Vogt-Koyanagi-Harada syndrome - current perspectives

Vogt-Koyanagi-Harada syndrome is a cause of noninfectious panuveitis, leading to significant vision loss in many patients. It is an autoimmune disease occurring in genetically susceptible individuals and clinically presents as bilateral panuveitis with serous retinal detachments and hyperemic, swollen optic discs, which are associated with neurological and auditory manifestations. Early diagnosis and prompt and adequate treatment with immunosuppressive agents (corticosteroids and other immunosuppressive drugs) may halt disease progression and prevent recurrences and vision loss. This review summarizes the current knowledge on the variable clinical aspects of this disease, highlighting diagnostic and treatment strategies

Predictors of Long-Term Visual Outcome in Intermediate Uveitis

PURPOSE: To describe factors that predict visual loss and complications in intermediate uveitis. DESIGN: Cross-sectional study. PARTICIPANTS: Subjects with intermediate uveitis were identified from a database of 1254 uveitis patients seen in the clinic of a single consultant (S.L.L.) between 2011 and 2013. S METHODS: Information was gathered from the clinical notes of all subjects examined in clinic. MAIN OUTCOME MEASURES: Best-corrected visual acuity (BCVA), moderate visual loss (MVL; ≤20/50), severe visual loss (SVL; ≤20/200). RESULTS: Three hundred and five subjects (550 eyes) were included in the study, comprising 24.3% of subjects seen in clinic. Mean (± standard deviation) age at diagnosis was 40.9±16.9 years, and 64.6% of subjects were female. Median follow-up was 8.2 years (mean, 9.7 years, 5452 eye-years). Systemic diagnosis was made in 36.1% of patients, with sarcoidosis (22.6%) and multiple sclerosis (4.6%) the most frequent systemic associations. Median BCVA was 20/30 (mean logarithm of the minimum angle of resolution [logMAR] 0.26±0.38, n = 550 eyes) at presentation, 20/30 (mean logMAR 0.22±0.42, n = 430) at 5 years, and 20/30 (mean logMAR 0.23±0.46, n = 260) at 10 years. Macular edema was observed in 224 eyes (40.7%) and was associated with idiopathic disease (P = 0.001) and diabetes (P = 0.001). Topical therapy was used in 82.7%, and 34.2% received local injections of corticosteroids. A total of 50.5% required oral steroids and 13.8% required second-line immunosuppression. Subjects with a diagnosis of sarcoidosis were less likely to require a second-line agent (4.3% vs. 16.2%, P = 0.011). On multivariate analysis, visual acuity at referral, retinal pigment epithelial atrophy, and macular scarring were associated with increased risk of MVL; and visual acuity at referral, local therapy, macular scarring, retinal detachment, and hypotony and phthisis were associated with increased risk of SVL. CONCLUSIONS: Intermediate uveitis has a long disease course with frequent complications and often requires systemic treatment. Despite this, most subjects are still able to achieve good long-term visual outcomes

Rhizobium radiobacter Endophthalmitis following Intravitreal Ranibizumab Injection.

We present the first reported case of acute endophthalmitis due to Rhizobium radiobacter after an intravitreal injection of ranibizumab for neovascular age-related macular degeneration

Comparing Treatment of Acute Retinal Necrosis With Either Oral Valacyclovir or Intravenous Acyclovir

PURPOSE: To compare the visual outcomes of patients with acute retinal necrosis (ARN) treated initially with intravenous acyclovir vs oral valacyclovir therapy. DESIGN: Retrospective, comparative, interventional case series. METHODS: Sixty-two patients (68 eyes) with ARN, treated at Moorfields Eye Hospital (United Kingdom) between 1992 and 2016, were identified through the hospital's electronic database. Exclusion criteria included insufficient patient records or follow-up (<150 days). Fifty-six patients had unilateral ARN, while 6 had bilateral ARN. Patients who received intravenous acyclovir on diagnosis (n = 33) were compared with patients treated with oral valacyclovir (n = 29) across outcomes including best-corrected visual acuity, retinal detachment, severe vision loss, and other complications. The impact of adjunctive intravitreal antiviral and prophylactic barrier laser treatment was also assessed. RESULTS: Change in best-corrected visual acuity was not significantly different for eyes treated initially with intravenous therapy vs oral therapy over 5 years of follow-up data (P = .16). There was no difference in the rates of severe vision loss between the 2 groups (46% and 59%, respectively, P = .18), or of those eyes retaining good vision (28% vs 31%, respectively, P = .80). Retinal detachment occurred in 63% of cases and did not differ across treatment groups (62% vs 66%, respectively, P = .67). Barrier laser and intravitreal therapy had no effect on retinal detachment rate in either group. CONCLUSION: Oral valacyclovir is clinically equivalent to intravenous therapy in the management of ARN. Oral valacyclovir as an outpatient therapy-with or without intravitreal foscarnet-can therefore be considered as an acceptable alternative to inpatient therapy required for intravenous treatment

Intravitreal bevacizumab injections for diabetic macular edema - predictors of response: a retrospective study

BACKGROUND: Outcomes of intravitreal antivascular endothelial growth factor injections are variable among patients with diabetic macular edema (DME). The aim of this study was to determine the ocular and systemic predictors of DME response to intravitreal bevacizumab (IVB). METHODS: Retrospective review over 2 years of 78 eyes from 54 patients. An anatomical response to IVB was defined as a 20% reduction in central macula thickness after the first course (three injections) of IVB. RESULTS: Twenty-eight percent of patients had an anatomical response after the first course of IVB. Systemic hypertension (odds ratio, 95% confidence interval: 12.1, 0.7-21) was a statistically significant predictor (P=0.025) of a good response to IVB, whereas previous macular laser was a statistically significant (P=0.0005) predictor of a poor response (0.07, 0.01-0.32). Sixty-eight percent of eyes underwent subsequent treatment for DME after the first course of IVB. The visual acuity gain at 24 months in hypertensive (0.7±3.6 letters) and nonhypertensive (5.2±3.7 letters) patients was not significantly different (P=0.41). CONCLUSION: Hypertension and previous macular laser were positive and negative predictors of response to IVB, respectively. However, long-term visual acuity changes were not significantly different between eyes with and without systemic hypertension

Risk Factors for the Development of Cataract in Children with Uveitis

PURPOSE: To determine the risk factors for the development of cataract in children with uveitis of any etiology. DESIGN: Cohort study. METHODS: Two hundred forty-seven eyes of 140 children with uveitis were evaluated for the development of vision-affecting cataract. Demographic, clinical, and treatment data were collected between the time of presentation and the first instance cataract was recorded or findings at final follow-up. Main outcome measures included the prevalence of cataract and distribution by type of uveitis, incidence of new onset cataract time to cataract development, and risk factors for the development of cataract. RESULTS: The prevalence of cataract in our cohort was 44.2% and was highest among eyes with panuveitis (77.1%), chronic anterior uveitis (48.3%), and intermediate uveitis (48.0%). The overall incidence of newly diagnosed cataract was 0.09 per eye-year, with an estimated 69% to develop uveitis-related cataract with time. The main factors related with cataract development were the number of uveitis flares per year (hazard ratio [HR] = 3.06 [95% confidence interval {CI}, 2.15–4.35], P < .001), cystoid macular edema (HR = 2.87 [95% CI, 1.41–5.82], P = .004), posterior synechia at presentation (HR = 2.85 [95% CI, 1.53–5.30], P = .001), and use of local injections of corticosteroids (HR = 2.37 [95% CI, 1.18–4.75], P = .02). Treatments with systemic and topical corticosteroids were not significant risk factors. CONCLUSIONS: In this study, we found that development of cataract is common among pediatric eyes with uveitis and is most strongly related to the extent of inflammation recurrences and ocular complications. We suggest that controlling the inflammation, even using higher doses of systemic and topical corticosteroids, is of importance in preventing ocular complications, such as cataract. Uveitis accounts for 10–15% of blindness in the developed world.1 Although pediatric uveitis is relatively uncommon, accounting for only 5–10% of all uveitis cases,2 it affects young patients, who in most cases are otherwise healthy. Vision loss results from ongoing inflammation that leads to ocular structural changes, such as cataract, corneal opacities, optic neuropathy, and retinal lesions. The most common causes of vision loss in children with uveitis are cataract, glaucoma, and chronic cystoid macular edema (CME).2, 3 In addition, any chronic visual obstruction can result in the development of amblyopia in younger children, with vision loss persisting after the inciting cause is treated.4 Such changes, together with the need for long-term treatment and continuous monitoring, can have a profound impact on their development, independence, and education. The prevalence of cataract in eyes with uveitis ranges from 20–64%,4, 5, 6, 7 and it is the most common complication of uveitis in children,8 occurring in approximately 35% of children with juvenile idiopathic arthritis (JIA)-associated uveitis9 and increasing ≤80% in adults.10, 11 Cataract progression can be the result of persistent intraocular inflammation,12, 13 can be caused by surgery for uveitis complications (eg, trabeculectomies and repair of retinal detachments), or can be a consequence of uveitis treatment, particularly the use of local or systemic corticosteroids.14, 15, 16, 17 It results in reduced visual acuity and can have a detrimental effect on the development and academic achievements of these children.18 Studies have examined risk factors for the development of cataract among children with JIA-associated uveitis, identifying risk factors such as the presence of posterior synechiae (PS) at presentation,12, 19 the use of systemic corticosteroids,13 topical corticosteroid therapy exceeding 3 drops a day,12 or persistent, uncontrolled active inflammation,3 while early treatment with methotrexate delayed cataract progression.19 However, JIA is a unique cause of uveitis, often localized to the anterior chamber, with frequent intraocular structural changes and the early use of systemic immunosuppressive agents. It may not represent the same risks as other causes of pediatric uveitis. We examined disease- and treatment-related risk factors for cataract development in children with uveitis of any etiology. We investigated clinical and ophthalmologic characteristics, as well as treatment strategies in relation to the time interval between the first presentation with uveitis and cataract development