Mimickers of anterior uveitis, scleritis and misdiagnoses- tips and tricks for the cornea specialist.

BACKGROUND: Anterior uveitis, inflammation of the anterior chamber and related structures, is a cohort of diseases that can present to almost any general or sub-specialty Ophthalmology practice. Its features classically involve anterior chamber cell and flare. Below the surface of these two signs exist a panoply of diagnoses. BODY: The purpose of this review is to provide a general framework for diagnoses of anterior uveitis that are often missed as well as non-uveitic pathologies that often mimic anterior uveitis. Diagnostic deviation in either direction can have vision-threatening and rarely life-threatening consequences for patients. Using a comprehensive literature review we have collected a broad spectrum of etiologies of anterior uveitis that are easily missed and non-uveitic pathologies that can masquerade as anterior uveitis. CONCLUSIONS: We present a focused review on specific misdiagnosed anterior uveitis pathologies and some of the conditions that can masquerade as anterior uveitis and scleritis.

Specific postoperative complications of vitrectomy in hereditary transthyretin amyloidosis.

INTRODUCTION: Vitrectomy may improve visual acuity of hereditary transthyretin amyloidosis (ATTRv) patients presenting with vitreous opacities but is associated with severe complications. The objective of this study is to report visual outcomes, early and late complications of a series of ATTRv patients who underwent vitrectomy in the French ATTRv reference center. METHODS: This retrospective, single-center study, included all ATTRv patients who underwent vitrectomy between 2002 and 2017. Data were collected on pre and postoperative best corrected visual acuity (BCVA) and early and late postoperative complications. RESULTS: A total of 21 eyes from 15 patients were included. The mean postoperative follow-up was 40 ± 20 months (6-160 months). BCVA increased from 0.7 ± 0.4 LogMAR preoperatively to 0.3 ± 0.4 LogMAR (p = 0.003) at last postoperative visit. During follow-up, all initially glaucomatous eyes worsened, with three eyes (37%) requiring filtering surgery and two eyes (25%) had further vision loss. Among non-glaucomatous patients, four eyes (31%) developed glaucoma with two requiring trabeculectomy and one eye (8%) had further vision loss. Three eyes (three patients) presented with complications of amyloid angiopathy. Three eyes (three patients) experienced recurrence of vitreous deposits requiring surgical revision. CONCLUSION: Due to the potential complications, vitrectomy in ATTRv requires specific perioperative management and life-long postoperative monitoring.

Proton beam radiotherapy for uveal melanoma: results of Curie Institut-Orsay proton therapy center (ICPO).

PURPOSE: This study reports the results of proton beam radiotherapy based on a retrospective series of patients treated for uveal melanoma at the Orsay Center. METHODS AND MATERIALS: Between September 1991 and September 2001, 1,406 patients with uveal melanoma were treated by proton beam radiotherapy. A total dose of 60 cobalt Gray equivalent (CGE) was delivered in 4 fractions on 4 days. Survival rates were determined using Kaplan-Meier estimates. Prognostic factors were determined by multivariate analysis using the Cox model. RESULTS: The median follow-up was 73 months (range, 24-142 months). The 5-year overall survival and metastasis-free survival rates were 79% and 80.6%, respectively. The 5-year local control rate was 96%. The 5-year enucleation for complications rate was 7.7%. Independent prognostic factors for overall survival were age (p < 0.0001), gender (p < 0.0003), tumor site (p < 0.0001), tumor thickness (p = 0.02), tumor diameter (p < 0.0001), and retinal area receiving at least 30 CGE (p = 0.003). Independent prognostic factors for metastasis-free survival were age (p = 0.0042), retinal detachment (p = 0.01), tumor site (p < 0.0001), tumor volume (p < 0.0001), local recurrence (p < 0.0001), and retinal area receiving at least 30 CGE (p = 0.002). Independent prognostic factors for local control were tumor diameter (p = 0.003) and macular area receiving at least 30 CGE (p = 0.01). Independent prognostic factors for enucleation for complications were tumor thickness (p < 0.0001) and lens volume receiving at least 30 CGE (p = 0.0002). CONCLUSION: This retrospective study confirms that proton beam radiotherapy ensures an excellent local control rate. Further clinical studies are required to decrease the incidence of postirradiation ocular complications.

Systemic adverse effects of topical ocular treatments.

Some eyedrops, gels or ointments may cause adverse effects as serious as those observed with systemic therapies. Because of their relatively poor penetration into eye tissue, ophthalmic drugs usually contain high concentrations of their active ingredient. Asking patients about these drugs to prevent interactions is useful when prescribing a new systemic treatment. Conversely, it is advisable to ask about ophthalmic drugs during the etiological investigation of possible iatrogenic effects.

HSV1 latency sites after inoculation in the lip: assessment of their localization and connections to the eye.

PURPOSE: To localize the sites of HSV1 latency in mice after a primary infection induced by injection into the lip and to assess their connection to the eye. METHODS: The SC16 strain of HSV1, or a recombinant virus containing the HSV1 latency-associated transcript (LAT)-promoter driving expression of the LacZ reporter gene, were injected into the left upper lip. Tissues from animals killed at 6, 28, 180, and 720 days postinoculation (dpi) were analyzed for LATs, either by in situ hybridization (ISH) or by identifying LAT-promoter-driven transgene expression. HSV1 antigens were detected by immunochemistry. RESULTS: At 28 dpi, all the neurologic structures that were acutely infected at 6 dpi exhibited a pattern of virus gene expression consistent with HSV1 latency--that is, LATs with no detectable HSV1 antigens. LAT staining differed among structures: intense and widespread within trigeminal neurons, intermediate within the sympathetic intermediolateral cell group of the spinal cord and the facial motor nucleus, and weak in other sites. Long-term expression of LATs (positive at 180 and 720 days) was observed only in tissues where the staining was intense or intermediate at 28 dpi. CONCLUSIONS: After inoculation into the upper lip of mice, HSV1 established latency in several nervous system structures that have direct or indirect connections with ocular tissues. These results suggest that after an oral primary infection, the most frequent in humans, HSV1 may establish latency in several sites connected to the eye and may finally result in herpetic ocular disease involving the cornea, the iris, or even the retina.

Low-dose proton beam therapy for circumscribed choroidal hemangiomas.

OBJECTIVE: To evaluate the efficacy and safety of proton beam therapy for complicated circumscribed choroidal hemangiomas. METHODS: The study was a retrospective nonrandomized investigation. Seventeen consecutive patients, referred to the Institut Gustave-Roussy, Villejuif, France, for circumscribed choroidal hemangioma associated with serous retinal detachment were studied. Each eye received a total dose of 20 cobalt gray equivalents (CGEs) delivered in 15-second fractions of 5 CGEs over 4 days. Functional tests included the initial and final best-corrected visual acuity, slitlamp examination, intraocular pressure, fundus examination, fluorescein angiography, and indocyanine green angiography. Tumor thickness was determined on B-scan ultrasonography. RESULTS: The macula was involved in 7 eyes and the lesion was juxtapapillary in 2 eyes. The mean (SD) tumor thickness was 3.06 (9.0) mm. The mean initial tumor diameter was 6.82 mm (range, 3.2-12.1 mm). The right eye was involved in 7 cases and the left eye in 10 cases. The mean (SD) follow-up period was 52 (58) months (range, 36-90 months). Retinal reattachment was obtained in all cases after a mean period of 2 months (range, 1-12 months; median, 1 month). Tumor regression was obtained in all cases. One recurrence occurred 1 year after the initial treatment in an undertreated area. After re-treatment, however, resolution of the retinal detachment occurred, and flattening of the choroidal lesion was obtained. Final visual acuity improved to 2 Snellen lines or more in 16 eyes (94%), was stable in 1 eye, and attained 20/40 or more in 12 eyes (70.6%). No radiation therapy complications occurred during follow-up. CONCLUSIONS: Proton beam therapy for choroidal hemangiomas seems to be an effective and safe alternative option. A total dose of 20 CGEs delivered in 4 daily 15-second fractions of 5 CGEs seems adequate for local control of both the tumor and serous retinal detachment.

Non-preserved 1% lidocaine solution has less antibacterial properties than currently available anaesthetic eye-drops.

PURPOSE: Some anaesthetics inhibit bacterial growth, and thus may lead to low rates of positive cultures from bacterial keratitis. Antibacterial properties of lidocaine were compared with those of oxybuprocaine or tetracaine, either in current commercial eye lotions or in extemporaneous solutions. METHODS: Forty-eight bacterial strains were used to determine the minimum inhibitory and bactericidal concentrations of four commercial eye lotions containing oxybuprocaine or tetracaine, of a non-ophthalmic 1% lidocaine commercial solution and of extemporaneously prepared solutions of oxybuprocaine, tetracaine, lidocaine and benzalkonium. RESULTS: Most strains had their growth inhibited by 0.2% oxybuprocaine or 0.4% tetracaine, which corresponds to a 1/2 dilution of the commercial eye-drops. Bacterial growth was still observed with a 1% lidocaine solution. CONCLUSIONS: Currently available anaesthetic eye-drops that are used before corneal specimen collection may lead to false-negative bacterial cultures. Conversely, a non-preserved 1% lidocaine solution might be more appropriate in corneal specimen collection.

[Ocular infections of the elderly]. / Les infections oculaires du sujet âgé.

A CLINICAL ASPECT DEPENDING ON THE PHYSIOPATHOGENESIS: Ocular infections are a frequent motive for ophthalmological consultations in geriatric settings because of the mechanical factors related to age (modifications in palpebral dynamics and lacrymal function) and in local and general immune factors leading to the rapid and/or more severe development of infections. The mechanism of microbial contamination of the eye also determines the clinical damage: predominantly local (dirty hands, traumas) with involvement of the surface tissues (conjunctive and cornea) or general, hematogenic or neurogenic, frequently at the origin of more internal infections (iris, choroid, retina, optical nerve). CONJUNCTIVITIS AND KERATITIS: These provoke reddening of the eyes, tears and above all pain when the corneal epithelium is involved. Microbiological samples are useful in cases of severe, presumably infectious keratitis or conjunctivitis. Two emergency situations must be distinguished: any suspicion of herpes for which local corticosteroids are contraindicated and keratitis or conjunctivitis with the use of lenses, often due to Gram negative bacilli, amoeba or fungus, the treatment of which is intensive and the prognosis often severe. OPHTHALMOLOGICAL HERPES ZOSTER: The rapid diagnosis and introduction of efficient doses of antivirals reduces the initial pain, the ocular complications of herpes zoster and post-zoster pain. The latter, when it exists, requires specialized management. ACUTE UVEITIS: A context of intra-ocular inflammation in an elderly patient must always evoke a pseudo-uveitis syndrome, the principle cause of which is lymphoma. Conversely, an uveitis occurring in the days or weeks following ocular surgery, including cataract, must be considered as suggestive of a post-surgical infection and rapidly referred to a specialist. ACUTE DACRYOCYSTITIS: Is manifested by a hard and painful tumefaction below the internal angle of the eye. Following collection, it requires draining through an in incision in the skin, washing and packing of the sac, and systemic antibiotherapy. The preventive treatment of recurrences requires open dacryocystorhinostomy or via endonasal endoscopy.

Corneo-conjunctival autograft transplantation for pterygium surgery.

PURPOSE: To evaluate the efficacy of surgical management of pterygium with corneo-conjunctival autograft transplantation. SETTING: Ophthalmology Department, Bicêtre Hospital, University Paris XI and the Assistance Publique Hôpitaux de Paris, France. METHODS: The records of 104 patients (114 eyes), comprising 40 women and 64 men, who underwent corneo-conjunctival autograft transplantation for primary (104 eyes) and recurrent (10 eyes) pterygia between 1992 and 1998, were reviewed in a retrospective survey. Follow-up ranged from 12 to 78 months (mean 22.5 months). RESULTS: All grafts were planted promptly and donor sites re-epithelialized with no excessive scar tissue formation. No recurrence was noted. Improvement of visual acuity was achieved in 24 patients and stabilization was achieved in 76 patients. The main complication was progression of corneal astigmatism exceeding 4 dioptres in two patients. CONCLUSION: These results indicate that corneo-conjunctival autograft transplantation is an effective treatment for pterygia.

Phacoemulsification combined with silicone oil removal through the posterior capsulorhexis tear.

PURPOSE: To evaluate phacoemulsification combined with silicone oil removal through the posterior capsulorhexis tear. METHOD: The records of 20 patients with cataract after silicone oil repair of retinal detachment with giant retinal tear or complicated by proliferative vitreoretinopathy were reviewed. All eyes underwent phacoemulsification, posterior capsulorhexis, aspiration of silicone oil with an irrigation-aspiration hand piece, and intraocular lens implantation into the capsular bag. Lens calculation was based on the fellow eye. The mean follow-up period after cataract surgery was 15.4 months. RESULTS: There were three recurrences of retinal detachment (15%). Transient corneal edema was noted in two eyes. Unpredictable refraction was the main problem, but the myopic refractive error was <4.5 diopters in all cases. CONCLUSION: Cataract extraction combined with silicone oil removal is an effective technique.

Uveítis viral / Viral uveitis

La uveítis puede ser producida por varios tipos de virus, incluyendo los virus ARN y ADN. Los métodos diagnósticos tradicionales de cultivo utilizados en las infecciones virales o en la determinación de los títulos de anticuerpos contra los antígenos específicos, requieren un conocimiento de las condiciones imprescindibles para el crecimiento de algunos determinantes antigénicos específicos. Estas condiciones, sin embargo, han limitado nuestra posibilidad para identificar los virus que producen uveítis. Las nuevas técnicas de biología molecular, como la técnica de PCR, han mejorado nuestras posibilidades diagnósticas en esta enfermedad. En el presente trabajo, realizamos una revisión de los virus ADN y ARN relacionados con la uveítis en humanos, siendo los más frecuentes los virus del herpes. Varios tipos de virus del herpes pueden producir una inflamación uveal, con afectación de los segmentos anterior y posterior; otros virus ARN están implicados con menos frecuencia. El diagnóstico precoz y tratamiento inmediato de ciertas formas de uveítis de etiología viral, pueden prevenir las lesiones uveales y permitir una rápida recuperación de la visión. (AU)