This is to certify that this dissertation titled “A CLINICALSTUDY ON POSTERIORUVEITIS” is bonafide record of the research work done by DR. KASTHURI. B,Post graduate in the Regional Institute of Ophthalmology & Government Ophthalmic Hospital, Madras Medical College and Government General Hospital, Chennai-03, in partial fulfillment of the regulations laid down by the Tamil Nadu Dr. M.G.R Medical University for the award of M.S. Ophthalmology Branch III, under my guidance and supervision during the academic year 2012 – 2015.
In adults treated with a single DEX implant for nonin- fectious intermediate or posterioruveitis during the HURON study, < 5% of eyes experienced an IOP of ≥35 mmHg and <10% an IOP of ≥25 mmHg . The MEAD study, where patients with diabetic macular edema (DME) were treated with DEX implants over a time period of 3 years, showed that a steroid induced cataract in adults can not be expected after 1 DEX im- plant, which was also confirmed in our patients . During the MEAD study most cataract surgeries were per- formed after 18 to 30 months and repeated DEX implants. The above mentioned studies [30 – 33] may indicate that development of cataract occurs earlier in paediatric pa- tients than in adults. But in most cases the induced cataract did not yet seem to impact relevantly on VA. In addition it has to be noted that long standing and insuffi- ciently controlled uveitis itself leads to earlier cataract formation and progression in children than in adults.
from the zone of injury too. Another advantage is the size of the vessel at its origin which is almost always 2mm or so. This facilitates converting the pedicled flap into micro vascular flap in case of doubtful reverse flow during the procedure. This flap can be used in limited cases of thumb reconstruction where an osteo-cutaneous flap is raised. Another regional flap which does not interrupt the vascular axis is the dorso-ulnar artery flap, its main disadvantage being a short pedicle and limited arc of rotation. The Posterior Interosseous artery flap in contrast has a longer pedicle and wide arc of rotation. In addition the PIA flap provides soft supple skin with good colour and texture match.
In a study of over 10,000 patients with DM in the UK the prevalence of diabetic retinopathy has been reported to be 16.5% [16,17]. Our cohort had diabetic retinopathy in 24 patients (66.7%), which is four times higher. The UK Prospective Diabetes Study showed that people with improved glucose control reduced the requirement of laser treatment of the eye by a quarter . Progression of diabetic retinopathy to the proliferative stage over a 4-year follow up in WESDR study in 1075 patients was reported to be 4.7% . In our study 18.4% of patients went on to develop proliferative diabetic retinopathy over an average of 4.36 years. The co-existing uveitis could trigger mechanisms for progression of diabetic retinopathy amongst other factors. However we were unable to identify other main risk factors, such as hypertension and hyperlipidaemia to have a contribu- tory role in our cohort. It was interesting to note rapid progression of non-proliferative diabetic retinopathy to proliferative in one eye of a patient with panuveitis in that eye. There are a number of reports in the litera- ture suggesting either a causative or a protective role of uveitis in relation to proliferative diabetic retinop- athy [20-23]. In the current literature 6 uveitic eyes progressed to PDR in patients with DM whereas two eyes did not progress. This suggests a possible role of worsen- ing diabetic retinopathy in patients with uveitis.
The eye has a particular relationship with the immune system which is known as “immune privilege” and involves physical barriers, immunosuppressive factors and protein antigens . The term “uveitis” is often used to describe the inflammation of the middle layer of the eye, known as uveal tract, but in general it can be used to describe any intraocular inflammatory process [2,3]. The International UveitisStudy Group classification system considers location, clinical course (acute if lasting less than three months, chronic if otherwise, and recurrent when acute flares appear after a complete resolution of the previous event) and laterality (unilateral or bilateral in relation to both eyes) to define its pattern . According to location, uveitis is considered to be anterior if it affects the iris or the ciliary body (iritis or iridocyclitis), intermediate when limited to the vitreous (vitritis), peripheral retina, pars plana or the ciliary body, posterior if it involves the choroid and possibly the retina (choroiditis, retinochoroiditis and chorioretinitis), and finally panuveitis when at least two of these segments are involved [3,4]. Uveitis can be a co-manifestation of systemic autoimmune rheumatic diseases (SARD), a side effect of medications, a consequence of exposure to toxins or just an idiopathic disorder . It has been traditionally categorized as infectious or non-infectious . Infectious uveitis can be secondary to viral, bacterial, parasitic or fungal infections [5,7]. Non-infectious uveitis is believed to be either autoimmune, when it is mediated by aberrant immune recognition of self, or immune-mediated, if an innate inflammatory reaction is triggered by environmental or autologous signals [8,9]. Some authors consider autoimmune uveitis (AIU) to be an organ-speciﬁc disorder characterized by irreversible ocular lesions, even though some SARD can present uveitis and overlapping AIU . In this article, AIU is considered to include both organ-specific and SARD-associated uveitis, regardless of which immune response (adaptive or innate) predominates.
The incidence of uveitis recurrence after cataract surgery, to the end of the study, was compared in implanted and non-implanted eyes. This analysis was not limited to the 3-month postoperative period. The rate of uveitis recurrence after cataract surgery was statistically significantly greater in non-implanted eyes than in implanted eyes (44.4% vs 26.5%; P = 0.0433). Figure 1 illustrates the time course to recurrence of uveitis for implanted and non-implanted eyes as a function of time following both procedures undergone by all study patients (FA implantation and cataract extraction). The figure demonstrates that more non-implanted eyes than implanted eyes experienced a recurrence of uveitis within the first 3 months after cataract surgery. Onset of many of the recurrences reported for implanted eyes occurred well after cataract extraction and intravitreal FA implantation, suggesting that, in at least some of these eyes, drug depletion may have played a role in the recurrence.
Bartynski et al in 2007 reported 136 patients of Posterior Reversible Encephalopathy Syndrome with the clinical features: seizure activity in 97 (71%), consciousness impairment 39 (26%), headaches 39 (26%), visual impairment 39 (26%), acute hypertension 97 (67%), focal neurological deficit not reported. The radiological features in cases of bartynski et al were bilateral lesions in 98 out of 136 patient studied (72%), asymmetric lesions in 21 out of 136 patients (16%), grey matter involvement was not reported, posterior > anterior in 30 patients (22%), occipital in 34 patients (99%), parietal in 134 patients (99%), frontal in 93 patients (63%), temporal in 55 patients (40%). Some cases had brainstem, cerebellum and basal ganglion involvement.
TIAs occur at least 2 weeks prior to posterior circulation stroke presentation in 50% of patients. In a study of 85 cases of angiographically proven basilar artery or bilateral vertebral artery occlusion, prodromal or progressive symptoms occurred in 75% of cases. The most common prodromal symptoms included vertigo, nausea and headache ranging from days to months before the stroke. Only 5% of patients had isolated vertigo as a prodromal symptom. In 63% of patients, the onset of symptoms was gradual and progressive. The most common presenting symptoms were vertigo, nausea, headache, dysarthria and cranial nerve palsies. Hemiparesis or Tetraparesis was present in 61% of the patients. Thirty-six percent presented awake, while twenty-three percent were somnolent and thirty percent were comatose. [42, 43]
The VMA status of both study and fellow eyes of sub- jects was assessed using SD-OCT images from the eli- gible subjects at the baseline and month 6 visit by two independent graders (NN and MH); a third senior grader was employed in cases of disagreements. The subjects were classified into either VMA+ or VMA− groups. The International Vitreomacular Traction Study group (IVTS) classification was used to define the presence of VMA . The IVTS defines VMA as the presence of detachment of peri-foveal vitreous cortex from the retinal surface along with attachment of vitre- ous cortex within 3-mm radius of the fovea and no secondary changes in the foveal contour or underlying retinal tissue. The VMA is further classified by the size of the adhesion area into focal (< 1500 μm) or broad (≥ 1500 μm).
Data were compiled and summarized using descriptive statistics. Event rates per person-year were calculated based on the sum of time from the first DEX injection to the event onset for patients with the event and the follow-up time for patients without the event. SAEs and AESIs were coded using the Medical Dictionary for Regulatory Activities nomenclature and are presented by primary system organ class (SOC) and preferred term. Analyses of SAEs and AESIs were preplanned to include stratification by indication (RVO vs NIPSU), history of DEX use (DEX-naïve vs previously treated with DEX), and number of DEX injections during study (#2 vs .2). This threshold was chosen to fulfill a need for data on DEX safety in patients who receive more than two injections, as no patients received more than two injec- tions in the global registration studies of DEX for treatment of RVO-associated macular edema and NIPSU. Observed data were used in the analyses. There was no imputation for missing values, except in estimation of dates for treatments and start/stop dates of adverse events, when partial data were available.
choice of FUS as a control could be discussed as not ideal, as it is a chronic disease, with only mild inflamma- tory activity. In our study, the amount of corneal DCs did not correlate with the anterior chamber cell count or flare. We therefore believe that their increase does not reflect increasing intensity of unspecific inflammation but possibly indicates active immune mechanisms against the herpes viruses. Therefore, we also think that the differences in numbers of DCs seen between HAU and FUS are not due to less inflammatory activity in FUS. Still, to further support this theory, DCs in patients with other forms of AU need to be studied. Further, this is a cross-sectional study; no serial confocal microscopic exams were performed. Lastly, we only collected infor- mation on the central cornea. However, as shown in the study from Mastropasqua et al., this is the region of interest for corneal inflammatory diseases, showing the most significant differences towards healthy controls . Other authors reported a decreased subepithelial nerve fibre density in the central corneas in herpetic keratitis as an additional finding [9,36]. We have not looked into this in the study presented here. The HRT-RCM is a non-invasive and low-risk technique to acquire corneal images. DCs are easily displayed, and high amounts were seen in our study in patients with HAU. We conclude that confocal microscopy may be a useful additional tool in diagnosing HAU. How DCs behave in quiescent or treated disease as well as in other anterior uveitis sub- types remains to be evaluated.
Ankle fractures are common fractures seen at the emergency department. Posterior malleolar fractures are a common component of the ankle fractures with the incidence of 7-44% of ankle fractures . The posterior malleolus contributes to the congruity of the ankle joint . The main ligamentous attachment for the posterior malleolus includes the posterior inferior tibiofibular ligament provides 42% of the syndesmotic stability [3-5]. Inadequate anatomical reduction of the ankle fractures leads to prolonged periods of pain, decreased range of motion and early arthritis [6-11]. The size of the fragment, usually given as the percentage of involvement of distal tibial articular surface as measured on the lateral ankle radiographs, is an important parameter used to decide whether a fragment should be fixed or not. When the ratio of the posterior fragment is less than 25% of the Antero-posterior dimension of the articular surface, conservative treatment is suggested by some authors [2,12-21]. However, the joint congruency and stability are shown to be more important than the size of the posterior malleolus fragment for long-term radiological outcome [22- 23].
This study was a prospective, observational, case-control study of 186 patients, 93 with non-infectious uveitis and 93 patients from general ophthalmology clinic (aged 15 to 75 years) presented from April 2015 to June 2016 to our tertiary eye care institute located at Southern India. In this study, we evaluated a middle socioeconomic class of our populations, mainly comprised of Hindu ethnicity who presented to a private, exclusive eye care institution. We analyzed two groups, one with an immune disorder, on multiple topical and systemic medications, and an- other relatively healthy population on few or no medica- tions. The study was approved by the internal review board and adhered to the Declaration of Helsinki. Informed consent was obtained from all the participants for personality evaluation. Uveitis patients formed group A and the control group formed group B. Diagnosis of uveitis required a comprehensive ocular and systemic history, slit-lamp biomicroscopy, and indirect ophthal- moscopy where needed. Patient with active or resolved uveitis with or without associated systemic disease were included in the study. Acute uveitis cases were first treated for the same and then enrolled into the study after relieving their acute symptoms. Patients diagnosed with HLA-B27 uveitis were diagnosed on the basis on clinical examination and relevant history, regardless of positive or negative HLA-B27 test. Patients diagnosed with traumatic uveitis, postoperative uveitis, infectious
Methods: Single center, prospective, 6-year duration, follow-up study on 50 consecutive patients (20 [40%] males and 30 [60%] females with a mean age of 37.5 ± 12.3 years) with refractory BD-associated PU (36 patients) and idiopathic PU (14 patients) who had failed at least one immunosuppressive drug. At baseline, patients received prednisone 1 mg/kg/day with rapid tapering and infliximab infusions (5 mg/kg) at weeks 0, 2, 6, and every 8 weeks thereafter. Nonresponders after the third infusion withdrew from the study. Primary outcome measures were visual acuity (VA) value improvement compared to baseline. Secondary outcome measures were proportion of patients with VA improvement from baseline; proportion of patients achieving disease remission; number of PU flare-ups; and incidence of adverse events.
as VZV iritis. Patients without a skin lesion were subjected to PCR assays for HSV, VZV, and CMV DNA using anter- ior chamber fluid. The presence of > 100 copies/mL of viral DNA were judged as a positive finding. Patients with negative PCR results for HSV, VZV, and CMV DNA, and good response to anti-herpetic treatment were classified as herpetic iridocyclitis (clinical diagnosis), while those who did not undergo PCR assays were classified as sus- pected herpetic iritis. The diagnoses of bacterial and fun- gal endophthalmitis were based on matching of ocular symptoms suggesting bacterial or fungal etiology, the re- sults of laboratory tests (blood culture, serum β- D -glucan), detection of bacterial or fungal DNA in aqueous humor samples by broad-range PCR [20, 21], and a response to antibiotics or antifungal drugs. As for intraocular lymph- oma, we diagnosed this disease if at least two of the follow- ing four criteria were met: cytology >class 3, interleukin (IL)-10/IL-6 ratio > 1 or IL-10 > 50 pg/mL in the intraocu- lar fluid , κ/λ ratio on fluorescence-activated cell sort- ing analysis, and positive PCR results for immunoglobulin heavy chain (IgH) gene rearrangement . Regarding acute anterior uveitis (AAU), patients with unique symp- toms of ankylosing spondylitis, ulcerative colitis, or psoria- sis were diagnosed as having systemic disease-associated uveitis. Those with HLA-B27 were diagnosed as AAU, while those without HLA-B27 or with unknown HLA typing were diagnosed as unclassified uveitis. We diag- nosed ocular tuberculosis based on a combination of ocu- lar symptoms indicating tuberculous etiology, laboratory tests, and response to anti-tuberculosis therapy. Conse- quently, we used the diagnostic criteria for presumed ocu- lar tuberculosis . The diagnostic criteria for diabetic iritis in this study were (1) acute severe iridocyclitis in patients with poor glycemic control (HbA1c ≥ 8.0%) and (2) other investigations for systemic disease associated
diagnosis based solely on clinical examination, defining criteria for the diagnosis of uveitis, the expertise of dedicated ophthalmologist in making the diagnosis and the standardization of the slit lamp bio microscope used for examining patients are all extremely important determinants of the accuracy of the diagnosis made. In our study, we employed stringent diagnostic criteria, which included both history and clinical findings. Examination techniques and instruments were standardized, and pre-test agreement was calculated between the two ophthalmologists conducting the clinical examination and making the diagnosis, which showed excellent agreement on kappa analysis (k=1). However, it is possible that, while the accuracy of diagnosis would have been high, we may have underestimated the prevalence of uveitis, by missing out on mild cases of past anterior uveitis without significant sequelae in the eye. On the other hand, many previous studies had used less stringent criteria for the diagnosis of uveitis and may have overestimated the prevalence of uveitis in spondyloarthritis patients. 6,8,11
Other clinical entities that have been described in the literature are relentless placoid chorioretinitis (RPC) and ampiginous chorioretinopathy. These diseases have char- acteristics similar to APMPPE and serpiginous choroidi- tis but with atypical and chronic or recurrent clinical course . The lesions can be unilateral or bilateral, with abrupt vision loss in the affected eye and delayed onset possibly occurring in the other eye. RPC has been reported to affect healthy men and women between the ages 16 and 51 years [7,8]. Previous publications report that there is typically greater than 50 lesions throughout the retina with RPC. Jones and co-investigators have reported that the retinal lesions seen with RPC resemble APMPPE and serpiginous choroiditis, but the lesions occurred in distinctive retinal distribution with pro- longed relapsing clinical course. New active lesions have been noted in patients as long as 24 months after initial evaluation . Overall prognosis of visual acuity shows a positive trend. Ampiginous chorioretinopathy causes progressive destruction of retina while sharing features of both APMPPE and serpiginous choroiditis . Its chronic nature causes poor visual prognosis, and recur- rences are common [4,9-14].
Serpiginous-like choroiditis presents as a grayish yellow lesion in the posterior pole with creeping snake-like activity. Both healed and active stages of the disease are found in the same eye because of its propensity to recur from its edges[Figure 32]. Frequently they are bilateral with significant vitreous inflammation and in few casescan present as panuveitis. Vision is mildly decreased because of vitritis and is fairly maintained until the lesion involves the fovea sometimes almost at last stage where patients present with extensive healed and active lesion[Figure33]. They must be differentiated from the autoimmune etiology of multifocal serpiginous choroiditis where the lesions start at in the juxta papillary region and extends in the posterior pole. Serpiginous-like choroiditis is thought to be a hypersensitive reaction to tubercle bacilli residing in RPE. Patients responds well to immunosuppressive therapy  . Recurrence rate is reduced by suspecting its tubercular etiology and starting ATT.
Some of the limitations of our study are discussed as follows. (1) If elasticity of the elastic band decreases dur- ing its use, sustaining a fixed pressure on the surgical wound turns difficult. (2) No postoperative MRI examin- ation for evaluating postoperative hematomas in the op- erative area is performed. (3) Owing to the small sample size and the single-center design, the study findings are limited. To further confirm our findings, an immediate attention is required for the multicenter, randomized, controlled study.
Results: The study included 644 eyes of 491 patients. Patients with mild visual loss (logMAR 0.4) at presentation were younger than those with severe visual loss (SVL, logMAR 1.0) (P=0.002). Females were more likely to have mild visual loss as compared to males (P=0.025). Median overall BCVA was logMAR 0.18 at initial and final presen- tation (P=1.00). Vision loss at diagnosis was a predictor for moderate visual loss (MVL, logMAR 0.4 to 1.0) to SVL at last follow-up (P0.001). Eyes with ocular hypertension were positively associated with MVL and SVL as compared to normotensive eyes (1.89 times at baseline, 2.62 times at last follow-up). Median BCVA was 0.18 logMAR for the anterior uveitis (AU) and 0.48 logMAR for the non-AU patients (P0.001). AU patients were less likely to have SVL than non-AU group (P0.001). AU group received local corticosteroids more frequently and systemic corticosteroids less commonly than non-AU patients (P0.001). AU patients with MVL to SVL were more likely to have ophthalmic surgery (cataract, glaucoma or pars plana vitrectomy [PPV]) than those without MVL or SVL (P0.001). Non-AU patients with MVL to SVL were more likely to have PPV than those without MVL or SVL (P=0.001).