Efficacy and safety of topical ganciclovir in the management of cytomegalovirus (CMV)-related anterior uveitis.

BACKGROUND: The aim of this study was to evaluate the efficacy and safety of topical ganciclovir 0.15 % gel in the management of patients with cytomegalovirus (CMV) anterior uveitis. RESULTS: This was a retrospective cohort study of the disease course of 31 patients (33 eyes) with aqueous polymerase chain reaction (PCR) positive for CMV. Data from a total of 160 episodes of anterior uveitis flare for 20 years, dating from December 1992 to December 2012, was collected. All patients were treated with concomitant topical anti-inflammatory medication. The disease course of each eye was analysed before and after the use of topical ganciclovir 0.15 %. The mean age at initial presentation of anterior uveitis was 57.5 ± 12.6 years. Twenty-eight (90.3 %) patients were Chinese. Patients on topical ganciclovir gel had a statistically significant fewer episodes of uveitis flare per person year (median -0.88 episodes/person years, p = 0.029). The time-to-quiescence was not significantly affected by topical ganciclovir use (median -1.25 days, p = 0.610). In the survival analysis using the Cox regression model, the use of topical ganciclovir was associated with a lower risk of recurrence, but this was not statistically significant (hazard ratio = 0.857, 95 % CI 0.543-1.36, p = 0.511). The overall median time-to-recurrence was 290 days (95 % CI 113 to 274 days) and 164 days (125 to 404 days) (p = 0.492), with and without topical ganciclovir, respectively. CONCLUSIONS: Topical ganciclovir may be beneficial in reducing the frequency of recurrence in patients with CMV anterior uveitis, but it was not statistically associated with prolonging the time-to-recurrence. The time-to-quiescence was also not significantly affected by topical ganciclovir. Prospective studies with a larger number of patients would be required to verify our findings.

Assessment of Depression, Anxiety, and Quality of Life in Singaporean Patients With Glaucoma.

PURPOSE: To determine the prevalence and risk factors for anxiety disorder and depression among glaucoma patients in Singapore, and to assess the relationship between quality of life (QOL) and depression/anxiety. METHODS: In this cross-sectional study, glaucoma patients aged 21 and above with a known diagnosis of primary open-angle glaucoma or primary angle-closure glaucoma were recruited from a tertiary care hospital. Patients with other types of glaucoma, and coexisting ocular or psychiatric disorders were excluded.Ophthalmic examination was carried out on all participants, which included best-corrected visual acuity (BCVA), intraocular pressure (IOP), gonioscopy, standard automated perimetry, and optic disc evaluation. Sociodemographic information and treatment histories were also collected.The Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), and Visual Function Questionnaire (VFQ25) were administered to evaluate for depression, anxiety, and impact on QOL, respectively. RESULTS: A total of 100 patients were included in this study. The mean age was 67.1±12.0 years (range, 24 to 90 y). The frequency of depression and anxiety among our patients was 30% and 64%, respectively. The mean HAM-D score was 4.37±4.17 (range, 0 to 17), whereas the mean HAM-A score was 2.38±2.80 (range, 0 to 13). The mean VFQ25 score was 78.8±16.0 (range, 42.4 to 97.0). The poorest subscale on the VFQ25 was driving, with a mean score of 42.4±42.6 (range, 0.0 to 100.0).We did not find any significant difference between the presence of depression/anxiety between patients with primary open-angle glaucoma (P=0.263) and primary angle-closure glaucoma (P=0.830). Risk factors for depression included: female sex (P=0.020), higher logMAR BCVA in the worse eye (P=0.004), higher cup-disc ratio (P=0.016), lower MD in the better and worse eye (P=0.022 and 0.001, respectively), and lower mean VFQ25 score (P<0.001). Risk factors for anxiety included: lower MD in the worse eye (P=0.004) and lower mean VFQ25 score (P=0.004). There was also no significant association between the use of topical ß-blockers/carbonic anhydrase inhibitors with depression (P=0.793) or anxiety (P=0.282). CONCLUSIONS: There is a relatively high prevalence of depression (30%) and anxiety disorders (64%) among glaucoma patients in Singapore. Female glaucoma patients are more likely to suffer from depression. Other risk factors for depression include higher cup-disc ratio, higher logMAR BCVA, lower MD, and a lower mean VFQ25 score. Risk factors for anxiety disorder include lower MD and lower mean VFQ25 score. Ophthalmologists could consider use of the VFQ25 as an assessment for impairments in QOL in a glaucoma patient. If a glaucoma patient is at high risk of depression or anxiety disorder, a multidisciplinary management approach involving ophthalmology and psychiatry may be required.

Trends in patterns of intermediate uveitis in a tertiary institution in Singapore.

PURPOSE: The study aims to describe the characteristics and etiologic causes of intermediate uveitis (IU) patients seen by a tertiary eye center in Singapore over 8 years. METHODS: This was a retrospective analysis of the clinical records of consecutive new cases of IU that presented to the uveitis subspecialty clinic from 2004-2011 at Tan Tock Seng Hospital. Data collected included demographics, clinical and laboratory findings. Diagnoses were based on standardized clinical history, ophthalmological examination and investigations. RESULTS: There were 66 new cases of IU, comprising 5.7% of 1168 new uveitis patients. The median age of diagnosis was 40 years (mean 39.4±15.9), with largest subgroup of the patients in the age group of 41-60 years (36.4%). The majority was Chinese (57.6%), followed by Asian Indians (18.2%) and Malays (16.7%). The ethnicity distribution was dissimilar to our ethnic distribution in Singapore (p<0.001) with an increased incidence of IU in the Asian Indian population. Most were idiopathic (59.1%) in etiology, followed by tuberculosis (TB) (15.2%). Ocular complications developed in 21 patients (31.8%), with cystoid macular edema (CME) being the commonest (28.8%). Severe vitritis occurred in 9.1% of patients, and was significantly associated with TB-associated IU (p<0.001). There was a downward trend for the incidence of the proportion of IU patients over the total uveitis patients (p = 0.021), with Spearman's rho of -0.786. CONCLUSIONS: Despite the downward trend, TB-associated IU was still of higher prevalence compared to less endemic areas, emphasizing the need for increased TB surveillance. A high index of suspicion for TB-associated IU is required in patients with severe vitritis. Comparisons with other countries revealed disparities in the IU etiologies, indicating possible geographical differences. Prevalence of known immune-mediated etiologies of IU is less compared to the western population. Our study also suggests a probable predisposition of the Singapore local Indian population for IU.

The epidemiology and incidence of cytomegalovirus retinitis in the HIV population in Singapore over 6 years.

PURPOSE: We report the epidemiologic trend of cytomegalovirus (CMV) retinitis among human immunodeficiency virus (HIV) patients in Singapore. METHODS: Our study included a retrospective case series of HIV patients with newly diagnosed CMV retinitis (CMVR) at the Singapore CDC between 2005 and 2010. Demographics, symptoms, signs, and laboratory results, including CD4 counts, were collected. Prevalence and disease trends over time were measured. RESULTS: Of 224 new patients, 92.9% were male and 96.0% were on antiretroviral therapy (ART). Median age was 43.0 years, with a median CD4 count of 38.0 cells/µL at HIV diagnosis. There was a decline in CD4 counts at diagnosis, and median duration of ART initiation from HIV diagnosis generally was earlier. Overall incidence rate was 10.4 cases per 1000 person-years (PY) and the mortality rate was 19.4 per 1000 PY. Mean survival time was 160.2 months (95% confidence interval [CI] 150.3-170.2). The 25 patients who died during the study period were older at the time of CMVR diagnosis (P = 0.003) and had lower CD4 counts (P = 0.030). Worse prognoses were associated with older age (hazard ratio [HR] 1.06, 95% CI 1.02-1.10) and shorter time lag from HIV to CMVR diagnosis (HR 0.97, 95% CI 0.95-0.99). Patients who did not receive highly active antiretroviral treatment (HAART) had a higher mortality risk (HR 4.70, 95% CI 1.54-14.33). CONCLUSIONS: The incidence rate of CMVR was decreasing with earlier initiation of ART and lower CD4 counts at HIV diagnosis. Poor prognostic factors included older age, shorter time lag from HIV to CMVR diagnosis, and the absence of HAART. Constant ophthalmologic surveillance until immune reconstitution is recommended.