Peripheral ulcerative keratitis due to systemic diseases.

PURPOSE OF REVIEW: To discuss peripheral ulcerative keratitis, with a focus on the evaluation and management of associated systemic diseases. RECENT FINDINGS: Peripheral ulcerative keratitis (PUK) is a sight-threatening condition that is often defined by the presence of a crescent-shaped area of peripheral corneal thinning, an epithelial defect, and an inflammatory corneal infiltrate. It is highly associated with rheumatoid arthritis, systemic necrotizing vasculitides like granulomatosis with polyangiitis, and collagen vascular diseases like systemic lupus erythematosus. Undertreated PUK carries a risk of vision loss and premature death. SUMMARY: Multidisciplinary collaboration between the ophthalmologist, rheumatologist, and other consultants is required. Early and aggressive steroid-sparing therapy should be considered in cases due to noninfectious systemic disease.

Noninfectious immune-mediated uveitis and ocular inflammation.

Noninfectious uveitis encompasses a diverse group of ocular inflammatory disorders that share an underlying immune etiology and may be associated with systemic disease or confined primarily to the eye. Uveitis is commonly classified by anatomical location of inflammation into anterior, intermediate, posterior, and panuveitis. The treatment of noninfectious uveitis consists of corticosteroids, immunosuppressive agents, and surgically placed steroid implants. We review the epidemiology, immunopathology, and clinical features of several noninfectious immune-mediated uveitides, including HLA-B27 acute anterior uveitis, juvenile idiopathic arthritis, intermediate uveitis, sarcoidosis, Behcet's disease, Vogt-Koyanagi-Harada syndrome, sympathetic ophthalmia, and white dot syndromes. We also discuss the stepwise approach to medical treatment of immune-mediated uveitis as well as the characteristics, safety, and efficacy of immunosuppressive agents used to treat ocular inflammatory disease.

Diagnostic yield of vitreous biopsy in presumed sarcoidosis-related posterior segment inflammation.

PURPOSE: Diagnostic vitrectomy is frequently used to help establish a diagnosis in challenging uveitis cases. The usefulness of this procedure in patients with suspected sarcoidosis with posterior segment involvement, in whom a diagnosis cannot be determined by conventional methods, has not been well-described. We hypothesized that diagnostic vitrectomy would help establish a diagnosis of presumed sarcoidosis-related posterior segment inflammation in these challenging cases, and evaluated the diagnostic yield of vitreous biopsy in these eyes. DESIGN: Retrospective interventional case series. METHODS: Diagnostic vitrectomy was performed on eyes with intermediate, posterior, or panuveitis in which an etiology could not be characterized by history, clinical examination, ancillary testing, and/or laboratory testing. Retrospective chart review was conducted on consecutive eyes that underwent diagnostic, or diagnostic and therapeutic vitrectomy by a single surgeon between January 1989 and June 2006. RESULTS: Diagnostic and therapeutic vitrectomy was performed on 150 eyes. The final diagnosis was established by positive vitreous fluid analysis in 63 eyes (42 %). Eight of these vitreous specimens (5.3 %) yielded cytopathology consistent with presumed sarcoidosis-related posterior segment inflammation. CONCLUSIONS: Sarcoidosis can cause characteristic inflammatory changes in the vitreous. In the appropriate clinical setting, cytopathologic assessment of these inflammatory changes observed in vitreous specimens can support the diagnosis of presumed sarcoidosis-related posterior segment inflammation, and help direct clinical management.

Design, implementation, and evaluation of population-specific telehealth nursing services.

An implementation project was conducted to introduce a structure for telehealth nursing practice (TNP) which would address the specific needs of complex endocrinology patients in a hospital-based clinic. Outcomes of the pilot study include analysis of 727 advice calls, survey responses from a sample of 101 patients, and feedback from 9 providers. Results support current evidence that disease management needs of chronically ill patients include prescription refills, medication and symptom management, lab results, and patient education. 81.2% of patients rated satisfaction with telehealth nursing services as very high or high. A statistically significant relationship was found between timeliness of response and patient satisfaction. A focus on care coordination provided through telehealth nursing services may emerge as an important element in the care of chronically ill patient populations.

Long-term follow-up results of a pilot trial of a fluocinolone acetonide implant to treat posterior uveitis.

PURPOSE: To investigate the safety and efficacy of a fluocinolone acetonide intravitreal implant in the treatment of noninfectious posterior uveitis. DESIGN: Noncomparative interventional case series, dose randomized, dose masked, prospective. PARTICIPANTS: Thirty-six eyes of 32 patients with a history of recurrent noninfectious posterior uveitis. METHODS: Patients were randomized to receive either a 0.59-mg or a 2.1-mg fluocinolone acetonide intravitreal implant. Patients were observed every 4 to 6 weeks for the first 3 months and then every 3 months thereafter. MAIN OUTCOME MEASURES: Preoperative and postoperative ocular inflammation, visual acuity (VA), antiinflammatory medication use, and safety. RESULTS: Mean follow-up duration was 683+/-461 days (range, 204-1817). Mean baseline visual acuity for the device-implanted eyes was +1.1 logarithm of the minimum angle of resolution (logMAR) units (20/250), which improved significantly to +0.81 logMAR units (20/125) at 30 months (P<0.05). Inflammation was effectively controlled over the follow-up period. The average number of recurrences in the 12 months before implantation was 2.5 episodes per eye. None of these eyes experienced a recurrence for the first 2 years after implantation. There was a reduction in systemic and local therapy use in the device-implanted eyes; of the patients who remained on systemic medication after implantation, dosage was reduced in 68%. The posterior sub-Tenon's capsule injection rate significantly decreased from a mean of 2.2 injections per eye per year to 0.07 injections per eye per year (P<0.0001) The most common adverse event was intraocular pressure (IOP) rise. At baseline, 11.0% of eyes used pressure-lowering agents, versus 56.1% over the follow-up period (P = 0.005). Filtering procedures were performed in 7 (19.4%) eyes. Four of the 8 phakic eyes, each of which had some level of cataract at device implantation, subsequently underwent cataract extraction. There were no device explantations or patients lost to follow-up during the investigation. CONCLUSION: The fluocinolone acetonide intravitreal implant effectively controlled intraocular inflammation in the studied population. Elevated IOP and cataracts that occurred in fluocinolone device-implanted eyes were managed by standard means. The fluocinolone acetonide sustained drug delivery implant seems to be promising in patients with posterior uveitis who do not respond to or are intolerant to conventional treatment.

Development of a quality improvement program in a department of ophthalmology.

OBJECTIVE: To design and implement a quality improvement (QI) programme in an academic department of ophthalmology. DESIGN: The six core competencies of the Accreditation Council for Graduate Medical Education serve as the model for this programme in an institutional practice. The authors review departmental rates of postoperative infections, unplanned reoperations, intraoperative complications, specific subspecialty postoperative complications and successes, and patient and staff compliments and complaints. RESULTS: The authors describe the structure and evolution of the QI programme in our ophthalmology department. CONCLUSIONS: It is possible to implement a structured QI programme in an academic department of ophthalmology. With healthcare oversight increasing, physician self-monitoring of quality of care measures will become even more important.

Retinal thickening in iridocyclitis.

PURPOSE: To determine the frequency of retinal thickening (RT) in eyes with iridocyclitis and to examine the correlations among anterior chamber (AC) inflammation, RT, and visual acuity. DESIGN: Retrospective, observational case series. METHODS: Records were reviewed of patients seen at the Duke University Eye Center Uveitis Clinic from January 2002 through March 2008. Patients with unilateral iridocyclitis without panuveitis, vitreitis, pars planitis, posterior uveitis, or a combination thereof who had undergone optical coherence tomography (OCT) of both eyes were included. The AC cell grade and OCT-RT measurements were recorded. Subretinal fluid and intraretinal cysts were determined from OCT scans according to Duke Reading Center guidelines. RESULTS: Forty-three patients were studied. RT typically was present in a ring-like distribution around the fovea. The median difference between the study eye and fellow eye in RT was statistically significant for total macular volume (TMV) and for all OCT subfields (P < .001). In the study eye, there was a modest correlation between the RT and AC cell grade for the OCT-TMV (P = .039; r(2) = 0.1) and the subfield comprised of the quadrants in the outer ring on OCT (P = .027; r(2) = 0.12), and between RT and visual acuity for OCT-TMV and all but the central subfields (P = .003 to .007; r(2) = 0.261 to 0.227). RT decreased after anti-inflammatory therapy. CONCLUSIONS: RT is strongly associated with iridocyclitis and decreases after treatment. RT, as determined by OCT, is a useful clinical parameter to evaluate patients with iridocyclitis and to monitor response to treatment.

Demographic-related variations in posterior segment ocular sarcoidosis.

OBJECTIVE: To compare the frequency of posterior segment involvement (PSI), the prevalence of specific posterior segment signs, and visual acuity in ocular sarcoidosis by patient race, sex, and age. DESIGN: Retrospective, cross-sectional observational study. PARTICIPANTS: Seventy-six consecutive patients with biopsy-proven or presumed ocular sarcoidosis seen at the Duke University Eye Center between 1989 and 2001. METHODS: Medical record review. MAIN OUTCOME MEASURES: Patient demographics, presence and laterality of specific posterior segment signs, and visual acuity at initial examination. RESULTS: Of the 76 patients, 68% were black (34 female and 18 male) and 32% were white (18 female and 6 male). A total of 68 patients (89%) had PSI: black patients had 85% and white patients had 100% (P = 0.05). For patients with PSI, white females had the highest mean age at initial examination (58 years compared with 37 years for all others; P = 0.005). The most common findings among the 68 patients with posterior segment disease were vitritis (69%); choroidal "punched-out" lesions (56%); "snowball" lesions (46%); cystoid macular edema (CME; 31%); and periphlebitis, vitreous opacity, and posterior vitreous detachment (29% each). There was a significantly higher prevalence of "punched-out" lesions and CME in whites (79% and 54%, respectively) compared with blacks (43% and 18%, respectively; P = 0.005 each). Additionally, the prevalence of CME was highest in white females (61%) compared with all others (20%; P = 0.002). Patients with vitreous hemorrhage were more likely to be in the youngest age group (P = 0.02). Female patients with posterior segment disease had a significantly lower visual acuity compared with males in both the better (P<0.001) and worse (P = 0.002) eye. CONCLUSIONS: We have identified variations based on patient race, sex, and age in PSI, specific posterior segment signs, and visual acuity in cases of ocular sarcoidosis.

Diagnostic yield of vitrectomy in eyes with suspected posterior segment infection or malignancy.

PURPOSE: To determine the yield of diagnostic pars plana vitrectomy in eyes with suspected posterior segment inflammation or malignancy when clinical examination and systemic laboratory testing did not yield a specific diagnosis. DESIGN: Non-comparative interventional case series PARTICIPANTS: Eighty-seven consecutive patients (90 eyes) who underwent diagnostic pars plana vitrectomy from 1989 through 1999. INTERVENTIONS: Vitreous samples were analyzed in a directed manner based on the preoperative clinical examination and systemic laboratory testing. MAIN OUTCOME MEASURES: Diagnosis from each test performed on the vitreous samples. RESULTS: Diagnostic vitrectomy was performed alone in 6 eyes (7%) and as part of a therapeutic procedure in the remaining 84 eyes. The diagnostic tests performed most frequently included cytopathology (83%), microbiologic culture and sensitivity (43%), polymerase chain reaction (PCR) (36%), and intraocular antibody levels for T. canis (14%). Of these, intraocular antibody testing and PCR had the highest positive yield, 46% and 39%, respectively. Overall, directed vitreous analysis identified a specific cause in 35 eyes (39%). Of the 65 cases in which an underlying infection was suspected preoperatively, the procedure yielded a specific diagnosis in 27 (42%). When intraocular malignancy was considered preoperatively (71 eyes), a diagnosis of intraocular lymphoma was obtained in seven (10%). This difference between these diagnostic yields was significant (P = 0.02, Fisher's exact test). CONCLUSIONS: Diagnostic vitrectomy with directed vitreous fluid analysis yields a specific cause and guides subsequent therapy in a high percentage of cases. This procedure is a valuable adjunct in cases that cannot be diagnosed by less invasive methods.