Uveitis Registries - A Digital Tool for Patient Care, Education, Research, and Collaboration.

PURPOSE: Clinical registries are increasingly important in research and clinical advancement. This review explores and compares current uveitis registries and recommends future directions on how uveitis registries can complement one another for synergistic effect and benefit. METHODS: From a systematic search, 861 citations were screened for longitudinal, non-interventional, and multicenter uveitis-specific registries. Additional registries were identified via consultations with uveitis experts. Characteristics of all registries were analyzed and compared. RESULTS: Four registries were identified: Treatment Exit Options for Non-infectious Uveitis, AutoInflammatory Disease Alliance International Registry, Ocular Autoimmune Systemic Inflammatory Infectious Study, and Fight Uveitis Blindness!. Despite certain differences, these registries have the overarching goal of collecting large quantities of real-world, high-quality patient data to improve the understanding of uveitis. CONCLUSION: The four uveitis registries share similar goals and collect clinical data from overlapping geographical regions. There is vast potential for collaboration, including data sharing to further augment datasets for analysis.

Uveitis in Tumor Patients Treated with Immunological Checkpoint- and Signal Transduction Pathway-Inhibitors.

PURPOSE: New tumor therapies like immune checkpoint inhibitors and small molecule inhibitors of MEK and BRAF have increased the patient's survival rate but can be burdened with severe side-effects including uveitis. Here, we show the spectrum, treatment, and outcome of uveitis types induced by tumor treatment. METHODS: In this retrospective study, we have included 54 patients from different centers who were developing uveitis under tumor therapy. A 16-item questionnaire was analyzed for type, treatment, and outcome of uveitis and type of tumor treatment, which we have correlated here. RESULTS: Irrespective of the tumor treatment, most patients developed anterior uveitis. All patients received corticosteroids and some additional immunosuppressive treatments. Cessation of tumor therapy was necessary only in a minority of cases. CONCLUSIONS: Ocular autoimmunity should be differentiated from toxic effects of cancer treatment and timely recognized since it can be generally well controlled by anti-inflammatory treatment, preserving the patient's vision without cessation of the tumor treatment.

Infective Necrotizing Scleritis After XEN Gel Stent With Mitomycin-C.

PURPOSE: The purpose of this study was to report a case of infective necrotizing scleritis following XEN Gel Stent with mitomycin-C. METHODS: Case report. This is a case report of a 68-year-old woman. RESULTS: XEN Gel Stent glaucoma surgery enhanced with mitomycin-C 0.04% and combined with cataract surgery was performed at a regional center to manage the patient's primary open-angle glaucoma. Past medical history was significant for rheumatoid arthritis requiring treatment with methotrexate and adalimumab. Periocular pain and swelling developed 14 months after the initial operation, followed by a rapid deterioration of visual acuity to 20/60, intraocular pressure of 4 mm Hg, and worsening pain 5 months later. On initial presentation to Sydney Eye Hospital, 180 degrees of scleral necrosis was evident with a moderate anterior segment inflammatory reaction and a large temporal choroidal effusion due to hypotony. Empirical hourly topical ofloxacin and cephalothin 5% drops, with oral moxifloxacin, were initiated. Conjunctival swab grew Staphylococcus aureus and Staphylococcus lugdunensis. Significant clinical improvement occurred, but the XEN Gel Stent became exposed after 9 days of treatment with worsening hypotony. Urgent surgical revision was performed to remove the XEN Gel Stent and apply a tutoplast plug with overlying amniotic membrane graft. Intraocular pressure gradually improved over 6 weeks to 15 mm Hg with reversal of hypotonous changes, and visual acuity stabilized at 20/40. CONCLUSIONS: To our knowledge, this is the first reported case of necrotizing scleritis following XEN Gel Stent insertion. It is a reminder that infection should always be the primary differential diagnosis in patients with surgical-induced necrotizing scleritis.

Psychotropic Drug-Induced Glaucoma: A Practical Guide to Diagnosis and Management.

This article provides a practical review of the diagnosis and management of angle closure induced by psychotropic agents, including tricyclic antidepressants, antipsychotics and anticonvulsants. Selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, monoamine oxidase inhibitors and antipsychotics may trigger angle closure by influencing pupil configuration through adrenergic, anticholinergic, serotonergic or dopaminergic mechanisms. Patients with narrow iridocorneal angles are at risk, and these are more common in people with hypermetropia (near-sightedness), older people and individuals with an Asian background. These patients may benefit from a laser peripheral iridotomy, either prophylactically or to relieve an acute angle-closure episode. An idiosyncratic reaction to medications such as topiramate may lead to angle closure through an alternate mechanism, leading to a uveal effusion. Ophthalmological review may be considered prior to commencing medications in high-risk patients.

UVEITIS CAUSED BY TREATMENT FOR MALIGNANT MELANOMA: A CASE SERIES.

BACKGROUND/PURPOSE: To report the largest case series to date of uveitis occurring in association with immunomodulatory therapy for malignant melanoma. METHODS: A retrospective multicenter case review. Twenty-two patients with uveitis occurring in association with either immunotherapy or targeted immune therapy for malignant melanoma were identified. RESULTS: Of 22 patients, 11 had anterior uveitis in isolation. The remainder showed a variety of clinical features including panuveitis, ocular hypotony, papillitis, cystoid macular edema, and melanoma-associated retinopathy. Most patients responded well to treatment. CONCLUSION: We report the largest case series to date of patients with uveitis secondary to drug treatment for malignant melanoma. These cases are likely to increase in number in the future as newer immunomodulatory therapies for cancers are developed and the indications for these drugs increase. A dilemma arises when patients respond well to these drugs but develop vision-threatening side effects.

Development, Implementation, and Evaluation of Treatment Guidelines for Herpes Simplex Keratitis in Sydney, Australia.

PURPOSE: To develop and measure the uptake of a local guideline for herpes simplex keratitis (HSK) and to standardize initial antiviral therapy in Australia. METHODS: The Registered Nurses' Association of Ontario Toolkit: "Implementation of Best Practice Guidelines" was used to develop, implement, and evaluate the guideline at Sydney Eye Hospital. An implementation team was established to reach consensus on antiviral therapy guidelines through review of available evidence, identifying stakeholders, facilitators and barriers, creating strategies for implementation, and developing a sustainability plan. An audit of all adult HSK cases during a 6-month postguideline implementation period was conducted, and the results were compared with a preimplementation audit. A web-based survey was created to assess clinician awareness, usage, and level of knowledge of the guideline. RESULTS: Clinicians, pharmacists, and administrative staff were identified as stakeholders. Changing clinician's behavior was the major barrier to implementation. Implementation strategies included printed and online materials and lectures to clinicians. A postimplementation audit included 85 patients, and 95 clinicians received a web-based survey. The dose of the prescribed antiviral medication was in alignment with the local guideline in 80% (51/64) of the patients compared with 73% (163/223) before implementation (P = 0.331). Stromal HSK with ulceration and keratouveitis were excluded because there were no recommendations before implementation. Over 70% of clinicians (30/41) were aware of the guideline and accessed them through educational resources. CONCLUSIONS: Guidelines for the management of HSK may improve standardization of initial antiviral therapy in HSK. In practice, most clinicians were aware of and adhered to the local guideline.

Post-surgical versus post-intravitreal injection endophthalmitis: changing patterns in causative flora.

IMPORTANCE: Endophthalmitis is a serious complication of intraocular procedures: knowledge of its causative organisms and outcomes may guide prevention and treatment. BACKGROUND: To determine the outcomes and spectrum of causative organisms in acute post-procedural endophthalmitis. DESIGN: A retrospective observational case series performed at a tertiary referral hospital during the period 1 July 2012 to 31 July 2017. PARTICIPANTS: Two hundred and forty-eight patients diagnosed with acute (≤ 6 weeks post-inciting event) endophthalmitis. METHODS: Chart review of microbiological and clinical data. MAIN OUTCOME MEASURES: The main outcome measure was odds of any improvement in visual acuity (3 months versus presentation). Secondary outcomes included causative organism, likelihood of vitrectomy and likelihood of evisceration. RESULTS: One hundred and ninty cases were post-cataract surgery or post-intravitreal injection (49 and 141, respectively). Causative organisms were identified in 45% of post-cataract surgery and 54% of post-injection cases (OR = 0.69; P = 0.61). Staphylococcus epidermidis was the most frequent causative organism. Streptococcus species accounted for 32% of post-surgical and 7% of culture-positive post-injection cases (OR = 6.63; P = 0.02). At 3 months, 81% of post-surgical and 84% of post-injection cases had improved BCVA over presentation (OR 0.59; P = 0.61). CONCLUSIONS AND RELEVANCE: S. epidermidis is the most common causative organism. In contrast to other studies, we did not find evidence for an increased odds of Streptococcus spp. endophthalmitis following intravitreal injection. This may in turn reflect guideline-driven changes in practice.

Normal tension glaucoma management: a survey of contemporary practice.

OBJECTIVE: The aim of this study was to investigate contemporary practice patterns with respect to normal tension glaucoma (NTG) management and to determine whether the 2 largest NTG trials have influenced ophthalmologists' clinical practice. METHODS: A survey questionnaire was sent to ophthalmologists via the American Glaucoma Society, the Canadian Glaucoma Society, and the Canadian Ophthalmological Society. The questionnaire was designed to investigate ophthalmologists' usual practice with respect to NTG and the extent to which practice has been influenced by the Collaborative Normal Tension Glaucoma Study (CNTGS) and the Low pressure Glaucoma Treatment Study (LoGTS). RESULTS: In total, 419 ophthalmologists completed the survey. Of these, 264 respondents were glaucoma subspecialists. The survey showed that 95% and 64% of ophthalmologists were familiar with the CNTGS and the LoGTS, respectively. Of the respondents, 70% indicated that they would initiate treatment in mild-to-moderate NTG without waiting for documented disease progression. Of the respondents, 61% of the total surveyed and 50% of the glaucoma subspecialists felt that the LoGTS results had no impact on their usual clinical practice. The first-choice topical drug for NTG was a prostaglandin analogue (88% of respondents) or brimonidine (10% of respondents). CONCLUSIONS: Most ophthalmologists treat NTG more aggressively than recommended by the CTNGS protocol. Most ophthalmologists felt that the LoGTS results had no impact on their normal clinical practice. The prostaglandin analogues are, by far, the most popular choice of drug for contemporary management of NTG.

Topical difluprednate monotherapy for uveitic macular edema.

OBJECTIVE: To describe the use of topical difluprednate for the treatment of uveitic macular edema. DESIGN: Retrospective review of 3 consecutive cases of uveitic macular edema. METHODS: Patients were treated with topical difluprednate monotherapy. RESULTS: All patients experienced complete resolution of uveitic macular edema within 2-4 weeks. We observed a statistically significant improvement in central subfield macular thickness (p = 0.04). There was an overall improvement in visual acuity, but this result was not statistically significant (p = 0.33). CONCLUSIONS: Topical difluprednate can be effective for uveitic macular edema. Further investigation of this therapy in prospective randomized controlled trials is warranted.

Accuracy of Intraocular Pressure Measurement With the Icare Tonometer in Children.

PURPOSE: The aim of this study was to evaluate the difference between intraocular pressure (IOP) measurements in children with the Icare tonomer (IT) and applanation (AT), pneumatic (PT), or digital tonometers (TT). DESIGN: A randomized prospective trial of children younger than age 16 attending the pediatric ophthalmology department of Manchester Royal Eye Hospital was conducted. METHODS: Children had IOP measured twice, once with an IT and again with a TT, PT, or AT during the same clinic appointment. RESULTS: Forty-four children (88 eyes) were included, with a mean [range (R)] age of 57 (2-144) months. Twelve eyes had anterior segment pathology (ASP), defined as aniridia, congenital glaucoma, or Peters anomaly. Regardless of the presence or absence of ASP, total mean difference (MD), R, positive bias (PB), and limits of agreement (LOA) between IT and other instruments were as follows: PT: MD = 3.2, R = 0 to 8, PB = 2.9, LOA = -1.0 to 6.9; TT: MD = 2.6, R = 0 to 6, PB = 0.9, LOA = -1.8 to 3.5; and AT: MD = 1.4, R = -3 to 5, PB = 0.6, LOA = -4.2 to 7.3. In eyes with ASP, IT comparisons with PT were as follows: MD = 3.9, R = 0 to 8, PB = 3.9, LOA = -0.9 to 8.8. CONCLUSIONS: In children with ASP, IOP measured with IT is higher than expected when compared with other tonometers, in some cases by up to 8 mm Hg. We found an overestimation of IOP in children using the IT with a positive bias of 4 mm Hg. We propose that the IT overestimates IOP measurements in children compared with standard tonometers. Further work should be carried out on a much larger cohort to establish a suitable correction factor for such children.

Risk of angle-closure glaucoma with bupropion and topiramate.

IMPORTANCE: Epidemiologic studies have shown that antidepressants may increase the risk of angle-closure glaucoma. We examined the risk of angle-closure glaucoma with bupropion hydrochloride, a unique, popular antidepressant also marketed as a smoking cessation aid. OBSERVATIONS: A nested case-control study was conducted using a large health claims database in the United States from January 1, 2006, to March 31, 2014. The database contained deidentified information pertaining to a cohort of 6 110 723 patients. Cases were defined according to the first coding for angle-closure glaucoma. For each case, 10 control participants were selected and matched to the cases using density-based sampling. Adjusted rate ratios were computed for bupropion, topiramate (positive control group drug), and esomeprazole (negative control group drug). The adjusted rate ratio was 1.09 (95% CI, 0.75-1.59) for bupropion and 2.59 (95% CI, 1.56-4.30) for topiramate. In a prespecified analysis of patients younger than 50 years, the adjusted rate ratio was 1.98 (95% CI, 1.02-3.84) for bupropion and 5.30 (95% CI, 2.54-11.04) for topiramate. CONCLUSIONS AND RELEVANCE: Both bupropion and topiramate are widely prescribed drugs. The risk of angle-closure glaucoma in patients younger than 50 years was twice as high in patients taking bupropion and more than 5 times higher in patients taking topiramate.

Ophthalmic surgical training following modernising medical careers: regional variation in experience across the UK.

OBJECTIVES: To evaluate surgical experience among current doctors appointed into ophthalmology training posts since the introduction of the Modernising Medical Careers programme. Additionally, to identify regional variations in surgical experience and training programme delivery. DESIGN: A cross-sectional survey. SETTING: The UK's four largest deaneries (Schools of Ophthalmology). PARTICIPANTS: Trainee ophthalmologists, all having completed three or more years of training, who were appointed to the new ophthalmic specialty training programme. PRIMARY AND SECONDARY OUTCOME MEASURES: The mean annual surgical rate for each deanery in phacoemulsification cataract extractions and experience in other common elective and emergency surgical operations. Second, to calculate the mean timetabled clinical activity. RESULTS: The responses of 40 doctors were analysed, with a response rate of 83%. Overall, the phacoemulsification rate was 73.52±29.24 operations/year. This was significantly higher in the South Thames Deanery (99.69±26.16, p=0.0005) and significantly lower in the North Western Deanery (48.08±19.72, p=0.0008). The annual mean complex cataract rate was 5.21±4.38. Only 40% were confident in dealing with the most common complication of cataract surgery (vitreous loss). The mean trabeculectomy (surgery for glaucoma) rate was 0.47±1.16 and for squint surgery it was 3.54±2.82 operations/year. Regarding the common ocular trauma surgery, 42.5% had not sutured a corneal laceration and 60% a globe rupture. 50% thought the training programme would adequately prepare them surgically. The timetabled clinical activity was highest in the South Thames Deanery (48.17 h/week) and lowest in the North Western Deanery (40.82 h/week) due to variations in the European Working Time Directive implementation and on-call commitments. CONCLUSIONS: Significant regional variations in surgical training experience exist between UK deaneries, particularly with respect to cataract surgery, and they appear to be correlated to timetabled activity. Experience and confidence levels in managing complex cataract surgery and complications were low and experience with previously commonly performed elective and emergency operations was minimal. Although doctors from all the regions surveyed were very likely to achieve the minimum cataract extractions required for specialist training completion, we have identified shortcomings of the current training programme that need attention.

Automated keratometry in routine cataract surgery: comparison of Scheimpflug and conventional values.

PURPOSE: To compare the mean keratometry (K) readings obtained with a conventional automated keratometer (IOLMaster) and a Scheimpflug keratometer (Pentacam) in eyes having preoperative assessment for routine cataract surgery. SETTING: Epsom and St. Helier University Hospitals, London, United Kingdom. DESIGN: Evaluation of diagnostic technology. METHODS: Mean K values were obtained with the conventional and Scheimpflug keratometers. The following Scheimpflug readings were evaluated: anterior K, true net power, and Holladay equivalent K measured at 1.0 to 7.0 mm corneal diameters. Mean readings for each type of keratometry were compared. Bland-Altman plots were used to determine the 95% limits of agreement (LoA) for the conventional and Scheimpflug keratometers. RESULTS: The mean conventional K was statistically significantly greater than the mean Scheimpflug K for true net power and equivalent K at 1.0 mm, 2.0 mm, 3.0 mm, and 4.0 mm corneal diameters. The mean conventional K was significantly less than the equivalent K at 5.0 mm, 6.0 mm, and 7.0 mm. The smallest mean difference was for equivalent K at 4.5 mm (0.02 diopters [D]). The smallest 95% LoA were -0.68 to 1.16 D (equivalent K at 5.0 mm) and -0.91 to 0.95 D (equivalent K at 4.5 mm). CONCLUSIONS: Overall, the equivalent K at 4.5 mm had the closest match with the conventional K values. The degree of interdevice variability with the conventional keratometer was lowest for the equivalent K at 4.5 mm and 5.0 mm, although this variability would be sufficient to influence intraocular lens power selection.

Scheimpflug keratometry versus conventional automated keratometry in routine cataract surgery.

PURPOSE: To evaluate keratometry (K) readings obtained with an automated keratometer (IOLMaster) and Scheimpflug imaging (Pentacam) in eyes having routine cataract surgery and to compare the predicted and actual refractive outcomes. SETTING: Epsom/St. Helier University Hospitals, London, United Kingdom. METHODS: In this retrospective study, the mean absolute prediction errors (MAEs) were obtained for automated keratometry and Scheimpflug keratometry: true net power, anterior K, and equivalent K [corrected] values for 1.0 to 7.0 mm corneal diameters. Eyes were divided into lower delta K (mean 1.15 diopters [D]) and higher delta K (mean 2.13 D) groups and lower preoperative astigmatism (mean 0.83 D) and higher preoperative astigmatism (mean 2.55 D) groups to determine notable trends. RESULTS: The study evaluated 29 eyes. The lowest MAE was 0.424 D +/- 0.421 (SD) for Scheimpflug equivalent [corrected] K at 3.0 mm; the second lowest was 0.452 +/- 0.359 D for automated keratometry, which had the smallest SD overall. The difference was not statistically significant. In the lower delta K and astigmatism groups, the automated keratometer had the lowest MAE and smallest standard deviation. In the higher groups, there was a trend toward increased accuracy for the Scheimpflug equivalent [corrected] K values at 3.0 mm. CONCLUSION: In this small study, Scheimpflug imaging was not superior to automated keratometry overall, but the data suggest a trend toward increased accuracy of Scheimpflug equivalent [corrected] K values in eyes with more irregular corneas. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Corneal graft surgery combined with subconjunctival bevacizumab (avastin).

PURPOSE: To describe the use of subconjunctival bevacizumab (Avastin) as an adjunctive treatment in a vascularized cornea at the time of lamellar keratoplasty to reduce the risk of graft rejection. MATERIALS AND METHODS: After a significant ocular high-velocity thermal injury, a patient developed extensive corneal scarring and a traumatic cataract. To improve vision, a corneal graft was indicated, but the presence of extensive neovascularization increased the risk of early graft rejection. RESULTS: Bevacizumab was injected subconjunctivally before surgery to reduce the corneal vessel load. There was a dramatic response in terms of vessel regression, but this was short lived and the vessels quickly regrew. The subconjunctival bevacizumab injection was repeated at the time of combined cataract extraction and lamellar corneal graft surgery, and the feeder vessels were cauterized at the limbus. After 6 months, the graft remained clear of vessels. CONCLUSIONS: This case is of interest because the eye was treated twice with subconjunctival bevacizumab with good short-term results in both instances but different longer-term outcomes in terms of vessel regrowth. This case suggests that the antiangiogenic effects of bevacizumab may be effectively harnessed at the time of a definitive surgical procedure, which reduces the stimulus for vessel regrowth.

Corneal perforation associated with pellucid marginal degeneration and treatment with crescentic lamellar keratoplasty: two case reports.

PURPOSE: To describe 2 cases of corneal perforation associated with pellucid marginal degeneration (PMD) and subsequent successful management with crescentic lamellar keratoplasty. METHODS: Two cases are discussed along with the relevant literature. RESULTS: Both patients presented with spontaneous corneal perforations and associated features consistent with PMD. In both cases, there was fellow eye evidence of PMD, and 1 of the patients was already known to our unit with this diagnosis. Initial conservative measures were unsuccessful, and both patients underwent crescentic lamellar keratoplasty as the definitive surgical management with a good visual outcome. CONCLUSIONS: Crescentic lamellar keratoplasty is an effective technique for the management of this rare complication of PMD.