[Deficient prevention and late treatment of diabetic retinopathy in Mexico]. / Prevención deficiente y tratamiento tardío de las complicaciones retinianas de la diabetes en México.

INTRODUCTION: Retinopathy is a frequent complication of diabetes, causing visual impairment in 10% and blindness in 2% of diabetic patients. The aim of this study is to describe the clinical profile of diabetic patients in an ophthalmologic unit in Tijuana, México. METHODS: Retrospective study of a random sample of 500 clinical charts of patients with diabetes who attended the Retina Service of "Fundación CODET para la Prevención de la Ceguera IBP" Ophthalmologic Center between 2006 and 2010. RESULTS: The main complaint of 58% of patients was decreased visual acuity in first evaluation. Only 6.2% of patients were referred by a health professional. Forty-six percent of the patients had a history of diabetes of at least 15 years. Thirty percent had clinically significant visual impairment at first visit, which was associated with a long history of diabetes and previous eye surgery. Twenty-five percent of these patients who were treated at our clinic experienced visual deterioration due to advanced retinopathy. CONCLUSION: Patients with diabetic retinopathy are referred to ophthalmological service tardily, when visual loss is usually severe and irreversible.

Mycophenolate mofetil therapy for sarcoidosis-associated uveitis.

PURPOSE: To evaluate the control of ocular inflammation and the steroid sparing effect in patients with sarcoidosis-associated uveitis treated with mycophenolate mofetil (MMF). METHODS: Retrospective case series. All patients with a diagnosis of sarcoidosis-associated uveitis that were treated with MMF between 2005 and 2007 were identified. The dose and duration of MMF therapy and side effects were recorded. RESULTS: Seven patients (14 eyes) with sarcoidosis-associated uveitis were treated with MMF. The mean duration of treatment was 10 +/- 4.7 months and the average time to control uveitis was 6.7 weeks. The flare-up rate was 51.5 per 100 person-years follow-up. The best-corrected mean logMAR VA revealed improvement in all 14 eyes. The efficacy of MMF in keeping disease activity under control was maintained in 6 patients. CONCLUSION: These data suggest that MMF is effective in controlling sarcoidosis-related ocular inflammation, has a corticosteroid sparing effect and a manageable side-effect profile.

Intravitreal bevacizumab in refractory uveitic macular edema: one-year follow-up.

PURPOSE: Uveitis is a major cause of ocular morbidity in developed countries. It has been demonstrated that macular edema is a significant cause of decreased visual acuity and macular edema in these patients. In this article, we evaluate the long-term outcome of intravitreal bevacizumab in the treatment of refractory uveitic macular edema. METHODS: In this retrospective, noncomparative, interventional case series, uveitic patients with macular edema who were refractory to conventional therapy and who were treated with intravitreal bevacizumab were identified and assessed. Best-corrected visual acuity and optical coherence tomography central macular thickness measurements were collected and analyzed with correlative statistical analysis, including the use of Student paired t-test, Kaplan-Meier, and linear regression analysis. RESULTS: Twenty-nine eyes of 27 patients with diverse uveitic etiologies were analyzed and followed up at 1 year. Thirteen patients received a single intravitreal bevacizumab injection. Six patients required a second intravitreal bevacizumab injection, while 10 patients received combination therapy of intravitreal bevacizumab and triamcinolone acetonide. Baseline mean logMAR visual acuity was -0.59. At 1 year, the mean logMAR visual acuity was -0.42-/+ 0.36 (p=0.0045). Baseline mean central macular thickness was 383.66 microm. At 1 year, the mean thickness was 294.32-/+110.87 (p=0.0007). CONCLUSIONS: Intravitreal bevacizumab is a useful and therapeutically beneficial agent in the treatment of refractory uveitic macular edema. Some patients will require adjunctive intravitreal bevacizumab injections or the use of combination therapy with intravitreal triamcinolone acetonide.

Intravitreal triamcinolone acetonide injection for treatment of refractory diabetic macular edema: a systematic review.

OBJECTIVE: To compare intravitreal triamcinolone acetonide (IVTA) injection versus no treatment or sub-Tenon triamcinolone acetonide (STTA) injection in improving visual acuity (VA) of patients with refractory diabetic macular edema (DME; unresponsive to focal laser therapy). CLINICAL RELEVANCE: Diabetic macular edema is the leading cause of visual loss in diabetic retinopathy. Laser therapy has been the standard of care for patients with persistent or progressive disease. More recently, it has been suggested that IVTA injection may improve VA. METHODS AND LITERATURE REVIEWED: The following databases were searched: Medline (1950-September Week 2 2008), The Cochrane Library (Issue 3, 2008), and the TRIP Database (up to September 1, 2008), using no language or other limits. Randomized controlled trials were included that consisted of patients with refractory DME, those comparing IVTA injection with no treatment or STTA injection, those reporting VA outcomes, and those having a minimum follow-up of 3 months. RESULTS: In the 4 randomized clinical trials comparing IVTA injection with placebo or no treatment, IVTA injection demonstrated greater improvement in VA at 3 months, but the benefit was no longer significant at 6 months. Those who received IVTA injection had significantly higher IOP at 3 months and at 6 months. In the 2 randomized clinical trials comparing IVTA injection with STTA injection, IVTA injection demonstrated greater improvement in VA at 3 months, but not at 6 months. Intravitreal triamcinolone acetonide injection demonstrated no difference in IOP at 3 months or at 6 months. CONCLUSIONS: Intravitreal triamcinolone acetonide injection is effective in improving VA in patients with refractory DME in the short-term, but the benefits do not seem to persist in the long-term. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Outcomes of cataract surgery in children with chronic uveitis.

PURPOSE: To evaluate the outcomes of cataract surgery in children with chronic uveitis. SETTING: Massachusetts Eye Research and Surgery Institution, Boston, Massachusetts, USA. METHODS: This retrospective chart review was of patients younger than 17 years with a history of uveitis who had cataract surgery before June 2004. RESULTS: Thirty-four children (41 eyes) were identified. The mean age of the 10 boys and 24 girls was 9.8 years (range 4 to 17 years) and the mean total follow-up, 4.1 years (range 0.3 to 15.7 years). Twenty-one children had juvenile idiopathic arthritis-associated uveitis, 7 had pars planitis, and 6 had other conditions. Sixteen patients had concomitant posterior segment pathology, 25 received perioperative immunomodulatory therapy, and 13 had intraocular lens (IOL) implantation. The postoperative best corrected visual acuity improved in 35 of 41 eyes; 31 eyes had an improvement of 3.6 lines at 1 year. Most patients (92%) improved after IOL implantation. Most patients (88%) who received immunomodulatory therapy attained better vision, but this was not statistically significant compared with those who did not (P = .47). Similarly, there was no statistically significant difference between those with posterior pathology and those without. At the end of the analysis (1 year), the cumulative probability of improvement in visual acuity in 41 eyes reached 0.91. CONCLUSION: In most cases, and with optimum control of intraocular inflammation, cataract surgery improved the visual outcome in children with chronic uveitis. Intraocular lens implantation was well tolerated in most cases, which may result in optimal vision.

Flare-up rates with bimatoprost therapy in uveitic glaucoma.

PURPOSE: To evaluate the rate of flares in patients with uveitic glaucoma treated with topical bimatoprost and to assess its effect on intraocular pressure (IOP) in this subset of patients. DESIGN: Retrospective case series. METHODS: All patients seen at one subspecialty uveitis practice with history of uveitic glaucoma treated with topical bimatoprost were identified and the data collected, which included onset, type, duration of uveitis, onset of secondary glaucoma, and previous therapies for glaucoma. The time of onset of bimatoprost therapy, the IOP, and flare-up rate before and after initiation of treatment with bimatoprost were recorded at one week and one, three, and six months of follow-up. RESULTS: Of the 42 patients (59 eyes) identified, 12 patients had used other topical lipid agents, which were replaced by bimatoprost. Twenty-three patients had not used any lipid agents and bimatoprost was added to their existing antiglaucoma regimen. Seven patients were newly diagnosed with uveitic glaucoma and were commenced with topical bimatoprost. The rate of uveitis flares while on other antiglaucoma therapy was 52 per 100 person-years follow-up, while on bimatoprost therapy it was 32.4 per 100 person-years follow-up (P = .206). The mean IOP prior to bimatoprost therapy was 27 +/- 13.2 mm Hg and after initiation of topical bimatoprost was 15 +/- 5.5 mm Hg at the end of six months (P = .0008). CONCLUSION: These data suggest that bimatoprost is an effective IOP-lowering agent in patients with uveitic glaucoma in whom the uveitis is controlled on immunomodulatory therapy, and it does not increase the rate of flares of uveitis in these patients.

Biologic response modifier therapy for psoriatic ocular inflammatory disease.

PURPOSE: To evaluate the efficacy and safety of biologic response modifiers (BRMs) in the treatment of patients with psoriatic ocular inflammatory disease. METHODS: The records of 8 patients diagnosed with psoriatic ocular inflammatory disease who received adalimumab or infliximab were reviewed. Main outcome measures were control of intraocular inflammation, visual acuities, and adverse effects of therapy. RESULTS: The mean patient age was 53 +/- 15 years. Three patients had psoriatic panuveitis, 3 had psoriatic scleritis, and 2 patients had psoriatic anterior uveitis. The ocular inflammatory disease was bilateral in 7 patients. Four patients received adalimumab, and 4 received infliximab. Average time of therapy was 6.1 +/- 4.7 months. Six patients were treated concurrently with methotrexate. With respect to visual acuity, 2 patients demonstrated improvement, 2 patients demonstrated deterioration, and 4 patients remained stable. Seven patients achieved remission of their ocular inflammation. CONCLUSIONS: BMRs can be a useful adjunctive therapy for psoriatic ocular inflammatory disease.

Patterns of exacerbations of chronic non-infectious uveitis in pregnancy and puerperium.

PURPOSE: To determine patterns of exacerbations of recurrent non-infectious uveitis during pregnancy and puerperium. DESIGN: Retrospective cohort study. METHODS: The medical records of 32 women with a history of chronic non-infectious uveitis, who were pregnant during their follow-up at the Ocular Immunology and Uveitis Service of the Massachusetts Eye and Ear Infirmary, from 1983 through 2003, were reviewed. The uveitis relapse rate during pregnancy was compared to the relapse rate during pregnancy-free periods in these women and to the relapse rate in a control group of women of childbearing age with recurrent non-infectious uveitis. RESULTS: Among the 32 women who were pregnant during follow-up (40 pregnancies), the rate of flare-ups during pregnancy (1.0 recurrence per year) was lower than that observed during non-pregnant periods (2.4 per year; p<0.001) and lower than that observed in the non-pregnant control group (3.1 per year; p<0.001). Flare-ups were most frequent in the first trimester of pregnancy and decreased markedly in the second and third trimesters (2.3, 0.5, and 0.4 recurrences per year, respectively; p<0.001). CONCLUSIONS: Pregnancy is associated with lower numbers of flare-ups of non-infectious uveitis compared to the non-pregnant state. If flare-ups do occur during pregnancy, they happen predominantly in the first trimester.

Comparison of postoperative pain in patients following photorefractive keratectomy versus advanced surface ablation.

PURPOSE: To compare postoperative pain associated with advanced surface ablation versus traditional photorefractive keratectomy (PRK). SETTING: Codet-Aris Vision Institute, Tijuana, Mexico. METHODS: This prospective double-masked randomized study included 56 eyes of 28 myopic patients who received traditional PRK in 1 eye and advanced surface ablation in the contralateral eye. For advanced surface ablation, removal of corneal epithelium was performed by incubating the cornea with 18% ethanol. Subsequently, the epithelium was removed by a surgical microsponge. For eyes treated by PRK, mechanical debridement of corneal epithelium was performed with a surgical blade. Excimer laser corneal ablation was performed using the Nidek EC-5000 excimer laser in all eyes. On postoperative days 1 and 3, patients were instructed to rate their pain via 3 pain measuring tools: (1) a global subjective rating; (2) a 100 mm visual analog scale (VAS); and (3) an 11-point numerical rating scale. RESULTS: All 28 patients completed postoperative questionnaires on day 1 and day 3. On postoperative day 1, all reported pain in both eyes. Using the global assessment rating, patients reported statistically significant more pain in eyes treated by advanced surface ablation (P = .0037; confidence interval [CI], 59%-92%). Furthermore, based on the 11-point numerical rating scale, mean pain scores were significantly higher in the advanced surface ablation treated eyes (P = .0121), while the VAS mean pain scores were marginally significantly higher (P = .0822). On postoperative day 3, 23 patients reported the presence of some pain, at least in 1 eye. Using the global assessment rating, 70% of the those who had pain reported more pain in the advanced surface ablation-treated eye (advanced surface ablation 16/23 versus PRK 7/23) (P = .0931; 95% CI, 47%-87%). In addition, on postoperative day 3, advanced surface ablation-treated eyes demonstrated slightly higher mean pain scores based on the 11-point numerical rating scale and on the VAS; however, mean differences were not statistically significant (P = .3494 and P = .3337, respectively). CONCLUSIONS: Advanced surface ablation was associated with statistically significantly more postoperative pain than PRK on postoperative day 1. A greater percentage of patients reported more pain in the advanced surface ablation-treated eyes on day 3. Refractive surgeons should consider the postoperative pain associated with advanced surface ablation when deciding on the type of epithelial debridement for their patients.

Analysis of pediatric uveitis cases at a tertiary referral center.

OBJECTIVE: To analyze demographics, anatomic data, diagnoses, systemic associations, and visual outcomes of pediatric patients in a large tertiary eye center. DESIGN: Retrospective cohort study. METHODS: The records of 1242 patients with uveitis referred to the Ocular Immunology and Uveitis Service of the Massachusetts Eye and Ear Infirmary (MEEI) from 1985 to 2003 were reviewed retrospectively. Two hundred sixty-nine patients 16 years and younger were identified. RESULTS: Among 269 children with uveitis, 53.5% were girls, 82% were Caucasian, and 82% were born in the United States. Mean age was 8 years (standard deviation, 3.8; range, 1-16). Anterior uveitis represented 56.9% of cases; intermediate, 20.8%; panuveitis, 16%; and posterior, 6.3%. Nongranulomatous (77.6%) and noninfectious (85.7%) were the most frequent types of inflammation. The process was bilateral in 74.4% of patients. Mean follow-up was 22 months, with mean age of 8 years at diagnosis. Mean duration of uveitis at the time of presentation at the MEEI was 2 years. The range of time between the diagnosis of uveitis and referral was 1 day to 5.6 years. The length of time between diagnosis of uveitis and the referral to the tertiary center strongly correlated with the complication rate and degree of visual impairment in our study. The longer the time before the patients were seen by the uveitis expert, the worse the visual outcomes. No systemic associations were found in 58% of patients, juvenile idiopathic arthritis was responsible for 33% of cases, 8% of patients had other systemic associations, and 1% had tubulointerstitial nephritis uveitis syndrome. CONCLUSIONS: Uveitis remains a serious cause of morbidity and visual loss in children. Timely referral to uveitis specialists in the tertiary referral centers may lead to improved visual outcomes in children with chronic uveitis.