Aqueous penetration of topical tacrolimus.

PURPOSE: To evaluate the penetration of topical tacrolimus 0.05% into the aqueous humor. OBSERVATIONS: A total of four patients scheduled for routine cataract surgery were included prospectively. We excluded patients with corneal pathology or ocular surface diseases. Topical tacrolimus 0.05% was compounded at our facility. It was dosed every 1 min for 5 min an hour before the aqueous was sampled. Aqueous samples were collected at the time of cataract surgery and were subjected to detection of presence and level of tacrolimus. There were 2 male and 2 female patients. The age range was 58-73 years with a mean age of 66 years. Tacrolimus was detected in the aqueous humor in all patients. The concentration of tacrolimus in the aqueous ranged from 2.6 to 5.6 ng/ml (mean 4.15 ± 1.18 ng/ml). In all patients, the aqueous tacrolimus concentration was greater than the minimal therapeutic level. The study was registered at clinicaltrials.gov (registration number is NCT02794610). CONCLUSIONS AND IMPORTANCE: Tacrolimus was detected in the aqueous humor following topical application. Topical tacrolimus may be a promising steroid-sparing modality for the treatment of anterior uveitis.

Hydroxychloroquine dosing and toxicity: A real-world experience in Saudi Arabia of 63 patients.

PURPOSE: To assess the ocular toxicity in patients on high doses of hydroxychloroquine (HCQ) per weight, as per the latest American Academy of Ophthalmology (AAO) screening guidelines for HCQ toxicity. METHODS: This is a multi-center study looking at consecutive patients attending the ophthalmology clinics at a tertiary hospital and a private clinic in Saudi Arabia. A data collection sheet was used to collect patient's information regarding the dose per body weight, duration of HCQ use and any risk factors associated with the use of the medication as per the latest AAO guidelines for HCQ screening. Ancillary testing including fundus photography, automated visual field (10-2) and spectral domain ocular coherence tomography were done. Further testing with fundus auto-fluorescence and multifocal ERG were done when needed. The presence or absence of toxicity was recorded. RESULTS: A total of 63 patients were included in the study, 58 females and 5 males. The average patient age was 45 years (range 18-72). The mean dosage of HCQ was 3.9 mg/kg. Fourteen (22%) patients were on doses higher than 5 mg/kg. The duration of treatment ranged from 1-30 years (average 8.3). Thirty six (57%) patients were on the drug for more than 5 years. We found only one (1.58%) patient with HCQ toxic retinopathy over a mean of 8 years treatment period. CONCLUSION: A significant number of our patients were found to be on doses of >5 mg/kg of HCQ, which may put them at a higher risk for retinal toxicity. Low dose HCQ such as 100 mg tablets should be made available to help physicians in adjusting the dose as per the latest reported guidelines by the AAO.

Incidence of posterior capsule opacification following phacoemulsification in patients with uveitis.

PURPOSE: The purpose of this study was to evaluate the incidence of posterior capsule opacification (PCO) in patients with inactive uveitis who underwent phacoemulsification with acrylic hydrophobic intraocular lens. METHODS: Thus was a retrospective review of 25 consecutive patients (31 eyes) with uveitis who underwent phacoemulsification. A group of 100 patients (140 eyes) without uveitis served as historical controls. RESULTS: In patients with uveitis, PCO occurred in 11 eyes (35.5%), 6 (19%) of which were visually significant and required treatment with neodymium-doped yttrium aluminum garnet (Nd: YAG) laser. In the control group, PCO developed in 17 (12%) eyes which required treatment with Nd: YAG laser. The incidence of PCO was significantly higher in uveitis patients compared to the control group (P = 0.001), but the incidence of visually significant PCO requiring laser capsulotomy was not statistically significant (P = 0.3). CONCLUSION: The incidence of PCO in patients with uveitis was significantly higher than those without uveitis, but the need for Nd: YAG laser capsulotomy for visually significant PCO was not statistically significant.

Topical Tacrolimus in Thygeson Superficial Punctate Keratitis.

PURPOSE: To evaluate the efficacy of topical tacrolimus 0.02% eye drops in the treatment of patients with Thygeson superficial punctate keratitis. METHODS: Ten consecutive patients with Thygeson superficial punctate keratitis were included retrospectively. Seven patients were unresponsive to topical steroids and/or lubricants. Diagnosis was made based on the history and clinical findings. All patients were treated with topical tacrolimus 0.02% solution twice daily. Outcome measures included improvement in symptoms of tearing and photophobia, whereas improvement in signs included decrease in the number of the lesions, resolution of the lesions, flattening of the lesions, and decrease in stain of the lesions. RESULTS: There were 3 male and 7 female patients with an age range of 3 to 51 years (mean 17 years). All patients had bilateral ocular involvement. Duration of treatment ranged from 1 to 42 weeks (mean 10 weeks). All patients had subjective improvement in symptoms of tearing and photophobia and resolution of the superficial punctate keratitis. The response to treatment was noted 72 hours after initiation of therapy in all patients. Topical tacrolimus was well tolerated in all patients. CONCLUSIONS: Topical tacrolimus 0.02% is safe and effective in reducing ocular surface inflammation in patients with Thygeson superficial punctate keratitis who are not responsive to conventional therapy. Tacrolimus is helpful as a steroid-sparing agent to avoid vision-threatening complications.

Visual loss following cosmetic facial filler injection / Perda da visão após injeção de preenchimento facial para fins cosméticos

ABSTRACT Facial filler injection for soft-tissue augmentation, wrinkle reduction, and rejuvenation has recently become increasingly popular. This procedure is well accepted and widely performed because of its safety and excellent outcomes. However, complications may occur even in the most skilled hands. A 36-year-old female presented with immediate loss of vision in her right eye following the periocular injection of cosmetic hyaluronic acid facial filler into the glabellar region. The visual loss was accompanied by weakness of her left arm. Blindness may complicate cosmetic facial filler injection. The treating physician should have a firm knowledge of the facial vascular anatomy, and the patient should be aware of the potential blinding complications associated with facial filler injection.

RESUMO A injeção de preenchimento facial para o aumento de tecido mole, redução de rugas e rejuvenescimento tornou-se recentemente3 cada vez mais popular. Este procedimento é bem aceito e amplamente realizado devido à sua segurança e excelentes resultados. Porém, complicações podem ocorrer mesmo nas mãos mais habilidosas. Uma mulher de 36 anos apresentou perda da visão no seu olho direito imediatamente após uma injeção periocular de preenchimento facial à base de ácido hialurônico cosmético na região glabelar. A perda visual foi acompanhada de fraqueza no braço esquerdo. A cegueira pode ser uma complicação da injeção de preenchimento facial para fins cosméticos. O médico deve ter um sólido conhecimento da anatomia vascular da face e o paciente deve estar ciente das possíveis complicações associadas à injeção de preenchimento facial.

Visual loss following cosmetic facial filler injection.

Facial filler injection for soft-tissue augmentation, wrinkle reduction, and rejuvenation has recently become increasingly popular. This procedure is well accepted and widely performed because of its safety and excellent outcomes. However, complications may occur even in the most skilled hands. A 36-year-old female presented with immediate loss of vision in her right eye following the periocular injection of cosmetic hyaluronic acid facial filler into the glabellar region. The visual loss was accompanied by weakness of her left arm. Blindness may complicate cosmetic facial filler injection. The treating physician should have a firm knowledge of the facial vascular anatomy, and the patient should be aware of the potential blinding complications associated with facial filler injection.

Initial misdiagnosis of Vogt-Koyanagi-Harada disease.

PURPOSE: To report the initial misdiagnosis of patients with Vogt-Koyanagi-Harada (VKH) disease. METHODS: The medical records of 76 consecutive patients diagnosed with VKH disease were reviewed retrospectively at The Eye Center, Riyadh, Saudi Arabia. Patients were referred to The Eye Center from Saudi Arabia and other Middle Eastern countries. The initial diagnosis was made by an ophthalmologist or neurologist. The main outcome measure was to evaluate cases with VKH disease who were initially misdiagnosed. RESULTS: In 7 (9.2%) out of the 76 patients the initial diagnosis was incorrect. Patients were initially misdiagnosed as optic neuritis (1.3%), intracranial hypertension (1.3%), brain tumor (1.3%), Susac disease (1.3%), migraine (1.3%), rhegmatogenous retinal detachment (1.3%) or anterior granulomatous uveitis of unknown etiology (1.3%). Patients underwent unnecessary tests including MRI and invasive procedures including CSF analysis and anterior chamber paracentesis. CONCLUSION: The initial diagnosis of patients with VKH disease was incorrect in 9 % of the cases. Delay in the diagnosis of VKH disease may lead to delay in management and may cause irreversible damage to the photoreceptors with poor visual outcome.

Topical tacrolimus in anterior segment inflammatory disorders.

Immune mediated inflammatory anterior segment diseases are variable and their management requires intense immunosuppression. Treatment with topical steroids is associated with serious ocular side effects. In order to overcome the potentially blinding complications of topical steroids, immunomodulatory drugs are being used more frequently. Tacrolimus is a calcineurin inhibitor that induces suppression of T lymphocytes activity and reduction of ocular inflammation. Tacrolimus was recently investigated for application in various anterior segment inflammatory disorders. In this review, we will discuss the therapeutic application of topical tacrolimus as a steroid-sparing agent in treating T cell mediated anterior segment inflammation.

Intravitreal Antiangiogenic Therapy of Uveitic Macular Edema: A Review.

Uveitic (or inflammatory) macular edema (UME) is one of the most common cause of visual impairment in patients with uveitis and the most frequent structural complication of uveitis. The use of antiangiogenic agents in the management of macular edema due to inflammation is a fairly new approach. It is not entirely clear if these agents should be used as an adjunct to anti-inflammatory therapy or if they can be used as stand-alone agents in edema due to infections where immunosuppressive therapy could be detrimental to the resolution of infection. This treatment paradigm is largely borrowed from large randomized trials in other retinovascular diseases. Similar prospective studies are needed to clarify the role of antiangiogenic therapy in UME.

Topical tacrolimus solution in autoimmune polyglandular syndrome-1-associated keratitis.

PURPOSE: To evaluate the efficacy of topical tacrloimus eye drops in the treatment of keratitis associated with autoimmune polyglandular syndrome (APS)-1. METHODS: This is a retrospective review of 10 patients with APS-1. The patients were treated with topical tacrolimus 0.01% solution at The Eye Center, between 1 March 2012 and 30 April 2016. The outcome measures included improvement in visual acuity, photophobia and keratitis following treatment. Clinical assessment was carried out before, during and on the last visit following initiation of therapy. RESULTS: A total of 10 patients were included. There were five male and five female patients. The mean age was 11 years with age range of 3-42 years. The mean duration of treatment with topical tacrolimus was 26 months (range 8-46 months). There was improvement of photophobia in 7 out of 10 patients following therapy with topical tacrolimus. In three patients, the photophobia was persistent. There was no clinically detectable improvement in the severity of keratitis in all patients. The mean best corrected visual acuity was 0.1 before and following therapy. CONCLUSION: Topical tacrolimus is effective in reducing the photophobia in patients with APS-1-associated keratitis, but showed no effects on the severity of keratitis.

Efficacy of topical cysteamine in nephropathic cystinosis.

PURPOSE: The aim of this study is to evaluate the efficacy of topical cysteamine 0.55% eye drops in the treatment of corneal cystine crystal deposits in patients with nephropathic cystinosis. METHODS: Thirty-two patients with nephropathic cystinosis were prospectively included in the study. Patients with corneal cystinosis were treated with topical cysteamine 0.55% eye drops. They were examined before treatment, on each monthly visit and after treatment at the last follow-up. Photophobia was classified as grade 0 (none) for no photophobia, grade 1 (mild) for photophobia in bright light, grade 2 (moderate) for photophobia in room light and grade 3 (severe) for photophobia in dim light. Corneal cystine crystals were graded as grade 0=none, grade 1=1-10 crystals/mm2, grade 2=11-50 crystals/mm2, grade 3=more than 50 crystals/mm2. The main outcome measure was evaluation of photophobia and resolution of corneal cystine crystals. RESULTS: There were 13 male and 19 female patients. The mean age was 8 years with an age range of 8 months to 19 years. The mean follow-up period was 4.1 years with a range of 2-8 years. Improvement of photophobia was not clinically significant in symptomatic patients. Patients displayed statistically significant worsening of corneal cystine deposits during the follow-up period. CONCLUSIONS: This study has shown that topical 0.55% cysteamine eye drops may have limited effects in decreasing the corneal cystine deposits in patients with severe forms of nephropathic cystinosis. TRIAL REGISTRATION NUMBER: NCT02766855, Results.

Selective and complementary use of Optical Coherence Tomography and Fluorescein Angiography in retinal practice.

The current field of posterior pole and retinal imaging of the human eye has expanded into detailed analyses of the macula, retinal periphery, individual retinal layers, vitreoretinal interface, imaging of the choroid and the optic nerve head. The challenge in retinal imaging is the enduring pursuit of deeper penetration into tissues, increased resolution to the cellular level, and interpretation of observations. How much deeper can we go and with what resolution and reproducibility? These are fundamental questions for experts in search of novel imaging modalities. New discoveries may resolve existing controversies, but inevitably stimulate new questions. Emerging technologies in retinal imaging include adaptive optics retinal imaging and optical coherence tomography-based retinal angiography. In this review, the focus of our discussion will be the discrepancy between the findings (interpretation) of one imaging technology that do not agree or are not even found with a complementary technology. If a clearly seen abnormality is present with one technology but absent in another, what are the possible explanations? Following is a summary of key concepts of retinal and optic nerve imaging modalities and current controversies regarding their interpretation and/or limitations.

Ocular findings in systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disease. Ocular complications occur in up to one-third of patients with SLE. The ocular findings may represent the initial manifestation of the disease and may lead to severe ocular morbidity and loss of vision. Early diagnosis and prompt management of patients with SLE are mandatory and require collaboration between the ophthalmologist and the rheumatologist.

Efficacy and safety of low-dose topical tacrolimus in vernal keratoconjunctivitis.

OBJECTIVE: The objective of this study was to evaluate the efficacy and safety of topical low-dose tacrolimus (0.01%) solution in patients with vernal keratoconjunctivitis (VKC). PATIENTS AND METHODS: A total of 62 consecutive patients with VKC refractory to conventional treatment were included retrospectively. Tacrolimus 0.01% ophthalmic solution was administered to patients twice daily after discontinuation of all previous topical medications. The duration of treatment ranged from 1 month to 29 months. The clinical symptoms of itching, redness, foreign body sensation, and discharge and the clinical signs of conjunctival hyperemia, conjunctival papillary hypertrophy, limbal infiltration, Trantas dots, and superficial punctate keratopathy were graded as 0 (normal), 1+ (mild), 2+ (moderate), or 3+ (severe). Assessment was carried out before initiation of therapy and on the last visit after treatment. RESULTS: There were 62 patients with VKC comprising 49 male and 13 female patients. The median age was 12 years (range: 5-47 years). The mean visual acuity improved from 20/30 to 20/25 following treatment. There was statistically significant improvement in symptoms of itching (P<0.001), redness (P<0.001), foreign body sensation (P<0.001), and discharge (P<0.001). Statistically significant improvement was also observed in clinical signs of conjunctival hyperemia (P<0.001), limbal infiltration (P<0.001), Trantas dots (P<0.001), superficial punctate keratopathy (P<0.001), and conjunctival papillary hypertrophy (P<0.001). The solution form of tacrolimus was well tolerated. None of the patients developed elevation of intraocular pressure, cataract, or infectious keratitis. CONCLUSION: Low-dose topical tacrolimus 0.01% solution is effective and safe in the management of patients with refractory VKC.

Associations of Systemic Diseases with Intermediate Uveitis.

PURPOSE: To determine the associations of systemic diseases with intermediate uveitis. METHODS: The medical records of 50 consecutive cases with intermediate uveitis referred to The Eye Center in Riyadh, Saudi Arabia, were reviewed. Age- and sex-matched patients without uveitis served as controls. Patients had complete ophthalmic and medical examinations. RESULTS: There were 27 male and 23 female patients. Mean age was 29 years with a range of 5-62 years. Overall, 21 cases (42%) had systemic disorders associated with intermediate uveitis and 29 cases (58%) had no associated systemic disease. A total of 11 patients (22%) had asthma, 4 (8%) had multiple sclerosis, 3 (6%) had presumed ocular tuberculosis, 1 (2%) had inflammatory bowel disease, 1 (2%) had non-Hodgkin lymphoma and 1 (2%) had sarcoidosis. Evidence of systemic disease was found in 50 (5%) of the 1,000 control subjects. Bronchial asthma was found in 37 patients (3.7 %), multiple sclerosis in 9 patients (0.9%), inflammatory bowel disease in 3 patients (0.3%), and tuberculosis in 1 patient (0.1%). None of the control patients had sarcoidosis or lymphoma. There were statistically significant associations between intermediate uveitis and bronchial asthma (p = 0.0001), multiple sclerosis (p = 0.003) and tuberculosis (p = 0.0005). CONCLUSION: Bronchial asthma and multiple sclerosis were the most frequently encountered systemic diseases associated with intermediate uveitis in our patient population. Patients with intermediate uveitis should undergo careful history-taking and investigations to rule out associated systemic illness.

Clinical manifestations and outcome of tuberculous sclerokeratitis.

AIM: To study the clinical manifestations and outcome of patients with tuberculous sclerokeratitis treated with antituberculous therapy without concomitant use of systemic steroids. METHODS: We reviewed retrospectively the medical records of eight consecutive patients with tuberculous sclerokeratitis. Patients were treated unsuccessfully with topical and/or systemic steroids. They underwent complete ophthalmic examination, systemic evaluation, laboratory investigations and imaging. Tuberculin skin test was done with purified protein derivative (PPD) on all patients. The diagnosis of tuberculous sclerokeratitis was made based on clinical findings of scleritis with adjacent peripheral corneal stromal keratitis, positive PPD test of 15 mm of induration or more, response to antituberculous treatment (ATT) within 4 weeks and exclusion of other causes of sclerokeratitis. Antituberculous drugs were given for a minimum of 6 months without concomitant use of corticosteroids. The outcome measure was resolution of the ocular surface inflammation of the sclera and cornea. RESULTS: Eight consecutive patients with a diagnosis of tuberculous sclerokeratitis were included. There were one male and seven female patients. The mean age was 29 years with an age range of 7-43 years. The involvement of the sclera was nodular in six patients and diffuse in two. The involvement of the cornea consisted of peripheral corneal stromal inflammation adjacent to the area of scleritis. Patients responded to antituberculous medications with complete resolution of the sclerokeratitis without topical or systemic anti-inflammatory agents. CONCLUSIONS: Antituberculous medications can lead to complete resolution of the sclerokeratitis without concomitant use of steroids, or other anti-inflammatory agents.

Polymerase chain reaction in unilateral cases of presumed viral anterior uveitis.

BACKGROUND AND OBJECTIVES: Anterior uveitis is the most common form of intraocular inflammation. The main aim of this study was to determine the viral etiology in patients with unilateral cases of anterior uveitis. PATIENTS AND METHODS: A total of 12 consecutive patients with the diagnosis of idiopathic unilateral anterior uveitis were included prospectively. Aqueous specimens were obtained from each patient by anterior chamber paracentesis and subjected to the detection of viral DNA/RNA genome by polymerase chain reaction assay for herpes simplex virus, varicella zoster virus, cytomegalovirus, Epstein-Barr virus, and rubella virus. RESULTS: There were six male and six female patients. The mean age was 43 years, with an age range of 11-82 years. All 12 cases presented with unilateral anterior uveitis. In four (33%) patients, polymerase chain reaction was positive for viral genome. Two patients were positive for herpes simplex virus type 1, one patient was positive for cytomegalovirus and one for Epstein-Barr virus. CONCLUSION: Recent molecular diagnostic assays would help in the identification of the causative agent in patients with unilateral anterior uveitis.