Cyclosporin A therapy in refractory non-infectious childhood uveitis

AIMS—To assess the immunosuppressive efficacy, steroid sparing effect and adverse effects of cyclosporin A (CsA) therapy in refractory non-infectious childhood uveitis.
METHODS—A retrospective case series review of the medical records of children on CsA therapy attending a tertiary referral centre for refractory endogenous uveitis was performed. Low dose (5.0 mg/kg/day) CsA therapy was started either as monotherapy or in combination with other agents. The CsA immunosuppressive efficacy was assessed by visual acuity and binocular indirect ophthalmoscopy (BIO) score outcomes and steroid sparing effect by growth charts and ability to withdraw or maintain a low steroid dose. Possible CsA adverse effects were monitored by routine biochemistry (including serum creatinine) and haematological tests, blood pressure recordings, and symptoms.
RESULTS—14 patients (25 eyes, 10 males, four females) were recruited with steroid failure as the most common CsA indication. Age (mean (SD)) at start of CsA therapy was 8.7 (4.1) years with a duration of CsA therapy of 20.9 (range 3.5-88.3) months at a maintenance CsA dose of 4.0 (1.0) mg/kg/day. From baseline, visual acuity improved or was maintained in 23 (92%) eyes and BIO score improved in 19 (76%) eyes. Height centiles were preserved and the maintenance prednisolone dose was 6.3 (3.3) mg/day, where required, in 10 (71%) patients. Nephrotoxicity was not observed, with transient systemic hypertension developing in one patient. Minor adverse effects were more common but were well tolerated.
CONCLUSIONS—Cyclosporin A therapy is effective and safe in the medium term, if closely monitored, in refractory non-infectious childhood uveitis.

Keywords: cyclosporin A; childhood uveitis     

The use of low dose methotrexate in children with chronic anterior and intermediate uveitis

AIM: To assess the efficacy of low dose methotrexate (MTX) therapy for children with chronic anterior and intermediate uveitis. METHODS: A retrospective case review of 10 children who received MTX for chronic uveitis at a tertiary referral centre was performed. The following data were recorded for each patient: age, sex, race, duration of uveitis, primary diagnosis, anatomical localisation of uveitis, corticosteroid therapy, dose range of MTX, duration of MTX therapy, and side effects of MTX therapy. Several clinical parameters were evaluated to study the effect of MTX. These included visual acuity, anterior chamber inflammation, and topical and oral corticosteroid requirement. RESULTS: After MTX VA of 6/6 or better was present in 100% right eyes and 80% left eyes (p = 0.055 and p = 0.016, respectively). Anterior chamber inflammation decreased in 60% of children after MTX (p = 0.0168). The requirement of topical steroid decreased from a mean of 5.6 times a day before MTX to 1.5 times a day after MTX (p = 0.005). The dose of oral steroid decreased from a mean of 18 mg per day to 2.85 mg per day (p = 0.012). The most common adverse effect was nausea (20%). No patient required discontinuation of MTX because of side effects. CONCLUSION: MTX is effective and safe for chronic anterior and intermediate uveitis in children. An increase awareness of its efficacy is required among paediatricians and ophthalmologists to prevent sight threatening complication of chronic uveitis and its treatment with long term use of steroids.     

Pars-plana vitrectomy in cystoid macular edema associated with intermediate uveitis

BACKGROUND: Cystoid macular edema (CME) is a common complication in the course of intermediate uveitis. In spite of systemic therapy with steroids or carbonic anhydrase inhibitors, persistence of CME is observed. Pars plana vitrectomy (PPV) is known to influence the course of intermediate uveitis positively. The present study was performed to investigate the role of PPV in the therapy of CME in intermediate uveitis. MATERIALS AND METHODS: Forty-two eyes of 32 patients were re-examined after PPV for CME. In all eyes fluorescein angiography was performed. Average age at the time of surgery was 31.9 years (range 6-64 years). All patients had received systemic corticosteroid and/or immunosuppressive treatment during the course of their disease. In some patients systemic therapy with carbonic anhydrase inhibitors was performed. The mean duration of postoperative follow-up was 20.2 months (range 6-102 months). RESULTS: Preoperative visual acuity (VA) in all eyes was between 1/10 and 0.5. Total regression of CME after surgery was observed in 18 of 42 eyes (42.8%), partial improvement in 7 eyes (16.7%). In 13 of 42 eyes (30.9%) the CME remained unchanged. Twenty-one of 42 eyes (50.0%) experienced a postoperative improvement of VA of 2 lines or more. In 18 of 42 eyes (42.8%) there was no change; in 3 eyes (7.2%) VA was less. In the long-term follow-up the corresponding results were slightly worse (17/17/8 eyes) due to secondary complications. In the majority of patients systemic medical therapy could be reduced or discontinued. CONCLUSION: Pars-plana vitrectomy led to regression of CME in 59% of cases and to subsequent improvement of VA in 50% of eyes with intermediate uveitis. PPV should be considered soon after medical therapy has been shown to be ineffective.     

Clinical outcomes of cyclosporine treatment for noninfectious uveitis

Purpose

To assess the clinical outcomes of cyclosporine treatment for noninfectious uveitis.

Methods

A retrospective review of medical records was completed for 182 noninfectious uveitis patients who were treated with cyclosporine between January 2001 and August 2010. Data was obtained relevant to demographic characteristics, anatomic classification, and laterality of uveitis, associated systemic disorder, dosage of cyclosporine and prednisolone, usage of other immunosuppressive drugs, visual acuity (VA), control of uveitic activity, and adverse effects during the cyclosporine use.

Results

Uveitic activity was controlled to a level of minimal inflammation in 89.0% and completely in 78.6% of patients by the median duration of 49 and 98 days, respectively. Prednisolone-sparing (dose ≤10 mg) control of inflammation equal to or less than the minimal activity was achieved in 75.3% of patients. VA was aggravated more than 0.2 logarithm of the minimum angle of resolution in 17.3% of eyes in spite of cyclosporine treatment for the mean follow-up of 698.4 days. Dose reduction and cessation of cyclosporine was required only in 3.3% and 9.3%, respectively, due to the intolerable toxicity, although 44.0% of patients experienced mild to moderate adverse effects.

Conclusions

Cyclosporine combined with corticosteroids or other immunosuppressive drugs as needed is an effective treatment for noninfectious uveitis, thus minimizing the adverse effects of corticosteroids and other toxic drugs. However, careful monitoring for the toxicity of cyclosporine is needed, because a small group of patients cannot tolerate its toxicity.     

Intravitreal triamcinolone for persistent cystoid macular oedema in eyes with quiescent uveitis

Background:  To determine the outcome following injections of triamcinolone acetate (IVTA) in the treatment of persistent cystoid macular oedema (CMO) in quiescent, non-infectious uveitis.
Methods:  Retrospective analysis of patients with inactive uveitis requiring/not requiring immunosuppressive therapy who received IVTA because of chronic CMO refractory to previous systemic steroids. Number of IVTA (re-)treatments, distance visual acuity, near visual acuity, mean foveal thickness, intraocular pressure, duration of CMO, type of uveitis and systemic therapy were assessed previous to and 1, 4, 12 weeks following each IVTA treatment.
Results:  Between March 2003 and May 2006, 24 eyes of 18 patients received between one and three IVTA injections. A resolution of chronic CMO was observed in 7/24 eyes (29.2%, 5 eyes after single injection of IVTA, 1 eye each after two and three injections of IVTA), a significant increase in distance visual acuity in 9/24 eyes (37.5%; 5 eyes with resolution of CMO, 4 eyes despite persistent CMO) and in near visual acuity in 13/24 eyes (54.6%; 6 eyes with resolution of CMO, 7 eyes despite persistent CMO).
Conclusions:  IVTA might be considered as a treatment for patients with chronic CMO when persistent despite previous systemic steroid therapy. Even patients without sustained resolution of CMO after IVTA might benefit in terms of transiently increasing visual acuity, but progression of cataract and rise in intraocular pressure limit repeatability.     

The efficacy of sirolimus in the treatment of patients with refractory uveitis

AIMS: To determine the efficacy of sirolimus in the treatment of patients with severe non-infectious uveitis. METHODS: Eight patients with severe non-infectious uveitis were recruited to an open study. Inclusion criteria were limited to patients whose disease was not controlled with at least two or more separate steroid sparing immunosuppressants (either because of unacceptable side effects or ineffectiveness of the drug) or who required regular doses of corticosteroids either as high dose systemic or orbital floor injections in order to control their disease. Intraocular inflammation, visual acuity, symptoms, corticosteroid burden, drug toxicity, and side effects were monitored. RESULTS: Sirolimus therapy was effective in five of the eight patients, all of whom had their dose of corticosteroids reduced or discontinued. Treatment in three patients was considered a failure as it caused intolerable side effects and/or failed to control the uveitis. Side effects were common and were typically gastrointestinal or cutaneous in nature. The severity of symptoms was dose dependent in most cases and occurred at trough blood levels above 25 ng/ml. CONCLUSION: Sirolimus is an effective and potent immunosuppressive treatment in the majority of patients with non-infectious uveitis and can reduce the need for long term supplementary corticosteroid therapy. Further studies are required to establish the long term efficacy and safety of sirolimus alone or in combination with other steroid sparing immunosuppressants.     

Infliximab Treatment for Ocular and Extraocular Manifestations of Behçet's Disease

Purpose

To assess the efficacy and safety of infliximab in the treatment of sight-threatening uveitis and extraocular manifestations in patients with Behçet's disease.

Methods

Twelve patients with Behçet's disease and uveitis were treated with infliximab after unsuccessful therapy with other immunosuppressive drugs. The main outcome measures were as follows: the number of uveitis relapses, the number of Behçet's disease-related extraocular lesions, and the amount of corticosteroids administered during the treatment as well as during an equal prior period of time while the patients were on other immunosuppressive agents. Visual acuity was recorded at the beginning of infliximab therapy and at the end of follow-up, and was defined as stable if it did not change from baseline, increased if it showed at least one line of improvement from baseline, and decreased if it showed at least a one line decrease from baseline.

Results

During an average follow-up of 16.67 ± 7.63 months (median, 15 months), 11 patients (91.6%) showed a reduction in the number of ocular relapses (relapse/month, from 0.35 ± 0.17 to 0.12 ± 0.17, P < 0.001). All of the patients (n = 11) who were taking corticosteroids before infliximab were able to reduce the amount of corticosteroids taken daily during infliximab treatment (from 24.33 ± 10.84?mg/prednisone per day to 8.97 ± 6.81?mg/prednisone per day, P < 0.001), and all presented with a reduced onset of extraocular manifestations of Behçet's disease (mean total number, from 2.83 ± 3.61 to 1.51 ± 2.35, P = 0.039). One patient, who had to stop treatment 2 months after starting because of the onset of pulmonary tuberculosis, showed the same number of relapses during infliximab treatment but was able to reduce the mean daily corticosteroid dose. Visual acuity increased by one or more lines in three eyes (12.5%) and remained unchanged in 87.5% of the eyes. Infliximab-related side effects appeared in four patients (33.3%).

Conclusions

Infliximab was effective in the treatment of uveitis in these Behçet's disease patients, significantly reducing the number of ocular relapses and making possible a significant reduction in the daily dose of corticosteroids administered. Extraocular manifestations of Behçet's disease were also controlled by infliximab. Nevertheless, side effects were not uncommon, and an extensive study of systemic conditions before infliximab administration had to be carried out to exclude systemic infection, particularly prior tuberculosis.?Jpn J Ophthalmol 2007;51:191–196 © Japanese Ophthalmological Society 2007

     

Long-term Treatment with Golimumab for Severe Uveitis

Abstract

Purpose: To evaluate the long-term efficacy of golimumab in patients with severe recalcitrant uveitis who had inadequate response to previous biologics.

Methods: Retrospective study (13 patients with JIA, 4 with HLA-B27-associated uveitis). Indication for treatment was active uveitis despite biologics. Golimumab dosing was 50?mg monthly/subcutaneously. Main outcome measures: uveitis activity, visual acuity improvement, reduction of systemic therapy (corticosteroids/immunosuppressants), adverse events.

Results: Of 17 patients (34 affected eyes), response to golimumab was seen in 14 patients; at last visit uveitis was inactive in 12 patients. Three patients were nonresponders. Mean follow-up time on golimumab was 21.9 months. Visual acuity remained stable in 26 eyes, improved in 7, and worsened in 1. Mean systemic prednisolone dose before and after golimumab was 12.5–3.5?mg/day. One patient developed pulmonary infection.

Conclusions: Golimumab may be a promising new therapeutic option for severe uveitis patients who have not responded to other biologics.     

Clinical trial to compare efficacy and side-effects of injection of posterior sub-Tenon triamcinolone versus orbital floor methylprednisolone in the management of posterior uveitis

AIM: To compare the efficacy and side-effects of posterior sub-Tenon injection of triamcinolone acetonide (Kenalog) with orbital floor injection of methylpredisolone acetate (Depomedrone) in the management of posterior uveitis. METHODS: Non-randomized comparative prospective clinical study. Sixty-four eyes from 60 consecutive patients with non-infectious posterior uveitis requiring treatment were allocated on an alternate 1:1 basis to receive either orbital floor methylprednisolone or sub-Tenon triamcinolone using standard procedures and assessed at 6 and 12 weeks. RESULTS: After five eyes of five patients who had received the same treatment bilaterally were excluded from the statistical analysis, 14 out of 29 eyes treated with orbital floor methylprednisolone and 10 out of the 30 eyes given sub-Tenon triamcinolone improved at 6 weeks. There was no statistically significant difference in the improvement rate between the two groups. However, two patients given triamcinolone had prolonged upper lid ptosis, which required surgery, and another two developed markedly raised intraocular pressure, neither of which occurred in the methylprednisolone-treated group. CONCLUSIONS: Although the two drugs and routes compared were of similar efficacy, lid ptosis occurred in the triamcinolone-treated but not the methylprednisolone group. This should be borne in mind when choosing the preferred route of delivery of periocular corticosteroid in the treatment of posterior uveitis.     

The outcomes of mycophenolate mofetil therapy combined with systemic corticosteroids in acute uveitis associated with Vogt–Koyanagi–Harada disease

Purpose: To study the effectiveness of mycophenolate mofetil (MMF) as first‐line therapy combined with systemic corticosteroids in acute uveitis associated with Vogt–Koyanagi–Harada (VKH) disease. The outcomes in this group were compared with those of another group of patients with VKH disease who were treated with corticosteroid monotherapy or with delayed addition of immunomodulatory therapy. Methods: This prospective study included 19 patients (38 eyes) diagnosed with acute uveitis associated with VKH disease. Results: The mean follow‐up period was 27.0 ± 11.1 months (range 16–54 months). Corticosteroid‐sparing effect was achieved in all patients. The mean interval between starting treatment and tapering prednisone to 10 mg or less daily was 5.1 ± 1.2 months (range 3–7 months). Ten (53%) patients discontinued treatment without relapse of inflammation. The mean time observed of treatment was 17.3 ± 11.9 months (range 3–41.5 months). Visual acuity of 20/20 was achieved by 38% of the eyes in the corticosteroid group and by 74% in the corticosteroid + MMF group (p < 0.001). Recurrent inflammation of ≥3 times was reduced significantly (p = 0.0383) in the corticosteroid + MMF group (3%) as compared to corticosteroid group (18%). Development of all complications was significantly higher in the corticosteroid group (43%) compared with the corticosteroid + MMF group (8%) (p < 0.001). None of the eyes in the corticosteroid + MMF group developed ‘sunset glow fundus’. Conclusions: Addition of MMF as first‐line therapy to corticosteroids in patients with acute uveitis associated with VKH disease leads to significant reduction in recurrences of uveitis and development of late complications and significantly improves visual outcome.     

Results of intravitreal dexamethasone implant 0.7 mg (Ozurdex®) in non-infectious posterior uveitis

AIM:To evaluate the safety and efficacy of dexamethasone implant in patients with non-infectious posterior uveitis withcystoid macular edema (CME).METHODS:Retrospective analysis of patients reports with CME secondary to non-infectious uveitis treated with dexamethasone implant. Data included type of posterior uveitis, any systemic immunosuppressive therapy, Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity (BCVA), central macular thickness (CMT) on optical coherence tomography (OCT) and signs of intraocular inflammation at baseline and then at 2wk postoperatively and monthly thereafter. Follow-up is up to 10mo. Any per-operative and post-operative complications were recorded.RESULTS:Six eyes of 4 patients with CME due to non-infectious posterior uveitis treated with dexamethasone implant. Diagnosis included idiopathic panuveitis, birdshot chorioretinopathy and idiopathic intermediate uveitis. At baseline mean ETDRS BCVA was 63 letters and mean CMT 556 μm at 2wk postoperatively mean ETDRS BCVA improved to 70 letters and mean CMT decreased to 329 μm. All eyes showed clinical evidence of decreased inflammation. The duration of effect of the implant was 5 to 6mo and retreatment was required in 2 eyes. Two patients required antiglaucoma therapy for increased intraocular pressures.CONCLUSION: In patients with non-infectious posterior uveitis dexamethasone implant can be a short-term effective treatment option for controlling intraocular inflammation.     

Effizienz von Mycophenolat-Mofetil bei der Therapie der intermediären und posterioren Uveitis

Background. The severity of disease and the side-effects of long-term corticosteroid treatment support the rationale for other immunosuppressive drugs in the management of uveitis. Mycophenolate mofetil (MMF) is a selective inhibitor of ionosine monophosphate dehydrogenase and exerts its major effects by modulation of the function of T and B lymphocytes. This study was undertaken to evaluate the clinical effect of MMF in the control of intermediate and posterior uveitis. Methods. A retrospective study of 18 consecutive patients with intermediate or posterior uveitis treated with MMF was performed. Activity of intraocular inflammation was graded according to the guidelines of the international uveitis study group before and during treatment with MMF. Furthermore, the ability of MMF treatment to reduce the steroid dosage and/or substitute other immunosuppressive agents with unacceptable side-effects (cyclosporin A, tacrolimus, azathioprine) was evaluated. Results. The indication for treatment with MMF in all 18 patients (age range: 11–73 years) was either poor control of ocular inflammation by the previous immunosuppressive therapy or unacceptable side-effects of this therapy. The daily MMF dose was 2 g and therapy was combined with cyclosporin A and/or prednisolone. One patient received MMF monotherapy. Corticosteroids were discontinued in 4 patients and the steroid dose could be reduced in 14 patients following MMF therapy. Marked resolution of ocular inflammatory activity occurred in 13 patients. The most frequently observed side-effects of MMF were myalgia, fatigue, headache and gastrointestinal problems. Conclusion. MMF was effective in disease control in the majority of patients with intermediate and posterior uveitis and proved to be a useful second line immunosuppressant for refractory intraocular inflammatory disease with an acceptable profile of side-effects.     

Periocular corticosteroid injection in the management of uveitis in children

Acta Ophthalmol. 2010: 88: e299–e304

Abstract.

Purpose: To report the outcome of orbital floor corticosteroid injection (OFCI) in the management of uveitis in children. Methods: A retrospective noncomparative interventional case series. The medical records of 15 consecutive children (19 eyes) with various forms of uveitis treated with OFCI of 40 mg/ml methylprednisolone acetate or a combination of 20 mg/0.5 ml Triamcinolone and 2 mg/0.5 ml dexamethasone were reviewed. Data were collected 6 months postinjection and included details of uveitis, best corrected visual acuity (BCVA), ocular inflammation, systemic therapy required and potential complications of OFCI. Results: The mean BCVA improvement was 0.18 logarithm of the minimum angle of resolution (p < 0.001), at a mean of 6 weeks (range, 4–20). Fourteen eyes (74%) had significant improvement in inflammation, 4–7 weeks post‐OFCI, with a median of 4 weeks. Anterior uveitis was treated effectively in all eyes, vitritis resolved in all but one case and resolution of cystoid macular oedema was achieved in six eyes (55%). Uveitis relapsed in seven eyes (50%) after a median time of 4 months (range, 2–5 months). Four eyes (21%) underwent more than one injection. The dosage of immunosuppressive systemic therapy was reduced or able to be stopped in three patients (50%). Steroid‐induced cataract was observed in four eyes (21%), 5 months post‐OFCI. One patient developed cushingoid features 6 weeks post his second OFCI. Conclusion: Corticosteroid orbital floor injections resulted in control of active uveitis and visual acuity improvement in most children. However, the effect might be transient and induce cataract formation.     

Safety and efficacy of intravitreal triamcinolone acetonide for uveitic macular edema

BACKGROUND: To evaluate the safety and efficacy of intravitreal triamcinolone acetonide (TA) for treating macular edema secondary to non-infectious uveitis. METHODS: Retrospective review of sixteen patients (20 eyes) with chronic cystoid macular edema (CME) as a consequence of controlled intermediate uveitis, posterior uveitis, or panuveitis who received at least one intravitreal injection of TA. Main outcome measures were visual acuity (VA), intraocular pressure (IOP), formation or progression of an existing cataract, and CME resolution during the follow-up period. RESULTS: At last follow-up, VA showed improvement (compared to baseline) in 11 eyes (55%), deterioration in three eyes (15%), remained completely unchanged in one eye (5%), and showed improvement initially but returned to baseline levels in five eyes (25%). At last follow-up, CME had relapsed or was still present in 10 of the eyes (50%). The remaining eyes showed complete resolution of the CME, without evidence of recurrence during the follow-up time. Mean VA at last follow-up showed statistically significant improvement (p = 0.02) in nonvitrectomized eyes (mean baseline VA: 1.14 +/- 0.58; mean final VA: 0.96 +/- 0.66) compared to the almost unaltered mean visual acuity for vitrectomized eyes (mean baseline VA: 0.76 +/- 0.41; mean final VA: 0.71 +/- 0.48)(p = 0.40, paired samples t-test). Elevation of IOP was transient in all cases and responded well to topical medications, except for one patient who required placement of an Ahmed valve. Preexisting cataract progressed in three of the 15 phakic eyes (20%). One patient developed a retinal detachment and required additional surgery to reattach it. Patients were followed for a mean of 34 weeks (median: 32 weeks; range: 19-56 weeks). CONCLUSIONS: Intravitreal TA may play a role in the treatment of uveitis-related CME. Further controlled studies are necessary to test this hypothesis.     

Methotrexate for uveitis associated with juvenile idiopathic arthritis: value and requirement for additional anti-inflammatory medication

PURPOSE: To study the value of methotrexate (MTX) and the requirement for additional anti-inflammatory drugs for the treatment of severe chronic iridocyclitis associated with juvenile idiopathic arthritis (JIA). METHODS: Institutional study of 35 consecutive patients with JIA started on MTX as the single systemic immunosuppressive drug for the treatment of associated iridocyclitis. The clinical epidemiologic data, course of visual acuity (VA), development of complications, and the need for additional anti-inflammatory drugs were analyzed. RESULTS: Mean follow-up with MTX treatment was 27.6 months. Uveitic complications were present in 31 patients before MTX treatment. With MTX, quiescence of uveitis was obtained with (n=21) or without (n=4) additional topical steroids. Additional systemic immunosuppressive drugs were required in another 7 patients: cyclosporine A (n=4), azathioprine (n=1), infliximab (n=1), or etanercept (n=1). Three patients had active uveitis at the end of the follow-up period. During MTX therapy, uveitis first developed in the unaffected fellow eyes in 2 patients, and secondary glaucoma or ocular hypertension occurred in 7 patients. The VA deteriorated in 6, improved in 13, and was stable in the remaining eyes. CONCLUSIONS: The data suggest that MTX is very effective in controlling inflammation of uveitis in patients with JIA. However, additional topical steroids or systemic immunosuppressive drugs are often required.     

Mycophenolate mofetil in the treatment of ocular inflammation in ANCA-associated vasculitis.

AIM: The aim of this study was to describe the use of mycophenolate mofetil (MMF) in the treatment of patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis with ocular involvement. METHODS: A retrospective review was performed. Ocular and systemic manifestations, history of previous immunosuppressive drug therapy, concurrent therapy with MMF, response to treatment, side effects related to the use of MMF, and follow-up period were recorded. RESULTS: Nine (9) eyes of 5 patients were evaluated. Ocular involvement included scleritis, choroidal and orbital granuloma, multifocal choroiditis, intermediate uveitis, and lacrimal gland involvement. Mycophenolate was started at 2 g daily. Mean follow-up after the initiation of MMF was 36 months. Mean prednisolone dose at onset of treatment with MMF was 27 mg daily and was reduced to 7 mg daily as disease control was achieved. Visual acuity was maintained or improved in all eyes, apart from 1 eye, which developed cataract formation. One (1) patient required a reduction in the dose of mycophenolate owing to diarrhea. CONCLUSIONS: Our study suggests that mycophenolate mofetil may be a safe, effective therapeutic modality for ocular inflammation associated with ANCA-associated vasculitis.     

Uveitic cystoid macular edema: intravitreal triamcinolone

BACKGROUND: Cystoid macular edema (CME) is the most frequent cause of severe loss of visual acuity in uveitis. Among the systemic corticosteroids and immunosuppressive agents, the local use of intravitreal triamcinolone acetate (TA) is evaluated. METHODS AND PATIENTS: Intravitreal injections of 10 mg TA were performed in ten eyes of six patients with persisting uveitic CME in spite of systemic cortisone or immunosuppressive therapy. RESULTS: The mean follow-up time was 9.8 months (range: 3-18). Visual acuity increased from 0.58 logMAR to 0.21 logMAR. In two eyes of one patient, repeated intravitreal injections of TA were necessary. Side effects included a increase of intraocular pressure (IOP) up to 25 mmHg or more in 30% of the eyes. In these three eyes, IOP was successfully controlled by local antiglaucomatous therapy (IOP < or = 20 mmHg). The dosage of systemic steroids had to be augmented in two eyes. In no patient was injection-related endophthalmitis, vitreous hemorrhage or retinal detachment observed. CONCLUSIONS: Intravitreal TA is an effective local therapy for CME due to uveitis without systemic side effects. It cannot replace the systemic basal therapy of uveitis, since the long-term effects are limited. It can be used as a bridging therapy until a systemic immunosuppression is started. It may, furthermore, be a therapeutic option when side effects of immunosuppressive agents are expected.     

Intraoperative use of intravitreal triamcinolone in uveitic eyes having cataract surgery: pilot study

PURPOSE: To report the outcomes of cataract extraction with intraoperative intravitreal triamcinolone (IVTA) in eyes with a history of posterior uveitis. SETTING: Moorfields Eye Hospital Uveitis Service, London, United Kingdom. METHODS: Nineteen eyes of 17 patients with posterior uveitis thought to require systemic corticosteroid prophylaxis for cataract surgery were included. The use of systemic corticosteroids at the time of surgery would have been problematic in 7 of the patients, who had a history of systemic hypertension. Three of the 7 patients were also diabetic. All patients were not happy about using oral corticosteroids. RESULTS: Median visual acuity 1 day after surgery was 20/40 (range 20/20 to counting fingers). At final follow-up (mean 25.2 months; range 7 to 41 months), 17 eyes (89.5%) eyes achieved visual acuity of 20/40 or better; 2 eyes failed to achieve a final visual acuity of 20/40 or better, 1 as a result of optic atrophy and the other as a result of macular edema. No patient lost acuity and no eye developed macular edema within 4 months of surgery. Intraocular pressure elevation occurred after surgery in 3 eyes; all were controlled by topical medication that was discontinued after 3 months. One patient developed severe intraocular inflammation after surgery that resolved with intensive topical corticosteroid therapy within 1 week. CONCLUSIONS: Cataract extraction by phacoemulsification with concurrent IVTA appears a useful treatment option. Targeted delivery of corticosteroid is achieved without the risks of systemic corticosteroid prophylaxis. The incidence of postoperative macular edema was markedly reduced. Levels of visual acuity after cataract surgery, similar to those in eyes without uveitis, were achieved in eyes with posterior uveitis.     

Seventeen cases of central serous chorioretinopathy associated with systemic corticosteroid therapy

PURPOSE: To determine the relationship between the clinical characteristics of patients with central serous chorioretinopathy (CSC) and systemic corticosteroid therapy. METHODS: The medical records of 17 cases of CSC that developed during systemic corticosteroid treatment from 1987 to 1999 at Chiba University Hospital were reviewed. The relationship of CSC to the age, gender, laterality, and disease requiring the corticosteroid treatment, and the dose and duration of corticosteroid therapy were examined. RESULTS: There were 6 men and 11 women, and 2 of these developed bilateral and 15 developed unilateral CSC. The duration from the beginning of corticosteroid treatment to the onset of CSC ranged from 3 days to 23 years; 9 patients developed CSC within 1 year after the beginning of the corticosteroid medication and 6 patients after more than 8 years. The amount of corticosteroid medication at the onset of CSC ranged from 5 to 1,000 mg/day equivalent prednisolone units. There was a significant correlation between age at the onset of CSC and the daily dosage of corticosteroid. CONCLUSION: Even small amounts of daily corticosteroids (5-10 mg/day) can cause CSC, especially in elderly patients. These findings indicate that we need to monitor patients undergoing corticosteroid treatment carefully.     

So-called "central retinal vein occlusion". II. Venous stasis retinopathy.

28 patients (29 eyes) with venous stasis retinopathy (VSR) were studied. This study indicates that VSR is a self-limited, chronic and comparatively benign condition as compared to hemorrhagic retinopathy. No patient with VSR progressed to hemorrhagic retinopathy. The main complication which required management in VSR was the deterioration of central visual acuity (VA) due to development of macular edema which, if untreated, ended in cystoid macular degeneration and permanent central scotoma. Thus the indication for treatment in these cases was the fall of central VA. Ten eyes showed no deterioration of vision throughout follow-up (group I) and hence required no treatment. The remaining 19 eyes developed deterioration of vision: 5 eyes (4 patients) amongst these were not treated (group II) while the other 14 eyes (group III) were treated by systemic corticosteroids, to control the macula edema starting with a dose of 40-60 mg of oral prednisolone daily and gradually tapering to a maintenance dose. The results of group III cases strongly suggested that adequate doses of systemic steroids have a distinct beneficial effect on the VA -they help to prevent deterioration of vision and in the recovery of deteriorated vision. However, these patients require therapy for months or even longer during the course of VSR; on stopping the therapy, poor VA recurred in ten of these eyes. This factor may limit the usefulness of this therapy, if contraindications to such prolonged steriod therapy or serious side-effects of steroid therapy exist in a patient. In such cases one may be confronted with the dilemma of either not treating them and running a fairly high risk of permanent loss of central vision, or treating them with adequate doses of systemic steriods, retaining good VA but running the risk of side effects. While evaluating the effectiveness of steroid therapy, the improvement in VA should be the primary criterion because the fundus appearances almost always show no significant improvement for weeks although the VA rapidly returns to a normal level.