Corticoterapia vs. corticoterapia con inmunosupresores en el tratamiento de la fase aguda del síndrome de Vogt-Koyanagi-Harada / Corticotherapy vs. Corticotherapy Plus Immunosuppressive Therapy in Acute Vogt-Koyanagi-Harada Disease

INTRODUCCIÓN: La enfermedad de Vogt-Koyanagi-Harada es un trastorno multisistémico que se caracteriza por ser una panuveítis bilateral granulomatosa. Diferentes esquemas de tratamiento se han usado para controlar la inflamación en la fase aguda con el fin de prevenir la pérdida visual irreversible. El propósito de este trabajo es comparar el efecto en el resultado funcional y anatómico del tratamiento en la fase aguda de la enfermedad con esteroides vs. esteroides con inmunosupresores (IMT) (grupo A vs. grupo B). MÉTODOS: Estudio retrospectivo de una serie de casos con enfermedad de Vogt-Koyanagi-Harada, con una evolución menor o igual a 2 semanas, que acudieron a la Clínica de Enfermedades Inflamatorias Oculares, de 2001 a 2015. Se incluyeron datos demográficos, características clínicas, tratamiento y mejoría de agudeza visual (AV). RESULTADOS: Se incluyeron 16 casos; 15 mujeres (93,75%). Edad media: 30,81 ± 10,53 años, y seguimiento (meses): 54,94 ± 43,43. Diez pacientes con IMT (66,6%) (azatioprina, metotrexato y ciclofosfamida). En el grupo A, la AV inicial fue < 20/200 en el 66,7%; y la final ≥ 20/40 en 9 casos (75%). En el grupo B, la AV inicial < 20/200 en el 65%; y la AV final ≥ 20/40 en 15 ojos (75%). En el grupo A, la AV mejoró más rápido en el primer y tercer mes (ANOVA p < 0,057). Los datos clínicos de fase de convalecencia y complicaciones fueron similares. Las recurrencias del segmento anterior se observaron en los dos grupos; en el grupo A, también se vieron recurrencias de polo posterior. El tiempo hasta la primera recurrencia fue similar (p < 0,279).La frecuencia de recurrencia fue de 2,33 ± 1,80 vs. 1,5 ± 0,79 (p < 0,01). En ese momento 15 pacientes continuaban con esteroide vía oral, 9 del grupo A, y 6 del grupo B. En el grupo A, la prednisona se dio por un tiempo mayor: media 15,17 ± 12,08 meses, y el tiempo en llegar a dosis de 10 mg o menor fue mayor: 8,60 ± 11,7 (p < 0,008 y p < 0,046). CONCLUSIONES: El agregar IMT a los corticoesteroides como primera línea de tratamiento no cambió el resultado final de AV, ni de complicaciones. En el grupo de IMT más corticoesteroides el número de recurrencias fue menor y se observó un efecto ahorrador de esteroides

INTRODUCTION: Vogt-Koyanagi-Harada disease is a multisystem disorder characterized by a bilateral granulomatous panuveitis. Multiple therapeutic regimens have been used to control inflammation in acute uveitic stage to prevent irreversible visual loss. The purpose of this paper is to compare the effect, on functional and anatomic outcomes, of early treatment with standard corticotherapy vs. corticotherapy plus immunosuppressive (IMT) therapy in acute Vogt-Koyanagi-Harada disease (Group A vs Group B). METHODS: A retrospective chart review of patients with Vogt-Koyanagi-Harada disease, with an evolution time of 2 weeks or less, who attended the Inflammatory Eye Disease Clinic, from 2001 to 2015. Data collected included demographic information, presenting features, treatment and improvement in visual acuity (VA). RESULTS: Sixteen charts were reviewed; 15 females (93.75%). Mean age: 30.81 ± 10.53 years, follow-up time (months): 54.94 ± 43.43. Ten patients (66.6%) had IMT, azathioprine, methotrexate and cyclophosphamide. In group A, initial VA < 20/200 in 66.7%; final VA was ≥ 20/40 in 9 eyes (75%). In group B, initial VA < 20/200 in 65%; final VA ≥ 20/40 in 15 eyes (75%). In group A, VA improved faster at one and 3 months (ANOVA P < .057). Clinical characteristics in convalescent stage and complications were similar. Anterior chamber recurrences occurred in both groups and posterior pole recurrences were observed in group A. Time to first recurrence was similar (P < .279). Frequency of recurrence was 2.33 ± 1.80 vs 1.5 ± 0.79 (P<.01). At recurrence 15 patients were still having oral steroids, nine in group A, 6 in Group B. In group A, prednisone was given during more time: mean 15.17±12.08 months, and time to reach to 10 mg dose was longer: 8.60 ± 11.7 (P < .008 and P < .046). CONCLUSIONS: Adding IMT as first line therapy to corticosteroids, do not matter significantly in terms of final VA or development of visually significant complications. In the IMT plus corticosteroids group number of recurrences was significantly lower, and a steroid sparing effect was evident

Corticotherapy vs. Corticotherapy Plus Immunosuppressive Therapy in Acute Vogt-Koyanagi-Harada Disease. / Corticoterapia vs. corticoterapia con inmunosupresores en el tratamiento de la fase aguda del síndrome de Vogt-Koyanagi-Harada.

INTRODUCTION: Vogt-Koyanagi-Harada disease is a multisystem disorder characterized by a bilateral granulomatous panuveitis. Multiple therapeutic regimens have been used to control inflammation in acute uveitic stage to prevent irreversible visual loss. The purpose of this paper is to compare the effect, on functional and anatomic outcomes, of early treatment with standard corticotherapy vs. corticotherapy plus immunosuppressive (IMT) therapy in acute Vogt-Koyanagi-Harada disease (Group A vs Group B). METHODS: A retrospective chart review of patients with Vogt-Koyanagi-Harada disease, with an evolution time of 2 weeks or less, who attended the Inflammatory Eye Disease Clinic, from 2001 to 2015. Data collected included demographic information, presenting features, treatment and improvement in visual acuity (VA). RESULTS: Sixteen charts were reviewed; 15 females (93.75%). Mean age: 30.81±10.53 years, follow-up time (months): 54.94±43.43. Ten patients (66.6%) had IMT, azathioprine, methotrexate and cyclophosphamide. In group A, initial VA<20/200 in 66.7%; final VA was ≥20/40 in 9 eyes (75%). In group B, initial VA<20/200 in 65%; final VA≥20/40 in 15 eyes (75%). In group A, VA improved faster at one and 3 months (ANOVA P<.057). Clinical characteristics in convalescent stage and complications were similar. Anterior chamber recurrences occurred in both groups and posterior pole recurrences were observed in group A. Time to first recurrence was similar (P<.279). Frequency of recurrence was 2.33±1.80 vs 1.5±0.79 (P<.01). At recurrence 15 patients were still having oral steroids, nine in group A, 6 in Group B. In group A, prednisone was given during more time: mean 15.17±12.08 months, and time to reach to 10mg dose was longer: 8.60±11.7 (P<.008 and P<.046). CONCLUSIONS: Adding IMT as first line therapy to corticosteroids, do not matter significantly in terms of final VA or development of visually significant complications. In the IMT plus corticosteroids group number of recurrences was significantly lower, and a steroid sparing effect was evident.

Asociación de membranas epirretinianas con edema macular en pars planitis / Association of epiretinal membranes with macular edema in pars planitis

INTRODUCCIÓN: La pars planitis (PP) es una uveítis intermedia idiopática que presenta múltiples complicaciones en el segmento posterior, las cuales incluyen el edema macular quístico o cistoideo (EM) y la formación de membranas epirretinianas (MER). Comúnmente se decide realizar tratamiento antiinflamatorio o inmunosupresor ante la presencia de EM. Sin embargo, este puede coexistir con la presencia de MER y, por lo tanto, existe la posibilidad de que el enfoque del tratamiento deba ser diferente. OBJETIVOS: Determinar la asociación que existe entre la presencia de MER con EM en PP. MATERIALES Y MÉTODOS: Serie de casos y controles donde se analizaron de manera retrospectiva los expedientes de pacientes con PP, todos ellos seguidos con angiografía con fluoresceína (AF) y tomografía de coherencia óptica de dominio espectral (SD-OCT). Se determinó la presencia de MER por SD-OCT, mientras que el EM fue determinado por AF. Se realizaron tablas de contingencia para determinar cómo influyen las MER como factores de riesgo para desarrollar EM. RESULTADOS: 31 ojos presentaron MER. 16 ojos presentaron EM. La razón de riesgo para presentar EM por MER fue de 0,971 con un valor de p determinada por χ2 de 0,77. CONCLUSIONES: No existe una asociación significativa entre la formación de MER y el desarrollo de EM. No existe evidencia que sugiera considerar un abordaje quirúrgico como primera línea de tratamiento ante la presencia de MER en PP

INTRODUCTION: Pars planitis (PP) is a form of intermediate uveitis that manifests with several posterior segment complications, including cystoid macular edema (CME) and epiretinal membrane formation (ERM). On the presence of CME the patient is usually treated with anti-inflammatory and/or immunosuppressive drugs. However the presence of CME may coexist with ERM formation, and therefore the treatment could be different. PURPOSE: To determine the association between ERM and CME in PP. MATERIALS AND METHODS: Case control series. The charts of patients diagnosed with PP were retrospectively reviewed. All patients had fluorescein angiogram (FA) and spectral domain optical coherence tomography (SD-OCT). Presence of ERM was determined by SD-OCT, while CME was determined by FA. Contingency tables were used to determine the risk of developing CME with ERM. RESULTS: 31 eyes presented ERM. 16 eyes presented CME. Relative risk to have CME and ERM was 0.971, with a P value of 0.77 (χ2). CONCLUSIONS: There is no association between ERM formation and the development of CME. There is no evidence to suggest a surgical approach as first line of treatment with the presence of ERM in PP

[Association of epiretinal membranes with macular edema in pars planitis]. / Asociación de membranas epirretinianas con edema macular en pars planitis.

INTRODUCTION: Pars planitis (PP) is a form of intermediate uveitis that manifests with several posterior segment complications, including cystoid macular edema (CME) and epiretinal membrane formation (ERM). On the presence of CME the patient is usually treated with anti-inflammatory and/or immunosuppressive drugs. However the presence of CME may coexist with ERM formation, and therefore the treatment could be different. PURPOSE: To determine the association between ERM and CME in PP. MATERIALS AND METHODS: Case control series. The charts of patients diagnosed with PP were retrospectively reviewed. All patients had fluorescein angiogram (FA) and spectral domain optical coherence tomography (SD-OCT). Presence of ERM was determined by SD-OCT, while CME was determined by FA. Contingency tables were used to determine the risk of developing CME with ERM. RESULTS: 31 eyes presented ERM. 16 eyes presented CME. Relative risk to have CME and ERM was 0.971, with a P value of 0.77 (χ(2)). CONCLUSIONS: There is no association between ERM formation and the development of CME. There is no evidence to suggest a surgical approach as first line of treatment with the presence of ERM in PP.

[Central serous chorioretinopathy versus sympathetic ophthalmia. Case report]. / Coroidopatía serosa central versus oftalmía simpática. A propósito de un caso.

CLINICAL CASE: A 29 year old patient with a history of sutured corneal wound treated with oral antibiotics and steroids. After stopping steroid treatment, he referred reduced visual acuity in the non-traumatized eye. Previous treatment was reintroduced and he was referred to our hospital diagnosed with sympathetic ophthalmia. Bilateral macular folds, white and yellowish lesions, and subretinal fluid were found. DISCUSSION: The association of stress, anxious personality, and steroid use can favor atypical presentations of central serous chorioretinopathy.

Coroidopatía serosa central versus oftalmía simpática: A propósito de un caso / Central serous chorioretinopathy versus sympathetic ophthalmia. Case report

Caso clínico: Paciente varón de 29 años de edad con antecedente de herida corneal suturada que recibió tratamiento con antibióticos y esteroides. Al suspender los esteroides, refiere disminución de la agudeza visual del ojo no traumatizado. Se reinicia tratamiento y se envía a nuestro hospital con diagnóstico de oftalmía simpática. Fondo de ojo con pliegues maculares y lesiones blanco amarillentas con líquido subretiniano en ambos ojos. Discusión: La asociación de estrés, personalidad ansiosa y uso de esteroides favorecen el desarrollo de formas atípicas de coroidopatía serosa central(AU)

Clinical case: A 29 year old patient with a history of sutured corneal wound treated with oral antibiotics and steroids. After stopping steroid treatment, he referred reduced visual acuity in the non-traumatized eye. Previous treatment was reintroduced and he was referred to our hospital diagnosed with sympathetic ophthalmia. Bilateral macular folds, white and yellowish lesions, and subretinal fluid were found. Discussion: The association of stress, anxious personality, and steroid use can favor atypical presentations of central serous chorioretinopath(AU)

Revised diagnostic criteria for Vogt-Koyanagi-Harada disease: report of an international committee on nomenclature.

PURPOSE: To present revised criteria for the diagnosis of Vogt-Koyanagi-Harada disease, a chronic, bilateral, granulomatous ocular and multisystem inflammatory condition of unknown cause. METHODS: Diagnostic criteria and nomenclature were subjects of discussion at the First International Workshop on Vogt-Koyanagi-Harada Disease on October 19-21, 1999, at the University of California, Los Angeles, Conference Center, Lake Arrowhead, California. A committee appointed by the workshop participants was charged with drafting revised criteria for Vogt-Koyanagi-Harada disease, based on discussions held during the conference. This article is the consensus committee report. RESULTS: New criteria, taking into account the multisystem nature of Vogt-Koyanagi-Harada disease, with allowance for the different ocular findings present in the early and late stages of the disease, were formulated and agreed upon by the committee. These criteria are based on additional knowledge and experience of experts in the field and are believed to reflect disease features more fully than previously published criteria. CONCLUSIONS: The revised definition of Vogt-Koyanagi-Harada disease, with expanded diagnostic criteria, will facilitate performance of studies involving homogeneous populations of patients, at various stages of disease, that address unanswered questions regarding treatment and disease mechanisms.

Effect of chloroquine on experimental melanin-protein-induced uveitis in Lewis rats.

PURPOSE: To evaluate the effect of chloroquine on experimental recurrent autoimmune melanin-protein-induced uveitis in Lewis rats. METHODS: Five Lewis rats were immunized with melanin to induce uveitis (group I); another six were immunized and treated with 5 mg/kg/day of chloroquine (group II). To reinduce uveitis, they received two booster injections of melanin. They were killed when uveitis was present after the last booster injection; every eye was evaluated by means of clinical and histopathological examination. A control group of four rats received the same chloroquine dose to evaluate retinal toxicity (group III). RESULTS: Rats in group I showed more severe uveitis episodes than rats in group II. The second uveitis episode was more severe in group I than in group I. Rats in group III showed no clinical or histopathological abnormalities. CONCLUSIONS: Chloroquine decreased the severity and duration of uveitis, and in two rats it prevented recurrences. Thus, chloroquine can be considered an effective treatment for chronic, recurrent experimental uveitis.

Ahmed valve implant for uncontrolled uveitic glaucoma.

To evaluate the efficacy of the Ahmed valve implant in patients with uncontrolled uveitic glaucoma, the medical records of all patients with uncontrolled uveitic glaucoma who underwent Ahmed valve implant surgery between October 1993 and March 1996 were reviewed. Surgery was considered a success if intraocular pressure (IOP) was less than 22 mmHg and greater than 4 mmHg (with or without antiglaucoma medications) at the last postoperative visit. It was not a success when further glaucoma surgery had been performed, or chronic hypotony, phthisis, or loss of light perception occurred. Fourteen patients (14 eyes) with a mean age of 45.7 years were included. Most of them were high-risk patients, many of whom had already had cataract surgery (71.4%) and undergone one to three previous glaucoma surgeries (57.1%). Follow-up for eyes in which IOP was controlled ranged from 11 to 40 months (mean 22.6 months). Success was achieved in eight of 14 eyes (57.14%). Intraocular pressure was reduced from a mean of 32.64 +/- 7.79 mmHg (range 23-46 mmHg) with 2.78 +/- 0.57 antiglaucoma medications (range 2-4) preoperatively to 17.57 +/- 10.93 mmHg (range 0-38 mmHg) (p < 0.0001) with 0.71 +/- 0.99 antiglaucoma medications (range 0-3) postoperatively (p < 0.0001). The most common complications were encapsulated bleb in six eyes (42.8%), transient hypotony in six eyes (42.8%), and hyphema in three (21.4%). Ahmed valve implant appeared to be a safe alternative in high-risk patients with uncontrolled uveitic glaucoma who have had multiple previous ocular surgeries.

HLA-DR is strongly associated with Vogt-Koyanagi-Harada disease in Mexican Mestizo patients.

PURPOSE: To analyze the genetic background of human leukocyte antigens (HLA) of Vogt-Koyanagi-Harada (VKH) disease in Mexican Mestizo patients in order to establish whether the pathogenesis is related to the same genes or sequences described in other populations. PATIENTS AND METHODS: In 48 VKH patients, we performed HLA class I and class II typing using the standard microlymphocytotoxicity tests; a group of 100 nonrelated healthy subjects were analyzed for comparison. Antigen and gene frequencies were calculated for every antigen tested in patients and in controls. RESULTS: The frequency of HLA-DR4 was significantly increased in VKH Mexican patients (x2Y = 19.95; p = 0.00001; pc = 0.0002; RR = 5.3; EF = 0.52); a discrete increase in DR1 was also found (p = 0.02). HLA-DQ8 also showed a significant association with the disease with a lower RR (3.2) and EF (0.41) than DR4. CONCLUSION: The strong association found with HLA-DR4 and the slight DR1 increase shown in Mexican patients with VKH suggest that a common shared sequence present in the third hypervariable region of DRB1 genes is relevant for the expression of the disease. The stronger association with DR4 than the one with DQ8 suggests that the DR locus carries the primary susceptibility genes involved in the pathogenesis of VKH.

Chorioretinitis secondary to mycobacterium tuberculosis in acquired immune deficiency syndrome.

BACKGROUND: Several opportunistic intraocular infections have been described in patients with the human immunodeficiency virus, among them infections caused by Mycobacterium tuberculosis. In most cases, the diagnosis is based on clinical findings. Recent reports have described the usefulness of polymerase chain reaction techniques in the diagnosis of bacterial infections. METHODS: The authors observed a 29-year-old woman with acquired immune deficiency syndrome in whom unilateral chorioretinitis developed. The chorioretinitis appeared after cessation of treatment for pulmonary tuberculosis. We obtained aqueous humor by paracentesis and tested it by polymerase chain reaction to detect M. tuberculosis DNA. RESULTS: The polymerase chain reaction of the aqueous humor was positive for M. tuberculosis DNA. CONCLUSION: Polymerase chain reaction was useful in identifying M. tuberculosis in aqueous from a patient with chorioretinitis, pulmonary tuberculosis, and acquired immune deficiency syndrome.

Peripheral corneal endotheliopathy and pars planitis.

A peripheral corneal endotheliopathy (PCE), named autoimmune endotheliopathy was described in association with corneal graft rejection and as an isolated corneal alteration unrelated to surgery, trauma, or infection. It has also been found in patients with pars planitis (PP), but the significance of this association is unknown. The authors retrospectively reviewed the clinical charts of 53 PP patients (106 eyes) examined at the Uveitis Clinic from 1988 to 1993. Special attention was paid to the description of corneal clinical findings. PCE was found in 18.8+ of the eyes, and of these, 70+ showed bilateral involvement. The presence of PCE was not related to PP severity, but PCE was more frequently seen in younger patients. This descriptive study shows that identification of PCE may aid in the diagnosis of childhood PP.

Pars planitis: epidemiology and clinical outcome in a large community hospital in Mexico City.

Medical records of 51 patients with a diagnosis of pars planitis (97 eyes) were reviewed. Based upon the severity of vitreous inflammation, in 34 eyes (35%) the condition was classified as mild, in 38 (39%) as moderate, and in 25 eyes (26%) as severe. Vascular sheathing was present in 51 eyes (53%), snowballs in 42 (43%), snowbanks in 29 (30%), cataract in 19 (20%), cystoid macular edema in 26 (27%), retinal detachment in 4 (4%) and glaucoma in 3 (3%) eyes. Treatment consisted of prednisone and periocular injections of deposteroids or immunosuppressive agents; 13 patients required surgery for retinal repair, glaucoma, vitreous opacities or cataract. After treatment the visual acuity improved in 58% of the eyes, did not change in 33%, and worsened in 9%.