Control Of Intraocular Inflammation Research Articles

Effect of Therapeutic Pars Plana Vitrectomy on Total Immunosuppression Load in Patients with Non-Infectious Uveitis

ABSTRACT Purpose The anti-inflammatory effect of therapeutic pars plana vitrectomy (PPV) in the management of posterior segment uveitis is incompletely quantified. In this study, we evaluated the change in total immunosuppression load (TIL) following PPV for the eyes of patients with non-infectious uveitis. Methods Retrospective chart review of patients with non-infectious posterior segment uveitis on continuous anti-inflammatory therapy (systemic corticosteroids ± immunomodulatory therapy [IMT]) ±3 months, who received therapeutic PPV for non-resolving inflammation. The TIL scores were calculated by adding the total daily dose of prednisolone graded on a scale of 0–9, and of the IMT graded between 0 and 3, and calculating the mean values for the pre-operative and post-operative visits, respectively. Results Sixty-five eyes of 65 patients were included. Mean follow-up was 19.1 ± 14.6 months pre-operatively and 9.4 ± 7.1 months post-operatively. Mean TIL scores for the post-operative visits (2.6 ± 1.9) were significantly lower than the pre-operative (4.4 ± 1.7) visits (p < 0.001). Mean logMAR BCVA was four lines better 1 month post-operatively (0.5 ± 0.4) than the immediate pre-operative vision (0.9 ± 0.6, p < 0.001). On multivariate regression analyses, the reduction in mean TIL scores post-operatively was more with longer durations of pre-operative treatment (adjusted risk ratio [aRR] = -0.04, p = 0.04), while the improvement in one-month post-operative BCVA was more if pre-operative vitreous haze was ≥2+ (aRR = −0.25, p = 0.02). Post-operative adverse outcomes included new-onset cystoid macular edema (n = 6), raised intraocular pressure (n = 5), and intra-operative retinal break (n = 1). Eleven (16.9%) patients were off all immunosuppression during the final follow-up. Conclusions Therapeutic PPV allowed control of intraocular inflammation on less intensive systemic anti-inflammatory therapy. Post-operative adverse outcomes observed were manageable.

Efficacy and Safety of Anti-TNFα Therapy for Uveitis Associated with Juvenile Idiopathic Arthritis: A Systematic Review and Meta-Analysis.

IntroductionTo investigate the efficacy and safety of anti-TNFα therapy in patients with juvenile idiopathic arthritis associated uveitis (JIA-U).MethodsEmbase, PubMed, Cochrane Library, and Web of Science were systematically searched for studies reporting anti-TNFα treatment in patients with JIA-U. The primary outcome was the control of intraocular inflammation (CII). The pooled proportion of CII was assessed by the random-effects method when I2 > 50%, otherwise, by the fixed-effect method. This study was registered with PROSPERO (CRD42020161749).ResultsThree randomized clinical trials (RCTs), twelve case series, three retrospective cohort studies, and three case reports were identified. A total of 399 patients were receiving anti-TNFα therapy, of which 201 patients were treated with adalimumab (ADA), 139 with infliximab (IFX), 36 with etanercept (ETA), 20 with golimumab (GLM), and 3 with certolizumab pegol (CZP). The pooled proportions of CII on observational studies were 82% (95% CI 63–96%) in patients receiving ADA, 56% (95% CI 30–80%) in IFX, 38% (95% CI 8–73%) in ETA and 65% (95% CI 42–86%) in GLM, respectively. All three patients treated with CZP reached improved activity. ADA therapy led to a significantly higher proportion of CII compared to IFX therapy (χ2 = 26.24, P < 0.001), or to ETA therapy (χ2 = 13.43, P < 0.001); but no statistical difference was observed between IFX and ETA (χ2 = 0.13, P = 0.71). As to safety, most reported adverse events were tolerable and two cohort studies consistently showed that ADA was safer than IFX.ConclusionsThe existing evidence suggests that ADA is better than IFX regarding efficacy and safety. The effectiveness of IFX is higher than ETA with no statistical difference. GLM and CZP may be proxies for ADA but the evidence is limited.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40744-021-00296-x.

Clinical outcomes of intravenous immunoglobulin therapy in refractory uveitis.

Intravenous immunoglobulin (IVIg) therapy has multiple mechanisms of immunomodulatory action. We wished therefore to assess itsefficacy in a spectrum of patients with refractory uveitis. Retrospective review of clinical chartswas conducted to document response to IVIg treatment in consecutive patients with treatment-refractory uveitis. Main outcome measures were control of intraocular inflammation, visual acuity, progression of the disease, and complications. Four (two male) patients, with a mean age at the beginning of the treatment of 47years (range: 39-64), were included in the study. Indication fortreatment was patients with active non-infectious uveitis refractory to steroids and immunomodulatory therapy. All patients received a course of 0.5g/kg per day of IVIg for three consecutive days, repeating this course at a mean of 11week (range: 2-39weeks) intervals when indicated clinically. The median duration of the IVIg therapy was 7months (range: 3-14months). In three patients treatment resulted in stabilisation and prevention of progression of the disease, and additionally in two patients it facilitated a decrease in prednisolone dose. Treatment failed to induce long-term remission in one patient with recurrence of macular oedema. IVIg was well tolerated with neither immediate nor longer-term adverse events observed. In three out of four cases IVIg was an effective adjunctive therapy and well tolerated for the management of treatment-refractory uveitis.

Mycophenolic acid in the treatment of birdshot chorioretinopathy: long-term follow-up

AimTo assess the long-term efficacy and tolerability of both derivatives of mycophenolic acid, mycophenolate mofetil (MMF) and mycophenolate sodium (MPS), in the therapy of patients with birdshot chorioretinopathy (BSCR).MethodsRetrospective analysis...

Dexamethasone intravitreal implant (Ozurdex) for the treatment of pediatric uveitis

To report our experience using Ozurdex (Allergan, Irvine, CA), a biodegradable intravitreal implant containing of 0.7 mg of dexamethasone approved for use in adults with noninfectious uveitis in adults, in the treatment of pediatric uveitis. The medical records of consecutive patients with noninfectious posterior uveitis who were unresponsive to standard treatment and subsequently received the Ozurdex implant from March 2011 to March 2013 were retrospectively reviewed. A total of 14 eyes of 11 patients (mean age, 10.1 years; range 4-12) received 22 Ozurdex implants during the study period. Of the 11 patients, 7 had idiopathic intermediate or posterior uveitis, 1 had sympathetic ophthalmia, 2 had juvenile idiopathic arthritis, and 1 had sarcoidosis. All patients were uncontrolled with standard treatment, including topical or sub-Tenon's or systemic corticosteriods and/or immune-modulation. Visual acuity improved after Ozurdex implant in 5 of 8 patients (63%). Intraocular inflammation was controlled or improved after 17 of 22 of implants (12 eyes [77%]). The frequency of topical corticosteroids was decreased and/or discontinued after 18 of 22 implants (12 eyes [82%]). Complications included implant migration into the anterior chamber (4 aphakic eyes), increased intraocular pressure (5 eyes), and progression of a preexisting cataract (1 eye). The uveitis reoccurred in 57% of eyes at 4.3 months (2-7 months) after injection. The Ozurdex implant in combination with systemic immunomodulatory therapy resulted in improved visual acuity, control of intraocular inflammation, and a decrease in corticosteroid use. In the majority of eyes the uveitis reoccurred around 4 months after injection. The adverse events in our study are similar to those identified in adult studies.

Periocular Triamcinolone Acetonide Injections for Control of Intraocular Inflammation Associated with Uveitis

Purpose: To describe the effectiveness of periocular corticosteroid injections for the control of intraocular inflammation associated with noninfectious uveitis.Methods: A total of 81 patients (109 eyes) who received a periocular injection were evaluated for active inflammation, visual acuity, intraocular pressure, degree of intraocular inflammation, and the presence of ocular complications, including macular edema.Results: Of all eyes, 36% (95%CI: 25%, 45%) demonstrated clinical resolution of inflammation at the 1-month visit after first injection, and 48% (95%CI: 37%, 59%) at 3 months. For multiple injections, 50% (95%CI: 28%, 72%) demonstrated resolution of inflammation at 1 month after the last injection, and 41% (95%CI: 20%, 63%) resolution of inflammation at 3 months after the last injection. Of the 49 eyes that initially responded, the estimated median time to recurrence was 7.6 months.Conclusions: Approximately half of the treated eyes had resolution of intraocular inflammation at 3 months after corticosteroid injection.

Long-term results of therapy with mycophenolate mofetil in chronic non-infectious uveitis

Short-term studies have shown mycophenolate mofetil (MMF) to be a useful immunosuppressive agent for the treatment of intraocular inflammation. The aim of our study was to assess the long-term efficacy and tolerability of MMF in patients with chronic non-infectious uveitis, as well as to analyze disease course following discontinuation of therapy. This is a retrospective case series on 60 uveitis patients treated with MMF with a follow-up period of at least 5 years. The main outcome measures were: control of inflammation, corticosteroid-sparing potential, side-effects, ability to stop/taper MMF treatment because of effective control of inflammation and relapse rate after therapy discontinuation. Control of intraocular inflammation (efficacy of MMF), defined as inactive disease under prednisolone dose of ≤ 10 mg daily, was achieved in 43 of 60 patients (72%) after 1 year of MMF treatment at a rate of 0.72 per patient-year (PY), and in 45 of 55 patients (82%) after 2 years therapy (rate: 0.41/PY). An improvement (3 lines) or stabilization of visual acuity was observed in 49 patients (82%), and a worsening in 11 patients (18%, 95% CI: 10-30%). The probability of discontinuing prednisolone, estimated by the Kaplan-Meier method, was 40% after 5 years therapy. The probability of discontinuing mycophenolate mofetil due to efficacy was 33% after 5 years treatment. Recurrences of uveitis occurred in six of 21 patients (29%, rate: 0.11/PY) after MMF discontinuation due to efficacy. The treatment was stopped because of inefficacy in 12 patients (rate: 0.05/PY) and because of side-effects in four patients (rate: 0.02/PY). The rate of adverse effects during MMF therapy was 0.17/PY. Our data show that mycophenolate mofetil is generally effective and well tolerated in the treatment of chronic non-infectious uveitis.

Manifestations oculaires de la maladie de Behçet

Eye involvement in Behçet's disease (BD) is frequent and an important cause of morbidity. The mean age at onset of uveitis is between 20 and 30 years in male and 30 years in female patients. Ocular involvement includes anterior, posterior or panuveitis. Uveitis may be the presenting manifestation of the disease in 20% of cases or may appear 2 or 3 years after the disease onset. The estimated risk of blindness at 5 years ranges from 15 to 25%. The main goals in the management of patients with BD uveitis are the rapid control of intraocular inflammation, the prevention of recurrent attacks, the achievement of complete remission, and preservation of vision. The medical treatment of patients with severe uveitis relies on the use of systemically administered drugs, including corticosteroids and cytotoxic agents. Anti-TNF agents and interferon-alpha seem to be efficient and well-tolerated alternative therapeutic options. Controlled clinical trials are mandatory to define the place of these new immunomodulatory agents in the therapeutic strategy, and especially their use as first-line therapy.

Implantation of intraocular lens in children with uveitis : long term visual outcome and prognosis

Abstract Purpose To evaluate long term visual acuity, intra ocular inflammation and late complications for children with chronic uveitis who underwent cataract surgery with posterior chamber intra ocular lens (IOL) implantation. Methods Retrospective, monocentric study of children under 16 with chronic uveitis and who underwent cataract surgery between january 1996 and december 2001. Surgical protocol included : phacoaspiration with posterior capsulorhexis, anterior vitrectomy and IOL implantation. Visual acuity, intra ocular pressure, slight lamp examination, laser flare photometry and anti inflammatory treatment were analyzed at different time points. Results 17 eyes of 12 children (8 boys, 4 girls) were included. Uveitis was bilateral in 6 cases. The mean age at surgery was 10.5 years (ranged from 4 to 15) and the mean follow up time was 8.9 years (from 7 to 13). Diagnosis of uveitis was idiopathic juvenile arthritis in 8 cases (64.7%), sarcoidosis in 1 case and finally no etiology was identified in 3 cases (29.4%). Seven years after surgery, the mean visual acuity was 0.33 logMAR and 82% of children had still an immuno modulatory treatment. Late complications were : glaucoma (11.7%) , Elschnig perls (11.7%) , giant cells on IOL (35%) and CME (6%) of cases. Conclusion IOL implantation in children with chronic uveitis prevents amblyopia and allows rapid visual recovery. Complete surgical procedure in this group of children has interesting results on visual acuity and rehabilitation. Strict and long‐term control of intraocular inflammation is mandatory in order to prevent major complications and blindness. Implantation should not be proposed in young children with JIA‐associated uveitis.

Retrospective analysis of children with uveitis treated with infliximab

Tumor necrosis factor-alpha (TNF-alpha) antagonists have been successfully used in refractory cases of pediatric uveitis.(1-7) We report our experience with the monoclonal anti-TNF-alpha antibody infliximab in the treatment of uveitis in 20 children. Twenty children with noninfectious uveitis were treated with infliximab as an initial line of immunomodulatory therapy (4 children) or for uncontrolled intraocular inflammation despite aggressive immunosuppressive therapy (16 children). Intraocular inflammation was controlled in the short term in all children; resistance developed in 4 children after long-term therapy.

Biologic Response Modifier Therapy for Psoriatic Ocular Inflammatory Disease

Purpose: To evaluate the efficacy and safety of biologic response modifiers (BRMs) in the treatment of patients with psoriatic ocular inflammatory disease. Methods: The records of 8 patients diagnosed with psoriatic ocular inflammatory disease who received adalimumab or infliximab were reviewed. Main outcome measures were control of intraocular inflammation, visual acuities, and adverse effects of therapy. Results: The mean patient age was 53 ± 15 years. Three patients had psoriatic panuveitis, 3 had psoriatic scleritis, and 2 patients had psoriatic anterior uveitis. The ocular inflammatory disease was bilateral in 7 patients. Four patients received adalimumab, and 4 received infliximab. Average time of therapy was 6.1 ± 4.7 months. Six patients were treated concurrently with methotrexate. With respect to visual acuity, 2 patients demonstrated improvement, 2 patients demonstrated deterioration, and 4 patients remained stable. Seven patients achieved remission of their ocular inflammation. Conclusions: BMRs can be a useful adjunctive therapy for psoriatic ocular inflammatory disease.

Management of Pediatric Vogt-Koyanagi- Harada (VKH)-Associated Panuveitis

Purpose: To assess the clinical course, determine the efficacy and safety of oral methotrexate in the control of intraocular inflammation, and evaluate the outcomes of lensectomy-vitrectomy and goniosynechiolysis on pediatric VKH-associated panuveitis. Design: Retrospective non-comparative interventional case series. Participants: Ten patients (20 eyes) with pediatric VKH-associated panuveitis (onset of disease at age 14 years or younger). Intervention: Stepwise medical treatment consisted of oral prednisolone (0.5–1 mg/kg), supplemented by oral methotrexate (5–7.5 mg/wk) in refractory cases. Surgical intervention was performed for complications such as visually significant cataracts and secondary glaucoma and included pars plana lensectomy-vitrectomy and peripheral anterior synechiolysis in a one-stage procedure. Main outcome measures: Control of inflammation, corticosteroid requirement, visual acuity, and intraocular pressure (IOP). Results: Ten consecutive patients with a minimum follow-up duration of six months were analyzed. All patients were initially treated with oral corticosteroids; methotrexate was additionally required in six subjects. In all eyes, inflammation decreased and vision was preserved or improved. Side effects of methotrexate were mild and transient. Nine eyes of five patients underwent combined lensectomy and vitrectomy. The procedure was successful in all eyes without any exacerbation of inflammation. Eight eyes had elevated IOP, six of which underwent peripheral anterior synechiolysis at the time of lensectomy-vitrectomy. IOP was controlled after the procedure in all eyes with timolol only. Overall, final visual acuity was ≥20/40 in 30% of the eyes and < 20/200 in only 20%. Conclusions: Pediatric VKH-associated panuveitis seems to follow an aggressive course; the development rate of cataracts and secondary glaucoma seems to be high. Oral methotrexate is a safe and effective adjunct and displays steroid-sparing properties in the control of inflammation. Surgical interventions including peripheral anterior synechiolysis in addition to pars plana lensectomy and vitrectomy may be effective in controlling IOP in eyes with cataract and glaucoma. Precis: Vision may be preserved in pediatric VKH panuveitis using steroids and methotrexate for the control of inflammation, lensectomy-vitrectomy for visual improvement, and synechiolysis for IOP control.

Efficacy of Intravenous Immunoglobulin Treatment in Refractory Uveitis

Purpose: To assess the efficacy of intravenous immunoglobulin (IVIg) therapy in patients with severe uveitis otherwise unresponsive to conventional immunomodulatory agents. Methods: Data on five consecutive patients treated with IVIg and followed to the present time by one of the authors (CSF) were reviewed. All patients had severe and recalcitrant uveitis of diverse etiologies. Main outcome measures were control of intraocular inflammation, steroid-sparing effect, visual acuity, and side effects. Results: The duration of IVIg therapy was 3 to 36 months (mean, 16.8 months). Treatment was effective in controlling the intraocular inflammation in 3 of 5 patients. One of those patients required maintenance of systemic steroids at a dose of 10 mg per day. Visual acuity has stabilized or improved in these three patients. No immediate or long-term side effect was observed in any of the patients. Conclusions: Intravenous immunoglobulin therapy was an effective therapeutic modality in the treatment of three of five patients with severe uveitis that was unresponsive to conventional immunomodulatory agent(s). No adverse events were observed.

A Prospective Trial of Infliximab Therapy for Refractory Uveitis

Infliximab, a monoclonal antibody against tumor necrosis factor alpha, is approved by the US Food and Drug Administration for treatment of numerous autoimmune disorders. We conducted a prospective, open-label phase 2 clinical trial to assess the effectiveness of infliximab in treating refractory autoimmune uveitis. We prospectively enrolled 23 patients from the uveitis clinic of the Casey Eye Institute, Portland, Ore, into this trial. All patients meeting eligibility criteria received 3 infliximab infusions at weeks 0, 2, and 6. Clinical success was ascertained at week 10. Patients meeting initial criteria for success received an infusion at week 14 and every 8 weeks thereafter, with dose escalation permitted for breakthrough inflammation, and underwent outcome measurements at week 50. All patients underwent outcome assessment at week 10. Eighteen (78%) of these subjects met criteria for clinical success at this time. Success was judged by the composite clinical end point of visual acuity, control of intraocular inflammation, ability to taper concomitant medication therapy, and improvement in inflammatory signs on fluorescein angiography and/or ocular coherence tomography. Successful grading required improvement in at least 1 of 4 subcomponents and worsening in none. Seven of 14 patients enrolled for 1 year continued infliximab therapy and maintained their successful grading. Five did not complete 1 year of treatment because of significant adverse events, and 2 terminated treatment early for reasons unrelated to the study. Serious adverse events that were potentially related to infliximab included pulmonary embolus, congestive heart failure, lupus-like reaction in 2, and vitreous hemorrhage in 2 patients. Antinuclear antibodies developed in 15 of 20 enrolled patients receiving 3 or more infusions. Infliximab was an effective short-term immunosuppressive agent in most of the patients, with 18 of 23 meeting criteria for clinical success at week 10. Infliximab was effective in the long term in all patients able to complete 50 weeks of therapy. Although some patients achieved clear benefit, the rate of serious toxic effects was unexpectedly high. Further long-term studies are warranted to determine the safety and efficacy of infliximab in treating intraocular inflammation.

Long-Term Follow-Up of Patients with Birdshot Retinochoroidopathy Treated with Systemic Immunosuppression

Purpose: Birdshot retinochoroidopathy (BRC) is a rare uveitis syndrome of presumed autoimmune etiology. Therapy with systemic and periocular corticosteroids is of inconsistent efficacy, attendant with numerous potential long-term side effects. Corticosteroid-sparing strategies with agents such as cyclosporine A or azathioprine have been suggested for this disease. Methods: We retrospectively reviewed the medical charts of patients with BRC who were evaluated consecutively at a tertiary-care, referral-based North American uveitis clinic over a 15-year period. Results: Eleven Caucasian patients (22 eyes) were diagnosed with BRC, representing approximately 1% of all cases seen at the uveitis clinic. HLA-A29 was positive in all 11 patients. We elected to treat five patients with azathioprine, methotrexate, cyclosporine A, mycophenolate mofetil, and/or IvIg, as well as systemic or periocular corticosteroid injections. The median period of follow-up for the five treated patients was six years (range: 8 months–13 years). Inflammation was reduced or stabilized in five of five patients. Conclusion: Although the definitive strategy for the management of BRC is unknown, control of intraocular inflammation and preservation of vision is possible with corticosteroid-sparing immunosuppressive agents.

Comparative performance of intraocular lenses in eyes with cataract and uveitis

Purpose To evaluate the postoperative outcomes in uveitic eyes after phacoemulsification and posterior chamber intraocular lens (IOL) implantation. Setting Multicenter (19) international study. Methods This prospective randomized comparative interventional case series comprised 140 eyes of 140 patients who had phacoemulsification and implantation of IOLs of various materials: hydrophobic acrylic (n = 48), silicone (n = 44), poly(methyl methacrylate) (PMMA) (n = 26), or heparin-surface-modified PMMA (HSM PMMA) (n = 22). Preoperative and postoperative grading and control of intraocular inflammation were performed. Clinically significant observations, visual outcomes, and the incidence of postoperative complications were recorded. Results At the final follow-up, 64 eyes (46.3%) had a best corrected visual acuity of 20/40 or better, an improvement that was highly significant ( P < .0001). One day after surgery, the acrylic group had the lowest inflammation values and the silicone group the highest ( P = .02). The acrylic group continued to have the lowest inflammation grade values until the 3-month follow-up. The acrylic and HSM PMMA groups had the lowest incidence of relapses. Posterior capsule opacification developed in 48 eyes (34.2%), with the highest incidence in the silicone group. Conclusions Phacoemulsification with IOL implantation in selected uveitic eyes was safe and effective. Acrylic IOLs provided a better visual outcome and lower complication rate than IOLs of other materials.

Control of intraocular inflammation after cataract surgery: New perspectives

Anti-inflammatory treatment is routinely prescribed to all patients after cataract surgery to prevent intraocular inflammation. A review of the literature was conducted to determine the optimal control of postcataract surgery inflammation. Intraocular steroid delivery systems, safer steroids, and nonsteroidal anti-inflammatory drugs have been found to be beneficial. Selective cyclooxygenase-2 inhibitors may circumvent many side effects of the earlier agents.

LONG-TERM FOLLOW-UP OF TRABECULECTOMY WITHOUT ANTIMETABOLITES IN PATIENTS WITH UVEITIS

Abstract PURPOSE: To determine the long-term success rate after trabeculectomy without antimetabolites in patients with uveitis. METHODS: Review of data from all patients with uveitis who underwent trabeculectomy for uncontrolled intraocular pressure secondary to intraocular inflammation between May 1990 and December 1994. Results were compared with those from a group of patients with primary open-angle glaucoma matched for sex and surgeon. RESULTS: The uveitis group consisted of 32 eyes (20 patients). Maximum control of intraocular inflammation was achieved for a minimum of 2 months before surgery. Mean (± SD) age was 40.0 ± 12.5 years (range, 14 to 67 years), with a median (± SE) follow-up of 53.0 ± 1.8 months (range, 33 to 84 months). The primary open-angle glaucoma group consisted of 33 eyes (23 patients), with a mean age of 62.0 ± 13.7 years (range, 26 to 81 years) and a median follow-up of 63.0 ± 12.0 months (range, 34 to 299 months). The overall 5-year success rate (intraocular pressure ≤ 21 mm Hg with or without topical medication) for the uveitis group was 78% compared with 82% for the primary open-angle glaucoma group ( P = .7). The absolute 5-year success rate (intraocular pressure ≤ 21 mm Hg with no medication) for the uveitis group was 53% compared with 67% for the primary open-angle glaucoma group ( P = .87). CONCLUSIONS: In the absence of other risk factors, such as Afro-Caribbean race and previous intraocular surgery, and with adequate preoperative control of inflammation, trabeculectomy without antimetabolites may be considered the primary surgical procedure for increased intraocular pressure in patients with uveitis.

Low-dose Cyclosporine Therapy in the Treatment of Birdshot Retinochoroidopathy

Birdshot retinochoroidopathy is an uncommon uveitic syndrome of presumed autoimmune etiology. Therapy with systemic and periocular steroids is of inconsistent efficacy, attendant with numerous potential long-term side effects. Steroid-sparing strategies with more specific agents such as cyclosporine (Cyclosporin A, CSA) have been suggested as the first line treatment for this disease. The records of 19 patients (35 eyes) with the clinical diagnosis of birdshot retinochoroidopathy were examined. Age at onset ranged from 33 to 69 years (mean, 46.1 years) in nine men and ten women. The median follow-up from disease onset was 36 months. Eight patients were treated with low-dose (2.5-5 mg/kg daily) CSA alone, six required the addition of azathioprine (1.5-2 mg/kg daily), and six received no systemic immunosuppressive therapy. HLA-A29 was positive in 94% (16 of 17) of patients tested. Vitreous inflammation was controlled in 23 (88.5%) treated eyes, with fewer bouts of recurrent inflammation, and a corresponding improvement or stabilization of visual acuity in 20 (83.3%) eyes. In contrast, intraocular inflammation never was controlled fully in untreated eyes, and visual acuity decreased in six (54.5%) eyes by an average of 2.5 Snellen lines. Nephrotoxic side effects of low-dose CSA therapy were not observed, but hypertension developed in two patients. Although the definitive strategy for the management of birdshot retinochoroidopathy is unknown, control of intraocular inflammation with a favorable visual outcome, together with a lack of demonstrable CSA-associated nephrotoxicity and secondary side effects in these patients with birdshot retinochoroidopathy indicate that vision preservation is possible with low-dose CSA alone or in combination with other steroid-sparing immunosuppressive agents as an alternative to the long-term use of corticosteroids.

THC:YAG Laser Sclerostomy: The Resident Experience

Retrospective review of 14 consecutive THC:YAG laser sclerostomies done without the use of anti-metabolites revealed a uniform closure of the filtering bleb within 6 months of follow up. Also, the sclerostomy site was closed by iris or fibrous tissue. Based on these findings, I recommend that the present THC:YAG laser sclerostomy protocol be altered to allow for antimetabolite usage, prevention and treatment of iris prolapse, and control of intraocular inflammation.