Mortality rate in rheumatoid arthritis patients developing necrotizing scleritis or peripheral ulcerative keratitis. Effects of systemic immunosuppression

We performed a nonrandomized clinical trial comparing the ocular and systemic efficacy of cytotoxic immunosuppression with steroidal and nonsteroidal anti-inflammatory therapy in the care of 34 patients with rheumatoid arthritis who developed peripheral ulcerative keratitis and/or necrotizing scleritis. Nine of the 17 patients managed with conventional therapy died of a vascular-related event during the ten-year period of the study. In 13 of the 17 patients, the ocular inflammatory process progressed, and in 5 patients extraocular, although nonlethal, vasculitic lesions developed. One of 17 patients treated with long-term immunosuppressive therapy died during the ten-year follow-up period, and this death occurred after cytotoxic therapy was withdrawn. None of the patients on immunosuppressive regimens developed extraocular vasculitis while taking the drug, and none had progression of the ocular destructive lesion. The results of this study emphasize that the eye is a sensitive indicator for potentially lethal occult systemic vasculitis in patients with rheumatoid arthritis who develop peripheral ulcerative keratitis or necrotizing scleritis. Our mortality data strongly suggest that the use of cytotoxic drugs may alter favorably the general as well as the ocular prognosis in these patients.     

Bilateral Orbital IgG4-Related Disease with Systemic and Corneal Involvement Showing an Excellent Response to Steroid and Rituximab Therapy: Report of a Case with 11 Years Follow-Up

IgG4-related disease is a newly recognized fibro-inflammatory condition. The purpose of this report is to present a patient with 11 years of follow-up, who revealed characteristic features of IgG4-related disease with systemic, orbital and corneal involvement and showed a favorable response to steroids and rituximab treatment.     

Fungal endophthalmitis in a case of granulomatosis with polyangitis

A 70-year-old immuno-compromised man, due to multiple comorbidities, particularly granulomatosis with polyangitis (GPA) and its related treatment, presented with generalized weakness, odynophagia and loss of taste sensation. After a complete evaluation, a diagnosis of right frontal lobe brain abscess was made. The patient then developed headache and sudden painful loss of vision in the right eye. Clinical examination revealed anterior chamber cells and flare, vitreous haze and cells, and hemorrhagic chorioretinitis with severe vasculitis in the right eye. Culture from the drained pus of the frontal brain abscess came positive for Aspergillus fumigatus. Incidental echocardiogram showed large vegetation in the mitral valve. Pars plana vitrectomy was done and a specimen was sent for culture that came positive for Aspergillus fumigatus. Although all the necessary medical and surgical interventions were timely carried out in the affected right eye, the patient’s vision worsened due to retinal damage.     

Rituximab and Acute Retinal Necrosis in a Patient with Scleromalacia and Rheumatoid Arthritis

Background: Rituximab is a widely used biologic agent, which has shown favourable results in the treatment of vasculitis. But immunosuppressive treatment also bears the risk of severe complications.

Methods: A patient with rheumatoid arthritis, progressive scleromalacia, and acute retinal necrosis on therapy with rituximab is reported.

Results: For the first time, a correlation between rituximab and acute retinal necrosis in a patient with progressive rheumatoid scleromalacia is shown.

Conclusions: Although rituximab is a promising biologic agent for the treatment of autoimmune diseases, it bears the risk of reactivation of viral infections, including the onset of acute retinal necrosis.     

Methotrexate as a first-line corticosteroid-sparing therapy in a cohort of uveitis and scleritis

Purpose: To evaluate the clinical experience with methotrexate as a first-line corticosteroid-sparing drug in patients with resistant ocular inflammation. Methods: We retrospectively studied 39 consecutive patients with uveitis (n = 36) or scleritis (n = 3) who were treated with methotrexate following inadequate control with corticosteroids lasting five years. Criteria for initiating treatment with methotrexate and defining outcome were strictly defined. Results: The cohort included 21 females and 18 males, all Caucasians, with a mean age of 26.6 years (range: 3–73 years). Patients were followed up for 21.5 ± 12.6 months. Treatment was discontinued due to side effects in 10 patients (26%). Of the remaining 29 patients, full or partial control of inflammation was achieved in 23 (79%). Response to treatment was observed after a mean of 2.4 ± 0.8 months. Ten patients were fully controlled and discontinued methotrexate therapy after a mean of 20.9 ± 9.2 months, with no recurrence of inflammation. Use of topical and systemic corticosteroids was markedly reduced in responsive patients. Conclusions: Methotrexate is recommended as a first-line adjunct to or replacement of systemic corticosteroids in the treatment of ocular inflammation.     

局部应用氟米龙联合免疫抑制剂治疗边缘性角膜溃疡

目的探讨边缘性角膜溃疡患者的临床药物治疗方法。方法对2008年3月至2010年12月就诊于我院眼科门诊的28例(29只眼)边缘性角膜溃疡患者局部联合应用氟米龙滴眼液和环孢霉素A滴眼液治疗,观察疗效。结果 27只眼用药2周后眼部刺激症状消失,用药1个月后25只眼痊愈,2只眼好转,1只眼复发无效。结论对于初次发病、临床症状较轻的边缘性角膜溃疡局部联合应用氟米龙滴眼液和环孢霉素A滴眼液治疗可以取得满意疗效。     

Inverse hypopyon as the presenting feature of infectious scleritis in a case of tropical pyomyositis

Case report: A 25-year-old man presented with inverse hypopyon due to dense inflammatory exudation in the left eye. He was an ascetic with a history of long pilgrimages barefoot. Drainage of the pyogenic material with superficial exploration revealed localized scleral thinning at 2′o clock. Two days later, a thigh abscess was noted, which on ultrasonography showed hypoechoic areas with increased muscle mass suggestive of tropical pyomyositis. The culture from anterior chamber aspirate grew Staphylococcus aureus, as did 200 mL of pus drained from the thigh. His ocular condition improved significantly with high-dose systemic antibiotics.Comments: To our knowledge, this unusual presentation of infectious scleritis and coexistent pyomyositis has not been previously reported in the literature.     

多层羊膜联合结膜瓣覆盖治疗周边溃疡性角膜炎分析

目的 应用多层羊膜移植联合结膜瓣覆盖的手术方法治疗近穿孔的周边溃疡性角膜炎,从而探讨该手术方法的临床价值.方法 自2008-2011年收集的21例(21只眼)周边溃疡性角膜炎近穿孔病例,其周边凹槽样角膜溶解,厚度约1/3～1/4CT,术前血液风湿系列检查所有患者显示异常,其中类风湿因子(RF)均超出正常值3～5倍,部分患者抗链球菌溶血素O定量测定(ASO)或超敏C反应蛋白测定高于正常值,抗环瓜氨酸多肽(ccp)抗体正常.术前药物控制角膜创面合并的混合感染;术中尽可能清除角膜溃疡局部坏死组织及角膜周边部免疫复合物沉积处,将营养液冷冻法保存羊膜组织片,复水后分层贴附于溃疡表面,上皮面向上,缝线间断固定,溃疡较深处再以羊膜条填塞其中,将自体带蒂转位的结膜瓣覆盖于羊膜表面,间断固定.术后结合局部感染情况给予糖皮质激素眼水、眼膏点眼,同时根据内科会诊意见全身使用糖皮质激素治疗相关性自身免疫性疾病.结果 术后10～14 d,18例患者周边溃疡性角膜炎近穿孔区有新生血管长入,术后1～2月角膜创面愈合;仅3例患者术后1.5月角膜创面再次出现部分结膜、角膜缘组织的溶解,即行第二次同术式手术,二次术后2月角膜创面全部愈合.患者随诊中仅1例患者在术后1年时,在距原手术区1个钟点位处出现新的周边溃疡性角膜炎溃疡病灶.结论 周边溃疡性角膜炎是一种与自身免疫相关性眼病.在角膜供体材料匮乏的今天,多层羊膜联合结膜瓣覆盖为治疗周边溃疡性角膜炎近穿孔病例提供了一种有效的手术治疗方式.     

Prediction of response to treatment in patients with scleritis using a standardised scoring system

Scleritis is a severe chronic inflammation of the eye wall. High-dose corticosteroids and other immunosuppressive drugs are often required to control the inflammatory process. With the development of new and potentially more effective treatment modalities for scleritis has emerged the need for an accurate and reproducible system for quantifying the severity of scleritis and evaluating the response of individual patients to treatment.
We have developed a quantitative scoring system, based on common clinical signs of scleritis, and evaluated it in 24 patients with scleritis. Our results indicate that this system is simple, rapid, reproducible and useful in grading the severity of scleritis and in predicting the response of patients to systemic immunosuppressive therapy.     

Rituximab for Remission Induction in a Patient with Relapsing Necrotizing Scleritis Associated with Limited Wegener's Granulomatosis

Purpose: The authors report a case of necrotizing scleritis associated with Wegener's granulomatosis (WG), which was treated with rituximab for relapsing disease. Method: Observational case report. Results: A 32-year-old male patient presented with necrotizing scleritis in his left eye. The patient was diagnosed as having limited WG. Cyclophosphamide was begun. Under maintenance treatment with azathioprine two relapses of scleritis occurred. Since a high cumulative dose of cyclophosphamide (22.5 g) was utilized initially, two intravenous infusions of rituximab 1 g was given. Complete resolution of scleritis occurred. Conclusions: Rituximab may be effective to induce remission in patients with scleritis due to WG.     

单纯疱疹病毒性角膜炎药物联合治疗的临床观察

目的评价华蟾素联合阿糖胞苷注射液和无环鸟苷滴眼液治疗单纯疱疹病毒性角膜炎的疗效。方法将186例(200只眼)单纯疱疹性病毒角膜炎患者随机分为治疗组106例和对照组94例,治疗组采用静脉滴注华蟾素、结膜下注射阿糖胞苷注射液和结膜囊滴用无环鸟苷滴眼液联合治疗。对照组采用上述三种治疗方法中的一种或两种。结果治疗组第一疗程治疗时间最长10天,最短3天,平均6天痊愈,治愈率为94.3％,而对照组治疗时间最长40天,最短7天,平均15．2天,治愈率为64．9％,两组相比差异有显著性(P<0．05)。结论本方法能明显缩短疗程,减少瘢痕形成,提高治愈率。     

环孢素滴眼液联合抗感染治疗中重度化脓性角膜炎的临床疗效

目的 探讨应用环孢素滴眼液联合抗感染治疗中重度化脓性角膜炎的效果。 设计 回顾性病例系列。 研究对象 2018年10月至2019年11月在北京同仁眼科中心就诊的连续中重度化脓性角膜炎患者20例（20眼）。 方法 对20例中重度化脓性角膜炎患者应用环孢素滴眼液联合抗感染治疗，治疗方法：患眼用1%环孢素滴眼液点眼，每日4次；同时根据角膜炎类型先进行经验性抗感染治疗，待微生物培养及药敏结果回报后再调整用药；出现前房炎性反应（如角膜后沉着物，大量浮游细胞，前房积脓）可加用硫酸阿托品眼用凝胶。所有患者随访至停药后6个月，记录患者的一般情况、病因、外院诊疗情况、角膜感染程度分级、角膜炎类型、视力、眼压、药物不良反应，停药后复发情况等资料，并根据患者首诊、治疗1周、1、2、3个月后的眼前节照相进行结膜充血、角膜水肿分级，并测量角膜溃疡面积，前房积脓高度。疗效判断标准：有效：疼痛症状减轻或消失，角膜溃疡部分或全部愈合，荧光素染色（±），后弹力层皱褶及水肿明显减轻或消失，前房积脓减少或消失，视力无变化或有提高；无效：各种症状改善不明显，病灶无变化或扩大，前房积脓无消失或有并发症发生。主要指标 视力、眼压、结膜充血、角膜水肿分级，角膜溃疡面积，前房积脓高度，药物不良反应，停药后复发情况等。 结果 20例患眼首诊时结膜充血评分[中位数（M），25%分位数（Q25）~75%分位数（Q75）]为2.50，2.00～3.00；治疗1周、1、2、3个月后结膜充血评分分别为2.00，2.00~3.00；1.50，1.00~2.00；1.00，0~1.00；0，0~1.00；治疗后各时间点与首诊时的差异均有统计学意义（P均<0.05）。首诊时角膜水肿评分为2.00，2.00～3.00；治疗1周、1、2、3个月后角膜水肿评分分别为1.50，1.00～2.75；1.00，0～1.75；0，0～0；0，0～0；治疗后各时间点与首诊时的差异均有统计学意义（P均<0.05）。首诊时角膜溃疡面积为7.63 mm2，6.00～29.81 mm2；治疗1周、1、2、3个月后角膜溃疡面积分别为4.50 mm2，3.00～21.88 mm2；0 mm2，0～4.88 mm2；0 mm2，0～0 mm2；0 mm2，0～0 mm2；治疗后各时间点与首诊时的差异均有统计学意义（P均<0.05）。首诊时前房积脓高度为0.25 mm，0～1.88 mm；治疗1周、1、2、3个月后前房积脓高度分别为0 mm，0～0.95 mm；0 mm，0～0 mm；0 mm，0～0 mm；0 mm，0～0 mm；治疗后各时间点与首诊时的差异均有统计学意义（P均<0.05）。12例患眼的首诊视力＜0.05，6例患眼视力在0.05～0.3之间，2例患眼视力＞0.3；治疗后，6例患眼的愈后视力＜0.05，8例患眼视力在0.05～0.3之间，6例患眼视力＞0.3，治疗后所有患眼视力均有不同程度的提高，但愈后视力与首诊视力比较，差异无统计学意义（χ2=4.286，P=0.134）。仅1例患眼治疗过程中出现眼压升高。所有患者均治疗有效，且未出现药物刺激症状及不良反应，停药后6个月内均无复发。 结论 眼局部应用环孢素滴眼液联合抗感染治疗中重度化脓性角膜炎安全、有效。     

普拉洛芬滴眼液联合小牛血去蛋白提取物滴眼液治疗中重度干眼

目的：探究普拉洛芬滴眼液联合小牛血去蛋白提取物滴眼液治疗中重度干眼的临床效果。

方法：选取2016-01/2017-01在郑州市第二人民医院接受治疗的中重度干眼患者84例132眼。按随机数字表法分为对照组42例68眼,观察组42例64眼,其中对照组采用聚乙烯醇滴眼液联合普拉洛芬滴眼液治疗,观察组采用普拉洛芬滴眼液联合小牛血去蛋白提取物滴眼液治疗。在治疗前及治疗后记录患者主客观评分。

结果：治疗前两组患者FL、BUT、SⅠt、视力4个客观指标组间比较差异无统计学意义(P>0.05)。两组患者治疗后干眼症状评分均较治疗前显著下降,组内比较差异有统计学意义(P<0.05); 治疗后观察组较对照组干眼症状评分均显著下降,差异有统计学意义(P<0.05)。两组治疗后FL评分治疗前显著下降、BUT、SⅠt、视力指标较治疗前显著上升,组内比较差异有统计学意义(P<0.05); 治疗后,各指标组间比较差异有统计学意义(P<0.05),说明观察组受试者治疗后客观症状改善优于对照组。所有患者均未出现严重不良反应,安全性较好。

结论：普拉洛芬滴眼液联合小牛血去蛋白提取物滴眼液治疗中重度干眼的临床效果较好,且安全性有保证。     

中药联合激光光凝治疗糖尿病视网膜病变

糖尿病视网膜病变(diabetic retinopathy,DR)是糖尿病眼病不可逆盲的最严重的并发症,严重影响患者的生存质量。目前,我国在DR手术治疗方面已进行了广泛的开展,对于增殖前期DR,增殖期糖尿病视网膜病变(proliferative DR,PDR)采取全视网膜光凝术,破坏缺血区视网膜,减少需氧量,以防止新生血管形成,阻止病情恶化。中医药对治疗DR有着非常丰富及个性化的治疗方案,本文就中药联合激光光凝治疗DR的研究进行综述。     

抗VEGF联合激光治疗重度非增殖期糖尿病视网膜病变对黄斑区血流密度的影响

目的：探讨抗血管内皮生长因子(VEGF)联合全视网膜光凝术(PRP)治疗重度非增殖期糖尿病视网膜病变(sNPDR)合并黄斑水肿(DME)对黄斑区血流密度变化的影响。

方法：回顾性选取2018-10/2019-04在我院确诊的sNPDR合并DME患者30例30眼,根据治疗方案进行分组,其中A组15例15眼采用“1+PRN”方案采用玻璃体腔内注射雷珠单抗7d后行PRP治疗,B组15例15眼采用单纯PRP治疗。对比两组治疗前后黄斑区6mm×6mm浅层毛细血管(SCP)和深层毛细血管(DCP)血流密度、黄斑中心凹厚度(CMT)、最佳矫正视力(BCVA)变化情况。

结果：与术前相比,A组患者术后2wk,1mo DCP血流密度显著增加、CMT明显降低、BCVA明显改善(均P<0.05),B组患者术后1mo CMT降低、BCVA改善(均P<0.05)。术后2wk、1mo,A组患者DCP血流密度较B组明显增加(43.37%±2.72% vs 41.03%±2.60%,45.01%±2.28% vs 41.20%±2.43%,均P<0.05),CMT较B组明显降低(303.4±30.36μm vs 329.60±31.47μm,268.67±30.27μm vs 319.40±28.63μm,均P<0.05),BCVA(LogMAR)较B组明显改善(0.28±0.11 vs 0.40±0.13,0.23±0.14 vs 0.38±0.15,均P<0.05)。

结论：抗VEGF联合PRP治疗sNPDR合并DME患者短期内可有效增加DCP血流密度,减轻黄斑水肿,改善视力。