Nongranulomatous Anterior Uveitis Research Articles

Intérêt de la recherche du cytomégalovirus par polymerase chain reaction dans le syndrome de Posner-Schlossman

To investigate the possible association between cytomegalovirus (CMV) infection and Posner-Schlossman syndrome using PCR. To evaluate the clinical effect of valganciclovir treatment. Patients with anterior uveitis associated with suspected Posner-Schlossman syndrome had their aqueous humor prospectively analyzed for viral deoxyribonucleic acid by HXFL4 gene detection using quantitative real-time PCR. Seven patients (two females and five males from 15 to 56 years old) with clinical signs of Posner-Schlossman syndrome (anterior nongranulomatous hypertensive uveitis with anterior chamber cells, central keratic precipitates, anisocoria, without iris atrophy) were tested. Examinations of the aqueous humor by polymerase chain reaction demonstrated CMV-DNA in five patients and were negative for other herpes viruses in all patients. Two patients were treated with oral antiviral therapy (valganciclovir). Relapses occurred in all cases after cessation of therapy. Aqueous humor analysis by PCR is useful in differentiating between CMV and other herpes viruses and in making a positive etiological diagnosis in anterior hypertensive uveitis. Valganciclovir may be effective in treating CMV anterior uveitis, but its exact role should be determined in larger studies with a longer follow-up. Cytomegalovirus detection in aqueous humor using polymerase chain reaction is useful in the management of patients with Posner-Schlossman syndrome.

Anterior Uveitis Associated with High-dose Cytosine Arabinoside

Purpose: To report a case of anterior uveitis associated with high-dose cytosine arabinoside (Ara-C) treatment.Design: Observational case report.Methods: A 14-year-old girl was seen for pain, redness, and photophobia shortly after finishing a cycle of high-dose Ara-C.Results: Portable slit-lamp examination revealed bilateral diffuse fine keratic precipitates, indicative of a nongranulomatous anterior uveitis. This was treated successfully with a course of topical prednisolone acetate 1%.Conclusions: Ophthalmologists who are asked to evaluate patients on high-dose Ara-C for a “red eye” should consider anterior uveitis as a potential diagnosis.

Symptoms and signs of anterior uveitis

Abstract Purpose Based on the anatomic classification of uveitis, iritis and iridocyclitis are classified as anterior uveitis. Methods Symptoms and signs of anterior uveitis will be presented Results Patients with acute anterior uveitis typically present with red eyes, photophobia, ocular pain, and sometimes visual blurring. In chronic anterior uveitis, onset is usually insidious and patients may be asymptomatic until the development of complications. Ciliary injection, endothelial dusting or fine keratic precipitates (KPs), cells and flare in the anterior chamber with or without hypopyon formation or fibrinous exudate are the typical findings of alternating unilateral acute nongranulomatous anterior uveitis which is most commonly seen in association with HLA‐B27 antigen and spondyloarthropaties. Medium‐size KPs or large mutton‐fat KPs, chronic flare, Koeppe and Busacca nodules of the iris, peripheral anterior synechiae and broad‐based posterior synechiae are the typical findings of granulomatous anterior uveitis which is often chronic. Viral anterior uveitis is characterized by unilateral recurrent episodes of anterior uveitis characterized by endotheliitis, elevated intraocular pressure, and patchy or sectoral iris atrophy. JIA‐associated anterior uveitis is typically a bilateral nongranulomatous chronic anterior uveitis often complicated by band keratopathy, seclusion of the pupil, and cataract. Conclusion Symptoms and signs in anterior uveitis vary depending on the acute or chronic, ganulomatous or nongranulomatous nature of the disease. Specific anterior uveitic entities are characterized by a distinct constellation of ocular signs.

Refractory Noninfectious Anterior Uveitis Associated with Systemic Mastocytosis

A 10-year-old boy with biopsy-proven systemic mastocytosis presented with bilateral nongranulomatous anterior uveitis associated with high intraocular pressure. Anterior chamber paracentesis was performed for cytological evaluation, which demonstrated monocytes and macrophages but no evidence of mast cells. His uveitis was partially controlled with frequent topical steroid drops and weekly oral methotrexate therapy. The glaucoma was controlled with topical antiglaucoma medications in the right eye. Deep sclerectomy was required in the left eye to control the intraocular pressure. To the best of the authors' knowledge, this is the first report of such an association.

Tubulointerstitial nephritis and uveitis (TINU) syndrome: a case report and review of the literature

We aim to describe the first case of tubulointerstitial nephritis and uveitis (TINU) syndrome reported in Scandinavia and to underline the importance of the syndrome, which should be better known among ophthalmologists. We report an 11-year-old boy who was admitted to hospital because of general fatigue and weight loss. Blood tests showed renal insufficiency and a renal biopsy revealed acute tubulointerstitial nephritis. One week after admission the patient developed transitory blurred vision and flickering shadows in the left eye. Slit-lamp examination revealed bilateral anterior non-granulomatous uveitis and TINU syndrome was diagnosed. Because of renal insufficiency the patient was treated with systemic prednisone 50 mg/day for 3 weeks. Evolution was favourable, and prednisone was tapered over 10 weeks. Uveitis was treated with topical steroid with good effect. The only complication after 18 months of follow-up was transitory cushingoid aspect. Tubulointerstitial nephritis and uveitis syndrome is a rare syndrome that is probably underdiagnosed in clinical practice. Co-operation between ophthalmologists and nephrologists/paediatricians is crucial for early diagnosis and instigation of treatment. Uveitis may occur before tubulointerstitial nephritis or the renal symptoms may be so mild that the patient is unaware of them. Therefore, ophthalmologists play an important role in the initial discovery of patients with TINU syndrome. Tubulointerstitial nephritis tends to be self-limiting, whereas uveitis tends to relapse and recurrences tend to be more severe than the initial uveitis. Therefore, the patient must be ophthalmologically monitored very carefully.

Causes of Uveitis at a Referral Center in Saudi Arabia

Purpose: The main purpose of this study was to determine the causes of uveitis at the Eye Center in Saudi Arabia. Methods: A retrospective review. The causes of uveitis were analyzed according to various patient characteristics. Results: A total of 488 cases were encountered. The age range was 3 to 99 years (mean age: 38 years). The most common causes of uveitis included anterior uveitis 60%, panuveitis 24%, posterior uveitis 11%, and intermediate uveitis 6%. Conclusions: The authors found a high prevalence of acute anterior nongranulomatous uveitis. The most commonly encountered infectious uveitis included herpes virus, tuberculosis, and toxoplasmosis.

Uveitis survey in children

Background/aims:This is a retrospective cohort uveitis survey to determine the clinical features of uveitis in children and assess the rate of complications at two referral centres in Saudi Arabia.Methods:All children...

Evaluating the cost-effectiveness of anterior uveitis investigation by Canadian ophthalmologists

Background: To evaluate the cost-effectiveness of anterior uveitis investigation by Canadian ophthalmologists and to assess the role of implementing national clinical guidelines for such investigation. Methods: Based on data extracted from the Canadian National Uveitis Survey (CNUS, 2007 version), the cost of investigating a patient with anterior uveitis, according to current practice patterns of Canadian ophthalmologists, was determined and grouped across 4 clinical scenarios: ( i) nongranulomatous anterior uveitis in an adult, ( ii) granulomatous anterior uveitis in an adult, ( iii) granulomatous anterior uveitis with suspected sarcoidosis in an adult or a child, and ( iv) nongranulomatous anterior uveitis in a child. Similarly, the cost of investigating a patient with anterior uveitis as per published evidence-based guidelines was determined and compared with the current practice pattern using a cost-minimization model, sensitivity analyses, and Monte Carlo simulations. Results: Ophthalmologists were found to consistently order more tests than recommended by evidence-based guidelines, across each of the scenarios studied ( p < 0.05). Overall, complete blood count, erythrocyte sedimentation rate, C-reactive protein, antinuclear antibody, and rheumatoid factor were the most commonly ordered extraneous tests that were not included in the evidence-based guidelines for the routine investigation of anterior uveitis. Also, there were significant differences in the cost of investigating a patient with anterior uveitis when compared with those predicted by adhering to evidence-based clinical practice guidelines. Cost minimization and sensitivity analyses revealed that published guidelines imparted cost savings when compared with current practice patterns across the 4 clinical scenarios studied ( p < 0.01).The maximum additional cost was associated with investigating nongranulomatous anterior uveitis in an adult, where a minimal additional cost of $75 per patient was spent. For granulomatous anterior uveitis in an adult, the additional cost was approximately $40, whereas the additional cost for investigating an adult or a child with suspected sarcoidosis was $36. Only $11 of additional cost was spent in the workup of a child with nongranulomatous anterior uveitis.When applied to the Canadian population, adherence to the Clinical Practice Guidelines recommended by the CNUS may result in cost savings of $600,000 per year to the Canadian health care system. Interpretation: Adherence to the evidence-based Clinical Practice Guidelines recommended by the CNUS may result in significant cost savings, with virtually no loss of sensitivity in the routine investigation of anterior uveitis in Canada.

Uveitis in children with human immunodeficiency virus–associated arthritis

To describe the ocular inflammatory manifestations and clinical characteristics of children with Human Immunodeficiency Virus (HIV)-associated arthritis. A retrospective review of the charts of children with chronic uveitis and HIV-associated arthritis seen between June 2004 and September 2006 at Inkosi Albert Luthuli Central Hospital, Durban, South Africa. The following data were analyzed: age at presentation, gender, race/ethnicity, rheumatologic problems, uveitic diagnosis, laboratory findings, and ocular complications. Seven black African males with a mean age of 9 years (range, 4 to 13 years) were identified. There were no other significant laboratory findings apart from HIV; all patients were antinuclear antibody negative. Arthritis was polyarticular in 6 patients and pauciarticular in 1. Four patients had intermediate uveitis and 3 patients had nongranulomatous anterior uveitis. Visual acuity ranged from 20/20 to hand movements. Ocular complications included cataract, cystoid macular edema, hypotony, pupillary membranes, band keratopathy, posterior synechiae and optic disk edema. HIV-associated arthritis and uveitis in children is a clinical syndrome that may be associated with severe sight-threatening intraocular inflammation. Routine eye screening in HIV-positive children, particularly those with arthritis, is warranted to facilitate prompt treatment.

Akute anteriore nichtgranulomatöse Uveitis nach intravitrealer Bevacizumab-Injektion

Recently, bevacizumab (Avastin(R)) has been used widely as a potential off-label treatment of CNV. The ocular side effects appear to be quite rare, but one concern is the risk of an inflammatory response. We report on an acute nong-ranulomatous anterior uveitis after intravitreal injection of bevacizumab. A 74-year-old female with subfoveal CNV due to ARMD presented after the second injection of bevacizumab with a symptomatic acute non-granulomatous anterior uveitis. Work-up ruled out any other aetiology. Treatment with topical prednisolone and scopolamine resolved inflammation and symptoms. Intravitreal injection of bevacizumab is related with the possible development of acute non-granulomatous anterior uveitis, after having excluded infectious or other causes of uveitis unrelated to the bevacizumab injection. In recent clinical trials bevacizumab-induced uveitis has been demonstrated to be a rare event. The pathogenesis remains unclear. One possible explanation is the Fc portion of the antibody, which may offer the possibility of an increased cellular immune response. This case underlines the importance to inform patients about the possibility of such an episode.

Syphilitic uveitis: an Asian perspective

Aim:To examine the clinical manifestations of syphilitic uveitis in a population and review trends in incidence at a tertiary referral centre.Methods:A retrospective, non-comparative interventional case series of 22 consecutive patients...

Ocular Involvement Associated With an Epidemic Outbreak of Chikungunya Virus Infection

To study the range of ocular symptoms in a cohort of patients with chikungunya infection. Retrospective, observational case series. Patients attending a tertiary eye care hospital in South India were included in the study. We included adult patients with serologically confirmed chikungunya virus infection who received clinical care at the Aravind Eye Hospital, Madurai, South India. They were assessed for demographic characteristics, ocular symptoms, laboratory parameters, and chikungunya virus infection severity. Patients underwent a complete ophthalmologic examination that included visual acuity, slit-lamp examination, and indirect funduscopic examination. Visual outcome at the end of three months was the main outcome measure. The charts of 37 patients were analyzed based on the clinical picture and the serologic results. Forty patients were included as controls and tested negative. There were 21 males and 16 females with a mean age of 44.17 years. The main ocular symptoms included granulomatous and nongranulomatous anterior uveitis, optic neuritis retrobulbar neuritis, and dendritic lesions. Of the 26 patients who were followed up for three months, the visual acuity improved in 11 patients (42.3%), remained the same in 12 patients (46.15%), and worsened in three patients (11.5%). The main ocular manifestation associated with the recent epidemic outbreak of chikungunya virus infection in South India included granulomatous and nongranulomatous anterior uveitis, optic neuritis, retrobulbar neuritis, and dendritic lesions. The visual prognosis generally was good, with most patients recovering good vision. Further studies are needed to understand the pathogenesis of this disease.

Ocular complications of Rift Valley fever outbreak in Saudi Arabia

To report ocular complications of Rift Valley fever (RVF) during its first reported outbreak in southwest Saudi Arabia in autumn 2000. Cross-sectional study of patients in a referral hospital. One hundred forty-three consecutive patients with confirmed RVF serologic test results and ocular lesions were enrolled in the study. Hospitalized patients (n = 30) and outpatients (n = 113) with clinical symptoms consistent with RVF, positive RVF serologic test results, and ocular abnormalities were studied. Ophthalmologic examinations, including fundus photography and fluorescein angiography, were performed. Patients were followed up at regular intervals to determine the prognosis and outcome of identified ocular abnormalities. Visual acuity at initial presentation and course of anterior and posterior segment complications. Among 143 patients (78% males; mean age, 53.2 years), 212 eyes were affected, comprising 47 eyes in 30 inpatients and 165 eyes in 113 outpatients. The mean interval between the onset of RVF and visual symptoms ranged from 4 to 15 days (mean, 8.8 days). Macular or paramacular retinitis was identified in all the affected eyes (n = 212) at the time of initial assessment. Lesions included retinal hemorrhages (40%), vitreous reactions (26%), optic disc edema (15%), and retinal vasculitis (7%). Anterior uveitis was present in 31% of outpatients. Fluorescein angiography of the retinitis showed early hypofluorescence with late staining of retinal lesions and blood vessels. Initial visual acuity was less than 20/200 in 80% of eyes in the outpatient group; their vision improved, deteriorated, or remained the same in 13%, 15%, or 72%, respectively. Evaluation at the last follow-up showed macular (60%) or paramacular (9%) scarring, vascular occlusion (23%), and optic atrophy (20%) in the outpatient group. Rift Valley fever was associated with major ocular morbidity. Ocular manifestations of RVF occurred with a relatively higher frequency than reported up to now and were not limited to severe infections. Rift Valley fever affects the uvea and posterior chorioretinal area and is associated with permanent visual loss resulting from macular and paramacular scarring, vascular occlusion, and optic atrophy. The study demonstrated for the first time that transient nongranulomatous anterior uveitis is associated with RVF.

Propionibacterium acnes endophthalmitis with bacterial sequestration in a Molteno's implant after cataract extraction

To report a case of Propionibacterium acnes endophthalmitis following uncomplicated cataract extraction with bacterial sequestration in a preexisting Molteno's drainage implant. Interventional case report. A 7-year-old girl with congenital glaucoma and a preexisting Molteno's drainage implant developed anterior nongranulomatous uveitis 4 months following cataract surgery. P. acnes endophthalmitis was diagnosed by polymerase chain reaction, Southern blot, and electron microscopy. Extraction of the Molteno's implant was required to control the persistent intraocular inflammation and to convert the results of polymerase chain reaction and Southern blot testing of aqueous sample for P. acnes from positive to negative. P. acnes may be sequestered in glaucoma implants, potentially requiring implant removal to treat cases of P. acnes endophthalmitis.

Presumed ocular sarcoidosis

Sarcoidosis is a multisystemic granulomatous disease of unknown etiology. Ocular manifestations commonly occur in patients with sarcoidosis, with a granulomatous anterior uveitis as the most-prevalent ocular sign. Acute symptoms of uveitis, such as pain, photophobia, lacrimation, or redness, may be absent. Without early detection and timely treatment, this "silent uveitis" may cause permanent ocular damage. Two patients came in for routine eye examinations, with no symptoms of anterior uveitis. The first, a 36-year-old man, had a bilateral granulomatous anterior uveitis. The uveitis was treated with topical corticosteroids, with no complications. The second case involved a 44-year-old woman with chronic, recurrent, bilateral, non-granulomatous anterior uveitis. Despite treatment with topical and oral corticosteroids. the patient had a prolonged course with recurrent episodes leading to secondary sequelae, including glaucoma and cataract. Both patients were co-managed with internal medicine, and in each case, systemic workups were consistent with sarcoidosis. Anterior uveitis often manifests as the initial presentation of sarcoidosis. Without acute symptoms, the detection and diagnosis may be delayed, leading to visual deterioration. The diagnosis of sarcoidosis may be difficult, owing to the lack of definitive diagnostic criteria and a variety of presentations. Histologic confirmation may not always be possible or practical. However, a range of serological and radiological tests, when combined with physical and ophthalmic evaluation, can lead to the presumed diagnosis of sarcoidosis. Aggressive treatment is imperative in order to prevent permanent structural damage to the eye resulting from this idiopathic inflammation.

Bilateral nongranulomatous anterior uveitis associated with bimatoprost

A 72-year-old man with long-standing bilateral glaucoma became refractory to levobunolol ophthalmic solution therapy after many years. Brimonidine was prescribed, but the patient developed a hypersensitivity several months later that was treated with loteprednol ophthalmic suspension. Bimatoprost was initiated 2 weeks later. Within an hour of the first dose of bimatoprost, the patient reported eye pain and photophobia that remained unresolved the following day. Examination revealed acute bilateral nongranulomatous anterior uveitis that was effectively treated with loteprednol. While observations in human and animal models suggest an association between certain prostaglandin-like agents and intraocular inflammation, this report is one of the first to suggest a link between bimatoprost and intraocular inflammatory reaction.

The monthly variation in acute anterior uveitis in a community-based ophthalmology practice

Background: A significant increase in the number of episodes of acute anterior uveitis was found in December for two consecutive years at a community-based ophthalmology practice. Purpose: To evaluate the monthly variation in episodes of acute anterior uveitis (AAU). Methods: The charts of all patients with AAU in a practice within a community-based multispecialty ophthalmology group in Albuquerque, New Mexico, were reviewed. Seventy-seven patients with acute, self limited, nontraumatic, unilateral, nongranulomatous anterior uveitis over a two-year period were identified. Results: Ninetyfour episodes of AAU occurred in 77 patients (42 men, 35 women).The median number of episodes of AAU was three episodes per month (range: 0–14 episodes/month). An increased number of episodes was found in December of both years (11 in December 1996 [p < 0.01] and 14 in December 1997 [p < 0.003]). Smaller clusters of AAU were seen in other months, but did not reach statistical significance. Conclusions: The presence of a seasonal variation in the number of episodes of AAU suggests that environmental factors are important. A search for such factors that increase the risk of AAU during selected periods may be useful for a better understanding of disease pathogenesis.

Equine recurrent uveitis - an update

UVEITIS may arise from a number of causes, including blunt or perforating injury to the globe and, rarely, haematogenous spread of bacterial pathogens such as Streptococcus equi var equi or...

Metipranolol-associated Nongranulomatous Anterior Uveitis

To describe the findings in a patient with a nongranulomatous anterior uveitis, presumed to be induced by metipranolol. A 69-year-old woman developed bilateral, nongranulomatous, anterior uveitis while undergoing treatment with metipranolol 0.3% for primary open-angle glaucoma. Four months after resolution of the initial episode, the patient was challenged with metipranolol 0.3% in the right eye. On reinstituting metipranolol 0.3%, the patient once again developed a unilateral, nongranulomatous, anterior uveitis in the challenged eye. Metipranolol 0.3% eyedrops, used to treat primary open-angle glaucoma, appear to cause a nongranulomatous anterior uveitis.

Anterior Nongranulomatous Uveitis after Intravitreal HPMPC (Cidofovir) for the Treatment of Cytomegalovirus Retinitis: Analysis and Prevention

The authors characterize and analyze the incidence of a previously reported mild anterior nongranulomatous uveitis associated with intravitreal injections of (S)-1-(3-hydroxy-2-phosphonylmethoxypropyl)cytosine (HPMPC), also termed cidofovir (Vistide, Gilead Sciences, Foster City, CA). This is an acyclic nucleoside phosphonate analogue with a potent anticytomegalovirus effect. The authors also analyzed the effects of probenecid therapy, as well as prophylaxis with probenecid plus topical corticosteroids and cycloplegics on the course and outcome of the uveitis. Prospective case series from a tertiary referral center, which included 46 consecutive patients with acquired immune deficiency syndrome (AIDS) and cytomegalovirus (CMV) retinitis. There was a total of 130 injections in 69 eyes treated with 20 micrograms of intravitreal HPMPC. Forty-one patients (119 injections) received oral probenecid, 5 patients (11 injections) did not, and 21 patients (53 injections) received topical corticosteroids and cycloplegics as an adjuvant to probenecid in the prophylaxis of iritis. Mild to moderate nongranulomatous iritis was seen in 26% of patients after their first injection (n = 12). Patients receiving probenecid prophylaxis after first injection had a significantly lower frequency of iritis versus patients who did not receive probenecid at the time of first injection (P = 0.0089). In contrast, treatment with topical corticosteroid and cycloplegics after injection did not statistically significantly affect the frequency of iritis in patients (P = 0.44). The development of iritis after a second injection of HPMPC was more likely if it had occurred after the initial injection (P = 0.015; Fisher's exact test). All cases of iritis were treated with topical corticosteroids and cycloplegics, and there was no permanent impairment of vision secondary to iritis after HPMPC injection in any eyes. Anterior uveitis was seen in 26% of patients after first-time HPMPC injection. Concomitant use of probenecid appears to decrease the frequency of the iritis from 71% to 18% in patients with AIDS and CMV retinitis after the first intravitreal injection of HPMPC. Topical corticosteroid administration after injection (before iritis) was ineffective in preventing iritis treatment with topical corticosteroids and cycloplegics resulted in resolution of all iritis cases.