Tofacitinib for refractory uveitis and scleritis.

PURPOSE: To report the successful use of tofacitinib in the treatment of refractory uveitis and scleritis. OBSERVATIONS: Two patients, one with scleritis and another with anterior and intermediate uveitis, presented with refractory disease after failure of multiple steroid-sparing therapies. Treatment with tofacitinib led to durable resolution of uveitis and scleritis. CONCLUSIONS AND IMPORTANCE: Tofacitinib is a potential novel treatment option for refractory, noninfectious inflammatory eye disease.

Prevention and reversal of selenite-induced cataracts by N-acetylcysteine amide in Wistar rats.

BACKGROUND: The present study sought to evaluate the efficacy of N-acetylcysteine amide (NACA) eye drops in reversing the cataract formation induced by sodium selenite in male Wistar rat pups. METHODS: Forty male Wistar rat pups were randomly divided into a control group, an N-acetylcysteine amide-only group, a sodium selenite-induced cataract group, and a NACA-treated sodium selenite-induced cataract group. Sodium selenite was injected intraperitoneally on postpartum day 10, whereas N-acetylcysteine amide was injected intraperitoneally on postpartum days 9, 11, and 13 in the respective groups. Cataracts were evaluated at the end of week 2 (postpartum day 14) when the rat pups opened their eyes. N-acetylcysteine amide eye drops were administered beginning on week 3 until the end of week 4 (postpartum days 15 to 30), and the rats were sacrificed at the end of week 4. Lenses were isolated and examined for oxidative stress parameters such as glutathione, lipid peroxidation, and calcium levels along with the glutathione reductase and thioltransferase enzyme activities. Casein zymography and Western blot of m-calpain were performed using the water soluble fraction of lens proteins. RESULTS: Morphological examination of the lenses in the NACA-treated group indicated that NACA was able to reverse the cataract grade. In addition, glutathione level, thioltransferase activity, m-calpain activity, and m-calpain level (as assessed by Western blot) were all significantly higher in the NACA-treated group than in the sodium selenite-induced cataract group. Furthermore, sodium selenite- injected rat pups had significantly higher levels of malondialdehyde, glutathione reductase enzyme activity, and calcium levels, which were reduced to control levels upon treatment with NACA. CONCLUSIONS: The data suggest that NACA has the potential to significantly improve vision and decrease the burden of cataract-related loss of function. Prevention and reversal of cataract formation could have a global impact. Development of pharmacological agents like NACA may eventually prevent cataract formation in high-risk populations and may prevent progression of early-stage cataracts. This brings a paradigm shift from expensive surgical treatment of cataracts to relatively inexpensive prevention of vision loss.

Floppy iris syndrome and cataract surgery.

PURPOSE OF REVIEW: Intraoperative floppy iris syndrome (IFIS) occurs in 2% of cataract surgeries and is associated with an increased risk of surgical complications. These complications can be avoided when high-risk patients are identified by preoperative screening and appropriate measures are used intraoperatively. The purpose of this article is to review emerging risk factors for IFIS and to summarize management strategies used in IFIS. RECENT FINDINGS: Although α1-antagonists in general, and tamsulosin (Flomax, Jalyn) in particular, have long been associated with IFIS, recent studies have more firmly demonstrated the elevated risk of IFIS attributed to tamsulosin. This resulted in a revision of the American Society of Cataract and Refractive Surgery/American Academy of Ophthalmology guidelines on IFIS. Our understanding of additional medications and medical conditions involved in IFIS is also evolving, including an appreciation that women are also susceptible to IFIS. New modifications of techniques used in the intraoperative management of IFIS are also discussed. SUMMARY: Preoperative screening should include both men and women. Current or prior use of α1-antagonists and antipsychotics should be documented, along with hypertension. Surgeons should be prepared to employ a range of perioperative interventions in a graded response to IFIS of different severities.

Automated and simultaneous fovea center localization and macula segmentation using the new dynamic identification and classification of edges model.

Detecting the position of retinal structures, including the fovea center and macula, in retinal images plays a key role in diagnosing eye diseases such as optic nerve hypoplasia, amblyopia, diabetic retinopathy, and macular edema. However, current detection methods are unreliable for infants or certain ethnic populations. Thus, a methodology is proposed here that may be useful for infants and across ethnicities that automatically localizes the fovea center and segments the macula on digital fundus images. First, dark structures and bright artifacts are removed from the input image using preprocessing operations, and the resulting image is transformed to polar space. Second, the fovea center is identified, and the macula region is segmented using the proposed dynamic identification and classification of edges (DICE) model. The performance of the method was evaluated using 1200 fundus images obtained from the relatively large, diverse, and publicly available Messidor database. In 96.1% of these 1200 cases, the distance between the fovea center identified manually by ophthalmologists and automatically using the proposed method remained within 0 to 8 pixels. The dice similarity index comparing the manually obtained results with those of the model for macula segmentation was 96.12% for these 1200 cases. Thus, the proposed method displayed a high degree of accuracy. The methodology using the DICE model is unique and advantageous over previously reported methods because it simultaneously determines the fovea center and segments the macula region without using any structural information, such as optic disc or blood vessel location, and it may prove useful for all populations, including infants.

The inner diameter of the optic disc pit decreases with pars plana vitrectomy.

To report a patient with optic disc pit who showed decreased inner diameter of the optic disc pit along with resolution of recurrent macular detachment after pars plana vitrectomy. Pneumatic retinopexy and peripapillary laser photocoagulation was performed in a 28-year-old female with optic disc pit and serous macular detachment. Two months after the initial therapy, serous macular detachment recurred. Then, pars plana vitrectomy with removal of the posterior hyaloid was performed, and intraocular perfluoro-octane (C3F8) tamponade was used. Fundus photography and ocular coherence tomography were obtained at each visit. The patient was followed up for 1 year. Visual acuity was 20/400 (Snellen) at first presentation, improved to 20/40 at 2 weeks after pneumatic retinopexy and peripapillary laser treatment. Then, 2 months later visual acuity decreased to 20/200, improved to 20/40 at 2 weeks after the vitreoretinal surgery, and stayed stable during the 1-year follow-up. It was also noticed on clinical examinations as well as fundus photographs that the inner diameter of the optic disc pit had decreased significantly. Vitreous traction plays an important role in the formation of serous macular detachments with optic disc pits. In these patients, pars plana vitrectomy and posterior hyaloid removal may be an effective treatment for reduction of the inner diameter of the optic pit and resolution of the serous macular detachments.

Intravitreal bevacizumab followed by laser photocoagulation for retinal capillary hemanginoblastomas.

PURPOSE: To report a patient with retinal capillary hemangioblastomas associated with Von Hippel-Lindau syndrome who achieved long-term visual improvement with single intravitreal bevacizumab injection followed by laser photocoagulation. METHODS: Intravitreal bevacizumab injection was performed in a 17-year-old girl with bilateral multiple retinal capillary hemangioblastomas. Laser photocoagulation was then performed to augment the initial response to bevacizumab. The visual acuity, fundus photography, fundus fluorescein angiography, and ocular coherence tomography were obtained at each visit. The patient was followed-up for 3 years. RESULTS: Two weeks after injection, the macular edema and exudation significantly decreased with an improvement in the visual acuity. Laser photocoagulation performed 2 weeks after the intravitreal bevacizumab injection provided further regression of exudation and scarring of the hemangioblastomas. No further intervention was required, and the visual acuity returned to baseline at the third year of follow-up. CONCLUSION: Combined intravitreal bevacizumab with laser photocoagulation is a viable option in retinal capillary hemangioblastomas associated with Von Hippel-Lindau syndrome.

In vivo inhibition of l-buthionine-(S,R)-sulfoximine-induced cataracts by a novel antioxidant, N-acetylcysteine amide.

The effects of N-acetylcysteine amide (NACA), a free radical scavenger, on cataract development were evaluated in Wistar rat pups. Cataract formation was induced in these animals with an intraperitoneal injection of a glutathione (GSH) synthesis inhibitor, l-buthionine-(S,R)-sulfoximine (BSO). To assess whether NACA has a significant impact on BSO-induced cataracts, the rats were divided into four groups: (1) control, (2) BSO only, (3) NACA only, and (4) NACA+BSO. The control group received only saline ip injections on postpartum day 3, the BSO-only group was given ip injections of BSO (4mmol/kg body wt), the NACA-only group received ip injections of only NACA (250mg/kg body wt), and the NACA+BSO group was given a dose of NACA 30min before administration of the BSO injection. The pups were sacrificed on postpartum day 15, after examination under a slit-lamp microscope. Their lenses were analyzed for selective oxidative stress parameters, including glutathione (reduced and oxidized), protein carbonyls, catalase, glutathione peroxidase, glutathione reductase, and malondialdehyde. The lenses of pups in both the control and the NACA-only groups were clear, whereas all pups within the BSO-only group developed well-defined cataracts. It was found that supplemental NACA injections during BSO treatment prevented cataract formation in most of the rat pups in the NACA+BSO group. Only 20% of these pups developed cataracts, and the rest retained clear lenses. Further, GSH levels were significantly decreased in the BSO-only treated group, but rats that received NACA injections during BSO treatment had these levels of GSH replenished. Our findings indicate that NACA inhibits cataract formation by limiting protein carbonylation, lipid peroxidation, and redox system components, as well as replenishing antioxidant enzymes.

Refractive and topographic results of transepithelial cross-linking treatment in eyes with intacs.

PURPOSE: To evaluate the efficacy of transepithelial cross-linking (CXL) in keratoconic eyes after Intacs implantation. PATIENTS AND METHODS: Twenty-five eyes of 17 patients with bilateral keratoconus underwent Intacs implantation with subsequent cross-linking (CXL) treatment. Inclusion criteria were absence of corneal scarring, contact lens intolerance, corneal thickness higher than 400 mum, and endothelial cell density more than 3000 per square millimeter. Preoperative and 3-month-postoperative uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), manifest refractions, and mean and steepest keratometric (K) values were reviewed retrospectively. The results in Intacs group were compared with those obtained after CXL/Intacs. RESULTS: There were 10 males and 5 females; mean age was 25.14 +/- 7.11 (range 16-39) years old. Mean time between implantation of Intacs and CXL was 3.98 months. CXL after Intacs resulted in an additional improvement in UCVA, BCVA, sphere, cylinder, and keratometry. Intacs resulted in an improvement of 1.9 Snellen lines (P < 0.05) of UCVA and 1.7 Snellen lines (P < 0.05) of BCVA. CXL performed after Intacs treatment yielded an additional 1.2 Snellen lines (P < 0.05) of UCVA and 0.36 Snellen lines (P < 0.05) of BCVA. The decrease in spherical, cylindrical, mean K, and steepest K values was 2.08 diopters (D) (P < 0.05), 0.47 D (P > 0.05), 2.22 D (P < 0.05), and 1.27 D (P < 0.05), respectively, after Intacs treatment with an additional 0.5 D (P < 0.05), 0.15 D (P > 0.05), 0.35 D (P > 0.05), and 0.76 D (P < 0.05) of improvement gained after CXL in each respective parameter. CONCLUSIONS: Intacs implantation with transepithelial CXL is effective in eyes with keratoconus. Collagen cross-linking has an additive effect on Intacs implantation in these eyes and may be considered as an enhancement/stabilizing procedure.

Factors influencing flap and INTACS decentration after femtosecond laser application in normal and keratoconic eyes.

PURPOSE: To compare accuracy of LASIK flap and INTACS centration following femtosecond laser application in normal and keratoconic eyes. METHODS: This is a retrospective case series comprising 133 eyes of 128 patients referred for refractive surgery. All eyes were divided into two groups according to preoperative diagnosis: group 1 (LASIK group) comprised 74 normal eyes of 72 patients undergoing LASIK with a femtosecond laser (IntraLase), and group 2 (INTACS group) consisted of 59 eyes of 39 patients with keratoconus for whom INTACS were implanted using a femtosecond laser (IntraLase). Decentration of the LASIK flap and INTACS was analyzed using Pentacam. RESULTS: Temporal decentration was 612.56 +/- 384.24 microm (range: 30 to 2120 microm) in the LASIK group and 788.33 +/- 500.34 microm (range: 30 to 2450 microm) in the INTACS group. A statistically significant difference was noted between the groups in terms of decentration (P < .05). Regression analysis showed that the amount of decentration of the LASIK flap and INTACS correlated with the central corneal thickness in the LASIK group and preoperative sphere and cylinder in the INTACS group, respectively. CONCLUSIONS: Decentration with the IntraLase occurred in most cases, especially in keratoconic eyes. The applanation performed for centralization during IntraLase application may flatten and shift the pupil center, and thus cause decentralization of the LASIK flap and INTACS. Central corneal thickness in the LASIK group and preoperative sphere and cylinder in the INTACS group proved to be statistically significant parameters associated with decentration.

Retrospective analysis of etiopathogenesis of all cases of endophthalmitis at a large tertiary referral center.

PURPOSE: To report a large, consecutive series of endophthalmitis of all causes managed at a tertiary referral retina center. METHODS: Retrospective chart review of all cases diagnosed with endophthalmitis that received reatment and follow-up between January 2000 and January 2005. RESULTS: A total of 67 patients were diagnosed with endophthalmitis. The most common cause was postoperative endopthalmitis after cataract surgery. Initial management was vitreous needle biopsy with intravitreal antimicrobial injection in a majority of cases (79%). Vitreous cultures were positive in 32 eyes (44.4%); the most common isolate was coagulase negative Staphylococci. Final visual acuity was improved in 61% of patients. More than a third (38%) had vision worse than count fingers. Twenty-eight eyes (39%) needed pars plana vitrectomy for secondary complications as a consequence of endophthalmitis. CONCLUSIONS: Cataract surgery remains the most common cause of endophthalmitis in this large tertiary referral retina center. Endophthalmitis resolved with vitreous needle biopsy and intravitreal injections in more than half of the cases. However, more than a third of patients required additional vitreoretinal surgery for secondary complications. More than a third of patients had nonfunctional vision after the resolution of endophthalmitis, which highlights the severity of this condition in the current expanding era of office-based intravitreal pharmacotherapy for retinal diseases.