Gender and Ocular Manifestations of Connective Tissue Diseases and Systemic Vasculitides

Ocular manifestations are present in many connective tissue diseases which are characterized by an immune system that is directed against self. In this paper, we review the ocular findings in various connective tissue diseases and systemic vasculitides and highlight gender differences in each disease. In rheumatoid arthritis, we find that dry eyes affect women nine times more than men. The other extra-articular manifestations of rheumatoid arthritis affect women three times more commonly than men. Systemic lupus erythematosus can involve all ocular structures and women are nine times more affected than men. Systemic sclerosis is a rare disease but, again, it is more common in women with a female to male ratio of 8 : 1. Polymyositis and dermatomyositis also affect women more commonly than men but no gender differences have been found in the incidence or disease course in the systemic vasculitides associated with antineutrophil cytoplasmic antibody such as granulomatosis with polyangiitis (GPA, formerly known as Wegener’s granulomatosis). Finally, Behcet’s disease is more common in males, and male gender is a risk factor for Behcet’s disease. There is a slight female preponderance in sarcoidosis with female gender carrying a worse prognosis in the outcome of ocular disease

Differential Effectiveness of Etanercept and Infliximab in the Treatment of Ocular Inflammation

Anti–tumor necrosis factor α (anti–TNF-α) agents are being used increasingly in refractory inflammatory eye diseases. We reviewed our patients on etanercept and infliximab to determine whether these medications are equally efficacious in controlling ocular inflammation. Exploratory retrospective analysis. Patients with ocular inflammatory disease on an anti–TNF-α agent (etanercept, infliximab). Case records of 22 patients treated with anti–TNF-α therapy were reviewed for demographic information, ocular and systemic diagnosis, duration and dose of anti–TNF-α treatment, concomitant ocular and systemic immunosuppressive medications, and treatment response. Uveitis recurrence rate, initial treatment response, treatment response, and medication use at 6 months, 1 year, and last visit. Patients treated with infliximab had a significant decrease in uveitis recurrences after starting therapy compared with those treated with etanercept (59% vs. 0%, P = 0.004). One year after treatment initiation and at final visit, more infliximab-treated patients had an improvement in their ocular inflammation (100% vs. 33%, P = 0.002, and 94% vs. 0%, P<0.001, respectively) and a decreased requirement for topical prednisolone acetate 1% (94% vs. 33%, P = 0.009, and 89% vs. 29%, P = 0.007, respectively) compared with those treated with etanercept. No significant differences in the use of oral corticosteroids and immunosuppressive agents were noted between the 2 groups at 6 months, 1 year, and final visit. Infliximab was more effective than etanercept in the treatment of recalcitrant uveitis and decreased the use of topical steroids

Visual recovery and vascular reperfusion after vaso-occlusive retinopathy from anti-phospholipid syndrome associated with systemic lupus erythematosus.

PurposeTo report a case of visual recovery and vascular reperfusion after vaso-occlusive retinopathy from anti-phospholipid syndrome associated with systemic lupus erythematosus.ObservationsA 15-year-old boy with a known diagnosis of systemic lupus erythematosus and a clinically significant anti-phospholipid panel presented with sudden vision loss in the left eye. Examination and ocular imaging revealed signs of vaso-occlusive retinopathy. The patient was immediately started on high dose intravenous steroids, followed by mycophenolate mofetil. He remained on aspirin. After showing no improvement in retinal arteriole and capillary perfusion he was started on therapeutic anti-coagulation with enoxaparin. He regained 20/20 vision. Intravenous fluorescein angiography demonstrated reperfusion of retinal arterioles. Optical coherence tomography angiography showed return of flow in the capillary networks.ConclusionsWe present a case of vaso-occlusive retinopathy in a patient with known systemic lupus erythematosus and a clinically significant anti-phospholipid panel, thus meeting criteria for anti-phospholipid syndrome. He was treated with intravenous methylprednisolone, mycophenolate motefil, aspirin, and enoxaparin. The patient not only had great recovery of visual acuity, but also demonstrated reperfusion of arterioles and reconstitution of flow in the retinal capillary network. These findings suggest that the vaso-occlusive disease is reversible if the diagnosis is made promptly and intensive therapy is initiated.ImportanceCurrently there are no reported cases of vaso-occlusive retinopathy from APLS and SLE with visual recovery, reperfusion, and return of capillary flow

Surgical drainage of chronic serous retinal detachment associated with uveitis

To evaluate the anatomic and visual outcomes after surgical management of chronic serous retinal detachments (SRD) associated with uveitis. Retrospective, interventional, case study of patients with uveitis with controlled ocular inflammation who underwent drainage of a chronic SRD at the Cole Eye Institute (1998-2006). Data collected included diagnosis, ophthalmic findings, medical management, surgical technique, complications, and anatomic and visual outcomes. Five patients with uveitis were identified who underwent surgical drainage of a SRD. Preoperative medical treatment included prednisone 1 mg/kg with various tapering regimens. The median time on oral corticosteroids preoperatively was 4 months (range 3-6 months). Four patients received further adjuvant treatment. Median time from SRD diagnosis to surgical drainage was 6 months (range 3-15 months). No patient had active intraocular inflammation preoperatively. Retinal reattachment was achieved in all patients after a median follow-up of 55 months (range 1-61 months). Four of five patients experienced improvement in visual acuity after surgical intervention. Select patients with uveitis with a SRD whose subretinal fluid fails to resorb after medical therapy and resolution of inflammation can achieve long-term retinal reattachment by surgical management

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

Predictive factors for short‐term visual outcome after intravitreal triamcinolone acetonide injection for diabetic macular oedema: an optical coherence tomography study

Aim: To evaluate the predictive factors for visual outcome after intravitreal triamcinolone acetonide injection to treat refractory diabetic macular oedema (DME). Methods: A retrospective chart review of patients with DME who met the following inclusion criteria was performed: clinically significant diabetic macular oedema, receipt of a 4 mg/0.1 ml intravitreal triamcinolone acetonide injection and an optical coherence tomography (OCT) of the macula performed up to 10 days before injection. All patients received a full ophthalmic examination including best-corrected Snellen visual acuity (VA). The main outcome measure was the mean change in vision 3 months after injection. Results: Data from 73 eyes of 59 patients were analysed. After a mean follow-up of 324 days, the mean change in vision was −0.075 logarithm of minimum angle of resolution (logMAR) units, with 27.3% improving ⩾3 lines, 6.8% declining ⩾3 lines and 60.2% remaining stable within 1 line of baseline vision. Statistical analysis was performed using multivariate generalised estimating equations on the basis of data from 52 eyes of 42 patients. Factors associated with an improvement in vision 3 months after injection were worse baseline VA (−0.27 logMAR units/unit increase in baseline VA, p = 0.002) and presence of subretinal fluid (−0.17 logMAR units, p = 0.06). The presence of cystoid macular oedema negatively affected the visual outcome (0.15 logMAR units, p = 0.03). In addition, the presence of an epiretinal membrane (ERM) was associated with less visual improvement. ERM modified the effect of baseline VA as demonstrated by a significant interaction between these two variables (0.34 logMAR units/unit increase in baseline VA, p = 0.04). Conclusions: OCT factors and baseline VA can be useful in predicting the outcomes of VA 3 months after intravitreal triamcinolone acetonide injection in patients with refractory DME