A sore red eye with systemic involvement

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Estudo comparativo entre as manifestações oftalmológicas, sorológicas e resposta terapêutica de pacientes com esclerite isolada e esclerite associada a doenças sistêmicas

INTRODUCTION: Scleritis is a rare, progressive and serious disease, the signs of which are inflammation and edema of episcleral and scleral tissues and is greatly associated with systemic rheumatoid diseases. PURPOSE: To perform a prospective and comparative study between ophthalmologic manifestations, serologic findings and therapeutic response of patients with isolated scleritis and scleritis associated with systemic rheumatoid disease. METHODS: Thirty-two outpatients with non-infectious scleritis were studied, from March 2006 to March 2008. The treatment was corticoid eye drops associated with anti-inflammatory agents, followed by systemic corticoids and immunosuppressive drugs if necessary, was considered successful after six months without scleritis recurrence. RESULTS: Fourteen of 32 patients had scleritis associated with systemic rheumatoid disease, of which nine had rheumatoid arthritis, two systemic lupus erythematosus, one Crohn's disease, one Behçet's disease and one gout. There were no difference in relation to involvement and ocular complications, there was predominance of nodular anterior scleritis and scleral thinning was the most frequent complication. The scleritis associated with systemic rheumatoid disease group had 64.3% of autoantibodies, versus 27.8% among those with isolated scleritis and this difference was statistically significant. In the isolated scleritis group 16.7% used anti-inflammatory, 33.3% corticosteroids, 27.8% corticosteroids with one immunosuppressive drug, 5.5% two immunosuppressive drugs, 16.7% corticosteroids with two immunosuppressive drugs and 33.3% pulse of immunosuppressive drugs, there was remission in 88.9%. In the scleritis associated with systemic rheumatoid disease group 7.1% used anti-inflammatory, 7.1% corticosteroids, 50% corticosteroids with one immunosuppressive drug, 7.1% two immunosuppressive drugs and 22.2% pulse of immunosuppressive drugs, 100% had treatment success. CONCLUSION: Prevalence of unilateral nodular scleritis was noted in both groups and higher rates of all the parameters tested were noted in the scleritis associated with systemic rheumatoid disease group. There were no differences between the groups with respect to the use of immunosuppressive drugs and therapeutic response, which was fully satisfactory in the scleritis associated with systemic rheumatoid disease group and satisfactory in the isolated scleritis group.INTRODUÇÃO: Esclerite é uma doença grave, rara e progressiva, que envolve inflamação e edema dos tecidos episcleral superficial, profundo e escleral e está associada com doenças sistêmicas reumatológicas em muitos casos. OBJETIVOS: Realizar um estudo prospectivo comparativo entre as manifestações oftalmológicas, achados sorológicos e resposta terapêutica de pacientes com esclerite isolada e com esclerite associada a doenças sistêmicas reumatológicas. MÉTODOS: Trinta e dois pacientes com esclerite não infecciosa participaram do estudo, de março de 2006 a março de 2008. O tratamento realizado baseou-se no uso de colírios de corticoides associados aos anti-inflamatórios não-hormonais, seguidos de corticoides sistêmicos e imunossupressores, se necessário. O sucesso do tratamento foi considerado como seis meses sem crises de esclerite. RESULTADOS: Quatorze dos 32 pacientes apresentaram esclerite associada à doença sistêmica, dos quais nove com artrite reumatóide, dois com lúpus eritematoso sistêmico, um com doença de Crohn, um com doença de Behçet e um com gota. Não houve diferenças em relação ao envolvimento ocular e suas complicações, predominando a esclerite anterior nodular e o afinamento escleral, respectivamente. O grupo com esclerite associada a doenças sistêmicas apresentou 64,3% de positividade de autoanticorpos contra 27,8% no grupo com esclerite isolada, sendo tal diferença estatisticamente significante. No grupo com esclerite isolada, 16,7% fez uso de apenas anti-inflamatórios, 33,3% de corticoide sistêmico, 27,8% de corticoide com um imunossupressor, 5,5% dois imunossupressores, 16,7% corticoide com dois imunossupressores e 33,3% pulsoterapia com imunossupressor; sendo que houve sucesso do tratamento em 88,9%. No grupo com esclerite associada à doença sistêmica, 7,1% fez uso de anti-inflamatórios, 7,1% corticoide sistêmico, 50% corticoide com um imunossupressor, 7,1% dois imunossupressores e 22,2% pulsoterapia com imunossupressor; com 100% de sucesso no tratamento nesse grupo. CONCLUSÃO: Em ambos os grupos houve predomínio da esclerite nodular unilateral e o grupo com esclerite associada a doença sistêmica apresentou taxas maiores de todos os autoanticorpos testados. Não houve diferença entre os grupos em relação ao uso de imunossupressores e à resposta terapêutica, a qual foi totalmente satisfatória no grupo com esclerite associada à doença sistêmica e satisfatória no grupo com esclerite isolada.Universidade Federal de São Paulo (UNIFESP)Universidade de Santo AmaroUniversidade Federal de São Paulo (UNIFESP) Departamento de Oftalmologia Setor de Doenças Externas Oculares e CórneaUNIFESP, Depto. de Oftalmologia Setor de Doenças Externas Oculares e CórneaSciEL

Tibial Periosteum For The Surgical Perforation

Purpose: Report a successful case of scleral perforation repair, refractive to treatment with bank-scleral graft, using pretibial periosteum graft patch. Case Report: A patient who suffered a traumatic scleral perforation was treated unsuccessfully with bank-scleral patch graft. An autologous pretibial periosteal patch graft was then obtained and sutured to the scleral rupture with the osteogenic layer facing the sclera. The periosteum patch was covered by amniotic membrane and conjunctiva. Results: Early vascularization was observed in the first seven days postoperative. The autologous periosteal patch graft and conjunctiva remained stable over a follow-up period of 6 months. Conclusion: An autologous periosteal patch graft could be a good alternative after a non-successful bank-scleral patch repair of a scleral perforatio

Nodular Posterior Scleritis: Clinico-Sonographic Characteristics and Proposed Diagnostic Criteria

Purpose: To report the clinical and ultrasound features and outcomes of a series of nodular posterior scleritis. / Methods: Retrospective medical record review of 11 consecutive patients with nodular posterior scleritis. Patient demographics, ocular and systemic findings, ultrasound features, and final anatomical and visual outcomes were recorded. / Results: There were 9 females and 2 males (11 eyes) with mean age at presentation of 57 years (range, 30-84 years). Underlying systemic inflammatory disease was present in 73%. Symptoms included pain in 73% and blurred vision in 45%. A solitary amelanotic mass without the presence of lipofuscin was found in all cases. Associated ocular features included retinal pigment epithelial changes (67%), intraocular inflammation (55%), subretinal fluid (50%), macular edema (50%), and choroidal folds (30%). B-mode ultrasound showed a sclerochoroidal mass with high internal reflectivity (100%) of mean elevation of 4.1 mm. There was nodular thickening of the sclera (100%) and fluid in Tenon space or "T" sign (36%). A complete regression of the nodule after the treatment was observed only in 1 patient (11%) and partial regression in 4 patients (44%). / Conclusion: Nodular posterior scleritis should be considered in the differential diagnosis of a single amelanotic choroidal mass showing high internal reflectivity on ultrasound B-scan. It can produce intraocular inflammation in 50% of the cases and may be painless in 25%. It has a high association with a systemic underlying disease

The impact of new methods of investigation and treatment on the understanding of the pathology of scleral inflammation

Recent advances in the understanding of the initiation and perpetuation of the immune response strongly suggest that all forms of noninfective immunologically induced scleral inflammation have a common origin. Analysis of the progress of patients with scleritis corroborates the current clinical classification that, together with studies of the immunohistology fluoresceine/ICG angiography, 3D proteoglycan, and keratan sulphate electron microscopy of scleritis, strongly suggests that from the initiation of the inflammatory process, necrotizing scleritis and diffuse and nodular scleritis not only pursue a different course but also have a different pathogenesis; nonnecrotizing scleritis being the consequence of an auto immune response, whereas necrotizing scleritis being the complication of an already present (if not always manifest), systemic immune-mediated systemic disease and its associated vasculitis. the increasing imaging capacity of anterior segment ocular coherence tomography (OCT) and en face OCT enables the changes occurring in the sclera during the course of the disease to be observed for the first time. These observations suggest that the inflammatory changes involve the potential suprachoroidal space between choroid and sclera, an observation supported by the presence of subscleral granulomas on histopathology. New imaging techniques have also been able to explain the changes seen in the cornea as a complication of scleritis. These findings have implications for investigation and the treatment of these conditions.Optovue, Inc.Addenbrookes Univ Hosp, Dept Ophthalmol, Cambridge, EnglandMoorfields Eye Hosp, London, EnglandLeiden Univ, Leiden, NetherlandsUniversidade Federal de São Paulo, Paulista Sch Med, Dept Ophthalmol, São Paulo, BrazilUniv Miami, Miller Sch Med, Miami, FL 33136 USANeovista Eye Ctr, Americana, BrazilUniversidade Federal de São Paulo, Paulista Sch Med, Dept Ophthalmol, São Paulo, BrazilWeb of Scienc

Vogt-Koyanagi-Harada Syndrome in Two Patients with Immunoglobulin A Nephropathy

We describe herein 2 patients who developed Vogt-Koyanagi-Harada syndrome in the course of renal biopsy-proven immunoglobulin A (IgA) nephropathy. A 61-year-old man with an 11-year history of IgA nephropathy and a 16-year history of thyroiditis, and a 56-year-old man with a 5-year history of IgA nephropathy developed Vogt-Koyanagi-Harada syndrome. At the time of the eye disease presentation, IgA nephropathy was stable without corticosteroids in both patients. Vogt-Koyanagi-Harada syndrome was successfully treated with intravenous administration of prednisolone tapered from 200 mg daily. Vogt-Koyanagi-Harada syndrome is associated with IgA nephropathy, suggesting a similar autoimmune mechanism for both diseases