Candida Endophthalmitis Treated Successfully With Isavuconazole: A Case Report.

Candida endophthalmitis is a serious complication of candidemia. Diagnosis requires identification of ocular lesions on dilated fundoscopy, aided by isolation of the organism from blood and/or vitreous humor. However, the initial ophthalmological examination may be negative in some cases. Experience with isavuconazole for the treatment of Candida endophthalmitis is limited. We present a case of a 65-year-old woman with metastatic breast cancer on chemotherapy who developed Candida dubliniensis endophthalmitis with initial negative ophthalmological examination. She was treated with vitrectomy and 6 weeks of oral fluconazole. Despite vitrectomy and culture-directed antifungal treatment, management was complicated by lack of response to fluconazole and intolerance to other antifungals, necessitating the use of isavuconazole, which proved efficacious.

Pediatric Uveitis and Scleritis in a Multi-Ethnic Asian Population.

Purpose: To describe the demographics and clinical characteristics of pediatric uveitis and scleritis at a tertiary eye care center.Methods: Clinical records of children with either uveitis or scleritis that presented between January 1989 and January 2016 were reviewed retrospectively.Results: Seventy-three patients were identified. Fifty-four had uveitis and 19 had scleritis. Posterior uveitis was the most common (27.8%), followed by intermediate uveitis (25.9%), panuveitis (25.9%) and anterior uveitis. Majority were noninfectious uveitis (37.0%), and 29.6% were idiopathic. Common associations were sarcoidosis (14.8%), HLA-B27 haplotype (9.3%) and toxoplasmosis (7.4%). Posterior scleritis was more common (94.7%) than anterior scleritis and majority were idiopathic (68.4%). Delayed patient presentation and presenting visual acuity worse than 0.3 LogMAR were associated with poor visual outcome (p = .03; OR = 0.17; 95% CI, 0.03-0.84 and p = .007; OR = 0.09; 95% CI, 0.02-0.52 respectively).Conclusion: Majority had noninfectious etiologies. Uveitis associated with juvenile idiopathic arthritis was rare.

Intra-cameral level of ganciclovir gel, 0.15% following topical application for cytomegalovirus anterior segment infection: A pilot study.

PURPOSE: To investigate the intra-cameral level of ganciclovir following topical application of ganciclovir gel, 0.15% for cytomegalovirus (CMV) anterior segment infection. DESIGN: Non-randomized, prospective, interventional clinical study. METHODS: Patients with active CMV anterior segment infection seen at Singapore National Eye Centre, confirmed by positive CMV real time PCR (RT-PCR) of the aqueous humor, that had not been treated with any form of ganciclovir in the preceding 1 month were recruited. They were treated with ganciclovir gel, 0.15% 1cc 5 times a day. Following 6 weeks of treatment, CMV load in the aqueous humor was measured using CMV RT-PCR and the ganciclovir drug levels in tears and aqueous humor were measured using high-performance liquid chromatography-mass spectrometry. The clinical features of the disease activity and the central corneal thickness (CCT) were recorded at the baseline and post-treatment. RESULTS: There were 29 eyes of 29 patients, of which 23 eyes had CMV anterior uveitis and 6 eyes had CMV endotheliitis. At the end of week 6, 26 eyes had undetectable CMV titre in the aqueous humor and no anterior chamber (AC) activity. Two patients had an increased CMV titre and increased AC inflammation. Both of these patients were non-compliant with the treatment. One patient had a reduced CMV titre in the aqueous humor with minimal AC inflammation. The mean ganciclovir concentration in the aqueous humor and the tears were 17.4 ± 30.6 ng/ml and 20,420.9 ± 33,120.8 ng/ml respectively. Mean CCT was 552.2 ± 42.3 microns. There was a weak correlation between the ganciclovir concentration in the aqueous humor and CCT (Spearmen's r = + 0.42, p = 0.025). There was no significant correlation between the ganiclovir concentration in the tears and CCT (Spearmen's r = + 0.39, p = 0.11). CONCLUSION: Ganciclovir levels in the aqueous humor was below the 50% inhibitory dose (ID50) for CMV replication, following topical application of the ganciclovir gel, 0.15%. TRIAL REGISTRATION: SingHealth Centralized Institutional Review Board, Singapore; R733/17/2010, ClinicalTrials.gov; NCT01647529.

The Pattern of Uveitis among Chinese, Malays, and Indians in Singapore.

PURPOSE: To describe the pattern of uveitis among Chinese, Malays, and Indians at a tertiary referral institution in Singapore. METHODS: Charts between January 1997 and December 2010 were retrospectively reviewed. Charts between January 2014 and December 2014 were prospectively reviewed. RESULTS: A total of 1249 and 148 charts were retrospectively and prospectively reviewed, respectively. The top causes of anterior uveitis (AU) were HLA-B27, idiopathic, and CMV AU. The top known causes of intermediate uveitis were tuberculosis, primary intraocular lymphoma, and sarcoidosis. The top causes of posterior uveitis were CMV retinitis, toxoplasmosis, and dengue maculopathy. The top causes of panuveitis were VKH, idiopathic panuveitis, tuberculosis, and Behçet disease. HLA-B27 and CMV AU were more frequent among Chinese (21% vs 9% (non-Chinese); p<0.001; 10% vs 5% (non-Chinese); p<0.001, respectively). Tuberculous uveitis was more frequent among Malays and Indians (12% (non-Chinese) vs 5% (Chinese), p<0.001). CONCLUSIONS: Different uveitis patterns were encountered among patients of different races.

Specialized moisture retention eyewear for evaporative dry eye.

OBJECTIVES: To evaluate the suitablity of commercially available moisture retention eyewear for treating evaporative dry eye. METHODS: Eleven patients with evaporative dry eyes were prescibed moisture retention eyewear for 3 months in addition to regular lubricant eye drops. Frequency and severity of dry eye symptoms, corneal fluorescein staining and tear break up time (TBUT) were evaluated at baseline and 3-month post-treatment. Main outcome measure was global symptom score (based on severity and frequency of dry eye symptoms on a visual analog scale) and secondary outcomes were changes in sectoral corneal fluorescein staining and tear break up time (TBUT) from pre-treatment level. RESULTS: There was a significant improvement in dry eye symptoms after using moisture retention eyewear for 3 months (p < 0.05). Corneal fluorescein staining in all five zones of the cornea in both eyes improved significantly (p < 0.05). There was no significant improvement in TBUT. Patients used ocular lubricants less frequently (p < 0.05) compared to the commencement of the study. Patients found moisture retention eyewear to be useful in relieving dry eye symptoms in windy, air-conditioned environments or when doing vision-related daily tasks. CONCLUSIONS: This study shows that moisture retention eyewear might be a valuable adjunct in management of evaporative dry eye and this new design of commercially available eyewear could have a good acceptability rate.

Aqueous cytokine changes associated with Posner-Schlossman syndrome with and without human cytomegalovirus.

AIM: To study the differences in aqueous cytokines in Posner-Schlossman Syndrome (PSS) patients with and without human cytomegalovirus (CMV) DNA in the aqueous humor. METHODS: This is a prospective study. Fifty-three uveitis patients with clinical signs of PSS were enrolled and aqueous humor samples were collected. Fourteen PSS patients were positive of CMV DNA in the aqueous by polymerase chain reaction (PCR) analysis. These eyes were negative of common ocular pathogens such as herpes simplex virus, varicella-zoster virus, rubella virus and toxoplasma. Twenty-five otherwise healthy cataract patients were enrolled as controls. Cytokine concentration was measured by a magnetic color-bead-based multiplex assay and analyzed using statistical and classification approaches. RESULTS: The average age of 53 PSS patients was 48.74±13.43 years (yrs) (mean ± standard deviation) and 66.3±15.0 yrs for the controls. The median CMV viral DNA copy number was 26000/mL aqueous (range 1400 to 85000 copies/mL) in 14 CMV positive patients as determined by quantitative PCR. PSS aqueous had significantly higher Interleukin (IL)-8 (CXCL8), monocyte chemotactic protein-1 (CCL2), macrophage inhibitory protein 1-ß (CCL4), granulocyte colony-stimulating factor (GCSF) and transforming growth factor-ß (TGF-ß) levels than controls after adjusted by age and gender. IL-2, IL-12, tumor necrosis factor-α (TNF-α) and interferon-α (IFN-α) levels were significantly lower in PSS aqueous than controls. No difference between CMV positive PSS and CMV negative PSS aqueous was observed. Over 97% of PSS samples were distinguished from controls by elevated CXCL10 (>500 ng/mL), CXCL8 (>30 ng/mL) and CCL2 (>60 ng/mL) levels. CONCLUSION: PSS eyes were characterized by elevated aqueous chemokine concentration. The presence of CMV viral DNA was not associated with significant change of the type of cytokine expression in PSS patients.

Lubricant with gelling agent in treating dry eye in adult Chinese patients.

PURPOSE: To investigate the efficacy of a lubricant eye drop containing gelling agent in adult Chinese dry eye patients. METHODS: This is a prospective, randomized, double-masked, double-arm, parallel, interventional single-site clinical study. Thirty Chinese dry eye patients were randomized into two arms, 15 patients each, receiving lubricant eye drops either containing hydroxypropyl-guar (HP-guar) gelling agent (Systane Ultra) or no gelling agent (Refresh Tears), 1 drop, four times a day for 6 weeks. The main outcome measure was global symptom score (based on severity and frequency of dry eye symptoms on a visual analog scale) at weeks 1, 3, and 6. Secondary outcomes were changes in sectoral corneal fluorescein staining, tear break-up time, and Schirmer's I test results from pretreatment level. RESULTS: Both groups showed significant improvement in symptoms from baseline (p < 0.001). There was no significant difference in the global symptom score at weeks 1, 3, and 6 between the two groups. There was significantly more severe corneal fluorescein staining in the HP-guar group at baseline in the left nasal (p = 0.023) and left inferior (p = 0.046) zones, but no difference in staining was observed between the two arms at weeks 1, 3, and 6. There were no differences in Schirmer's test results or tear break-up time (final and pretreatment) between the two groups (p > 0.05). CONCLUSIONS: Both lubricant eye drops, with or without HP-guar gelling agent, benefit patients in relieving dry eye symptoms. There was no difference in the efficacy of these drugs in terms of improving symptoms and altering objective signs of dry eye.

Cost of dry eye treatment in an Asian clinic setting.

OBJECTIVES: To estimate the cost and patterns of expenditure of dry eye treatment. METHODOLOGY: We retrieved data on the type and cost of dry eye treatment in Singapore National Eye Centre from pharmacy and clinic inventory databases over a 2 year period (2008-2009) retrospectively. According to the type of treatment, data were sorted into 7 groups; meibomien gland disease (MGD) treatment, preservative free lubricant eye drops, preserved lubricant eye drops, lubricant ointments and gels, cyclosporine eye drops, oral supplements and non-pharmacological treatments/procedures. Each recorded entry was considered as one patient episode (PE). Comparisons in each group between two years were carried out using Pearson Chi-Square test. Significance level was set at alpha  =  0.05. RESULTS: Cost data from 54,052 patients were available for analysis. Total number of recorded PEs was 132,758. Total annual expenditure on dry eye treatment for year 2008 and 2009 were US$1,509,372.20 and US$1,520,797.80 respectively. Total expenditure per PE in year 2008 and 2009 were US$22.11 and US$23.59 respectively. From 2008 to 2009, there was a 0.8% increase in total annual expenditure and 6.69% increase in expenditure per PE. Pharmacological treatment attributes to 99.2% of the total expenditure with lubricants accounting for 79.3% of the total pharmacological treatment expenditure. Total number of units purchased in preservative free lubricants, cyclosporine eye drops and MGD therapy have increased significantly (p<0.001) whereas number of units purchased in preserved lubricants and ointments/gels have reduced significantly (p<0.001) from 2008 to 2009. CONCLUSION: Dry eye imposes a significant direct burden to health care expenditure even without considering indirect costs. Health care planners should be aware that these direct costs appear to increase over the time and more so for particular types of medications. Given the limitations of socio-economic data, true societal costs of Dry eye syndrome are likely to be much higher than estimated.