Search

Purpose: To demonstrate the reliability of conjunctival biopsy analyzed by direct immunofluorescence (DIF) and supplemented with avidin-biotin complex immunoperoxidase (ABC) in diagnosing oMMP, and...

PurposeTo evaluate the long-term visual acuity (VA) outcome of cataract surgery in inflammatory eye disease.SettingTertiary care academic centres.DesignMulticentre retrospective cohort study.MethodsA total of 1741 patients with non-infectious inflammatory eye disease (2382 eyes) who underwent cataract surgery while under tertiary uveitis management were included. Standardised chart review was used to gather clinical data. Multivariable logistic regression models with adjustment for intereye correlations were performed to evaluate the prognostic factors for VA outcomes. Main outcome measure was VA after cataract surgery.ResultsUveitic eyes independent of anatomical location showed improved VA from baseline (mean 20/200) to within 3 months (mean 20/63) of cataract surgery and maintained through at least 5 years of follow-up (mean 20/63). Eyes that achieved 20/40 or better VA at 1 year were more likely to have scleritis (OR=1.34, pConclusionsOur results suggest that adult and paediatric eyes with uveitis typically have improved VA following cataract surgery and remain stable thereafter for at least 5 years.

PURPOSE: To estimate the incidence of corneal endothelial transplantation and identify risk factors among patients with non-infectious ocular inflammation. DESIGN: Retrospective cohort study. METHODS: Adult patients attending United States tertiary uveitis care facilities diagnosed with non-infectious ocular inflammation were identified from the Systemic Immunosuppressive Therapy for Eye Diseases Cohort Study. Time-to-event analysis was used to estimate the incidence of corneal endothelial transplantation (CET), including penetrating keratoplasty, Descemet stripping endothelial keratoplasty, or Descemet Membrane Endothelial Keratoplasty procedures. The incidence of CET was calculated; potential risk factors for CET were also evaluated using Cox regression, accounting for correlation between eyes of the same patient. RESULTS: Overall, 14,264 eyes met eligibility criteria for this analysis with a median follow-up 1.8 eye-years. The Kaplan-Meier estimated incidence of CET within 10 years was 1.10% (95% CI, 0.68%–1.53%). Risk factors for CET included age >60 years vs.

Purpose To compare mycophenolate mofetil (MMF) to methotrexate (MTX) as corticosteroid-sparing therapy for ocular inflammatory diseases. Design Retrospective analysis of cohort study data. Methods Participants were identified from the Systemic Immunosuppressive Therapy for Eye Diseases Cohort Study. Demographic and clinical characteristics were obtained via medical record review. The study included 352 patients who were taking single-agent immunosuppression with MTX or MMF at 4 tertiary uveitis clinics. Marginal structural models (MSM)-derived statistical weighting created a virtual population with covariates and censoring patterns balanced across alternative treatments. With this methodological approach, the results estimate what would have happened had none of the patients stopped their treatment. Survival analysis with stabilized MSM-derived weights simulated a clinical trial comparing MMF vs MTX for noninfectious inflammatory eye disorders. The primary outcome was complete control of inflammation on prednisone ≤10 mg/day, sustained for ≥30 days. Results The time to success was shorter (more favorable) for MMF than MTX (hazard ratio = 0.68, 95% confidence interval: 0.46-0.99). Adjusting for covariates, the proportion achieving success was higher at every point in time for MMF than MTX from 2 to 8 months, then converges at 9 months. The onset of corticosteroid-sparing success took more than 3 months for most patients in both groups. Outcomes of treatment (MMF vs MTX) were similar across all anatomic sites of inflammation. The incidence of stopping therapy for toxicity was similar in both groups. Conclusions Our results suggest that, on average, MMF may be faster than MTX in achieving corticosteroid-sparing success in ocular inflammatory diseases.

Purpose: To evaluate adalimumab as an immunomodulatory treatment for non-infectious ocular inflammatory diseases.Methods: Characteristics of patients treated with adalimumab were abstracted in a standardized chart review. Main outcomes measured were control of inflammation, corticosteroid-sparing effect, and visual acuity.Results: In total, 32 patients with ocular inflammation were treated with adalimumab. The most common ophthalmic diagnoses were anterior uveitis, occurring in 15 patients (47%), and scleritis, occurring in 9 patients (28%). At 6 months of therapy, among 15 eyes with active inflammation, 7 (47%) became completely inactive, and oral prednisone was reduced to ≤10 mg/day in 2 of 4 patients (50%). On average, visual acuity decreased by 0.13 lines during the first 6 months of treatment. Adalimumab was discontinued because of lack of effectiveness in four patients within 6 months.Conclusions: Adalimumab was moderately effective in controlling inflammation in a group of highly pre-treate...

To evaluate the risk of and risk factors for retinal neovascularization (NV) in cases of uveitis.Retrospective cohort study.Patients with uveitis at 4 US academic ocular inflammation subspecialty practices.Data were ascertained by standardized chart review. Prevalence data analysis used logistic regression. Incidence data analysis used survival analysis with time-updated covariates where appropriate.Prevalence and incidence of NV.Among uveitic eyes of 8931 patients presenting for initial evaluation, 106 of 13,810 eyes had NV (prevalence = 0.77%, 95% confidence interval [CI], 0.60-0.90). Eighty-eight more eyes developed NV over 26,465 eye-years (incidence, 0.33%/eye-year; 95% CI, 0.27-0.41). Factors associated with incident NV include age35 years compared with35 years (adjusted hazard ratio [aHR], 2.4; 95% CI, 1.5-3.9), current cigarette smoking (aHR, 1.9; 95% CI, 1.1-3.4), and systemic lupus erythematosus (aHR, 3.5, 95% CI, 1.1-11). Recent diagnosis of uveitis was associated with an increased incidence of NV (compared with patients diagnosed5 years ago, aHR, 2.4 [95% CI, 1.1-5.0] and aHR, 2.6 [95% CI, 1.2-6.0] for diagnosis within1 year vs. 1-5 years, respectively). Compared with anterior uveitis, intermediate uveitis (aHR, 3.1; 95% CI, 1.5-6.6), posterior uveitis (aHR, 5.2; 95% CI, 2.5-11), and panuveitis (aHR, 4.3; 95% CI, 2.0-9.3) were associated with a similar degree of increased NV incidence. Active (aHR, 2.1, 95% CI, 1.2-3.7) and slightly active (aHR, 2.4, 95% CI, 1.3-4.4) inflammation were associated with an increased incidence of NV compared with inactive inflammation. Neovascularization incidence also was increased with retinal vascular occlusions (aHR, 10, 95% CI, 3.0-33), retinal vascular sheathing (aHR, 2.6, 95% CI, 1.4-4.9), and exudative retinal detachment (aHR, 4.1, 95% CI, 1.3-13). Diabetes mellitus was associated with a somewhat increased incidence of retinal NV (aHR, 2.3, 95% CI, 1.1-4.9), and systemic hypertension (aHR 1.5, 95% CI, 0.89-2.4) was associated with nonsignificantly increased NV incidence. Results were similar in sensitivity analyses excluding the small minority of patients with diabetes mellitus.Retinal NV is a rare complication of uveitis, which occurs more frequently in younger patients, smokers, and those with intermediate/posterior/panuveitis, systemic vasculopathy, retinal vascular disease, or active inflammation. Inflammation and retinal NV likely are linked; additional studies are needed to further elucidate this connection.

Purpose To estimate the incidence of medication-free remission of chronic anterior uveitis and identify predictors thereof. Design Retrospective cohort study. Participants Patients diagnosed with anterior uveitis of longer than 3 months’ duration followed up at United States tertiary uveitis care facilities. Methods Estimation of remission incidence and identification of associated predictors used survival analysis. Main Outcome Measures Incidence of medication-free remission. For the primary analysis, remission was defined as inactive uveitis while off treatment at all visits spanning an interval of at least 90 days or—for patients who did not return for follow-up after 90 days—remaining inactive without receiving suppressive medications at all of the last visits. Association of factors potentially predictive of medication-free remission was also studied. Results Two thousand seven hundred ninety-five eyes of 1634 patients with chronic anterior uveitis were followed up over 7936 eye-years (4676 person-years). The cumulative medication-free, person-year remission incidence within 5 years was 32.7% (95% confidence interval [CI], 30.4%–35.2%). Baseline clinical factors predictive of reduced remission incidence included longer duration of uveitis at presentation (for 2 to 5 years vs. less than 6 months: adjusted hazard ratio [aHR], 0.61; 95% CI, 0.44–0.83), bilateral uveitis (aHR, 0.75; 95% CI, 0.59–0.96), prior cataract surgery (aHR, 0.70; 95% CI 0.56–0.88), and glaucoma surgery (aHR, 0.63; 95% CI, 0.45–0.90). Two time-updated characteristics were also predictive of reduced remission incidence: keratic precipitates (aHR, 0.36; 95% CI, 0.21–0.60) and synechiae (aHR, 0.62; 95% CI, 0.41–0.93). Systemic diagnosis with juvenile idiopathic arthritis and spondyloarthropathy were also associated with reduced remission incidence. Older age at presentation was associated with higher incidence of remission (for age ≥40 years vs. Conclusions Approximately one third of patients with chronic anterior uveitis remit within 5 years. Longer duration of uveitis, younger age, bilateral uveitis, prior cataract surgery, glaucoma surgery, presence of keratic precipitates and synechiae, and systemic diagnoses of juvenile idiopathic arthritis and spondyloarthropathy predict reduced remission incidence; patients with these factors should be managed taking into account the higher probability of a longer disease course.

Purpose To report the outcomes of infliximab treatment of birdshot retinochoroidopathy (BSRC) refractory to conventional immunomodulatory therapy. Design Retrospective case series. Participants Twenty-two refractory birdshot retinochoroidopathy patients (44 eyes) who received infliximab between July 2005 and June 2012 were identified by retrospective chart review. Methods All patients received 4 to 5 mg/kg infliximab at 4- to 8-week intervals. Data regarding patient demographics, use of immunosuppressive drugs, biologic agents, and reason for conventional therapy discontinuation were gathered. Disease activity markers, including signs of ocular inflammation, fluorescein angiography evidence of retinal vasculitis or papillitis, indocyanine green angiography evidence of active choroiditis, electroretinography parameters indicative of stable or worsening of retinal functions, and optical coherence tomography findings indicative of static or worsening macular edema were recorded. Main Outcome Measures Abolition of all evidence of active inflammation, visual acuity (VA), presence of cystoid macular edema at 6 months and 1 year, and adverse responses to infliximab. Results Mean duration of disease before starting infliximab was 58.6 months. Before infliximab therapy, all patients received and failed conventional immunosuppressive therapy. Ten patients had received another biologic agent. After initiating infliximab, control of inflammation was achieved in 81.8% at 6 months and in 88.9% at the 1-year follow-up. Three patients had active inflammation during therapy. The rate of cystoid macular edema decreased from 22.7% at baseline to 13.9% at 6 months and 6.7% at 1 year after receiving the drug. Initial VA of 20/40 or better was found in 34 eyes (84.1%). At 6 months and 1 year, 91.7% and 94.4% of eyes, respectively, had VA of 20/40 or better. Six patients had adverse events; infliximab therapy was discontinued in these patients because of neuropathy, drug-induced lupus, allergic reaction, or fungal infection. Conclusions The data suggest that infliximab is effective for controlling inflammation in otherwise treatment-refractory cases of BSRC. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

To evaluate the incidence of remission among patients with intermediate uveitis; to identify factors potentially predictive of remission.Retrospective cohort study.Involved eyes of patients with primary noninfectious intermediate uveitis at 4 academic ocular inflammation subspecialty practices, followed sufficiently long to meet the remission outcome definition, were studied retrospectively by standardized chart review data. Remission of intermediate uveitis was defined as a lack of inflammatory activity at ≥2 visits spanning ≥90 days in the absence of any corticosteroid or immunosuppressant medications. Factors potentially predictive of intermediate uveitis remission were evaluated using survival analysis.Among 849 eyes (of 510 patients) with intermediate uveitis followed over 1934 eye-years, the incidence of intermediate uveitis remission was 8.6/100 eye-years (95% confidence interval [CI], 7.4-10.1). Factors predictive of disease remission included prior pars plana vitrectomy (PPV) (hazard ratio [HR] [vs no PPV] = 2.39; 95% CI, 1.42-4.00), diagnosis of intermediate uveitis within the last year (HR [vs diagnosis5 years ago] =3.82; 95% CI, 1.91-7.63), age ≥45 years (HR [vs age45 years] = 1.79; 95% CI, 1.03-3.11), female sex (HR = 1.61; 95% CI, 1.04-2.49), and Hispanic race/ethnicity (HR [vs white race] = 2.81; 95% CI, 1.23-6.41). Presence/absence of a systemic inflammatory disease, laterality of uveitis, and smoking status were not associated with differential incidence.Our results suggest that intermediate uveitis is a chronic disease with an overall low rate of remission. Recently diagnosed patients and older, female, and Hispanic patients were more likely to remit. With regard to management, pars plana vitrectomy was associated with increased probability of remission.

Inadequately controlled uveitis is a leading cause of permanent visual loss, accounting for 5–20 % of cases of legal blindness [1–4]. Ocular inflammation is the principal cause of complications and morbidities. Delayed or inadequate control of inflammation can lead to serious sequelae resulting in visual impairment [5–8]. Therefore, the primary goal of management is to control the inflammation. There are two phases of treatment of ocular inflammation. First is induction of control of inflammation, the goal of which is to suppress the sight-threatening ocular inflammation as soon as possible with a rapidly effective medication, usually using topical, systemic, and/or injected corticosteroids. For remitting forms of uveitis, this may be the only treatment necessary. For chronic disease requiring suppressive therapy, the second aim is maintenance of control of inflammation after successful treatment in order to prevent recurrence or relapse of the ocular inflammation. Immunosuppressives have their primary role in maintenance of control of inflammation.

Objective To evaluate the demographic and clinical characteristics of patients referred to a tertiary care hospital cornea clinic for ocular cicatricial pemphigoid (OCP) assessment. Design Retrospective, nonrandomized, consecutive case series. Participants Thirty three patients with OCP who were treated at the corneal clinic of Toronto Western Hospital from 2003 to 2012. Methods Database search of patients from 2003 to 2012 with a referral request or diagnosis of OCP was conducted at a tertiary care hospital cornea clinic. Charts of 33 patients (64 eyes) were reviewed. Outcome measures included patient demographics, methods of diagnosis, visual acuity, ocular features, and disease staging using Foster’s staging system, systemic modes of treatment, disease progression, and presence of systemic involvement. Results Mean patient age at presentation was 69.8 years (range 40–91), and 81% (27/33) were female. At presentation, disease staging consisted of stage I (subepithelial fibrosis) 7.8% (5/64), stage II (shortened fornices) 21.8% (14/64), stage III (symblepharon formation) 65.6% (42/64), and stage IV (keratinization with or without globe immobility) 4.6% (3/64). At the final follow-up visit, the proportions of the involved eyes for stages I to IV were 1.5% (1/64), 10.9% (7/64), 76.5% (49/64), and 10.9% (7/64), respectively. Conjunctival biopsies were obtained from 81% (27/33) of patients and reported as positive in 30% (8/27), negative in 63% (17/27), and inconclusive in 7% (2/27) of patients. Mean duration of follow-up was 6.8 ± 5.6 years (range 0.5–22), and 66.6% (22/33) of patients had progressive disease. Systemic mucocutaneous involvement was noted in 36.3% (12/33) of patients. Conclusions The high rate of disease progression suggests the need for improved therapeutic options. Additional modalities are needed in addition to conjunctival biopsy to confirm a diagnosis of OCP in patients with clinical signs of the disease.

Purpose To evaluate the clinical features and outcomes of patients with recurrent corneal erosion syndrome who underwent anterior stromal puncture. Study Design Retrospective, nonrandomized, consecutive case series. Methods Database search of patients from 2003-2013 who underwent anterior stromal puncture was conducted at a tertiary care hospital cornea clinic. Charts of 30 patients (35 eyes) were reviewed. Outcome measures included demographics, laterality, history of corneal trauma, prior ocular history, frequency and duration of symptoms, failed treatments, signs on examination, degree of symptom resolution, additional treatments needed, and complications. Results Mean patient age at presentation was 37 (± 11.5 SD) years, 60% were male. A total of 83.3% of patients had unilateral and 16.7% had bilateral involvement. In all, 62.9% of eyes had prior history of corneal trauma and 2.9% had prior laser-assisted in situ keratomileusis. Ninety-seven percent of eyes had symptoms of pain upon awakening refractory to conservative treatment. In 97% of eyes, there were findings of microcysts, fingerprint lines, loose epithelium, and/or faint scars. Mean follow-up was 14 months (range: 3-120 months). At final follow-up, 62.9% of eyes were symptom free and 37.1% experienced milder episodes. Seventeen percent required additional treatment: 16.6% superficial keratectomy, 66% repeat anterior stromal puncture, and 16.7% phototherapeutic keratectomy. No complications were observed. Conclusion Anterior stromal puncture using a short (5/8 inch) 25 gauge bent needle is a simple, safe, and cost-effective procedure for symptomatic relief in patients with recurrent corneal erosion syndrome refractive to conservative measures. Repeat treatment may be performed prior to additional surgical intervention.

Purpose To identify factors predictive of remission of inflammation in new-onset anterior uveitis cases treated at tertiary uveitis care facilities. Design Retrospective cohort study. Participants Patients seeking treatment at participating academic uveitis clinics within 90 days of initial diagnosis of anterior uveitis. Methods Retrospective cohort study based on standardized chart review. Main Outcome Measures Factors predictive of remission (no disease activity without corticosteroid or immunosuppressive treatments at all visits during a 90-day period). Results Nine hundred ninety eyes (687 patients) had a first-ever diagnosis of anterior uveitis within 90 days before initial presentation and had follow-up visits thereafter. The median follow-up time was 160 days. Systemic diagnoses with juvenile idiopathic arthritis (JIA; adjusted hazard ratio [aHR], 0.38; 95% confidence interval [CI], 0.19–0.74) and Behcet's disease (aHR, 0.10; 95% CI, 0.01–0.85) were associated with a lower incidence of uveitis remission. Cases of bilateral uveitis (aHR, 0.68; 95% CI, 0.54–0.87) and those with a history of cataract surgery before presentation (aHR, 0.51; 95% CI, 0.29–0.87) also had a lower incidence of remission. Regarding clinical findings at the initial visit, a high degree of vitreous cells at initial presentation was associated with a lower incidence of remission (for 1+ or more vs. none: aHR, 0.72; 95% CI, 0.55–0.95). An initial visual acuity of 20/200 or worse, with respect to 20/40 or better, also was predictive of a lower incidence of remission (aHR, 0.52; 95% CI, 0.32–0.86). Conclusions Factors associated with a lower incidence of remission among new-onset anterior uveitis cases included diagnosis with JIA, Behcet's disease, bilateral uveitis, history of cataract surgery, findings of 1+ or more vitreous cells at presentation, and an initial visual acuity of 20/200 or worse. Patients with these risk factors seem to be at higher risk of persistent inflammation; reciprocally, patients lacking these factors would be more likely to experience remission. Patients with risk factors for nonremission of uveitis should be managed taking into account the higher probability of a chronic inflammatory course.

To evaluate the efficacy of bromfenac drops alone or with a single intravitreal injection of bevacizumab (IVB) or triamcinolone acetonide (IVTA) in the treatment of uveitic macular edema (UME).Comparative case series. STUDY PARTICIPANT: Sixty-seven eyes (of 55 patients) with UME that received either bromfenac drops alone (n = 34), IVB plus bromfenac (n = 21) or IVTA plus bromfenac (n = 12).Chart review of patients at the Massachusetts Eye Research and Surgery Institution (MERSI) was done. Eyes that received either bromfenac drops alone (Br), IVB plus bromfenac (IVB/Br) or IVTA plus bromfenac (IVTA/Br), with follow-up of up to 3 months, were included.Visual acuity.There was no statistically significant effect seen in VA or CMT in the Br group, with 17 of 34 eyes (50 %) needing re-injection before 3 months of follow-up. Mean change in CMT at 4 weeks for the Br group was 5.06 µm. Compared to baseline, both the IVTA/Br and IVB/Br groups showed significant decrease in CMT and improvement in VA at 1 and 3 months follow-up. There was also a continuous decrease in CMT up to 3 months of follow-up with the IVTA/Br group, which was found to be significant in comparison with the IVB/Br group; this trend was not seen in the IVB/Br group at 3 months. The greatest mean change in CMT at 1 month was seen in the IVTA/Br group (154.33 ±178.22 µm), and this was statistically significant in comparison with the other groups (p = 0.0001). However, in terms of mean change in VA, there was no change in the Br group (0.01 ± 0.11 VA logMAR), and only 0.12 ± 0.19 and 0.15 ± 0.20 in the IVB/Br and IVTA/Br groups, respectively.IVB and IVTA are both effective in improving VA and decreasing CMT up to 3 months. Bromfenac is ineffective alone for UME treatment, but may have a synergistic effect with IVTA in reducing CMT up to 3 months of follow-up.

Purpose To study the prevalence of conjunctival neoplasia in clinically diagnosed pterygia and the clinicopathologic characteristics of conjunctival tissues obtained from pterygium excision. Design Prospective, observational case series. Participants From February through August 2007, consecutive subjects indicated for pterygium excision were enrolled from an outpatient eye clinic of King Chulalongkorn Memorial Hospital, Bangkok, Thailand, and from the eye camp at the 6th Station of the Thai Red Cross Society, Aranyaprathet District, Sa Kaeo, Thailand. A total of 498 eyes from 482 subjects were studied. The mean age of the subjects was 56.5±11.7 years. The male-to-female ratio was 3:7. Methods Clinical data were gathered, including age, sex, occupation, family history, and medical history. Pterygia were clinically graded as mild, intermediate, or fleshy. Tissues from surgical fields were fixed in formalin and processed using standard pathology laboratory methods. Main Outcome Measures Histopathologic results were examined in a masked fashion by 3 pathologists. Results Ninety-one percent of tissue was from primary pterygia. Most lesions were classified as intermediate grade (45.2%). Histopathologic results showed that 4 eyes had conjunctival intraepithelial neoplasia. Two eyes had minimal cellular atypia at the conjunctival epithelium. Two eyes had complex choristoma. For the subjects who had conjunctival epithelial neoplasia, the mean age was 57.0±8.0 years, 44.4% were male, and none had a history of carcinoma in other organs or any history of herpes virus, human papilloma virus, or human immunodeficiency virus infections. Conclusions The prevalence of conjunctival epithelial neoplasia in clinically diagnosed pterygia is approximately 1.8%. Because the clinical characteristics of subjects who have conjunctival epithelial neoplasia apparently did not differ from those without, tissue pathologic examination may be required to diagnose the condition. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Cheryl A Arcinue,1,2 Khayyam Durrani,1–3 Pichaporn Artornsombudh,1,2 Alaa Radwan,1,2 Ravi Parikh,1,2 Ana M Suelves,1,2 Sana S Siddique,1,2 Ian Chang,1,2 Janine M Preble,1,2 Charles Stephen Foster1–3 1Massachusetts Eye Research and Surgery Institution, 2Ocular Immunology and Uveitis Foundation, Cambridge, 3Department of Ophthalmology, Harvard Medical School, Boston, MA, USA Objective: To evaluate the efficacy and safety of adalimumab in the management of ocular inflammation at our institution. Methods: We performed a review of all patients with active ocular inflammation treated with adalimumab at our institution. Results: Seventy eyes of 49 patients were reviewed. The mean duration of follow-up was 19.6 months. Therapy with an average of 2.1 immunomodulatory agents had been attempted prior to adalimumab therapy. At 1-year follow-up, adalimumab was effective in achieving quiescence in 33 eyes (47%). The most common side effects were injection-site reactions, arthralgias, and nausea, occurring in two patients each. Adalimumab was discontinued due to side effects in 12 patients. Conclusion: These results suggest that adalimumab is an effective and safe therapeutic modality in ocular inflammation. Keywords: uveitis, biologic response modifier, TNF-α, adverse effects, therapeutic outcomes, scleritis, peripheral ulcerative keratitis