Role of the Infectious Disease Consultant in Management of Patients With Tuberculosis-Associated Ocular Inflammation

Posted Posted in Retina, uveitis
Mycobacterium,ocular infections,tuberculosis,uveitis
Open Forum Infect Dis. 2015 Dec 15;3(1):ofv195. doi: 10.1093/ofid/ofv195. eCollection 2016.

Role of the Infectious Disease Consultant in Management of Patients With Tuberculosis-Associated Ocular Inflammation.

Abstract

Background.  Tuberculosis is a disease with continued worldwide prevalence, morbidity, and mortality. Tuberculosis-associated ocular inflammation (TB-AOI) is a manifestation that can occur with pulmonary or extrapulmonary TB. Evaluation of these ocular presentations and treatment in the United States are limited. Our objective was to describe cases in an urban area and assess the role of the infectious diseases specialist in managing these complex patients. Methods.  We performed a retrospective case series of all patients referred to our infectious disease clinic for presumed TB-AOI from 2005 through 2013. Patients with ocular inflammation were determined to have presumed TB-AOI based on clinical presentation with correlative positive tuberculin skin test and/or QuantiFERON-TB Gold. Attempts were made to exclude other diagnoses. Data were collected and analyzed with respect to demographics, ocular manifestations, and treatment. Results.  Sixty eyes of 42 patients were included in the study; anterior uveitis was the most common site of involvement. The median age was 46 years, and 33 patients (79%) were foreign born. Forty patients (95%) received a course of antituberculous therapy with 38% experiencing treatment-related side effects. A 6-month duration was recommended in 78% cases. There was improvement or stability of the vision in 42 eyes (74%) of those treated. Conclusions.  Ocular involvement is an uncommon but important manifestation of TB. Our data further characterize TB-AOI cases in the United States. Treatment provides significant benefit to properly selected patients. A multidisciplinary approach, with care provided by ophthalmology and infectious disease providers, should be used to allow for the most efficacious treatment.

Conclusions:

Conclusions.  Ocular involvement is an uncommon but important manifestation of TB. Our data further characterize TB-AOI cases in the United States. Treatment provides significant benefit to properly selected patients. A multidisciplinary approach, with care provided by ophthalmology and infectious disease providers, should be used to allow for the most efficacious treatment.

KEYWORDS:

Mycobacterium; ocular infections; tuberculosis; uveitis

Posterior Segment Drug Delivery Devices: Current and Novel Therapies in Development

Posted Posted in Drugs, eye health, Retina
Posterior Segment,Drug Delivery Devices,Therapy
J Ocul Pharmacol Ther. 2016 Jan 26. [Epub ahead of print]

Posterior Segment Drug Delivery Devices: Current and Novel Therapies in Development.

Abstract

Ocular drug delivery by conventional routes of administration does not maintain therapeutic drug concentrations in the target tissues for a long duration because of various anatomical and physiological barriers. Treatment of diseases of the posterior segment of the eye requires novel drug delivery systems that can overcome these barriers for efficacious delivery, provide controlled release for the treatment of chronic diseases, and increase patient’s and doctor’s convenience to reduce the dosing frequency and associated side effects. Thereby, an increasing number of sustained-release drug delivery devices using different mechanisms have been developed. This article discusses various current and future sustained-release drug delivery systems for the posterior segment disorders

J Ocul Pharmacol Ther. 2016 Jan 26. [Epub ahead of print]

Posterior Segment Drug Delivery Devices: Current and Novel Therapies in Development.

Abstract

Ocular drug delivery by conventional routes of administration does not maintain therapeutic drug concentrations in the target tissues for a long duration because of various anatomical and physiological barriers. Treatment of diseases of the posterior segment of the eye requires novel drug delivery systems that can overcome these barriers for efficacious delivery, provide controlled release for the treatment of chronic diseases, and increase patient’s and doctor’s convenience to reduce the dosing frequency and associated side effects. Thereby, an increasing number of sustained-release drug delivery devices using different mechanisms have been developed. This article discusses various current and future sustained-release drug delivery systems for the posterior segment disorders

Thereby, an increasing number of sustained-release drug delivery devices using different mechanisms have been developed. This article discusses various current and future sustained-release drug delivery systems for the posterior segment disorders

Serratia marcescens endogenous endophthalmitis in an immunocompetent host.

Posted Posted in Infection
Serratia marcescens,endogenous endophthalmitis,immunocompetent host
BMJ Case Rep. 2016 Jan 20;2016. pii: bcr2015209887. doi: 10.1136/bcr-2015-209887.

Serratia marcescens endogenous endophthalmitis in an immunocompetent host.

Abstract

A systemically well 66-year-old white Caucasian man presented to the urgent care department with a short history of progressive pain and blurring of vision in his left eye. He denied a history of trauma, intraocular surgery or use of illicit drugs. He was diagnosed with endogenous endophthalmitis. Vitreous biopsy grew Serratia marcescens, a Gram negative bacteria. In spite of extensive investigation, there was no obvious source of infection. He had an indwelling urine catheter for prostate hypertrophy, but urine culture was negative. There was no evidence of immunocompromise. He was treated with systemic as well as intravitreal antibiotics. In spite of appropriate treatment, the patient lost vision. S. marcescens endophthalmitis, seen even in immunocompetent people, carries a poor visual prognosis.

BMJ Case Rep. 2016 Jan 20;2016. pii: bcr2015209887. doi: 10.1136/bcr-2015-209887.

Serratia marcescens endogenous endophthalmitis in an immunocompetent host.

Abstract

A systemically well 66-year-old white Caucasian man presented to the urgent care department with a short history of progressive pain and blurring of vision in his left eye. He denied a history of trauma, intraocular surgery or use of illicit drugs. He was diagnosed with endogenous endophthalmitis. Vitreous biopsy grew Serratia marcescens, a Gram negative bacteria. In spite of extensive investigation, there was no obvious source of infection. He had an indwelling urine catheter for prostate hypertrophy, but urine culture was negative. There was no evidence of immunocompromise. He was treated with systemic as well as intravitreal antibiotics. In spite of appropriate treatment, the patient lost vision. S. marcescens endophthalmitis, seen even in immunocompetent people, carries a poor visual prognosis. He was treated with systemic as well as intravitreal antibiotics. In spite of appropriate treatment, the patient lost vision. S. marcescens endophthalmitis, seen even in immunocompetent people, carries a poor visual prognosis.

Associations with Intraocular Pressure in a Large Cohort

Posted Posted in glaucoma
Ophthalmology. 2016 Jan 12. pii: S0161-6420(15)01425-6. doi: 10.1016/j.ophtha.2015.11.031. [Epub ahead of print]

Associations with Intraocular Pressure in a Large Cohort: Results from the UK Biobank.

Abstract

PURPOSE:

To describe the associations of physical and demographic factors with Goldmann-correlated intraocular pressure (IOPg) and corneal-compensated intraocular pressure (IOPcc) in a British cohort.

DESIGN:

Cross-sectional study within the UK Biobank, a large-scale multisite cohort study in the United Kingdom.

PARTICIPANTS:

We included 110 573 participants from the UK Biobank with intraocular pressure (IOP) measurements available. Their mean age was 57 years (range, 40-69 years); 54% were women, and 90% were white.

METHODS:

Participants had 1 IOP measurement made on each eye using the Ocular Response Analyzer noncontact tonometer. Linear regression models were used to assess the associations of IOP with physical and demographic factors.

MAIN OUTCOME MEASURES:

The IOPg and IOPcc.

RESULTS:

The mean IOPg was 15.72 mmHg (95% confidence interval [CI], 15.70-15.74 mmHg), and the mean IOPcc was 15.95 mmHg (15.92-15.97 mmHg). After adjusting for covariates, IOPg and IOPcc were both significantly associated with older age, male sex, higher systolic blood pressure (SBP), faster heart rate, greater myopia, self-reported glaucoma, and colder season (all P < 0.001). The strongest determinants of both IOPg and IOPcc were SBP (partial R2: IOPg 2.30%, IOPcc 2.26%), followed by refractive error (IOPg 0.60%, IOPcc 1.04%). The following variables had different directions of association with IOPg and IOPcc: height (-0.77 mmHg/m IOPg; 1.03 mmHg/m IOPcc), smoking (0.19 mmHg IOPg, -0.35 mmHg IOPcc), self-reported diabetes (0.41 mmHg IOPg, -0.05 mmHg IOPcc), and black ethnicity (-0.80 mmHg IOPg, 0.77 mmHg IOPcc). This suggests that height, smoking, diabetes, and ethnicity are related to corneal biomechanical properties. The increase in both IOPg and IOPcc with age was greatest among those of mixed ethnicities, followed by blacks and whites. The same set of covariates explained 7.4% of the variability of IOPcc but only 5.3% of the variability of IOPg.

CONCLUSIONS:

This analysis of associations with IOP in a large cohort demonstrated that some variables clearly have different associations with IOPg and IOPcc, and that these 2 measurements may reflect different biological characteristics.

Diabetic Retinopathy Screening and Monitoring of Early Stage Disease in Australian General Practice: Tackling Preventable Blindness within a Chronic Care Model.

Posted Posted in Retina
J Diabetes Res. 2016;2016:8405395. doi: 10.1155/2016/8405395. Epub 2015 Dec 20.

Diabetic Retinopathy Screening and Monitoring of Early Stage Disease in Australian General Practice: Tackling Preventable Blindness within a Chronic Care Model.

Abstract

Introduction. Diabetic retinopathy (DR) is the leading cause of preventable blindness in Australia. Up to 50% of people with proliferative DR who do not receive timely treatment will become legally blind within five years. Innovative and accessible screening, involving a variety of primary careproviders, will become increasingly important if patients with diabetes are to receive optimal eye care. Method. An open controlled trial design was used. Five intervention practices in urban, regional, and rural Australia partnered with ophthalmologists via telehealth undertook DR screening and monitoring of type 2 diabetes patients and were compared with control practices undertaking usual care 2011-2014. Results. Recorded screening rates were 100% across intervention practices, compared with 22-53% in control practices. 31/577 (5%) of patients in the control practices were diagnosed with mild-moderate DR, of whom 9 (29%) had appropriate follow-up recorded. This was compared with 39/447 (9%) of patients in the intervention group, of whom 37 (95%) had appropriate follow-up recorded. Discussion and Conclusion. General practice-based DR screening via Annual Cycle of Care arrangements is effective across differing practice locations. It offers improved recording of screening outcomes for Australians with type 2 diabetes and better follow-up of those with screen abnormalities.

Abstract

Introduction. Diabetic retinopathy (DR) is the leading cause of preventable blindness in Australia. Up to 50% of people with proliferative DR who do not receive timely treatment will become legally blind within five years. Innovative and accessible screening, involving a variety of primary careproviders, will become increasingly important if patients with diabetes are to receive optimal eye care. Method. An open controlled trial design was used. Five intervention practices in urban, regional, and rural Australia partnered with ophthalmologists via telehealth undertook DR screening and monitoring of type 2 diabetes patients and were compared with control practices undertaking usual care 2011-2014. Results. Recorded screening rates were 100% across intervention practices, compared with 22-53% in control practices. 31/577 (5%) of patients in the control practices were diagnosed with mild-moderate DR, of whom 9 (29%) had appropriate follow-up recorded. This was compared with 39/447 (9%) of patients in the intervention group, of whom 37 (95%) had appropriate follow-up recorded. Discussion and Conclusion. General practice-based DR screening via Annual Cycle of Care arrangements is effective across differing practice locations. It offers improved recording of screening outcomes for Australians with type 2 diabetes and better follow-up of those with screen abnormalities.

Interventions for Age-Related Macular Degeneration: Are Practice Guidelines Based on Systematic Reviews?

Posted Posted in Retina
Ophthalmology. 2016 Jan 21. pii: S0161-6420(15)01427-X. doi: 10.1016/j.ophtha.2015.12.004. [Epub ahead of print]

Interventions for Age-Related Macular Degeneration: Are Practice Guidelines Based on Systematic Reviews?

Abstract

PURPOSE:

Are existing systematic reviews of interventions for age-related macular degeneration incorporated into clinical practice guidelines?

DESIGN:

High-quality systematic reviews should be used to underpin evidence-based clinical practice guidelines and clinical care. We examined the reliability of systematic reviews of interventions for age-related macular degeneration (AMD) and described the main findings of reliable reviews in relation to clinical practice guidelines.

METHODS:

Eligible publications were systematic reviews of the effectiveness of treatment interventions for AMD. We searched a database of systematic reviews in eyes and vision without language or date restrictions; the database was up to date as of May 6, 2014. Two authors independently screened records for eligibility and abstracted and assessed the characteristics and methods of each review. We classified reviews as reliable when they reported eligibility criteria, comprehensive searches, methodologic quality of included studies, appropriate statistical methods for meta-analysis, and conclusions based on results. We mapped treatment recommendations from the American Academy of Ophthalmology (AAO) Preferred Practice Patterns (PPPs) for AMD to systematic reviews and citations of reliable systematic reviews to support each treatment recommendation.

RESULTS:

Of 1570 systematic reviews in our database, 47 met inclusion criteria; most targeted neovascular AMD and investigated anti-vascular endothelial growth factor (VEGF) interventions, dietary supplements, or photodynamic therapy. We classified 33 (70%) reviews as reliable. The quality of reporting varied, with criteria for reliable reporting met more often by Cochrane reviews and reviews whose authors disclosed conflicts of interest. Anti-VEGF agents and photodynamic therapy were the only interventions identified as effective by reliable reviews. Of 35 treatment recommendations extracted from the PPPs, 15 could have been supported with reliable systematic reviews; however, only 1 recommendation cited a reliable intervention systematic review. No reliable systematic review was identified for 20 treatment recommendations, highlighting areas of evidence gaps.

CONCLUSIONS:

For AMD, reliable systematic reviews exist for many treatment recommendations in the AAO PPPs and should be cited to support these recommendations. We also identified areas where no high-level evidence exists. Mapping clinical practice guidelines to existing systematic reviews is one way to highlight areas where evidence generation or evidence synthesis is either available or needed.

Age-related macular degeneration in Portugal: prevalence and risk factors in a coastal and an inland town. The Coimbra Eye Study

Posted Posted in Retina
age-related macular degeneration,prevalence,risk factors,michael duplessie
Acta Ophthalmol. 2016 Jan 25. doi: 10.1111/aos.12950. [Epub ahead of print]

Age-related macular degeneration in Portugal: prevalence and risk factors in a coastal and an inland town. The Coimbra Eye Study – Report 2.

Abstract

PURPOSE:

To determine the age- and sex-specific prevalence of early and late age-related macular degeneration (AMD) in two Portuguese population-based samples and to identify its risk factors.

POPULATION:

A population of 6023 adults aged ≥55 years was recruited from two Portuguese primary healthcare units in the central region of Portugal – one from a coastal (n = 3000) and another from an inland town (n = 3023).

METHODS:

Cross-sectional population-based study. Participants were enrolled in the two locations between August 2009 and October 2013. Responders underwent standardized interviews and ophthalmologic examination, including digital fundus imaging. All fundus photographs were graded according to an International Classification and Grading System. The main outcome measures consisted of age- and sex-adjusted prevalence of early and late AMD. Potential epidemiologic risk factors were also evaluated using logistic regression analysis.

RESULTS:

Of the 6023 subjects enrolled, 5996 had gradable fundus images and were included in the analysis. The crude prevalence of early and late AMD was 6.99 and 0.67%, respectively, for the coastal town and 15.39 and 1.29% for the inland town. Age- and sex-adjusted prevalence of any AMD for the Portuguese population was 12.48% (95% CI: 11.61-13.33) with late AMD accounting for 1.16% (95% CI: 0.85-1.46). Neovascular AMD (NV-AMD) and geographic atrophy (GA) accounted for 0.55% (95% CI: 0.36-0.75) and 0.61% (95% CI: 0.37-0.84) of individuals, respectively. After adjusting for possible confounding factors, prevalence of early and late AMD increased with increasing age (OR = 1.35; 95% CI: 1.23-1.49 for early and OR = 3.01; 95% CI: 2.22-4.08 for late AMD, per each decade of age increase, p < 0.001). After adjustment for age, sex, family history, smoking history, hypertension, diabetes and BMI, subjects from the inland town presented a significantly higher OR of early and late AMD than subjects from the coastal town (OR = 2.57, 95% CI: 2.12-3.12, p < 0.001 for early and OR = 2.06, 95% CI: 1.07-3.95, p = 0.029 for late AMD).

CONCLUSIONS:

The prevalence of early and late AMD in this Portuguese population was similar to other large-scale population-based cohorts. After controlling for confounders, age and study site of inclusion were significant independent predictors for both early and late forms of the disease. Further analysis will be needed to completely unravel the underlying reasons for this difference regarding geographic location.

© 2016 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

KEYWORDS:

age-related macular degeneration; prevalence; risk factors

Anterior chamber aqueous flare, pseudoexfoliation syndrome, and glaucoma.

Posted Posted in glaucoma, uveitis
Anterior chamber,aqueous, flare,pseudoexfoliation syndrome,glaucoma
Int Ophthalmol. 2016 Jan 19. [Epub ahead of print]

Anterior chamber aqueous flare, pseudoexfoliation syndrome, and glaucoma.

Abstract

The purpose of this study is to evaluate anterior chamber aqueous flare (ACAF) in Tunisian patients with pseudoexfoliation (PEX) syndrome with or without associated glaucoma. This is a prospective, cross-sectional, comparative study including 53 patients (88 eyes) with PEX syndrome, 48 patients with PEX glaucoma (86 eyes), and 53 healthy sex-and age-matched control subjects (106 eyes). All patients underwent a complete ophthalmic examination and laser flare photometry. Mean ACAF was significantly higher in the PEX syndrome group in comparison with the control group (17.96 ± 10.05 vs 7.06 ± 2.95 ph/ms; p = 10-4), in patients with PEX glaucoma compared to PEX syndrome without associated glaucoma (27.99 ± 15.45 vs 17.96 ± 10.05 ph/ms; p = 10-4), in the PEX glaucoma group in comparison with control group (27.99 ± 15.45 vs 7.06 ± 2.95 ph/ms; p = 10-4), and in patients with unilateral PEX syndrome in comparison with contralateral-unaffected eyes (25.72 ± 14.88 vs 8.58 ± 3.45 ph/ms; p = 0.000). For patients with PEX syndrome, a high ACAF might be a predictor for the development of glaucoma. Further investigations are needed to clarify the role of laser flare photometry in predicting the risk of glaucoma in patients with PEX syndrome.

KEYWORDS:

Glaucoma; Laser flare photometry; Pseudoexfoliation syndrome

Abstract

The purpose of this study is to evaluate anterior chamber aqueous flare (ACAF) in Tunisian patients with pseudoexfoliation (PEX) syndrome with or without associated glaucoma. This is a prospective, cross-sectional, comparative study including 53 patients (88 eyes) with PEX syndrome, 48 patients with PEX glaucoma (86 eyes), and 53 healthy sex-and age-matched control subjects (106 eyes). All patients underwent a complete ophthalmic examination and laser flare photometry. Mean ACAF was significantly higher in the PEX syndrome group in comparison with the control group (17.96 ± 10.05 vs 7.06 ± 2.95 ph/ms; p = 10-4), in patients with PEX glaucoma compared to PEX syndrome without associated glaucoma (27.99 ± 15.45 vs 17.96 ± 10.05 ph/ms; p = 10-4), in the PEX glaucoma group in comparison with control group (27.99 ± 15.45 vs 7.06 ± 2.95 ph/ms; p = 10-4), and in patients with unilateral PEX syndrome in comparison with contralateral-unaffected eyes (25.72 ± 14.88 vs 8.58 ± 3.45 ph/ms; p = 0.000). For patients with PEX syndrome, a high ACAF might be a predictor for the development of glaucoma. Further investigations are needed to clarify the role of laser flare photometry in predicting the risk of glaucoma in patients with PEX syndrome.

Limbal Stem Cell Deficiency: Current Treatment Options and Emerging Therapies.

Posted Posted in cornea
Limbal,Stem Cell,Deficiency,Current Treatment Options,Emerging Therapies,amniotic
Stem Cells Int. 2016;2016:9798374. doi: 10.1155/2016/9798374. Epub 2015 Dec 14.

Limbal Stem Cell Deficiency: Current Treatment Options and Emerging Therapies.

Abstract

Severe ocular surface disease can result in limbal stem cell deficiency (LSCD), a condition leading to decreased visual acuity, photophobia, and ocular pain. To restore the ocular surface in advanced stem cell deficient corneas, an autologous or allogenic limbal stem cell transplantation is performed. In recent years, the risk of secondary LSCD due to removal of large limbal grafts has been significantly reduced by the optimization of cultivated limbal epithelial transplantation (CLET). Despite the great successes of CLET, there still is room for improvement as overall success rate is 70% and visual acuity often remains suboptimal after successful transplantation. Simple limbal epithelial transplantation reports higher success rates but has not been performed in as many patients yet. This review focuses on limbal epithelial stem cells and the pathophysiology of LSCD. State-of-the-art therapeutic management of LSCD is described, and new and evolving techniques in ocular surface regeneration are being discussed, in particular, advantages and disadvantages of alternative cell scaffolds and cell sources for cell based ocular surface reconstruction.

Abstract

Severe ocular surface disease can result in limbal stem cell deficiency (LSCD), a condition leading to decreased visual acuity, photophobia, and ocular pain. To restore the ocular surface in advanced stem cell deficient corneas, an autologous or allogenic limbal stem cell transplantation is performed. In recent years, the risk of secondary LSCD due to removal of large limbal grafts has been significantly reduced by the optimization of cultivated limbal epithelial transplantation (CLET). Despite the great successes of CLET, there still is room for improvement as overall success rate is 70% and visual acuity often remains suboptimal after successful transplantation. Simple limbal epithelial transplantation reports higher success rates but has not been performed in as many patients yet. This review focuses on limbal epithelial stem cells and the pathophysiology of LSCD. State-of-the-art therapeutic management of LSCD is described, and new and evolving techniques in ocular surface regeneration are being discussed, in particular, advantages and disadvantages of alternative cell scaffolds and cell sources for cell based ocular surface reconstruction.

The diagnostic value of saccades in movement disorder patients: a practical guide and review.

Posted Posted in neuro-ophthalmology
Eye movement,Movement disorders, Ocular motility, Saccade,michael duplessie
J Clin Mov Disord. 2015 Oct 15;2:14. doi: 10.1186/s40734-015-0025-4. eCollection 2015.

The diagnostic value of saccades in movement disorder patients: a practical guide and review.

Abstract

Saccades are rapid eye movements designed to shift the fovea to objects of visual interest. Abnormalities of saccades offer important clues in the diagnosis of a number of movement disorders. In this review, we explore the anatomy of horizontal and vertical saccades, discuss practical aspects of their examination, and review how saccadic abnormalities in hyperkinetic and hypokinetic movement disorders aid in diagnosis, with video demonstration of classic examples. Documentation of the ease of saccade initiation, range of motion and conjugacy of saccades, speed and accuracy of saccades, dynamic saccadic trajectory, and the presence or absence of saccadic intrusions and oscillations are important components of this exam. We also provide a practical algorithm to demonstrate the value of saccades in the differential diagnosis of the movement disorders patient.

KEYWORDS:

Eye movement; Movement disorders; Ocular motility; Saccade

Abstract

Saccades are rapid eye movements designed to shift the fovea to objects of visual interest. Abnormalities of saccades offer important clues in the diagnosis of a number of movement disorders. In this review, we explore the anatomy of horizontal and vertical saccades, discuss practical aspects of their examination, and review how saccadic abnormalities in hyperkinetic and hypokinetic movement disorders aid in diagnosis, with video demonstration of classic examples. Documentation of the ease of saccade initiation, range of motion and conjugacy of saccades, speed and accuracy of saccades, dynamic saccadic trajectory, and the presence or absence of saccadic intrusions and oscillations are important components of this exam. We also provide a practical algorithm to demonstrate the value of saccades in the differential diagnosis of the movement disorders patient.

KEYWORDS:

Eye movement; Movement disorders; Ocular motility; Saccade