Measuring Choroid Thickness as a Marker of Systemic Inflammation in Patients With Ankylosing Spondylitis.

BACKGROUND AND OBJECTIVE: Ankylosing spondylitis (AS) is an inflammatory disease, and choroidal thickness (CT) has been proposed and evaluated as a potential marker of systemic inflammation associated with AS and other inflammatory diseases. This study compared CT measurements taken from patients with severe AS disease activity without eye inflammation with those taken from healthy subjects. METHODS: This cross-sectional, multicenter study compared CT in 44 patients with high AS disease activity, and no history of eye inflammation with CT in 44 matched healthy subjects aged between 18 and 65 years. In the AS group, the correlation between CT and C-reactive protein, human leukocyte antigen (HLA) B27 positivity, disease duration, and disease activity was calculated. RESULTS: Mean CT values of patients with AS were significantly higher in the right eye, the left eye, and the thickest choroid eye. The right eye mean CT was 338.3 ± 82.8 µm among patients with AS and 290.5 ± 71.2 µm among healthy subjects (p = 0.005). The left eye mean CT was 339.5 ± 84.7 µm for patients with AS and 298.4 ± 68.9 µm for healthy subjects (P = 0.015). The thickest choroid eye CT was 358.4 ± 82.1 µm among patients with AS and 314.1 ± 65.2 µm among healthy subjects (P = 0.006). We did not find a significant correlation between CT and disease activity, C-reactive protein, human leukocyte antigen B27 positivity, or disease duration. CONCLUSIONS: Patients with active AS but without a history of eye inflammation had a thicker choroid than healthy subjects. This finding suggests that CT is a marker of systemic inflammation in patients with inflammatory disease, regardless of known eye symptoms.

Choroidal Thickness Is a Biomarker Associated With Response to Treatment in Ankylosing Spondylitis.

OBJECTIVE: Choroidal thickness (CT) has been evaluated as a marker of systemic inflammation in ankylosing spondylitis (AS). This study evaluates the CT of AS patients before and after 6 months of biological treatment. METHODS: This longitudinal multicenter study evaluated CT in 44 AS patients. The correlations between CT and C-reactive protein (CRP) with disease activity indices were calculated. The concordance between CT and CRP was determined. We assessed factors associated with response to treatment. Clinically important improvement was defined as a decrease in Ankylosing Spondylitis Disease Activity Score of 1.1 points or greater. RESULTS: Forty-four eyes in patients aged 18 to 65 years were included. Mean CT values were significantly higher at baseline than after 6 months of treatment (baseline: 355.28 ± 80.46 µm; 6 months: 341.26 ± 81.06 µm; p < 0.001). There was a 95% concordance between CT and CRP at baseline and 6 months. Clinically important improvement was associated with lower baseline CT and age as independent factors (odds ratios, 0.97 [95% confidence interval, 0.91-0.93; p = 0.009] and 0.81 [95% confidence interval, 0.7-0.95; p = 0.005]), with baseline CT of less than 374 µm (sensitivity 78%, specificity 78%, area under the curve 0.70, likelihood ratio 3.6). CONCLUSIONS: Choroidal thickness decreased significantly after 6 months of biological treatment in all treatment groups. Choroidal thickness and CRP had a 95% concordance. A high CT was associated with a risk of biological treatment failure. Choroidal thickness can be considered a useful biomarker of inflammation and a factor associated with response to treatment in AS.

Visual acuity loss and development of ocular complications in white dot syndromes: a longitudinal analysis of 3 centers.

PURPOSE: To compare the clinical prognosis among selected white dot syndromes (WDS) (birdshot chorioretinopathy (BRC), multifocal choroiditis, serpiginous choroidopathy (SC), and others) and to identify risk factors of poor visual prognosis. METHODS: Retrospective longitudinal cohort study including 84 patients (143 affected eyes) diagnosed with WDS between 1982 and July 2017, followed up until loss of follow-up or December 2017, and recruited from three Uveitis Clinics (Madrid Community, Spain). Our main outcome measures were temporary or permanent moderate (corrected visual acuity in the Snellen scale < 20/50) or severe (< 20/200) vision losses, and development of new ocular complications. Incidence rates (IR) of the main outcome measures were estimated per 100 eye-years. Bivariate and multivariate Cox robust regression models analyzed the association of demographic- and clinical-related variables with vision loss. RESULTS: SC exhibited the greatest IR of vision loss, even in the multivariate models. Previous events of vision loss, presence of choroidal neovascularization, and cataracts exhibited worse visual prognosis. Monotherapy with immunosuppressive drugs but not combine therapy was also associated with higher IR of visual loss. Regarding new ocular complications, BRC showed the highest IR of epiretinal membrane and macular edema. CONCLUSIONS: SC presents the worst visual prognosis. Some ocular manifestations can identify patients with WDS at risk of a worse clinical evolution.

Development of an activity disease score in patients with uveitis (UVEDAI).

To develop a disease activity index for patients with uveitis (UVEDAI) encompassing the relevant domains of disease activity considered important among experts in this field. The steps for designing UVEDAI were: (a) Defining the construct and establishing the domains through a formal judgment of experts, (b) A two-round Delphi study with a panel of 15 experts to determine the relevant items, (c) Selection of items: A logistic regression model was developed that set ocular inflammatory activity as the dependent variable. The construct "uveitis inflammatory activity" was defined as any intraocular inflammation that included external structures (cornea) in addition to uvea. Seven domains and 15 items were identified: best-corrected visual acuity, inflammation of the anterior chamber (anterior chamber cells, hypopyon, the presence of fibrin, active posterior keratic precipitates and iris nodules), intraocular pressure, inflammation of the vitreous cavity (vitreous haze, snowballs and snowbanks), central macular edema, inflammation of the posterior pole (the presence and number of choroidal/retinal lesions, vascular inflammation and papillitis), and global assessment from both (patient and physician). From all the variables studied in the multivariate model, anterior chamber cell grade, vitreous haze, central macular edema, inflammatory vessel sheathing, papillitis, choroidal/retinal lesions and patient evaluation were included in UVEDAI. UVEDAI is an index designed to assess the global ocular inflammatory activity in patients with uveitis. It might prove worthwhile to motorize the activity of this extraarticular manifestation of some rheumatic diseases.

Interobserver Reliability and Sensitivity to Change of a Composite Ocular Inflammatory Activity Index: UVEDAI©.

INTRODUCTION: This was a multicenter, prospective, longitudinal, observational study involving eight Spanish tertiary hospitals to determine the interobserver reliability of an uveitis disease activity index, (UVEDAI) and assess its sensitivity to change in patients with receiving pharmacologic treatment. METHODS: Patients aged ≥ 18 years diagnosed with active noninfectious uveitis were included. A complete baseline assessment was performed by two ophthalmologists who determined ocular inflammatory activity using the UVEDAI index independently of each other. The principal ophthalmologist made a new visit at 4 weeks to determine the change in inflammatory activity. The interobserver reliability analysis was performed by calculating the intraclass correlation coefficient (ICC), with the values of the variables and the UVEDAI obtained by both ophthalmologists in the more active eye at the baseline visit. Sensitivity to change in the UVEDAI index was assessed at 4 weeks from the start of pharmacologic treatment by determining the clinically relevant change, defined as a change in UVEDAI of ≥ 0.8 points over baseline. The mean change between both measures was compared using the repeated-measures t-test. RESULTS: A total of 111 patients were included. In the interobserver reliability analysis, the ICC for the UVEDAI value was 0.9, and, when compared with the mean UVEDAI values obtained by the ophthalmologists, no statistically significant differences were found (p value > 0.05). As for the sensitivity to change in UVEDAI, statistically significant differences (p value = 0.00) were found for the mean values of the index compared with baseline. In all cases, the index value decreased by > 1 point at the 4-week visit. CONCLUSIONS: The interobserver reliability of the UVEDAI was high in the total sample. Furthermore, the index was sensitive in determining the change in inflammatory activity after treatment. We believe that UVEDAI is a disease activity index that enables objective comparison of results in clinical practice and trials.

Validation of UVEDAI: An Index for Evaluating the Level of Inflammatory Activity in Uveitis.

INTRODUCTION: Uveitis is the inflammation of the middle layer of the eye, the uvea, and is a major cause of blindness. None of the instruments used in clinical practice are, in themselves, sufficient to evaluate the course of uveitis. Therefore, it is necessary to develop instruments enabling standardized measurement of inflammatory activity. We developed a composite disease activity index for patients with uveitis known as UVEDAI, which considers the overall activity of the eye. The objective of this study was to validate the composite index of ocular inflammation, UVEDAI. METHODS: A multicenter cross-sectional study involving eight Spanish tertiary hospitals. Sixty-two patients aged ≥ 18 years with acute uveitis were recruited. Participants gave informed consent before participating in the study. A full ophthalmological examination was performed by two ophthalmologists to determine inflammatory activity: one used the UVEDAI score and the other used clinical judgment. The ophthalmologists did not share their findings with each other to avoid introducing bias into the analysis. Construct validity was established by means of factor analysis. The criterion validity of the index was determined using an ordinal multivariate regression model, in which the dependent variable was the degree of uveal inflammation (mild, moderate, or high/severe). Cut-off points were determined for the UVEDAI and for the receiver operating characteristic (ROC) curves. RESULTS: Sixty-two patients were included. Total variance with the three components accounted for 80.32% of the construct validity. Each of the three components identified one type of eye involvement. The discriminatory capacity of UVEDAI was 0.867 (95% CI 0.778; 0.955 p < 0.001) for mild versus moderate-high and 0.946 (95% CI 0.879; 1.000 p < 0.001) for high versus mild-moderate. CONCLUSIONS: The variables included in UVEDAI enable ocular inflammatory activity to be described with a high degree of accuracy. The index may be used to evaluate and classify this activity with considerable discriminatory power.

Severe keratomycosis secondary to Scedosporium apiospermum.

PURPOSE: To report an unusual case of severe keratomycosis caused by Scedosporium apiospermum without any known previous ocular injury, that resulted in a corneal perforation, which was treated with an emergency penetrating tectonic keratoplasty and later with phacoemulsification and astigmatic keratotomy to restore good visual function. METHODS: A 45-year-old woman with a history of multiple sclerosis presented with a severe and refractory corneal abscess in her right eye without any known prior injury. Corneal scrapings were obtained and stained for microscopic evaluation. The samples were sent for aerobic and anaerobic bacterial and fungal cultures. RESULTS: Microbiologic examination of the corneal scraping showed Scedosporium apiospermum micelle. The fungal culture was sensitive to miconazole, itraconazole and voriconazole. Partial clinical improvement was achieved with hourly topical natamycin, amphotericin B, and systemic itraconazole application, although in vitro sensitivity tests showed resistance to the topical antifungal agents used. A corneal paracentral perforation occurred despite aggressive treatment. An emergency eccentric penetrating keratoplasty was performed with satisfactory results. Subsequent phacoemulsification and astigmatic keratotomy restored a good visual function. CONCLUSION: A fungal etiology should be suspected in a progressive and refractory corneal abscess. This report highlights the utility of microbiologic investigation to perform an early and accurate diagnosis. Aggressive medical treatment and even therapeutic penetrating keratoplasty to remove infected tissue could result in the maintenance of useful visual function. In view of the poor prognosis of this specific fungus, a closer observation and early keratoplasty might be required to preserve the ocular globe.