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

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

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

Statins as anti-inflammatory agents: A potential therapeutic role in sight-threatening non-infectious uveitis

In addition to the known lipid-lowering effects, statins are now widely accepted to have antiinflammatory and immunomodulatory effects. Adjunctive use of statins has proven beneficial in the context of a wide range of inflammatory diseases, including rheumatoid arthritis. Evidence also suggests that statins may also have utility in the management of uveitis, a form of sight threatening inflammation which occurs in the eye. In this article, we outline our rationale behind a clinical trial of simvastatin as a steroid-sparing agent in uveitis, to which patient recruitment started last year. Potential risks associated with the clinical use of statins, including putative effects on the eyes, are discussed

Clinical Outcome of Retinal Vasculitis and Predictors for Prognosis of Ischemic Retinal Vasculitis

PURPOSE: To determine factors affecting the visual outcome in eyes with retinal vasculitis and the rate of neovascularization relapse in ischemic vasculitis. DESIGN: Retrospective cohort study. METHODS: We reviewed 1169 uveitis patients from Moorfields Eye Hospital, London, UK. Retinal vasculitis was observed in 236 eyes (121 ischemic, 115 nonischemic) that were compared with a control group (1022 eyes) with no retinal vasculitis. Ultra-widefield fluorescein angiography images were obtained in 63 eyes with ischemic vasculitis to quantify area of nonperfusion measured as ischemic index. RESULTS: The risk of vision loss was significantly more in the retinal vasculitis compared with the non-vasculitis group (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.24–2.25, P = .001). Retinal vasculitis had twice the risk of macular edema compared to the non-vasculitis group. Macular ischemia increased the risk of vision loss in vasculitis eyes by 4.4 times. The use of systemic prednisolone in eyes with vasculitis was associated with a reduced risk of vision loss (HR 0.36, 95% CI 0.15–0.82, P = .01). Laser photocoagulation was administered in 75 eyes (62.0%), out of which 29 (38.1%) had new vessel relapse and required additional laser treatment. The median ischemic index was 25.8% (interquartile range 10.2%–46%). Ischemia involving ≥2 quadrants was associated with increased risk of new vessel formation (HR 2.7, 95% CI 1.3–5.5, P = .003). CONCLUSION: Retinal vasculitis is associated with an increased risk of vision loss, mainly secondary to macular ischemia, and has a higher risk of macular edema compared to eyes with no vasculitis. Ischemia involving ≥2 quadrants is a risk factor for new vessel formation

Reply

Refers to: Koushik Tripathy, Re: Niederer et al.: Predictors of long-term visual outcome, in: intermediate uveitis (Ophthalmology. 2017;124:393-398) Ophthalmology, Volume 124, Issue 7, July 2017, Pages e59. https://doi.org/10.1016/j.ophtha.2017.02.01

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