Association of retinal detachment with age 50 years or younger at onset in patients with acute retinal necrosis.

BACKGROUND: Due to the guarded prognosis of acute retinal necrosis (ARN), it is relevant to develop a strategy to early categorize those patients in a higher risk of worse outcomes. The purpose of this study is to describe clinical features and predictive factors for retinal detachment (RD) in patients with ARN. METHODS: Retrospective observational case series of 34 adult patients (38 eyes) with ARN examined between January 2005 and July 2015 in the National Eye Institute (Bethesda, USA), the Department of Ophthalmology, University of Chile (Santiago, Chile), and APEC (CDMX, Mexico). RESULTS: A total of 16 males and 18 females with a mean age at presentation of 44.5 ± 16.8 years were included. Twenty-seven patients (79.4%) received intravenous acyclovir as first-line treatment, and 7 patients received either oral antiviral (4 patients) or oral plus intravitreal antiviral (3 patients). All subjects were treated with prednisone, with a mean initial dose of 57.7 ± 16.3 mg per day. Seventeen patients (50.0%) developed retinal detachment. An association of retinal detachment with age at onset was observed (p = 0.04), with patients younger than 50 years presenting a higher risk (OR = 14.86, p = 0.0009). Additionally, patients in this higher risk group had more inflammation in both anterior chamber and vitreous (p = 0.04 and 0.03, respectively). No other predictive factor for retinal detachment was found in the present study. CONCLUSIONS: RD represents an important complication in patients with ARN. Younger patients may be at higher risk of this complication, possibly secondary to the presence of a higher level of inflammation.

Outcomes in Patients with Vogt-Koyanagi-Harada Disease from the First-line Antimetabolites for Steroid-sparing Treatment Uveitis Trial.

PURPOSE: To compare the effectiveness of methotrexate (MTX) and mycophenolate mofetil (MMF) in achieving corticosteroid-sparing control of uveitis in patients with Vogt-Koyanagi-Harada (VKH) disease. METHODS: A subanalysis of patients with VKH from the First-line Antimetabolites as Steroid-sparing Treatment (FAST) Uveitis Trial, a randomized, observer-masked, comparative effectiveness trial, with comparisons by treatment (MTX versus MMF) and disease stage (acute versus chronic). Individuals with noninfectious uveitis were placed on a standardized corticosteroid taper and block randomized 1:1 to either 25mg weekly oral MTX or 1.5g twice daily oral MMF. The primary outcome was treatment success defined by corticosteroid-sparing control of uveitis at 6 months. Additional outcomes included change in best spectacle-corrected visual acuity (BSCVA), retinal central subfield thickness (CST), and resolution of serous retinal detachment (SRD). RESULTS: Ninety-three out of 216 enrolled patients had VKH; 49 patients were randomized to MTX and 44 to MMF, of which 85 patients (46 on MTX, 39 on MMF) contributed to the primary outcome. There was no significant difference in treatment success by antimetabolite (80.4% for MTX compared to 64.1% for MMF; P=.12) or in BSCVA improvement (P=.78). Methotrexate was superior to MMF in reducing CST (P=.003) and resolving SRD (P=.02). There was no significant difference in treatment success by disease stage (P=.25), but patients with acute VKH had greater improvement in BSCVA (P<.001) and reduction of CST (P=.02) than chronic VKH patients. CONCLUSIONS: MTX and MMF have comparable outcomes as corticosteroid-sparing immunosuppressive therapies for VKH. Visual acuity improvement was greater in acute vs chronic VKH. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00182929.

Risk of failing both methotrexate and mycophenolate mofetil from the First-line Antimetabolites as Steroid-sparing Treatment (FAST) uveitis trial.

BACKGROUND: The antimetabolites methotrexate (MTX) and mycophenolate mofetil (MMF) are commonly used as initial corticosteroid-sparing treatment for uveitis. There is little data examining risk factors for failing both MTX and MMF. The objective of this study is to determine risk factors for failing both MTX and MMF in patients with non-infectious uveitis. MAIN BODY: This is a sub-analysis of the First-line Antimetabolites as Steroid-sparing Treatment (FAST) uveitis trial, which was an international, multicenter, block-randomized, observer-masked, comparative effectiveness trial comparing MTX and MMF as initial treatments for non-infectious uveitis. This study was undertaken at multiple referral centers in India, the United States, Australia, Saudi Arabia and Mexico between 2013 and 2017. A total of 137 patients who completed all 12 months of follow-up from the FAST trial, were included in this study. The primary outcome was failing both antimetabolites over the 12 months of the trial. Potential predictors included: age, sex, bilateral involvement, anatomic location of the uveitis, presence of cystoid macular edema (CME) and retinal vasculitis at baseline visit, uveitis duration, and country/study sites as risk factors for failing both MTX and MMF. The presence of retinal vasculitis posterior to the equator on fluorescein angiogram was associated with failing both MTX and MMF. CONCLUSION: Retinal vasculitis may be a risk factor for failing multiple antimetabolites. Clinicians could consider more quickly advancing these patients to other medication classes, such as biologics.

Risk factors for subretinal fibrosis in patients with Vogt Koyanagi Harada syndrome.

PURPOSE: To identify the risk factors for the development of subretinal fibrosis (SRF) among patients with Vogt-Koyanagi-Harada (VKH) syndrome. METHODS: In this case-control study, electronic clinical records from patients diagnosed with VKH syndrome who attended the Inflammatory Eye Disease Clinic at a tertiary care ophthalmology reference center were assessed to identify risk factors from demographic, clinical, and epidemiological variables. Cases were defined as SRF and VKH, whereas the controls were VKH patients without SRF. RESULTS: A total of 150 electronic charts were reviewed, 92 patients with a follow-up longer than 12 months were included; 39 cases and 53 controls. A multivariate analysis found bullous serous retinal detachment as a significant risk factor for SRF (adjusted OR 8.93, 95% CI 1.94-41.1). CONCLUSION: Patients with VKH syndrome who develop a bullous retinal detachment have an 8 times higher risk of developing SRF in the long term.

Alternaria chartarum sclerokeratouveitis: A new fungus cause.

We report a case of Alternaria chartarum sclerokeratouveitis with an unfavorable response to treatment. To the best of our knowledge, there are no previous reports of this fungus invading the sclera. A 68-year-old diabetic farmer male patient presented with a 3-week history of pain and redness and a decrease in visual acuity occurring 5 days before admittance in the right eye. Examination revealed severe mixed hyperemia and a scleral calcified plaque with a surrounding area of ischemia and lysis. The cornea showed diffuse infiltrates, stromal edema, and hypopyon. Initial scrapings were negative, and empiric antibiotics were started. After a fungus was reported, topical and systemic antifungals were initiated, but there was no clinical response. The eye was enucleated. A slow-growing fungus A. chartarum, resistant to voriconazole, was isolated. Fungal etiology must be kept in mind when dealing with infectious scleritis. Despite treatment, the outcome of this case was unfavorable due to the slow-growing nature of the fungus and this strain's resistance to voriconazole.

Characterization of cyclitic membranes by ultrabiomicroscopy in patients with pars planitis.

BACKGROUND: In previous studies, authors use ultrasound biomicroscopy (UBM) to analyze the characteristics of cyclitic membranes and the associated complications in patients with pars planitis. However, there are no reports regarding the prevalence of cyclitic membranes or complications at diagnosis and during follow-up. PURPOSE: To describe the characteristics and complications of cyclitic membranes, as determined by UBM in patients with pars planitis using AVISO-S™ (Quantel Medical) equipment with a 50-MHz linear probe with a focus at the pars plana. DESIGN: This retrospective study reviewed UBM images of patients diagnosed with pars planitis, from the Inflammatory Eye Disease Clinic in Mexico City from January 2010 to June 2016. RESULTS: Cyclitic membranes were observed in the first UBM image in 67 eyes (56.7%) and during follow-up in 81 eyes (68.62%). In 67 eyes (82.71%), the cyclitic membranes extended through one or two quadrants. Extension toward the posterior lens capsule was recognized in 15 eyes (18.52%) and extension toward the peripheral retina in 12 eyes (14.81%). Complications included ciliary body detachments in 10 eyes (12.35%) and peripheral retinal traction in 8 eyes (9.88%). CONCLUSIONS: UBM is a valuable tool for the diagnosis of cyclitic membranes at admittance and during follow-up of patients with pars planitis; it helps the clinician to detect this complication early.

Ultrabiomicroscopic Findings in Acute Uveitic, Convalescent and Chronic Recurrent Stage of Vogt-Koyanagi-Harada Syndrome.

PURPOSE: To describe the ultrabiomicroscopy (UBM) characteristics in patients with uveitic, convalescent, and recurrent Vogt-Koyanagi-Harada (VKH) disease. METHODS: In this prospective, non-interventional, and observational study, all UBM variables, namely pars plicata and pars plana thickness, ciliochoroidal detachment, angle chamber, anterior chamber depth, ID2, and presence of ciliary processes, were compared between acute uveitic, convalescent, and chronic-recurrent phases. RESULTS: Ninety-one eyes were analyzed. Ciliochoroidal detachment (20%) and unclear ciliary processes (15%) are the most characteristic findings of the uveitic phase. At 1 and 3 months, ciliochoroidal detachment is no longer observed. In recurrent phase, pars plicata and pars plana thickness increases again and then decreases after the first month of treatment. Convalescent-phase does not show significant differences in UBM variables after a 6-month follow up. CONCLUSIONS: UBM may have a role in evaluating response to treatment in uveitic and recurrent phases and in the early detection of recurrences.

Initial-onset acute and chronic recurrent stages are two distinctive courses of Vogt-Koyanagi-Harada disease.

PURPOSE: To describe distinctive stages of Vogt-Koyanagi-Harada (VKH) disease: initial-onset acute versus chronic recurrent disease. METHODS: A comprehensive literature review regarding stages and clinical presentations of VKH disease was conducted. RESULTS: Despite a list of signs that has been described as characteristic features of early or late phases of VKH disease, the current classification -developed by an international committee and published in 2001- does not consider a distinction regarding the time from onset of disease symptoms, and specific findings observed at certain time point from the symptoms presentation and outcomes related to the stage of VKH disease. In that sense, chronic recurrent VKH disease is more refractory to treatment and is associated with a higher rate of complications. Accordingly, this subset of VKH patients has poorer functional and anatomical outcomes than patients with an initial-onset acute disease. CONCLUSIONS: An early clear distinction of VKH phenotype [Initial-onset acute versus chronic recurrent disease] should be considered in each clinical scenario, evaluating the delay in diagnosis and the clinical presentation, since it may help clinicians to perform a correct disease prognosis categorization and thus to make treatment decisions in terms of potential refractoriness or expected clinical outcomes.

[Efficacy of prednisolone and rimexolone in HLA-B27 positive patients with acute anterior uveitis]. / Comparación de la eficacia de la prednisolona y la rimexolona en el tratamiento de iridociclitis aguda en pacientes HLA-B27 positivos.

PURPOSE: To compare the efficacy and safety of prednisolone acetate 1% vs. rimexolone 1% ophthalmic suspension in the treatment of acute anterior uveitis (AAU) in HLA-B27+ patients. METHODS: Sixty-eight AAU HLA-B27+ patients were randomly selected for treatment with prednisolone acetate 1% or Rimexolone 1%. All patients showed mild to moderate anterior chamber inflammation. This was a prospective, randomized, double blind, clinical trial. RESULTS: There was no statistically significant difference between both groups when anterior chamber cells were measured. In the rimexolonae group, flare diminished since the first week. In both groups the intraocular pressure (IOP) raised since the first week, the increase was highly significant in the rimexolone group. Final intraocular pressure was higher in the prednisolone group. CONCLUSION: Rimexolone 1% is as effective as prednisolone acetate 1% in the treatment of mild to moderate AAU HLA-B27+. IOP increased in both groups, but this variation was not clinically significant.

Extensive dynamics in location, shape, and size of aneurysms in a patient with idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome. Idiopathic retinal vasculitis, aneurysms, and neuroretinitis.

PURPOSE: To describe an unusual case of idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome with rapid dynamics in the number and appearance of the aneurysms. DESIGN: Observational case report. METHODS: Clinical and angiographic data of the patient were reviewed. RESULTS: In the course of only 6 months, preexisting retinal aneurysms resolved while new ones appeared. Changes were observed in the shape and size of preexisting lesions. The resolution of lesions in eyes previously untreated by laser is reported for the first time. CONCLUSIONS: Vascular lesions in IRVAN syndrome may show an unusually rapid turnover. The resolution of aneurysms is a part of the natural course of the disease and may occur without previous retinal laser photocoagulation.

Pars planitis in the Mexican Mestizo population: ocular findings, treatment, and visual outcome.

PURPOSE: To describe the clinical manifestations of classic pars planitis (CPP) in Mexican patients. We report here the most frequent complications, medical and surgical treatment, and visual prognosis. MATERIAL AND METHODS: A retrospective, descriptive case series examined the clinical features, complications, and treatment (medical and surgical) of CPP patients seen at the Inflammatory Eye Disease Clinic from January 1990 to September 1999. RESULTS: One hundred and sixty patients met inclusion criteria for the study. Mean age at presentation was 10 years and males were more frequently affected. Both eyes were affected in 84.4% of the cases. The most frequent complaint was decreased visual acuity. Initial visual acuity (VA) ranged from no light perception to 20/20 (mean 20/50), and mean final VA was 20/30. The most frequent clinical manifestations were vitritis (99.7%), snowballs (99.3%), retinal vasculitis (89.2%), and snowbanks (63.1%). The most common complications were cystoid macular edema (63.4%) and cataract (47.5%). Periocular corticosteroids were used in 97.5% of cases, systemic corticosteroids in 68.1%, and other immunosuppressive drugs in 21.3%. CONCLUSIONS: CPP in the Mexican population is more frequent in males and usually presents in patients less than 14 years of age. It is typically bilateral, and the most common symptom is decreased visual acuity. The most important clinical findings are located in the vitreous and retina. Cataract and cystoid macular edema are the most frequent complications. Treatment comprises periocular and systemic corticosteroids or other immunosuppressive drugs.

Fuchs' heterochromic iridocyclitis: clinical manifestations in dark-eyed Mexican patients.

PURPOSE: To describe the clinical features of Fuch's heterochromic iridocyclitis (FHI) in dark-eyed Mexican patients. MATERIAL AND METHODS: A longitudinal, retrospective, and analytical study of the clinical features of FHI patients was performed. It reviewed the clinical charts of all patients with a diagnosis of FHI seen at the Inflammatory Eye Diseases Clinic of 'Dr. Luis Sánchez Bulnes' Hospital between April 1988 and September 1999. RESULTS: Data of 68 patients (136 eyes) were reviewed. One eye was affected in 89.71% of the cases (61 patients). Fifty patients had brown eyes and iris heterochromia was clinically evident in 25%. Mild stellate keratic precipitates were seen in 80% of the affected eyes. Blurring of the iris surface was found in 40 eyes; iris nodules (Koeppe and/or Busacca) were present in half the cases. A cataract was observed in 69% of the affected eyes, 57.7% of which underwent surgery. Ocular hypertension was present in 30.66% of the affected eyes, glaucoma in 4%. CONCLUSIONS: The more common clinical features in this group of patients were fine and stellate keratic precipitates, atrophy of the iris crypts, and iris nodules. Clinically evident iris heterochromia was present in only 25% of the affected eyes. FHI diagnosis in brown-eyed patients cannot rely on iris heterochromy only.

Corneal ectasia secondary to peripheral endotheliopathy in a patient with classic pars planitis.

PURPOSE: To report a case of corneal ectasia secondary to pars planitis corneal endotheliopathy METHODS: Clinical case description and proposed hypothesis regarding development of corneal ectasia RESULTS: Eight-year-old male presented with 360° peripheral corneal endotheliopathy and edema, granulomatous keratic precipitates, and mild iritis OD. A progressive corneal ectasia then developed. Twenty months later, OS presented similarly and anterior chamber inflammatory cells, vitreous snowballs, and retinal vasculitis were observed OU. Classic pars planitis was diagnosed CONCLUSION: This is the first case of endotheliopathy as the first manifestation of pars planitis and as a cause of a secondary central cornea ectasia developed.

[Ocular manifestations of primary systemic vasculitis]. / Manifestaciones oculares de las vasculitis primarias sistémicas.

A variety of ophthalmic manifestations can occur in patients who have systemic vasculitides and may be the presenting feature. Ocular involvement is frequently found and can result in significant morbidity, even in blindness. Early diagnosis and treatment may improve visual outcome. The management is challenging and requires a multidisciplinary approach. Treatment of ocular manifestations and systemic disease usually follows the same path. The mainstay of treatment is the use of systemic corticosteroids, usually combined with steroid-sparing immunosuppressive drugs. New, promising, emerging therapies rely on the development of biologic agents, which seem useful in the ocular manifestations of systemic vasculitides.