Uveitis Patterns and Severity: An Epidemiologic Study from a Tertiary Care Private Referral Center in Buenos Aires, Argentina.

PURPOSE: To report uveitis' spectrum in a private practice cohort in the city of Buenos Aires, Argentina. METHODS: Retrospective review at Instituto de la Visión (November 2011-October 2015). Standard demographics, ethnicity and Native American aboriginal ancestry were recorded. RESULTS: Among 212 patients, median age 45 (6-97), 10% pediatric, 35% bilateral, 72% non-idiopathic, 36% infectious. Anterior uveitis presented in 50%, followed by posterior (32%), intermediate (9%) and panuveitis (8%). Frequent visits (≥ 6 per year) needed by 29%: posterior, non-idiopathic disease with 79% systemic immunosuppression requirement was their main presentation. Native American aboriginal ancestry was reported by 22.64% of the whole cohort and 37% of frequent visits' subgroup. CONCLUSIONS: Unilateral, non-idiopathic, non-infectious anterior uveitis was the most frequent presentation, in agreement with reports coming from western developed cities. The multi-racial Argentinian population with specific Native American aboriginal ancestry might contribute to certain forms of posterior uveitis and their response to treatment.

Are intravitreal injections essential during the COVID-19 pandemic? Global preferred practice patterns and practical recommendations.

Tertiary outpatient ophthalmology clinics are high-risk environments for COVID-19 transmission, especially retina clinics, where regular follow-up is needed for elderly patients with multiple comorbidities. Intravitreal injection therapy (IVT) for chronic macular diseases, is one of the most common procedures performed, associated with a significant burden of care because of the vigorous treatment regimen associated with multiple investigations. While minimizing the risk of COVID-19 infection transmission is a priority, this must be balanced against the continued provision of sight-saving ophthalmic care to patients at risk of permanent vision loss. This review aims to give evidence-based guidelines on managing IVT during the COVID-19 pandemic in common macular diseases such as age-related macular degeneration, diabetic macula edema and retinal vascular disease and to report on how the COVID-19 pandemic has affected IVT practices worldwide.To illustrate some real-world examples, 18 participants in the International Retina Collaborative, from 15 countries and across four continents, were surveyed regarding pre- and during- COVID-19 pandemic IVT practices in tertiary ophthalmic centers. The majority of centers reported a reduction in the number of appointments to reduce the risk of the spread of COVID-19 with varying changes to their IVT regimen to treat various macula diseases. Due to the constantly evolving nature of the COVID-19 pandemic, and the uncertainty about the normal resumption of health services, we suggest that new solutions for eye healthcare provision, like telemedicine, may be adopted in the future when we consider new long-term adaptations required to cope with the COVID-19 pandemic.

[What will cataract surgery look like in the future? Alternatives in the pipeline]. / Que sera la chirurgie de la cataracte du futur ? Alternatives et voies de développement.

Phacoemulsification is the most frequently performed surgery in the world. Over the past few years, this surgery seems to have reached a plateau with no further innovative breakthroughs. In this paper, we focus on alternatives techniques, the latest innovations, and the research and development pipeline in this field.

First-in-human study of the safety and viability of intraocular robotic surgery.

Microsurgery of the retina would be dramatically improved by instruments that offer supra-human precision. Here, we report the results of a first-in-human study of remotely controlled robot-assisted retinal surgery performed through a telemanipulation device. Specifically, 12 patients requiring dissection of the epiretinal or inner limiting membrane over the macula were randomly assigned to either undergo robot-assisted-surgery or manual surgery, under general anaesthesia. We evaluated surgical success, duration of surgery and amount of retinal microtrauma as a proxy for safety. Surgical outcomes were equally successful in the robotic-surgery and manual-surgery groups. Differences in the amount of retinal microtrauma between the two groups were statistically insignificant, yet dissection took longer with robotic surgery (median time, 4 min 5 s) than with manual surgery (1 min 20 s). We also show the feasibility of using the robot to inject recombinant tissue plasminogen activator under the retina to displace sight-threatening haemorrhage in three patients under local anaesthesia. A safe and viable robotic system for intraocular surgery would enable precise and minimally traumatic delivery of gene therapy or cell therapy to the retina.

The additional value of blood culture bottles in the diagnosis of endophthalmitis.

PURPOSE: To assess the additional value of blood culture bottles (BCBs) in the diagnosis of endophthalmitis by comparing its culture yield with that of conventional media (CM). DESIGN: Retrospective consecutive case series. METHODS: We included patients who were treated between January 2001 and January 2010 for clinically suspected endophthalmitis of any etiology, and had vitreous specimens cultivated in both BCB and CM. RESULTS: Specimens from 85 eyes from 85 patients were included. The culture yield of BCB was 69%, and that of CM was 72% (difference not significant). Adding the results of BCB improved the yield of CM significantly by 13%, resulting in a combined yield of 81%. The sensitivity of detection of Haemophilus influenzae in BCB seemed lower compared with CM, possibly due to the lack of growth factors in the BCB. There was no difference in yield between specimens obtained by tap or by vitrectomy. CONCLUSION: In contrast with earlier reports, we did not find BCB superior to CM. The combined use of BCB and CM increased the pathogen detection rate significantly and should therefore be considered as the microbiological method of choice in the work-up of endophthalmitis.

Use of heavy Trypan blue in macular hole surgery.

PURPOSE: Intraocular dyes facilitate the identification of the inner limiting membrane (ILM) during surgery. Appropriate dyes should be safe, provide adequate staining, and be easy to use. Heavy Trypan blue eliminates the need for an air-fluid exchange (AFX) and appears to have little retinal toxicity. This study refers to a prospective, consecutive trial with heavy Trypan blue in macular hole surgery. PATIENTS AND METHODS: A consecutive group of 20 patients with full thickness macular holes was recruited in a single institution study. Patients were operated using conventional methods. Heavy Trypan blue was prepared by mixing isovolumetrically glucose 10% with MembraneBlue (DORC, Zuidland, The Netherlands). Patients were assessed for ease of surgery and post-operatively at 3 and 6 months (vision and ocular coherence tomography) for hole closure and vision. RESULTS: Twenty eyes were included in the study. Reapplication of dye was used in 75% of the cases, leading to improved contrast further facilitating the ILM peel. In no case was an AFX necessary to obtain sufficient staining. Macular hole closure was achieved in 19 of 20 patients with one surgery. No retinal detachment or other complication was observed in the follow-up period. CONCLUSION: Heavy Trypan blue can be delivered efficiently to the retinal surface without the need for an AFX. Staining was sufficient to help visualise and peel the ILM. Repeat applications were easily performed. The macular hole closure rate was similar to that of other series with a comparable visual improvement.

Mycobacterium bovis endophthalmitis from BCG immunotherapy for bladder cancer.

BACKGROUND: We report a patient who developed BCG endophthalmitis after BCG immunotherapy for bladder cancer. Comparison of this case with 2 other reported cases reveals a similar pattern of elderly, debilitated and immunocompromised patients with poor response to systemic antituberculous therapy in whom systemic steroids are used concurrently. Age and glucocorticoids are known to lead to thymic involution, reduce cell mediated immunity, and a lowering in the number of naive T cells capable of mounting an effective defense to new infectious agents. CONCLUSIONS: Physicians should be aware of the potential for ocular complications of BCG immunotherapy in the elderly, immunocompromised, on oral steroids.

Uveitic macular oedema: correlation between optical coherence tomography patterns with visual acuity and fluorescein angiography.

AIMS: (1) To associate optical coherence tomography (OCT) patterns with particular fluorescein angiography (FA) findings in uveitis patients with macular oedema. (2) To investigate the correlation between tomographic features and visual acuity (VA). (3) To determine the impact of OCT patterns on visual improvement over time. METHODS: 129 eyes of 90 patients followed for uveitis with macular oedema and adequate media clarity were consecutively included from February to November 2004. We examined the relationship between VA, the fluorescein angiograms grading and central thickness. RESULTS: Mean retinal thickness at the central fovea was 357 (SD 128) microm. The mean VA was 0.5 (logMAR). There was agreement between OCT and FA in 112 eyes (86.8%). In eight eyes (6.2%), serous retinal detachment (SRD) was detected on OCT but not on FA. Nine eyes (7%) had perifoveal leakage on FA without macular thickening on OCT. There were three patterns of macular oedema on OCT: diffuse macular oedema (DMO), cystoid macular oedema (CMO) and SRD. CMO was detected in 61 eyes (50.8%), and in 18 of these eyes (15%), CMO was associated with SRD. DMO was detected in 45 eyes (37.5%), and in eight (6.7%) of these eyes, DMO was associated with SRD. SRD without retinal thickening was present in 14 eyes (11%). Epiretinal membrane was detected by OCT in 27 eyes (21%). Six eyes demonstrated vitreomacular traction (4.7%). There was a correlation between VA and central thickness on OCT (r = 0.407, p = 0.000001). Correlation between VA and central thickness is significant in the group with CMO (r = 0.401, p = 0.001) but not significant in the group with DMO. Furthermore, vision recovery was observed in patients with CMO but was limited in patients with DMO. SRD did not have a significant impact on visual recovery, but its presence reduced the correlation between vision and central thickness. CONCLUSION: OCT is effective in detection of macular oedema. It allows determination of the distribution of fluid and quantification of retinal thickness particularly in patients with CMO. In these patients, a potential for vision recovery was also identified. DMO was associated with a poor visual prognosis and a poor prognosis for vision recovery. SRD is associated with a high probability of vision recovery when observed alone or underlying CMO eyes. It should be substracted from the central thickness measurement when attempting to correlate central thickness with vision in patients with macular oedema in uveitis.

Minimally invasive surgery-endoscopic retinal detachment repair in patients with media opacities.

PURPOSE: Evaluate the use of an ophthalmic endoscope in patients with a retinal detachment and anterior media opacity. MATERIALS AND METHODS: A retrospective interventional case series. Search of a comprehensive database of retinal detachment patients with pre-operatively impaired anterior segments such that lens extraction, a keratoprosthesis, or extensive anterior segment manipulation was required for adequate repair. Pars plana vitrectomy was carried out with an endoscope without manipulation of the anterior segment. Characteristics of the detachment were recorded, as were complications/subsequent surgeries, pre-operative, 3-month post-operative, and final follow-up visual acuities. RESULTS: Before surgery, five patients had a gas-induced cataract after a failed pneumatic retinopexy; one patient had a Reis-Buckler's dystrophy and corneal ulcer; three patients had synechiae around iris-fixed lenses. One patient had proliferative vitreoretinopathy. The median pre-operative vision was hand motion (20/30 to light perception). The median final visual acuity was 20/30 (20/20-20/200). Two patients required a subsequent lens extraction, one patient had a recurrent detachment. CONCLUSION: In appropriate retinal detachment patients, endoscopy can be safe and effective, while limiting the scope of the surgical intervention.

Influence of cataract on optical coherence tomography image quality and retinal thickness.

BACKGROUND: As optical coherence tomography (OCT) is widely used for diagnosis and monitoring of ocular pathology, especially in the elderly people, the influence of cataract on image quality and macular retinal thickness was studied. METHODS: In 29 patients scheduled for cataract surgery, preoperative and postoperative OCT scans were obtained. Cataracts were categorised as nuclear, posterior or cortical. Parameters for image quality (signal-to-noise ratio (SNR)) and signal strength and macular thickness were compared. A three-level expert grading scale was used to evaluate the discriminative abilities of SNR and signal strength. RESULTS: Nuclear cataracts (n = 12) provided better preoperative scans (higher SNR/signal strength) than posterior (n = 7) and cortical (n = 10) cataracts (p<0.004). Postoperatively SNR and signal strength increased significantly in all patients (p<0.001). The SNR was better at discriminating poor from acceptable and good scans than signal strength (area under the receiver operating curve: 0.879 and 0.810, respectively). Postoperative macular thickness overall showed a significant increase (p = 0.005), most evident in patients with posterior cataracts (p = 0.028). CONCLUSIONS: OCT imaging is influenced by cataract; image quality is reduced preoperatively and macular thickness measurements are slightly increased postoperatively. In individual patients, OCT scans remain reliable for gross clinical interpretation, even in the presence of cataract.

Precursor B lymphoblastic lymphoma of the orbit in a child: an unusual presentation of a non-Hodgkin lymphoma.

OBJECTIVE: The majority of ocular adnexal lymphomas are marginal zone lymphomas, which occur rarely in children. This case report describes a 6 years old child with a precursor B lymphoblastic lymphoma presenting in the ocular adnexa. The combination of multi-agent chemotherapy with adjuvant radiotherapy seems to be necessary in order to achieve a complete remission of this subtype of lymphoma's in ocular adnexa. DESIGN: Retrospective case study. METHOD: A review of the clinical, pathological, radiological findings and follow-up in a patient from the files available at our center, which were reviewed between the years 1974 and 2004.

Single spot PDT in patients with circumscribed choroidal haemangioma and near normal visual acuity.

BACKGROUND: In circumscribed choroidal hemangiomas (CCH) a long observation period and decreased visual acuity before treatment are risk factors for poor visual outcome. Therefore, we studied the use of limited, single spot photodynamic therapy (PDT) with Visudyne for the timely treatment of CCH. METHODS: Six consecutive patients with CCH, and metamorphopsia but (near) normal visual acuity were treated with PDT, using a single spot covering only the most prominent part of the tumour, and a radiance exposure of 50 J/cm(2). Start of treatment was 6 min following a 1-min infusion with Visudyne (6 mg/m(2) BSA), using a diode laser (692 nm). RESULTS: In all patients, the metamorphopsia disappeared, the OCT images returned to a normal foveal contour, and visual acuity remained 20/20 or improved to 20/20. In five patients, the tumour became ultrasonographically undetectable; in three after one PDT session, in one patient after two and in another patient after three PDT sessions. The last patient had a residual tumour height of 1.2 mm, but no metamorphopsia, a normal foveal contour on OCT, and fluorescein angiography showed no residual leakage. CONCLUSION: The present series demonstrates that single spot PDT might be an effective treatment for CCH with a visual acuity > or =20/30, without serious side-effects during a follow-up of at least 18 months.

Added value of OCT in evaluating the presence of leakage in patients with age-related macular degeneration treated with PDT.

BACKGROUND: Evaluating the presence of leakage on fluorescein angiography (FA) in patients with age-related macular degeneration (AMD) retreated with photodynamic therapy (PDT) can be difficult. New diagnostic tools such as optical coherence tomography (OCT) might help to optimize PDT management. METHODS: Thirty AMD patients scheduled for regular follow-up FA in conjunction with PDT treatment were also scanned with OCT. Follow-up data at 9 months were retrieved from the patients' medical records. Inter-observer agreement [kappa coefficient] for the presence of leakage on FA, for OCT parameters for leakage, and agreement between FA and OCT evaluations were calculated. The indication for retreatment was evaluated using the leakage analysis based on FA alone, OCT alone, and both examinations combined, and compared to the actual follow-up of the patients at 9 months. RESULTS: Agreement between the two observers for the presence of leakage on FA was moderate (kappa=0.51). OCT agreement between the two observers for the presence of leakage was good (kappa=0.85). Agreement between FA and OCT for the presence of leakage was poor (kappa=0.16). Follow-up data at 9 months on all patients were analyzed. Seven out of 30 patients were not retreated at the time of examination, and four of these patients (57%) remained stable without further treatment. Twenty-three patients did receive a PDT treatment at the time of examination; and eight of these patients did not show leakage on OCT, and five of these patients (62%) remained stable without additional treatment. In contrast, only three out of 15 patients (20%) with leakage on both FA and OCT remained stable during this 9 month follow-up period. CONCLUSIONS: Inter-observer agreement for the presence of leakage was moderate for FA and good for OCT. There was considerable disagreement between leakage as judged by OCT and by FA. OCT could be of help in the decision regarding PDT retreatment. Assuming that 57% of the patients without leakage either on FA or OCT would remain stable without retreatment, the rate of probable ineffective retreatment could be reduced from 35% to 20%.

Evaluation of central serous retinopathy with en face optical coherence tomography.

BACKGROUND: The diagnosis of idiopathic central serous retinopathy (CSR) is usually based on biomicroscopy and fluorescein angiography (FA). The optical coherence tomography (OCT) ophthalmoscope produces en face OCT scans (OCT C-scans) and provides additional information not readily available by conventional imaging techniques. The authors describe the characteristic features observed in patients with a clinical diagnosis of CSR using the OCT ophthalmoscope. METHODS: 38 eyes with a clinical diagnosis of CSR, seen at the Academic Medical Centre (Amsterdam, Netherlands) and the New York Eye and Ear Infirmary (New York, USA) between August 2002 and March 2004, were evaluated with standard digital FA and scanned with the OCT ophthalmoscope. RESULTS: Nine of 38 eyes had no serous neurosensory detachment (inactive CSR) when scanned with the OCT ophthalmoscope. Characteristics for active CSR (n=29) were large neurosensory detachment (23/29), subretinal hyper-reflective depoits (20/29), and pigment epithelial detachment (15/29). One third of the patients, either active or inactive, had multiple small pigment epithelial detachments located both within and outside the neurosensory detachment. CONCLUSION: The OCT ophthalmoscope provides complementary morphological information on patients with CSR. The presence of more diffuse retinal pigment epithelium (RPE) changes lends further support to the concept that CSR is a diffuse rather than localised RPE anomaly.

[News on therapies for uveitis]. / Actualités sur les modalités thérapeutiques des uvéites.

The immunosuppression required for the treatment of uveitis can be achieved through conventional agents or through the use of specific modulators of inflammation. Whatever the choice, it is important to limit side effects: by restricting access to certain drugs in patients presenting a high risk of complications (tuberculosis screening before using Remicade), reducing side effects through preventive measures (use of alendronates during oral corticotherapy), or choosing a local delivery route (intraocular triamcinolone). Intraocular triamcinolone has certain beneficial characteristics such as high local dosage without systemic effect. However, it can cause a pressure rise in 10% to 20% of patients. It requires certain precautions when given to prevent development of a pseudo-endophthalmitis. Remicade is a novel synthetic immunosuppressant directed against TNF-alpha. This chimeric antibody can be useful in the treatment of severe uveitis that is unresponsive to conventional therapy. It is currently being tested in clinical trials in uveitis both in Europe and the USA.

The surgical management of chronic hypotony due to uveitis.

PURPOSE: Evaluate surgery in chronic hypotony secondary to uveitis. METHOD: Retrospective analysis of six patients operated for chronic hypotony (< or =5 mmHg) of at least 1 month's duration. Surgery involved removal of all traction and membranes on the ciliary processes. Use of oil was limited to patients with atrophic ciliary processes. RESULTS: The average postoperative follow-up was 24 months (12-43). The average pressure increase was 7 mmHg at 6 months. Four of six uveitis patients had significantly increased vision. CONCLUSION: Improved vision, and a sustained pressure rise are possible in hypotonous uveitis. The presence of ciliary processes is necessary. However, they do not need to be intact.

[From gene to disease; primary open-angle glaucoma and three known genes: MYOC, CYP1B1 and OPTN]. / Van gen naar ziekte; primair openkamerhoekglaucoom en 3 bekende genen: MYOC, CYP1B1 en OPTN.

Primary open-angle glaucoma (POAG) is a group of multifactorial diseases that affects 1.5% of the population. If untreated, the disease leads to irreversible damage to the visual system. The clinical features of POAG are excavation of the optic disc and visual field defects, probably due to degeneration of retinal ganglion cells. Important risk factors for POAG are older age, elevated intraocular pressure, the presence of POAG in relatives, and still largely unknown molecular genetic factors. The clinical, genetic and pathological heterogeneity most likely reflects the complex heterogeneous situation at the molecular level. The three genes known to be involved in POAG (MYOC, CYP1B1 and OPTN) account for up to 18% of the POAG cases. These findings result in new possibilities for the presymptomatic molecular diagnosis of POAG.