Sustained-release dexamethasone intravitreal implant in juvenile idiopathic arthritis-related uveitis

The purpose of this study is to review the results of treatment of juvenile idiopathic arthritis-related uveitis with the use of intravitreal dexamethasone implant. Sixteen eyes with Juvenile idiopathic arthritis (JIA)-associated uveitis received intravitreal dexamethasone implant to treat recalcitrant anterior segment inflammation (43.7 %), chronic macular edema (6.2 %), or a combination of both (50 %). One month after injection, mean visual acuity had improvement to 39.6 \ub1 11 ETDRS letters (p < 0.001). Mean AC cells measure at 1 month was 0.79 and 0.75 at 3 months. One month after injection, there was a significant reduction of central retinal thickness (CRT) to 342.4 \ub1 79.3 \ub5m (p < 0.01). One month after the second implant, 11 eyes (91.6 %) achieved improved activity of the anterior uveitis, and mean best-corrected visual acuity improved to 44.6 \ub1 8.1 ETDRS letters (p < 0.01). At 1 month after the second injection, 4/5 eyes had resolution of macular edema with CRT of 250.4 \ub1 13.7 \ub5m (p < 0.01). Of the 16 eyes, 12 eyes received a second injection at mean of 7.5 \ub1 3.1 months after the first treatment, and 5 eyes received a third Ozurdex injection on average 7 \ub1 4.6 months after the second injection. Of the 16 eyes, five eyes were pseudophakic prior to injection. Of the remaining 11 eyes, 8 (73 %) developed worsening posterior subcapsular cataract at a mean of 7.3 \ub1 1.2 months after the first injection. After the first injection, only one eye required topical antiglaucoma therapy with maximum pressure of 25 mmHg. In patients with recalcitrant JIA-associated active uveitis, injection of sustained-release dexamethasone can achieve control of anterior inflammation and resolution of macular edema

Peripheral retinoschisis in intermediate uveitis

Purpose: To examine cases of intermediate uveitis complicated by retinoschisis and review the pathogenetic hypothesis. Methods: A retrospective chart review of patients with intermediate uveitis. Data were collected at three uveitis referral centers on sex, age, best-corrected visual acuity, degree of vitritis, extent and location of snowbanking, presence of hard exudates, neovascularization, vitreous hemorrhage, and extent and nature of retinal elevations. Results: A series of 23 eyes of 20 patients were examined; patient's age ranged from 10 years to 70 years and follow-up period from 8 months to 6 years. Twenty-two eyes had retinoschisis (95.6%), and 1 had retinoschisis associated with serous retinal detachment (4.3%). Extensive inferior pars plana exudates with snowbanking were present in 12 eyes (52.2%), whereas 3 eyes had inferior snowballs over the elevated retina. Neovascularization of the vitreous base accompanied by vitreous hemorrhage occurred in one eye. There was no coexisting macular pathology in 16 eyes, whereas 4 eyes had cystoid macular edema. Conclusion: The appearance of peripheral retinoschisis in this series of uncontrolled intermediate uveitis patients seems to be secondary to a complex balance between the persistent fluorescein leakage, a subclinical peripheral ischemia, and the constant low-grade vitreous inflammation that causes vitreous shrinkage and traction. The results of this study suggest that the absence of macroscopic changes in the retina does not preclude ischemic peripheral abnormalities, and the detection of a peripheral retinoschisis in an intermediate uveitis patient with active fluorescein leakage must suggest the need for a more aggressive form of treatment despite the good visual acuity

Fibrin reaction after uveitic cataract surgery : treatment and prevention

Purpose: To describe the management with intracameral recombinant tissue plasminogen activator (rtPA) of severe fibrin effusion after phacoemulsification, and its prevention with sustained-release dexamethasone intravitreal implant. Methods: A 59-year-old man with chronic HLA-B27-associated uveitis underwent phacoemulsification followed by a sustained-release dexamethasone intravitreal implant. Results: A postoperative severe fibrin reaction was completely resolved after intracameral injection of rtPA. At the time of the phacoemulsification of the fellow eye, a dexamethasone implant was injected 5 days prior to surgery, with no fibrin formation. Conclusions: Intracameral rtPA may be successfully used in the management of severe fibrin reaction. Dexamethasone intravitreal implant to control postoperative inflammation may take several days until it achieves high concentrations in the vitreous

Acute and chronic staphylococcus epidermidis post-operative endophthalmitis : the importance of biofilm production

To report two cases of acute and chronic-onset, postoperative Staphylococcus epidermidis endophthalmitis and discuss the virulence and treatment of this saprophytic pathogen. After clinical diagnosis of endophthalmitis, prompt vitreous culture was performed with injection of intravitreal vancomycin 1\ua0mg/0.1\ua0mL and ceftazidime 2.25\ua0mg/0.1\ua0mL. With no improvement after this procedure, a pars plana vitrectomy and lensectomy were performed to further decrease microbial load and repeat the intravitreal antibiotic. The lens and large amounts of fibrotic tissue were removed, and the posterior capsule was stripped. Vitreous cultures grew S. epidermidis sensitive to vancomycin. Intraoperative findings included dense vitreous opacification with extensive vitreous bands and pus extending into the zonules. During the removal of the IOL, adherent pus filaments were removed; however, only a moderate amount of bacteria was detected on the IOL. Further intravitreal vancomycin (1\ua0mg/0.1\ua0mL) and ceftazidime (2.25\ua0mg/0.1\ua0mL) were injected. Staphylococcus epidermidis is widely reported as responsible for medical device-related sepsis. This is mainly due to the production of slime, an exopolysaccharide that eventually leads to the formation of biofilm, one of the most important virulence factors. The failure of intravitreal antibiotic treatment in our two biofilm-associated infections may be due to the considerable amount of slime and pus found extending into the zonules and adherent to the IOL during surgery

Genetic of uveitis

Immune-mediated uveitis may be associated with a systemic disease or may be localized to the eye. T-cell-dependent immunological events are increasingly being regarded as extremely important in the pathogenesis of uveitis. Several studies have also shown that macrophages are major effectors of tissue damage in uveitis. Uveitis phenotypes can differ substantially, and most uveitis diseases are considered polygenic with complex inheritance patterns. This review attempts to present the current state of knowledge from in vitro and in vivo research on the role of genetics in the development and clinical course of uveitis. A review of the literature in the PubMed, MEDLINE, and Cochrane databases was conducted to identify clinical trials, comparative studies, case series, and case reports describing host genetic factors as well as immune imbalance which contribute to the development of uveitis. The search was limited to primary reports published in English with human subjects from 1990 to the present, yielding 3590 manuscripts. In addition, referenced articles from the initial searches were hand searched to identify additional relevant reports. After title and abstract selection, duplicate elimination, and manual search, 55 papers were selected for analysis and reviewed by the authors for inclusion in this review. Studies have demonstrated associations between various genetic factors and the development and clinical course of intraocular inflammatory conditions. Genes involved included genes expressing interleukins, chemokines, chemokine receptors, and tumor necrosis factor and genes involved in complement system. When considering the genetics of uveitis, common threads can be identified. Genome-wide scans and other genetic methods are becoming increasingly successful in identifying genetic loci and candidate genes in many inflammatory disorders that have a uveitic component. It will be important to test these findings as uveitis-specific genetic factors. Therefore, the burgeoning understanding of the human genome promises to result in new insight into the pathogenesis of uveitis

En Face Optical Coherence Tomography and Optical Coherence Tomography Angiography of Multiple Evanescent White Dot Syndrome : New Insights Into Pathogenesis

PURPOSE:: To localize the various levels of abnormalities in multiple evanescent white dot syndrome by comparing \u201cen face\u201d optical coherence tomography (OCT) and OCT angiography with various conventional imaging modalities. METHODS:: In this retrospective case series, multimodal imaging was performed in 9 retinal centers on 36 patients with multiple evanescent white dot syndrome and included widefield fundus autofluorescence (FAF), fluorescein angiography (FA), and indocyanine green angiography, and B-scan and \u201cen face\u201d C-scan enhanced depth imaging and spectral domain OCT. Optical coherence tomography angiography was also performed at the level of the superficial and deep retinal capillary plexus and choroid. RESULTS:: Multiple evanescent white dot syndrome lesions were more numerous and more easily detectable with FA and FAF. Two types of lesions were identified with FAF, FA, and indocyanine green angiography: larger widely scattered \u201cspots\u201d (approximately 200 \u3bc in diameter) that were hyperfluorescent with FA, hyperautofluorescent with FAF, and hyporeflective in indocyanine green angiography, representing abnormalities primarily at the retinal pigment epithelium/photoreceptor junction; and punctate \u201cdots\u201d (less than 100 \u3bc in diameter) that were hyperfluorescent with FA, hyperautofluorescent, or isoautofluorescent with FAF, and hypofluorescent with indocyanine green angiography and that localized to the outer nuclear layer. These lesions colocalized with \u201cen face\u201d OCT. The larger confluent \u201cspots\u201d were hyporeflective and colocalized to the level of the ellipsoid zone, whereas smaller hyperreflective \u201cdots\u201d colocalized to the outer nuclear layer. The location of the \u201cdots\u201d in the outer nuclear layer was further confirmed by structural spectral domain optical coherence tomography which showed coalescence of the dots into hyperreflective lines extending from the external limiting membrane to the outer plexiform layer in certain cases. Optical coherence tomography angiography analysis of the retinal microvasculature and choriocapillaris and choroid were entirely unremarkable in 100% of our patients. CONCLUSION:: By combining multimodal imaging, the authors propose that multiple evanescent white dot syndrome is primarily the result of inflammation at the outer photoreceptor level leading to a \u201cphotoreceptoritis\u201d and causing loss of the inner and outer segments. Its evanescent nature suggests that the photoreceptor cell bodies remain intact ensuring complete recovery of the photoreceptor inner and outer segments in most cases, compatible with the clinical course of spontaneous resolution of white spots and dots

New appraisals of Kyrieleis plaques: a multimodal imaging study.

PURPOSE: Kyrieleis retinal periarteritis reflects the severe intraocular inflammation experienced by the eye. Its aetiology has not been well established, since only nine cases have been reported and there is no pathological study available in the literature. We determine the pathogenesis of Kyrieleis periarteritis based on interpretation of multimodal imaging findings. METHODS: Charts of patients with Kyrieleis arteritis seen between 2006 and 2014 were retrieved from eight uveitis referral centres throughout the world. Follow-up ranged from 5 to 12\u2005months. RESULTS: Twenty-five eyes with Kyrieleis arteritis from 25 patients were included in the study. Nineteen patients (72%) were male and six (28%) were female. Twenty-three patients were diagnosed with toxoplasmosis retinochoroiditis and two patients had cytomegalovirus retinitis. Fluorescein angiography, fundus autofluorescence and indocyanine green angiography were performed on 25/25 (100%) eyes. In eight eyes (32%), baseline spectral domain optical coherence tomography (SD-OCT) scans were performed along the segmental Kyrieleis arteritis. Fluorescein angiography showed early hypofluorescence and intermediate hyperfluorescence associated with the areas of focal arteritis, whereas indocyanine green angiography of these accumulations showed early hypofluorescence and late hyperfluorescence. Fundus autofluorescence revealed an increased autofluorescence of the vessels corresponding to the Kyrieleis plaques, while SD-OCT scans along the segmental Kyrieleis arteritis showed hyperreflectivity of the vessel wall. CONCLUSIONS: These imaging modalities provide in vivo, quasi-histologic images demonstrating that Kyrieleis plaques are characterised by an inflammatory involvement within the vessels' endothelium. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing