Severe Panuveitis Research Articles

Pars Plana Vitrectomy in the Treatment of Severe Complicated Toxoplasmic Retinochoroiditis

To present the anatomic and functional results of pars plana vitrectomy performed in severe complicated toxoplasmic retinochoroiditis. Three patients, 2 women and 1 man aged 57, 22, and 57 years, are presented. The first patient was under immunosuppressive therapy for dermatomyositis and underwent diagnostic/therapeutic vitrectomy for severe toxoplasmic panuveitis with dense vitritis. The other 2 patients underwent vitrectomy for macula-off rhegmatogenous retinal detachment that developed after severe toxoplasmic panuveitis. Preoperative visual acuity was hand movement for the first 2 patients and 20/400 for the third. All patients received pars plana vitrectomy with epiretinal membrane peeling, laser photocoagulation, and SF6 gas tamponade. The second and third patients needed 5 and 3 additional operations, respectively, including extensive retinotomies and silicone-oil tamponade, for recurrent retinal detachment due to proliferative vitreoretinopathy. At the end of the follow-up period (11, 5, and 1 year, respectively), the retina was attached and visual acuity was 20/30 for the first patient but counting fingers for the other 2 patients. Severe panuveitis and/or recurrent retinal detachment may develop in some cases of ocular toxoplasmosis, compromising the visual prognosis. Retinal detachment due to toxoplasmosis is generally complex, and long-acting tamponade with silicone oil should be contemplated for anatomic retinal reattachment.

Very Severe HLA B27-associated Panuveitis Mimicking Endophthalmitis: A Case Series

Purpose: To report rare but important instances of very severe, hyperacute HLA B27-associated panuveitis, mimicking infective endophthalmitis and providing challenges to both diagnosis and management.Design: Retrospective case review.Methods: Four patient records were reviewed. Demographic features, clinical findings, course of uveitis, diagnostic/therapeutic measures, and outcomes are reported.Results: All cases presented with severe panuveitis with visual acuities below 6/60 and poor fundal views. Three patients underwent intraocular fluid sampling for microbiology. All required systemic high-dose corticosteroid treatment, and two also needed oral immunosuppression. All eventually required cataract extraction. Final visual acuity varied from 6/12 to 6/6.Conclusions: HLA B27-associated uveitis may be unusually severe and may cause a panuveitis, mimicking infective endophthalmitis. The course may be prolonged and difficult with frequent complications including cataract.

Proliferative Vitreoretinopathy in a Child with Visceral Leishmaniasis

We present a rare case of ocular leishmaniasis complicated by proliferative vitreoretinopathy in a child with active visceral leishmaniasis. A 10-year-old boy with active visceral leishmaniasis presented with a 5- day history of redness, photophobia, and blurred vision in his left eye. Visual acuity was measured and the child had a complete ocular examination. Snellen best-corrected visual acuity (BCVA) was 10/10 in the right eye and 7/10 in the left eye at presentation. Ophthalmic examination of the right eye was normal but the left eye showed clinical signs of panuveitis. Laboratory investigations were negative. Treatment with systemic and local steroids was initiated and clinical improvement achieved. Eight months later, the patient had a relapse of systemic and ocular disease with severe panuveitis in both eyes. A combined tractional-rhegmatogenous retinal detachment was present in the left eye. Pars plana vitrectomy was undertaken in the left eye and the patient was started on systemic and local steroid treatment. Retinal reattachment was achieved postoperatively but visual acuity in the left eye remained poor. Early diagnosis, prompt systemic and ocular treatment, as well as close ophthalmic examination are essential in such cases.

CMV retinitis after intravitreal triamcinolone acetonide injection in a patient with Behçet’s uveitis

We report the case of a patient with Behçet's uveitis who developed cytomegalovirus (CMV) retinitis after intravitreal triamcinolone acetonide (IVTA) injection. We reviewed the patient's chart for the purpose of this report. An IVTA injection was performed for treatment of severe panuveitis in the left eye of a 30-year-old male patient with Behçet's disease. Systemic treatment included high dose corticosteroid and azathioprine. Fourteen weeks after IVTA, extensive areas of necrotizing retinitis developed in the left eye. Polymerase chain reaction of serum and vitreous samples was positive for CMV DNA. Serum anti-CMV IgG was positive, IgM was negative, anti-HIV antibody was negative, complete blood count was normal, and CD4 count was 1,060 cells/μl. The patient responded well to intravitreal ganciclovir injection performed twice and intravenous ganciclovir treatment administered for five weeks. Local immunosuppression with IVTA may cause CMV retinitis. Awareness of this serious complication is important for correct diagnosis and treatment.

Choroidal melanoma masquerading as panuveitis in a patient with multiple myeloma.

Choroidal melanoma can sometimes present with associated anterior uveitis or panuveitis that can mask the underlying intraocular neoplasm and confound the diagnosis. Retrospective chart review. A 58-year-old woman presented with recurrent episodes of hypopyon, severe panuveitis, and a choroidal mass lesion in the right eye. Extensive systemic workup led to a diagnosis of multiple myeloma. Despite successful treatment of myeloma, the choroidal mass persisted and increased in size. Transscleral biopsy of the mass lesion revealed primary malignant choroidal melanoma. This case demonstrates that choroidal melanoma can present as masquerade syndrome with significant intraocular inflammation. Such cases pose a significant diagnostic dilemma to the clinician. Transscleral choroidal biopsy can provide critical information that is essential to establishing a definitive diagnosis and treatment plan.

Circulating immune complexes may play a regulatory and pathogenic role in experimental autoimmune uveoretinitis.

We compared the time course of changes in serum levels of circulating immune complexes (CICs) and of IgG antibody after sensitization of albino Lewis and pigmented Lister strain rats with uveitogenic (retinal S-antigen) and non-uveitogenic (ovalbumin) protein antigens of comparable molecular weight. Normal levels of CICs were far lower in Lewis rats in which experimental autoimmune uveoretinitis (EAU) takes the form of a severe panuveitis, than in Lister rats, in which the disease is mild, focal, confined to the posterior segment, and of lower incidence. After sensitization with either S-antigen or ovalbumin, polyethylene-glycol-precipitable CIC (PEG-CIC) peaked and fell as IgG antibody levels rose in both rat strains. However, peak levels of PEG-CIC were lower and subsequent IgG antibody levels were higher in the Lewis strain than in the less susceptible Lister strain. In both strains of rat these linked PEG-CIC/IgG antibody responses occurred earlier after sensitization with uveitogenic (S-) antigen than with ovalbumin, whether or not individual S-antigen-sensitized Lister rats developed EAU. In contrast, complement-binding CIC rose substantially only in those rats of both strains displaying EAU in response to S-antigen and not in response to ovalbumin. We suggest that immune complex (idiotypic) regulation of IgG antibody responses may be more readily perturbed by a pathogenic autoantigen (S-antigen) than by a bland antigen (ovalbumin). We also suggest that differences between the balance of regulatory and pathogenic CIC responses to uveitogenic retinal antigen may underlie or reflect strain differences in susceptibility to and severity of EAU.

A Case of Retisert™ Implant for Chronic Behcet's Panuveitis

Purpose: RetisertTM (fluocinolone acetonide implant) has recently been approved for clinical use in patients with noninfectious posterior uveitis. We report a patient with intractable chronic Behcet\'s panuveitis who underwent RetisertTM implantation and showed a favorable outcome. Case Summary: A 30-year-old male affected with intractable Behcet\'s uveitis of both eyes for over one year which did not respond to oral steroids and immunosuppressants; subcutaneous interferon injection caused undesirable side effects such as impotency and pyrexia. Initial visual acuities were 20/1000 in the right eye and 20/100 in the left eye, and both eyes showed severe panuveitis with posterior subcapsular cataract, especially in the right eye. The subtenon triamcinolone injection was performed in the right eye, which was only effective to anterior uveitis, and RetisertTM was implanted in the right eye after the cataract operation. Two months later the visual acuity increased to 20/25, and the inflammation was totally controlled. There were no ocular or systemic adverse events. Conclusions: RetisertTM is a fast, effective, and safe treatment for chronic, non‐infectious posterior uveitis. J Korean Ophthalmol Soc 49(6):1007-1012, 2008

Results of Intravitreal Triamcinolone Acetonide (IVTA) Injection for the Treatment of Panuveitis Attacks in Patients with Behçet Disease

The aim of this study was to report our experience on an intravitreal triamcinolone acetonide (IVTA) injection for the treatment of unilateral severe panuveitis attacks in patients with Behçet disease (BD). We reviewed the medical records of 18 eyes of 15 consecutive patients with BD who received an IVTA injection. The indication for an IVTA injection was severe panuveitis attacks in 15 patients who were unresponsive or intolerant to systemic medications. Intraocular inflammation resolved after a mean period of 25 days following the IVTA injection. During a mean followup period of 28 months (range, 9-50), all eyes showed improvement in visual acuity (mean, 0.71 logMAR units). Twelve (12) eyes (66.6%) had an elevation of intraocular pressure (IOP). Cataract progression or new cataract formation was detected in 10 eyes (55.5%). Four (4) eyes (22%) had relapses 10-28 months (mean, 19) after the IVTA injection. The IVTA injection may be used as an adjunct therapy for the treatment of panuveitis attacks in patients with BD who are unresponsive or intolerant to systemic medications. Although it hastens the resolution of attacks and seems to have a long-term, anti-inflammatory effect, relapses can occur in the long term. It is also associated with a high rate of IOP elevation and cataract progression in this group of patients.

Panuveitis as presenting sign of chickenpox in a young child

Case report: A previously healthy 2-year-old girl presented with severe panuveitis in her left eye. She developed chickenpox rash several days later. DNA particles of varicella-zoster virus (VZV) were detected by polymerase chain reaction (PCR) in the aqueous humor. No antiviral regimen was administered. The uveitis resolved completely after 1 week. Comments: Patients with chickenpox should undergo a thorough ophthalmologic examination at the onset of visual symptoms. Clinicians should be aware of the rare occurrence of chickenpox when evaluating a uveitis patient. If there is suspicion of chickenpox, the clinician may consider ordering serology or PCR tests.

RETINAL DETACHMENT IN ATOPIC DERMATITIS CAN MASQUERADE AS ACUTE PANUVEITIS WITH RAPIDLY PROGRESSIVE CATARACT

To report two cases of retinal detachment in young patients with atopic dermatitis masquerading as acute panuveitis. Retrospective observational clinical case reports. Patients with atopic dermatitis presenting with acute panuveitis and subsequently diagnosed with retinal detachment at the Singapore National Eye Centre. A review of the clinical case records. Two young patients aged 19 and 21 years with a history of atopic dermatitis presented with acute unilateral moderately severe panuveitis. Both developed rapidly progressing cataracts that made detailed visualization of the fundus difficult. Hypotony persisted in one eye despite partial response of uveitis to therapy. The other patient developed ocular hypertension when the vision in the affected eye suddenly deteriorated. Both eyes demonstrated partial response to steroid therapy. The diagnosis of shallow retinal detachment with anteriorly located incriminating retinal breaks was made after partial resolution of vitreous haze in one case and on repeated ultrasonography in the other case. A high index of suspicion is required when examining young patients with atopic dermatitis who present with acute panuveitis and a rapidly progressive cataract, which may mask the presence of a shallow retinal detachment.

Nitroxide stable radical suppresses autoimmune uveitis in rats

Free radicals have been implicated in the pathogenesis of experimental autoimmune uveoretinitis (EAU). Nitroxides are stable radicals with a superoxide-dismutase-mimicking activity, which exert an anti-inflammatory effect in various animal models of oxidative damage and inflammation, such as experimental colitis and head trauma. We examined the use of the SOD mimic nitroxide 4-hydroxy-2,2,6,6,-tetramethylpiperidine-1-N-oxyl (TPL) to suppress EAU. Adult male Lewis rats were immunized with 125 μg/rat synthetic human retinal S-Ag, emulsified with Freund’s adjuvant. Intravenous pertussis toxin was simultaneously injected. Beginning on Day 6, rats were injected with a daily intraperitoneal dose of 35, 175 or 350 μmol/rat of the nitroxide TPL. Control rats received intraperitoneal normal saline. The animals were examined daily, and on the 19th day the eyes were enucleated. Aqueous protein concentrations and retinal lipid peroxidation product levels (ketodienes and conjugated dienes) were determined. Histological sections were stained and examined microscopically. TPL was found to penetrate the aqueous humor readily. Beginning on day 12, rats developed a severe pan-uveitis. Rats in the treatment group had a lower mean clinical and histological score than that of controls. Levels of aqueous humor protein, retinal conjugated diens and ketodiens were all significantly lower in the treatment group. This effect was more pronounced with the lower TPL concentration. We conclude that TPL reduces clinical, biochemical and histopathological severity of S-Ag induced EAU in Lewis rats. This effect is probably mediated by removal of superoxide radicals, but other mechanisms may also be involved.

A case of sarcoidosis with proliferative retinopathy

A 19-year-old female manifested severe bilateral panuveitis with neovascularization in the iris, optic disc, and retina. Fluorescein fundus angiography showed dye leakage from the optic disc and retinal blood vessels, and a large non-perfused area was present in the peripheral retina of the right eye. Sarcoidosis was diagnosed histologically by conjunctival and skin biopsy. Although the patient was given a large dose of a corticosteroid systemically and received panretinal photocoagulation, a dense vitreous hemorrhage and cataract were apparent in the right eye. The right visual acuity decreased to hand motions. A pars plana lensectomy and vitrectomy were performed. After vitrectomy, inflammation and neovascularization regressed and the visual acuity improved to 20/100. Proliferative membrane obtained during vitrectomy was histopathologically studied by light and electron microscopy. Many new vessels containing neutrophils were observed. A direct effect of inflammation as well as ischemia in the retina may have been the stimulus for the proliferative changes.

Candida Endophthalmitis in Job Syndrome

This is the first report to our knowledge ofCandidaendophthalmitis complicating Job syndrome, and it serves to remind clinicians that the differential diagnosis of severe panuveitis needs to include endogenous endophthalmitis in patients with immunodeficiency states. Report of a Case. A 24-year-old woman with an established diagnosis of Job syndrome came to our unit for a second opinion. The vision in her right eye had been reduced for several weeks. Treatment for toxoplasma retinochoroiditis had already been given, on the basis of clinical appearance, with oral prednisolone acetate and clindamycin hydrochloride, but treatment with clindamycin had been stopped after 1 week because she developed diarrhea. On initial examination, she complained of intermittent ache in her right eye, and her vision was reduced to hand movements. There was a relative afferent pupillary defect and a severe panuveitis, with cells in the anterior chamber and marked vitreous opacities. A white retinochoroidal

Ocular Manifestation of Hairy Cell Leukemia With Dramatic Response to 2-Chloro-deoxy-adenosine

To demonstrate that hairy cell leukemia may involve the eye. We examined a patient who had a unique ocular manifestation of hairy cell leukemia with severe panuveitis in one eye and leukemic retinopathy in the fellow eye. Therapy with 2-chloro-deoxy-adenosine, a drug recently introduced for treatment of hairy cell leukemia, led to dramatic improvement of the ocular complications. Hairy cell leukemia may involve the eye and ocular symptoms may respond to systemic treatment with 2-chloro-deoxy-adenosine.

HLA and idiopathic uveitis

Idiopathic uveitis is the most common form of chronic uveitis seen in our area. Characteristically it is a heterogeneous entity in its clinical severity, evolution and therapeutic response, and immune mechanisms are thought to be involved. The phenotype frequencies of HLA antigens were studied in 62 patients with idiopathic uveitis and compared with their frequencies in northern Portugal. The authors also included two groups with a well known immunogenetic background-Behçet's syndrome (BS: n=20) and ankylosing spondylitis (AS: n=18) which are, respectively, the most severe and the most frequent of the rheumatic forms in the area. An increased frequency of HLA B5(B51) in Behçet uveitis (55%; RR=8) was confirmed in the authors' population. They also found in idiopathic uveitis an increased risk for HLA B27 (RR=14). HLA B27 positive idiopathic uveitis was predominantly unilateral (80%) and anterior (97%), whereas B27 negative forms showed a higher prevalence of severe panuveitis. In conclusion, the authors confirmed in their population the association of HLA B27 with uveitis, and HLA B51 with Behçet uveitis. In this last entity an intermediate frequency between northern Europe and the Mediterranean area was observed.

Uveite e dermodespigmentação (Síndrome de Vogt-Koyanagi- Harada) em cães Akita

A síndrome de Vogt-Koyanagi-Harada, caracterizada pela associação de uveite e alteraçõe cutaneas e de meninge, de causa desconhecida é bastante estudada na oftalmologia humana. Foi primeiro descrita no Japão uma síndrome semelhante em cães da raça Akita, sendo que relatos em outras raças e outrosçpaíses como Canadá, Estados Unidos e Inglaterra foram feitos posteriormente. Descrevemos pela primeira vez no Brasil esta associação úveo-dermatológica em 21cães da raça Akita. Caracterizada por uveíte e despigmentação ao redor das pálpebras, lábios, narina e escroto podendo haver ulceração com formação de crostas nestas regiões. A administração de altas doses de corticosteróides é o tratamento de eleição.

The nervous system and uveitis

This paper presents a short review of some inflammatory diseases which involve both the nervous system and the uvea, and of some forms of uveitis whose onset could be neurogenic. Multiple sclerosis and reticulum cell sarcoma are examples of systemic neurologic diseases which can be accompanied by uveitis or pseudo-uveitis. Syndromes such as Behçet's or Vogt-Koyanagi-Harada are characterized not only by a highly severe panuveitis but also by the participation of optic nerve, meningeal, and brain tissues in the inflammatory process. The occurrence of sympathetic ophthalmia and herpetic uveitis could to a certain extent be due to a neurogenic transmission of the antigen. For Fuchs' heterochromic cyclitis, however, the old theory of sympathetic nerve dysfunction at its origin is no longer widely accepted.

Mycoplasmal anterior and posterior uveitis. I. Clinical manifestations of the experimental disease.

This study describes the first experimental model of mycoplasma-induced uveitis. Inoculation of this infectious agent into the anterior chamber of the rabbit eye results in the production of a nongranulomatous uveitis which may remain confined to the anterior segment and clear completely, or spread to the choroid to involve the eye in severe panuveitis for four to five weeks, ultimately leaving some eyes with partial or total retinal detachments. Serial anterior chamber aspirations revealed living mycoplasma in the eyes until the seventh day. Antibody titers showed a low but definite rise in systemic levels over a four-week period.

Herpes simplex panuveitis. A clinical report.

Herpes simplex virus was isolated from the anterior chamber of a white woman with bilateral severe panuveitis. This was her second episode of uveitis, the first being anterior and unilateral; both attacks appeared to be precipitated by childbirth. Acute and convalescent antibody titers showed a significant drop in titer against the virus with resolution of the process. The significance of these findings in light of earlier clinical and laboratory evidence is discussed.