C-reactive protein and complement factor H polymorphism interaction in advanced exudative age-related macular degeneration.

PURPOSE: To determine the association of C-reactive protein (CRP) and complement factor H (CFH) gene with exudative age-related macular degeneration (AMD) and any possible interaction among these factors. METHODS: In this case-control study, 139 unrelated patients with exudative AMD and 123 non-AMD controls were recruited. Blood sample was taken for analysis of the CRP levels and DNA testing. DNA fragments of CFH gene variants containing 4 single nucleotide polymorphisms including rs800292, rs1061170, rs2274700, and rs3753395 were assessed. A CRP level of ≥3 mg/L was considered as elevated. The association of elevated CRP and CFH gene variants polymorphism with exudative AMD was compared between the groups. RESULTS: Mean age was 72.6 ± 6.4 for controls and 74.9 ± 7.4 for case group (P = 0.006). The difference between CRP levels in cases and controls was not statistically significant (P = 0.055). However, Y402H variant of CFH in both homozygous and heterozygous carriers C allele was significantly more frequent among exudative AMD patients than controls, 32.1 versus 6.5 % (P < 0.001). Evaluating various CRP levels in patients with CC and non-CC genotypes disclosed that in CC genotype group, higher CRP level (>3 mg/L) was associated with higher risk of developing exudative AMD (OR = 12.0, CI: 1.5-98.8) compared with the control group. CONCLUSION: This study disclosed no difference in CRP levels per se between exudative AMD patients with control group. However, higher levels of CRP in the presence of C allele of Y402H might confer more risk for the development of exudative AMD.

Systemic oxygen therapy versus oral enalapril for treatment of diabetic macular ischemia: a randomized controlled trial.

The purpose of this study was to evaluate the structural and functional effects of systemic oxygen therapy and enalapril in patients with diabetic macular ischemia (DMI). This randomized clinical trial consisted of 105 eyes with DMI divided into three groups. Group I received systemic oxygen by face mask at a flow rate of 10 L/min; Group II received 5 mg enalapril daily; and Group III received placebo tablets for 3 months. Best-corrected visual acuity (BCVA), central macular thickness (CMT) measured by optical coherence tomography (OCT), extent of foveal avascular zone (FAZ) on fluorescein angiograms, and electroretinograms (ERG) were obtained at baseline and after 3 and 6 months. Overall, 102 patients completed the study. Baseline characteristics were not significantly different among groups. Significant improvement in BCVA and decrease in CMT and FAZ occurred at months 3 and 6 in oxygen group compared to deterioration in enalapril and control groups (All P values <0.001). ERG parameters were significantly better in oxygen group compared to enalapril group at months 3 and 6 and better than those in control group at month 3. Normobaric oxygen therapy for 3 months in DMI decreased CMT and FAZ and improved BCVA and ERG parameters. Enalapril did not show any favorable effect.

Enhanced depth imaging OCT (EDI-OCT) findings in acute phase of sympathetic ophthalmia.

The purpose of this study was to describe the EDI-OCT findings in an acute phase of sympathetic ophthalmia (SO). A 24-year-old gentleman was referred to clinic complaining of progressive blurry vision of his right eye within last 3 days. He had a history of repaired corneoscleral laceration in his left eye followed by lensectomy and anterior vitrectomy approximately 1 month before his recent right eye discomfort. Physical examination revealed a granulomatous uveitis with an exudative RD of the right eye consistent with SO. EDI-OCT was done at initial exam and repeated 1 and 15 months after therapy. EDI-OCT 1 month following therapy showed significant improvement in choroidal thickening and outer retinal cell layers. The choroidal thickness in the right sympathizing eye decreased from 617 to 568 µm and in the left exciting eye from 539 to 521 µm. After 15 month follow-up, choroidal thickness that is reported in EDI-OCT is 436 µm in the right and 382 µm in the left eye. SO should be added to the list of choroidopathies that cause an increase in choroidal thickness in acute phase of disorder with subsequent decrease after therapy, so help us in assessing and estimation of response to treatment.

Uveitis profile and treatment response in Iranian patients with sarcoidosis.

The aim of the study was to assess the clinical features and treatment responses in Iranian patients with sarcoid uveitis. A retrospective review of patients diagnosed with sarcoid uveitis from 1996 to 2010 was performed in a referral clinic in Tehran, Iran. Demographic and clinical features of patients, treatment modalities and therapeutic responses, and outcomes were recorded. Sixty-six eyes from 36 patients were studied. Twenty cases had biopsy-proven sarcoidosis. Mean duration of follow-up was 44.7 ± 45 months (range 3-175). Thirty-six eyes (54.5 %) had intermediate uveitis, 25 (37.9 %) panuveitis, and 5 (7.6 %) anterior uveitis. Twenty patients (55.5 %) responded to both systemic and/or topical corticosteroids, and 16 (44.4 %) required immunomodulatory drugs for control of uveitis. All of the patients finally responded to treatment in the form of inflammation reduction and/or vision improvement. The average time interval before initial clinical response following treatment was 3.2 ± 3 months (range 1-72). This study disclosed a higher predominance of females and intermediate form of uveitis in Iranian patients with sarcoid uveitis. Use of immunomodulatory drugs combined with corticosteroids resulted in good visual outcome and control of uveitis with a possible fewer corticosteroid side effects.

Intravitreal diclofenac versus intravitreal bevacizumab in naive diabetic macular edema: a randomized double-masked clinical trial.

The purpose of the study is to compare single injection of intravitreal diclofenac (IVD) with intravitreal bevacizumab (IVB) in the treatment of eyes with naïve diabetic macular edema (DME). In this randomized clinical trial, 57 eyes of 57 patients were randomly assigned to IVD group (30 eyes), cases who received a single intravitreal injection of diclofenac (500 µg/0.1 ml), and IVB group (27 eyes), cases who received a single intravitreal injection of bevacizumab (1.25 mg). Change in best-corrected visual acuity in logMAR at week 12 was the primary outcome measure. Secondary outcomes included changes in central macular thickness, macular leakage, and potential injection-related complications. Best-corrected visual acuity improved significantly more in the IVD group than in the IVB group (P = 0.033), from 0.57 ± 0.25 to 0.49 ± 0.31 versus 0.55 ± 0.24-0.59 ± 0.27 logMAR at 12 weeks, respectively. However, the difference of macular thickness changes was in favor of IVB, but not to a significant level. The amount of change in leakage was not significantly different between the groups either. None of the eyes, in either group, developed ocular hypertension (≥23 mmHg) or cataract progression. No important injection-related complication was observed during the study period. This study demonstrated the superiority of IVD over IVB in the treatment of naïve DME regarding functional, but not anatomical outcomes. Therefore, using IVD as an adjunct or even alternative to other treatments might enhance the functional outcomes in such cases. Further studies are warranted to confirm potential benefit of IVD observed in this study.

Rate of Post-traumatic Endophthalmitis with or without Injection of Balanced Salt Solution.

PURPOSE: In a study complementing a previous multicenter randomized clinical trial on prophylactic injection of intraocular antibiotics during primary repair of penetrating eye injuries (PEIs), we sought to determine whether needle entrance and injection of balanced salt solution (BSS), per se, could increase the rate of acute post-traumatic bacterial endophthalmitis (APBE). METHODS: Patients randomized to the BSS injection arm (n=167) of the Traumatic Endophthalmitis Trial, and eligible patients who had refused enrollment and received no intraocular injections during primary repair (n=111) were compared for the development of APBE. RESULTS: APBE occurred in 8 of 167 (4.8%) eyes in the BSS group and in 5 of 111 (4.5%) eyes in the non-injection group (P=0.91). Retained intraocular foreign bodies were present in 46 eyes including 25 (15%) eyes in the BSS injection group and 21 (18.9%) eyes in the non-injection group (P=0.38). Logistic regression analysis showed no significant difference between BSS injected and non-injected eyes in terms of APBE (P=0.69). However, the presence of intraocular foreign bodies was strongly associated with the risk of endophthalmitis (P<0.001, OR=14.1, 95% CI: 4.1-48.5). CONCLUSION: Needle entrance and intraocular injection of BSS during primary repair of PEIs does not increase the risk of APBE.

Enhanced depth imaging OCT and indocyanine green angiography changes in acute macular neuroretinopathy.

The authors describe indocyanine green angiography (ICGA) and enhanced depth imaging optical coherence tomography (EDI-OCT) in a 46-year-old male patient with acute macular neuroretinopathy (AMN). The chief complaint was decreasing visual acuity and metamorphopsia in both eyes of 1-month duration. Visual field assessment, fluorescein angiography, OCT, ICGA, and EDI-OCT were performed initially and at 3 months. ICGA showed choroidal vascular hyperpermeability and punctuate choroidal hyperfluorescent spots, especially in the left eye. EDI-OCT showed increased choroidal macular thickness, with inner and outer retinal layers affected. EDI-OCT and ICGA reveal that both the choroid and retina can be affected in AMN; however, the primary pathology and localization of depth of involvement in AMN remains unclear.

Intravitreal diclofenac for refractory uveitic cystoid macular edema.

PURPOSE: To evaluate the effect of a single dose of intravitreal diclofenac on best- corrected visual acuity (BCVA) and central macular thickness (CMT) in patients with refractory uveitic cystoid macular edema (CME). METHODS: In this prospective non-comparative case series, 8 eyes of 8 patients with refractory CME secondary to chronic intermediate uveitis received a single intravitreal injection of diclofenac (500 µg/0.1ml) in addition to other systemic (oral prednisolone and methotraxate) and topical (betamethasone) remission maintaining drugs. Outcome measures were changes in BCVA and CMT after treatment. RESULTS: Mean BCVA remained relatively unchanged at 12, 24 and 36 weeks (0.69, 0.70 and 0.64 LogMAR, respectively) as compared to baseline (0.71 LogMAR). Mean CMT, however, decreased from 488 µm at baseline to 416 and 456 µm at 24 and 36 weeks, respectively. None of the changes were statistically significant. CONCLUSION: In eyes with refractory uveitic CME, intravitreal injection of diclofenac insignificantly reduced CMT but this was not associated with visual improvement.

A pilot study of intravitreal diclofenac versus intravitreal triamcinolone for uveitic cystoid macular edema.

PURPOSE: To compare the effect of intravitreal diclofenac (IVD) versus intravitreal triamcinolone (IVT) on refractory uveitic cystoid macular edema (CME). METHODS: In this pilot randomized clinical trial, 15 eyes were randomly assigned to an IVD group, patients (8 eyes) who received a single intravitreal injection of diclofenac (500 µg/0.1 mL), and an IVT group (7 eyes), cases who received a single intravitreal injection of triamcinolone (2 mg). Change in best-corrected VA in logMAR at week 36 was the primary outcome measure. Secondary outcomes included changes in best-corrected visual acuity (BCVA) at 12 and 24 weeks, central macular thickness (CMT), macular leakage, and potential injection-related complications. RESULTS: In the IVD group, BCVA was more than the baseline values in 4 eyes at 36 weeks; however, within-group analysis disclosed no statistically significant changes in the mean BCVA in this group. Nonetheless, in the IVT group, mean BCVA improved significantly at 12, 24, and 36 weeks compared to the baseline values. It was 0.86 ± 0.37 at baseline and 0.63 ± 0.48, 0.62 ± 0.42, and 0.43 ± 0.49 logMAR at 12, 24, and 36 weeks, respectively. Mean CMT reduction diminished also significantly only in the IVT group. Nevertheless, comparing the mean BCVA and CMT changes, macular leakage, and the occurrence of any injection-related complications, no significant difference was observed between the groups at any of the follow-up visits. CONCLUSION: This pilot study demonstrated the superiority of IVT over IVD in the treatment of refractory uveitic CME regarding both functional and anatomical outcomes. Further studies are warranted to confirm potential benefit of IVD observed in this study.

INTRAVITREAL DICLOFENAC VERSUS INTRAVITREAL TRIAMCINOLONE FOR THE TREATMENT OF UVEITIC CYSTOID MACULAR EDEMA.

PURPOSE:: To compare the effect of intravitreal diclofenac (IVD) versus intravitreal triamcinolone (IVT) on refractory uveitic cystoid macular edema. METHODS:: In this pilot, randomized, clinical trial, 15 eyes were randomly assigned to IVD group, patients (8 eyes) who received a single intravitreal injection of diclofenac (500 µg/0.1 mL), and IVT group (7 eyes) patients who received a single intravitreal injection of triamcinolone (2 mg). Change in best-corrected visual acuity in logarithm of the minimum angle of resolution at Week 36 was the primary outcome measure. Secondary outcomes included changes in best-corrected visual acuity (BCVA) at 12 weeks and 24 weeks, central macular thickness, macular leakage, and potential injection-related complications. RESULTS:: In the IVD group, BCVA was more than the baseline values in 4 eyes at 36 weeks; however, within-group analysis disclosed no statistically significant changes in the mean BCVA in this group. Nonetheless, in the IVT group, mean BCVA improved significantly at 12, 24, but not at 36 weeks compared with the baseline values. It was 0.86 ± 0.37 at baseline and 0.63 ± 0.48, 0.62 ± 0.42, and 0.43 ± 0.49 logarithm of the minimum angle of resolution at 12, 24, and 36 weeks, respectively. Mean central macular thickness diminished also significantly only in the IVT group. Nevertheless, comparing the mean BCVA and central macular thickness changes, macular leakage, and the occurrence of any injection-related complications, no significant difference was observed between the groups at any of the follow-up visits. CONCLUSION:: This pilot study demonstrated the superiority of IVT over IVD in the treatment of refractory uveitic cystoid macular edema regarding both functional and anatomical outcomes. Further studies are warranted to confirm potential benefit of IVD observed in this study.

25-gauge Vitrectomy for complicated chronic endogenous/autoimmune uveitis: predictors of outcomes.

PURPOSE: To describe the course of inflammation and identify predictors of successful outcome in chronic endogenous/autoimmune uveitic patients following 25-gauge vitrectomy. METHODS: In this retrospective study, charts of 74 patients (74 eyes) undergoing vitrectomy for complicated uveitis that had a minimum of 12 months follow-up were reviewed. Successful outcome measures were improvement (≥ 0.3 logMAR) of visual acuity (VA), decreased inflammatory activity (≥ 1+), and reduction of required drugs (more than one). Logistic regression techniques were used to identify predictors of successful outcomes. RESULT: A total of 44 (59%) of the 74 patients showed VA improvement, 38 (51%) showed decreased inflammatory activity, and 30 (40%) required fewer drugs following vitrectomy. Independent predictor for VA improvements was accompanying cataract extraction, for postoperative inflammatory decrease was the absence of preoperative cystoid macular edema and greater preoperative activity of inflammation, and for the reduction in the number of required drugs was preoperative presence of epiretinal membrane formation. CONCLUSION: 25-gauge vitrectomy may be beneficial in patients with complicated chronic endogenous uveitis in terms of VA and control of inflammation. Accompanying cataract extraction, when necessitated, during vitrectomy and the absence of preoperative cystoid macular edema were indicators of better outcomes. Establishing predictors may assist clinicians in better patient selection.

Bilateral uveitis after phakic intraocular lens implantation and management with adalimumab.

A 25-year-old woman with myopia who had an AC pIOL implantation in the left eye and posterior chamber pIOL implantation in the right eye developed bilateral granulomatous panuveitis 2 months after the second surgery. Physical examination showed bilateral Koeppe and Busacca nodules. Fluorescein angiography showed diffuse vascular and retinal pigment epithelial leakage in both eyes. With assessment of sympathetic ophthalmia, treatment with a high-dose systemic steroid was started. Oral cyclosporine and azathioprine were later added. Because the uveitis was not controlled, adalimumab was added. After 6 doses of adalimumab (40 mg subcutaneously), the uveitis subsided and corticosteroid and other immunosuppressive agents were tapered. Refractive AC pIOL implantation should be added to the list of intraocular procedures that may induce sympathetic ophthalmia. Adalimumab may have a therapeutic role in its management.

SD-OCT features of laser pointer maculopathy before and after systemic corticosteroid therapy.

The authors report spectral-domain optical coherence tomography findings of laser pointer-induced maculopathy in a 25-year-old man after accidental laser pointer exposure of less than 1 second. The Class 3R laser pointer (output wavelength 532 nm and output power 3.5 to 4.5 mW [continuous wave]) had U.S. Food and Drug Administration certification. One day after exposure, he had visual blurring and metamorphopsia of his right eye. He was treated with a systemic high-dose corticosteroid. Spectral-domain optical coherence tomography disclosed a hyperreflective band in the foveal region. After 1 week of treatment, disappearance of hyperreflectivity was observed on spectral-domain optical coherence tomography. At 6 months, residual disruption of the outer retinal layer at the fovea remained unchanged. Spectral-domain optical coherence tomography was a useful and sensitive tool for evaluating retinal damage and subsequent resolution after treatment.

Antiphospholipid syndrome following toxoplasma retinochoroiditis.

PURPOSE: To report a case of antiphospholipid syndrome (APS) following toxoplasma retinochoroiditis. DESIGN: Interventional case report. METHOD: The patient was a 24-year-old female with an attack of visual loss due to toxoplasma retinochoroiditis concomitant with branch retinal vein occlusion. Retinitis resolved with anti-toxoplasma treatment. However, a recurrent episode of BRVO and vitreous hemorrhage occurred later. RESULT: In systemic evaluation, evidence of APS was detected, including high titers of anti-cardiolipin antibody, increased beta-2 microglobulin and anti-toxoplasma IgG antibody, and also low titers of C3, C4, and CH50. CONCLUSION: Ocular toxoplasmosis should be included in the list of etiologies of secondary APS. Systemic evaluation for detection of APS is a necessary approach to patients with toxoplasma retinochoroiditis and concomitant vascular accident.

Topiramate-induced bilateral anterior uveitis associated with hypopyon formation.

PURPOSE: To report a rare case of bilateral anterior uveitis with hypopyon formation following systemic topiramate use. MATERIALS AND METHODS: A 40-year-old woman with migraine headache who was under topiramate treatment referred with bilateral ocular pain and visual blurring. Physical examination disclosed shallow anterior chamber and high intraocular pressure in both eyes. Following discontinuation of topiramate a severe bilateral anterior uveitis with posterior synechiae and hypopyon developed. RESULTS: Ocular inflammation resolved with systemic and topical steroid. Because of severe cataract and synechiae formation she underwent phacoemulsification/posterior chamber intraocular lens implantation and visual acuity of both eyes improved to 20/25. CONCLUSION: Topiramate should be added to the list of drugs that may cause anterior uveitis and hypopyon formation.