Multi-drug resistance and side-effects in a patient with Behçet's disease.

OBJECTIVES: To report on the clinical course of ocular and extraocular involvement in a multidrug-resistant patient with Behçet's disease (BD). METHODS: A 22-year-old male with BD (bilateral panuveitis and retinal vasculitis, oral ulcers, erythema nodosum, arthralgia, epididymitis) was followed-up from 1999 to 2014. He was treated continuously with corticosteroids in combination with different immunosuppressive therapies (cyclosporine, azathioprine, methotrexate, interferon, infliximab, mycophenolate), which exerted numerous side-effects such as nephrotoxicity, nephrolithiasis, increase of liver enzymes, severe depression with suicidal ideation, severe leucopenia, pulmonary tuberculosis, pulmonary legionellosis, recurrent bronchopneumonia. RESULTS: Despite immunosuppressive and corticosteroid therapies, the patient showed multiple relapses of uveitis and systemic BD lesions and developed severe osteoporosis with multiple vertebral fractures, bilateral cataracts and steroid-associated glaucoma until 2007. Since then he has been treated with prednisone alone, currently at low dosage, remaining free from uveitis and systemic symptoms. His final visual acuity is 9/10 in the right eye and counting fingers in the left one. CONCLUSIONS: BD patients are usually responsive to immunosuppressive drugs. The possibility of a multi-drug resistance as well as of multiple drug-related side effects cannot be disregarded and continuous therapy should be given in order to preserve a useful visual acuity until the disease, either spontaneously or drug-induced, runs into remission.

Ocular Behçet's Disease: Changing Patterns Over Time, Complications and Long-Term Visual Prognosis.

PURPOSE: To investigate demographic, clinical features and complications of Italian patients with ocular Behçet's disease (BD) over time. METHODS: Retrospective study of 385 patients examined from 1968 to 2011, 265 of whom had follow-up ≥ 12 months. RESULTS: A significant increase in the proportion of females (p = 0.03) and anterior uveitis (p < 0.001), and a decrease in the complete type of BD in all patients (p = 0.003) and in males (p = 0.002), and in hypopyon (p = 0.024) were observed over time. Optic neuropathy (p < 0.0001), maculopathy (p = 0.002), retinal detachment, and retinal neovascularization (p = 0.02) decreased over time, with no difference between genders, concomitant with an increase in the use of immunosuppressive drugs (p = 0.003). Visual acuity ≤1/10 was detected more often in males than females (p = 0.003). CONCLUSIONS: A significant shift in clinical manifestations of BD patients was observed over 44 years. Immunosuppressive therapy succeeded in lowering ocular complications. The incidence of ocular BD is increasing in females, but visual prognosis is still worse in males.

Levofloxacin and Tobramycin for Severe Bacterial Keratouveitis.

PURPOSE: To report on clinical features and outcome of severe bacterial keratouveitis. METHODS: Twenty patients with severe bacterial keratouveitis treated with topical tobramycin and levofloxacin and oral levofloxacin were included. Main outcome measures were ulcers location, bacterial isolates, risk factors, visual prognosis. RESULTS: Centrally located ulcer/abscess was present in 65% of patients. Contact lens (CL) wear was the most common risk factor (70%). Bacterial isolates were observed in 58% of patients, none resistant to tobramycin and levofloxacin. Pseudomonas aeruginosa was found in 47% of positive cases and in 64% of CL wearers. After therapy, the mean visual acuity improved significantly (p < 0.0001), particularly in contact lens wearers (p = 0.04) and in patients younger than 60 years old (p < 0.001). CONCLUSIONS: Pseudomonas aeruginosa is the most frequent cause of bacterial keratouveitis and CL wear the most common risk factor. Topical tobramycin and levofloxacin and oral levofloxacin are effective in the treatment of bacterial keratouveitis.

Fuchs' Heterochromic Iridocyclitis in an Italian Tertiary Referral Centre: Epidemiology, Clinical Features, and Prognosis.

Purpose. To study epidemiology, clinical findings and visual prognosis of patients with Fuchs' Heterochromic Iridocyclitis (FHI). Methods. A retrospective analysis was performed on 158 patients with FHI. Thirty-five patients were observed only once; the remaining 123 had a mean follow-up of 30.7 months (50 of them had a mean follow-up of 63.5 months) and in those we assessed complications, medical and surgical treatment, and long-term visual prognosis. Results. Average age at uveitis diagnosis was 27.2 years and 18.3% of patients were children. Blurred vision (54.5%) and floaters (40.5%) were the most frequent presenting symptoms. Small to medium-sized keratic precipitates (95.6%), iris atrophy (86.8%), and vitreous opacities (91.2%) were the most common signs; the prevalence of cataract and IOP increase was 63.5% and 20.1%, respectively, and their incidence was 0.1 and 0.06 eye/year. Significant risk factor for visual loss was IOP increase at presentation (p = 0.02). At final examination 98% of the eye had a visual acuity ≥ 0.6, and topical (p < 0.001) and systemic (p < 0.001) corticosteroids therapy were used less frequently than before referral. Conclusions. FHI has a good visual prognosis, despite the significant incidence of cataract and glaucoma. A correct and prompt diagnosis might avoid unnecessary therapies and provide excellent visual outcomes.

Vogt-Koyanagi-Harada disease after stapedotomy.

PURPOSE: To report on Vogt-Koyanagi-Harada disease that occurred after stapedotomy. METHODS: Case report. RESULTS: A 46-year-old woman developed bilateral choroiditis, papillitis, and serous retinal detachment 10 days after an uneventful surgical stapedotomy. The diagnosis was confirmed on the basis of the clinical features, fundus fluorescein angiography and optical coherence tomography findings, and a clinical course with subsequent involvement of the anterior segment, uveitis relapses with serous retinal detachment, and negative laboratory work-up for uveitis. CONCLUSIONS: Vogt-Koyanagi-Harada disease may appear after an uneventful surgical intervention of stapedotomy, suggesting that surgical trauma in the inner ear, a melanocyte-containing organ, may induce an inflammatory response within the eye.

Central serous chorioretinopathy as a presenting symptom of endogenous Cushing syndrome: a case report.

PURPOSE: To report a case of Cushing syndrome due to adrenocortical adenoma revealed by central serous chorioretinopathy. MATERIALS AND METHODS: A 45-year-old man presented with blurred vision and metamorphopsia in the left eye. He reported few episodes of high blood pressure in the last 3 months. RESULTS: Visual acuity was 20/40 in the left eye. Fundus oculi examination revealed central serous chorioretinopathy in the left eye. Grade 1 hypertension was found. Increased serum and urinary levels of cortisol and reduced serum levels of ACTH were observed. Diagnosis of Cushing syndrome was made. Computed tomography scan revealed a right adrenal mass that was surgically removed; histologic examination showed an adrenocortical adenoma. Three months after surgical treatment, visual acuity improved to 20/20 and central serous chorioretinopathy completely resolved. CONCLUSIONS: Central serous chorioretinopathy may be the presenting symptom of Cushing syndrome in a patient with adrenocortical adenoma.

Intermediate uveitis in a pediatric Italian population.

PURPOSE: To investigate clinical data, outcome, and treatment of intermediate uveitis in children. METHODS: Retrospective cohort study, including 116 children affected by intermediate uveitis. RESULTS: Sixty-two percent of patients were males. Ocular involvement was bilateral in 84%. Mean age at uveitis onset was 10.3 ± 3.6 years and 12.2 ± 7 years at first visit. Ninety-seven percent were classified as having idiopathic uveitis. The incidence of ocular complications during follow-up was 0.131/eye-year. Macular edema or a marked vitreous haze at presentation may be risks factors for incident visual loss. The most frequent causes of visual loss were macular edema (64%) and cataract (21%). CONCLUSIONS: Most cases are idiopathic (pars planitis); only few children presented associated systemic disease. Macular edema and severe vitritis at presentation are associated with increased risk of visual impairment. Cystoid macular edema is the main cause of visual impairment.