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PubMed2005

Management of chronic pediatric uveitis.

PURPOSE OF REVIEW: The diagnosis and management of chronic pediatric uveitis can be particularly challenging, with an estimated 25-33% of childhood uveitis cases resulting in severe, life-long visual disability. This paper reviews the recent literature on the management of chronic pediatric uveitis. RECENT FINDINGS: This review highlights recent advances in the diagnosis and medical and surgical management of pediatric uveitis. Several systemic diseases associated with chronic uveitis in children are highlighted, including juvenile idiopathic arthritis, sarcoidosis and Behçet's disease. The treatment of primary ocular diseases associated with chronic pediatric uveitis such as intermediate uveitis and Fuchs' heterochromic iridocyclitis is discussed. The management of infectious causes of pediatric uveitis is not covered in this review. SUMMARY: Knowledge of the ocular complications of chronic pediatric uveitis can help to customize efficacious therapeutic regimens for each patient, maximize the visual potential and minimize complications of these diseases. In addition a close relation should be fostered between pediatricians, pediatric rheumatologists and ophthalmologists to effectively monitor these patients who have multiple medical, surgical and refractive needs. Finally, surgical intervention must be appropriately timed with expert perioperative management of immunosuppressive medications with pediatric concerns in mind.

Adolescent↗

PubMed2004

Paediatric uveitis: a Sydney clinic experience.

PURPOSE: The aim of this study was to retrospectively review uveitis cases at The Children's Hospital at Westmead, Sydney, since its inception in 1997 to 2001, including patients presenting at the Camperdown, Sydney, campus between 1989 and 1997 attending Westmead for further care. Comparison is made with international centres. METHODS: Information was obtained from medical records. RESULTS: Forty patients (53 eyes) presented, of whom 23 (57.5%) were female and 17 (42.5%) were male (mean age 6.7 years). Of 53 eyes, 35 (66%) had anterior uveitis, three (5.7%) intermediate uveitis, seven (13.2%) posterior uveitis and eight (15.1%) panuveitis. Twenty-seven (67.5%) patients had disease unilaterally and 13 (32.5%) bilaterally. Twenty-four (60%) cases were idiopathic. Seven (17.5%) cases were associated with juvenile rheumatoid arthritis, three (7.5%) with herpes zoster, two (5%) with herpes simplex, two (5%) with toxocara, one (2.5%) with toxoplasma, and one (2.5%) with ulcerative colitis. Complications included cataract in 14 (26.4%) eyes; band keratopathy in four (7.5%) eyes; macular scarring in three (5.7%) eyes; and glaucoma in four (7.5%) eyes. Last measured acuity was 6/6 for 19 (35.8%) eyes, < or =6/18 for 15 (28.3%) eyes and <6/60 for eight (15.1%) eyes. CONCLUSIONS: Despite small numbers, the comparisons of this study with some international studies, and its contrasts with other studies, are due to similarities and differences amongst these studies with respect to factors of referral bias, and the aetiological basis of disease.

Child↗

PubMed1994

Uveitis survey at the University Eye Clinic in Turku.

We conducted a retrospective analysis of 1122 patients with endogenous uveitis treated at the University Eye Clinic in Turku during the years 1980-1982 and 1988. Of the 1122 patients 568 were men and 554 women; 1034 (92.2%) had anterior uveitis, 15 (1.3%) intermediate uveitis, 64 (5.7%) posterior uveitis and 9(0.8%) panuveitis; 867 (77.3%) were unilateral and 255 bilateral; 789 of 1067 cases (73.9%) were of sudden onset and 278 of insidious onset; 808 of 1102 cases (73.3%) were of short duration and 294 of long duration; and 519 (46.3%) single and 603 repeated. In this study uveitis occurred significantly more often (44.2%) in the age group 20-39 years than in other age groups (p < 0.00001). Anterior and posterior uveitis were more often unilateral than bilateral (p < 0.0005) and of sudden onset than of insidious onset (p < 0.00008). Acute anterior uveitis was the most common uveitic entity and accounted for 745 cases (66.4%). Acute anterior uveitis associated with ankylosing spondylitis was the single most frequently seen diagnostic group including 144 cases (12.8%) with a statistically significant male predominance (p < 0.00001).

Acute Disease↗

PubMed2006

Pars plana vitrectomy with intravitreal triamcinolone: effect on uveitic cystoid macular oedema and treatment limitations.

OBJECTIVE: To investigate the effect of pars plana vitrectomy (PPV) in combination with intraoperative intravitreal triamcinolone acetonide injection on the course of cystoid macular oedema (CME) in patients with uveitis. METHODS: Patients with uveitis with CME (n = 19) not responding to systemic corticosteroids and/or immunosuppression combined with acetazolamide were retrospectively studied after PPV with additional intravitreal injection of 4 mg triamcinolone acetonide. Patients had chronic anterior uveitis (n = 4), intermediate uveitis (n = 9), posterior uveitis (n = 3) or panuveitis (n = 3). Visual acuity tests, tonometry, fluorescein angiographic appearance and postoperative complications were analysed. Mean follow-up was 14 months (SD 4.6). RESULTS: CME improved in 58% of the patients within the first 6 weeks postoperatively. After 12 months, CME was further improved in 44% and worsened in another 12%. Improvement of visual acuity was noted in 42% after 3 months and in 28% after 12 months. Cataract progressed in 85% of the phacic patients postoperatively. Increased intraocular pressure was detected in 27% at 2 weeks and in 11% at 12 months after surgery. CONCLUSION: Uveitic CME that is unresponsive to systemic immunosuppression and acetazolamide may improve after PPV with additional intravitreal triamcinolone application. The effect seems to be transient in many of the patients. Frequent complications were cataract formation and ocular hypertension.

Adolescent↗

PubMed1994

Long-term results of pars plana vitrectomy in the management of complicated uveitis.

This retrospective study evaluates the long term efficacy of pars plana vitrectomy on the preservation of vision in complicated chronic uveitis, including endogenous intermediate uveitis and other entities. Combined vitrectomy-lensectomy was performed in 10 eyes with complicated cataracts, and 18 vitrectomies were done without lensectomies. The mean follow up was 45 months. Additional retinal surgery (for example, scleral buckling) was performed in five eyes. Visual acuity improved in 23 eyes (82.8%) following surgery, with 16 eyes (57%) achieving a vision better than 6/24. The main causes for vision less than 6/24 were persistent cystoid macular oedema (three eyes), macular puckers (one eye), retinal vascular obliterations (four eyes), optic atrophy (five eyes), and chorioretinal scars (seven eyes). Postoperative complications were cataract formation (seven eyes), cystoid macular oedema (one eye), and tractional retinal detachments (three eyes). The surgical intervention resulted in a remarkable reduction of the severity of inflammation or frequency of exacerbations, and allowed significant tapering (11 eyes) or withdrawal (11 eyes) of the topical steroids, or oral corticosteroids (10 cases). Pre-existent cystoid macular oedema resolved in three eyes. Pars plana vitrectomy, eventually combined with lensectomy, may visually rehabilitate eyes with chronic uveitis and media opacities, and may reduce the activity of disease postoperatively.

Adolescent↗

PubMedDate not supplied

Uveitis and pseudouveitis presenting for the first time in Japanese elderly patients.

PURPOSE: To evaluate the clinical characteristics of uveitis or pseudouveitis presenting de novo in Japanese elderly patients. METHODS: We retrospectively examined 296 patients with uveitis or pseudouveitis who were treated at Toyama Medical and Pharmaceutical University Hospital. Patients were followed up for 1 week to 5 years (mean, 11 months). RESULTS: Of 296 patients, 82 (38 men and 44 women, 120 eyes) presented with their first episode of uveitis or pseudouveitis at the age of > or = 60 years. Forty patients had anterior uveitis, 2 had intermediate uveitis and the other 40 had posterior and/or pan-uveitis. Of 82 patients, 53 (64.6%) had idiopathic uveitis. The prevalence of Vogt-Koyanagi-Harada syndrome and Behçet disease in elderly patients was lower than that in younger patients. Complicated cataract was frequently seen in the eyes with uveitis. Most eyes with uveitis had poor visual acuity. CONCLUSIONS: The prevalence of Vogt-Koyanagi-Harada syndrome and Behçet disease in elderly patients was lower than that in younger patients.

Adolescent↗

PubMed2000

[Evaluation and monitoring of selected inflammation patterns in uveitis using laser tyndallometry].

AIM: The purpose of the present study was to evaluate the degree of inflammation and to monitor the dynamics of the blood-aqueous barrier disruption in selected cases of uveitis using laser tyndalometry. MATERIAL AND METHOD: Measurements with the use of laser tyndalometer (Kowa FM-500) were performed in 72 patients (90 eyes) with various types of uveitis. They were divided into four groups: anterior uveitis (28 eyes), intermediate uveitis (pars planitis) (28 eyes), posterior uveitis (26 eyes) and panuveitis (8 eyes). Aqueous flare values were expressed as photon counts per millisecond. RESULTS: Tyndalometric mean values in control eyes were 4.8 +/- 1.0 ph/msec. Mean initial flare was pronounced in multifocal choroiditis and panuveitis--196.0 ph/msec, HLA-B27 positive acute anterior uveitis--145.4 ph/msec, and in acute herpes zoster anterior uveitis--52.4 ph/msec. It was mild to moderate in Fuchs uveitis syndrome--7.8 ph/msec, pars planitis--15.7 ph/msec, posterior uveitis in toxoplasmosis--6.8 ph/msec and toxocariasis--17.5 ph/msec. The potential of laser flare-meter for precise follow-up and adjustment of therapy was demonstrated in selected cases. CONCLUSIONS: Laser tyndalometry has been proved to be a useful tool for the objective and quantitative evaluation of anterior chamber flare in uveitis and for monitoring the effectiveness of the treatment, thus improving therapeutic efficacy of uveitis.

Adolescent↗

PubMed2005

Serum cytokine receptor levels in noninfectious uveitis.

PURPOSE: Understanding of the role of cytokines in uveitis may provide new clues to its treatment. Therefore, the purpose of our study was to evaluate systemic cytokine receptor expression in patients with noninfectious uveitis. METHOD: Serum concentrations of soluble interleukin-2 receptor alpha (IL-2 s Ralpha) and soluble tumor necrosis factor receptor-1 (sTNF-R1) were measured in patients with intermediate uveitis (n = 26), posterior uveitis (n = 23) and healthy controls (n = 12) using ELISA. All patients were identified in a consecutive series of 996 uveitis patients who had been diagnosed between 1998 and 2002 and classified according to the recommendations of the International Uveitis Study Group. Inclusion criteria were idiopathic, active intraocular inflammation, uveitis as a primary process and no systemic anti-inflammatory treatment at the time of blood sampling. None of the patients had an underlying systemic disease. RESULTS: Serum concentrations of IL-2 s Ralpha were significantly increased in patients with posterior (p < 0.005) and intermediate uveitis (p < 0.005) as compared to healthy controls. Similarly, concentrations of sTNF-R1 appeared to be increased in posterior (p < 0.005) and intermediate (p < 0.005) uveitis patients when compared to controls. CONCLUSIONS: Our results may suggest that patients with noninfectious uveitis express systemic cytokine receptors such as TNF-R1 and IL-2 Ralpha, which may have an important role in the immune response of the eye and may lead to new immunomodulatory approaches.

Adolescent↗

PubMed2000

Uveitis in children.

PURPOSE: To summarize the prevalence and patterns of uveitis in children. METHODS: Pertinent articles were reviewed. RESULTS: Children constitute 5-10% of the patients with uveitis seen at tertiary referral centers, and girls appear to develop uveitis slightly more frequently than boys. Among all children with intraocular inflammation, anterior uveitis accounts for 30-40%, posterior uveitis accounts for 40-50%, intermediate uveitis accounts for 10-20%, and diffuse uveitis accounts for 5-10%. The most common cause of anterior uveitis is juvenile idiopathic arthritis (JIA), whereas the most frequent type of posterior uveitis is toxoplasmic retinochoroiditis. Most cases of intermediate and diffuse uveitis are bilateral, chronic, and idiopathic. The most common causes of vision loss in children with uveitis are cataract, band keratopathy, glaucoma, and cystoid macular edema. Up to one-third of the children with uveitis are left with severely impaired vision as a result of these complications. CONCLUSIONS: Uveitis is an important cause of ocular morbidity in children. Prompt diagnosis and treatment is essential to minimize the risk of long-term vision loss.

Child↗

PubMed2003

Endogenous uveitis: experiences in Kaohsiung Veterans General Hospital.

BACKGROUND: The distribution of uveitis varies in different parts of the world, which is attributed to geographic, alimentary or genetic factors. Epidemiological studies in uveitis may be extremely important in an effort to better understand the etiology of the disease and the classification of its subtypes. The purpose of this study was to determine the profile and characteristics of endogenous uveitis in southern Taiwan. METHODS: Retrospective chart review ofthe patients diagnosed and treated as endogenous uveitis in Kaohsiung Veterans General Hospital from January 1991 to December 2000 was performed. Demographic data, past history, ophthalmic examination and other laboratory tests were recorded and analyzed. RESULTS: One-hundred and sixty patients were collected, including 93 (58.1%) males and 67 (41.9%) female, with average age of 41.1 +/- 17.1 years (range 16-77), and mean follow-up period of 13.7 months. The diagnoses included 46 (28.8%) cases of acute anterior nongranulomatous uveitis (AAU), 26 (16.3%) cases of Vogt-Koyanagi-Harada (VKH) disease, 18 (11.3%) cases of intermediate uveitis, 14 (8.8%) cases of Behcet's disease, 26 (16.3%) cases of infectious origin, 7 (4.4%) cases of other diagnoses, and 23 (14.4%) undefined cases. Final visual acuity equal to or better than 0.5 was obtained in 78.2% of eyes of AAU, 65.4% of eyes of VKH disease, 48.1% of eyes of Behcet's disease, and 66.7% of eyes of intermediate uveitis. CONCLUSIONS: Acute anterior nongranulomatous uveitis was the most common endogenous uveitis, while VKH was the most common panuveitis in this series. As infectious origin contributes a significant proportion of endogenous uveitis, infectious etiology should be considered in any type of uveitis that responds poorly to conventional treatment.

Adolescent↗

PubMed2006

Pattern of childhood-onset uveitis in a referral center in Tunisia, North Africa.

PURPOSE: To analyze the pattern of childhood uveitis in a referral center in Tunisia, North Africa. METHODS: The study included 64 patients with uveitis examined at the Department of Ophthalmology of Monastir (Tunisia) from January 1994 to July 2005. All patients had a comprehensive ocular and systemic history, including an extensive review of medical systems. Complete ophthalmic examination was performed in all cases, including best-corrected Snellen visual acuity, slit-lamp examination, applanation tonometry, and dilated fundus examination with 3-mirror lens. Standard diagnostic criteria were employed for all syndromes or entities of uveitis. RESULTS: The mean age at onset of uveitis was 12.4 years. The male-to-female ratio was 0.68. The process was unilateral in 51.6% of patients. Mean follow-up was 43.2 months. Anterior and intermediate uveitis each represented 31.25% of cases, posterior uveitis 20.3%, and panuveitis 17.2%. Noninfectious uveitis (75%) was the most frequent type of inflammation. Idiopathic uveitis was found in 50% of patients. Infectious uveitis was responsible for 25% of the cases, with toxoplasmosis (14.1%) being the most frequent cause. Twenty percent of the patients had systemic associations; juvenile idiopathic arthritis was found in 6.25%. Ocular complications occurred in 74.7% of affected eyes, of which the most common were posterior synechiae (28.4%), cataract (17.9%), cystoid macular edema (19%), and optic disc edema (32.6%). Fifty-seven affected eyes (60%) had a final visual acuity more than 20/40 and nine (9.5%) had a final visual acuity less than 20/200. CONCLUSIONS: In a hospital population in Tunisia, a specific cause of uveitis in children was found in half the patients. Idiopathic intermediate uveitis was the leading cause of uveitis in our study, followed by idiopathic anterior uveitis and toxoplasmosis. Uveitis associated with juvenile idiopathic arthritis was rare. Visual prognosis appeared to be good.

Adolescent↗

PubMed2006

Validity of using vision-related quality of life as a treatment end point in intermediate and posterior uveitis.

AIM: To evaluate the responsiveness of the Vision core module 1 (VCM1) vision-related quality of life (VR-QOL) questionnaire to changes in visual acuity in patients with posterior and intermediate uveitis and to validate its use as a clinical end point in uveitis. METHODS: Logarithm of the minimum angle of resolution visual acuity and VR-QOL using the VCM1 questionnaire were prospectively recorded in 37 patients with active posterior segment intraocular inflammation before starting systemic immunosuppression with ciclosporin, tacrolimus or the anti-tumour necrosis factor (TNF) agent, p55TNFr-Ig, and again 3 months later. Spearman analysis was used to correlate improvements in visual acuity and VR-QOL between baseline and 3 months. RESULTS: The correlation between changes in visual acuity and VR-QOL was moderate to good for the worse eye (r = 0.47, p = 0.003), but poor for the better eye (r = -0.05, p = 0.91). The responsiveness indices effect size and standardised response mean were 0.57 and 0.59, respectively, showing that the VCM1 questionnaire is moderately responsive to immunsosuppressive therapy for active uveitis. CONCLUSION: Changes in VR-QOL measured with the VCM1 questionnaire correlated moderately well with changes in the worse eye visual acuity, suggesting that the VCM1 is a valid instrument for monitoring response to treatment in uveitis.

Adult↗

PubMed1998

Posterior sub-Tenon's triamcinolone injections in the treatment of uveitis.

PURPOSE: This is the first study reported in the United Kingdom to investigate the efficacy and safety of posterior, sub-Tenon's triamcinolone acetonide injections in the treatment of posterior and intermediate uveitis. METHODS: Twenty-eight posterior sub-Tenon's triamcinolone injections (40 mg) were given and the results analysed with a 6 month prospective follow-up in 13 cases. RESULTS: At 6 weeks follow-up, objective improvement in visual acuity occurred in 25 eyes (p < 0.05). Vitreous cellular activity was diminished in 21 eyes (p < 0.05). In most cases improvement was observed within 2 weeks of injection. No patient required repeat triamcinolone injection within 3 months and all patients previously treated with systemic immunosuppression were able to decrease or discontinue this treatment. Complications included transient elevation of intraocular pressure in 4 patients and persistent mild ptosis in 2 patients. CONCLUSIONS: We have demonstrated that posterior sub-Tenon's triamcinolone injection significantly decreases cystoid macular oedema, with a corresponding increase in visual acuity, in patients with posterior uveitis. Systemic immunosuppression may be reduced or discontinued with the avoidance of associated systemic side effects, and the technique has a high level of patient acceptability.

Administration, Topical↗

PubMed1994

Neuroendocrine alterations in uveitis patients.

Experimental models of autoimmune uveitis are consistently associated with pinealitis. To investigate the interaction between the neuroendocrine and immune systems in humans with uveitis, we measured serum levels of the predominant pineal hormone melatonin (MEL), prolactin (PRL) and interleukin-2 (IL-2). A total of 100 patients with different forms of uveitis and 30 age-matched, healthy blood donors were evaluated retrospectively. The day-time MEL was reduced significantly (P < or = 0.01) in patients with iritis and iridocyclitis, and highly significantly (P < or = 0.001) in patients with intermediate uveitis, chorioretinitis and panuveitis. In 38% of patients day-time MEL levels in plasma were below the limit of detection. PRL was significantly reduced (P < 0.01) in patients with intermediate uveitis. IL-2 was reduced to about 50% of control values in all groups of patients. The results suggest a possible neuroendocrine-immune interaction in uveitis patients.

Adolescent↗

PubMed1995

[Early vitrectomy in endogenous juvenile uveitis intermedia--a long-term study].

BACKGROUND: The intermediate uveitis is one of the most common intraocular manifestations of inflammation during infancy and adolescence. The success of intensive pharmacological treatment is rather limited and often associated with heavy side effects. PATIENTS AND METHODS: In 25 eyes with juvenile uveitis intermedia (age of the patients between 5 and 18 years, mean 13.5 years) and visual acuities between 0.02 and 0.4 (mean 0.19) an early vitrectomy was performed after failure of conservative treatment and peripheral cryocoagulation. RESULTS: Almost all patients (22 out of 25) showed an improvement of visual acuity within the first 6 months of the surgery. Among the patients with a remarkable improvement of visual acuity 7 eyes had a chronic cystoid macular oedema which showed a regression postoperatively. Additionally, the number and the course of inflammatory periods could be reduced postoperatively. An increase of preexisting lens opacities, however, has not been noticed even after a follow-up period of 10 years. CONCLUSIONS: The results show that an early vitrectomy in cases of juvenile uveitis intermedia often leads to a stabilization or an improvement of visual acuity and a regression of the inflammatory attacks (episodes). Therefore, in children and adolescents with endogenous uveitis intermedia a pars plana vitrectomy instead of a long-term systemic immunosuppression associated with heavy side-effects should be considered.

Adolescent↗

PubMed2003

Genetic polymorphism of HLA DR in a Scottish population of patients with pars planitis.

PURPOSE: Human leucocyte antigen (HLA) class II influences the immunological susceptibility for a variety of diseases including many types of non-infectious intraocular inflammation. Previous studies on North American patients with pars planitis, a subtype of intermediate uveitis, reported an increased prevalence of HLA DR15 in this population. In contrast, two European studies could not find an association between HLA DR2 or its allelic subtype DR15 and various forms of intermediate uveitis. We therefore investigated the genotype frequency of HLA DR alleles in a Scottish population of patients with typical pars planitis. METHODS: Twenty patients with pars planitis were identified from the uveitis database of Grampian University Hospitals. Only patients with bilateral vitritis and snowbanks in at least one eye in the absence of systemic disease were included in the study. Fifteen patients and 34 healthy controls underwent HLA DR genotyping for all DRB genes using PCR sequence specific primers. RESULTS: HLA DR15 was found in 13% of patients with pars planitis and in 24% of controls. There was no statistically significant difference between these two groups. Furthermore, the frequencies of HLA DR 1, 3-14, and 16 did not differ significantly between patients and controls. CONCLUSIONS: There appears to be no association between the occurrence of pars planitis and the HLA DR15 or other known HLA DR genotypes in Scottish patients. However, the small sample size limits the power of this study.

Alleles↗

PubMed2003

Vitreous surgery in the management of chronic endogenous posterior uveitis.

OBJECTIVES: There is evidence that pars plana vitrectomy (PPV) has a beneficial effect on the clinical course of chronic endogenous posterior uveitis (EPU) possibly by physically removing any resident inflammatory cells with the vitreous. We assessed the anatomical and therapeutic effects of PPV performed on patients with chronic EPU for any indication. PATIENTS AND METHODS: Retrospective review of 41 eyes of 38 consecutive patients with EPU who underwent a PPV for any reason, over a 5-year period. The mean age of the patients was 36.2 years, 46% of the eyes had intermediate uveitis, 32% panuveitis, and 22% posterior uveitis. The visual acuity, disease activity, and the requirement for medications to control it were recorded for 12 months pre- and postoperatively. RESULTS: Overall, 61% of the eyes gained more than 2 Snellen lines (P<0.001) and the incidence of cystoid macular oedema (CMO) significantly reduced from 44 to 20% (P<0.05). Postoperatively, there was a significant decrease in the recurrence rate of intermediate uveitis, posterior uveitis, and panuveitis (P<0.001). The use of systemic and local depot immunosuppressive agents did not change over the study period, although the use of topical agents increased (P<0.05). CONCLUSION: PPV appears to have a beneficial effect on the clinical course of EPU in selected cases. This may be mediated by the physical clearance of inflammatory debris, the anti-inflammatory effect of replacing vitreous by aqueous humour, by a reduction of CMO and/or the anatomical correction of sight-threatening retinal pathology.

Adolescent↗

PubMed1993

Diagnostic problems in chronic vitreous inflammation.

We reviewed 188 patients with chronic vitreous inflammation initially diagnosed as intermediate uveitis, who were seen at the Ghent Eye Clinic during the period 1978 to 1988. We were able to establish a more specific diagnosis in 55 patients. The different approaches that contributed to the diagnosis were analyzed, (comprehensive history-taking and clinical examination, laboratory tests and special investigations, vitrectomy, and following the evolution of the disease). No etiology was found in 133 patients (70.7%), subsequently diagnosed as idiopathic intermediate uveitis. The major characteristics of the disease were analyzed.

Adolescent↗