Postoperative anterior uveitis in a patient submitted to combined treatment with cataract surgery and iStent inject®. How to manage? / Uveíte anterior no pós-operatório de facectomia combinada com implante de iStent inject®. Como manejar?

ABSTRACT Minimally invasive glaucoma surgeries are surgical treatment alternatives for glaucoma aimed at reducing intraocular pressure with a better safety profile compared to traditional trabeculectomy. However, in spite of less invasive techniques, complications may develop in any surgical procedure. To the best of our knowledge, this is the first case report of anterior uveitis following combined treatment with cataract surgery and iStent inject® which addresses the management of postoperative inflammation.

RESUMO As cirurgias minimamente invasivas para glaucoma consistem em uma opção de tratamento cirúrgico para glaucoma, a qual promove redução da pressão intraocular com melhor perfil de segurança do que a trabeculectomia. Todavia, complicações são inerentes à realização de procedimentos cirúrgicos, apesar do uso de técnicas menos invasivas. Este é o primeiro relato que apresenta um caso de uveíte anterior após cirurgia combinada de catarata e iStent inject®, além de orientações quanto ao manejo do quadro inflamatório.

Acute uveitis: A rare adverse effect of miltefosine in the treatment of post-kala-azar dermal leishmaniasis

Abstract Post-kala-azar dermal leishmaniasis is a skin disorder occurring in 5-10% of visceral leishmaniasis patients after treatment with miltefosine,the first-line drug for this skin disorder. We reported a case of acute anterior uveitis,a rare adverse effect, experienced by a patient treated with miltefosine for post-kala-azar dermal leishmaniasis. This adverse effect developed after 15 days of miltefosine consumption, and the patient himself discontinued the treatment. The ophthalmic complication was completely resolved with antibiotics and steroid eye drops. After recovery from the ophthalmic complication, the patient was successfully treated with liposomal amphotericin B for the skin lesions.

Evaluation of factors for predicting risk of uveitis recurrence in Behcets disease patients

This study aimed to investigate the predictive factors for uveitis recurrence (UR) risk in Behcet's disease (BD) patients. BD patients (n=164) with a history of uveitis were recruited, and demographic data, clinical features, and laboratory tests were recorded. Uveitis was defined as anterior uveitis, intermediate uveitis, posterior uveitis, panuveitis referring to the "International Uveitis Study Group recommendations for the evaluation of intraocular inflammatory disease". In total, there were 70 UR patients and 94 non-UR patients. Compared to non-UR patients, UR patients appeared to be older and presented with increased uveitis occurrence rate and times within 3 months, oral ulcers occurrence rate, as well as higher concentrations of triglycerides (TG), total cholesterol (TC), low-density lipoprotein (LDL), and serum amyloid A (SAA). Multivariate logistic model disclosed that uveitis occurrence times within 3 months, oral ulcers, TG, LDL, and SAA independently predicted higher risk of UR. Furthermore, receiver operating characteristic curve analysis showed that the combination of uveitis occurrence times within 3 months, oral ulcers, TG, LDL, and SAA exhibited a high predictive value for UR risk with an area under the curve of 0.983 (95%CI: 0.969−0.998). In conclusion, uveitis occurrence times within 3 months, oral ulcers, TG, LDL, and SAA might be potential predictive factors for UR risk in BD patients, which can help in prevention and management of the disease.

Aspectos clínicos e tratamento de pacientes com tuberculose ocular presumida em centro de referência de São Paulo, Brasil. Estudo retrospectivo / Clinical description and treatment of patients with presumed ocular tuberculosis in São Paulo, Brazil. Retrospective study

Resumo Objetivo: Descrever aspectos clínicos e esquema terapêutico dos pacientes com tuberculose ocular presumida tratados em um centro de referência em tuberculose de São Paulo. Métodos: Estudo retrospectivo descritivo. O teste exato de Fisher foi realizado quando apropriado. Resultados: A queixa mais comum foi baixa acuidade visual (83,1%), seguida por dor ocular generalizada (25,3%) e visão turva (22,8%). A uveíte posterior foi a apresentação mais comum (35,7%). O tratamento consistiu no esquema atualmente recomendado de rifampicina, isoniazida, pirazinamida e etambutol (RHZE). A prednisona oral foi incluída no tratamento de 37 pacientes, para tratamento da inflamação aguda, embora não tenha diminuído a prevalência de complicações crônicas, em comparação com a recuperação completa (p = 0,1). O diagnóstico precoce (<70 dias) foi associado a maiores taxas de recuperação total (p = 0,005). Não houve significância estatística quando se comparou a terapia de 6 a 9 meses (p = 0,7). Conclusão: A uveíte tuberculosa pode ser tratada por uma terapia com duração de seis meses. Um breve curso de esteroides melhora os sintomas agudos, embora não reduza as complicações a longo prazo.

Abstract Purpose: To analyze and describe the therapy used in presumed ocular tuberculosis in a referral center in São Paulo, Brazil. Methods: Retrospective, descriptive study. Fisher's exact test was performed when appropriate. Results: The most common complaint was low visual acuity (83.1%), followed by generalized ocular pain (25.3%) and blurred vision (22.8%). Posterior uveitis was the most common presentation (35.7%). Treatment consisted of the currently recommended association of rifampin, isoniazid, pyrazinamide, ethambutol (RHZE) regimen. Oral prednisone was included in the treatment of 37 patients for acute inflammation, although it did not significantly decrease the prevalence of chronic complications compared to full recovery (p = 0,1). Early diagnosis (< 70 days) was associated with higher rates of full recovery (p = 0.005). No statistical significance was observed when comparing 6 to 9-month therapy (p = 0.7). Conclusion: Tuberculous uveitis can be treated with a 6-month duration RHZE therapy. A brief course of steroids may improve acute symptoms, although it did not reduce long-term disabilities.

Tubulointerstitial nephritis and uveitis syndrome in children: report of three cases / Nefrite tubulointersticial e uveíte em idade pediátrica: descrição de três doentes

ABSTRACT Tubulointerstitial nephritis and uveitis syndrome is a rare and probably underdiagnosed condition. Renal and ocular manifestations may not occur simultaneously, making the diagnosis more difficult. Nephritis may be asymptomatic; therefore, renal function evaluation is essential for diagnosis. Urinary β2-microglobulin levels may be particularly useful. Uveitis, mostly anterior, nongranulomatous and bilateral, occurs usually after the onset of nephritis. Treatment includes corticosteroids and, eventually, other immunosuppressant agents. Renal disease is usually benign and resolves spontaneously or after treatment with systemic corticosteroids. Uveitis, however, may be chronic or recurrent. The authors described the cases of three pediatric patients diagnosed with tubulointerstitial nephritis and uveitis syndrome. The goal of this paper was to warn the medical community over the need to screen patients with uveitis for renal disease.

RESUMO A síndrome nefrite tubulointersticial e uveíte é uma doença rara, provavelmente subdiagnosticada. As manifestações renais e oculares podem não ocorrer simultaneamente, tornando o diagnóstico mais difícil. A nefrite é geralmente assintomática, tornando fundamental a avaliação da função renal em doentes com uveíte. O doseamento da excreção urinária de β2-microglobulina é particularmente útil para o diagnóstico. A uveíte, tipicamente anterior, não granulomatosa e bilateral, manifesta-se após a nefrite na maioria dos casos. O tratamento inclui corticoides e, por vezes, outros imunossupressores. A doença renal tem evolução benigna, resolvendo-se espontaneamente ou com terapêutica com corticoides sistêmicos na maioria dos casos, no entanto, a uveíte pode ser crônica ou recorrente. Os autores descrevem três casos de síndrome nefrite tubulointersticial e uveíte, diagnosticados em idade pediátrica, e pretendem alertar para a necessidade de pesquisar sempre alterações renais nos doentes com uveíte.

Effects of sub-Tenon's triamcinolone injections in patients with uveitis / Efeitos da injeção subtenoniana de triancionolona em pacientes com uveítes

ABSTRACT Purpose: To evaluate the response to sub-Tenon's triamcinolone injection in patients with uveitis. Methods: We studied 28 eyes with macular edema associated with controlled uveitis. We administered sub-Tenon's injection of triamcinolone and followed the patients for 180 days to analyze the positive effects (improvement of macular edema and visual acuity) and monitor the possible adverse effects. This prospective study was conducted at the Department of Ophthalmology, Hospital de Clínicas de Porto Alegre, Brazil. Results: We observed improvement in macular edema in 86% of patients. The mean central macular thickness at each time point of assessment was 432.22, 298.80, 286.37, 267.49, 253.87, and 253.49 mm at baseline (before sub-Tenon's injection of triamcinolone), 15 days after the procedure, at 30 days, at 60 days, at 90 days, and at 180 days, respectively. The mean reduction in retinal thickness was 30.8%, 33.7%, 38.11%, 41.2%, and 41.35% at 15, 30, 60, 90, and 180 days of follow-up, respectively. Visual acuity also improved in 85.7% of patients, with a mean improvement of 1.36, 1.93, 2.23, 2.26, and 2.30 lines gained on the Early Treatment Diabetic Retinopathy Study chart at 15, 30, 60, 90, and 180 days of follow-up, respectively. No statistically significant increases in intraocular pressure and conjunctival abnormalities were caused by the procedure, and no other adverse effects were observed. Overall, the results of this study were similar to those described in the literature. Conclusions: Sub-Tenon's injection of triamcinolone provides reduced macular thickness and improvement in visual acuity with no significant adverse effects and is therefore an effective and safe procedure for the treatment of sequelae of uveitis.

RESUMO Objetivos: Avaliar os efeitos da injeção subtenoniana de triancinolona em pacientes com uveítes. Métodos: Foram incluídos na avaliação 28 olhos com edema macular associado à uveíte. Esses pacientes foram submetidos à injeção subtenoniana de triancinolona e acompanhados ao longo de 180 dias, para analisar os efeitos em relação à melhora do edema macular, da acuidade visual e acompanhamento de possíveis efeitos adversos. Trata-se de um estudo prospectivo, realizado no Serviço de Oftalmologia do Hospital de Clínicas de Porto Alegre. Resultados: Foi verificada melhora do edema macular em 86% dos pacientes, sendo uma redução média da espessura retiniana de 30,8% aos 15 dias, 33,7% aos 30 dias, 38,11% aos 60 dias, 41,2% aos 90 dias e 41,35% aos 180 dias de seguimento. Também foi observado melhora da acuidade visual em 85,7% dos pacientes e ganho de linhas na tabela de acuidade visual, sendo 1,36 linhas aos 15 dias de seguimento, 1,93 linhas aos 30 dias, 2,23 linhas aos 60 dias, 2,26 linhas aos 90 dias e 2,30 linhas aos 180 dias. Não houve significância estatística em relação ao aumento da pressão intraocular e às alterações conjuntivais causadas pelo procedimento, sem detecção de qualquer outro efeito colateral. Foi concluído que os resultados encontrados nesse estudo são similares aos descritos na literatura. Conclusões: A injeção subtenoniana de triancinolona é um procedimento eficaz e seguro para o tratamento das sequelas por quadros de uveítes, proporcionando redução da espessura macular e melhora da acuidade visual, sem relação com efeitos adversos significativos.

Análise da frequência de uveítes em pacientes com espondiloartrites, suas complicações e associação com parâmetros clínicos da doença / Analysis of the frequency of uveitis in spondyloarthritis patients and associations with clinical parameters of the disease

Resumo Objetivo: A uveíte anterior aguda é a principal manifestação extra-articular na espondiloartrite. O objetivo deste estudo foi analisar se a presença da uveíte se associa com diferentes manifestações clínicas, laboratoriais, radiológicas e a terapêutica nos pacientes com espondiloartrite. Métodos: Estudo observacional retrospectivo realizado com 153 pacientes portadores de espondiloartrite atendidos no período de 1997 a 2017 na Grande Florianópolis, Brasil. Foram analisados dados demográficos, laboratoriais, clínicos e do tratamento de pacientes com espondiloartrite em relação a presença ou não de uveíte. Resultados: A uveíte foi encontrada em 26,8% dos pacientes. A presença de complicações foi rara, ocorrendo catarata em somente quatro pacientes e glaucoma em dois deles. Foi observada uma tendência a maior frequência de uveíte anterior aguda no sexo masculino (p=0,06), nos pacientes com história familiar (p=0,19) e HLA-B27 positivos (p=0,14). Pacientes com espondiloartrite e uveíte mais frequentemente usavam anti-TNF (p=0,04) e apresentavam sacroiliite em exames de imagem (p=0,02). Não observou-se associação entre a uveíte e o acometimento cardiovascular (p=0,44), cutâneo (p=0,13) ou gastrointestinal (p=0,10). Conclusão: A uveíte que ocorre em pacientes com espondiloartrite é comum, tem predomínio no sexo masculino e é mais frequente em pacientes com HLA-B27 positivo. O uso de imunobiológicos como o anti-TNF é frequente nos pacientes com uveíte.

Abstract Objective: Acute anterior uveitis (AAU) is the most common extra-articular manifestation of spondyloarthritis. The aim of this study is to analyze if the presence of uveitis is associated with a diferent clinical manifestation, laboratorial, radiological and therapetiuc among spondyloarthritis patients. Methods: This was a observational retrospective study with 153 patients with spondyloarthritis attended in the period from 1997 to 2017 in Florianopolis, Brazil. It was analyzed demografical, laboratorial, clinical and therapeutic data in spondyloarthritis patients with or without uveitis. Results: 26,8% of the patients with spondyloarthritis presented uveitis. The presence of complications was rare, with cataract occurring in only four patients and glaucoma in two of them. A higher frequency of acute anterior uveitis in males (p = 0.06) was observed in patients with a family history (p = 0.19) and HLA-B27 positive (p = 0.14). Patients with spondyloarthritis and uveitis more frequently used anti-TNF (p = 0.04) and presented sacroiliitis on imaging tests (p = 0.02). There was no association between uveitis and cardiovascular (p = 0.44), cutaneous (p = 0.13) or gastrointestinal involvement (p = 0.10). Conclusion: Uveitis in patients with spondylarthritis is common, predominantly in males, and more frequently in HLA-B27 positive patients. The use of immunobiological agents such as anti-TNF is common in patients with uveitis.

Acometimento visceral e ocular simultâneo em infecção por toxocara canis acompanhado de farmacodermia / Concurrent visceral and ocular involvementin toxocara canis infection and pharmacodermia

A toxocaríase humana é uma infecção parasitária de distribuição mundial causada pelos nematelmintos das espécies Toxocara canis e Toxocara cati, presentes no intestino do cão e do gato, respectivamente. Clinicamente, na maioria das vezes, é assintomática, porém pode apresentar-se de duas formas: visceral ou ocular. Visceralmente, gera uma síndrome hipereosinofílica crônica, acompanhada por leucocitose e hepatomegalia, podendo ocorrer algum grau de infiltrado pulmonar e febre. Na toxocaríase ocular, ocorre uveite intermediária ou posterior, podendo haver formação de granuloma, geralmente unilateral. O acometimento misto é raro, o que motivou este relato. Trata-se de paciente de 19 anos, sexo masculino, que apresentou como sintoma inicial perda da acuidade visual em olho esquerdo. Recebeu tratamento, sem melhora, com sulfametoxazol + trimetoprima e corticoide, fazendo farmacodermia. Evoluiu com diarreia, febre, dor abdominal e hepatoesplenomegalia. Descartadas infecções agudas por toxoplasmose, sífilis, vírus da imunodeficiência humana (HIV), citomegalovirose e dengue; apresentou leucocitose com hipereosinofilia. Foi solicitada sorologia para toxocaríase, confirmando esta infecção. Após o tratamento, apresentou completa remissão dos sintomas. O objetivo aqui foi debater os fatores confundidores, diagnósticos diferenciais, necessidade de exames complementares específicos e conduta terapêutica, de acordo com o quadro clínico.(AU)

Human toxocariasis is a worldwide parasitic infection caused by ascarid nematodes species: Toxocara canis and Toxocara cati, that are present in the intestines of dogs and cats, respectively. Although clinically, most human infections are asymptomatic, two syndromes of human toxocariasis are recognized: visceral and ocular. The visceral form is a hypereosinophilic syndrome accompanied by leukocytosis, hepatomegaly, some degree of pulmonary infiltrate and fever. In ocular toxacariasis there is intermediate or posterior uveitis, and there may be granuloma formation, usually unilateral. The simultaneous involvement of the two forms is rare, which is what, motivated this report. It is a 19-year-old male patient who initially presented loss of visual acuity in the left eye. He received treatment, without improvement, with sulfamethoxazole-trimethoprim and corticoid, causing a pharmacodermia. He developed diarrhea, fever, abdominal pain and hepatosplenomegaly. It was discarded acute infections by toxoplasmosis, syphilis, human immunodeficiency virus (HIV), cytomegalovirus and dengue. The patient also manifested leukocytosis with hypereosinophilia. Serological testing for toxacariasis was requested, diagnosing the infection. After treatment, he progressed with full symptoms remission. The aim of this study was to discuss confounding factors, differential diagnoses, the need for specific complementary exams and therapeutic management, according to the clinical aspects.(AU)

Anti-inflammatory effect of lycopene on endotoxin-induced uveitis in rats / Efeito anti-inflamatório do licopeno na uveíte induzida por endotoxina em ratos

ABSTRACT Purpose: We evaluated the efficacy of lycopene, a dietary carotenoid and potent antioxidant, against ocular inflammation and oxidative stress in an experimental uveitis model. Methods: Endotoxin-induced uveitis (EIU) was induced in Sprague-Dawley rats by a single subcutaneous injection of 200 μg lipopolysaccharide (LPS). Induction of EIU was preceded by daily intraperitoneal injection of 10 mg/kg lycopene for three consecutive days (Lycopene + LPS group) or equivolume vehicle (Vehicle + LPS group). A positive control group received 1 mg/kg dexamethasone pretreatment (DEX + LPS), and a negative control group received daily vehicle injection but no LPS (Vehicle Control). Twenty-four hours after LPS or final vehicle administration, eyes were enucleated, and aqueous humor was collected for measurement of the number of infiltrating cells, total protein concentration, and levels of nitric oxide (NO), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and oxidative stress markers. Inflammatory response severity was compared among groups clinically and histopathologically. Results: Infiltrating cell number, total protein concentration, and NO, TNF-α, and IL-6 levels were significantly elevated in the aqueous humor of Vehicle + LPS group rats compared to Vehicle Controls. Compared to the Vehicle + LPS group, lycopene pretreatment significantly reduced aqueous humor concentrations of oxidative stress markers, NO (0.29 ± 0.1 μM vs. 0.19 ± 0.1 μM, p=0.003), TNF-α (71.0 ± 22.3 ng/ml vs. 50.1 ± 2.1 ng/ml, p=0.043), and IL-6 (121.6 ± 3.0 pg/ml vs. 111.1 ± 5.6 pg/ml, p=0.008). Inflammatory score was also reduced (2.0 ± 0.0 vs. 0.4 ± 0.5, p=0.001). Lycopene reduced the infiltrating cell count and protein concentration, but differences did not reach significance. Most lycopene effects were equivalent to dexamethasone. Conclusions: Lycopene may aid in the clinical management of uveitis by suppressing inflammation and oxidative stress.

RESUMO Objetivo: Avaliamos o efeito do licopeno, um carotenóide dietético e um potente anti-oxidante, sobre a inflamação ocular e estresse oxidativo em modelo de uveíte experimental. Métodos: Uveíte foi induzida por endotoxina (EIU) em ratos Sprague-Dawley por uma única injeção subcutânea de 200 ug de lipopolissacárido (LPS). A indução de EIU foi precedida por injeção intraperitoneal de licopeno em uma dose de 10 mg/kg (grupo LPS + Licopeno) ou veículo de mesmo volume (grupo LPS + Veículo), durante 3 dias consecutivos. O grupo controle positivo recebeu uma dose de 1 mg/kg de Dexametasona (grupo DEX + LPS) e o grupo controle negativo recebeu doses diárias de veículo mas sem LPS (grupo Controle Veículo). Vinte e quatro horas após a administração do LPS, os olhos foram enucleados, humor aquoso foi recolhido, e o número de células infiltrativas, a concentração de proteína, assim como os níveis de óxido nítrico (NO), fator de necrose tumoral α (TNF-α), interleucina-6 e marcadores de estresse oxidativo foram determinados no humor aquoso. Além disso, a resposta inflamatória foi avaliada clinicamente e histologicamente. Resultados: As células infiltrativas, concentração de proteína, o NO, TNF-α, interleucina-6 foram significativamente elevados no humor aquoso de ratos do grupo Grupo LPS + Veículo quando comparados ao Grupo Controle Veículo. O tratamento com licopeno diminuiu significativamente estes aumentos. Comparado ao Grupo LPS + Veículo, o licopeno reduziu significativamente as concentrações no humor aquoso dos marcadores de estresse oxidativo e NO (de 0,29 ± 0,1 μM para 0,19 ± 0,1 μM, p=0,003), o TNF-α (de 71,0 ± 22,3 ng/ml para 50,1 ± 2,1 ng/ml, p=0,043), interleucina-6 (de 121,6 ± 3,0 pg/ml para 111,1 ± 5,6 pg/ml, p=0,008). Do mesmo modo, o aumento do número de células infiltrativas no tecido uveal em seções histológicas foi significativamente inibido pelo licopeno, a pontuação inflamatória diminuiu de 2,0 ± 0,0 para 0,4 ± 0,5, p=0,001. Embora, não tenha sido estatisticamente significativo, o licopeno reduziu a contagem de células infiltrativas e a concentração de proteínas no humor aquoso. Conclusões: Estes resultados sugerem que o licopeno pode ter efeitos benéficos no tratamento da inflamação ocular, através dos seus efeitos anti-inflamatórios e antioxidantes.

Mycophenolate mofetil as an immunomodulator in refractory noninfectious uveitis / Micofenolato mofetila como agente imunomodulador no tratamento das uveítes não infecciosas refratárias

ABSTRACT Purpose: To evaluate the efficacy and tolerance of mycophenolate mofetil (MMF) for the treatment of noninfectious uveitis using the methods advocated by the Standardization of Uveitis Nomenclature (SUN) Working Group and to compare this with other studies of immunosuppression in ocular inflammation. Methods: Retrospective case series. Patients with noninfectious uveitis, followed at a tertiary Uveitis Service in São Paulo, Brazil, from 2007 to 2014 and receiving oral MMF for a minimum of 6 months, were retrospectively reviewed. After reaching an optimal dose of MMF, patients were evaluated after 6 (T6), 12 (T12), and 24 months (T24). The optimal dose varied for each patient (medium 2.2 g/day, range 1.0-3.0 g/day). The main outcome measures were: 1) success on achieving complete control of inflammation in both eyes and/or oral prednisone dosage reduction to ≤10 mg per day, and 2) the length of time required to reduce oral prednisone to ≤10 mg/day, partial control of ocular inflammation, and side effects. Results: In a cohort of 16 patients with refractory noninfectious uveitis, 67% reached the ideal prednisone dose after 1 year of MMF treatment and 83% after 2 years of MMF treatment. Complete or partial inflammation control was achieved in 43.7% at T12. Two patients (14%) had disease remission after 4.7 years of MMF treatment. Adverse effects were gastrointestinal disturbances, infection, insomnia, and liver function abnormalities at a rate of 0.03 patient-year each. Conclusions: This small retrospective case series is consistent with the literature concerning the high efficacy and moderate tolerability of MMF in noninfectious uveitis. Observation of patients should be continued for at least 1 year to clearly determine MMF efficacy.

RESUMO Objetivo: Avaliar a eficácia e tolerância do micofenolato de mofetila (MMF) para o tratamento das uveítes não infecciosas refratárias, utilizando os métodos de análises definidos pelo "Standardization of Uveitis Nomenclature Working Group." Método: Estudo retrospectivo de série de casos. Foram incluídos pacientes com uveíte não infecciosa, em tratamento oral com MMF por um período mínimo de seis meses, acompanhados no Serviço de Uveítes, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil, no período de 2007 a 2014. Todos os pacientes faziam uso de pelo menos um imunossupressor e apresentavam doença ocular ativa. Os pacientes foram avaliados aos seis meses (T6), 12 meses (T12) e 24 meses (T24) após atingir a dose ótima do MMF. A média da dose ótima foi 2,2g/dia (intervalo 1,0-3,0g/dia). Os principais desfechos analisados foram: 1) Sucesso no controle total da inflamação em ambos os olhos e/ou redução da dose de prednisona oral para ≤10 mg/dia; 2) Intervalo até a redução da prednisona oral para ≤10 mg/dia, controle parcial de inflamação ocular e efeitos adversos. Resultados: Na presente coorte com 16 pacientes com uveíte não infecciosa refratária, observou-se 67% e 83% de probabilidade de alcançar a dose ideal de prednisona em T12 e T24, respectivamente. Controle total ou parcial da inflamação foi observado em 43,7% dos pacientes em T12. Dois pacientes (14%) tiveram remissão da doença após 4,7 anos do início de MMF. Os efeitos adversos foram distúrbios gastrintestinais, infecção, insônia e anormalidade da função hepática com 0,03 eventos paciente-ano (PPY) respectivamente. Conclusões: Esta pequena série retrospectiva de casos ratifica os achados na literatura sobre a alta eficácia e tolerância moderada de MMF em uveítes não infecciosas. Uma importante observação é que, para melhor avaliar a eficácia do MMF, deve se esperar o intervalo mínimo de um ano.

A case of atypical nocardia asteroides sclerouveitis resistant to fourth-generation fluoroquinolones / Um caso atípico de esclero-uveíte por Nocardia Asteroides resistente a fluorquinolona de quarta-geração

ABSTRACT We describe an unusual case of Nocardia spp scleritis in a health girl resistant to topical fourth-generation fluoroquinolones. Clinically, there was only partial response of the scleritis to initial therapy. Treatment was changed to meropenem intravenously and topical amikacin. Following several weeks of antibiotic treatment, the patient's infection resolved but her vision was reduced to no light perception. Nocardia asteroides must be considered as a possible agent in cases of necrotizing scleritis in patients without a clear source. Antibiotic sensitivity testing has a definitive role in view of the resistance to these new medications.

RESUMO Nós descrevemos um raro caso de esclerite por Nocardia spp em uma criança sadia resistente a utilização tópica de fluorquinolona de quarta-geração. Clinicamente, a paciente apresentou apenas uma resposta parcial do quadro de esclerite a terapêutica inicial. O tratamento foi então modificado para meropenem intravenoso e amicacina tópica. Após várias semanas de tratamento com antibiótico, o quadro infeccioso regrediu porém a visao da pacientes evoluiu para perda da percepção luminosa. Em casos de esclerite necrotizante em pacientes sem fatores de risco aparente é necessário considerer a Nocardia Asteroides como possível agente causador. Os testes de sensibilidade medicamentosa apresentam importância significativa em virtude do aparecimento de resistência aos novos medicamentos.

Effects of morphine on the expression of cytokines and inflammatory mediators in a rabbit model of endotoxin-induced experimental uveitis / Efeitos da morfina na expressão de citocinas e de mediadores inflamatórios em coelhos com uveítes experimental induzida por endotoxina

ABSTRACT Purpose: To evaluate the effects of 1% morphine instillation on clinical parameters, aqueous humor turbidity, and expression levels of tumor necrosis factor alpha (TNF-α), interleukin-1 beta (IL-1beta), prostaglandin E2 (PGE2), and myeloperoxidase (MPO) in rabbits with endotoxin-induced experimental uveitis. Methods: Twenty four New Zealand white rabbits were divided into four groups (n=6 each): control (CG), morphine (MG), naloxone (NG), and morphine-naloxone (MNG) groups. Under dissociative anesthesia, 0.1 mL of solution containing 0.2 µg of lipopolysaccharide (LPS) endotoxin from the Salmonella typhimurium cell wall was injected in the vitreous chamber. Clinical evaluations (conjunctical hyperemia, chemosis blepharospasm, and ocular discharge) and laser flaremetry were performed before (baseline), and 10 and 20 hours after induction of uveitis. Rabbits were subsequently euthanized and eyes were enucleated to quantify expression levels of TNF-α, IL-1 beta, PGE2, and MPO. Results: No significant differences in clinical parameters and flare values were observed between the study groups. TNF-α and IL-1 beta levels increased significantly in the CG, MG, NG, and MNG groups compared to baseline (P<0.05). Significant differences in PGE2 levels were observed between the MG and NMG groups (P<0.05). A trend toward increased MPO activity was observed in response to uveitis induction; however, this trend did not reach statistical significance (P>0.05). Conclusions: Morphine has no effect on clinical parameters, flare, or expression levels of inflammatory mediators in a rabbit model of uveitis induced by intravitreal injection of LPS.

RESUMO Objetivo: Estudaram-se os efeitos da instilação de morfina 1% sobre parâmetros clínicos, turbidez do humor aquoso e expressão de fator de necrose tumoral alfa (TNF-alfa), de interleucina-1 beta (IL-1beta), de prostaglandina E2 (PGE2) e de mieloperoxidase (MPO), em olhos de coelhos com uveíte induzida por endotoxina. Material e Métodos: Vinte e quatro coelhos da raça Nova Zelândia Branco foram distribuídos em quatro grupos (n=6, em cada): grupo controle (GC), morfina (GM), naloxona (GN) e morfina-naloxona (GMN). Sob anestesia dissociativa, injetou-se 0,1 mL de solução contendo 0,2 µg de lipossacarídeo (LPS) endotóxico da parede celular de Salmonella typhimurium na câmara vítrea. Realizou-se avaliação clínica (hiperemia conjuntival, quemose, blefaroespasmo e secreção ocular) e a flaremetria a “laser” antes (basal) e após 10 e 20 horas da indução da uveíte. No final, os coelhos foram submetidos à eutanásia e os olhos com uveíte foram enucleados para a quantificação dos níveis de TNF-alfa, IL-1 beta, PGE2 e MPO. Diferenças foram consideradas significativas quando p<0,05. Resultados: Os grupos da pesquisa não diferiram quanto aos parâmetros clínicos e os valores de “flare”. Observou-se elevação significativa nos níveis de TNF-alfa e de IL-1 beta, comparativamente ao basal, nos grupos GC, GM, GN e GMN (p<0,05). Valores de PGE2 variaram entre os grupos GM e GNM (p<0,05). A atividade de MPO aumentou após a indução da uveíte, porém, sem significância estatística (p>0,05). Conclusões: A morfina não atuou sobre parâmetros clínicos, “flare” e expressão dos mediadores inflamatórios estudados, quando instilada em olhos de coelhos com uveíte induzida por injeção intravítrea de LPS.

Visual loss resulting from immunosuppressive therapy in patients with syphilitic uveitis / Perda visual resultante do uso de terapia imunossupressora em pacientes com uveíte por sífilis

ABSTRACT Permanent visual loss can be caused by improper use of immunosuppressive therapy in cases of uveitis without differential diagnosis of syphilitic uveitis. We present four cases of syphilitic uveitis that were incorrectly diagnosed as being secondary to rheumatic diseases and were subsequently treated with immunosuppressive therapy, leading to permanent visual loss. These cases highlight the importance of ruling out syphilis in the differential diagnosis of inflammatory ocular diseases before starting use of immunosuppressive therapy.

RESUMO Elucidar os efeitos adversos do uso de medicações imunossupressoras em pacientes com uveíte não diagnosticada por sífilis. Avaliação de quatro pacientes com uveíte por sífilis submetidos a tratamento com drogas imunossupressoras por suspeita de uveíte secundária a doenças reumáticas, que desenvolveram perda visual permanente. Sífilis deve ser sempre um diagnóstico diferencial nas doenças inflamatórias oculares, principalmente antes do início de terapia imunossupressora.

Azathioprine for cortico-resistant noninfectious uveitis

The systemic steroids represent the first line treatment in the majority of the noninfectious uveitis, except some specific indications as the Behcet disease. Nevertheless, this treatment may be ineffective and immunosuppressive therapy is mandatory. To evaluate effectiveness and side effects of azathioprine [AZA] in corticosteroid resistant noninfectious uveitis [CRNIU]. This prospective study [2002- 2009], concerned 21 patients [mean age 37 years], 37 eyes, with CRNIU. Patients received oral AZA 2,5mg/kg/day, initiated in association with high dose steroids, with an end-point of 12 months. Response was defined as complete, partial response and failure, for each of the 3 following out-come measurements: improvement of BCVA, improvement of inflammation, steroids-sparing. Statistical analysis was considered significant if p value < 0,05. Side effects occurred in 42,8% [9/21] of patients, in which 5/9 patients stopped the treatment. Regarding BCVA, complete success was observed in 62,5%, partial response in 20,9%, and failure in 16,6% of cases. Regarding inflammation, complete success was noted in 70,8%, partial response in 29,1% and failure in 16,6 % of cases. Complete response of steroid sparing was observed in 85,7% of cases without failure. Complete success of the 3 criteria was observed in 57,1% of patients / 62,5% of eyes. Cataract [p=0,013] and pallor of optic nerve head [p=0,013] were associated to poor visual prognosis, BCVA of 20/40 or more [p=0,003, RR=2,38]] and papilledema [p=0,022, RR=2] to good visual prognosis. BCVA of 20/200 or less [p=0,001] was associated to failure of AZA on inflammatory response. AZA is safe and effective in corticosteroid-sparing and controlling inflammation in CRNIU. Its low cost and availability allow proposing it as a first-line option, especially when new biological treatments are difficult to obtain

Implante intravítreo de Dexametasona en uveítis no infecciosa. Resultados clínicos en un grupo de pacientes de la ciudad de Medellín / Dexamethasone intravitreal implant for noninfectious uveitis. Clinical results in a patients group in Medellín

Objetivos: describir los resultados clínicos del uso del implante de dexametasona intravítrea en un grupo pacientes con uveítis no infecciosa de la ciudad de Medellín. Diseño del estudio: estudio descriptivo, retrospectivo y observacional. Métodos: se revisaron las historias clínicas de 19 pacientes con uveítis no infecciosa a los que se les realizó el implante de dexametasona. Se compararon variables clínicas antes de la aplicación, al lograr una mejoría de los parámetros inflamatorios y en la última valoración que tuvieran los pacientes. Se realizaron cálculos de medias y rangos y se aplicó la t de Student pareada para la diferencia de medias de las variables clínicas descritas antes del procedimiento y al lograr la mejoría clínica, y antes del procedimiento y en la última valoración. Resultados: se realizaron 24 implantes de dexametasona en los 19 pacientes. La mayoría de los pacientes tuvieron uveítis intermedia idiopática (42.1%) o panuveitis (42.1%). Se encontró una mejoría de los parámetros inflamatorios en un promedio de 8.39 semanas (rango 4-16 semanas) con una diferencia significativa antes de la aplicación y en el momento de la mejoría, en las variables de agudeza visual (p=0,025), celularidad en cámara anterior (p=0,000), celularidad en vítreo (p=0,000) y opacidad vítrea (p=0,000). Con respecto a la última valoración hubo una mejoría estadísticamente significativa de los parámetros inflamatorios, excepto de la agudeza visual (p=0,331). Conclusión: el implante intravítreo de dexametasona es una alternativa para pacientes con uveítis no infecciosas que no mejoren con tratamiento estándar. A las 8 semanas se observa una mejoría estadísticamente significativa de todos los parámetros inflamatorios, que pueden persistir hasta las 34 semanas, a pesar de que hay pacientes que requieren reaplicaciones y/o continuidad de la terapia sistémica o tópica.

Purpose: to describe the clinical results of intravitreal dexamethasone implants in a group of patients with noninfectious uveitis. Methods: a retrospective analysis of the records of 19 patients with noninfectious uveitis who underwent intravitreal dexamethasone implants was performed to compare clinical measures before the application, during the improvement phase of infl ammatory parameters and in the last visit. Paired t student was used to assess differences of clinical parameters before and after the clinical procedure. Results: nineteen patients were treated with 24 dexamethasone implants. Most of the patients had idiopathic intermediate uveitis (42.1%) or panuveitis (42.1%). Improvement was found in 8.39 weeks (R= 4-16 weeks) in the inflammatory parameters with a significant improvement in visual acuity (p=0,025), anterior chamber cells (p=0,000), vitreous cells (p=0,000) and vitreous haze (p=0,000). Average follow up to the last visit was 39.4 weeks (8-104 weeks) with improvement on these clinical variables with exception of visual acuity (p=0,331). Conclusions: The intravitreal dexamethasone implant is a good alternative for patients with non infectious uveitis who don't get better with the standard treatment or have contraindications for it. Significant improvement in the parameters were observed as early as week 8 and were maintained over 34 weeks, despite there were patients who required reapplications and/or topic or systemic or therapy.

Vogt-Koyangi-Harada en fase crónica y terapia biológica: reporte de cuatro casos / Vogt-Koyanagi-Harada in chronic phase of recurrence and biological therapy: report of four cases

Objetivo: describir cuatro casos de Vogt Koyanagi Harada (VKH), con uveítis en fase crónica de recurrencia y la respuesta a fármacos anti TNF alfa. Diseño: reporte de casos. Métodos: se realizó estudio descriptivo tipo reporte de caso, mediante recolección y análisis de historias clínicas de pacientes adultos de un centro de referencia de enfermedades autoinmunes, que cumplieran criterios diagnósticos de VKH y que estuvieran en tratamiento con terapia biológica para dicha patología. Resultados: en el presente artículo informamos una serie de cuatro casos de VKH, de los cuales todas fueron mujeres entre los 19 y 57 años, en fase crónica y de recurrencia de la enfermedad. En todos los casos existió refractariedad al uso de esteroides a dosis altas y no respuesta a inmunosupresores como ciclosporina y metotrexate, requiriéndose instauración de terapia biológica anti TNF alfa con control de su patología. Conclusiones: En el VKH en fases tardías la respuesta a altas dosis de esteroides y a inmunosupresores convencionales puede ser fallida, ante lo cual el uso de terapia biológica con fármacos anti TNF alfa y anti CD20 es una alternativa factible, requiriéndose aún mayores estudios en este campo que permitan una prescripción eficaz y segura.

Objective: to describe four cases of Vogt Koyanagi Harada (VKH) disease, in chronic and recurrence phase that were treated with anti-TNF biological therapy and their response to this therapy. Design: cases reports. Methods: We performed a descriptive, case report with clinical chart review of adult patients in a center of autoimmune diseases who met diagnostic criteria for VKH and treated with biological therapy. Results: We report four cases of VKH treated in our center of autoimmune diseases, which were all women between 19 and 57 years, in chronic and recurrence phase of disease. In all cases there was refractory to steroid use at high doses and no response to immunosuppressive treatment as cyclosporine and methotrexate, requiring introduction of anti-TNF biological therapy to control their disease. Conclusions: In chronic phases of VKH the response to high doses of steroids and conventional immunosuppressive therapy may be failed, therefore the use of biological therapy with anti-CD20 and anti-TNF alpha is a viable alternative, still requiring further study in this fi eld to enable an eff ective and safe prescription.

Manifestaciones oftalmológicas por virus de Epstein-Barr / Ophthalmological manifestations caused by Epstein-Barr virus

Se trata de un paciente masculino de 26 años que acude por disminución brusca de la visión del ojo derecho. Se ingresó como una uveítis posterior dada por exudación extensa en área macular del ojo derecho, acompañada de edema del disco óptico, vasculitis aledaña a la lesión y hemorragias dispersas en llama en el polo posterior. La etiología era controversial y, el tratamiento más apropiado era debatible, por lo que se le realizaron estudios como retinografías seriadas, angiografías fluoresceínicas y reacción en cadena de polimerasa a una muestra del humor acuoso, que confirmó la etiología viral; lo que resultó en una agudeza visual final de 0,1. Posterior a 6 meses del cuadro inicial, el paciente presentó queratitis intraestromal en forma numular -que recurre ante episodios de stress-, para desaparecer luego de terapia tópica con antiinflamatorios no esteroideos y esteroideos. La baja incidencia de casos reportados con uveítis posterior por virus de Epstein Barr resulta de un pobre conocimiento de la presentación de la enfermedad, por tanto un retraso en la instauración del tratamiento. En estos casos la prueba de oro es la reacción de cadena de polimerasa

This article presented a 26 years-old male patient who went to the ocular service with sudden reduction of vision in his right eye. He was admitted to the hospital and diagnosed as posterior uveitis based on extensive exudation in the macular area of the right eye, edema of the optic disk, vasculitis next to the lesion and disperse hemorrhages in the posterior pole. The etiology of this case was controversial and the most suitable treatment was under discussion, so it was decided to perform serial retinographies, fluorescein angiographies and polymerase chain reaction in a aqueous humor sample taken from the patient. The viral etiology was confirmed, resulting in final visual acuity of 0.1. After 6 months of the initial clinical picture, the patient suffered nummular-shaped intrastromal keratitis - it appears in stress episodes- and finally disappears after topical therapy with non-steroidal and steroidal anti-inflammatory drugs. The low incidence of cases reported with posterior uveitis caused by Epstein Barr virus is due to the poor knowledge about the onset of this disease, and leads to delay in applying treatment. The golden rule in this case is the polymerase chain reaction

Compromiso ocular en la enfermedad de Chagas congénita: Cases report / Ocular involvement in congenital Chagas disease

El compromiso ocular es una forma de presentación infrecuente en los niños con la enfermedad de Chagas congénita. Se presentan tres pacientes menores de dos meses de edad con compromiso ocular, todos ellos derivados al hospital para control oftalmológico por prematuridad. El diagnóstico oftalmológico fue de vitreítis bilateral intensa (uveítis posterior) asociada a enfermedad de Chagas. Se realizó tratamiento antiparasitario, con buena respuesta en los tres casos. Debe considerarse la enfermedad de Chagas como diagnóstico diferencial de una patología ocular en los lugares donde la enfermedad es endémica y solicitar una evaluación oftalmológica en los niños con diagnóstico de la enfermedad, en especial aquellos sintomáticos y con antecedente de prematuridad.

Ophthalmic compromise is infrequent in children with congenital Chagas disease. We present 3 patients under 2 months of age, with ocular involvement, all of them referred to the hospital for ophthalmic evaluation of the premature newborn. The ophthalmic finding was bilateral severe vitreitis (posterior uveitis) related to Chagas disease. They received antiparasitic therapy with a good outcome in all cases. Chagas disease must be considered as differential diagnosis of ocular pathology in those countries where the pathology is endemic, and fundoscopic evaluation must be done in those children with the diagnosis, especially those symptomatic and prematurely born.

Managing bevacizumab-induced intraocular inflammation.

The outcome of four cases of sterile endophthalmitis that developed after intravitreal injections of bevacizumab has been reported here. All four eyes received 1.25 mg/0.05 ml intravitreal bevacizumab from 0.2-ml aliquots for different etiologies. The inflammation predominantly involved the anterior chamber with mild vitreous reaction. All patients were culture negative and regained preinjection visual acuity and were culture negative following intravitreal antibiotic administration. This report highlights that intravitreal bevacizumab can cause sterile endophthalmitis and this has to be kept in mind, and clinical judgment should be used to differentiate it from infective endophthalmitis.