Corticosteroids in uveitis

No strong evidence exists with which to answer questions about the effectiveness of CS in treating visual loss from intraocular inflammation. Steroids are valuable and quickly working anti-inflammatory medications, which may prevent visual loss in many patients with noninfectious uveitis. The value of prolonged treatment in uveitis is not yet established. The literature on efficacy of CS in diverse uveitic entities contains no results from randomized clinical trials; all of the information originated from case series. In addition, a quality of life assessment was not studied. These are serious limitations; the information about the effect of medication should be obtained by comparing a treated group with an untreated control group similar in all the important respects. Necessary documentation would include details about the patient selection criteria. Use of standardized follow-up intervals and outcomes assessment would further improve the quality of information, as would comparisons with the natural history of the untreated patient population. Because case series have no control group and do not use randomization, there is no way to estimate how CS might have changed a final outcome. Because of the severe adverse effects associated with chronic use of CS and unknown efficacy on final visual prognosis, it is recommended for those of need of long-term anti-inflammatory medication to start CS in the acute stage of the disease and taper off subsequently with use of CS-sparing medications. Randomized clinical trials are needed to determine the short- and long-term effectiveness of CS in uveitis.     

Medical treatment of cystoid macular edema

Although cystoid macular edema (CME) represents a major cause of visual loss in uveitis, the consensus on its treatment has not yet been reached. We performed a literature review on the efficacy of diverse medical treatment modalities for uveitic CME and suggest novel treatment recommendations. A literature search retrieved 173 citations (MEDLINE, conducted in March 2002, terms: macular edema, uveitis, treatment) and relevant publications were studied. The literature contained information based mainly on case series; the specific treatment targets were not clear. Causal treatment of the underlying ocular condition was considered essential and various approaches of symptomatic treatment were attempted (immunosuppressive and immunomodulatory agents, acetazolamide, octreotide), all with different inclusion criteria and evaluation protocols. The decision to initiate the symptomatic treatment of CME was usually made in cases with already compromised visual acuity. Despite aggressive treatment, the progression of CME with accompanying visual loss was common. On the basis of published results, we recommend starting treatment of CME at an early stage, even in eyes with full visual acuity. Randomized clinical trials are needed to determine the efficacy of diverse treatment modalities and to evaluate the effects of early intervention on inflammatory CME.     

Birdshot chorioretinopathy: long-term manifestations and visual prognosis

PURPOSE: To ascertain the clinical features and long-term visual prognosis of birdshot chorioretinopathy (BCR), and to identify patients at risk of visual loss. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Fifty-five consecutive patients with HLA-A29-positive BCR who were identified in ophthalmology departments of the University Medical Center of Utrecht and The Eye Hospital Rotterdam, of whom 37 were observed for at least 5 years. INTERVENTION: A review of the medical and photographic and/or angiographic records of 55 patients with HLA-A29-positive BCR. MAIN OUTCOME MEASURES: Numerous variables were compared, including age and gender distribution, onset and course of BCR, ocular manifestations, therapeutic strategies and their outcomes, complications, systemic diseases, visual acuity (VA), and features associated with poor visual outcome. RESULTS: Loss of VA was gradual; the number of affected eyes with VA less than 20/200 increased from 9 of 108 (8%) at onset to 22 of 73 (30%) at 5 years and 19 of 49 (39%) at 10 years of follow-up. The cause of compromised VA was predominantly macular edema and macular atrophy (42 of 55 [76% of cases]). We found strong associations between the VA at onset and visual outcome after 5 and 10 years (P = 0.005 and P = 0.006, respectively). Mean VA at the 5-year follow-up was significantly lower if macular leakage was observed on angiography (P<0.001). No differences in annual loss of VA were observed between patients treated by standard therapeutic modalities and untreated patients. CONCLUSION: The visual prognosis of BCR in a spectrum of uveitis is poor, and the recommended therapeutic regimens have had no effect on long-term visual prognosis. New treatment strategies are needed for this blinding disorder.     

Ocular manifestations of toxoplasmosis

PURPOSE OF REVIEW: The concepts of toxoplasmosis and its ocular manifestations in humans have thoroughly changed in the past 3 years. This review addresses new epidemiologic data, specifically the occurrence of ocular disease in postnatal infections, and puts the changed views on the frequency and pathogenesis of toxoplasmic ocular manifestations into historical perspective. RECENT FINDINGS: Newly described clinical presentations are discussed together with their recent diagnostic possibilities. The new data on congenital or postnatal acquisition of infection and their importance for ocular involvement are presented as well as the high prevalence of 79% of recurrent disease in ocular toxoplasmosis, which cannot be prevented by short-term treatments. Recently published analyses of literature showed, unexpectedly, the lack of efficacy of short-term treatments for ocular disease as well as of the long-term prenatal treatments on fetal transmission rate and the severity of congenital disease. SUMMARY: The recent guidelines for treatment are included together with the up-to-date recommendations for the treatment of ocular toxoplasmosis in the immunosuppressed host.     

Grid laser photocoagulation for macular oedema in uveitis or the Irvine-Gass syndrome

AIMS—To determine the effect of modified macular grid photocoagulation in patients with refractory macular oedema due to uveitis or cataract extraction.
METHODS—In this study 20 patients with macular oedema underwent modified macular grid laser photocoagulation and were followed by means of standardised examinations (day 0, months 2, 6, and 12) consisting of best corrected visual acuity and fluorescein angiography.
RESULTS—The mean visual acuity increased from 0.16 before to 0.3 after laser treatment (p=0.013), and fluorescein leakage was significantly reduced (p=0.005). Visual prognosis was influenced by duration of the uveitis, not by sex or age.
CONCLUSION—Modified macular grid laser photocoagulation had a beneficial effect on macular oedema caused by uveitis or the Irvine-Gass syndrome. A prospective, randomised study is needed to determine the exact place of modified macular grid photocoagulation in the treatment of patients with inflammatory or postsurgical macular oedema.

Keywords: macular grid photocoagulation; Irvine-Gass syndrome; macular oedema     

Relationship between rubella virus and Fuchs heterochromic uveitis; 2 patients

Two otherwise healthy men, aged 26 and 29 years, were diagnosed with Fuchs heterochromic uveitis (FHU) on the basis of the presence of iris heterochromia or iris atrophy, stellate corneal precipitates, and/or cataract. Microbiological investigation of aqueous humour demonstrated intraocular antibody production against rubella virus, but not against Toxoplasma gondii, herpes simplex virus or varicella zoster virus. Microbial nucleic acid detection was negative for all pathogens. Some time later, both patients underwent cataract surgery, which improved their vision considerably. FHU is a chronic, generally unilateral iridocyclitis, accompanied by the above-mentioned ophthalmologic manifestations in the absence of systemic disease. Little is known about the pathogenesis ofFHU, but recent publications have provided evidence for the possible involvement of the rubella virus.     

Fuchs''s heterochromic cyclitis in congenital ocular toxoplasmosis.

We report a follow-up after 25 years of a patient with a congenital bilateral ocular toxoplasmosis who developed Fuchs's heterochromic cyclitis in her left eye. Whether Toxoplasma gondii can cause the development of Fuchs's heterochromic cyclitis, as our case suggests, or whether the iridocyclitis is a secondary ocular response to other agents, is not yet clear.     

HLA typing in congenital toxoplasmosis.

HLA-A, HLA-B, HLA-C, and HLA-D typing was performed in 47 mothers of patients suffering from ocular toxoplasmosis to investigate whether an immunogenetic predisposition exists for developing congenital toxoplasmosis in their offspring. No significant association between any HLA antigen was observed in the mothers of patients with ocular toxoplasmosis, although a total absence of the HLA-B51 antigen was found in this group. HLA-A, HLA-B, and HLA-C typing was also performed in their children (52 patients with ocular toxoplasmosis), to investigate a possible relation between the severity of ocular toxoplasmosis and an eventual immunogenetic factor. In the patients with ocular toxoplasmosis an increased frequency of the HLA-Bw62 antigen was observed in correlation with severe ocular involvement.