Histologic findings of bevacizumab-treated human conjunctiva in Stevens-Johnson syndrome.

PURPOSE: To present the histopathologic findings of the conjunctiva of a patient with Stevens-Johnson syndrome (SJS)-associated ocular surface neovascularization (OSN) after topical bevacizumab (TB) treatment. METHODS: A 40-year-old man with SJS and OSN received topical bevacizumab (25 mg/mL) for 12 months in 1 eye in addition to previously bilaterally administered tobramycin/dexamethasone eye drops. He subsequently underwent bilateral release of symblephara to relieve diplopia. Conjunctival samples from both eyes were obtained for histopathologic study. RESULTS: The TB-untreated conjunctiva manifested marked stromal vascularization (approximately 4-5 blood vessels per high-power field) and perivascular mononuclear inflammatory cells. The TB-treated eye manifested with markedly less stromal vascularization (approximately 1-2 vessels per high-power field) in the conjunctiva and absence of perivascular inflammatory cells. CONCLUSIONS: These histopathologic findings provide evidence that TB penetrates the ocular surface, induces regression of OSN, and possibly moderates ocular inflammation. TB may be a useful additional treatment for OSN among patients with SJS.

Limbal relaxing incisions and Graves ophthalmopathy with lower eyelid retraction.

Limbal relaxing incisions (LRI) were performed in a 35-year-old man with Graves ophthalmopathy and lower eyelid retraction. He underwent intraocular lens exchange in 1 eye and cataract surgery in the other. Despite the return of normal thyroid function, aggressive lubrication, and antiinflammatory medication, the LRIs failed to heal, leaving gaps in the limbal cornea. Limbal relaxing incisions should be avoided in Graves ophthalmopathy with lower eyelid retraction and/or exposure keratopathy.

Surgery for hypotony in patients with juvenile idiopathic arthritis-associated uveitis.

PURPOSE: To describe the clinical response to cyclitic membrane excision of eyes with juvenile idiopathic arthritis (JIA)-associated uveitis and hypotony. METHODS: The clinical records of patients with JIA-associated uveitis in a tertiary referral center were reviewed. Those patients with JIA-associated uveitis and hypotony who underwent cyclitic membrane excision were included in the study. Patients with hypotony secondary to active inflammation, retinal detachment, and surgical intervention (filtering, cyclo-destructive procedures, and glaucoma valve implantation) were excluded. RESULTS: Two pediatric and two adult patients (4 eyes) were identified. The range of pre-operative intraocular pressure (IOP) was 0-5 mmHg. The two adult patients were noted to have atrophic ciliary processes intra-operatively, while the two pediatric patients had normal ciliary processes. At six months follow-up, the adult patients had IOPs of 5 mmHg, while the two pediatric patients had IOPs of 16 mmHg. At last consultation (mean duration of follow-up: 3.6 years), IOP was normal in all eyes. None of the eyes had a decrease in vision. CONCLUSIONS: Release of traction on the ciliary body by inflammatory membranes may play a role in the management of hypotony in patients with JIA-associated uveitis. However, even though the IOP was successfully elevated, preventing phthisis, vision remained poor due to the long-standing complications secondary to chronic uveitis. This emphasizes the critical importance of early diagnosis and appropriate treatment of the inflammation before vision-robbing complications occur.

Obliterative microangiopathy presenting as chronic conjunctivitis in a patient with relapsing polychondritis.

PURPOSE: To report histopathologic findings and treatment of obliterative microangiopathy in a patient with chronic conjunctivitis due to relapsing polychondritis (RP). METHODS: This interventional case report describes a 50-year-old woman with relapsing polychondritis was referred to the Ocular Immunology and Uveitis Service for bilateral tearing due to refractory chronic conjunctivitis. Ocular examination revealed the presence of bilateral follicular conjunctivitis. Conjunctival biopsy of the inferior palpebral conjunctiva was performed, and the histopathologic findings guided the therapeutic intervention. RESULTS: The pathology of the conjunctival biopsy included granulomatous obliterative microangiopathy with numerous eosinophils, plasma cells, lymphocytes, and epithelioid cells in the substantia propia. The chronic conjunctivitis resolved with systemic methotrexate therapy. CONCLUSIONS: Microangiopathy may cause chronic conjunctivitis in patients with RP and may be a harbinger of evolving nonocular problems as a consequence of incomplete control of this autoimmune disorder. Immunomodulatory therapy should be considered in such cases to prevent possible cardiovascular, renal, respiratory, and neurologic complications of vasculitis. Although methotrexate has been used in treatment of RP-related necrotizing scleritis with poor results, it can be sufficient for the conjunctivitis with microangiopathy associated with RP.

Outcomes of treatment with immunomodulatory therapy in patients with corticosteroid-resistant juvenile idiopathic arthritis-associated chronic iridocyclitis.

PURPOSE: To describe the clinical outcome of patients with juvenile idiopathic arthritis (IA)-associated chronic iridocyclitis unresponsive to conventional therapy, in whom inflammation was eventually controlled using immunomodulatory therapy (IMT), and to determine if patients treated early with IMT have better visual acuity outcomes than those treated with corticosteroid alone. METHODS: Patients with JIA-associated chronic iridocyclitis receiving immunomodulatory therapy at the Ocular Immunology and Uveitis Service of the Massachusetts Eye and Ear Infirmary between 1981 and 2001 were studied. INCLUSION CRITERIA: JIA with chronic corticosteroid-dependent uveitis; IMT for a minimum of one year; minimum follow-up of three years; inflammation eventually controlled for a minimum of six consecutive months by IMT. RESULTS: At last visit, 51% of eyes (23 eyes) had acuity of 20/20 to 20/40, 16% (7 eyes) had 20/50 to 20/100, and 33% (15 eyes) had 20/200 or less. In patients whose chronic inflammation was eventually controlled within three years from onset of the uveitis, final bilateral vision was maintained within 20/20 to 20/30, except for a patient whose one eye had poor vision at initial consultation. When acuities at the end of the follow-up period of patients treated early with IMT were compared with acuities at the initial consultation of patients treated late with IMT, with duration of uveitis matched for each patient, visual acuities of those treated early were statistically significantly better than those treated late with IMT (p < 0.005 right and left eyes pooled; p = 0.0075 best eyes; p = 0.0375 worst eyes). CONCLUSIONS: We noted improvement or maintenance of visual acuity (86%) during the course of follow-up of patients with treatment-resistant JIA-associated uveitis treated with effective IMT. However, only IMT given early in the disease course was noted to be associated with bilateral visual acuity of 20/30 or better.

Mycophenolate mofetil as an immunomodulatory agent in the treatment of chronic ocular inflammatory disorders.

PURPOSE: To evaluate the outcomes of patients with chronic ocular inflammatory disease treated with mycophenolate mofetil as an immunosuppressive and steroid-sparing agent. DESIGN: Retrospective noncomparative interventional case series. PARTICIPANTS: All patients with ocular inflammatory disease treated with mycophenolate mofetil at a single institution between 1998 and 2001. METHODS: Charts of patients seen on the Ocular Immunology and Uveitis Service at the Massachusetts Eye and Ear Infirmary were reviewed. Patients with chronic ocular inflammatory disease were included in the study. MAIN OUTCOME MEASURES: Control of inflammation, steroid-sparing effect, visual acuity, and adverse reactions were measured. RESULTS: A total of 54 patients were evaluated. Control of ocular inflammation with mycophenolate mofetil as monotherapy was achieved in 35 patients (65%) and in 67 eyes (62%), and a steroid-sparing effect was achieved in 29 (54%) patients. Visual acuity was maintained or improved in 51 patients (94%) and in 97 eyes (90%). Side effects requiring discontinuation of medication occurred in 10 patients (18%). There was neither long-term morbidity nor mortality due to mycophenolate mofetil. CONCLUSIONS: Mycophenolate mofetil is effective in the treatment of patients with steroid-dependent or -resistant chronic ocular inflammatory disorders that fail to respond to conventional steroid treatment. It is a safe and effective steroid-sparing immunomodulatory agent and can be considered an important addition to our armamentarium in the care of patients with ocular inflammatory disease.

Chronic postoperative endophthalmitis due to pseudomonas oryzihabitans.

PURPOSE: To report a case of chronic postoperative endophthalmitis caused by the gram-negative bacterium Pseudomonas oryzihabitans. DESIGN: Interventional case report. METHODS: A 77-year-old man was referred to our service for nonpainful uveitis in the right eye accompanied by increased intraocular pressure of 2 years' duration with onset 4 months after uncomplicated extracapsular cataract extraction and posterior chamber intraocular lens implantation. The uveitis partially responded to topical corticosteroid therapy but was recurrent with tapering of steroids. An anterior chamber tap and vitreous biopsies sent for cultures were negative. Owing to the persistence of inflammation despite intraocular vancomycin injection, the lens implant and capsule were removed and culture of the latter revealed the bacterium P. oryzihabitans. RESULTS: There was no recurrence of inflammation after removal of the lens implant and capsule. CONCLUSIONS: Unlike other gram-negative organisms, which are associated with poor outcomes, P. oryzihabitans may masquerade as chronic uveitis because of its low virulence.