1/53. tacrolimus (FK506) in the treatment of posterior uveitis refractory to cyclosporine. OBJECTIVE: To assess the efficacy and side effects of tacrolimus, a potent immunosuppressive macrolide antibiotic, in the treatment of sight-threatening uveitis. DESIGN: A clinical study of tacrolimus in patients who required systemic immunosuppression for control of uveitis, but were refractory to cyclosporine. PARTICIPANTS: Six patients with uveitis were treated: three had Behcet disease, one had microscopic polyangiitis, one had pars planitis, and one had idiopathic retinal vasculitis. INTERVENTION: patients with sight-threatening uveitis refractory to cyclosporine were treated with tacrolimus. MAIN OUTCOME MEASURES: Intraocular inflammation, visual acuity (VA), neovascularization. Adverse effects of tacrolimus were documented. RESULTS: The posterior uveitis remained controlled in all patients while they were taking tacrolimus. Five of the six patients showed improvement, defined as improvement of two or more lines of Snellen acuity or a decrease in the binocular indirect ophthalmoscopy score (P < 0.05, Sign test). One patient with Behcet disease showed a marked improvement in best-corrected VA from 1/60 to 6/24. Two patients with Behcet disease showed a modest improvement in VA in the affected eye and had no disease activity in the other eye. The patient with microscopic polyangiitis was symptomatically improved, and there was no progression of the posterior uveitis. The patient with pars planitis had an improvement in VA from 6/18 to 6/9. The patient with retinal vasculitis showed partial regression of neovascularization on tacrolimus. Side effects were less troublesome than with cyclosporine. CONCLUSIONS: tacrolimus (FK506) has a useful role as an immunosuppressive agent for the treatment of sight-threatening uveitis in patients who did not respond to cyclosporine either because of lack of therapeutic effect or unacceptable adverse effects. ( info) |
2/53. Posterior uveitis in Hodgkin's disease. PURPOSE: To describe the features of posterior uveitis in patients who either developed or were known to have, biopsy-proven Hodgkin's disease (HD). methods: Four patients were identified who were attending the uveitis clinic. Their charts were reviewed retrospectively and information on their HD was obtained from other hospitals where necessary. Their case histories are presented. RESULTS: Two patients presented with uveitis prior to the diagnosis of HD and in the other two, the HD was thought to be in remission. The commonest ocular signs were of vitritis and discrete, white, chorioretinal lesions. No difference in the ocular findings were apparent between those who had a known diagnosis of HD and the those that did not. CONCLUSIONS: HD can occur in the eye and can mimic posterior uveitis. In two of the patients, the uveitis preceded the diagnosis of HD and at the time of presentation all investigations were normal. No specific diagnostic features were apparent, though three of the patients had vitritis and chorioretinal lesions. ( info) |
3/53. Nanophthalmic uveal effusion syndrome after prophylactic laser treatment. PURPOSE: We report a case of nanophthalmic uveal effusion syndrome (NUES) with total exudative retinal detachment (RD) after prophylactic argon laser (AL) treatment. The RD subsided and eventually resolved with i.v. steroid therapy. methods: A 45-year-old woman was referred to us with NUES and total exudative RD after prophylactic AL treatment for retinoschisis performed elsewhere. The patient had been scheduled for surgical intervention and was given i.v. prednisolone. RESULTS: Two days after starting i.v. prednisolone, the subretinal fluid partially resolved. Intervention had therefore been postponed. After 15 days the RD almost disappeared and vision improved to 20/400. Ten days later the macula was flat and vision was 20/200. At the six-month follow-up visit vision was 20/40. CONCLUSIONS: To our knowledge this is the first report of NUES and total exudative RD following AL treatment that resolved with i.v. steroid therapy alone. Since the AL treatment clearly seemed to play a role in the pathogenesis of the NUES and associated RD we strongly advise careful assessment of the risk/benefit ratio of prophylactic laser treatment in nanophthalmic patients. Although sclerectomy and vortex vein decompression are well-established techniques, we believe steroid therapy might be tried before proceeding to surgery. ( info) |
4/53. Tubulointerstitial nephritis and uveitis with bilateral multifocal choroiditis. PURPOSE: To report a case of bilateral multifocal choroiditis secondary to tubulointerstitial nephritis and uveitis. methods: Case report. A 16-year-old women with an 11-month history of tubulointerstitial nephritis and uveitis and bilateral anterior uveitis developed bilateral multifocal choroiditis. After initial unsuccessful treatment with topical steroids, treatment was augmented by a 2-week course of systemic prednisone. RESULTS: Intensive steroid treatment resulted in steroid-induced glaucoma, which required bilateral trabeculectomies, but the uveitis became inactive. Two years after uveitis onset, bilateral intraocular pressure was normal, there were occasional (12 ) anterior chamber cells, and inactive depigmented chorioretinal lesions on topical steroid drops. See also pp. 764-768, 798-799. CONCLUSIONS: Tubulointerstitial nephritis and uveitis usually involves only the anterior uvea, although a few cases of posterior uveitis have been described. This article reports a case of multifocal choroiditis associated with tubulointerstitial nephritis and uveitis. It is important for ophthalmologists to be aware of possible posterior uveal involvement in tubulointerstitial nephritis and uveitis so they can choose the most appropriate immunosuppressive therapy for the uveitis. ( info) |
5/53. Systemic toxicity of topical and periocular corticosteroid therapy in an 11-year-old male with posterior uveitis. PURPOSE: To report a case of systemic corticosteroid toxicity resulting from topical and periocular therapy. methods: Treatment and follow-up of an 11-year-old male with uveitis are illustrated. Initial presentation of the patient was bilateral iridocyclitis, for which he was treated with prednisolone acetate 1% every 2 hours for 6 months. Subsequently, posterior uveitis developed, necessitating posterior subtenon injections. RESULTS: After initial topical corticosteroid therapy, the patient developed a cushingoid habitus accompanied by increased lanugo hair, acanthosis nigricans, posterior subcapsular lens opacities, and increased intraocular pressure. Cushingoid stigmata worsened after administration of posterior subtenon injection of corticosteroids. The patient's truncal obesity worsened, and his linear growth stopped. CONCLUSIONS: Systemic toxic effects may develop as a result of topical and local use of ophthalmic corticosteroid preparations in susceptible patients. ( info) |
6/53. Birdshot retinochoroidopathy: measurement of the posterior fundus spots and macular edema using a retinal thickness analyzer, before and after treatment. PURPOSE: To measure the retinal thickness in the macular area and at the typical fundus spots in a patient with birdshot retinochoroidopathy, using the retinal thickness analyzer (RTA), a new image analyzer involving laser-slit biomicroscopy, and to quantify the changes after systemic corticosteroid therapy. CASE REPORT: A 54-year-old man with posterior uveitis underwent visual acuity measurement, fluorescein and indocyanine green (ICG) angiographies, optical coherence tomography (OCT) and RTA measurements before and after steroid treatment. RESULTS: The thickness at the birdshot spots measured with RTA remained unchanged after treatment, but the thickness at the fovea decreased in both eyes. Fluorescein and ICG angiographies and OCT showed no change with treatment. CONCLUSIONS: RTA seems a more sensitive method for assessing changes in macula thickness in the course of birdshot retinochoroidopathy and can help document the effect of treatment. ( info) |
7/53. Efficacy of interferon alfa-2a in severe and refractory uveitis associated with Behcet's disease. PURPOSE: To evaluate the efficacy of interferon alfa-2a (IFN alfa) in severe uveitis associated with Behcet's disease, that is refractory to steroids and conventional immunosuppressive agents. patients AND methods: patients with Behcet's disease (according to the International Study Group criteria), who relapsed despite steroids and immunosuppressive agents, were included in this retrospective study. Ophthalmological examination, laser flare photometry, and fluorescein angiography associated with laboratory tests were performed at regular intervals. IFN alfa (3 millions units thrice a week) was injected subcutaneously. RESULTS: Eight patients (sex ratio: 1) were included between May 1995 and January 1999. The mean age was 29.1 years (14-54 years) and the disease was present between 11 and 167 months before the administration of IFN alfa. IFN alfa was efficient in all cases with a mean follow-up of 22 months (10-55 months). steroids were tapered from a mean dosage of 47 mg/d to a mean dosage of 8.5 mg/d. Ocular inflammation was controlled and visual acuity improved in all cases. Treatment was generally well tolerated despite a constant but transient flu-like syndrome. IFN alfa was tapered in three patients and stopped in one case without any relapse after five months. CONCLUSIONS: Within the limitations of this retrospective study, low-dose IFN alfa seems to be well tolerated, promising in the management of refractory forms of uveitis due to Behcet's disease, and effective in allowing a reduction of steroid dosage. A prospective controlled study is necessary to confirm these preliminary results. ( info) |
8/53. Precise monitoring and differentiation of inflammatory events by indocyanine green (ICG) angiography in a case of recurrent posterior sarcoid uveitis. PURPOSE: By providing information on choroidal lesions, indocyanine green (ICG) angiography is complementary to fluorescein angiography in the workup of posterior uveitis. The aim here was to illustrate practically the suitability of performing dual fluorescein/ICG angiograms in a demonstrative case of recurrent presumed posterior sarcoid uveitis. methods: Sequential dual fluorescein/ICG angiograms were performed for the workup and follow-up of a case of recurrent presumed sarcoid uveitis. RESULTS: Dual fluorescein and ICG angiograms performed during the first recrudescence of inflammation showed mainly retinal involvement with cystoid macular edema, diffuse posterior pole retinal hyperfluorescence, and papillitis, whereas the second recurrence after tapering oral corticosteroid therapy showed new choroidal lesions of the posterior pole in the absence of significant retinal involvement. CONCLUSIONS: Dual fluorescein/ICG angiography clearly allowed the differentiation of two different inflammatory events, one involving the retina and the other involving the choroid, at the origin of similar clinical manifestations. ( info) |
9/53. Syphilitic posterior uveitis: correlative findings and significance. Twenty-one patients with syphilitic posterior uveitis were investigated retrospectively to study the disease spectrum, associations with neurosyphilis, and therapeutic implications. Ophthalmologic manifestations of syphilitic posterior uveitis are differentiated into acute and chronic uveitides. The several distinct acute uveitic syndromes are usually florid and are associated with early syphilis, with VDRL-positive syphilitic meningitis, and frequently with human immunodeficiency virus coinfection. The chronic posterior uveitides are often insidious, a manifestation of late syphilis, and associated commonly with subclinical neurosyphilis. All patients with acute cases and 54% of patients with chronic cases in our study received penicillin therapy appropriate for neurosyphilis. The frequent association of syphilitic posterior uveitis with neurosyphilis and the analogous spirochetal sequestration beyond the blood-brain and the blood-ocular barriers suggest that all patients with syphilitic posterior uveitis, irrespective of ocular disease intensity, should undergo evaluation of cerebrospinal fluid and be treated with penicillin regimens appropriate for neurosyphilis. ( info) |
10/53. Ocular manifestations of tuberculosis. OBJECTIVE: To present the clinical and histopathologic findings in five cases of tuberculosis (TB) with various ocular manifestations. DESIGN: Observational case series. methods: Retrospective review of clinical findings, course, and treatment of five patients. Diagnostic techniques, including biomicroscopic, histopathologic, and molecular biologic test results, are presented. MAIN OUTCOME MEASURES: visual acuity, slit-lamp biomicroscopy, indirect ophthalmoscopy, and fluorescein angiography results. RESULTS: The ocular manifestations of TB in our patients included panophthalmitis, endophthalmitis, posterior uveitis with choroidal tubercles, keratitis, and a lid mass. mycobacterium tuberculosis was identified in four cases in ocular specimens using acid-fast bacilli microscopy and in three cases by culture. Rapid diagnosis using polymerase chain reaction was obtained in one case. Extraocular foci of TB were identified in three cases with an intraocular infection at presentation. No patients had the human immunodeficiency virus (hiv) and none were immunocompromised. Two eyes could not be saved using antituberculous treatment because of delayed diagnosis and treatment. CONCLUSIONS: In this age of the hiv pandemic, TB is becoming more common. Because it is curable, heightened awareness and better understanding of the disease's ocular manifestations should be of concern to all ophthalmologists. ( info) |