Diagnosis, Treatment, and Prevention of Noninfectious Acute Anterior Uveitis with or without Human Leukocyte Antigen B27 in Adults - Expert Consensus in Taiwan.

BACKGROUND: Anterior uveitis is the most common anatomical type of uveitis. Patients with noninfectious anterior uveitis may develop various ocular complications and eventually visual impairment. Appropriately differentiating the etiologies can help clinicians to predict the outcome, arrange clinical follow-up, and decide the treatment or prevention strategy. Adequate treatment and effective prevention strategies can reduce the frequency of recurrence and the risk of developing complications. Human leukocyte antigen (HLA)-B27 is the most common positive finding in patients with noninfectious AAU in many countries including Taiwan. PURPOSE: To report a consensus from experienced uveitis specialists and rheumatologists was made in Taiwan. METHODS: A panel of nine ophthalmologists from nine different referral centers with expertise in the management of uveitis and an experienced rheumatologist was held on January 16, 2022. A comprehensive literature review was performed. Differential diagnoses for etiologies, general treatments, and prevention strategies were discussed. Each statement in the consensus was made only if more than 70% of the experts agreed. RESULTS: A flow chart and seven statements regarding the differential diagnoses for etiologies, treatments and preventions, and co-management with rheumatologists were included in the consensus. CONCLUSIONS: This article discusses the general diagnosis, treatment, and prevention of noninfectious acute anterior uveitis, with or without HLA-B27, in adults for general ophthalmologists to improve overall outcomes of these patients.

Bilateral Optic Disc Edema as an Initial Presentation of Acute Retinal Necrosis.

PURPOSE: We reported a case of acute retinal necrosis (ARN) that presented as isolated bilateral optic disc edema. METHODS: A case report. CASE: A 68-year-old male with a 3-day history of progressive blurred vision presented with isolated bilateral optic disc edema. Through history taking, we found that he was diagnosed with herpes zoster affecting the lumbar and sacral dermatomes in the past month. Five days later, the patient experienced acute deterioration in visual acuity, with the left eye deteriorating to perception of light only. Bilateral retinal necrosis was noticed. We tested the aqueous samples with polymerase chain reaction and identified positive varicella-zoster virus (VZV) results. A diagnosis of bilateral acute retinal necrosis caused by VZV infection was established and we administered intravitreal and intravenous antiviral medications, steroids, and performed prophylactic scleral buckling. SUMMARY: This report demonstrates a rare ARN case initially presented with isolated bilateral optic disc edema.

Sympathetic ophthalmia following radiation-induced scleral necrosis in choroidal melanoma.

Sympathetic ophthalmia (SO) is a bilateral granulomatous panuveitis. We report a rare case of SO presenting after scleral necrosis as a late complication of Gamma Knife radiotherapy for choroidal melanoma. A 55-year-old woman presented with primary choroidal melanoma in the right eye and has been treated with Gamma Knife radiotherapy with stable tumor size. Five years after radiotherapy, a pigmented protrusive uveal mass was visibly noted over the superior sclera of the same eye, corresponding to periocular soft tissue enhancement on computed tomography. Biopsies of the pigmented mass showed the absence of malignancy. One month later, acute blurred vision with signs of sympathetic ophthalmia developed in the left eye. The patient received high-dose systemic corticosteroids and immunomodulatory therapy. The intraocular inflammation in the left eye subsided with improving vision, and the uveal mass in the right eye flattened after the anti-inflammatory therapy. Scleral necrosis is a rare complication following radiotherapy for choroidal melanoma and may incite sympathetic ophthalmia, for which prompt and aggressive treatment is important to save vision, especially for the fellow eye.

Granulocyte Colony Stimulating Factor-induced Immune Recovery Uveitis Associated with Cytomegalovirus Retinitis in the Setting of Good Syndrome.

PURPOSE: To report a case of immune recovery uveitis (IRU) secondary to cytomegalovirus (CMV) retinitis in a patient with Good syndrome treated with granulocyte colony stimulating factor (GCSF). METHODS: A case report. CASE: A 54-year-old woman with a history of Good syndrome for 2 years presented with chronic panuveitis in her right eye for 6 months. She had received multiple doses of GCSF for a pulmonary infection. Her visual acuity was hand movement in the right eye. Few anterior chamber cells, dense vitreous haze, and chorioretinal lesions were noted. Granular retinal atrophic lesions without obvious infiltration were observed during diagnostic vitrectomy. Polymerase chain reaction of the vitreous sample was positive for CMV DNA. A diagnosis of IRU secondary to CMV retinitis was made. The inflammation was controlled with topical steroids after surgery. SUMMARY: In this report, we present a patient with Good syndrome who developed IRU secondary to CMV retinitis.

XEN45 Gel Stent implantation in eyes with primary open angle glaucoma: A study from a single hospital in Taiwan.

BACKGROUND: To evaluate the effectiveness and safety of the XEN45 Gel Stent in East Asian patients with primary open angle glaucoma (POAG). METHODS: We retrospectively reviewed 37 medically uncontrolled POAG patients who received XEN45 Gel Stent. The primary outcomes were reduction in intraocular pressure (IOP) and in the number of glaucoma medications 12 months after surgery. The secondary outcomes were requirement for intervention and further glaucoma surgery. The adverse intraoperative and postoperative events were investigated. RESULTS: At the 12-month postoperative follow-up, the mean IOP was significantly reduced from the preoperative value of 21.7 ± 7.7 mmHg to 15.0 ± 2.0 mmHg (p = 0.001). The mean number of glaucoma medications decreased from 3.4 ± 0.9 to 1.3 ± 1.5 (p < 0.001). Seventeen patients (45.9%) required postoperative interventions. Four patients (10.8%) received additional glaucoma surgery. Postoperative IOP at month 1 was significantly associated with outcomes at the 12-month follow-up and the need for subsequent intervention and additional glaucoma surgery. CONCLUSION: The XEN45 Gel Stent effectively reduced the IOP values and number of glaucoma medications in East Asian patients with POAG. No major complications were observed, but almost half of the eyes in the study required intervention for wound healing modification. Postoperative IOP at month 1 was a predictor of surgical success at 12 months after surgery.

Change of Eyelid Parameters in Patients With Marin-Amat Syndrome.

PURPOSE: Marin-Amat syndrome is an acquired facial synkinesis manifesting as involuntary eyelid closure on jaw movement. The authors investigate the clinical features, especially the quantitative changes in eyelid parameters of patients with Marin-Amat syndrome. METHODS: Patients with Marin-Amat syndrome between 2015 and 2017 in a medical center were collected. Clinical features and the change of eyelid parameters, including margin reflex distance 1 (MRD-1), margin reflex distance 2 (MRD-2), and palpebral fissure height, were evaluated. RESULTS: There were 5 men and 3 women with a mean age of 76 years. All had a history of facial palsy. The mean time to onset of Marin-Amat syndrome was 4.4 years after facial palsy. Seven patients (87.5%) developed subsequent ipsilateral facial spasm after facial palsy. Most patient complaints were ptosis (62.5%) and ptosis on eating (37.5%). The mean palpebral fissure height of involved eyes decreased from 5.88 to 2 mm on jaw opening (p = 0.011), which resulted from decrease in MRD-1 (from 2.06 to 0.06 mm, p = 0.012) and MRD-2 (from 3.81 to 1.94 mm; p = 0.012). Botulinum toxin A (Botox) injection into the periorbital orbicularis muscle in 6 patients significantly relieved the change of palpebral fissure height on jaw opening compared with that before injection (9.9% vs. 68.6 %, p = 0.027). CONCLUSIONS: Most patients with Marin-Amat syndrome present with ptosis and might be overlooked or underestimated. The reduction in palpebral fissure height in our patients with Marin-Amat syndrome was due to involuntary orbicularis oculi muscle contraction, resulting in decrease of both the MRD-1 and MRD-2 on jaw opening.

Bilateral cytomegalovirus retinitis comorbid with diabetic macular edema.

Cytomegalovirus (CMV) retinitis comorbid with diabetic retinopathy is uncommon. We report a case of bilateral CMV retinitis and diabetic retinopathy in a patient who underwent pancreas transplantation and share the experience of the treatment outcome. An 18-year-old male diagnosed with type-1 diabetes mellitus received pancreas transplantation and immunosuppressive therapy suffered from progressively blurred vision in both eyes for several days. His visual acuity was 20/100 in the right eye and 20/50 in the left eye. Ophthalmic examination revealed bilateral diabetic macular edema (DME) without intraocular inflammatory signs in either eye. The DME subsided after 2 monthly intravitreal injections of aflibercept. However, bilateral panuveitis with CMV retinitis was observed after antivascular endothelial growth factor therapy. The retinitis subsided gradually but completely after systemic and intravitreal antiviral therapy. However, bilateral DME recurred and persisted despite repeated injections of aflibercept during the resting follow-up period. Our case suggests that CMV retinitis can coexist with other retinal diseases, including diabetic retinopathy. Treatment is difficult in such cases.

Long-term outcome of combined vitrectomy and transscleral suture fixation of posterior chamber intraocular lenses in the management of posteriorly dislocated lenses.

BACKGROUND: There is no general consensus on the optimal choice of intraocular lenses (IOLs) or fixation methods in eyes with inadequate capsular support. The purpose of this study was to determine the long-term safety, efficacy and refractive status of combined vitrectomy and transscleral suture fixation of posterior chamber (PC) IOLs in the management of posteriorly dislocated lenses in Taiwan. METHODS: We conducted a retrospective interventional study at our medical facility. The posteriorly dislocated crystalline lenses (or dislocated IOL) were removed with pars plana vitrectomy followed by transscleral suture fixation of PC IOLs at the same setting. Additionally, preexisting ocular condition, postoperative visual acuity (VA) and refraction were recorded. RESULTS: Fifteen patients were enrolled for analysis, including traumatic posteriorly dislocated IOLs in seven cases, and traumatic posteriorly dislocated crystalline lenses or retained lens nuclei after cataract surgery in eight cases. The end result of our study showed that best-corrected VA of 6/12 or better was achieved in 13 patients (87%) after a mean 45 months follow-up. The mean VA significantly improved from 0.98 logarithm of the minimum angle of resolution (logMAR) at baseline to 0.14 logMAR at last follow-up (p < 0.01). The refractive status after suture fixation of PC IOL revealed a mean myopic shift of -1.18 ± 1.47 D from the predicted spherical equivalent. Overall, most complications were minor. Ciliary body hemorrhage occurred during operation in one case and was cleared without visual compromise. Erosion of prolene suture through conjunctiva was noted in three patients. Elevated intraocular pressure was well controlled by topical antiglaucoma medications in three cases. No suture breakage or IOL dislocation was noted in any of the patients. There were no serious adverse events of retinal detachment, corneal compromise, or endophthalmitis in any of the patients. CONCLUSION: Our data showed that use of combined vitrectomy and transscleral suture fixation of PC IOLs is a safe and efficient technique to correct aphakia in eyes without adequate capsular support. Our study demonstrated good long-term visual outcome with only minor complications. Furthermore, we recommend that the IOL power should be adjusted 1.00 D less for transscleral suture fixation.

Inverse relationship between central obesity and osteoporosis in osteoporotic drug naive elderly females: The Tianliao Old People (TOP) Study.

To examine the relationship between central obesity and osteoporosis in elderly females in a rural community, a total of 368 ambulatory elderly women were recruited by random sampling during July 2009. Structured questionnaires were completed to survey possible osteoporosis-related risk factors. Subjects were dichotomized into either noncentral obese (waist circumference [WC]<80cm) or central obese subgroups (WC≥80cm) for further analysis. Bone mineral densities were scanned by dual-energy X-ray absorptiometry installed in a mobile bus. Thoracolumbar spine X-ray examination was interpreted by the same radiologist. Of the 365 subjects with completed data, 275 (75.3%) aged women were classified as having osteoporosis based on diagnostic Model III. Compared with the nonosteoporosis subjects, the subjects with osteoporosis had relatively higher mean age, lower body mass index, and a lower percentage of central obesity. Using the binary logistic regression method, central obesity was negatively associated with osteoporosis in all 3 models (odds ratios in the 3 models were 0.348, 95% confidence interval [CI]: 0.130-0.927; 0.444, 95% CI: 0.218-0.905; and 0.415, 95% CI: 0.184-0.936, respectively; p<0.05). Our study suggests that the paradox between central obesity and osteoporosis in elderly women should be of concern and warrants further study.