Bilateral acute anterior uveitis: a rare ocular side effect of erlotinib.

Erlotinib used in the treatment of advanced non-small cell lung cancer (NSCLC) is a first-generation small-molecule tyrosine kinase inhibitor which reversibly inhibits the kinase domain of epithelial growth factor receptor (EGFR). The incidence of ocular toxicities as adverse effects (AE) of erlotinib is relatively common. However, post-marketing, acute anterior uveitis (AAU) has been reported in a small number of cases as a putative AE resulting from erlotinib therapy. We present a case of a 67-year-old, Caucasian woman, lifelong non-smoker with stage IV NSCLC who presents with decreased visual acuity and 'floaters' 6 weeks after commencing erlotinib. She was later diagnosed with erlotinib-associated bilateral AAU. This is the fifth documented case of erlotinib-associated bilateral AAU since 2010, highlighting the rarity of this AE. Thus, the possibility of AAU should always be considered in patients on EGFR-blocking therapies as significant ocular damage can occur if ophthalmic complaints are not triaged and assessed quickly.

Transscleral cyclophotocoagulation as primary management in a nanophthalmic eye with anterior uveitis and secondary mixed mechanism glaucoma.

A 36-year-old woman presented with eye pain and blurring of vision in her right eye. On eye examination, it was noted that there were angle-closure glaucoma and anterior uveitis in both eyes. Ocular ultrasound showed short axial lengths as well as a choroidal thickening in both eyes, confirming the diagnosis of nanophthalmos. Nanophthalmos is a condition where the eye is abnormally short, resulting in axial hyperopia and predisposing it to angle-closure glaucoma. The patient was initially managed medically, but the glaucoma was intractable. The patient underwent repeated sessions of transscleral cyclophotocoagulation which eventually lowered the intraocular pressure. The management of nanophthalmic eyes can be quite challenging due to the risk of inciting uveal effusion syndrome with any form of intraocular surgery. Controlled and repeated sessions of transscleral cyclophotocoagulation may be considered as a viable management option in these cases.

Superficial and deep retinal foveal avascular zone OCTA findings of non-infectious anterior and posterior uveitis.

PURPOSE: To compare the superficial (FAZ-S) and deep foveal avascular zones (FAZ-D) of non-infectious anterior and posterior uveitis to healthy controls, using optical coherence tomography angiography (OCTA). METHODS: OCTA was performed on 74 eyes: 34 eyes with non-infectious posterior uveitis (with (post+CME) and without macular edema (post-CME)), 11 eyes with non-infectious anterior uveitis (with (ant+CME) and without macular edema (ant-CME)), and the control group which included 29 healthy eyes. RESULTS: Eyes suffering from non-infectious posterior uveitis presented with significantly larger FAZ-D when compared to healthy controls, both in the presence or in the absence of macular edema (p < 0.001). In the presence of macular edema, eyes presenting with anterior uveitis (ant+CME) also showed significantly larger FAZ-S (p = 0.03) and FAZ-D (p < 0.001), when compared to healthy controls. In the absence of macular edema, eyes with anterior uveitis cannot be distinguished from controls (p > 0.6). CONCLUSION: The deep retinal foveal avascular zone seems to be enlarged in eyes presenting with non-infectious posterior uveitis, both in the presence or absence of macular edema.

Sacroiliac Joint Magnetic Resonance Imaging in Asymptomatic Patients with Recurrent Acute Anterior Uveitis: A Proof-of-concept Study.

OBJECTIVE: Our aim was to quantify bone marrow edema (BME) and/or structural lesions in the sacroiliac joints (SIJ) of patients with recurrent acute anterior uveitis (rAAU) with or without back pain, to evaluate the frequency of axial (axSpA) and peripheral spondyloarthritis (pSpA) and to establish which criterion for magnetic resonance imaging (MRI) positivity best reflected the global assessment of SIJ MRI. METHODS: A total of 50 patients with rAAU without prior rheumatologic diagnosis were included in our cross-sectional study, and these patients were compared to 21 healthy volunteers. SIJ MRI scans were read by 2 rheumatologists according to the Spondyloarthritis Research Consortium of Canada (SPARCC/MORPHO) protocol. Discrepant cases were adjudicated by a radiologist. RESULTS: Patients with rAAU were diagnosed with axSpA (Group 1, n = 20, 40%) and nonspecific back pain (Group 2, n = 6, 12%), or as being asymptomatic (Group 3, n = 24, 48%). Group 3 results showed 9 patients (37.5%) had SIJ MRI and/or were radiography-positive for axSpA (5 MRI and radiograph, 1 MRI, 3 radiograph). SIJ MRI scans that were compatible with SpA in groups 1 (n = 12) and 3 (n = 6) were similar in acute and structural lesions that were analyzed according to SPARCC/MORPHO. The best sensitivity/specificity criterion for defining a positive global MRI assessment was a BME score ≥ 3 (88%/94%). CONCLUSION: This is the first study evaluating SIJ MRI in patients with rAAU without back symptoms, showing positive findings for sacroiliitis. Moreover, a BME score ≥ 3 had better performance to define an SIJ MRI as positive for axSpA.

A prospective, observational study on the application of ultra-wide-field angiography in the evaluation and management of patients with anterior uveitis.

PURPOSE: Evaluation of peripheral retinal vascular changes in anterior uveitis using ultra-wide-field fluorescein angiography. DESIGN: A prospective, observational study of a case series of patients diagnosed with anterior uveitis. SETTING: Clinical observation at an academic medical center. Patient or Study Population: A total of 65 eyes of 33 patients corresponded with the research criteria of anterior uveitis in the opinion of specialists of Peking University First Hospital. OBSERVATION PROCEDURES: Patients were diagnosed primarily through clinical examinations and conventional fluorescein angiography. Subsequently, ultra-wide-field fluorescein angiograms were obtained for each patient. MAIN OUTCOME MEASURES: The main outcome was the detection of peripheral retinal changes by ultra-wide-field fluorescein angiography, and how these changes influenced the evaluation and management of the disease. RESULTS: Peripheral vessel leakage was detected in 27 eyes (42%) with anterior uveitis, of which 15 eyes displayed active inflammation and 12 eyes displayed inactive inflammation. Peripheral vessel leakage was found in seven of eight eyes with cystoid macular edema. Cystoid macular edema was detected in 7 of 27 eyes (26%) with peripheral vessel leakage, whereas 1 of 38 eyes (3%) did not display peripheral vessel leakage (p<0.01). 44.4% of the patients with peripheral vessel leakage had a specific etiology. The relevant treatment strategies were modified based on the results of the ultra-wide-field fluorescein angiography. 12 patients with peripheral vessel leakage and a quiescent anterior segment were added to those receiving topical glucocorticoids, while 3 patients with serious peripheral vessel leakage and an active anterior segment received a sub-Tenon injection of triamcinolone acetonide. CONCLUSIONS: Ultra-wide-field fluorescein angiography was very effective in detecting peripheral retinal vascular pathology in anterior uveitis. The changes found in the periphery were important in the evaluation and management of anterior uveitis.

Mechanisms for in-the-bag uveitis-glaucoma-hyphema syndrome.

We propose 2 mechanisms of uveitis-glaucoma-hyphema (UGH) syndrome in 2 patients with intracapsular or in-the-bag single-piece acrylic intraocular lenses (IOLs). In the first case, pseudophacodonesis secondary to zonular laxity from pseudoexfoliation syndrome caused chafing of the posterior iris by the square-edged haptic. In the second case, focal capsular fibrosis around the square-edged haptics combined with anteriorly rotated ciliary processes in plateau iris configuration caused points of chafing. Extensive capsular fibrosis of the haptic in both cases precluded IOL exchange. In the first case, a capsular tension ring redistributed zonular tension and reduced symptoms. In the second case, endoscopic cyclophotocoagulation relieved areas of chafing and resolved symptoms. In-the-bag square-edged haptics of single-piece acrylic IOLs are a potential source of iridociliary chafing in certain situations. The mechanisms observed here should be considered to promptly diagnose and treat UGH.

Ultrasound biomicroscopy in chronic pseudophakic ocular inflammation associated with misplaced intraocular lens haptics.

PURPOSE: To evaluate the usefulness of ultrasound biomicroscopy in confirming intraocular lens haptic-induced ocular irritation and in the management of these patients. DESIGN: A retrospective review of patient data. METHODS: Twenty pseudophakic patients who underwent ultrasound biomicroscopy examination between May 2009 and February 2011 to confirm the clinical suspicion of misplacement of intraocular lens haptics were reviewed. Ophthalmic findings at the time of presentation and at each follow-up visit, and management of each patient, were recorded. RESULTS: Intraocular lens haptic misplacement was confirmed by ultrasound biomicroscopy in all suspected cases. In 75% of the eyes 1 haptic was embedded in the iris; it extended into the ciliary body process in 35% and into the pars plana in 10%. Focal iris thinning/atrophy was detected by ultrasound biomicroscopy in 15% of cases and focal angle closure in 25%. Intraocular lens exchange was performed in 40% of patients. The remaining 60% were kept under observation, with the addition of topical steroids and/or cycloplegics in eyes that demonstrated anterior chamber inflammation and intraocular pressure-lowering medications in eyes with persistent elevated intraocular pressure or glaucoma. CONCLUSIONS: Ultrasound biomicroscopy appears to be a valuable tool in confirming the presence of haptic-induced ocular irritation and in assisting the management of these patients.

IgG4-positive sclerosing orbital inflammation involving the conjunctiva: a case report.

PURPOSE: To describe IgG4-positive sclerosing orbital inflammation with prominent conjunctival and scleral involvement. DESIGN: Case report. METHODS: Clinical, radiologic, and pathologic correlation. RESULTS: A 66-year-old man presented with right eye redness and irritation. Examination revealed unilateral scleritis and nongranulomatous anterior uveitis with elevated p-ANCA and CRP. Orbital CT scan showed inferotemporal scleral thickening. Biopsy revealed sclerosis and IgG4-positive plasma cells in the conjunctiva and inferior rectus. CONCLUSIONS: IgG4-mediated sclerosing inflammation is well-recognized in the orbit and adnexa, particularly the lacrimal gland. Scleritis with anterior uveitis should be recognized as a possible presentation for this entity, which has important systemic associations.

Relapsing acute myeloid leukemia presenting as hypopyon uveitis.

Anterior segment infiltration in acute myeloid leukemia (AML) presenting as hypopyon uveitis is very rare. We report this case as an uncommon presentation in a patient on remission after bone marrow transplant for AML. In addition to the hypopyon, the patient presented with "red eye" caused by ocular surface disease due to concurrent graft-versus-host disease and glaucoma. The classical manifestations of masquerade syndrome due to AML were altered by concurrent pathologies. Media opacities further confounded the differential diagnosis. We highlight the investigations used to arrive at a definitive diagnosis. In uveitis, there is a need to maintain a high index of clinical suspicion, as early diagnosis in ocular malignancy can save sight and life.

Tubulointerstitial nephritis and uveitis syndrome: use of gallium scintigraphy in its diagnosis and treatment.

Prompt diagnosis and treatment with corticosteroids of the tubulointerstitial nephritis with uveitis (TINU) syndrome may assist in the preservation of renal function. We present a case illustrating the characteristic clinical features of this syndrome. Gallium scintigraphy assisted in the diagnosis and management of this case, which was complicated by relapsing pyelonephritis.

Long-term results of out-of-the-bag intraocular lens implantation.

PURPOSE: To evaluate long-term results of out-of-the-bag intraocular lens (IOL) implantation. SETTING: Department of Ophthalmology, Tenri Yorozu Hospital, Nara, Japan. METHODS: This study comprised 22 patients, 13 women and 9 men, who had cataract surgery by phacoemulsification and out-of-the-bag IOL implantation because of a posterior lens capsule rupture. Sixteen patients had in-the-bag IOL implantation in the fellow eye, and these eyes were used as a control group. The IOL's position was determined by ultrasound biomicroscopy (UBM). Anterior chamber flare counts were measured by a laser flare meter. The corneal endothelium was observed by specular microscopy. RESULTS: Mean follow-up after cataract surgery was 35 months +/- 22 (SD). The UBM revealed that in the 19 eyes with sulcus-to-sulcus IOL fixation, the optics touched the iris. In 3 eyes, 1 haptic was fixated at the sulcus and the other at the ciliary body. In 2 of these eyes, the optics did not touch the iris. Anterior chamber flare counts in eyes with sulcus-to-sulcus IOL fixation were significantly higher than in eyes with in-the-bag or sulcus-to-ciliary-body fixation (P < .05). There were no statistical differences in corneal endothelial cell counts based on haptic placement. CONCLUSION: Rubbing between the IOL optic and iris seems to contribute to the high flare counts in eyes with a sulcus-to-sulcus IOL fixation. A larger haptic angle may be needed to prevent contact between the iris and IOL optic in such cases.

Anterior uveitis as a first sign of primary orbital lymphosarcoma.

A 47-year-old woman had a painless anterior uveitis in her right eye. Later, it appeared to be secondary to a developing extraocular orbital tumor, which also caused marked proptosis. Histopathologic examination of the tumor revealed lymphocytic lymphosarcoma. The tumor regressed rapidly after irradiation and cytological treatment.

[The significance of fluorescein angiogarphy in ocular toxocara granuloma (author's transl)]. / Fluoreszenzangiographie beim okulären Toxocara-Solitärgranulom.

Four serologically-proved cases of intraocular toxocara infections are demonstrated. Three different manifestations in the following way were found: 1. Solitary granuloma on the posterior pole (2 patients). 2. Anterior and posterior uveitis of both eyes with granuloma near the ora (1 patient). 3. Iridocyclitis of both eyes (1 patient). The fluorescein angiography examination in two cases with solitary granuloma have been repeated over a period of time and the relation of the satisfactory results to the further development of the disease is shown.

Diagnosis of uveo-parotid fever by 67Ga-citrate imaging.

67Ga-citrate scan from skull to mid-abdomen showed increased uptake in both parotid glands, mediastinum, lungs, uvei and/or enlarged lacrimal glands. The differential diagnosis of the positive radiogallium scan is discussed with emphasis on the value of the extrathoracic findings. Tissue diagnosis confirmed the imaging diagnosis of sarcoidosis. The case illustrates the usefulness of double radionuclide study--67Ga and 99mTc-MAA--and of the tomographic scanner in defining the spread of the active granulomatous disease.