Prognostic factors of Vogt-Koyanagi-Harada disease in Singapore.

PURPOSE: To determine prognostic factors of Vogt-Koyanagi-Harada disease (VKH). DESIGN: Retrospective noninterventional. METHODS: Chart review of VKH patients of Singapore National Eye Centre for age at onset (age), gender, race, presenting visual acuity (VA) and VA at one month after starting treatment, severity of inflammation, treatment regime, and hearing loss. Outcome measures were: VA, persistent inflammation, cataracts, glaucoma, macular lesions, chorioretinal degeneration, and vitiligo at three years after onset. RESULTS: There were 134 eyes of 67 patients. Majority were Chinese (n = 53, 79.1%) and female (n = 40, 59.7%). Median duration of follow-up was 9.1 years (range, 3.0 to 53.6 years). Median age was 42.3 years (range, 5.4 to 70.9 years). Main prognostic factors were VA at one month, age, and treatment regime. Good VA at one month was associated with greater likelihood of good VA at three years (odds ratio [OR], 43.9; P = .02), less persistent inflammation (OR, 0.5; P = .006), cataract (OR, 0.10; P = .01), and chorioretinal degeneration (OR, 0.2; P = .04). Older age was associated with higher likelihood of cataract (OR, 1.1; P = .02), chorioretinal degeneration (OR, 1.1; P = .03), and vitiligo (OR, 1.1; P = .004). Early treatment with high-dose systemic corticosteroids resulted in less persistent inflammation (OR, 0.2; P = .04). Late high corticosteroid treatment was associated with greater risk of cataract (OR, 9.6; P = .03). CONCLUSION: Good VA at one month, younger age at onset, and early treatment with high-dose corticosteroids were associated with better outcomes.

Foveolitis associated with dengue Fever: a case series.

BACKGROUND: Dengue fever (DF), a viral infection caused by dengue virus, is characterized by fever, headache, muscle and joint pains. Approximately 50-100 million people are infected annually. Ocular manifestations during DF are uncommon and include intraretinal hemorrhages and cotton wool spots; manifestations predominantly characterized by foveal involvement have not been described before in DF or any other retinopathies. We describe the clinical features of a series of patients with DF-associated foveolitis. METHODS: A retrospective review of patients with maculopathy associated with DF was conducted. Patients found to have a yellow-orange lesion at the fovea, supported by a typical optical coherence tomography (OCT) finding of disruption of the outer neurosensory retina, were analyzed. RESULTS: Ten eyes of 6 patients were studied. The mean age was 19.8 years. The mean presenting best corrected visual acuity was 6/45 (range of 6/7.5 to counting fingers). Fundus examination revealed a yellow-orange lesion at the fovea which corresponded to outer neurosensory retina disruption on OCT. Multifocal electroretinography showed decreased foveal and parafoveal responses. Treatment was variable, depended on visual acuity and ranged from observation to immunosuppression. CONCLUSION: Foveolitis may be associated with DF. OCT is a useful tool for the diagnosis and monitoring of progression of this condition.

Clinical features of cytomegalovirus anterior uveitis in immunocompetent patients.

PURPOSE: To describe the clinical presentation of cytomegalovirus (CMV) anterior uveitis in human immunodeficiency virus (HIV)-negative patients. DESIGN: Retrospective, interventional case series. METHODS: HIV-negative patients with anterior uveitis associated with elevated intraocular pressure (hypertensive anterior uveitis) seen at the Singapore National Eye Centre had their aqueous analyzed for viral deoxyribonucleic acid by polymerase chain reaction, and their records were reviewed for demographic data, ocular findings, laboratory results, and treatment. RESULTS: Aqueous was obtained from 105 of 106 eligible eyes. Twenty-four eyes demonstrated positive results for CMV (22.8%). Eighteen eyes had Posner-Schlossman syndrome (PSS; 75%) at presentation, five eyesba had Fuchs heterochromic iridocyclitis (FHI; 20.8%), and one eye had a presumed herpetic anterior uveitis. Twelve of the 24 eyes were treated with ganciclovir. Of the 12 who completed treatment, all responded clinically, and their aqueous demonstrated negative results for CMV on repeat testing. However, nine had recurrences within eight months of stopping treatment and required further courses of ganciclovir. The 81 CMV-negative eyes included 30 with PSS, 11 with FHI, 27 with uveitic glaucomas of unknown cause, and 13 with presumed herpetic anterior uveitis. CONCLUSIONS: CMV anterior uveitis is not uncommon in our immunocompetent patients and it may present as a recurrent acute or chronic inflammation, resembling PSS, herpetic anterior uveitis, or FHI.

Concomitant choroidal inflammation during anterior segment recurrence in Vogt-Koyanagi-Harada disease.

PURPOSE: To determine whether clinically isolated anterior segment recurrence is associated with concomitant subclinical choroidal inflammation in Vogt-Koyanagi-Harada (VKH) disease. DESIGN: Interventional, retrospective case series. METHODS: Nine patients with recurrent VKH disease who satisfied the following criteria: 1) presence of anterior chamber (AC) inflammation of at least 1+ cells after a period of quiescence of three months or more, 2) no posterior segment involvement, and 3) indocyanine green angiography (ICGA) performed during the time of anterior segment recurrence at the Singapore National Eye Centre. ICGA was performed. Therapy was administered based on clinical features. The main outcome measures were the ICGA features. RESULTS: Twelve eyes of nine patients were included in the study. All eyes had mild AC inflammation of 1 to 2+ cells, except for one eye that had 3+ cells. ICGA showed early large vessel hyperfluorescence, becoming fuzzy in character in the intermediate phase in 11 of 12 eyes with AC inflammation. In four eyes, few hypofluorescent dots were seen in the intermediate phase that remained hypofluorescent in the late phases. Late diffuse hyperfluorescence was observed in five eyes. All patients received high-dose oral prednisolone and topical prednisolone acetate. Four patients required additional steroid-sparing immunosuppressants. All patients attained clinical quiescence within two weeks to two months. Repeat ICGA showed absence of active leakage, significant decrease in choroidal vascular leakage, or no change in the number and density of hypofluorescent spots. CONCLUSIONS: Isolated anterior segment recurrence in VKH disease may occur concomitantly with subclinical choroidal inflammation and requires systemic therapy.

Prevalence of dengue maculopathy in patients hospitalized for dengue fever.

OBJECTIVE: Dengue fever causes numerous systemic manifestations, including maculopathy, with loss of vision. This study sought to determine the prevalence of dengue maculopathy in patients hospitalized with dengue fever. DESIGN: Cross-sectional observational study in which consecutive patients hospitalized with dengue fever during a dengue epidemic were enrolled over a 3-week period. PARTICIPANTS: Patients hospitalized in 2 general hospitals in Singapore with dengue fever. TESTING: Patients completed a standardized questionnaire and underwent tests for near and distance visual acuity (VA), Amsler grid testing, dilated retinal examination, serum complements C3 and C4, and urinary microalbumin. MAIN OUTCOME MEASURES: Dengue maculopathy found on retinal examination. RESULTS: One hundred ninety-seven patients were enrolled, of whom 119 (60.4%) were male and 78 (39.6%) female. The patients ranged between 12 and 67 years old (mean, 32.65). One hundred sixty of 197 patients had positive dengue immunoglobulin M serology. Dengue maculopathy was detected in 27 eyes of 16 of the seropositive patients, giving a prevalence of 10% (95% confidence interval, 6.03%-15.40%). None of the patients who were dengue immunoglobulin M negative had dengue maculopathy. Dengue maculopathy eyes were more likely to have distance acuity worse than logarithm of the minimal angle of resolution 0.15 (Snellen 6/9 or worse) (P = 0.005) and abnormalities on Amsler grid testing (P = 0.001), with a greater proportion of these patients having visual complaints (P = 0.002) and lower mean complement C3 levels (P = 0.008) as compared with patients without maculopathy. Logistic regression analysis showed Amsler grid abnormalities to be the most consistent factor associated with dengue-related maculopathy (P<0.001), with a hazard ratio of 8.669; sensitivity, 29.6%; and specificity, 95.4%. CONCLUSION: The prevalence of dengue maculopathy among patients hospitalized for dengue fever is 10% in our series. Amsler grid abnormalities, reduced distance VA, and the presence of visual symptoms are associated with dengue maculopathy. Low complement C3 levels in these patients suggest that this is an immune-mediated disease.

Dengue-associated maculopathy.

OBJECTIVE: To describe the clinical spectrum of fundus manifestations and angiographic and optical coherence tomographic features of dengue-associated maculopathy in a large series. METHODS: We reviewed clinical records of patients diagnosed as having dengue maculopathy at the Singapore National Eye Centre between January 1, 2002, and December 31, 2005. RESULTS: We identified 41 patients with serological evidence of dengue fever who had ocular signs and symptoms not attributable to other diseases within 1 month after onset of symptoms of dengue. Seventy-one eyes had maculopathy. Mean best-corrected visual acuity in the affected eye was 20/40 (range, hand motions to 20/20). Intraretinal hemorrhages were seen in 45% of eyes, usually in association with venous sheathing. Fundus fluorescein angiography demonstrated venular occlusion in 25% or arteriolar and/or venular leakage in 3% and 13%, respectively. Yellow subretinal dots were an unusual finding in 28%. Of these, 50% showed corresponding hypofluorescent spots on indocyanine green angiography. Central or paracentral scotomas were observed in 63%. Twenty-eight patients received steroid treatment. Mean visual acuity showed significant improvement between weeks 2 and 4, with an increasing proportion of eyes achieving a best-corrected visual acuity of 20/40 or better across time. CONCLUSION: Fundus fluorescein and indocyanine green angiography, optical coherence tomography, and visual field testing are useful tools in the diagnosis of dengue maculopathy.

Corneal endotheliitis associated with evidence of cytomegalovirus infection.

OBJECTIVE: To describe the clinical presentation of cytomegalovirus (CMV) corneal endotheliitis in human immunodeficiency virus (HIV)-negative patients. DESIGN: Retrospective interventional case series. PARTICIPANTS: Twelve consecutive patients with corneal endotheliitis diagnosed between 2002 and 2005. METHODS: Aqueous of eyes with corneal endotheliitis was analyzed for viral DNA by polymerase chain reaction (PCR), and patient records were reviewed for demographic data, medical and ocular history, best-corrected Snellen visual acuity, intraocular pressure (IOP), anterior and posterior segment findings, laboratory workup, diagnosis, and treatment. MAIN OUTCOME MEASURE: Presence of CMV DNA. RESULTS: Corneal endotheliitis was seen in 12 eyes of 10 patients during the study period. There were 8 men and 2 women, and all were Chinese. Their mean age was 49 years (range, 25-61 years). The corneal involvement ranged from small areas of focal endotheliitis to diffuse bullous keratopathy. The keratic precipitates had a variable appearance. There was only mild anterior chamber inflammation with no posterior synechiae. Two thirds of eyes had diffuse iris atrophy. All the eyes had elevated IOP. Eleven of the 12 eyes were positive for CMV DNA. None of the patients were positive for HIV. All patients had received local or systemic immunosuppression, or both, before corneal endotheliitis developed. Ten eyes of 8 patients were treated with systemic antiviral therapy. After treatment, the endotheliitis resolved completely in 7 eyes, and 3 eyes had significant improvement in corneal translucency. The IOP was normal, with no medications in all but 1 eye. Repeat PCR analysis in all the treated eyes was negative for CMV DNA. CONCLUSIONS: Cytomegalovirus infection is an important cause of corneal endotheliitis in our patients, and appropriate antiviral therapy may prevent more ocular damage.

Spectrum of Vogt-Koyanagi-Harada disease in Singapore.

PURPOSE: Review of all cases of Vogt-Koyanagi-Harada disease (VKH) handled in the Uveitis Clinic of the Singapore National Eye Centre, with the aim of determining the clinical spectrum of this disease in these patients and the outcomes of treatment. METHODS: The case notes were retrospectively analyzed for patient demographics, clinical signs, investigations, complications and treatment received. The treatment groups were classified according to the steroid regimen (dose and timing). The early-high (EH) group received > or =1 mg/kg per day of systemic prednisolone within 2 weeks of presenting with symptoms, the late-high (LH) group received the same dose between 2 and 4 weeks of presenting with symptoms, and the low-dose (LD) group received no or lower doses of oral corticosteroids, or received the same high dose, but only after more than 1 month of presenting with symptoms. RESULTS: A total of 178 eyes of 89 patients, mainly of Chinese ethnicity, were examined. The mean age of the patients at onset of the study was 41.80 +/- 14.65 (SE) years, and there were nearly equal numbers of male and female patients. The mean duration of the follow-up was 9.42 years (+/-9.87 years). There were 60 eyes in the EH group, 18 in the LH group, and 68 in the LD group. When the results on our patient group were compared to known data on a number of other ethnic groups, our patients were found to be similar to the Japanese with respect to gender distribution and prevalence, to the Hispanics for alopecia, and to the non-Hispanics of North America for tinnitus and vitiligo. The EH group were more likely to achieve complete resolution, with fewer complications, than the LD group, but one third of the former still developed chronic disease. CONCLUSION: Higher doses of systemic steroids may be required to ensure adequate immunosuppression in VKH patients.

Endophthalmitis after microincision cataract surgery.

We report the first case of streptococcal endophthalmitis after uneventful right bimanual phacoemulsification. Microincision cataract surgery is perceived to be minimally invasive as smaller wounds are equated to shortened healing time, increased safety, and reduced risk for postoperative endophthalmitis. Recommendations for modifications in wound construction are discussed.

A prospective, randomized comparison of Nd:YAG and sequential argon-YAG laser iridotomy in Filipino eyes

Methods: A prospective, randomized, controlled trial was performed involving patients requiring laser iridotomy who were randomized either to Nd:YAG laser or sequential argon-Nd:YAG laser iridotomy. Iris-perforation success rate, the average number of laser shots and amount of laser energy used, the intraocular pressure (IOP) after laser treatment, and the rate of complications were compared. The prelaser pupil size was correlated with the iris perforation success rate. Results: Forty-one eyes underwent laser iridotomy (23 Nd:YAG and 18 sequential). All eyes had patent iridotomies. There was no difference between the two groups in terms of the number of Nd:YAG laser shots delivered (p=0.97) and amount of Nd:YAG energy used (p=0.64). The total amount of laser energy used was higher in the sequential group (p=0.003). There was no significant difference in the IOP and complication rates after treatment. A positive correlation was seen between prelaser pupil size and number of Nd:YAG shots needed to enlarge (r=0.38, P=0.01). Conclusion: Nd:YAG laser alone and sequential argon-Nd:YAG have comparable success in attaining patency of laser iridotomy, IOP control, and rate of complications in dark irides of Filipinos.