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.     

Diagnosis of ocular toxocariasis by establishing intraocular antibody production

PURPOSE: To investigate the role of Toxocara canis in posterior uveitis of undetermined origin. DESIGN: Retrospective case-study. METHODS: Paired ocular fluid (47 aqueous humor [AH] and two vitreous fluids) and serum samples of 37 adults and 12 children with undetermined posterior uveitis were retrospectively analyzed for intraocular IgG antibody production against Toxocara canis by enzyme-linked immunosorbent assay and Goldmann-Witmer coefficient (GWC) determination. Previous diagnostic investigation by polymerase chain reaction and GWC for Herpes simplex virus, Varicella zoster virus, and Toxoplasma gondii had not provided a cause of the posterior uveitis. RESULTS: Three of 12 (25%) children showed intraocular IgG production against Toxocara canis. One child had vitritis, one presented with a low-grade uveitis and a peripheral retinal lesion, and the third had posterior uveitis and a chorioretinal scar. All three children had AH IgG titers exceeding those of the corresponding serum. In fact, two children had low Toxocara serum IgG titers (<1:32) and would have been considered seronegative upon routine serology screening. Intraocular antibody production against Toxocara canis was absent in all 37 adults, including five seropositive patients. CONCLUSIONS: Our results indicate that ocular toxocariasis is mainly a pediatric disease. Serological screening is not informative for the diagnosis of intraocular Toxocara infection. Toxocara GWC analysis, however, can be of value when diagnosing patients with posterior focal lesions or vitritis of unknown etiology.     

Analysis of recurrence patterns associated with toxoplasmic retinochoroiditis

PURPOSE: Toxoplasmic retinochoroiditis is thought to recur randomly. We sought to determine whether there is, instead, a longitudinal pattern of recurrences and to identify risk factors for recurrence. DESIGN: Longitudinal cohort study. METHODS: We collected the following data for 143 patients with toxoplasmic retinochoroiditis in The Netherlands: gender, first affected eye, age at first episode, mode of Toxoplasma gondii infection (congenital vs postnatal), treatment history, and presence of retinal scars at initial examination. For each episode, we determined age, duration since first episode, and interval since previous episode. We estimated the relationship between disease-free interval after an episode and recurrence risk. The influence of host and disease factors on recurrence risk was analyzed using Cox regression with frailty modeling for correlated intrapatient recurrence times. We performed a Monte Carlo test for occurrence of clusters after prolonged disease-free intervals. RESULTS: Follow-up ranged from 0.3 to 41 years (323 episodes in first-affected eyes). Recurrence risk was highest immediately after an episode, then decreased with increasing disease-free intervals, a pattern consistent with clustering. Relative risk (RR) of recurrence declined 72% (RR, 0.28; 95% confidence interval [CI], 0.22 to 0.36; P < .001) with each 10-year interval since first episode, and declined 15% (RR, 0.85; 95% CI, 0.71 to 1.01; P = .06) for each 10-year increase in age at first episode. Patients more than 40 years of age were at higher risk of recurrence than younger patients (RR, 1.74; 95% CI, 1.06 to 2.86; P = .03). Clusters of episodes occurred after prolonged disease-free intervals. CONCLUSIONS: Toxoplasmic retinochoroiditis occurs in clusters over time. Recurrence risk is influenced by patient age and duration of infection.     

Looking for Ocular Tuberculosis: Prevalence and Clinical Manifestations of Patients with Uveitis and Positive QuantiFERON®-TB Gold Test

Purpose: To report on the prevalence of ocular TB and positive QuantiFERON^®-TB Gold (QFT-G) test in uveitis patients and describe their clinical manifestations.

Methods: We performed a prospective study of 108 new human immunodeficiency virus-negative uveitis patients. All patients underwent a tailored screening protocol for uveitis and received QFT-G test and tuberculin skin tests (TST).

Results: QFT-G test was positive in 39/108 (36%) of patients, while TST ≥15 mm was positive in 16/108 (15%) patients. None of the patients were identified with active systemic TB. Out of 39 QFT-G-positive patients, 25 (64%) were of unknown cause, which represents a higher proportion than encountered in QFT-G-negative cases (29/69; 42%; p<0.03). Retinal occlusive vasculitis was frequently observed in patients with positive QFT-G outcomes (10/39 vs 3/69; p = 0.001) and was commonly associated with high QFT-G levels, young age, and male gender.

Conclusions: Out of all patients with uveitis, none had active systemic TB but 36% were positive for QFT-G test. QFT-G-positive patients frequently had uveitis of unknown cause and exhibited clinical features of occlusive retinal vasculitis.     

High incidence of corneal epithelium antibodies in Fuch''s heterochromic cyclitis.

Sera obtained from 26 patients with Fuchs' heterochromic cyclitis were examined for the presence of autoantibodies directed against the anterior segment of the eye by means of immunofluorescence techniques. Antibodies against human iris tissue could not be detected, whereas autoantibodies against corneal epithelium were found in almost 90% of cases. This is the first report describing the presence of autoantibodies in patients with Fuchs' heterochromic cyclitis and it provides a further clue that immunological mechanisms might play an important role in the aetiology of Fuchs' heterochromic cyclitis.     

Aqueous humor analysis as a diagnostic tool in toxoplasma uveitis

Analysis of local toxoplasma antibody production to confirm a suspected clinical diagnosis of toxoplasma chorioretinitis is a valuable diagnostic tool. Determination of toxoplasma antibodies in the blood of the patient is of limited use. When blood toxoplasma tests are negative this indicates that toxoplasma as a causative organism in the pathogenesis of uveitis is unlikely.A positive blood test is a sensitive test (100% patients positive) but not a specific test since so many healthy individuals already have undergone subclinical infection and have acquired humoral immunity against the parasite.We analysed 93 paired aqueous and serum samples for toxoplasma antibodies and total IgG and determined the Goldmann-Wittmer coefficient. In patients retrospectively diagnosed as having toxoplasma chorioretinitis 16 out of 22 had a positive coefficient, indicating local parasite antibody production. In one patient with AIDS we also found a positive toxoplasma coefficient. Three out of 15 patients with posterior uveitis of unknown origin also had a positive coefficient. None of the cataract patients tested (n=32) had a positive coefficient. Major drawbacks of aqueous humor analysis are that a false negative antibody coefficient can occur when a massive blood aqueous barrier breakdown has occurred.     

Polymerase chain reaction detection of Neisseria meningitidis in the intraocular fluid of a patient with endogenous endophthalmitis but without associated meningitis

PURPOSE: To report a patient with Neisseria meningitidis endophthalmitis without associated meningitis with full visual recovery, with early detection of the microorganism using polymerase chain reaction (PCR) analysis. DESIGN: Retrospective, observational case report. PARTICIPANTS: One patient with endogenous endophthalmitis. METHODS: Polymerase chain reaction analysis and culture of the intraocular fluid sample. Polymerase chain reaction analysis was performed with a universal (16S rRNA) primer set to detect bacterial DNA, and subsequently a specific probe was used to detect Neisseria species DNA. RESULTS: The 16S rRNA primers detected bacterial DNA, the specific probe detected Neisseria species DNA, and culture was positive for Neisseria meningitidis serotype C. CONCLUSIONS: A universal bacterial PCR can be very helpful for the diagnosis of endogenous bacterial endophthalmitis at an early stage of the disease.