Clinical Features of Japanese Patients with Ocular Inflammation and Their Surgical Procedures Over the Course of 20 Years.

PURPOSE: To review clinical characteristics of ocular inflammation patients in Osaka, Japan, over 20 years and investigate the efficacy of required surgeries. METHODS: We conducted a retrospective study involving 2730 eyes of 1815 patients with ocular inflammation examined at the Osaka Medical College Hospital from April 1999 to March 2019. RESULTS: Patients comprised 843 males and 972 females, with a mean age of 56.3 ± 18.5 years. Anterior uveitis, such as scleritis, acute anterior uveitis, and herpes iritis, was the most common anatomical classification (51.2%), followed by panuveitis (37.2%), posterior uveitis (9.4%), and intermediate uveitis (2.2%). Sarcoidosis occurred in 153 patients (8.4%), Vogt-Koyanagi-Harada disease (VKH) in 83 (4.6%), and Behçet's disease in 68 (3.7%). Sarcoidosis peaked in two age groups: 30s and 50-70s. Of the 1815 patients, 389 eyes of 271 patients (14.9%) had cataract surgery, 162 eyes of 133 (7.3%) had vitrectomy, and 124 eyes of 103 (5.7%) had glaucoma surgery. Among cataract surgery patients, 49 (18.1%) had sarcoidosis, 14 (5.2%) had VKH, and seven (2.6%) had Behçet's disease, and visual acuity (VA) was improved in 321 eyes (82.5%). Among vitrectomy patients, 15 (11.3%) had acute retinal necrosis, 14 (10.5%) had sarcoidosis, 12 (9.0%) had fungal endophthalmitis, and 11 (8.3%) had malignant lymphoma (ML); 83 eyes (51.2%) needed vitrectomy due to vitreous opacity, and VA improved in 88 eyes (54.3%). Among glaucoma surgery patients, 13 (12.6%) had sarcoidosis, and nine (8.7%) had Posner-Schlossman syndrome. CONCLUSION: Anterior uveitis was the commonest form of uveitis and sarcoidosis was the commonest underlying disease. The age distribution of sarcoidosis was older than in previous reports. 10% of patients with sarcoidosis needed glaucoma surgery, and vitrectomy was required in 50% for vitreous opacity caused by ML or sarcoidosis.

Development of central retinal artery occlusion accompanied by choroidal folds in a patient with antineutrophil cytoplasmic antibody-associated vasculitis: A case report.

RATIONALE: We report a case of central retinal artery occlusion (CRAO) accompanied by choroidal folds in a patient positive for myeloperoxidase (MPO)-antineutrophil cytoplasmic antibody (ANCA). PATIENT CONCERNS: The study involved a 67-year-old female patient who presented at the Department of Ophthalmology, Osaka Medical College, Takatsuki-City, Osaka, Japan on October 24, 2016 after becoming aware of a sudden decrease of visual acuity (VA) in her right eye. Other than suffering with scleritis 6-months previous, there was no obvious past history. DIAGNOSIS: Upon examination, the VA in her right eye was hand motion, and the anterior segment of that eye showed thinning of the superior sclera. Macular edema in the inner retina and cherry red spots were observed in the ocular fundus, and optical coherence tomography (OCT) findings showed hyperreflectivity of the inner retina and choroidal folds. Fluorescein angiography (FA) examination of the fundus showed scattered areas of no retinal perfusion, and indocyanine green angiography (IA) findings of the fundus indicated a possible choroidal circulatory disturbance in her right eye. Blood test findings revealed the patient to be positive for MPO-ANCA. Based on the above findings, the patient was diagnosed with CRAO and choroidal circulatory disturbance due to ANCA-associated vasculitis. INTERVENTIONS: For treatment, steroid semi-pulse therapy was initiated. OUTCOMES: Post treatment initiation, the fundus features and choroidal folds gradually improved, and her VA slightly improved to 0.08. LESSONS: Based on the FA, IA, and OCT findings, the present case was considered to have CRAO accompanied by choroidal circulatory disturbance due to ANCA-associated vasculitis, a rare disease that may be complicated by choroidal circulatory disturbances.

A Case of Large Sarcoid Choroidal Granuloma Treated with Steroid Pulse Therapy.

PURPOSE: To report a case of large sarcoid choroidal granuloma that was successfully treated with steroid pulse therapy. CASE REPORT: A 38-year-old man presented with the primary complaint of decreased visual acuity (VA) in his left eye. Upon examination, a large white protruding lesion of 10 × 8 papilla diameter in size was observed in the macular region, and slightly temporal to it, in the patient's left eye. Whole-body contrast-enhanced computed tomography performed for differential diagnosis detected numerous enlarged lymph nodes throughout the body, including the bilateral hilar regions. Sarcoidosis was diagnosed by biopsy of the right cervical lymph nodes showing noncaseating epithelioid cell granuloma. The fundus lesion was found to be a choroidal granuloma caused by sarcoidosis, and steroid pulse therapy was started. The granuloma was considerably decreased, and the VA in the left eye improved to 0.7 after 2 months. CONCLUSION: Steroid pulse therapy was found to be effective as an initial treatment for a large sarcoid choroidal granuloma.

A Case of Pneumatic Displacement with Gas Tamponade Performed for Macular Subretinal Hemorrhage Complicating Vogt-Koyanagi-Harada Disease.

We experienced a case of subretinal hemorrhage (SRH) from choroidal neovascularization (CNV) complicating Vogt-Koyanagi-Harada disease (VKH) that underwent pneumatic displacement of hematoma by intravitreal gas injection. A 76-year-old male revealed VKH relapses and optical coherence tomography showed irregular retinal pigment epithelium in his right eye and serous retinal detachment and retinal pigment epithelial detachment in his left eye. Fluorescein angiography of the left eye showed hyperfluorescence possibly attributable to CNV. One month later, SRH occurred in the left eye, yet it was spontaneously absorbed. However, approximately 1 year later, the SRH recurred in the left eye affecting a wide area, including the macular region, and his visual acuity (VA) decreased to 0.06. When pneumatic displacement of the hematoma by intravitreal gas injection was performed, the SRH was inferiorly displaced, and his VA improved to 0.4. Pneumatic displacement with gas tamponade was effective for treating a case of SRH caused by persistent CNV complicating VKH.

A case of scleritis associated rheumatoid arthritis accompanying an intraocular elevated lesion.

BACKGROUND: Scleritis and/or uveitis sometimes accompanies patients who suffer from rheumatoid arthritis. However, few studies have reported scleritis and/or uveitis accompanying a fundus elevated lesion, such as an intraocular tumor. In this study, we report a case of rheumatoid uveitis associated with an intraocular elevated lesion. CASE PRESENTATION: A 66-year-old female visited another eye clinic and was diagnosed as bilateral anterior uveitis, and was prescribed steroid eye drops for treatment. She had previously been diagnosed as rheumatoid arthritis at the age of 30 years. Due to vitreous opacity that appeared in her right eye, we increased the instillation of steroid eye drops and the amount of oral prednisolone. Although the inflammation had improved, anterior uveitis relapsed, and an intraocular whitish elevated lesion resembling an intraocular tumor at the superior nasal retina appeared. We speculated this lesion to be a granuloma complicated with rheumatoid arthritis. Thus, we increased the amount of prednisolone administration, and the lesion began to shrink and ultimately fully disappeared. CONCLUSIONS: We strongly believe that our case's lesion was a subretinal granuloma related with rheumatoid arthritis, as it disappeared by increased corticosteroid treatment. Our findings show that we should consider rheumatoid arthritis in a differential diagnosis of such types of fundus elevated lesions.

A Case of Syphilitic Uveitis in Which Vitreous Surgery Was Useful for the Diagnosis and Treatment.

PURPOSE: To report a case of atypical syphilitic uveitis complicated with retinal vasculitis, proliferative retinopathy, and vitreous hemorrhage in which vitreous surgery was useful for the diagnosis and treatment. CASE REPORT: A 38-year-old female was referred to our hospital after noticing visual disturbance in her right eye. Fundoscopy examination of that eye revealed retinal phlebitis accompanied by retinal hemorrhage and soft exudate, and remarkable exudative changes in the retinal vessels from the upper arcade to the macula region. After a blood examination, a serological test showed positive for syphilis; however, systemic findings were scarce. Syphilitic uveitis was suspected, so we administered treatment for syphilis, anticoagulant treatment for retinal vasculitis, steroids for intraocular inflammation, and photocoagulation for the retinal nonperfusion area. However, her visual acuity (VA) decreased to 30 cm/counting fingers due to vitreous hemorrhage resulting from fibrovascular membrane at the optic disc. Since the vitreous hemorrhage was insufficiently absorbed, vitreous surgery was performed to remove the hemorrhage and fibrovascular tissue. Following surgery, the uveitis and retinal vasculitis subsided, and her corrected VA improved to 0.3. Postoperative examination of a fixed quantity of collected vitreous fluid for syphilis showed a Treponema pallidum hemagglutination value of 5,120 times the normal amount, thus confirming the syphilitic uveitis diagnosis. CONCLUSIONS: Our findings show that when observing patients with obstructive retinal vasculitis of unknown causes, syphilitic uveitis should be considered as a differential diagnosis, and that vitreous surgery is useful for the diagnosis and treatment of atypical syphilitic uveitis which has progressed to proliferative retinopathy.

Ocular Behçet's disease is less complicated with allergic disorders. A nationwide survey in Japan.

OBJECTIVES: Behçet's disease (BD) is a systemic inflammatory disorder polarised to the Th1 and Th17 immune systems. Allergic diseases are polarised to the Th2 immune system. The aim of the present study is to investigate the prevalence of allergic diseases in patients who have BD. METHODS: The study involved a large-scale interview survey of Japanese patients with BD at 21 institutes of ophthalmology; 353 patients (255 males and 98 females) were recruited for this study. We analysed the history of allergic diseases such as atopic dermatitis (AD), allergic rhinitis (AR), bronchial asthma (BA) and drug/food allergies (FA). RESULTS: Oral aphthous ulcers, ocular lesions, skin lesions, genital ulcers, arthritis, neurological lesions, intestinal lesions, deep vein thrombosis and epididymitis were reported in 95.8%, 98.6%, 72.5%, 44.8%, 13.9%, 6.8%, 6.2%, 3.7% and 1.4% of the patients, respectively. It was also reported that 73 patients (20.7%) had histories of allergic diseases: AD (5 cases, 1.4%), AR (36 cases, 10.2%), BA (19 cases, 5.4%) and FA (30 cases, 8.5%). This percentage was significantly lower than in a survey that Japan's Ministry of Health, Labour and Welfare conducted for healthy population (47.6%) (odds ratio = 0.29, 95% confidence interval = 0.22-0.38, p=4.9×10-22). Frequencies of posterior/pan-uveitis, relatively severe ocular findings, and visual prognosis were not affected by a history of allergic diseases in BD. CONCLUSIONS: Patients with BD had fewer complications from allergic diseases than did the entire population of Japan.

Bilateral Cytomegalovirus Retinitis in a Patient with Systemic Lupus Erythematosus.

PURPOSE: The purpose of this study was to report the case of a patient who underwent vitrectomy for bilateral rhegmatogenous retinal detachment caused by cytomegalovirus (CMV) retinitis while undergoing steroid and immunosuppressant therapy for systemic lupus erythematosus (SLE). CASE REPORT: We report on a 29-year-old female who was undergoing steroids and immunosuppressants treatment for SLE at Osaka Medical College Hospital, Takatsuki City, Japan. Examination of the patient due to prolonged and worsening diarrhea revealed positive test results for C7-HRP, and she was diagnosed with CMV colitis. She was subsequently admitted to the hospital and started on intravenous ganciclovir for treatment. Approximately 1.5 months later, her primary complaint was deterioration of the upper visual field in her left eye, and she was then referred to the Department of Ophthalmology. Numerous granular exudative spots were found around the lower retinal area of her left eye with retinal breaks that had developed in an area of retinal necrosis that resulted in retinal detachment. After time was allowed for the patient's general condition to improve, a vitrectomy was performed on that eye. The patient subsequently developed a similar retinal detachment in her right eye, for which she underwent a vitrectomy. Although the patient required multiple surgeries on both eyes, her retinas currently remain reattached and the inflammation has subsided. CONCLUSION: The findings of this study show that strict attention must be paid to SLE patients on immunosuppressive therapy due to the possible association of CMV retinitis.