Oleander-Associated Keratitis and Uveitis.

PURPOSE: Oleander is a poisonous plant with extensively documented systemic side effects; however, oleander's ophthalmic side effects have not been detailed in the literature. We report a case of oleander-associated keratitis with subsequent corneal edema and anterior uveitis. METHODS: This is a case report and review of relevant literature. RESULTS: A 58-year-old woman presented with large corneal epithelial defect after being struck in the eye with an oleander leaf. Despite treatment with topical moxifloxacin, she developed severe corneal edema and anterior uveitis. A diagnosis of oleander-associated ocular inflammation with secondary corneal edema was made, given the temporal relationship, and treatment was initiated with topical prednisolone and cyclopentolate. However, the corneal edema and inflammation continued to progress until oral prednisone and topical difluprednate were initiated. Visual acuity, anterior uveitis, and corneal edema significantly improved with aggressive immunomodulation. Follow-up at 1 month confirmed complete recovery of symptoms, corneal edema and anterior uveitis. CONCLUSIONS: Severe corneal edema and anterior uveitis can be associated with oleander exposure. Aggressive treatment with oral and topical steroids may be required without persistent sequelae at the 5-month follow-up. Ophthalmologists should consider this inflammatory reaction if patients experience ocular exposure to oleander.

Alternative Biologic Therapy in Children Failing Conventional TNFα Inhibitors for Refractory, Noninfectious, Chronic Anterior Uveitis.

PURPOSE: A significant number of children with noninfectious, chronic anterior uveitis (CAU) fail to respond to conventional therapy; however, successful alternative biologic treatments (ABT) have not been well described. This study aims to review the clinical and treatment characteristics of children with CAU who require ABT. DESIGN: Retrospective, nonrandomized clinical study. METHODS: Setting: Tertiary center. STUDY POPULATION: Children with noninfectious CAU. OBSERVATION PROCEDURES: Clinical characteristics, uveitis course, complications, and treatment were compared among patients treated with methotrexate (MTX) monotherapy, conventional TNFα inhibitors (cTNFi), and ABT for >3 months. MAIN OUTCOME MEASURE: Success of ABT (abatacept, tocilizumab, and/or golimumab) in children failing conventional treatment. RESULTS: Of the 52 children with CAU, 75% had juvenile idiopathic arthritis. CAU was controlled in 15 children receiving MTX monotherapy, 28 receiving cTNFi, and 9 receiving ABT (n = 1, abatacept; n = 3, tocilizumab; n = 5, golimumab). Patients in the ABT group had a greater number of total ocular complications per person before ABT than those in the control groups (3.4 vs 0.7 [MTX], P < .001, and 1.5 [cTNFi], P < .001, respectively). In all 9 children on ABT, treatment led to control of CAU and topical glucocorticoids tapered to ≤2 drops/d with no new ocular complications. CONCLUSIONS: In this study, alternative biologics (abatacept, golimumab, and tocilizumab) were useful for treating CAU in children who fail MTX and cTNFi therapy. Patients who were controlled on ABT had more disease activity, ocular complications, and anti-cTNFi neutralizing antibodies (before ABT) than those managed with conventional therapy. Larger studies are required to confirm these findings.

[Ocular involvement in spondylarthritis--new mechanisms, new therapies]. / Afectarea oculara din spondilartrite--noi mecanisme, --noi terapii.

Spondyloarthrites (SPA) represent a group of heterogenous rheumatic diseases (ankylosing spondylitis/SA, psoriatic arthritis/PsA, reactive arthritis/ReA, spondyloarthritis in bowel inflammatory diseases/BID, undifferentiated spondyloarthritis/undif SpA) with distinct clinical features and common genetic predisposition (HLA-B27). SpA may also affect other organs, ocular involvement, represented by uveitis and conjunctivitis, being one of the most important extraskeletal manifestations. Pathogenic mechanisms of ocular involment in SpA are not entirely known; nevertheless, the inflammatory process which characterizes the main rheumatic diseases seems to be responsible for this extraskeletal manifestation. SpA treatment targeted at clinical remission has a favourable effect not only on articular but also on ocular involvement. The discovery of new pathogenic mechanisms of both rheumatic and eye disease in SpA have contributed to identification of new pathogenic therapies. The interdisciplinary team work of rheumatologists and ophtalmologists have prove essential for the management of SpA patients with ocular manifestations.

Paradoxical changes of retinal nerve fiber layer thickness in uveitic glaucoma.

IMPORTANCE: Measurement of retinal nerve fiber layer (RNFL) thickness using optical coherence tomography can aid in the diagnosis and management of glaucoma. We observed a previously unreported phenomenon in eyes with uveitis-associated glaucoma in which paradoxical changes in RNFL thickness were noted. OBSERVATIONS: Four eyes of 3 patients with uveitis-associated glaucoma had a relatively normal RNFL measurement on presentation during periods of active uveitis and raised intraocular pressure. Subsequent control of uveitis and intraocular pressure was associated with a paradoxical thinning of the RNFL and increased cupping. CONCLUSIONS AND RELEVANCE: Normal-appearing measurements of RNFL thickness in patients with uveitis should be interpreted cautiously in those with a raised intraocular pressure. Physicians should recognize that continued thinning of the RNFL and increased cupping, despite good intraocular pressure control in such eyes, may be due to resolution of edema of the RNFL.

Anterior chamber flare after femtosecond laser-assisted cataract surgery.

PURPOSE: To determine whether postoperative ocular inflammation is less after femtosecond laser-assisted cataract surgery than after conventional phacoemulsification (manual) cataract surgery. SETTING: Private clinic, Launceston, Tasmania, Australia. DESIGN: Prospective consecutive investigator-masked nonrandomized parallel cohort study. METHODS: Consecutive cataract patients who had femtosecond laser-assisted cataract surgery or manual cataract surgery by the same surgeon at a single center were assessed. The primary endpoint was postoperative aqueous flare measured by laser flare photometry at 1 day and 4 weeks. Secondary endpoints included retinal thickness measured by optical coherence tomography and slitlamp examination findings at 4 weeks. RESULTS: The per-protocol population comprised 176 patients (100 in laser group; 76 in manual group). Postoperative aqueous flare was significantly greater in the manual cataract surgery group at 1 day (P=.0089) and at 4 weeks (P=.003). There was a significant correlation between effective phacoemulsification time and 1-day postoperative aqueous flare (r = 0.35, P<.0001). The increase in outer zone thickness measured by optical coherence tomography was less in the laser group (P=.007). CONCLUSION: Anterior segment inflammation was less after femtosecond laser-assisted cataract surgery than after manual cataract surgery, and this appeared to be due to a reduction in phacoemulsification energy.

Evaluation of intraocular reactivity to metallic and ethylene oxide contaminants of medical devices in a rabbit model.

OBJECTIVE: To evaluate the intraocular reactivity to metallic and ethylene oxide (EO) contaminants of ophthalmic devices in rabbits. DESIGN: Two experimental animal studies. PARTICIPANTS: Thirty-five New Zealand white rabbits. METHODS: A metallic exposure study and an EO exposure study were performed. In the first study, both eyes of 25 rabbits were equally allocated to intracameral injections of alumina 0.2 µg, alumina 20 µg, copper sulfate 0.4 µg, copper sulfate 20 µg, or an aqueous control. In the second study, 10 rabbits were allocated (5 per group) to receive intracamerally an ophthalmic viscosurgical device (OVD) exposed to EO or not exposed to EO (control). All eyes were examined by slit lamp at baseline and 3, 6, 9, 24, 48, and 72 hours after exposure, with dilated indirect ophthalmoscopy being performed at 24 and 72 hours. Tonometry was performed only in the first study. MAIN OUTCOME MEASURES: Grade of corneal clouding, anterior chamber (AC) flare, AC cells, AC fibrin, iridal hyperemia, cell and fibrin on the lens surface, vitreous haze and cells, lens opacities, intraocular pressure, and onset time. RESULTS: For metallic compounds at the study's low doses, mean inflammatory grades were 0.2 or less above the control for all responses at all time points. For the high-dose alumina, mean inflammatory grades peaked at 6 to 9 hours at 0.5 to 0.7 above the control responses for conjunctival congestion, iris hyperemia, AC cells, flare, and fibrin and declined over the remaining time points. For the high-dose copper sulfate, mean inflammatory grades peaked between 3 and 24 hours at 1.2 to 1.8 above the control responses for conjunctival congestion, iris hyperemia, AC cells, flare, fibrin, and corneal clouding, then subsequently declined. The intraocular pressure changes appeared significant for only high-dose copper sulfate, with mean declines of 4.3 to 7.5 mmHg at 6 to 72 hours. No clinically meaningful differences in ocular inflammation were observed between the OVD exposed to EO and the OVD not exposed to EO. CONCLUSIONS: Alumina and copper sulfate did not cause clinically meaningful ocular inflammation at the low study levels (levels expected with ophthalmic devices). Ethylene oxide exposure of an OVD was not associated with inflammation.

The spectrum of ocular inflammation caused by euphorbia plant sap.

OBJECTIVE: To report the spectrum of clinical findings in patients with ocular inflammation caused by plant sap from Euphorbia species. DESIGN: Clinical case series. SETTING: Ophthalmology emergency referrals in the United Kingdom. PATIENTS: We examined 7 patients, all of whom gave a history of recent ocular exposure to the sap of Euphorbia species. INTERVENTIONS: All patients were treated with antibiotic drops or ointment (chloramphenicol). Cycloplegic and steroid drops were also used for some patients. Patients were observed until all signs and symptoms had resolved. MAIN OUTCOME MEASURES: Symptoms, visual acuity, and clinical signs of inflammation. All patients provided a specimen of the plant for formal identification. RESULTS: Initial symptoms were generally burning or stinging pain with blurred vision. In most cases, visual acuity was reduced between 1 and 2 Snellen lines. In 1 patient with age-related maculopathy, acuity dropped from 20/80 to hand motions before recovering. Clinical findings varied from a mild epithelial keratoconjunctivitis to a severe keratitis with stromal edema, epithelial sloughing, and anterior uveitis. All signs and symptoms had resolved by 1 to 2 weeks. CONCLUSIONS: These cases illustrate the range of severity of Euphorbia sap keratouveitis. The condition seems to be self-limiting when managed supportively. People who work with Euphorbia plant species should wear eye protection. Clinicians managing keratopathy caused by Euphorbia species should be aware of the danger of sight-threatening infection and uveitis, particularly during the first few days.