The safety of anterior chamber paracentesis in patients with uveitis

"Safety Assessment of Aqueous Humor Liquid Biopsy in Retinoblastoma: A Multicenter Study of 1,203 Procedures"

PURPOSE

To evaluate the safety profile of aqueous humor (AH) liquid biopsy in pediatric patients with retinoblastoma (RB) and RB-simulating lesions through a multicenter analysis of paracentesis procedures.

DESIGN

Retrospective multicenter study.

SUBJECTS

A total of 1,203 paracentesis procedures were performed on 484 eyes of 425 pediatric patients, including 352 patients with RB and 73 with RB-simulating lesions.

METHODS

Medical records were reviewed retrospectively to identify complications from anterior chamber paracentesis performed to obtain AH for liquid biopsy. Procedures were conducted during routine examination under anesthesia (EUA). AH samples were extracted using a 32-gauge needle and underwent cell-free DNA analysis. Complications were classified as mild, moderate, or severe based on clinical impact and required interventions.

MAIN OUTCOME MEASURES

Incidence and severity of complications related to the paracentesis procedure.

RESULTS

Among 1,203 procedures, 1 mild complication was identified, representing an overall complication rate of 0.08%. No moderate or severe complications, including vision, eye loss, extraocular tumor spread, or death were observed at a median follow-up of 16 months. The procedure demonstrated an excellent safety profile across multiple centers, with no permanent adverse outcomes.

CONCLUSION

AH liquid biopsy via anterior chamber paracentesis is a safe and well-tolerated procedure in pediatric patients with RB when performed by trained ocular surgeons under general anesthesia. This large-scale analysis supports the procedure's use as a minimally invasive diagnostic tool with minimal risk, providing valuable molecular insights for RB management. These findings offer reassurance to clinicians and parents regarding the safety of AH liquid biopsy for RB.

Using Electronic Health Record Data to Determine the Safety of Aqueous Humor Liquid Biopsies for Molecular Analyses

Purpose

Knowing the surgical safety of anterior chamber liquid biopsies will support the increased use of proteomics and other molecular analyses to better understand disease mechanisms and therapeutic responses in patients and clinical trials. Manual review of operative notes from different surgeons and procedures in electronic health records (EHRs) is cumbersome, but free-text software tools could facilitate efficient searches.

Design

Retrospective case series.

Participants

A total of 1418 aqueous humor liquid biopsies from patients undergoing intraocular surgery.

Methods

Free-text EHR searches were performed using the Stanford Research Repository cohort discovery tool to identify complications associated with anterior chamber paracentesis and subsequent endophthalmitis. Complications of the surgery unrelated to the biopsy were not reviewed.

Main Outcome Measures

Biopsy-associated intraoperative complications and endophthalmitis.

Results

A total of 1418 aqueous humor liquid biopsies were performed by 17 experienced surgeons. EHR free-text searches were 100% error-free for surgical complications, >99% for endophthalmitis (<1% false positive), and >93.6% for anesthesia type, requiring manual review for only a limited number of cases. More than 85% of cases were performed under local anesthesia without ocular muscle akinesia. Although the most common indication was cataract (50.1%), other diagnoses included glaucoma, diabetic retinopathy, uveitis, age-related macular degeneration, endophthalmitis, retinitis pigmentosa, and uveal melanoma. A 50- to 100-μL sample was collected in all cases using either a 30-gauge needle or a blunt cannula via a paracentesis. The median follow-up was >7 months. There was only one minor complication (0.07%) identified: a case of a small tear in Descemet membrane without long-term sequelae. No other complications occurred, including other corneal injuries, lens or iris trauma, hyphema, or suprachoroidal hemorrhage. There was no case of postoperative endophthalmitis.

Conclusions

Anterior chamber liquid biopsy during intraocular surgery is a safe procedure and may be considered for large-scale collection of aqueous humor samples for molecular analyses. Free-text EHR searches are an efficient approach to reviewing intraoperative procedures.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

CLINICAL CHARACTERIZATION OF AQUEOUS AND VITREOUS RETINOL-BINDING PROTEIN 3 CONCENTRATIONS IN RELATION TO DIABETIC RETINOPATHY SEVERITY, RETINAL STRUCTURES, AND SYSTEMIC COMPLICATIONS

PURPOSE

To evaluate Retinol-Binding Protein 3 (RBP3) from photoreceptors in aqueous and its association with vitreous concentrations, diabetic retinopathy (DR) severity, retinal layer thickness, and clinical characteristics in people with diabetes.

METHODS

RBP3 concentration was measured by custom-developed enzyme-linked immunosorbent assay in aqueous and correlated with vitreous concentrations in patients from the 50-Year Medalist study and Beetham Eye Institute at Joslin Diabetes Center.

RESULTS

Aqueous RBP3 concentration (N = 131) was elevated in eyes with no to mild DR (mean ± SD 0.7 nM ± 0.2) and decreased in eyes with moderate to severe DR (0.65 nM ± 0.3) and proliferative DR (0.5 nM ± 0.2, P < 0.001) compared to eyes without diabetes. Aqueous and vitreous RBP3 concentrations correlated with each other (r = 0.34, P = 0.001) and between fellow eyes (P < 0.0001). History of retinal surgery did not affect aqueous RBP3 concentrations, but cataract surgery affected both vitreous and aqueous levels. Elevated aqueous RBP3 concentration associated with increased thickness of the outer nuclear layer (P = 0.004) and correlated with hemoglobin A1c, whereas vitreous RBP3 concentrations correlated with diabetic systemic complications.

CONCLUSION

These findings suggest that aqueous RBP3 concentration may be an important endogenous clinical retinal protective factor, a biomarker for DR severity, and a promising VEGF-independent clinical intervention target in DR.

Liquid Biopsy Proteomics in Ophthalmology

Minimally invasive liquid biopsies from the eye capture locally enriched fluids that contain thousands of proteins from highly specialized ocular cell types, presenting a promising alternative to solid tissue biopsies. The advantages of liquid biopsies include sampling the eye without causing irreversible functional damage, potentially better reflecting tissue heterogeneity, collecting samples in an outpatient setting, monitoring therapeutic response with sequential sampling, and even allowing examination of disease mechanisms at the cell level in living humans, an approach that we refer to as TEMPO (Tracing Expression of Multiple Protein Origins). Liquid biopsy proteomics has the potential to transform molecular diagnostics and prognostics and to assess disease mechanisms and personalized therapeutic strategies in individual patients. This review addresses opportunities, challenges, and future directions of high-resolution liquid biopsy proteomics in ophthalmology, with particular emphasis on the large-scale collection of high-quality samples, cutting edge proteomics technology, and artificial intelligence-supported data analysis.

The Infectious Uveitis Treatment Algorithm Network (TITAN) Report 2-global current practice patterns for the management of Cytomegalovirus anterior uveitis

AIMS

To present current practice patterns in the diagnosis and management of Cytomegalovirus anterior uveitis (CMV AU) by uveitis experts worldwide.

METHODS

A two-round modified Delphi survey with masking of the study team was performed. Based on experience and expertise, 100 international uveitis specialists from 21 countries were invited to participate in the survey. Variation in the diagnostic approaches and preferred management of CMV AU was captured using an online survey platform.

RESULTS

Seventy-five experts completed both surveys. Fifty-five of the 75 experts (73.3%) would always perform diagnostic aqueous tap in suspected CMV AU cases. Consensus was achieved for starting topical antiviral treatment (85% of experts). About half of the experts (48%) would only commence systemic antiviral treatment for severe, prolonged, or atypical presentation. The preferred specific route was ganciclovir gel 0.15% for topical treatment (selected by 70% of experts) and oral valganciclovir for systemic treatment (78% of experts). The majority of experts (77%) would commence treatment with topical corticosteroid four times daily for one to two weeks along with antiviral coverage, with subsequent adjustment depending on the clinical response. Prednisolone acetate 1% was the drug of choice (opted by 70% of experts). Long-term maintenance treatment (up to 12 months) can be considered for chronic course of inflammation (88% of experts) and those with at least 2 episodes of CMV AU within a year (75-88% of experts).

CONCLUSIONS

Preferred management practices for CMV AU vary widely. Further research is necessary to refine diagnosis and management and provide higher-level evidence.

Long term outcome and prognostic indicators in Posner Schlossman syndrome

BACKGROUND

Posner Schlossman syndrome is a well-defined uveitis entity that is characterised by relapsing remitting unilateral anterior uveitis with markedly raised intraocular pressure. The aim of this study was to determine the risk factors for progression in patients with Posner Schlossman syndrome.

METHODS

Ninety-eight patients were enrolled in a retrospective case series. Progression was defined as a composite endpoint of any of development of permanent glaucoma (in patients with no evidence of glaucomatous loss on presentation), corneal failure, or chronic inflammation. Relapse was defined as a resolving episode of inflammation not meeting the criteria for progression.

RESULTS

Seventy seven percent of patients relapsed on average each 2.2 years. Forty percent of patients progressed. On univariate analysis, increased age at enrolment, immunocompromise at enrolment, the presence of glaucomatous optic neuropathy at enrolment, the performance of an anterior chamber tap and a positive anterior chamber tap were all associated with increased risk of progression. On multivariate analysis, age at enrolment, immunocompromise at enrolment, the performance of an anterior chamber tap, and the presence of glaucomatous optic neuropathy at enrolment were independently associated with increased risk of disease progression.

CONCLUSIONS

Posner Schlossman syndrome is not a benign uveitis entity and risk of both relapse and progression are high. Older patients, immunocompromised patients, patients with glaucomatous optic neuropathy at enrolment and those with a positive anterior chamber tap are all at increased risk of progression.

The Eye as a Diagnostic Tool for Alzheimer’s Disease

Alzheimer’s disease (AD) is a progressive neurodegenerative disorder impacting cognition, function, and behavior in the elderly population. While there are currently no disease-modifying agents capable of curing AD, early diagnosis and management in the preclinical stage can significantly improve patient morbidity and life expectancy. Currently, the diagnosis of Alzheimer’s disease is a clinical one, often supplemented by invasive and expensive biomarker testing. Over the last decade, significant advancements have been made in our understanding of AD and the role of ocular tissue as a potential biomarker. Ocular biomarkers hold the potential to provide noninvasive and easily accessible diagnostic and monitoring capabilities. This review summarizes current research for detecting biomarkers of Alzheimer’s disease in ocular tissue.

Prophylactic intraocular pressure lowering measures in anti-vascular endothelial growth factor therapy: A systematic review and meta-analysis

Acute intraocular pressure (IOP) elevation following repeat intravitreal anti-vascular endothelial growth factor (VEGF) injections (IVI) may pose a risk to the integrity of the retinal nerve fiber (RNFL). This meta-analysis investigates the role of IOP-lowering interventions such as an anterior chamber paracentesis (ACP) and IOP-lowering medications on the IOP in patients undergoing IVIs. MEDLINE, EMBASE, and the Cochrane Library were searched up to February, 2021. Studies investigating IOP-lowering interventions in patients undergoing IVI versus controls were included. The primary outcome was the IOP in the short- and long-term post-IVI. Secondary outcomes were changes in the RNFL thickness and best corrected visual acuity (BCVA). ACP at time of anti-VEGF injection significantly lowered IOP immediately post anti-VEGF (WMD: -27.98 mm Hg, P < 0.001). Patients in the ACP group also had significantly thicker RNFL compared to control (WMD: 2.07 um, P < 0.00001) at median follow-up of 16.5 months. IOP-lowering medications (on the day of injection or in the long-term) significantly reduced IOP up to 30 minutes after injection (WMD: -3.31 mm Hg, P = 0.003). This effect was statistically significant between the 2 arms up to 1 month follow-up. There was no difference in BCVA in intervention versus controls. ACP reduces immediate IOP spikes post-IVI and preserves the RNFL in the short- and longterms IOP-lowering medications also reduce IOP spike, with limited data on RNFL thickness.

Intraocular biopsy in uveitis

An intraocular biopsy is performed for diagnostic, prognostic and investigational purposes. Biopsies help to confirm or exclude malignancies and differentiate inflammatory from infectious processes. Histopathological analysis is the final verdict in unresponsive uveitis, atypical inflammation, metastases and masquerade syndromes. Advances and refinement of techniques in cytopathology, immunohistochemistry, microbiological and molecular biologic study offer much more than just diagnosis. They provide prognosis based on cell characteristics and are helpful in planning treatment and intervention. Many biopsy procedures have evolved to provide more safety and minimise complications thus improving the quality of specimens or samples available for analysis. The type of biopsy and technique adopted varies based on the clinical suspicion, size and location of lesions. In uveitis, a working diagnosis of intraocular inflammation is made on clinical examination and laboratory investigations and ancillary tests. Malignancy and uveitis is interlinked and masquerade syndromes are among the commonest indications for biopsy and analysis of specimen. The various types of intraocular biopsies include aqueous tap, fine needle aspiration biopsy, vitreous biopsy, iris and ciliary body, and retinochoroidal biopsy. They will be reviewed in this article with respect to current perspective

In vivo quantitative analysis of anterior chamber white blood cell mixture composition using spectroscopic optical coherence tomography

Anterior uveitis is the most common form of intraocular inflammation, and one of its main signs is the presence of white blood cells (WBCs) in the anterior chamber (AC). Clinically, the true composition of cells can currently only be obtained using AC paracentesis, an invasive procedure to obtain AC fluid requiring needle insertion into the AC. We previously developed a spectroscopic optical coherence tomography (SOCT) analysis method to differentiate between populations of RBCs and subtypes of WBCs, including granulocytes, lymphocytes and monocytes, both in vitro and in ACs of excised porcine eyes. We have shown that different types of WBCs have distinct characteristic size distributions, extracted from the backscattered reflectance spectrum of individual cells using Mie theory. Here, we further develop our method to estimate the composition of blood cell mixtures, both in vitro and in vivo. To do so, we estimate the size distribution of unknown cell mixtures by fitting the distribution observed using SOCT with a weighted combination of reference size distributions of each WBC type calculated using kernel density estimation. We validate the accuracy of our estimation in an in vitro study, by comparing our results for a given WBC sample mixture with the cellular concentrations measured by a hemocytometer and SOCT images before mixing. We also conducted a small in vivo quantitative cell mixture validation pilot study which demonstrates congruence between our method and AC paracentesis in two patients with uveitis. The SOCT based method appears promising to provide quantitative diagnostic information of cellular responses in the ACs of patients with uveitis.

Testing a Novel Disposable Aqueous Humor Collector: An Approach to Improve Safety, Accuracy, and Efficiency

Aqueous humor (AH) is a useful biofluid for differential diagnosis and disease monitoring in a variety of ophthalmologic conditions. There are no commercially available medical devices specially designed for AH sampling. To improve the safety, accuracy, efficiency, and convenience of anterior chamber (AC) paracentesis, a novel vacuum-based disposable AH collector with a draw volume of 50 μL was designed. The safety and performance of this novel medical device was tested in New Zealand white rabbits. A commonly used 25G 1 mL syringe was used as the control device with target AH collection volume also intentionally set at 50 μL. The 36 eyes included in the study (18 rabbits) were divided into collector (R), collector (L), syringe (R), and syringe (L) subgroups, and each included 9 eyes (R/L indicates the paracentesis was performed by right/left hand). The mean AH volume collected by the collector (R), collector (L), syringe (R), and syringe (L) subgroups were 46.66 ± 3.37 (range: 39.20-50.40), 48.71 ± 2.88 (range: 45.00-53.60), 85.11 ± 18.70 (range: 64.00-123.50), and 80.68 ± 20.87 (range: 36.8-115.8) μL, respectively. The mean absolute deviation from the target volume and mean operation time of the collector subgroups were significantly lower than the syringe subgroups. Seidel tests revealed no AH leakage in any of the tested eyes. This study revealed that this novel AH collector facilitates one-handed AC paracentesis and accurate AH sampling, and appeared to be safer and more efficient than the traditional syringe-based techniques.

Instrument-based tests for quantifying aqueous humour protein levels in uveitis: a systematic review protocol

BACKGROUND

Inflammation in anterior uveitis is characterised by breakdown of the blood-ocular barrier, which allows leakage of blood constituents of higher molecular weight into the aqueous humour. In routine clinical care, increase in aqueous protein levels can be observed at the slit lamp as 'flare' and the severity can be graded using various clinical grading systems, of which the Standardization of Uveitis Nomenclature (SUN) grading system is most commonly used. Alternative instrument-based technologies are available, which can detect aqueous protein levels in an objective and quantifiable way. This review will identify instruments capable of measuring anterior chamber inflammation in this way, their level of reliability, and how well the measurements correlate with clinical grading and/or actual aqueous protein concentration.

METHODS

Standard systematic review methodology will be used to identify, select and extract data from studies that report the use of any instrument-based technology in the assessment of aqueous protein levels. Searches will be conducted through bibliographic databases (MEDLINE, EMBASE and Cochrane Library), clinical trial registries and the grey literature. No restrictions will be placed on language or year of publication. The outcomes of interest are the level of correlation between identified instrument-based test measurements, clinical grading and/or actual aqueous protein concentration, as well as the reliability of each index test identified. Study quality assessment will be based on QUADAS2. Correlation and reliability outcomes will be pooled and meta-analysed if appropriate.

DISCUSSION

The assessment of inflammation in anterior chamber protein levels currently relies on crude and subjective clinical examination. The findings of this review will identify non-invasive technologies which show good correlation with actual protein concentration, which could be used in routine clinical practice for objective monitoring of AC inflammation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017084167. Study screening stage has just been completed.

Intraocular Biopsy and ImmunoMolecular Pathology for "Unmasking" Intraocular Inflammatory Diseases

Intraocular inflammation can hide a variety of eye pathologies. In 33% of cases, to obtain a correct diagnosis, investigation of the intraocular sample is necessary. The combined analyses of the intraocular biopsy, using immuno-pathology and molecular biology, point to resolve the diagnostic dilemmas in those cases where history, clinical tests, and ophthalmic and systemic examinations are inconclusive. In such situations, the teamwork between the ophthalmologist and the molecular pathologist is critically important to discriminate between autoimmune diseases, infections, and intraocular tumors, including lymphoma and metastases, especially in those clinical settings known as masquerade syndromes. This comprehensive review focuses on the diagnostic use of intraocular biopsy and highlights its potential to enhance research in the field. It describes the different surgical techniques of obtaining the biopsy, risks, and complication rates. The review is organized according to the anatomical site of the sample: I. anterior chamber containing aqueous humor, II. iris and ciliary body, III. vitreous, and IV. choroid and retina. We have excluded the literature concerning biopsy for choroidal melanoma and retinoblastoma, as this is a specialized area more relevant to ocular oncology.

Anterior chamber paracentesis during intravitreal injections in observational trials: effectiveness and safety and effects

A paracentesis prior to an intravitreal injection is a very safe procedure and can prevent IOP-spikes after injections. As these spikes pose the risk of inducing glaucomatous changes particularly in patients with frequent injections and/or with a risk profile, a regular paracentesis prior to an injection may be considered and discussed with the patient.

Central retinal artery occlusion-A new, provisional treatment approach

The retinal ganglion cells infarcted in central retinal artery occlusion (CRAO) are the somata of the optic nerve axons, part of the central nervous system. Consequently, CRAO with inner retinal infarction is a small vessel stroke, usually with the devastating consequence of severe visual loss in the affected eye. At present, there is no generally accepted, evidence-based therapy of nonarteritic CRAO in contrast to ischemic cerebral stroke that has well-accepted treatment protocols. Widely divergent and controversial therapeutic options for CRAO reflect the desperation of treating physicians and disparate conflicting studies. We examine reasons why treatment of nonarteritic CRAO remains problematic and then suggest a provisional new approach to treatment based on updated understanding of CRAO pathophysiology and analysis of current therapeutic options and their rationales.

Effects of intravitreal injection of bevacizumab with or without anterior chamber paracentesis on intraocular pressure and peripapillary retinal nerve fiber layer thickness: a prospective study

PURPOSE

To investigate the effects of intravitreal injection of bevacizumab (IVB) with or without anterior chamber paracentesis on intraocular pressure (IOP) and peripapillary retinal nerve fiber layer (PRNFL) thickness.

METHODS

In this prospective randomized clinical trial, 90 eyes with center involving diabetic macular edema or wet type age-related macular degeneration (AMD) were randomly assigned to receive IVB either without (group A) or with (group B) anterior chamber paracentesis. IOP was measured before and within 2 min, 30 min, 24 hours and 3 months after injections. Peripapillary spectral-domain optical coherence tomography (SD-OCT) was performed before and 3 months after injections.

RESULTS

Mean IOP changes 2 minutes, 30 minutes, 24 hours, and 3 months after injections were 26.4 ± 5.7 mmHg (P < 0.001), 6.5 ± 6.3 mmHg (P < 0.001), 0.2 ± 2.9 mmHg (P > 0.99) and 0.5 ± 2.4 mmHg (P > 0.99) in group A and -1.3 ± 2.4 mmHg (P < 0.001), -3.2 ± 1.8 mmHg (P < 0.001), -3.1 ± 1.8 mmHg (P < 0.001) and -1.8 ± 2.2 mmHg (P < 0.001) in group B, respectively Mean baseline average PRNFL thickness was 85.3±5.6 μm and 85.6 ± 5 μm in groups A and B respectively. Mean PRNFL thickness changes after 3 month was -2 ± 2 μm (P < 0.001) in group A and 0 ± 2 μm (P = 0.101) in group B. Mean PRNFL thickness in group A decreased more than group B (P < 0.001).

CONCLUSION

Conventional method of IVB injection was associated with acute IOP rise and significant PRNFL loss 3 months after injection. Anterior chamber paracentesis prevents acute IOP rise and PRNFL loss.

An Ocular Protein Triad Can Classify Four Complex Retinal Diseases

Retinal diseases generally are vision-threatening conditions that warrant appropriate clinical decision-making which currently solely dependents upon extensive clinical screening by specialized ophthalmologists. In the era where molecular assessment has improved dramatically, we aimed at the identification of biomarkers in 175 ocular fluids to classify four archetypical ocular conditions affecting the retina (age-related macular degeneration, idiopathic non-infectious uveitis, primary vitreoretinal lymphoma, and rhegmatogenous retinal detachment) with one single test. Unsupervised clustering of ocular proteins revealed a classification strikingly similar to the clinical phenotypes of each disease group studied. We developed and independently validated a parsimonious model based merely on three proteins; interleukin (IL)-10, IL-21, and angiotensin converting enzyme (ACE) that could correctly classify patients with an overall accuracy, sensitivity and specificity of respectively, 86.7%, 79.4% and 92.5%. Here, we provide proof-of-concept for molecular profiling as a diagnostic aid for ophthalmologists in the care for patients with retinal conditions.

System for Rapid, Precise Modulation of Intraocular Pressure, toward Minimally-Invasive In Vivo Measurement of Intracranial Pressure

Pathologic changes in intracranial pressure (ICP) are commonly observed in a variety of medical conditions, including traumatic brain injury, stroke, brain tumors, and glaucoma. However, current ICP measurement techniques are invasive, requiring a lumbar puncture or surgical insertion of a cannula into the cerebrospinal fluid (CSF)-filled ventricles of the brain. A potential alternative approach to ICP measurement leverages the unique anatomy of the central retinal vein, which is exposed to both intraocular pressure (IOP) and ICP as it travels inside the eye and through the optic nerve; manipulating IOP while observing changes in the natural pulsations of the central retinal vein could potentially provide an accurate, indirect measure of ICP. As a step toward implementing this technique, we describe the design, fabrication, and characterization of a system that is capable of manipulating IOP in vivo with <0.1 mmHg resolution and settling times less than 2 seconds. In vitro tests were carried out to characterize system performance. Then, as a proof of concept, we used the system to manipulate IOP in tree shrews (Tupaia belangeri) while video of the retinal vessels was recorded and the caliber of a selected vein was quantified. Modulating IOP using our system elicited a rapid change in the appearance of the retinal vein of interest: IOP was lowered from 10 to 3 mmHg, and retinal vein caliber sharply increased as IOP decreased from 7 to 5 mmHg. Another important feature of this technology is its capability to measure ocular compliance and outflow facility in vivo, as demonstrated in tree shrews. Collectively, these proof-of-concept demonstrations support the utility of this system to manipulate IOP for a variety of useful applications in ocular biomechanics, and provide a framework for further study of the mechanisms of retinal venous pulsation.

Polymerase chain reaction to search for Herpes viruses in uveitic and healthy eyes: a South African perspective

OBJECTIVE

To analyse aqueous polymerase chain reaction (PCR) results in patients diagnosed with undifferentiated uveitis and determine prevalence of herpesviridae in non-uveitic patients undergoing routine cataract extraction.

DESIGN

Retrospective comparative case series and prospective cross-sectional study.

SUBJECTS

72 patients with idiopathic uveitis and 57 surgical patients.

METHODS

Diagnostic aqueous paracentesis with PCR testing for 6 herpes viridae in uveitic patients. Anterior chamber paracentesis immediately pre-operative in the prospective arm, with PCR testing.

RESULTS

In the retrospective review we had a 47.2% positive PCR yield. Data analysis revealed a statistically significant correlation between a positive yield and being HIV+ (p=0.018); between an EBV+ yield and being HIV+ (p= 0.026) and a CMV+ result and being HIV+ (p=0.032). Posterior uveitis (p=0.014) and symptoms <30 days (p= 0.0014) had a statistically significant yield. In the prospective arm of the study: all 57 patients were HIV- and all aqueous samples were negative for the 6 herpesviridae.

CONCLUSION

We recommend PCR testing for Herpesviridae as a safe second line test for patients with undifferentiated uveitis. We were unable to establish prevalence and suggest that the idea of a commensal herpes virus is unlikely if the blood-ocular barrier is intact.

Effect of anterior chamber paracentesis on initial treatment of acute angle closure

OBJECTIVE

To compare anterior chamber paracentesis (ACP) with standard medical management of acute primary angle closure (APAC).

DESIGN

Prospective study.

PARTICIPANTS

Patients with APAC and intraocular pressure (IOP) ≥ 50 mm Hg were enrolled.

METHODS

Patients were randomized to receive ACP and medical treatment (group 1) or medical management alone (group 2).

RESULTS

There were 26 patients (mean age 69.3 ± 10.4 years, 31 eyes) in group 1 and 28 patients (mean age 67.0 ± 9.7 years, 30 eyes) in group 2. The IOP in group 1 was significantly lower at 15 minutes, 30 minutes, and 1 hour after treatment (p < 0.05). At 1, 2, and 24 hours after treatment, visual acuity was significantly better in group 1 than in group 2. At each time point after treatment, the grade of corneal edema was not different between the groups. Pain score at 1 and 2 hours after treatment was significantly lower in group 1 than in group 2; however, no difference was noted at 24 hours after treatment. The mean follow-up period in group 1 was 16.1 ± 1.3 months and in group 2 was 15.6 ± 1.4 months (p = 0.803). At last follow-up, IOP, pupil size, number of eyes with nonreactive pupils, and centre endothelial cell counts were not different; however, visual acuity was significantly better in group 1 (0.43 ± 0.06 logMAR vs 0.74 ± 0.10 logMAR, p = 0.007).

CONCLUSIONS

Immediate ACP is a safe and effective for rapidly lowering IOP, and is associated with better visual acuity than medical treatment alone.

Etiological agents of fungal endophthalmitis: diagnosis and management

Endophthalmitis caused by fungi is commonly diagnosed around the world in apparently healthy and immunocompromised individuals. An accurate clinical diagnosis for endophthalmitis confirmed by laboratory techniques is essential for early treatment with antifungal drugs, such as amphotericin B, imidazoles, and other antifungals. Here, we review endophthalmitis caused by fungi according to its classification into endogenous fungal endophthalmitis (EFE) and exogenous fungal endophthalmitis (EXFE). EFE is caused by endogenously acquired fungi, whereas the traumatic implantation of opportunistic fungal pathogens is the main feature of EXFE. We highlight the most important etiologies causing endophthalmitis and the steps required for a rapid diagnosis and management.

Aqueous cytokine and chemokine analysis in uveitis associated with tuberculosis

PURPOSE

The aim of this study was to study the aqueous cytokine and chemokine composition in patients with uveitis associated with tuberculosis (TAU).

METHODS

We present a prospective case series of consecutive new patients with active uveitis presenting at a single tertiary center (January 1, 2008-January 1, 2010). Patients with no ocular pathology other than cataracts were enrolled as non-inflammatory controls. Aqueous samples were taken from all study subjects and analyzed using a magnetic color-bead-based multiplex assay for cytokine and chemokine concentrations.

RESULTS

Twenty-five eyes of 25 patients with active uveitis with suspected tuberculosis (TB) and 23 non-inflammatory controls were enrolled. Ten patients tested positive on a tuberculin skin test and interferon-gamma release assay; all ten patients responded to anti-TB treatment with no recurrences (TAU). The remaining 15 eyes were negative for the above tests and had no other underlying causes for uveitis found on clinical evaluation and investigations; therefore, they were classified as "idiopathic uveitis" (IU). The TAU group showed significantly higher levels of interleukin-6 (IL-6; p=0.047), interleukin-8 (CXCL8; p=0.001), monokine induced by interferon-gamma (CXCL9; p=0.001), and interferon-gamma-induced protein 10 (IP-10 or CXCL10; p=0.002), compared to the controls. The IU group showed significantly higher levels of IL-6 (p=0.008), monocyte chemotactic protein-1 (CCL2; p=0.036), CXCL8 (p=0.001), and IL-9 (p=0.045), and significantly lower levels of IL-2 (p=0.011), IL-12 (p=0.001), and tumor necrosis factor (TNF)-α (p=0.001), compared to the controls. Heat map analysis revealed significant differences in aqueous cytokine and chemokine concentrations among the TAU patients, the IU patients, and the controls.

CONCLUSIONS

In our study population, aqueous cytokine and chemokine analyses suggest that subjects with uveitis associated with TB who respond to anti-TB therapy do not have an active ocular tuberculous infection, but rather an autoimmune-related ocular inflammation that may be triggered by TB.

Aqueous humor suppression of dendritic cell function helps maintain immune regulation in the eye during human uveitis

PURPOSE

Noninfectious uveitis is characterized by a dysregulated inflammatory or immune response in the eye. It is unclear whether this represents a failure of immune privilege or an overwhelming inflammatory drive that has exceeded the capacity of regulatory mechanisms that are still functioning. The authors investigated immune regulation in the human eye during intraocular inflammation (uveitis) and its impact on dendritic cell (DC) function and subsequent T-cell responses.

METHODS

Myeloid DCs were isolated from the aqueous humor (AqH) and peripheral blood of patients with active uveitis and characterized by flow cytometry. The effect of uveitis AqH was interrogated in an in vitro model of peripheral blood monocyte-derived DCs from healthy controls.

RESULTS

Myeloid DCs isolated from uveitic AqH were characterized by elevated major histocompatibility complex classes I and II (MHC I/II), but reduced CD86 compared with matched peripheral blood DCs. Exposure of peripheral blood monocyte-derived DCs from healthy controls to the inflammatory AqH supernatant recapitulated this phenotype. Despite interferon gamma (IFNγ)-dependent upregulation of MHC I, inflammatory AqH was overall suppressive to DC function, with reduced CD86 expression and diminished T-cell responses. This suppressive effect was equal to or greater than that induced by noninflammatory AqH, but was glucocorticoid independent (in contrast to noninflammatory AqH).

CONCLUSIONS

These data indicate that the ocular microenvironment continues to regulate DC function during uveitis, despite IFNγ-driven upregulation of MHC expression, supporting the hypothesis that immune regulation within the eye is maintained during inflammation.

Safety profile of anterior chamber paracentesis performed at the slit lamp

BACKGROUND

Anterior chamber paracentesis is a valuable diagnostic tool in the management of uveitis, but may be underutilized because of concerns over its safety. We evaluated the safety profile of anterior chamber paracentesis performed at the slit lamp as an outpatient procedure.

DESIGN

Retrospective, observational case series in a single tertiary centre.

PARTICIPANTS

Five hundred and sixty patients with uveitis undergoing anterior chamber paracentesis.

METHODS

All anterior chamber paracenteses performed at the slit lamp for diagnostic or research purposes between January 1997 and June 2009 were analysed with regard to adverse events and pipet/syringe used. Procedures were included whether carried out on undilated or dilated pupils.

MAIN OUTCOME MEASURES

Adverse events and serious adverse events.

RESULTS

Out of 560 paracenteses, 510 were performed with a 27-gauge fixed-needle tuberculin syringe, and 50 using an O'Rourke aqueous pipet. All patients were prescribed a short course of topical antibiotic and examined post-procedure and 1-2 weeks later. Out of 560 procedures there were four complications (0.7%). Two patients had inadvertent injection of sterile air into the anterior chamber but with spontaneous resolution and no adverse outcome (O'Rourke pipet for both). One patient had anterior lens capsule touch that was self-sealing and left a tiny localized opacity (tuberculin syringe). One patient had an allergic reaction to povidone iodine. No patients reported pain, and there were no cases of iris trauma, entry site leak, hypotony, hyphaema or endophthalmitis.

CONCLUSION

Anterior chamber paracentesis can be performed safely as an outpatient procedure at the slit lamp following adequate aseptic precaution, and appropriate counselling.

IL-10 measurement in aqueous humor for screening patients with suspicion of primary intraocular lymphoma

PURPOSE

To determine the value of IL-10 measurement in aqueous humor (AH) for screening in primary intraocular lymphoma (PIOL).

METHODS

One hundred consecutive diagnostic or therapeutic vitrectomies were performed in patients with uveitis. During surgery, 100 microL of both AH and pure vitreous was taken. IL-10 levels were determined with a standard quantitative sandwich enzyme immunoassay technique. Patients were distributed in two groups: 51 patients with proven PIOL, 108 patients with uveitis divided into 74 with uveitis of proven etiology and 34 with idiopathic uveitis. Groups were compared by ANOVA and the Tukey-Kramer test or nonparametric Wilcoxon test. Distributions were compared by using the chi(2) test. Segmentation was derived from the ROC curves by choosing a tradeoff between sensitivity and specificity.

RESULTS

In patients with PIOL, IL-10 mean values were 2205.5 pg/mL (median: 1467 pg/mL) in the vitreous and 543.4 pg/mL (median: 424 pg/mL) in AH. In patients with uveitis (idiopathic and diagnostic uveitis), mean values were 26.6 pg/mL (median: 8 pg/mL) in the vitreous, and 21.9 pg/mL (median: 8 pg/mL) in AH. IL-10 mean values were significantly different between patients with PIOL and patients with uveitis (P < 10(-3)). The areas under the curves were 0.989 and 0.962 for vitreous and AH, respectively. A cutoff of 50 pg/mL in the AH was associated with a sensitivity of 0.89 and a specificity of 0.93. In the vitreous, a cutoff value of 400 pg/mL yielded a specificity of 0.99 and a sensitivity of 0.8.

CONCLUSIONS

Diagnosis of PIOL is often made months or years after the initial onset of ocular symptoms. Cytology remains the gold standard for diagnosis. However, measurement of IL-10 in the AH is a good screening test to reduce diagnostic delays.

Anterior chamber paracentesis in patients with acute elevation of intraocular pressure

PURPOSE

The purpose was to evaluate the efficacy and the safety of anterior chamber paracentesis (ACP) in acute elevation of intraocular pressure (IOP).

METHODS

We prospectively enrolled 20 patients who presented with acute unilateral elevation of IOP above 50 mmHg. IOP was measured before, 10 min, and 1, 7 and 30 days after ACP. The outcome at 1 year was available in 19 patients.

RESULTS

The patients included 14 cases of primary acute angle-closure attacks and six cases of secondary glaucoma. IOP decreased from 53.4 +/- 4.2 mmHg to 24.1 +/- 12.5 mmHg at 10 min, to 18.2 +/- 11.1 mmHg at 24 h, and to 16.4 +/- 10.7 mmHg 7 days after ACP. ACP combined with antiglaucomatous medications provided immediate relief of symptoms in all cases and improvement of corneal oedema in 17 cases. We noted three failures in secondary glaucoma. We performed a laser peripheral iridotomy (LPI) in 14 patients and a surgical procedure in 17 eyes. No complications related to ACP were observed.

CONCLUSION

ACP is a safe and effective procedure for acute elevation of IOP in acute primary primary angle-closure but only remains an add-on therapy to usual treatments. However, this technique must be evaluated in larger series.