Corticotherapy vs. Corticotherapy Plus Immunosuppressive Therapy in Acute Vogt-Koyanagi-Harada Disease

INTRODUCTION

Vogt-Koyanagi-Harada disease is a multisystem disorder characterized by a bilateral granulomatous panuveitis. Multiple therapeutic regimens have been used to control inflammation in acute uveitic stage to prevent irreversible visual loss. The purpose of this paper is to compare the effect, on functional and anatomic outcomes, of early treatment with standard corticotherapy vs. corticotherapy plus immunosuppressive (IMT) therapy in acute Vogt-Koyanagi-Harada disease (Group A vs Group B).

METHODS

A retrospective chart review of patients with Vogt-Koyanagi-Harada disease, with an evolution time of 2 weeks or less, who attended the Inflammatory Eye Disease Clinic, from 2001 to 2015. Data collected included demographic information, presenting features, treatment and improvement in visual acuity (VA).

RESULTS

Sixteen charts were reviewed; 15 females (93.75%). Mean age: 30.81±10.53 years, follow-up time (months): 54.94±43.43. Ten patients (66.6%) had IMT, azathioprine, methotrexate and cyclophosphamide. In group A, initial VA<20/200 in 66.7%; final VA was ≥20/40 in 9 eyes (75%). In group B, initial VA<20/200 in 65%; final VA≥20/40 in 15 eyes (75%). In group A, VA improved faster at one and 3 months (ANOVA P<.057). Clinical characteristics in convalescent stage and complications were similar. Anterior chamber recurrences occurred in both groups and posterior pole recurrences were observed in group A. Time to first recurrence was similar (P<.279). Frequency of recurrence was 2.33±1.80 vs 1.5±0.79 (P<.01). At recurrence 15 patients were still having oral steroids, nine in group A, 6 in Group B. In group A, prednisone was given during more time: mean 15.17±12.08 months, and time to reach to 10mg dose was longer: 8.60±11.7 (P<.008 and P<.046).

CONCLUSIONS

Adding IMT as first line therapy to corticosteroids, do not matter significantly in terms of final VA or development of visually significant complications. In the IMT plus corticosteroids group number of recurrences was significantly lower, and a steroid sparing effect was evident.

[Association of epiretinal membranes with macular edema in pars planitis]

INTRODUCTION

Pars planitis (PP) is a form of intermediate uveitis that manifests with several posterior segment complications, including cystoid macular edema (CME) and epiretinal membrane formation (ERM). On the presence of CME the patient is usually treated with anti-inflammatory and/or immunosuppressive drugs. However the presence of CME may coexist with ERM formation, and therefore the treatment could be different.

PURPOSE

To determine the association between ERM and CME in PP.

MATERIALS AND METHODS

Case control series. The charts of patients diagnosed with PP were retrospectively reviewed. All patients had fluorescein angiogram (FA) and spectral domain optical coherence tomography (SD-OCT). Presence of ERM was determined by SD-OCT, while CME was determined by FA. Contingency tables were used to determine the risk of developing CME with ERM.

RESULTS

31 eyes presented ERM. 16 eyes presented CME. Relative risk to have CME and ERM was 0.971, with a P value of 0.77 (χ(2)).

CONCLUSIONS

There is no association between ERM formation and the development of CME. There is no evidence to suggest a surgical approach as first line of treatment with the presence of ERM in PP.

[Central serous chorioretinopathy versus sympathetic ophthalmia. Case report]

CLINICAL CASE

A 29 year old patient with a history of sutured corneal wound treated with oral antibiotics and steroids. After stopping steroid treatment, he referred reduced visual acuity in the non-traumatized eye. Previous treatment was reintroduced and he was referred to our hospital diagnosed with sympathetic ophthalmia. Bilateral macular folds, white and yellowish lesions, and subretinal fluid were found.

DISCUSSION

The association of stress, anxious personality, and steroid use can favor atypical presentations of central serous chorioretinopathy.

HLA-DR is strongly associated with Vogt-Koyanagi-Harada disease in Mexican Mestizo patients

PURPOSE

To analyze the genetic background of human leukocyte antigens (HLA) of Vogt-Koyanagi-Harada (VKH) disease in Mexican Mestizo patients in order to establish whether the pathogenesis is related to the same genes or sequences described in other populations.

PATIENTS AND METHODS

In 48 VKH patients, we performed HLA class I and class II typing using the standard microlymphocytotoxicity tests; a group of 100 nonrelated healthy subjects were analyzed for comparison. Antigen and gene frequencies were calculated for every antigen tested in patients and in controls.

RESULTS

The frequency of HLA-DR4 was significantly increased in VKH Mexican patients (x2Y = 19.95; p = 0.00001; pc = 0.0002; RR = 5.3; EF = 0.52); a discrete increase in DR1 was also found (p = 0.02). HLA-DQ8 also showed a significant association with the disease with a lower RR (3.2) and EF (0.41) than DR4.

CONCLUSION

The strong association found with HLA-DR4 and the slight DR1 increase shown in Mexican patients with VKH suggest that a common shared sequence present in the third hypervariable region of DRB1 genes is relevant for the expression of the disease. The stronger association with DR4 than the one with DQ8 suggests that the DR locus carries the primary susceptibility genes involved in the pathogenesis of VKH.

Ahmed valve implant for uncontrolled uveitic glaucoma

To evaluate the efficacy of the Ahmed valve implant in patients with uncontrolled uveitic glaucoma, the medical records of all patients with uncontrolled uveitic glaucoma who underwent Ahmed valve implant surgery between October 1993 and March 1996 were reviewed. Surgery was considered a success if intraocular pressure (IOP) was less than 22 mmHg and greater than 4 mmHg (with or without antiglaucoma medications) at the last postoperative visit. It was not a success when further glaucoma surgery had been performed, or chronic hypotony, phthisis, or loss of light perception occurred. Fourteen patients (14 eyes) with a mean age of 45.7 years were included. Most of them were high-risk patients, many of whom had already had cataract surgery (71.4%) and undergone one to three previous glaucoma surgeries (57.1%). Follow-up for eyes in which IOP was controlled ranged from 11 to 40 months (mean 22.6 months). Success was achieved in eight of 14 eyes (57.14%). Intraocular pressure was reduced from a mean of 32.64 +/- 7.79 mmHg (range 23-46 mmHg) with 2.78 +/- 0.57 antiglaucoma medications (range 2-4) preoperatively to 17.57 +/- 10.93 mmHg (range 0-38 mmHg) (p < 0.0001) with 0.71 +/- 0.99 antiglaucoma medications (range 0-3) postoperatively (p < 0.0001). The most common complications were encapsulated bleb in six eyes (42.8%), transient hypotony in six eyes (42.8%), and hyphema in three (21.4%). Ahmed valve implant appeared to be a safe alternative in high-risk patients with uncontrolled uveitic glaucoma who have had multiple previous ocular surgeries.

Chorioretinitis secondary to mycobacterium tuberculosis in acquired immune deficiency syndrome

BACKGROUND

Several opportunistic intraocular infections have been described in patients with the human immunodeficiency virus, among them infections caused by Mycobacterium tuberculosis. In most cases, the diagnosis is based on clinical findings. Recent reports have described the usefulness of polymerase chain reaction techniques in the diagnosis of bacterial infections.

METHODS

The authors observed a 29-year-old woman with acquired immune deficiency syndrome in whom unilateral chorioretinitis developed. The chorioretinitis appeared after cessation of treatment for pulmonary tuberculosis. We obtained aqueous humor by paracentesis and tested it by polymerase chain reaction to detect M. tuberculosis DNA.

RESULTS

The polymerase chain reaction of the aqueous humor was positive for M. tuberculosis DNA.

CONCLUSION

Polymerase chain reaction was useful in identifying M. tuberculosis in aqueous from a patient with chorioretinitis, pulmonary tuberculosis, and acquired immune deficiency syndrome.