Immunosuppressive therapy for Vogt-Koyanagi-Harada disease: a retrospective study and review of literature.

BACKGROUND: Vogt-Koyanagi-Harada (VKH) disease is an idiopathic autoimmune disease which targets melanin-containing tissues such as the uvea, meninges, ear and skin. This typically presents in the eye with acute findings of granulomatous anterior uveitis, diffuse choroidal thickening, multiple focal areas of sub-retinal fluid and, in severe cases, optic nerve involvement with bullous serous retinal detachment can occur. Early initiation of treatment has been advocated to prevent progression to the chronic stage of the disease, which can result to a sunset glow fundus with devastatingly poor visual outcome. Treatment is usually initiated with corticosteroids followed by an early introduction of immunosuppressive treatment (IMT) to achieve immediate response after disease presentation, although the choice of IMT for VKH can vary. MAIN FINDINGS: We conducted a retrospective case-series to investigate the management trend of treating VKH over a 20-year period. Twenty-six patients were included and we found a shift from steroid monotherapy to combined IMT/low-dose steroid for the management of acute initial-onset of VKH in the last 10 years. Our average time from diagnosis to initiation of IMT was 2.1 months. 81% (21 of 26 patients) of our patients treated with combined IMT/steroid were able to achieve disease stability with significant good visual outcome at 24 months (Median VApre-IMT = 0.3 Logmar vs VApost-IMT = 0.0 Logmar, p = 0.0001). MMF monotherapy was the most common IMT used and it was well-tolerated by our patients. Even so, 50% of our patients who were treated with MMF did not achieve disease control. We then performed a literature review to identify any IMT which could be superior in the treatment of VKH. We also share our experience (where applicable) on the various treatment options found from the literature review. SHORT CONCLUSION: Our study found that patients with VKH who were treated with combined IMT/low-dose steroids achieved significantly better visual improvement at 24 months compared to steroid monotherapy. We frequently chose MMF and this appears to be well tolerated by our patients. Since its introduction, anti-TNF agents are increasingly becoming a popular choice of treatment for VKH as these have been shown to be safe and effective. However, more data is required to provide evidence that anti-TNF agents can be used as first-line treatment and as monotherapy.

The incidence, presenting clinical findings and treatment patterns of Birdshot Retinochoroiditis in a high-prevalence region: findings from Northern Ireland, England and Wales.

BACKGROUND: Birdshot Retinochoroiditis (BSRC) is a rare, chronic posterior uveitis that is strongly associated with HLA-A*29.2 positivity. To date, no robust incidence studies of BSRC have been undertaken. We present the first epidemiological study of BSRC in a high-prevalence region. METHODS: In collaboration with the British Ophthalmological Surveillance Unit, all new cases of BSRC between May 2017 and June 2019 were prospectively collected. Presenting demographics, symptoms, signs and treatment modalities were collected. A follow-up questionnaire twelve months later was also sent. RESULTS: Thirty-seven confirmed cases meeting the reporting criteria were identified. Twenty-three cases had both baseline and follow-up data. The total population incidence of BSRC was 0.035 cases per 100,000 person-years [95% CI 0.025-0.048 cases per 100 000 people]. 97.3% were HLA-A*29 positive. The median age was 46 years, with females making up 78% of patients. There were no significant differences in the latitudinal incidence of BSRC. At presentation, floaters were the most common symptom. Optic disc swelling was the most common sign. Mean presenting visual acuity was independent of symptom duration. Combined systemic corticosteroids and immunomodulatory therapy were the most common treatments at baseline and follow-up. Intravitreal steroids were equally popular at follow-up. CONCLUSIONS: This study provides the first nationwide estimate of the incidence of BSRC in a high-prevalence region. Cases were more common in females, with a broad range of presentation ages. No significant latitudinal effect of incidence was identified. Systemic therapy with steroids and IMT remain the most common treatments.

Predictive Factors for Magnetic Resonance Imaging Changes Suggestive of Demyelination in Adult Patients with Uveitis Scanned Prior to Commencing Adalimumab Therapy.

PURPOSE: To report the predictive clinical factors for abnormal magnetic resonance imaging (MRI) scans suggestive of demyelination by analysis of MRI's performed for adult non-infectious uveitic patients prior to commencing adalimumab therapy. METHODS: Retrospective case review of 240 patients was conducted in a single tertiary institution between November 2017 and March 2020. Aetiology of underlying disease, clinical characteristics, and MRI outcomes were analysed. RESULTS: The presence of bilateral idiopathic intermediate uveitis (IIU) (p = .0048) and neurological symptoms (p = .028) were highly predictive of an abnormal MRI strongly suggestive of demyelination (MRSSD); 5 out of 64 scans (7.8%) with these clinical characteristics had MRSSD. CONCLUSIONS: Tumor necrosis factor antagonist-induced demyelination is a concern in adalimumab use. We propose an MRI screening protocol to identify those at high risk of demyelination; positive results can be maximised by screening all patients with IIU and those with neurological symptoms.

Efficacy of Tacrolimus in Uveitis, and the Usefulness of Serum Tacrolimus Levels in Predicting Disease Control. Results from a Single Large Center.

AIMS: To evaluate the efficacy of tacrolimus in patients with noninfectious uveitis, as well as the usefulness of serum tacrolimus concentration measurements in predicting disease control. METHODS: A retrospective review was carried out on 71 eligible patients from a single specialist uveitis center for minimum 1-year follow-up. Analysis was carried out on disease activity, visual acuity, and trough serum tacrolimus concentrations (STC). RESULTS: At 1-year follow-up, disease control was achieved in 49 patients (69.0%), this was significantly more likely in patients with trough STC levels above 5 ng/mL (88% vs 53%, p = .002). There was a significant reduction in oral prednisolone (dose ≥7.5 mg, 86% vs 54%, p < .0001). Tacrolimus was discontinued in 12 patients (17%) due to side effects. DISCUSSION: In this study cohort, oral tacrolimus was effective and well tolerated in the treatment of noninfectious uveitis. Trough STC between 5 ng/mL and 10 ng/ml was associated with better disease control at 1-year follow-up.

Multiple evanescent white dot syndrome: clinical course and factors influencing visual acuity recovery.

OBJECTIVE: To report the demographics and the clinical course of patients with multiple evanescent white dot syndrome (MEWDS) and to investigate for those factors which influence visual acuity (VA) recovery. METHODS: This is a retrospective single-centre observational study. Electronic medical records and retinal imaging of patients with a diagnosis of MEWDS with a minimum follow-up of 3 months were reviewed. Patients were categorised into three groups according to the VA at presentation and at the last visit: group 1 >0.48 logarithm of the minimum angle of resolution (LogMAR), group 2 ≤0.48 and ≥0.18 LogMAR and group 3 <0.18 LogMAR. All patients had non-invasive multimodal imaging including optical coherence tomography, near-infrared reflectance imaging and blue fundus autofluorescence at presentation and during follow-up. RESULTS: A total of 51 eyes from 51 patients (41 women, mean age 29.8±7.8 years) were included. Significantly more patients presented in the autumn (X2=8.69, p=0.034). The percentage of eyes recovering vision to 0.0 LogMAR or better was 80.3% (41/51). Worse presenting vision and young age at presentation were independent significant predictive variables for poorer final VA (p=0.002 and p=0.02, respectively). No imaging features were significantly predictive of complete versus incomplete recovery, but disc hyperfluorescence on fluorescein angiography was more common in those with incomplete recovery. CONCLUSIONS: Although the majority of cases have a benign prognosis, the clinical spectrum of MEWDS includes incomplete visual recovery. In our series, poor presenting VA and young age were associated with poor VA outcome. Further study is warranted to confirm these findings.

Ocular toxoplasmosis: phenotype differences between toxoplasma IgM positive and IgM negative patients in a large cohort.

PURPOSE: To investigate the differences in demographics and clinical characteristics of patients diagnosed with ocular toxoplasmosis according to their IgM status. METHODS: Retrospective case note analysis was carried out on patients who tested positive for serum Toxoplasma gondii-specific IgM antibodies (IgM+) as well as a comparator group who tested negative for serum IgM (IgM-), but positive for serum IgG. Patient demographics and clinical features were compared between the two groups to evaluate for any significant differences. RESULTS: One hundred and six patients were included in the study between March 2011 and June 2018, consisting of 37 in the IgM +group and 69 in the IgM- group. Patients in the IgM +group were significantly older (51.1 vs 34.1 years, p<0.0001), more likely to present with central macular lesions (32% vs 12%, p=0.012), and more likely to develop rhegmatogenous retinal detachment (11% vs 1%, p=0.049). In contrast, patients in the IgM- group were more likely present with pain (20% vs 3%, 0.017) and exhibit more severe inflammation of the anterior chamber and vitreous (p<0.05). Overall, retinal lesions were more likely to be superotemporal (55%) and superonasal (31%). Furthermore, age was associated with larger (p=0.003) and more peripheral lesions (p=0.007). CONCLUSIONS: This study demonstrated significant differences in clinical characteristics of ocular toxoplasmosis according to serum IgM status. IgM+ patients were older, less likely to report pain, had lower levels of intraocular inflammation, but were more likely to have macular involvement. We also found age to be correlated with larger and more peripheral lesions.

Exploring the impacts of mindfulness and yoga upon childbirth outcomes and maternal health: an integrative review.

BACKGROUND: Foetal development and the long-term outcomes of the infant are influenced by the intrauterine environment. Strategies to enhance maternal health in pregnancy are needed to improve health outcomes for childbearing women and babies, advancing the well-being of our general population. AIM: To synthesise the existing literature to determine the impacts of mindfulness and yoga practice upon birth outcomes and maternal health. METHODS: An integrative literature review using Whittemore and Knafl's framework was undertaken in 2016-2017. Two search strategies included database peer-reviewed journal articles and ancestry searching, that is exploring the reference list of relevant research articles. After screening and checking the eligibility, a total of 12 articles were included in this review. Data analysis involved coding, visual displays, thematic analysis and comparison, and conclusion drawing. RESULTS: The results of this review identified a broad theme that mindfulness and yoga practice is associated with improved maternal mental health antenatally and postnatally. Subthemes have been presented under the central theme including the following: increased mindfulness correlates with decreased fear of childbirth; reduced symptoms of anxiety and depression; and supportive group settings found to be beneficial by pregnant women. CONCLUSION: The evidence presented in this review suggests that mindfulness and yoga practice are feasible and cost-effective interventions to enhance maternal mental health, particularly for women experiencing mental health challenges. Mindfulness and yoga practised regularly in the antenatal period can significantly promote the health of pregnant women and potentially their developing babies.

Safety profile and efficacy of tacrolimus in the treatment of birdshot retinochoroiditis: a retrospective case series review.

AIM: Evaluation of the use of tacrolimus in the treatment of birdshot retinochoroiditis (BRC) at a tertiary referral centre with the aim to describe its safety and efficacy. METHODS: The medical records of 25 patients diagnosed with BRC at uveitis service, Moorfields Eye Hospital, and who had received tacrolimus treatment were retrospectively reviewed. The main outcome measures of the study were (1) safety of tacrolimus in terms of side effects and (2) efficacy, as measured both by control of inflammation and visual function assessed by Humphrey visual fields and electrophysiological testing over at least 6 months and then 1 year. RESULTS: Tacrolimus was commenced in 25 patients (mean age 50.4±10.8 years) and was well tolerated in 21 patients (84%). It was necessary to stop the tacrolimus in four patients. No patient showed major changes in renal function: 3/21 patients (14.28%) showed slightly abnormal (less than 30%) function at the end of the first month of treatment; 1/21 (4.76%) patients at 3 months, but at the end of a 6-month treatment period only 1/21 patients (4.76%) showed minor abnormality in renal function. The mean daily prednisolone dose was 19.7 mg at the beginning of the study, which had fallen to 6.9 mg at the end (t=5.071, p=0.001). Visual acuity mostly remained stable. Visual fields improved over time (mean improvement in Humphrey mean deviation, right eye=1.8±2.4 dB, t=3.821, p=0.004; left eye=1.9±2.7, dB, t=3.06, p=0.007). Electrophysiological function showed improvement in 10 patients, and in four patients an initial deterioration in function improved following tacrolimus dose adjustment. CONCLUSION: Tacrolimus has a good safety profile for long-term use in patients with BRC as a second-line agent enabling steroid sparing and visual function stabilisation or improvement.

Missed Hospital Appointments of Patients Receiving Ranibizumab Therapy for Neovascular Age-Related Macular Degeneration.

INTRODUCTION: The aim of this study was to investigate the frequency and duration of missed hospital appointments (MHAs) in a consecutive cohort of patients treated with ranibizumab for neovascular age-related macular degeneration (nAMD) and to assess their impact on outcomes of therapy in a real-world clinical setting. METHODS: Retrospective, cross-sectional study of consecutive patients attending medical retina clinics for nAMD treatment with ranibizumab. RESULTS: Seventy-eight eyes of 78 patients met the inclusion criteria for data analysis. Mean age was 78 years with mean follow-up of 27 months. Mean visual acuity (VA) was 52 ± 16 letters at baseline, 56 ± 17 letters at year 1 and 58 ± 16 letters at year 2. At the end of the second year, 90% of the patients had lost <15 letters, 26% had gained ≥15 letters and 10% had lost ≥15 letters. Nineteen patients had at least one MHA (24%) over 2 years. There were 26 MHA episodes in total leading to a median duration of 79 days (range 35-159) between attended hospital visits. None of these MHAs occurred during the first 3 months after treatment initiation. Mean VA and central retinal thickness difference between 2 years and baseline for the MHA group was not statistically different compared with the non-MHA group. CONCLUSIONS: Our data suggest that MHA may be a relatively common occurrence in AMD treatment clinics, but good outcomes of treatment can be achieved over 2 years despite missed hospital visits if patients are reviewed on average six times in the first year after an initial loading phase of three injections and nine times in the second year of treatment.

Gaze changes with binocular versus monocular viewing in age-related macular degeneration.

PURPOSE: To determine and explain gaze changes during binocular versus monocular viewing in patients with age-related macular degeneration (AMD). DESIGN: Cross-sectional study. PARTICIPANTS: Twenty-nine patients with bilateral late-stage AMD. METHODS: Distance acuity and fundus pathologic features were evaluated. Eye position was recorded while viewing a circular fixation target under monocular and binocular viewing conditions using an infrared eye tracker (SMI Gazetracker, SensoMotoric, Germany; Eyelink Software 2.04). Gaze changes were quantified by calculating the mean x-coordinate and y-coordinate eye position of the center of the bivariate contour ellipse area for a 30-second fixation task under both viewing conditions. Retinal loci used for monocular fixation for each eye were determined using the scanning laser ophthalmoscope (SLO; SLO 101, Rodenstock, Munich, Germany). MAIN OUTCOME MEASURE: Gaze position. RESULTS: Nine patients showed no shift in gaze position from monocular to binocular viewing. Three patients demonstrated a shift in both eyes, and 17 patients demonstrated a shift in only 1 eye. The mean shift was 4.7+/-5 degrees (standard deviation). The shift in gaze position in the worse eye was predictive of the distance between the 2 monocular preferred retinal loci (PRLs; better and worse eye; r(2) = 0.59; P<0.0001), whereas there was no association between the shift in gaze position in the better eye and distance (r(2) = 0.00; P = 0.91). CONCLUSIONS: Most AMD patients shift gaze position in 1 or both eyes when viewing binocularly compared with monocularly. These changes suggest that different retinal locations are used for fixation under the 2 viewing conditions. The SLO data showed that these patients are likely to demonstrate monocular PRLs that fall on noncorresponding areas. These results may have implications for the effective development of eccentric viewing and binocular behavior of AMD patients.

Filtering blebs at the site of sutured posterior chamber intraocular lenses.

A 78-year-old man with a traumatic giant retinal tear and phacodonesis had 3-port pars plana vitrectomy (3PPPV), lensectomy, and sutured posterior chamber intraocular lens (IOL) implantation. Two years after surgery, a filtration bleb was noted at 1 of the suture sites. In another case, a 32-year-old man with lens subluxation secondary to Marfan's syndrome had 3PPPV, lensectomy, and sutured posterior chamber IOL implantation. Two months after surgery, a filtration bleb was noted at 1 of the suture sites. Sutured posterior chamber IOL implantation is 1 of the few instances in which there is virtually a full-thickness suture through the sclera. We presume the filtering bleb formed as a direct result of the permanent passage created from the posterior chamber to the subconjunctiva due to presence of the suture. Presence of a filtering bleb can lead to complications including endophthalmitis.