratitis was induced in 47 rats by injection of bacteria into the corneal stroma. Treatment was started 48 hours later with one of three randomly assigned protocols: cefazolin drops (50 mg/mL) and AM transplantation (n = 16); nonpreserved 0.9% saline drops and AM transplantation (n = 15); or cefazolin without AM transplantation (n = 16). Cefazolin and saline drops were administered every 30 minutes for 6 hours, then hourly for 6 hours. AM was transplanted 24 hours after termination of cefazolin or saline treatment. Results were clinically assessed 7 days after AM transplantation or at the corresponding time in the nontransplanted animals. The rats were then killed, and their corneas were removed for bacterial counts or histopathologic examination. RESULTS The best clinical results were observed in the group treated with cefazolin and AM transplantation, manifested by the least corneal haze and neovascularization (P = 0.007 and P = 0.014, respectively) and minimal bacterial counts (28 colony-forming units [CFU]/mL compared with 160 CFU/mL and 240 CFU/mL, respectively). Histopathologic examination showed that the central corneal vessels from rats treated with cefazolin and AM were smaller and less congested than those from the other two groups. CONCLUSIONS AM transplantation is a useful adjunctive treatment after bacterial keratitis in this rat model. The transplanted AM improved the healing process, resulting in decreased corneal haze and less neovascularization.

Macular findings on optical coherence tomography in cat-scratch disease neuroretinitis

PurposeTo describe the macular findings on optical coherence tomography (OCT) in patients with cat-scratch disease (CSD) neuroretinitis.MethodsMedical records of all patients diagnosed with CSD neuroretinitis at the Tel Aviv Medical Center between April 2006 and May 2010 were retrospectively reviewed. All patients underwent Stratus OCT macular examination.ResultsEight eyes of seven patients with confirmed CSD neuroretinitis, (mean age 33±9.9 years, range 6–48 years) were included in the study. All patients presented clinically with optic nerve swelling and macular edema or macular exudates. OCT demonstrated flattening of the foveal contour, thickening of the neurosensory retina, and accumulation of subretinal fluid (SRF) in all studied eyes. Retinal exudates appeared as multiple hyper-reflective foci in the outer plexiform layer. The average central macular thickness was 460 μm (range 170–906 μm) and the average maximal retinal thickness was 613 μm (range 387–1103 μm), at presentation. The macula appeared normal on repeated exams during follow-up.ConclusionSimilar OCT findings were demonstrated in patients with CSD neuroretinitis. SRF was found in all eyes, although was not visible on clinical examination or fluorescein angiography. OCT may be used as an adjunct imaging tool in the diagnosis and follow-up of patients with CSD neuroretinitis.