Fever, Headache, and Visual Blurring in a 17-Year-Old Woman

A fascinating case, with much to learn about diagnosis and treatment of patients with abnormal CSF results. After learning from the case, take our online qui

Difference in glaucoma progression between the first and second eye after consecutive bilateral glaucoma surgery in patients with bilateral uveitic glaucoma

PURPOSE: To determine whether the second eyes (SE) of patients with bilateral uveitic glaucoma undergoing filtration surgery have more glaucomatous progression in terms of visual acuity, visual field (VF) and optic nerve changes compared to the first eyes (FE). METHODS: This retrospective study analysed data of 60 eyes from 30 patients with bilateral uveitic glaucoma who had undergone glaucoma surgery in both eyes on separate occasions. Humphrey VF progression was assessed using the Progressor software. RESULTS: The pre-operative IOP between the FE (43.1 ± 7.7 mmHg) and SE (40 ± 8.7 mmHg) was not statistically significant (p = 0.15). IOP reduction was greater in the FE (64 %) than SE (59.7 %) post-operatively, but the mean IOP at the final visit in the FE (12.3 ± 3.9 mmHg) and SE (14.5 ± 7 mmHg) was not statistically different (p = 0.2). There was no significant change in mean logMAR readings pre and post-operatively (0.45 ± 0.6 vs 0.37 ± 0.6, p = 0.4) or between the FE and SE. The number of SE with CDR > 0.7 increased by 23 % compared to the FE. From 23 available VFs, five SE (21.7 %) progressed at a median of five locations (range 1-11 points) with a mean local slope reduction of 1.74 ± 0.45 dB/year (range -2.39 to -1.26), whereas only one FE progressed. However, there was no significant difference between mean global rate of progression between the FE (-0.9 ± 1.6 dB/year) and SE (-0.76 ± 2.1 dB/year, p = 0.17) in the Humphrey VF. CONCLUSION: In eyes with bilateral uveitic glaucoma requiring glaucoma surgery, the SEs had more progressed points on VF and glaucomatous disc progression compared to FEs at the final visit

A Meta-Analysis of Studies Evaluating Visual and Anatomical Outcomes in Patients with Treatment Resistant Neovascular Age-Related Macular Degeneration following Switching to Treatment with Aflibercept

With the introduction of aflibercept, eyes with neovascular age-related macular degeneration (AMD) not responding well to injections of ranibizumab or bevacizumab can be switched to treatment with aflibercept. We carried out a meta-analysis to analyze all available evidence of visual and anatomical outcomes of eyes with resistant neovascular AMD switched to aflibercept at six months. Data from seven retrospective and prospective studies looking at change in best corrected visual acuity (BCVA) and central retinal thickness (CRT) were included. Weighted mean difference (WMD) and 95% CI were estimated using the standardized mean change method. The overall results of the meta-analysis showed a small but statistically significant improvement in BCVA six months following treatment switch to aflibercept (WMD 0.142, 95% CI 0.006 to 0.28; = 0.04), and the effect was more significant in data gathered from prospective studies (WMD 0.407, 95% CI 0.023 to 0.791, = 0.038). There was a significant improvement in CRT following treatment switch to aflibercept (WMD −0.36, 95% CI −0.485 to −0.235; < 0.0001). Our meta-analysis indicates that following treatment switch to aflibercept patients may have a significant improvement in CRT with stabilization or even some improvement in their visual acuity

A Review of Antimicrobial Therapy for Infectious Uveitis of the Posterior Segment

Treatment of infectious posterior uveitis represents a therapeutic challenge for ophthalmologists. The eye is a privileged site, maintained by blood ocular barriers, which limits penetration of systemic antimicrobials into the posterior segment. In addition, topical and subconjunctival therapies are incapable of producing sufficient drug concentrations, intraocularly. Posterior infectious uveitis can be caused by bacteria, virus, fungi, or protozoa. Mode of treatment varies greatly based on the infectious etiology. Certain drugs have advantages over others in the treatment of infectious uveitis. Topical and systemic therapies are often employed in the treatment of ocular infection, yet the route of treatment can have limitations based on penetration, concentration, and duration. The introduction of intravitreal antimicrobial therapy has advanced the management of intraocular infections. Being able to bypass blood-ocular barriers allows high drug concentrations to be delivered directly to the posterior segment with minimal systemic absorption. However, because the difference between the therapeutic and the toxic doses of some antimicrobial drugs falls within a narrow concentration range, intravitreal therapy could be associated with ocular toxicity risks.  In many cases of infectious uveitis, combination of intravitreal and systemic therapies are necessary. In this comprehensive review, the authors aimed at reviewing clinically relevant data regarding intraocular and systemic antimicrobial therapy for posterior segment infectious uveitis. The review also discussed the evolving trends in intraocular treatment, and elaborated on antibiotic pharmacokinetics and pharmacodynamics, efficacy, and adverse effects

A Review of Antimicrobial Therapy for Infectious Uveitis of the Posterior Segment

Treatment of infectious posterior uveitis represents a therapeutic challenge for ophthalmologists. The eye is a privileged site, maintained by blood ocular barriers, which limits penetration of systemic antimicrobials into the posterior segment. In addition, topical and subconjunctival therapies are incapable of producing sufficient drug concentrations, intraocularly. Posterior infectious uveitis can be caused by bacteria, virus, fungi, or protozoa. Mode of treatment varies greatly based on the infectious etiology. Certain drugs have advantages over others in the treatment of infectious uveitis. Topical and systemic therapies are often employed in the treatment of ocular infection, yet the route of treatment can have limitations based on penetration, concentration, and duration. The introduction of intravitreal antimicrobial therapy has advanced the management of intraocular infections. Being able to bypass blood-ocular barriers allows high drug concentrations to be delivered directly to the posterior segment with minimal systemic absorption. However, because the difference between the therapeutic and the toxic doses of some antimicrobial drugs falls within a narrow concentration range, intravitreal therapy could be associated with ocular toxicity risks.  In many cases of infectious uveitis, combination of intravitreal and systemic therapies are necessary. In this comprehensive review, the authors aimed at reviewing clinically relevant data regarding intraocular and systemic antimicrobial therapy for posterior segment infectious uveitis. The review also discussed the evolving trends in intraocular treatment, and elaborated on antibiotic pharmacokinetics and pharmacodynamics, efficacy, and adverse effects

A Review of Antimicrobial Therapy for Infectious Uveitis of the Posterior Segment

Treatment of infectious posterior uveitis represents a therapeutic challenge for ophthalmologists. The eye is a privileged site, maintained by blood ocular barriers, which limits penetration of systemic antimicrobials into the posterior segment. In addition, topical and subconjunctival therapies are incapable of producing sufficient drug concentrations, intraocularly. Posterior infectious uveitis can be caused by bacteria, virus, fungi, or protozoa. Mode of treatment varies greatly based on the infectious etiology. Certain drugs have advantages over others in the treatment of infectious uveitis. Topical and systemic therapies are often employed in the treatment of ocular infection, yet the route of treatment can have limitations based on penetration, concentration, and duration. The introduction of intravitreal antimicrobial therapy has advanced the management of intraocular infections. Being able to bypass blood-ocular barriers allows high drug concentrations to be delivered directly to the posterior segment with minimal systemic absorption. However, because the difference between the therapeutic and the toxic doses of some antimicrobial drugs falls within a narrow concentration range, intravitreal therapy could be associated with ocular toxicity risks.  In many cases of infectious uveitis, combination of intravitreal and systemic therapies are necessary. In this comprehensive review, the authors aimed at reviewing clinically relevant data regarding intraocular and systemic antimicrobial therapy for posterior segment infectious uveitis. The review also discussed the evolving trends in intraocular treatment, and elaborated on antibiotic pharmacokinetics and pharmacodynamics, efficacy, and adverse effects

Role of Autofluorescence in Inflammatory/Infective Diseases of the Retina and Choroid

Fundus autofluorescence (FAF) has recently emerged as a novel noninvasive imaging technique that uses the fluorescent properties of innate fluorophores accumulated in the retinal pigment epithelium (RPE) to assess the health and viability of the RPE/photoreceptor complex. Recent case reports suggest FAF as a promising tool for monitoring eyes with posterior uveitis helping to predict final visual outcome. In this paper we review the published literature on FAF in these disorders, specifically patterns in infectious and noninfectious uveitis, and illustrate some of these with short case histories

Can simvastatin reduce the need for immunomodulatory drugs to treat uveitis? A prospective, randomized, placebo-controlled trial

Objective: To assess the efficacy of simvastatin 80mg/day versus placebo in patients with non-infectious non-anterior uveitis receiving prednisolone ≥10mg/day./ Design: Randomized, double-masked, controlled trial./ Subjects: Adult patients with non-infectious non-anterior uveitis on oral prednisolone dose of ≥10 mg/day./ Methods: Patients were randomly assigned at a 1:1 ratio to receive either simvastatin 80mg/day or placebo. 32 patients were enrolled (16 in each arm) all of whom completed the primary endpoint and 21 reached the two-year visit (secondary end points)./ Main outcome measures: The primary endpoint was mean reduction in the daily prednisolone dose at 12 months follow-up. Secondary end points were mean reduction in prednisolone dose at 24 months, percent of patients with a reduction in second-line immunomodulatory agents, time to disease relapse and adverse events./ Results: Our results show that simvastatin 80mg/day did not have a significant corticosteroid-sparing effect at 12 months (estimate: 3.62, 95% CI: -8.15 to 15.38; p=0.54). There was no significant difference between the groups with regards to prednisolone dose or change in dose at 12 and 24 months. There was no difference between the two groups in percent of patients with reduction in second-line agent by 24 months. Among patients who achieved disease quiescence the median time to first relapse was longer for those receiving simvastatin (8.7 months, 95% CI 3.2-14.19) than placebo (3.2 months, 95% CI 0.17-6.23), though this was not statistically significant. There was no significant difference in adverse events or serious adverse events between the two groups./ Conclusions: Simvastatin 80mg/day did not have an effect on the dose reduction of corticosteroids nor conventional immunomodulatory drugs at one and two years. The results suggest that it may extend the time to disease relapse among those that achieve disease quiescence./ Systemic corticosteroids represent the mainstay treatment for patients with uveitis, particularly those with systemic involvement or bilateral disease. While treatment is very effective in controlling the intra-ocular inflammation, long-term systemic side effects limit their use, so that ophthalmologists continually aim to reduce the dose to ≤10mg/d.1 To achieve this, other immunomodulatory agents can be added to enhance and maintain inflammatory control. While they are effective in the majority of cases,2, 3, 4, 5 they are not without their own risks of complications and can affect hepatic, renal and gastrointestinal function, as well as increase the risk for opportunistic infections./ Statins are routinely prescribed to reduce serum cholesterol levels and improve clinical outcomes in patients with cardiovascular diseases. They are considered an effective treatment with a low risk of systemic side effects, primarily myalgia and rhabdomyolysis. Studies have shown that they also have pleiotropic immunomodulatory effects, both in vitro and in vivo.6 In animal models of uveoretinitis statins reduced the clinical and histological scores of inflammation and inhibited T lymphocyte recruitment into the retina.7 Two large observational population-based studies also showed a protective effect of statins against the development of uveitis.8 9 Clinical studies in multiple sclerosis patients showed a positive effect from simvastatin on brain atrophy, suggesting these drugs cross the blood-brain barrier and can play a role in controlling disease activity.10 In rheumatoid arthritis, statins led to improvement in disease activity scores and reduced the numbers of tender and swollen joints.11 A study on the effect of statins among patients with sarcoidosis, demonstrated an increased time to disease flare among patients with mild-moderate disease.12 Given the relatively safe side effect profile of statins, they would be a suitable treatment option for patients with uveitis, as well as reducing serum cholesterol levels and improving the cardiovascular outcomes in patients on long-term corticosteroid therapy./ The aim of this study was to prospectively examine in a randomized double masked clinical trial the additional anti-inflammatory effect and safety of simvastatin in patients with uveitis and to determine if their addition could reduce the amount of corticosteroid or number/ dose of additional immunomodulatory agents required to keep the uveitis controlled

Valacyclovir in the treatment of acute retinal necrosis

Background: To report the outcome of oral valacyclovir as the sole antiviral therapy for patients with acute retinal necrosis (ARN). Methods: This study reports a retrospective, interventional case series of nine consecutive patients with ten eyes with newly diagnosed ARN treated with oral valacyclovir as the sole antiviral agent. Eight patients received oral valacyclovir 2 g tid (Valtrex, GlaxoSmithKline) and one patient with impaired renal function received oral 1 g tid. The main outcome measures were response to treatment, time to initial response to treatment, time to complete resolution of retinitis, best corrected visual acuity (BCVA) at final follow-up, retinal detachment and development of recurrent or second eye disease. Results: Retinitis resolved in ten of ten (100%) affected eyes. The median time to initial detectable response was seven days and the median time to complete resolution was 21 days. A final BCVA of 20/40 or better was achieved in 6/10 (60%) of eyes. 3/10 eyes (30%) developed a retinal detachment. No patients developed either disease reactivation or second eye involvement over the course of the study (mean follow up 31 weeks, range 7 to 104 weeks). Conclusions: Treatment with oral valacyclovir as the sole antiviral therapy resulted in complete resolution of retinitis. Final BCVA and retinal detachment rate were comparable with previously reported outcomes for intravenous acyclovi