Plasmapheresis as a viable treatment option for scleritis.

Purpose: We describe a case and our experience with using plasmapheresis as a treatment for scleritis. Observations: Treating relapsing autoimmune scleritis can be challenging when it inadequately responds to traditional therapy. Our patient could not receive non-steroidal anti-inflammatory therapy for her scleritis due to recent gastrointestinal surgery and previously failed multiple steroid sparing treatments due to intolerance. There was good initial control with high dose oral prednisone, however, the steroid could not be tapered to a safe dosage (<10 mg per day) without relapse. Therefore, we opted to treat our patient with plasmapheresis. Conclusions and Importance: After undergoing plasmapheresis, our patient experienced total resolution of symptoms with corresponding clinical resolution of scleritis. Plasmapheresis derives great benefit by filtering circulating immune complexes. Although rarely used, plasmapheresis can be effective in treating non-infectious scleritis.

Endophthalmitis after pars plana vitrectomy with reused single-use devices: a 13-year retrospective study.

BACKGROUND: To describe the incidence, clinical characteristics, and treatment outcomes of endophthalmitis after pars plana vitrectomy (PPV) with recycled single-use devices. The recommended sterilization process as well as safety measures are discussed. METHODS: Medical charts of patients who developed endophthalmitis after PPV were retrospectively reviewed and reported in a descriptive manner. Cases undergoing PPV for preexisting endophthalmitis or open globe injury were excluded. Data collection included patient demographics, operative details, ocular findings, microbiological profiles, treatment modalities, and visual outcomes. RESULTS: Over the past thirteen years, a total of 12,989 pars plana vitrectomy operations were included. In total, 13 eyes of 13 cases (0.10%) experienced endophthalmitis after vitrectomy. These occurred in 3 cases (0.11%) using 20-gauge vitrectomy compared to 8 cases (0.09%) using 23-gauge vitrectomy and 2 cases (0.18%) using 25-gauge vitrectomy. There were no statistically significant differences between the 20-gauge and microincisional vitrectomy surgery (MIVS) group (P = 0.64), and the 23- and 25-gauge approach (P = 0.34). Causative pathogens were positive by culture in 5 cases (45%): 3 g-positive cases, 1 g-negative case, and 1 fungus case. CONCLUSIONS: The rate of endophthalmitis in patients who underwent 23-gauge PPV was comparable to those who underwent 25-gauge PPV. With our standardized protocol for instrument sterilization, endophthalmitis rates in those undergoing PPV using recycled single-use instruments were within the range of previously published results in which vitrectomy tools were disposed of after one use.

Risk factors for endophthalmitis after cataract surgery in diabetic patients: a case control study.

AIM: To identify risk factors associated with post-cataract surgery endophthalmitis (PCE) in type 2 diabetic patients. METHODS: A hospital-based retrospective case-control study was conducted on 194 type 2 diabetic patients undergoing cataract surgery in Rajavithi Hospital from January 2007 to December 2015. Fifteen patients with PCE were included as the case group and 179 patients without PCE were included as the control group. Potential factors associated with PCE among both groups including demographics, pre-operative characteristics, surgical settings and complications, were statistically analyzed using Chi-square testing and a logistic regression model. RESULTS: Within the case group, 53% were females and the median age was 68y. Univariate analysis of pre-operative characteristics, surgical settings and complications revealed that recent pre-operative fasting plasma glucose, insulin therapy, presence of diabetic retinopathy, and severe non-proliferative or proliferative diabetic retinopathy were significantly associated with PCE. In a multivariate analysis adjusting for blood glucose level, insulin treatment was the only significant factor associated with an increased risk of PCE (OR 3.9, 95%CI 1.0-15.0, P=0.04) compared to patients without insulin treatment. The most common causative organisms were gram-positive bacteria (89%). Staphylococcus species represented the most common group (67%). Median best corrected visual acuity at 1-month and 3-month follow-up was equal at 0.7 logMAR (20/100). CONCLUSION: The authors identify insulin treatment as the only risk factor associated with endophthalmitis after cataract surgery in type 2 diabetic patients. Further studies with serum levels of pre-operative glycated hemoglobin (HbA1c) and post-operative fasting plasma glucose level are essential to truly demonstrate the role of peri-operative glycemic markers as a risk factor for PCE.

Vogt-Koyanagi-Harada syndrome: Perspectives for immunogenetics, multimodal imaging, and therapeutic options.

Vogt-Koyanagi-Harada syndrome (VKH) is a bilateral, diffuse granulomatous uveitis associated with neurological, audiovestibular, and dermatological systems. The primary pathogenesis is T-cell-mediated autoimmune response directed towards melanocyte or melanocyte-associated antigens causing inflammation of the choroidal layer. This phenomenon usually leads to diffuse inflammatory conditions throughout most parts of eye before ocular complications ensue. The diagnosis is achieved mainly by clinical features according to the revised diagnostic criteria of VKH published in 2001, without confirmatory serologic tests as a requirement. However, ancillary tests, especially multimodal imaging, can reliably provide supportive evidence for the diagnosis of early cases, atypical presentations, and evaluation of management. Prompt treatment with systemic corticosteroids and early non-steroidal immunosuppressive drug therapy can lessen visually threatening ocular complications and bring about good visual recovery. Close monitoring warrants visual stabilization from disease recurrence and ocular complications. This article review aims not only to update comprehensive knowledge regarding VKH but also to emphasize three major perspectives of VKH: immunogenetics as the major pathogenesis of the disease, multimodal imaging, and therapeutic options. The role of anti-vascular endothelial growth factor therapy and drug-induced VKH is also provided.

Outcome of tocilizumab treatment in refractory ocular inflammatory diseases.

PURPOSE: To report the outcomes of tocilizumab treatment for refractory ocular inflammatory diseases. METHODS: A retrospective case series of 17 patients (28 eyes) diagnosed with recalcitrant ocular inflammatory diseases including uveitis (10 cases), scleritis (six cases) and orbital pseudotumour (one case), who received tocilizumab between April 2010 and March 2015. All patients were initiated with treatment of 4 mg/kg or 8 mg/kg tocilizumab. The primary outcome was absence of inflammation and achievement of steroid sparing at 6 and 9 months. Secondary outcomes were change in visual acuity and major adverse effects of tocilizumab causing discontinuation of the treatment. RESULTS: Mean age at initiation of tocilizumab was 41 ± 16 years. Prior to tocilizumab treatment, all patients underwent unsuccessful conventional immunosuppressive therapy while 94% of patients (16/17) failed treatment with various biological agents. After tocilizumab administration, control of inflammation and steroid sparing were achieved in 63% and 71% of uveitis patients at 6 and 9 months, while 50% of scleritis patients achieved the primary outcome at 6 and 9 months. Mean duration of tocilizumab therapy was 12.6 ± 10.0 (range, 2-35) months. Three of four patients who had a follow-up of at least 18 (range, 18-35) months experienced quiescent inflammation for up to 32 months of tocilizumab use until last visit. Four patients (24%) discontinued tocilizumab due to serious side effects including neutropenia, unacceptable dizziness and nausea, severe angioedema and severe abdominal pain. CONCLUSION: Our series demonstrated moderate efficacy of tocilizumab in recalcitrant uveitis and scleritis. Serious adverse effects were not uncommon.

Rapid isolation and purification of mitochondria for transplantation by tissue dissociation and differential filtration.

Previously described mitochondrial isolation methods using differential centrifugation and/or Ficoll gradient centrifugation require 60 to 100 min to complete. We describe a method for the rapid isolation of mitochondria from mammalian biopsies using a commercial tissue dissociator and differential filtration. In this protocol, manual homogenization is replaced with the tissue dissociator's standardized homogenization cycle. This allows for uniform and consistent homogenization of tissue that is not easily achieved with manual homogenization. Following tissue dissociation, the homogenate is filtered through nylon mesh filters, which eliminate repetitive centrifugation steps. As a result, mitochondrial isolation can be performed in less than 30 min. This isolation protocol yields approximately 2 x 10(10) viable and respiration competent mitochondria from 0.18 ± 0.04 g (wet weight) tissue sample.