The effectiveness of the 0.19 mg fluocinolone acetonide implant in treating non-infectious posterior uveitis: a real-world experience.

BACKGROUND: The 0.19 mg fluocinolone acetonide (FAc) implant (ILUVIEN) has been approved for prevention of relapse in recurrent non-infectious uveitis affecting the posterior segment of the eye (NIU-PS). There is little data assessing the long-term efficacy and safety of the FAc implant in this indication. Therefore, we conducted a retrospective interventional case review of 18 eyes from 13 patients with NIU-PS treated with the FAc implant at three ophthalmology departments in the Middle East between 2018 and 2021. MAIN TEXT: Baseline patient characteristics, including best-corrected visual acuity (BCVA), central retinal thickness (CRT) and intraocular pressure (IOP), were collected at the time of FAc implant administration and at 1-3 months, 6 months and every six months thereafter. The mean time of follow-up was 29.7 ± 14.6 (mean ± SD) months. Over the follow-up, the BCVA significantly increased from month 1 (P = 0.002) until month 36 (P = 0.024) and remained improving throughout the follow-up period (P = 0.004). The CRT significantly decreased from month 1 (P = 0.008) until month 12 (P = 0.003) and was persistently lower during the follow-up period (P = 0.022). Significant improvements in anterior chamber cells (P = 0.004) and vitritis scores (P = 0.001) were observed by Month 6. Similarly, at Month 12, significant improvements were noted in both parameters as well (anterior chamber cells: P = 0.012; vitritis scores: P = 0.004). Mean IOP remained relatively stable throughout (P = 0.205) the follow-up. CONCLUSIONS: Our results suggest improvements and long-term maintenance in functional and anatomical outcomes with FAc implant with a manageable safety profile in a real-world clinical setting in patients with NIU-PS.

Management of Diabetic Macular Edema: Guidelines from the Emirates Society of Ophthalmology.

In the United Arab Emirates, retinopathy has been shown to be present in 19% of the diabetic population, with diabetes identified in up to 40% of individuals aged over 55 years. Despite the prevalence of diabetic retinal diseases, there are no unified national guidelines on the management of diabetic macular edema (DME). These published guidelines are based on evidence taken from the literature and published trials of therapies, and consensus opinion of a representative expert panel with an interest in this condition, convened by the Emirates Society of Ophthalmology. The aim is to provide evidence-based, clinical guidance for the best management of different aspects of DME, with a special focus on vision-threatening diabetic retinopathy. Treatment should be initiated in patients with best-corrected visual acuity 20/30 or worse, and/or features of DME as seen on optical coherence tomography (OCT) with central retinal thickness (CRT) of at least 300 µm or in symptomatic patients with vision better than 20/25, and/or CRT less than 300 µm where there are OCT features consistent with center-involving macular edema. The treatment of DME is effective irrespective of glycated hemoglobin (HbA1c) level, and treatment must not be denied or delayed in order to optimize systemic parameters. All ophthalmic treatment options should be discussed with the patient for better compliance and expectations. Non-center-involving DME can be initially observed until progression toward the center is documented. Macular laser no longer has a primary role in center-involving DME, and anti-vascular endothelial growth factor (anti-VEGF) therapy should be considered as first-line treatment for all patients, unless contraindicated. If anti-VEGF is contraindicated, a steroid dexamethasone implant can be considered for first-line treatment. Recommendations for the treatment of DME in special circumstances and in relapsing and refractory DME are also discussed.

Treatment patterns in patients with age-related macular degeneration and diabetic macular edema: A real-world claims analysis in Dubai.

OBJECTIVES: To characterize the pattern of approved anti-vascular endothelial growth factor (VEGF) treatments among patients with neovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME) in the United Arab Emirates (UAE). METHOD: This was a retrospective, nonrandomized, observational cohort analysis of the Dubai Real-world Claims Database with a 360-day follow-up period. Adult patients diagnosed with nAMD or DME treated with ranibizumab or aflibercept for the first time were included. The primary objective was to evaluate anti-VEGF treatment patterns with respect to the proportion of patients receiving ranibizumab and aflibercept for nAMD and DME separately. RESULTS: Of the 451 patients included in the final study cohort, 83.6% and 16.4% had a diagnosis of DME (ranibizumab: 48.5%; aflibercept: 51.5%) and nAMD (ranibizumab: 40.5%; aflibercept: 59.5%), respectively, at baseline. Treatment frequency of ranibizumab/aflibercept was similar for nAMD (mean: 2.4/2.9 injections; p = 0.2389) with fewer injections in the ranibizumab cohort for DME (mean: 1.9/2.5 injections; p = 0.0002). Most patients received ≤3 anti-VEGF injections during the 360-day follow-up period. The time between consecutive treatments was large (nAMD: 73.6 days/10.5 weeks; DME: 80.5 days/11.5 weeks). Approximately 10%-13.5% of patients switched their anti-VEGF therapy. Most patients (83.8%) had a diabetes diagnosis during the follow-up period. CONCLUSIONS: This real-world study provides an initial understanding of anti-VEGF treatment patterns in patients with nAMD and DME in the UAE. Treatment frequency of the 2 anti-VEGF agents assessed was similar in both patient populations. Both treatments were infrequently administered with large dosing intervals.

The Collaborative Ocular Tuberculosis Study (COTS) Consensus (CON) Group Meeting Proceedings.

An international, expert led consensus initiative was set up by the Collaborative Ocular Tuberculosis Study (COTS) group to develop systematic, evidence, and experience-based recommendations for the treatment of ocular TB using a modified Delphi technique process. In the first round of Delphi, the group identified clinical scenarios pertinent to ocular TB based on five clinical phenotypes (anterior uveitis, intermediate uveitis, choroiditis, retinal vasculitis, and panuveitis). Using an interactive online questionnaires, guided by background knowledge from published literature, 486 consensus statements for initiating ATT were generated and deliberated amongst 81 global uveitis experts. The median score of five was considered reaching consensus for initiating ATT. The median score of four was tabled for deliberation through Delphi round 2 in a face-to-face meeting. This report describes the methodology adopted and followed through the consensus process, which help elucidate the guidelines for initiating ATT in patients with choroidal TB.

Standardization of Nomenclature for Ocular Tuberculosis - Results of Collaborative Ocular Tuberculosis Study (COTS) Workshop.

Purpose: To standardize a nomenclature system for defining clinical phenotypes, and outcome measures for reporting clinical and research data in patients with ocular tuberculosis (OTB).Methods: Uveitis experts initially administered and further deliberated the survey in an open meeting to determine and propose the preferred nomenclature for terms related to the OTB, terms describing the clinical phenotypes and treatment and reporting outcomes.Results: The group of experts reached a consensus on terming uveitis attributable to tuberculosis (TB) as tubercular uveitis. The working group introduced a SUN-compatible nomenclature that also defines disease "remission" and "cure", both of which are relevant for reporting treatment outcomes.Conclusion: A consensus nomenclature system has been adopted by a large group of international uveitis experts for OTB. The working group recommends the use of standardized nomenclature to prevent ambiguity in communication and to achieve the goal of spreading awareness of this blinding uveitis entity.

Ultra-wide-Field Fundus Autofluorescence for the Detection of Inherited Retinal Disease in Difficult-to-Examine Children.

PURPOSE: To assess the sensitivity of ultra-wide-field fundus autofluorescence (UWF-FAF) in comparison to fundus photography and clinical examination in diagnosing inherited retinal diseases in difficult-to-examine children. METHODS: In this single-center, non-invasive observational study, children with suspected inherited retinal disease were examined clinically and then underwent UWF imaging (color fundus imaging and fundus autofluorescence) using the Optos Tx-200 imaging system (Optos, Dunfermline, United Kingdom). Patient ages ranged from 1 to 13 years (mean: 5.6 years). RESULTS: The study included 112 eyes of 59 patients. Image acquisition was successful even in small children. UWF-FAF was the most sensitive in detecting the disease (94.9%), followed by UWF-CF (67.7%) and clinical examination (49.1%). CONCLUSIONS: UWF-FAF is superior to fundus photography and clinical examination in detecting pathology in children with suspected inherited retinal diseases. It is a feasible, non-invasive, and quick tool that provides important clinical information in treating these patients. [J Pediatr Ophthalmol Strabismus. 2019;56(6):383-387.].

Treatment of Retinitis Pigmentosa-Associated Cystoid Macular Oedema Using Intravitreal Aflibercept (Eylea) despite Minimal Response to Ranibizumab (Lucentis): A Case Report.

BACKGROUND: We present an interesting case of bilateral retinitis pigmentosa (RP)-associated cystoid macular oedema that responded on two separate occasions to intravitreal injections of aflibercept, despite previously demonstrating only minimal response to intravitreal ranibizumab. This unique case would support a trial of intravitreal aflibercept for the treatment of RP-associated cystoid macular oedema. CASE PRESENTATION: A 38-year-old man from Dubai, United Arab Emirates, presented to the UK with a 3-year history of bilateral RP-associated cystoid macular oedema. Previous treatment with topical dorzolamide, oral acetazolamide, and intravitreal ranibizumab had demonstrated only minimal reduction of cystoid macular oedema. Following re-confirmation of the diagnosis by clinical examination and optical coherence tomography imaging, bilateral loading doses of intravitreal aflibercept were given. Central macular thickness reduced and the patient returned to Dubai. After 6 months, the patient was treated with intravitreal ranibizumab due to re-accumulation of fluid and the unavailability of aflibercept in Dubai. Only minimal reduction of central macular thickness was observed. Once available in Dubai, intravitreal aflibercept was administered bilaterally with further reduction of central macular thickness observed. Visual acuity remained stable throughout. CONCLUSIONS: This is the first case report to demonstrate a reduction of RP-associated CMO following intravitreal aflibercept, despite inadequate response to ranibizumab on two separate occasions. Aflibercept may provide superior action to other anti-VEGF medications due to its intermediate size (115 kDa) and higher binding affinity. This is worthy of further investigation in a large prospective cohort over an extended time to determine the safety and efficacy of intravitreal aflibercept for use in this condition.

Refractory necrotizing scleritis successfully treated with adalimumab.

Necrotizing scleritis is the most severe and destructive form of scleritis with vision-threatening sequelae. It is divided into with inflammation and without inflammation (scleromalacia perforans). Adalimumab is a tumour necrosis factor (TNF)-inhibiting anti-inflammatory medication licensed for the treatment of rheumatoid and psoriatic arthritis, ankylosing spondylitis and inflammatory bowel disease (in the USA). We report two cases of necrotizing scleritis successfully treated with adalimumab.

The clinical utility of new combination phenylephrine/ketorolac injection in cataract surgery.

The maintenance of mydriasis throughout cataract extraction surgery and the control of ocular inflammation are crucial for successful surgical outcomes. The development of miosis during cataract surgery compromises the visualization of the surgical field and working space for surgeons. This may lead to complications that include posterior capsular tear and associated vitreous loss, longer surgical time, and postoperative inflammation. Postoperative inflammation is often uncomfortable and frustrating for patients. It causes pain, redness, and photophobia. This compromises the best-uncorrected vision following surgery and often leads to multiple clinic visits. This article examines the literature published on the current treatments used to manage mydriasis, pain, and inflammation in cataract extraction surgery. Combination phenylephrine/ketorolac injection offers an exciting new class of medication for use in cataract surgery. With the recent approval of Omidria™ (combination of phenylephrine 1% and ketorolac 0.3%) by the US Food and Drug Administration (FDA) for intraocular use, we review the clinical utility of this new combination injection in cataract surgery. PubMed, MEDLINE, and conference proceedings were searched for the relevant literature using a combination of the following search terms: cataract extraction surgery, pupil dilation (mydriasis), miosis, phenylephrine, ketorolac, Omidria™, intracameral mydriatic. Relevant articles were reviewed and their references checked for further relevant literature. All abstracts were reviewed and full texts retrieved where available.

Syphilitic uveitis and optic neuritis in Sydney, Australia.

AIMS: To describe ocular syphilis presentations to a tertiary referral eye hospital over a 5-year period and to document HIV coinfection frequency. METHODS: A retrospective chart review was conducted of consecutive ocular syphilis presentations to Sydney Eye Hospital from 2007 to 2012. Inclusion criteria were positive syphilis serology, ocular inflammation on clinical examination and appropriate syphilis treatment. Outcome measures were clinical features at presentation and best-corrected visual acuity (BCVA) at interval follow-up. RESULTS: Thirty-seven eyes of 25 patients were included in the series. Patients were predominantly male (92.0%, p<0.05) with mean age 43.7±14.0 years. Eight (32.0%) patients had confirmed HIV coinfection, three newly diagnosed with HIV. Twelve (32.4%) eyes demonstrated anterior segment involvement with anterior uveitis. Twenty-five (67.6%) eyes demonstrated posterior segment involvement, including panuveitis, acute syphilitic posterior placoid chorioretinitis, retinitis, necrotising retinitis, punctate retinitis and optic neuritis. There was a significant improvement in BCVA for involved eyes (p<0.05) at 1 month and 2-3 months follow-up. CONCLUSIONS: The clinical findings of 37 eyes with ocular syphilis demonstrated a broad spectrum of clinical manifestations. Rates of HIV coinfection were high, with patients exhibiting both anterior and posterior segment inflammation. Visual outcome improved following syphilis treatment.

Flashes, floaters and fuzz.

Flashing lights (photopsia) and floaters are common visual phenomena and patients frequently present to hospital with these symptoms. This article provides a guide for the non-specialist to the different pathologies that may result in photopsia and floaters.

Ocular complications associated with systemic medications used in allergy/immunology practice.

The repertoire of treatment options available to allergists and immunologists is ever increasing and with this comes the increased potential for these treatments to cause adverse ocular side effects. Corticosteroids remain the first line of treatment for most immunological disorders and physicians should be alerted to their extensive ocular morbidity profile. Patients requiring longer-term therapy may often receive immune modulators or newer biologic agents. While effective, these medications may have additional ocular side effects; as newer agents are more frequently used, some of these may not be previously documented. A number of patients will seek alternative or herbal remedies for these long-term conditions, often unknown to the treating physician; these too can cause harmful ocular morbidity. We review the latest information about the potential ocular side effects that may be encountered in treating patients with medications used in allergic and immunological disorders.

New agents for treating dry eye syndrome.

Dry eye syndrome (DES) is characterized by an inadequate volume and/or quality of tears resulting in chronic ocular surface irritation and inflammation. Affecting up to 30 % of adults, DES has a considerable impact on visual function and quality of life. DES may complicate allergic ocular disease and allergy medication may exacerbate DES. The pathophysiology of DES involves osmotic, mechanical and inflammatory insults to the tear film, epithelium and subepithelial nerve plexus. Various immune-related molecular targets have been the focus of research aimed at developing new therapeutic agents for treating DES. This article provides an overview of established, new and future agents for treating DES.

Ocular myositis.

Ocular myositis frequently manifests with orbital pain and diplopia. The diagnosis of ocular myositis falls within the overall classification of idiopathic orbital inflammatory diseases, defined as non-infective non-specific orbital inflammation without identifiable local or systemic causes. Orbital myositis may form part of more widespread systemic inflammatory processes such as Crohn's disease and the more recently described IgG4-related disease. There is also a broad range of ophthalmic differential diagnoses. Diagnosis, assessment and management of ocular myositis requires the cooperation of ophthalmologists and rheumatologists/immunologists in order to achieve the best patient outcomes. The current literature and avenues of future research are reviewed.

Topical prostaglandin analogues and conjunctival inflammation in uveitic glaucoma.

PURPOSE: A pilot study to determine whether topical prostaglandin analogues alter the expression of conjunctival inflammatory markers in patients with uveitic glaucoma. METHODS: Prospective, single-masked case series of 20 patients with uveitis and secondary raised intraocular pressure. Participants were divided into four groups of five patients dependent on their use of topical medication: (1) prostaglandin analogues only, (2) corticosteroids only, (3) both prostaglandin analogues and corticosteroids, (4) no topical medication. Conjunctival cells were harvested by impression cytology and were examined for inflammatory markers (CD3, CD54, HLA-DR, CCR4, CCR5) by flow cytometry. A tear fluid sample was also examined for inflammatory cytokines (IL-12p70, IL-2, IL-10, IL-8, IL-6, IL-4, IL-5, IFN-gamma, IL-1beta, IFN-alpha, IFN-beta) by multiplex bead arrays. RESULTS: All groups demonstrated increased markers of conjunctival inflammation. There was no significant difference in levels of any inflammatory markers between the four groups, suggesting that the use of topical prostaglandin analogues does not increase conjunctival levels of inflammation beyond those already seen in uveitis. CONCLUSIONS: The use of topical prostaglandins does not appear to induce conjunctival inflammation over that which is already present in patients with uveitic glaucoma. This supports the use of topical prostaglandin analogues in patients with uveitic glaucoma, indicating that their use is unlikely to adversely affect subsequent glaucoma filtration surgery through the induction of chronic conjunctival inflammation.

Antibiotic resistance in microbial keratitis: ten-year experience of corneal scrapes in the United Kingdom.

PURPOSE: To determine the scale of antibiotic resistance in microbial keratitis in East Kent, United Kingdom. DESIGN: Retrospective, observational case series. PARTICIPANTS: Corneal scrapes over a 10-year period to December 2008 were identified using the local microbiology database, which provided culture results and antibiotic sensitivity-resistance profiles. TESTING: Isolate sensitivity to chloramphenicol, cefuroxime, gentamicin, and ciprofloxacin was determined by microdilution using the Microscan System (Siemens Diagnostics, Dearfield, IL). MAIN OUTCOME MEASURES: Isolates were graded as sensitive, intermediate, or resistant to the tested antibiotics, with minimal inhibitory concentrations interpreted against breakpoints from the Clinical and Laboratory Standards Institute. RESULTS: There were 476 scrapes from 440 patients (female, 57.6%; mean age, 53.5 years). All samples were cultured. Culture was positive in 163 samples (34.2%), growing 172 organisms. Bacterial keratitis accounted for 162 isolates (94.2%), of which 99 (61.1%) were gram-negative. There was a general increase in the number of gram-negative isolates with time (P=0.003). In vitro testing showed widespread gram-negative resistance to chloramphenicol (74.1%), with reducing sensitivity over the study period (P=0.004). There was 97.3% sensitivity to combination gentamicin and cefuroxime, and 94.4% sensitivity to ciprofloxacin. Ciprofloxacin resistance was found in 8 (17.0%) of 47 gram-positive isolates tested, with no trend toward increasing resistance. CONCLUSIONS: This study has documented the highest levels of gram-negative keratitis in any open retrospective survey to date and highlights a trend of increasing gram-negative infection. We have demonstrated reducing chloramphenicol sensitivity, with high sensitivity to combination gentamicin and cefuroxime, as well as ciprofloxacin. Gram-positive fluoroquinolone resistance was higher than previously reported in the United Kingdom, but showed no evidence of increasing resistance. Second-generation fluoroquinolone monotherapy remains the recommended empirical treatment in microbial keratitis in the United Kingdom, and a change to fourth-generation compounds is not advised. Continued testing is essential to monitor for increasing resistance. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Treatment of acute postoperative endophthalmitis without hospital admission: do we dare?

INTRODUCTION: We report the successful management of a culture positive case of APE, without the need for hospital admission and discuss the merits of this strategy. CASE: A 79-year-old lady underwent uncomplicated cataract surgery in her left eye using phacoemulsification under topical and intracameral anaesthesia. She reported to eye casualty four days later, with pain and vision reduced to 6/60 in the left eye. A diagnosis of acute postoperative endophthalmitis was made. A vitreous biopsy was performed and antibiotics injected intravitreally on the same day. The patient was discharged on oral and topical antibiotics on the same day and reviewed subsequently in the clinic as an outpatient. Vision steadily improved and at one month following intravitreal injection her vision had improved to 6/9 unaided. The cornea remained clear, with a quiet anterior chamber and a clear view of the fundus. DISCUSSION: Current management of acute postoperative endophthalmitis in the UK includes a vitreous biopsy, administration of antibiotics into the vitreous cavity, admission of patients to a hospital ward and daily review. It is our opinion that under the circumstances where patients are fit and well, without significant co-morbidity, hospital admission is not necessary as demonstrated by the patient in our report.