SER recommendations for the treatment of uveitis

OBJECTIVE

To develop evidence-based expert-consensus recommendations for the management of non-infectious, non-neoplastic, non-demyelinating disease associated uveitis.

METHODS

Clinical research questions relevant to the objective of the document were identified, and reformulated into PICO format (patient, intervention, comparison, outcome) by a panel of experts selected based on their experience in the field. A systematic review of the available evidence was conducted, and evidence was graded according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria. Subsequently, recommendations were developed.

RESULTS

Three PICO questions were constructed referring to uveitis anterior, non-anterior and complicated with macular edema. A total of 19 recommendations were formulated, based on the evidence found and/or expert consensus.

CONCLUSIONS

Here we present the first official recommendations of the Spanish Society of Rheumatology for the treatment of non-infectious and non-demyelinating disease associated uveitis. They can be directly applied to the Spanish healthcare system as a tool for assistance and therapeutic homogenisation.

Uveitis: Study of 109 cases

PURPOSE

Analyse and describe the anatomical and etiological classification, clinical and epidemiological characteristics and most frequent symptoms of uveitis cases in our population.

PATIENTS AND METHOD

Descriptive, retrospective observational study of uveitis cases treated in the Ophthalmology Department of Virgen del Rocío University Hospital in 2021. The demographic and clinical characteristics were studied.

RESULTS

A total of 109cases of uveitis were studied, 46 men and 63 women, with a mean age of 45.43±16.11 years. The most frequent symptoms were pain (74.31%), hyperemia (73.39%) and blurred vision (65.14%). The most frequent anatomical classification was anterior (55.96%), followed by panuveitis (18.35%), posterior (12.84%) and intermediate uveitis (7.34%). Regarding etiology, most uveitis were idiopathic (42.99%), followed by non-infectious (38.32%) and finally infectious (18.69%).

CONCLUSIONS

In southern España, the characteristics of uveitis are similar to other studies in Western countries.

Complications of uveitis in a Spanish population, UveCAM study

OBJECTIVE

To estimate the population frequency of uveitis complications and to evaluate their main risk factors in the patients with uveitis from the UVECAM study.

PATIENTS AND METHODS

Development of complications in 386 patients with uveitis in the whole health area of the province of Toledo (UVECAM study) during a period of 1 year. Description of complications and study of their possible determinants by means of multivariate regression models.

RESULTS

Information on the development of complications was available in 371 of the 386 patients of the UVECAM study. The most frequent complications were posterior synechiae (19.0%), ocular hypertension (14.0%), macular edema (7.5%), epirretinal membrane (6.9%), glaucoma (6.6%), iridian atrophy (5.6%) and cataract (5.5%). The risk of complications increases with age, intermediate and panuveitis locations, and those of chronic or recurrent evolution.

CONCLUSION

Uveitis is associated with a high frequency of complications, especially in older patients, with intermediate or posterior localization of the inflammatory process and chronic or recurrent evolution.

The association between intestinal microbiome and autoimmune uveitis

INTRODUCTION AND OBJECTIVES

The microbiome is strongly implicated in a wide spectrum of immune-mediated diseases, whereas gut commensal microbiota plays a pivotal role in immune and intestinal homeostasis.

MATERIALS AND METHODS

A thorough literature search was performed in PubMed database. An additional search was made in Google Scholar to complete the collected items.

RESULTS

Due to complex interactions with the host genetics and other factors, intestinal dysbiosis has been linked to various immune-mediated disorders. In particular, the role of intestinal microbiota in the pathogenesis of uveitis has been demonstrated by several studies, indicating that changes in the microbiome can trigger autoimmune ocular inflammatory processes or affect their severity.

CONCLUSIONS

This review summarizes how alterations in the intestinal microbiota can conduce to immune-mediated ocular pathologies and how microbiome can be targeted in order to form novel therapeutic approaches to treat these severe and potentially blinding conditions.

Stalagmite-like pre-retinal deposits in the optical coherence tomography of two vitrectomy patients with panuveitis

Two patients with panuveitis are presented in whom, after undergoing a vitrectomy, the optical coherence tomography (OCT) revealed some unusual pre-retinal hyper-reflective deposits with the shape of stalagmites, distributed in a multifocal and perivascular pattern. Case 1: 51-year-old male with panuveitis in the right eye. After diagnostic-therapeutic vitrectomy, OCT showed pre-retinal stalagmite-like deposits. There was no clear aetiology, and the deposits persisted over the time. Case 2: 76-year-old woman with panuveitis in the right eye. After a surgery for cataract-vitrectomy and epiretinal membrane peeling, OCT revealed pre-retinal stalagmite-like deposits. The analysis reported elevated Toxoplasma IgG titres. Clarithromycin and corticosteroid were prescribed, resulting in the disappearance of pre-retinal deposits. The stalagmite-like deposits are not a very common tomographic sign of a posterior uveitis process, but they seem to correlate with inflammatory activity. There does not seem to be a clear mechanism or a particular aetiology.

Bacterial eye infections associated with sexual transmission infections: A review

The objective of this work was to collect updated information on Treponema pallidum, Chlamydia trachomatis and Neisseria gonorrhoeae, causing sexually transmitted infections (STIs) and etiological agents of eye infections, to provide relevant information on this public health problem. For this, a bibliographic review was carried out using different electronic databases such as: PubMed central, google academic, Lilacs, Scopus, Science Direct and Scielo, between March 2009 and August 2019. According to the WHO, more than a million people a day contract a sexually transmitted infection. For T. pallidum, a global prevalence of 0.5% is estimated for both men and women. It is a causative agent of syphilis and ocular syphilis, which manifests as uveitis. Overall, a prevalence of 2.8% in men and 3.8% in women for C. trachomatis is estimated. It is associated with oculo-genital disease, which includes STIs, inclusion conjunctivitis in adults and neonatal ophthalmia. Among its complications is trachoma, which is the leading cause of infectious blindness worldwide. Regarding N. gonorrhoeae, it has a global selection of 0.9% and 0.7% in women and men, respectively. It manifests with gonococcal conjunctivitis and neonatal ophthalmia. We can conclude that the information that relates T. pallidum, C. trachomatis and N. gonorrhoeae with their ocular compromise problems is insufficient, and even more so if we seek to find them related to each other, which makes it difficult to access data of clinical utility for visual health.

Psychosocial and economic impact of uveitis in Mexico

Objective

To determine the psychosocial and economic impact suffered by patients diagnosed with uveitis in Mexico.

Methods

Survey in uveitis-diagnosed patients. Demographic data and socioeconomic level were recorded. Symptoms, time to diagnosis, type of treatment, behavior, attitudes and feelings towards the disease were identified.

Results

One hundred surveys were conducted in patients with uveitis, who had a mean age of 45 ± 17.08 years, and socioeconomic level ≤ D; 54 were females. Diagnostic delay was 1.87 ± 2.73 years. Annually, patients attend 2.1 ± 2.14 appointments per month, and are admitted once to the emergency department and remain hospitalized for 3.7 days. Patients use systemic treatment with steroidal anti-inflammatory drugs (53 %), immunosuppressant agents (31 %), biological therapy (7 %), topical treatment with lubricants (44 %) or steroids (26 %) and undergo surgery (39 %). Observed comorbidities include hypertension, diabetes mellitus, rheumatoid arthritis (18 %), Sjögren's syndrome, systemic lupus erythematosus, and nonspecific chronic ulcerative colitis. Complications: visual impairment, cataracts and blindness. Uveitis affects their life in 83 % of cases, in 41 % does it daily, and 49 % need care from another person. Seventy-nine percent receive private care and 43 % have social security, with $ 3,590 ± $ 2,730.65 pesos being spent monthly on medicines, transportation, medical appointments and studies. Annually, work absenteeism is 8.5 ± 14.56 days, plus 7.0 days of disability or hospitalization; 51% refer lack of support to learn about the disease.

Conclusions

This is the first national study to portray the condition of patients with uveitis and the shortcomings they go through, including the economic and biopsychosocial fields.

Impact of novel coronavirus infection in patients with uveitis associated with an autoimmune disease: Result of the COVID-19-GEAS patient survey

Introduction

The objective of these study is to know the characteristics of COVID-19 in patients with uveitis associated with Systemic Autoimmune Disease (SAD) through telematic survey.

Material and methods

Internal Medicine Society and Group of Systemic Autoimmune disease conducted a telematic survey of patients with SAD to learn about the characteristics of COVID-19 in this population.

Results

A total of 2,789 patients answered the survey, of which 28 had a diagnosis of uveitis associated with SAE. The majority (82%) were female and caucasian (82%), with a mean age of 48 years. The most frequent SAEs were Behçet’s disease followed by sarcoidosis and systemic lupus erythematosus. 46% of the patients were receiving corticosteroid treatment at a mean prednisone dose of 11 mg/day. Regarding infection, 14 (50%) patients reported symptoms compatible with SARS-CoV-2 infection. RT-PCR was performed on the nasopharyngeal smear in two patients and in one of them (4%) it was positive.

Conclusions

Both asymptomatic and symptomatic COVID-19 patients with ASD-associated UNI had received similar immunosuppressive treatment.

Multidisciplinary care and units for uveitis in the internal medicine departments in Spain: Survey of the Systemic Autoimmune Diseases Group

OBJECTIVE

To identify the multidisciplinary uveitis units in which internal medicine departments participate in collaboration with ophthalmology departments in Spain.

MATERIAL AND METHODS

We conducted a multicentre, observational cross-sectional study that collected information using a structured survey sent by email to 1015 partners of the Systemic Autoimmune Diseases Workgroup of the Spanish Society of Internal Medicine (GEAS-SEMI) from the 1st to the 31st of March 2017.

RESULTS

We identified a total of 21 support units/consultations for the ophthalmology departments. Seventeen (81%) of the units were specific internal medicine-ophthalmology consultations, and 5 (24%) units had been created in the past 5 years. A median of 460 patients were assessed per unit by the end of the year.

CONCLUSIONS

This study shows, for the first time in Spain, the important and close collaboration between ophthalmologists and internists, especially in highly specialised national reference institutions.

Stalagmite-like pre-retinal deposits in the optical coherence tomography of two vitrectomy patients with panuveitis

Two patients with panuveitis are presented in whom, after undergoing a vitrectomy, the optical coherence tomography (OCT) revealed some unusual pre-retinal hyper-reflective deposits with the shape of stalagmites, distributed in a multifocal and perivascular pattern. Case 1: 51-year-old male with panuveitis in the right eye. After diagnostic-therapeutic vitrectomy, OCT showed pre-retinal stalagmite-like deposits. There was no clear aetiology, and the deposits persisted over the time. Case 2: 76-year-old woman with panuveitis in the right eye. After a surgery for cataract-vitrectomy and epiretinal membrane peeling, OCT revealed pre-retinal stalagmite-like deposits. The analysis reported elevated Toxoplasma IgG titres. Clarithromycin and corticosteroid were prescribed, resulting in the disappearance of pre-retinal deposits. The stalagmite-like deposits are not a very common tomographic sign of a posterior uveitis process, but they seem to correlate with inflammatory activity. There does not seem to be a clear mechanism or a particular aetiology.

Impact of novel coronavirus infection in patients with uveitis associated with an autoimmune disease: result of the COVID-19-GEAS patient survey

Introducción

El objetivo de este estudio es conocer las características de la COVID-19 en pacientes con uveítis asociada a enfermedades autoinmunes sistémicas (EAS) mediante una encuesta telemática.

Material y métodos

La Sociedad Española de Medicina Interna por medio del Grupo de Trabajo de Enfermedades Autoinmunes realizó una encuesta telemática a pacientes con EAS para conocer las características de la COVID-19 en esta población.

Resultados

Un total de 2.789 pacientes contestaron la encuesta, de los que 28 tenían un diagnóstico de uveítis asociada a una EAS. La mayoría (82%) eran mujeres y caucásicas (82%), con una media de 48 años. Las EAS más frecuentes fueron la enfermedad de Behçet seguida de la sarcoidosis y del lupus eritematoso sistémico. El 46% de los pacientes estaban recibiendo tratamiento con corticoides a una dosis media de prednisona de 11 mg/día. Respecto a la infección, 14 (50%) pacientes referían síntomas compatibles con infección por SARS-CoV-2. Se realizó RT-PCR en el frotis nasofaríngeo en dos pacientes y en uno de ellos (4%) fue positivo.

Conclusiones

Los pacientes con UNI asociada a EAS tanto los asintomáticos como los sintomáticos de COVID-19 habían recibido de forma similar tratamiento inmunosupresor.

Non-pharmacological complications associated with Intravitreal dexamethasone implant injection

OBJECTIVE

Intravitreal dexamethasone implant (IID) is an effective and safe treatment for macular oedema as described in the literature. Ocular hypertension and cataracts are the most frequent complications. The indications of IID in the last few years have led to the retrospective reporting of rare complications, with potential visual impact related to the injection procedure.

METHODS

A case series is presented of fifteen patients treated with IID for macular oedema who developed non-pharmacological complications related to the injection procedure or the implant itself, including, among others anterior chamber migration, intracrystalline injection, endophthalmitis, or segmentation. Differentiation was made between true complications and those that did not lead to any ocular damage. Epidemiological and baseline data were collected along with the treatment and outcome in each case. An analysis was made of multimodal imaging available.

RESULTS

The incidence of complications was 0.65% in this series Anterior chamber migration was the most frequent complication (n=4), followed by intracrystalline injection, and endophthalmitis (n=2). The times between the injection and complications were variable. Visual impairment was the most common symptom (n=6). However, despite the complications found, IID was an effective treatment in most of the reported cases.

CONCLUSIONS

Clinicians should be aware of these rare non-pharmacological complications so that they may be prevented and detected early, avoiding irreversible ocular damage.

Multiple sclerosis in ophthalmology: beyond optic neuritis

Disorders of the visual system are one of the main features of multiple sclerosis (MS), and have a great impact on the quality of life of patients. Although optic neuritis is the most frequent manifestation, there are other ophthalmological processes not related to neuritis, a knowledge of which is very useful in the management of patients with MS. These abnormalities are described, grouped into impairments of the afferent pathway, efferent pathway, or upper cerebral areas. Additionally, the main ophthalmological side effects of the drugs currently used in the control of MS are described.

Atypical toxoplasmic retinochoroiditis in patients with malignant hematological diseases

In immunocompromised patients, toxoplasmosis may have atypical presentation with bilateral, extensive or multifocal involvement. We report a case series of atypical toxoplasmic retinocoroiditis in patients with malignant hematological diseases who are usually immunosuppressed. Four patients were diagnosed of atypical toxoplasmic retinochoroiditis, all of them had immunosuppression (100%) and half of them (50%) had received a bone marrow transplant. The polymerase chain reaction for toxoplasma was positive in 75% of cases, and in one case (25%) the diagnosis was made with clinical and serological criteria. One patient presented ocular toxoplasmosis despite being on prophylactic treatment with atovaquone. Patients with atypical ocular toxoplasmosis and hematological diseases are generally immunocompromised, but they do not always have history of a bone marrow transplant. The presentation may be due to a primary infection or a reactivation of the disease. The aqueous humor and/or vitreous polymerase chain reaction allow confirming the diagnosis to perform a proper treatment.

About 3 cases of post-acute retinopathy of chikungunya fever

A descriptive study is presented on a case series of 3 patients, with IgM an IgG serology diagnosis of Chikungunya in whom other metabolic, autoimmune and infectious diseases were ruled out. They presented with other ocular manifestations with vascular changes and inflammatory characteristics. They were treated at the Retinovascular and Retinal and Vitreous clinics at the "Dr. Rodolfo Robles Valverde Hospital" and "Benemérito Comité Pro-ciegos y Sordos" in Guatemala City during 2019. Guatemala is a country with a high prevalence of vector-borne diseases, including chikungunya. In recent years cases of this disease has increased in recent years, and complications are currently seen more frequently. Within these complications, there have been reports of cases of optic neuritis, iridocyclitis, episcleritis, retinitis, uveitis, and blood dyscrasia that can affect the retina. It is important to consider these as an important differential diagnosis of ocular vascular alterations.

Multidisciplinary care and units for uveitis in the internal medicine departments in Spain: Survey of the Systemic Autoimmune Diseases Group

OBJECTIVE

To identify the multidisciplinary uveitis units in which internal medicine departments participate in collaboration with ophthalmology departments in Spain.

MATERIAL AND METHODS

We conducted a multicentre, observational cross-sectional study that collected information using a structured survey sent by email to 1015 partners of the Systemic Autoimmune Diseases Workgroup of the Spanish Society of Internal Medicine (GEAS-SEMI) from the 1st to the 31st of March 2017.

RESULTS

We identified a total of 21 support units/consultations for the ophthalmology departments. Seventeen (81%) of the units were specific internal medicine-ophthalmology consultations, and 5 (24%) units had been created in the past 5 years. A median of 460 patients were assessed per unit by the end of the year.

CONCLUSIONS

This study shows, for the first time in Spain, the important and close collaboration between ophthalmologists and internists, especially in highly specialized national reference institutions.

Ophthalmic manifestations of arbovirus infections in adults

INTRODUCTION AND OBJECTIVES

Emerging arbovirus infections have classic symptoms such as fever, arthralgia, or rash. As some of them have ophthalmic symptoms/signs, the main objective is to evaluate whether these findings could help to clarify the clinical diagnosis.

MATERIAL AND METHODS

A descriptive and retrospective study was conducted, in which cases of adults who attended an evaluation in 2016. The general and ophthalmic symptoms were analysed on those meeting the definition of dengue, Zika, and chikungunya.

RESULTS

A total of 10,327 cases of arbovirosis were recorded, of which 5,388 (52.2%) were Dengue, 3,529 (34.1%) Zika, and 1,410 (13.6%) were Chikungunya. The main symptoms and signs of Dengue were: fever, headache/retro-orbital pain, arthralgia, rash, and nausea/vomiting. For Zika cases they were: exanthema, swollen glands, headache, arthralgia, and conjunctivitis, and for Chikungunya cases: rash, fever, arthritis, headache, and náusea/vomiting. The group with the most ophthalmic signs/symptoms was Zika, predominantly non-purulent conjunctivitis and retro-orbital pain, epiphora, episcleritis, anterior uveitis, as well as neurological syndromes such as isolated cranial nerve palsy (III and IV) or Miller Fisher syndrome.

CONCLUSIONS

Ophthalmic signs/symptoms of Zika infection can help the clinical diagnosis of these arbovirosis.

Use of Immunomodulatory Drugs at a Uveitis Clinic

OBJECTIVE

The treatment of noninfectious uveitis includes steroids and immunomodulatory drugs, the use of which has increased in the last few years, and the options have been enriched with the development of new treatments. However, clear therapeutic guidelines and protocols have not been developed. The purpose is to analyze the response to the drugs used and the characteristics of the patients treated at a multidisciplinary uveitis clinic.

MATERIAL AND METHODS

Observational and retrospective study of the patients attended to from January 2012 to December 2015. Infectious, posttraumatic and postoperative uveitis, as well as masquerade syndrome, were excluded.

RESULTS

Two hundred six patients were included. Overall, 58.80% had uveitis without association of systemic disease, mostly idiopathic uveitis, and 35.65% had uveitis with systemic involvement, mainly related to spondyloarthritis. Uveitis without systemic association and anterior uveitis achieved disease control with local treatment more frequently than others (p=.002 and p <.001, respectively). In all, 49.76% of the patients required systemic treatment. Among those treated with immunomodulators, 53.26% needed a second drug and 31.52% needed a third drug. Women required immunomodulators more often than men (P=.042). Methotrexate was the most widely used immunomodulator. Posterior uveitis responded less favorably to the second immunomodulator than anterior uveitis (p=.006).

CONCLUSIONS

Almost half of the patients needed an immunomodulatory drug and some of them required successive drug changes. Intermediate uveitis was the most treatment-refractory uveitis.

Complications and visual acuity of patients with uveitis: Epidemiological study in a reference unit in northern Spain

OBJECTIVE

To describe uveitis complications and visual acuity in a cohort of 500 patients in a multidisciplinary unit in northern Spain.

MATERIAL AND METHODS

Retrospective-prospective study of complications and visual acuity of 500 adult patients evaluated in the Multidisciplinary Unit of the Navarra Hospital Complex from the period January 2010 until March 2015. An analysis was made of the complications, visual acuity and visual loss, with a follow-up of one-year. A comparative study was also made of the complications with 2 previous series published in Madrid and Holland.

RESULTS

Moderate-severe visual loss was 13.5% in the right eye, and 13% in the left eye. Visual loss was associated with an age of 65 years or above. Complications were observed in 35% of patients, and cataract was the most frequent complication (10%), followed by synechiae (8%), and macular oedema (5%). Compared with the 2 other series, the present cohort showed a higher proportion of cataracts.

CONCLUSIONS

Visual loss was associated with older age and cataract was the most common complication in our study.

Diagnosis of ocular toxocariasis by detecting antibodies in the vitreous humor

OBJECTIVES

To demonstrate the production of the local toxocara antibodies in the vitreous of patients with negative serology.

MATERIAL AND METHODS

Retrospective review of the medical records of patients seen in a Tertiary Referral Hospital, and at an Eye Institute, with an ocular diagnosis of toxocariasis who had a negative serology and positive titres in the vitreous.

RESULTS

After reviewing the medical records of 40 patients with a diagnosis of ocular toxocariasis, a total of six cases (15%) were found with a negative serology and a positive vitreous titre for toxocara antibody, both of them performed using an ELISA procedure. The mean age was 18 years, there were no differences observed between males and females. A peripheral granuloma was the most common clinic finding, and all patients underwent vitrectomy either to remove epiretinal membranes or to repair retinal detachments.

CONCLUSION

A negative serology does not rule out a diagnosis of ocular toxocariasis. Vitreous samples may be necessary to confirm a clinical diagnosis.

Bilateral acute iris depigmentation and bilateral acute iris transillumination syndrome

The case is presented of a 32 year-old male who arrived with acute bilateral symptoms with blurred vision, red eye, severe photophobia and severe ocular pain after suffering from a flu-like syndrome. The patient presented with a clinical picture of bilateral involvement characterised by pupils in mid-mydriasis, scarcely reactive to light, iris transillumination, diffuse depigmentation of the iridian stroma, pigment dispersion in the anterior chamber, and ocular hypertension. After the eye examination an inflammatory syndrome and pigmentary glaucoma were ruled out. The patient showed depigmentation characteristics as well as bilateral iris transillumination. Both conditions could form part of the spectrum of the same disease.

Papillitis and neuroretinitis of tuberculous etiology

A 57-year-old man with miliary tuberculosis reported visual loss in his right eye, a month after starting a four-drug antituberculous treatment regimen. On exploration, an inferior segmental optic disc edema was objectived and it was attributed to ischemic aetiology. Ethambutol was withdrawn and 60mg of oral prednisone daily were given with a tapering dosage. One and a half months later, he presented a sudden loss of vision in his left eye. In fundoscopy, a papillary edema accompanied by a foveal neurosensory detachment was observed but with no more accompanying uveitic signs. Treatment was intensified with moxifloxacin and corticosteroids were reduced, showing a resolution of the macular detachment but with optic atrophy. Isolated tuberculous involvement of the optic nerve may possible in the context of miliary tuberculosis. In this case, the adopted therapeutic approach to the initial papillitis, which was interpreted as ischemic, could favour the appearance of a neuroretinitis in the fellow eye.

Chronic Anterior Uveitis in a Patient with CREST Syndrome

Systemic sclerosis is a connective tissue pathology with very heterogeneous clinical manifestations, associated in a small percentage with inflammatory eye diseases. In the specific case of uveitis, only isolated cases have been reported in the literature, especially in relation to the CREST syndrome. We present the case of a 53-year-old woman with CREST syndrome and chronic anterior uveitis, which we consider of clinical relevance given its low prevalence.

Masquerade syndrome: An eye problem as a manifestation of a more sinister disease

A middle-aged man with cardiovascular risk factors, who suffered from a slight loss of unilateral vision for 6 months. After obtaining a diagnosis of diffuse choroiditis+papillitis within a probable masquerade syndrome, the patient was referred to outpatient Internal Medicine where this diagnosis was confirmed as an extended neoplastic disease.

Ahmed glaucoma drainage implant surgery in the management of refractory uveitic glaucoma: Long-term follow up

OBJECTIVE

To examine the long-term efficacy, safety and complications of Ahmed glaucoma drainage implant surgery in patients with refractory uveitic glaucoma.

METHODS

Retrospective review of consecutive cases of patients with refractory uveitic glaucoma who underwent Ahmed glaucoma drainage implant surgery between 2004-2014. Demographic characteristics of the study population, visual acuity, intraocular pressure (IOP), number of antiglaucoma medications and operative and postoperative complications were recorded. Complete success was defined as IOP≥5 and ≤18mmHg without any medication, as qualified success if IOP≤18mmHg with one or more medications. Patients with less than 12 months of follow-up were excluded.

RESULTS

21 patients (26 eyes) were included. The mean postoperative follow-up was 53.5±31 months. Eight eyes (30%) had at least one previously failed glaucoma surgery. IOP was reduced from a mean of 30.0mmHg to 14.0mmHg at the last follow-up visit (P<.001). The number of IOP-lowering medications was reduced from a median of 2.9 preoperatively to 1.1 at the last follow-up (P<.001). Overall, 7 eyes (27%) were classified as complete success, 13 eyes (50%) were considered as qualified success, and 6 eyes (23%) met the criteria for failure. The most common postoperative complication was hypertensive phase in 12 eyes (46%). Kaplan-Meier life-table analysis showed a cumulative probability of success after Ahmed glaucoma valve implantation of 65% at 84 months.

CONCLUSIONS

Ahmed glaucoma drainage implant surgery may be considered a long-term effective and safety surgical option for patients with refractory uveitic glaucoma.

Tattoo associated retinochoroiditis

CLINICAL CASE

A young woman was referred to our offices with impairment of visual acuity after she received a third tattoo on her arm. Systemic medical and laboratory work-up were performed in order to exclude an infectious agent or inflammatory disease. A yellowish juxtafoveal lesion in left eye along with a plaque-like outer retinal disruption and focal pigmentary defects was assessed using multi-modal diagnostic imaging.

DISCUSSION

Ophthalmologists treating uveitis should consider this uncommon association and question patients regarding tattoos and tattoo inflammation given the rise of subjects undergoing artistic tattooing.

Case series of ocular involvement due to dengue. First reported cases in Guatemala

OBJECTIVE

Describe the ocular findings of a case series of 8 patients with a diagnosis of dengue.

MATERIALS AND METHODS

Review of clinical records and interviews with patients during outpatient visits, after informed consent was obtained and following the ethical standards of the Helsinki declaration. The patients were diagnosed with diagnosis by IgM / IgG dengue serology in whom ocular involvement was identified, between January and October 2017 in Retinal-vascular clinic of the "Dr. Rodolfo Robles Valverde Hospital", Guatemala.

RESULTS

The 8 patients, 5 men and 3 women from rural areas in Guatemala, were diagnosed with dengue by IgM / IgG serology with associated ocular involvement. The mean age was 32.3 years, with the oldest being 45 years old and the youngest being 20 years old. The ocular manifestations identified were, 4 neuroretinitis, 3 venous obstructions, 3 maculopathies, 2 serous detachments, 1 episcleritis, and 1 vasculitis. Two patients developed optic atrophy after resolving the neuroretinitis, and 1 developed peri-foveal scarring after the maculopathy. The ocular involvement was resolved in all patients after treatment, with an improvement in visual acuity, although in some cases damage to the visual field developed as a sequela of neuroretinitis.

CONCLUSION

It is necessary to consider dengue as an important differential diagnosis in an endemic country such as Guatemala. There are a large number of ocular manifestations due to direct involvement, as well as by an immune system reaction, and thus avoid considering the different ocular manifestations as idiopathic, or due to a different condition.

Clinical Significance of Neutrophil/lymphocyte Ratio in Patients With Granulomatosis With Polyangiitis

OBJECTIVE

To determine to neutrophil-to-lymphocyte ratio (NLR) in granulomatosis with polyangiitis (GPA) patients and to study its relation to disease manifestations and activity.

METHODS

The study included 44 GPA patients and 44 matched age and sex controls. Full history taking, thorough clinical examination with more attention to ocular examination, laboratory and radiological investigations were considered. Disease activity was assessed using the Birmingham Vasculitis Activity Score (BVAS).

RESULTS

The patients (21 males and 23 females) had a mean age of 45.66±7.24 years, disease duration 6.8±3.6 years and BVAS 50.1±14.3. All patients had a positive cytoplasmic anti-neutrophil cytoplasmic antibody (c-ANCA) while only 5 had a positive p-ANCA. The NLR was significantly increased in the GPA patients (5.1±2.4) compared to the control (1.5±0.8) (P<.0001). Ten patients with uveitis had a significantly higher NLR (6.5±1.9) compared to those without (4.7±2.4) (0.03) while those with proptosis (n=10), cutaneous manifestations (n=17) or ischemic heart disease (n=9) had a significantly lower NLR than those without (P=.0001, P=.017 and P=.046 respectively). The NLR did not significantly correlate with any of the patients' characteristics. The NLR inversely yet insignificantly correlated with the disease activity (r=-0.02, P=.93).

CONCLUSION

The NLR may have a significant role in the pathogenesis of GPA, the development of uveitis or proptosis, cutaneous manifestations and ischemic heart disease. NLR may serve as a future potential companion to c-ANCA positivity in diagnosing and evaluating GPA and may play a role in the tissue-specific and clinical characteristics.

New imaging techniques in retinal vasculitis

The term retinal vasculitis (RV) encompasses a heterogeneous group of sight-threatening conditions that are included in the intraocular inflammatory diseases that affect the posterior segment of the eye. Based on the nature of the inflammatory process, RV are classified into predominantly inflammatory or ischaemic (occlusive RV). The diagnosis is clinical and the aetiology can be infectious or non-infectious (immune-mediated). RV can be an isolated ocular syndrome or be associated with a systemic disease, of which they can represent the first manifestation. New retinal imaging techniques such as ultra-wide field fluorescein angiography and optical coherence tomography angiography will help us classify the RV and aid the diagnostic process, which can be challenging and require a multidisciplinary approach. Therefore, clinical knowledge of RV is essential for prompt diagnosis and to establish the appropriate treatment.

Tubulointerstitial nephritis and uveitis syndrome (TINU). Treatment with immunosuppressive therapy

CASE REPORT

Two cases of tubulointerstitial nephritis and uveitis are presented. Immunosuppressive therapy was required to control the uveitis. Contrary to that usually described, uveitis became chronic, which made immunosuppressive therapy necessary. Nephritis was successfully treated with steroids.

DISCUSSION

Tubulointerstitial nephritis and uveitis syndrome is an under-diagnosed disorder and requires clinical suspicion due to there being no specific laboratory study available. Recurrences and relapses of ocular inflammation are common. Immunosuppressive therapy is not often needed.

Unilateral uveitis associated with IgA nephropathy

CASE REPORT

The case is presented of a 42 year-old man with episodes of unilateral uveitis in his right eye. Ophthalmic examination showed a granulomatous anterior uveitis with vitritis. Systemic investigations revealed non-nephrotic proteinuria and microhaematuria. A renal biopsy showed IgA nephropathy.

DISCUSSION

Uveitis and glomerulonephritis may have common immunological pathogenesis. IgA nephropathy should be a differential diagnosis in patients with uveitis and nephropathy.

Efficacy of immunomodulatory therapy with interferon-β or glatiramer acetate on multiple sclerosis-associated uveitis

AIM

To analyse the role of interferon-β or glatiramer acetate in reducing the inflammatory episodes of intra-ocular inflammation in multiple sclerosis-associated uveitis.

METHOD

A study was conducted on a non-randomised, retrospective case series of 13 patients with proven multiple sclerosis and uveitis (minimum follow-up, 12 months). All patients were given immunomodulatory treatment (interferon-β or glatiramer acetate) to control the course of the multiple sclerosis. Patients were compared to themselves before initiating the treatment, in order to assess the difference in uveitis episodes. The main outcome measurements were the number of uveitis episodes with/without immunomodulatory treatment.

RESULTS

Uveitis was bilateral in 10 (77%) out of 13 patients. Intermediate uveitis was observed in 11 patients, retinal vasculitis in 3 patients, and one patient was classified as a posterior uveitis. The patients had a mean of 4.15±3.1 episodes of uveitis (range 1-10) during the follow-up period (148.6±84.3 months). When compared to their pre-treatment status, patients on treatment with interferon-β or glatiramer acetate showed a significant decrease of 0.36 episodes of ocular inflammation per year (P=.02). Mild side effects related to immunomodulatory treatment were observed in 6 (46%) patients, 3 (23%) patients with a flu-like syndrome, and 3 (23%) patients with a skin rash.

CONCLUSIONS

Interferon β or glatiramer acetate could be effective in reducing the uveitis episodes in patients with multiple sclerosis-associated uveitis, and was well tolerated in most patients.

Profile of patients with uveitis referred to a multidisciplinary unit in northern Spain

OBJECTIVE

To describe the main characteristics of a cohort of patients with uveitis referred to a multidisciplinary unit in northern Spain.

MATERIAL AND METHODS

Retrospective analysis of clinical records of patients evaluated in the Multidisciplinary Unit of the Navarra Hospital Complex from the period January 2010 until March 2015. An analysis was performed on the demographic characteristics, origin, types of uveitis, laterality, and aetiology. The present series was also compared with 2 previous series from Castilla y León and Barcelona.

RESULTS

A total of 500 patients were identified, with a mean age of 47.9±16.4 years, with 50% women. The most frequent type of uveitis was anterior uveitis (65.4%), followed by posterior uveitis (17.6%), panuveitis (15.2%), and intermediate uveitis (1.8%). The origin was unclassifiable in 31.2%, followed by non-infectious systemic disease in 29.2%. Ankylosing spondylitis was the most frequent cause in 10.8% of patients, followed by herpes infection in 9.2%, and toxoplasmosis in 7.8%, respectively. Compared with the 2other cohorts, the present cohort showed a higher proportion of unilateral anterior uveitis. Furthermore, the patients from the Navarra series had a higher prevalence of unilateral and idiopathic uveitis compared to the series from Barcelona.

CONCLUSIONS

The main characteristics of the present cohort of patients with uveitis are similar to those of patients from other regions of our country. Unilateral anterior uveitis and idiopathic uveitis were the most frequent in our series.

Complicated uveitis in late onset juvenile idiopathic psoriatic arthritis

CASE REPORT

A 6 year-old girl with juvenile psoriatic arthritis (JPsA) and bilateral complicated anterior uveitis developed several ocular complications that required 5 surgical procedures. Despite the aggressive course of ocular inflammation, her visual acuity remained good. Arthritis (main criterion for the diagnosis of JPsA) appeared years after ocular involvement. She showed a good anti-tumour necrosis factor initial response.

DISCUSSION

The definitive diagnosis of JPsA was established years after the onset of symptoms. In addition, the patient maintained a good visual acuity, despite its complicated disease course. Finally, she showed a good clinical response to adalimumab.

Diagnostic categorization according to the First International Workshop on Ocular Sarcoidosis (FIWOS) criteria in a series of 11 patients

OBJECTIVE

Categorization of patients diagnosed with ocular sarcoidosis during the period 2009-2014.

METHODS

The medical records of patients with ocular sarcoidosis were reviewed and variables were collected to categorize the patients according to the criteria of the FIWOS.

RESULTS

We found 11 patients, 7 women and 4 men, with sarcoid uveitis; the median age was 58 years. Bilateral panuveitis was the most common pattern (54.5%), followed by chronic anterior uveitis (27.2%). The diagnosis of sarcoidosis was definitive in 4 patients (36.3%), presumed in 5 (45.4%), probable in 1 (9%) and possible in 1 (9%).

CONCLUSIONS

Ocular sarcoidosis was diagnosed in more than half of the patients who had no confirmatory biopsy. Bilateral panuveitis and chronic anterior uveitis were the patterns most frequently observed.

Ultrasound biomicroscopic analysis of iris cysts

PURPOSE

To describe the ultrasound biomicroscopic (UBM) features and complications associated with iris cysts.

DESIGN

A retrospective case series.

METHODS

Thirteen patients with iris cysts were identified in a 10 year period study at a ophthalmologic reference Center in Mexico City. The variables included demographic data, ocular and medical history, clinical course, and complications. All patients were examined by UBM, and type, number, location, and acoustic characteristics of cysts were evaluated. Descriptive statistics were performed.

RESULTS

Thirteen patients were included (8 men and 5 women). The mean age was 44.5 ± 15.5 years (range 6-70 years). The origin most prevalent was neuroepithelial (92.3%), and 7.7% had stromal cysts. Regarding to location 76.9% were found in the periphery, and 69.2% between meridians II and VI. All cysts showed a moderate to high reflectivity in the wall. Complications were present in 38.5% of cases (15.4% partial angle closure, 15.4% secondary angle closure glaucoma and 7.7% dyscoria).

CONCLUSIONS

Most cysts are derived from iris pigmented epithelium, with a benign course and a minor rate of complications. The UBM is an indispensable tool that allows us to plan more specific and conservative treatments, with less damage to ocular structures and, therefore, better visual prognosis.

[Two-year incidence of new immune-mediated inflammatory diseases in patients with inflammatory bowel disease: A study in the AQUILES cohort]

OBJECTIVE

To describe the 2-year incidence of new immune-mediated inflammatory diseases (spondylarthritis, uveitis, psoriasis) in the cohort of patients with inflammatory bowel disease (IBD) included in the AQUILES study.

MATERIALS AND METHODS

Over a 2-year period, 341 patients with IBD (53% women, mean age 40 years) diagnosed with Crohn's disease (60.5%), ulcerative colitis (38.1%) and indeterminate colitis (1.4%) were followed up. New diagnoses made during follow-up were based on reports of the corresponding specialists (rheumatologists, ophthalmologists, and dermatologists).

RESULTS

A total of 22 new diagnoses of immune-mediated inflammatory diseases were established in 21 patients (cumulative incidence of 6.5%, 95% confidence interval [CI] 3.7-9.2, incidence rate of 26 cases per 10,000 patient-years). Most diagnoses were new cases of spondylarthritis (n=15). The cumulative incidence of new diagnoses of immune-mediated inflammatory diseases was similar in patients with Crohn's disease (5.8%, 95% CI 3.4-9.9) and in patients with ulcerative colitis (7.7%, 95% CI 4.2-13.6). On multivariate analysis, the incidence of new immune-mediated inflammatory diseases was significantly associated with a family history of IBD (odds ratio=3.6, 95% CI 1.4-9.4) and the presence of extraintestinal manifestations of IBD (odds ratio=1.8, 95% CI .7-5.2).

CONCLUSIONS

In patients with IBD, the incidence of new immune-mediated inflammatory diseases at 2 years of follow-up was 6.5%. These diseases were more frequent in patients with extraintestinal manifestations of IBD and a family history of IBD.

Uveitis-glaucoma-hyphema syndrome associated with recurrent vitreous hemorrhage

CASE REPORT

A 61-year-old pseudophakic male with recurrent blurred vision episodes associated with uveitis, hyphema, glaucoma and vitreous hemorrhage. Iris transillumination defects and apposition of the optic and iris were found. The patient was diagnosed with Uveitis-Glaucoma-Hyphema (UGH) Syndrome.

DISCUSSION

Mechanical irritation of the iris is a consequence of intraocular lens malposition and causes UGH Syndrome. Occasionally it is associated with vitreous hemorrhage. Lens malposition is detected by optical coherence tomography and/or ultrasound biomicroscopy.

The importance of an ophthalmologic examination in patients with juvenile idiopathic arthritis

Uveitis occurs within the first year of arthritis onset in 73% of patients with juvenile idiopathic arthritis (JIA) considered at risk. The intraocular inflammation is characterized by an insidious onset and a silent and chronic clinical course capable of producing significant visual loss due to complications such as: cataract formation, secondary glaucoma, maculopathy and optic neuropathy. The absence of initial signs and symptoms, along with a deficient ophthalmic monitoring produce a delay in diagnosis with serious consequences. It has been estimated that 47% of JIA patients at risk for developing uveitis are legally blind (20/200 or worse) at least in one eye at the time of their first visit to the ophthalmologist. To reduce ocular complications and improve their visual outcome, it is necessary that rheumatologists refer all patients recently diagnosed (within the first month) with JIA for an ophthalmic evaluation, and maintain periodical follow-up visits based on classification and risk category of the disease.

[AIDS-related primary CNS non-Hodgkin's lymphoma in a patient with previous Epstein-Barr virus panuveitis. A clinico-pathological report]

CLINICAL CASE

Patient with AIDS and Epstein-Barr virus (EBV) uveitis. The PCR of the aqueous and vitreous humor was positive for EBV, and DNA quantification was 56.602×10(6) copies/ml in the vitreous humor, 173,400 copies/ml in the peripheral blood, and negative in the cerebrospinal fluid (CSF). The patient developed a non-Hodgkin's lymphoma (NHL), diagnosed in the autopsy.

CONCLUSION

The EBV is a rare cause of uveitis and it may be necessary to perform a quantitative PCR to reach the diagnosis. High amounts of EBV DNA are associated with a greater incidence of NHL.

Extra-articular disease in patients with spondyloarthritis. Baseline characteristics of the spondyloarthritis cohort of the AQUILES study

OBJECTIVES

To describe the prevalence of extra-articular disease (uveitis, psoriasis and inflammatory bowel disease [IBD]), in a cohort of patients with spondyloarthritis (SpA).

PATIENTS AND METHODS

AQUILES is an observational, prospective and multicentric study of three cohorts of patients with one of the following immune-mediated inflammatory diseases (IMID): SpA, psoriasis, or IBD. In the present cohort, patients ≥18 years of age with SpA were enrolled from Rheumatology clinics. The main objective was to assess the coexistence of these diseases and of uveitis, based on the patients' clinical history up to the study entry.

RESULTS

A total of 601 patients with SpA (men: 63.1%; women: 36.9%) were enrolled. The specific diagnoses were: ankylosing spondylitis (55.1%), psoriatic arthritis (25.1%), undifferentiated spondyloarthritis (16.1%), enteropathic arthritis (2.5%), and others (1.3%). In 43.6% (95% CI: 39.7-47.6) of the patients, at least one of the three abovementioned diseases was encountered, predominantly psoriasis (prevalence 27.8%, 95% CI: 24.4-31.5), uveitis (13.6%, CI 95%: 11.1-16.6) and IBD (5.1%, 95% CI: 3.7-7.2). In patients with ankylosing spondylitis the proportion of other disease was 25.3% (IBD: 3.9%, psoriasis: 5.4%, uveitis: 19.0%) whilst it was 94.7% in psoriatic arthritis, due to the presence of psoriasis (94.0%). The coexistence of these diseases was associated with age, female gender and the presence of other extra-articular manifestations associated with SpA.

CONCLUSIONS

Extra-articular disease in patients with SpA is common and, in this study, it was associated to age, female gender and the presence of other SpA-related extra-articular manifestations.

Immune-mediated inflammatory diseases and other comorbidities in patients with psoriasis: baseline characteristics of patients in the AQUILES study

INTRODUCTION AND OBJECTIVES

Patients with psoriasis often have comorbidities, including other immune-mediated inflammatory diseases (IMIDs), and cardiovascular risk factors. In this article we describe the baseline prevalence of comorbidities-including other IMIDs-in a cohort of patients with psoriasis.

PATIENTS AND METHODS

AQUILES was a prospective observational multicenter study of 3 patient cohorts (patients with psoriasis, spondyloarthritis, or inflammatory bowel disease) undertaken to investigate the prevalence of comorbidities, including other IMIDs, in these settings. The psoriasis cohort comprised patients aged at least 18 years who were seen in hospital dermatology clinics. A predefined protocol was used to collect demographic and clinical data.

RESULTS

The study enrolled 528 patients with psoriasis (60.2% men and 39.8% women). Mean age was 46.7 years; 89.8% of the participants had plaque psoriasis, and the median Psoriasis Area Severity Index score (PASI) was 3.2 (1.5-7.4). Comorbid IMIDs were present in 82 (15.5%) of the patients (CI 95%, 12.7%-18.9%). Spondyloarthritis was observed in 14% of patients (95% CI, 11.3%-17.2%), mostly in the form of psoriatic arthritis, for which the overall prevalence was 13.1% (95% CI, 10.5%-16.2%). Inflammatory bowel disease was present in 1.3% (95% CI, 0.6%-2.7%) and uveitis in .2% (95% CI, 0.1%-1.4%). Psoriatic arthritis was associated with male sex (odds ratio, 1.75 [.98-2.98]) and a disease duration of over 8 years (OR, 4.17 [1.84-9.44] vs a duration of < 4 years). In 73.1%, at least 1 cardiovascular risk factor was identified: smoking (40.5%), obesity (26.0%), dyslipidemia (24.8%), hypertension (24.3%), and diabetes mellitus (12.3%).

CONCLUSION

In patients with psoriasis the prevalence of other IMIDs was 15.5%, a level slightly higher than that found in the general population. Nearly three-quarters of these patients had at least 1 cardiovascular risk factor.

[Treatment of presumed tuberculous uveitis affecting the posterior segment: diagnostic confirmation and long term outcomes]

OBJECTIVE

To determine the level of agreement with the presumed diagnosis and long term clinical outcomes after antituberculous therapy (ATT) in a group of patients with presumed tuberculous uveitis (PTU) affecting the posterior segment.

METHODS

Retrospective case series.

RESULTS

A total of 17 patients with chronic refractory or newly diagnosed uveitis affecting the posterior segment were included. All included patients were diagnosed with PTU and received ATT. Median follow-up after ATT was 34 months (range 2-60). Complete control of inflammation was observed in 14/17 patients (82.3%) during the treatment period, and only 4/17 patients (23.5%) had a uveitis relapse over the entire follow-up period after ATT. All patients who had uveitis relapses (4/4), but none from the remaining group (0/13), required immunosuppressive therapy of some kind after ATT. The response to ATT was able to confirm diagnosis of PTU in 14/17 (82.3%) included patients.

CONCLUSION

When a clinical suspicion of PTU affecting the posterior segment exists, ATT may be highly effective for both confirming the diagnosis and resolving the inflammatory process. Thus, ATT may offer additional advantages, such as preventing latent-tuberculosis reactivations due to immunosuppressive therapy, and decreasing the number and/or severity of uveitis relapses in some patients. Prospective, randomized studies including a larger number of patients are required to support these and other potential advantages of ATT in such patients.