Long-term, drug-free remission of sympathetic ophthalmia with high-dose, short-term chlorambucil therapy.

OBJECTIVE: To evaluate the safety and effectiveness of short-term, high-dose chlorambucil therapy in achieving long-term, drug-free remission in the treatment of sympathetic ophthalmia (SO). DESIGN: Retrospective case series. PARTICIPANTS: Sixteen patients with SO treated with high-dose, short-term chlorambucil therapy between 1970 and 2010. METHODS: Descriptive and bivariate analyses were used to characterize disease and outcomes. MAIN OUTCOME MEASURES: Months of disease-free remission, prevalence rate of relapse, and prevalence of serious treatment-related adverse events. RESULTS: Sixteen patients with SO treated with short-term, high-dose chlorambucil were identified. Patients were treated with chlorambucil for a median of 14.0 weeks (mean, 14.5 weeks; range, 12.0-19.0 weeks). Median follow-up was 98.5 months (mean, 139.1 months; range, 48-441 months) from initiation of chlorambucil therapy. Control of inflammation was achieved in 100% of patients. Thirteen patients (81.3%) maintained vision of 20/40 or better in the sympathizing eye. Four patients (25%) relapsed after a median of 83 months (mean, 131 months) after cessation of systemic therapy. Seventy-five percent of relapses were controlled with topical therapy only. Conjunctival Kaposi's sarcoma developed in 1 patient. No patient demonstrated systemic malignancy. CONCLUSIONS: Short-term, high-dose chlorambucil therapy provides sustained periods of drug-free remission. With median follow-up of more than 8 years (mean, 11.6 years; range, 4-37 years), there was a low rate of recurrence and minimal long-term serious health consequences or adverse events. Because SO may be a lifelong condition and because chlorambucil therapy may offer long-term, drug-free remission, this treatment may be worth considering early in the decision-making process for severe sight-threatening disease.

Decline in Ocular Toxoplasmosis over 40 Years at a Tertiary Referral Practice in the United States.

PURPOSE: To identify whether there has been a decline in ocular toxoplasmosis at a tertiary uveitis practice. METHODS: Retrospective review of new patients at the University of Illinois Uveitis Service from 1973 to 2012. RESULTS: There were 6820 patients with adequate records for inclusion; 323 (4.7%) were diagnosed with ocular toxoplasmosis. There was a 78.0% decline in prevalence of ocular toxoplasmosis from 2008 to 2012 compared with 1973 to 1977. Compared with the aggregate uveitis population, toxoplasmosis patients were more likely to be Hispanic (p<0.0001) and less likely to be African American (p<0.0001). Ocular toxoplasmosis in Hispanics commonly occurred in foreign-born patients (85.3%). CONCLUSIONS: The diagnosis of ocular toxoplasmosis at our clinic declined, with Hispanics accounting for an increasing proportion of cases. These trends are consistent with the decreasing toxoplasmosis seropositivity in the United States, but may also reflect decreased referrals due to improved management of ocular toxoplasmosis in primary clinics.

Directed conjunctival biopsy and impact of histologic sectioning methodology on the diagnosis of ocular sarcoidosis.

BACKGROUND: Sarcoidosis is an idiopathic, multi-system, granulomatous disease with well-described ocular manifestations. However, other uveitic etiologies can manifest in a similar fashion, and ocular disease may precede systemic manifestations. Definitive diagnosis requires histologic confirmation of non-caseating granulomatous inflammation. This study reports the diagnostic yield of directed biopsy of conjunctival follicles in patients with uveitis suspected to be secondary to sarcoidosis, and compares an institutional standard tissue sectioning method to a multi-plane technique. RESULTS: A retrospective analysis was performed of all patients who underwent directed conjunctival biopsy for suspected ocular sarcoidosis. A total of eight patients were identified; all were females. Directed conjunctival biopsy was positive in three of seven patients using standard histologic processing method, a yield of 43%. Using the multi-plane technique increased the cumulative yield to 63%. CONCLUSIONS: Directed conjunctival biopsy is a minimally invasive, cost-effective, and moderately high yield method of diagnosing ocular sarcoidosis. Using a multi-plane sectioning method may increase biopsy yield when standard sectioning techniques are negative.

Mycobacterial ocular inflammation: delay in diagnosis and other factors impacting morbidity.

IMPORTANCE: The reported outcomes of ocular mycobacterial infection are commonly unfavorable. This study is among the first to elucidate factors associated with poor outcomes, as well as highlight the continued controversies in therapy, particularly the role of oral corticosteroids. OBJECTIVE: To describe presentations and outcomes of mycobacterial ocular disease in the Midwestern United States. DESIGN Retrospective case series. SETTING: A university-based uveitis clinic. PARTICIPANTS: Twenty-six eyes of 17 patients with mycobacterial ocular inflammatory disease seen at University of Illinois at Chicago from 1995 to 2010. MAIN OUTCOME MEASURES: Bivariate and regression analyses were performed to assess factors associated with delay in referral, relapse, and irreversible visual acuity loss (≤ 20/200). RESULTS: Of 17 patients, 13 had isolated ocular disease, 1 had miliary tuberculosis (TB), 2 had TB lymphadenopathy, and 1 had active pulmonary TB. Fourteen had Mycobacterium tuberculosis and 3 had nontuberculous mycobacterial infection. Chest imaging was consistent with granulomatous disease in 46.7%. Average delay from ocular disease onset to uveitis service referral was 755.3 days. Posterior uveitis and non-Hispanic white race were associated with increased delay. A relapsing course was observed in posterior uveitis (odds ratio [OR], 20.0; 95% CI, 1.39-287; P = .03) and those treated with systemic steroids for eye disease (OR, 10.1; 95% CI,1.60-64.0; P = .01). Disease control was achieved in 81%, although 38.5% had profound visual loss, associated with age older than 50 years and delay in diagnosis. Patients diagnosed after 500 days from initial ocular symptoms were more likely to lose vision (OR, 20.0; 95% CI, 1.41-282; P = .03). CONCLUSIONS: Ocular mycobacterial infection occurs in nonendemic areas and cannot be ruled out with negative chest imaging. Tuberculosis and atypical mycobacterial infection should be in the differential diagnosis of ocular inflammation, regardless of patient ethnicity. Significant delays exist in instituting antimicrobial treatment, associated with increased morbidity. Early referral is necessary for patients not responding appropriately to anti-inflammatory therapy.