Pyogenic granuloma after cosmetic eye whitening. / Granuloma piogénico tras blanqueamiento ocular cosmético.

CLINICAL CASE: A 46-year-old caucasian male with a history of chronic conjunctival hyperemia, presented at our clinic 5 years after he underwent the surgical procedure of cosmetic eye whitening. On examination we observed pyogenic granuloma in the right eye; besides acute nongranulomatous anterior uveitis and necrotizing scleritis in both eyes. RESULT: Complete clinical evaluation and full work-up exclusion of systemic diseases was done. The pyogenic granuloma was treated with surgical resection, as well as anterior uveitis and necrotizing scleritis were successfully treated with systemic corticoesteroids and methotrexate. CONCLUSION: The surgical cosmetic eye whitening could have as complication the pyogenic granuloma in addition to necrotizing scleritis and nongranulomatous anterior uveitis; and be present 5 years after the procedure. The surgical resection is a successful treatment for this presentation of pyogenic granuloma.

Dexamethasone intravitreal implant: an effective adjunctive treatment for recalcitrant noninfectious uveitis.

PURPOSE: To describe our experience in treating recalcitrant and severe cases of noninfectious posterior uveitis with the 0.7-mg dexamethasone intravitreal implant as adjunctive anti-inflammatory treatment. PROCEDURES: Retrospective study. Twelve patients (8 females; 4 males; 14 affected eyes, 15 implants) with severe recalcitrant uveitis were treated. Patients had an inadequate control of uveitis despite different immunosuppressants and periocular corticosteroid therapy. Primary outcome measures evaluated were: decrease in uveitis activity, improvement in visual acuity, reduction of macular thickness, and occurrence of adverse events. RESULTS: Uveitis activity decreased in all patients after the implant. The mean follow-up time from injection was 9 months. Best-corrected visual acuity improved from 20/80 to 20/40 at the end of follow-up. The mean retinal thickness improved from 496 to 226 µm. Adverse events encountered were: 3 eyes with intraocular pressure elevation, 1 vitreous hemorrhage and 1 subconjunctival hemorrhage. Three patients reduced the daily systemic corticosteroid dosage after treatment. CONCLUSIONS: The 0.7-mg dexamethasone intravitreal implant appears to be a novel and promising adjunctive treatment for patients with severe posterior noninfectious uveitis recalcitrant to different immunosuppressive agents.

Anti-CD 20 monoclonal antibody (rituximab) treatment for inflammatory ocular diseases.

Rituximab is a monoclonal antibody directed against the CD20 antigen expressed on B cells and widely used in the treatment of non-Hodgkin's lymphoma and rheumatoid arthritis. There is a growing amount of literature which suggests that rituximab may be useful for inflammatory ocular diseases and intraocular lymphoma. Few cases have been reported on treatment of refractory scleritis, peripherative ulcerative keratitis, uveitis and ocular surface inflammatory disorders. Rituximab may be effective in the treatment of ocular inflammatory diseases in particular the most aggressive, recalcitrant and sight-threatening forms of inflammation such as uveitis associated to juvenile idiopathic arthritis. We review the literature covering the use of Rituximab in these conditions and report our results on the efficacy of Rituximab in the treatment of 8 children with very severe and long-standing uveitis who failed to respond to one or more TNF blockers. Our patients showed improvement in activity of uveitis, reduction of concomitant corticosteroids and immunosuppressants after a mean follow-up time of 14.87 months on rituximab. No serious adverse events were encountered in our treated patients. Although further studies are needed for assessing the efficacy of rituximab and the exact dosing regimen, rituximab may be considered as a treatment alternative in patients with the most aggressive forms of inflammatory ocular diseases who fail to respond to conventional and anti-TNF immunosuppressive agents.

Gamma knife radiosurgery for uveal melanoma: 12 years of experience.

AIM: To present our treatment protocol and evaluate the results of Gamma knife radiosurgery (GKR) in treating patients with uveal melanoma. METHODS: Seventy-eight consecutive patients with uveal melanoma underwent stereotactic radiosurgery (radiation dose 30-50 Gy) with a Leksell Gamma-Knife at the San Raffaele University Hospital, Milan, Italy between 1994 and 2006. The main outcome measures evaluated were: survival rate, local tumour control, eye retention rate, visual acuity and treatment-related complications. RESULTS: Survival rate was 88.8% at 3 years and 81.9% at 5 years. Local tumour control was achieved in 91.0% of patients. The median tumour thickness reduction after treatment was 1.96 mm (p<0.0001) (-32.1%). The eye retention rate was 89.7%. A significant relative reduction of visual acuity was observed during follow-up. The most frequent treatment-related complications were: exudative retinopathy (33.3%), neovascular glaucoma (18.7%), radiogenic retinopathy (13.5%) and vitreous haemorrhages (10.4%). CONCLUSION: GKR can be considered an alternative to enucleation for the treatment of choroidal melanomas.

Effective treatment with topical cyclosporine of a child with steroid-dependent interstitial keratitis.

PURPOSE: To report a case of steroid-dependent idiopathic interstitial keratitis in a child successfullytreated with topical cyclosporine 2% drops. METHODS: Case report. RESULTS: The authors describe a case of a 6-year-old boy with a history of recurrent idiopathic bilateral interstitial keratitis. The patient had recurrent episodes of corneal inflammation that became more frequent and severe during the follow-up, and caused severe corneal opacities and visual loss. Long-term treatment with topical corticosteroid was required to avoid corneal scarring that eventually caused secondary elevation of intraocular pressure. Topical cyclosporine 2% was therefore introduced as a steroid sparing agent totreat the keratitis. The treatment was continued for 1 year and the patient achieved a complete remission of corneal inflammation with resolution of corneal scarring and normalization of intraocular pressure. CONCLUSIONS: In this child with recurrent episodes of interstitial keratitis, topical cyclosporine 2% has been shown to be a safe and effective alternative for treating corneal inflammation.

Immune recovery uveitis and human leukocyte antigen typing: a report on four patients.

PURPOSE: To report the typing of human leukocyte antigen (HLA) in four human immunodeficiency virus-positive (HIV) patients with immune recovery uveitis (IRU). METHODS: The medical history of four consecutive patients who presented at the Ocular Immunology and Uveitis Service (University Hospital San Raffaele, Milan, Italy) with definite diagnosis of IRU is reported. The HLA typing was tested in all patients. RESULTS: All patients presented the clinical and ophthalmological characteristics of IRU. The HLA typing analysis showed the presence of HLA B 8-18 in all patients. CONCLUSIONS: The data obtained from these patients indicate the presence of the same HLA typing (B 8-18). The clinical relevance of such association needs to be further evaluated.

Immune recovery uveitis in an iatrogenically immunosuppressed patient.

PURPOSE: To report a case of immune recovery uveitis (IRU) in an iatrogenically immunosuppressed human immunodeficiency virus (HIV)-negative patient. METHODS: Interventional case report. One patient was diagnosed with cytomegalovirus retinitis in the left eye while receiving immunosuppressive treatment following renal transplantation. The retinitis resolved completely with systemic ganciclovir. Further reduction of immunosuppressive treatment, causing a rapid increase in CD4-T lymphocyte count, was associated in the same eye with the occurrence of IRU consisting of anterior uveitis, vitritis, and macular edema. RESULTS: Visual acuity at IRU presentation onset was 20/200 in the left eye. After 6 weeks of follow-up, the uveitis resolved with topical and periocular steroid treatment. Visual acuity restored to 20/40. CONCLUSIONS: IRU can occur in iatrogenically immunosuppressed HIV-negative patients.

Herpes simplex virus type 2 acute retinal necrosis in an immunocompetent patient.

PURPOSE: To report a case of acute retinal necrosis caused by herpes simplex virus 2 in an otherwise healthy patient. CASE REPORT: A 45-year-old man presented with one month's history of decreased vision in the right eye. He had previously received a course of intravenous gancyclovir because of a clinical suspicion of cytomegalovirus retinitis. The patient's ocular history was remarkable for a similar episode in the left eye thirty years earlier, resulting in important visual impairment. System and laboratory investigations were unremarkable. Ocular examination showed severe anterior granulomatous uveitis, vitreous haze, areas of necrosis and retinal exudates. The anterior chamber tap disclosed the presence of HSV type 2, and oral steroids and acyclovir were instituted. Two weeks after the patient had been discharged, a retinal detachment occurred in the right eye, necessitating surgical repair. The presence of HSV type 2 was confirmed in the vitreous. Visual acuity recovered completely after surgery and the patient was placed on a maintenance dose of oral acyclovir. CONCLUSIONS: HSV type 2 is a rare cause of acute retinal necrosis in healthy patients. Bilateral involvement can occur in the fellow eye, even with a long delay. Acute retinal necrosis is a severe ocular inflammatory syndrome associated with a very poor visual outcome. It is caused by VZV, HSV type 1 and, less commonly, by HSV type 2. The disease can affect healthy patients and cause bilateral involvement in the fellow eye, even with a long delay.

Chronic cicatrizing conjunctivitis in a patient with ocular cicatricial pemphigoid and fatal Wegener granulomatosis.

PURPOSE: To describe a case of chronic cicatrizing conjunctivitis in a patient with ocular cicatricial pemphigoid and Wegener granulomatosis. METHODS: Observational case report. A retrospective study. RESULTS: An 80-year-old man presented with chronic cicatrizing conjunctivitis, peripheral corneal thinning, and Wegener granulomatosis, which were diagnosed by his referring physician based on clinical (recurrent epistaxis, sinus congestion) and histopathologic features of nasal mucosa (granulomatous inflammation, vasculitis). A conjunctival biopsy performed by us disclosed features of active Wegener granulomatosis and ocular cicatricial pemphigoid, which indicate lack of control of both diseases with methotrexate treatment. The patient died of pulmonary complications from Wegener granulomatosis 1 week after our evaluation. CONCLUSION: Ocular cicatricial pemphigoid and Wegener granulomatosis are both potentially fatal autoimmune diseases. Ocular involvement in Wegener granulomatosis indicates poor control of the underlying systemic condition and is a marker for active vasculitis, which indicates the need for treatment with cyclophosphamide.

A case of atypical Cogan's syndrome with uncommon corneal findings.

PURPOSE: We report a case of atypical bilateral interstitial keratitis associated with Cogan's syndrome. METHODS: A 28-year-old man presented with a 2-year history of recurrent bilateral keratitis. Bilateral hearing loss preceded the ocular symptoms by 2 years. The patient also complained of skin nodules, headache, back pain, and arthritis. Corneal finding were consistent with superior stromal keratitis with stromal neovascularization and lipid deposition in the stroma. The patient's audiogram revealed cochlear pathology compatible with Cogan's syndrome (sensorineural deafness). RESULTS: The patient was treated with topical steroids but eventually required corneal transplantation in the right eye as a consequence of progressive loss of vision secondary to progressive lipid keratopathy. Visual acuity at the patient's most recent follow-up evaluation was 20/40. CONCLUSION: This case represents an unusual type of interstitial keratitis associated with Cogan's disease. The absence of ocular symptoms at the time of initial ear involvement and the atypical presentation of the keratitis were responsible for the delay in diagnosis in this patient, resulting in hearing impairment.

Ocular features associated with anticardiolipin antibodies: a descriptive study.

PURPOSE: To evaluate ocular features in patients presenting with inflammation in the presence of anticardiolipin antibodies. METHODS: A descriptive study of 13 patients presenting with idiopathic ocular inflammation involving anterior and posterior segment was performed. Patients were followed for a mean follow-up of 22 months (range, 1 to 125). A comprehensive report of ocular involvement, including visual symptoms, visual acuity, clinical characteristics, funduscopic and fluorangiographic features, was reported. Systemic associated symptoms were analyzed. Laboratory investigations included anticardiolipin antibody titers and isotypes, presence of other autoantibodies, and markers of immune system activation. RESULTS: The most common ocular symptom at presentation was blurred vision (eight patients) followed by redness and pain(three patients) and visual loss(two patients). Anterior segment abnormalities, including iritis (eight patients) scleritis (two patients) and filamentary keratitis (one patient), were present in 76% of patients, whereas the most represented feature of posterior involvement was retinal vasculitis (60%) followed by vitritis (38%), retinal detachment (15%), posterior scleritis (7%), and central retinal artery occlusion (7%). All patients had abnormal titers of anticardiolipin antibodies, predominantly IgG isotype; six had markers of immune system activation. CONCLUSIONS: Although posterior pole disease is more commonly associated with anticardiolipin antibodies, the anterior segment can also be involved with a wide spectrum of features. Scleritis has never been previously described as associated with anticardiolipin antibodies. Systemic symptoms are frequently present in association with ocular disease.