Treatment of uveitis and scleritis patients in Malaysia

●AIM:To determine the common causes and visual outcome after treatment among uveitis and scleritis patients.●METHODS:This is a retrospective cohort observational study.All consecutive clinical records of patients with newly diagnosed uveitis and scleritis over a 4-year period,from Jan.1,2017 to Dec.31,2020,were analysed.Data was collected at the presentation and included a follow-up period of one year.●RESULTS:A total of 288 patients were recruited during the study period.Anterior uveitis was the most common anatomical diagnosis(50.0%)followed by panuveitis(25.0%),scleritis(13.5%),posterior uveitis(6.9%),and intermediate uveitis(4.5%).Viral Herpes was the most common cause of infectious cases,while Vogt-Koyanagi-Harada(VKH)disease and human leucocyte antigen(HLA)B27 spondyloarthropathy were the leading causes of identifiable non-infectious cases.Majority of patients presented with unilateral,non-granulomatous uveitis with an absence of hypopyon.Anatomical locations like posterior uveitis and panuveitis,and visual acuity worse than 3/60 at presentation were the factors associated with poor visual outcomes(P<0.05).About 60%of patients had an identifiable cause for the uveitis and scleritis,with nearly equal distribution of infectious(n=85,29.5%)and noninfectious causes(n=84,29.2%).About 14.5%of patients were clinically blind at 1y of follow-up.The most common complication in our uveitis patients was glaucoma(47.5%),followed by cystoid macula oedema(18.9%)and cataract(13.9%).●CONCLUSION:Uveitis and scleritis are important causes of ocular morbidity.They are potentially blinding diseases which can have a good outcome if diagnosed and treated early.

Clinical features and visual outcomes of scleritis patients presented to tertiary care eye centers in Saudi Arabia

AIMTo describe the clinical features, systemic associations, treatment and visual outcomes in Saudi patients with scleritis.METHODSA retrospective chart review was performed for patients with scleritis presenting to two tertiary care eye hospitals in Riyadh, Saudi Arabia, from 2001 to 2011. Data were collected on the clinical features of scleritis, subtypes of scleritis, associated systemic disease, history of previous ocular surgery and medical therapy, including the use of immunosuppressants. Treatment outcomes were evaluated based on best-corrected visual acuity (BCVA) and response to treatment.RESULTSOf the 52 patients included in the study, non-necrotizing anterior scleritis was the most common type of scleritis in 22 patients (42.3%), followed by posterior scleritis in 14 patients (26.9%). The majority of cases, 31 patients (59.6%), were idiopathic in nature. Systemic associations were present in 12 patients (23.1%). Infectious scleritis was confirmed in 6 patients (11.5%): 3 with bacterial scleritis after pterygium excision, 2 patients with scleritis related to tuberculosis and 1 patient with scleritis resulting from herpes simplex infection. For the various subtypes of scleritis, BCVA values after treatment and time to remission significantly differed (P&#x0003c;0.05, all cases). Systemic immunosuppressive therapies in addition to steroids were administered to 46.2% of all patients. The T-sign was present on B-scan ultrasonography in 9 (64.3%) of the 14 posterior scleritis patients.CONCLUSIONNon-necrotizing anterior scleritis was the most common subtype of scleritis. Final visual outcome and time to remission differed among the various scleritis subtypes.

The clinical features of posterior scleritis with serous retinal detachment: a retrospective clinical analysis

AIM: To summarize the clinical features, systemic associations, risk factors and choroidal thickness (CT) changing in posterior scleritis (PS) with serous retinal detachment.METHODS: This retrospective study included 23 patients diagnosed PS with retinal detachment from August 2012 to July 2017. All patients' medical history and clinical features were recorded. The examinations included best corrected visual acuity (BCVA), intraocular pressure (IOP), fundus examination, and routine eye examinations. Posterior coats thickness (PCT) was determined by B-scan ultrasound, the CT was measured by enhanced depth imaging spectral-domain optical coherence tomography (EDI-OCT) and clinical data were compiled and analyzed.RESULTS: After application of extensive exclusion criteria, 23 patients with PS remained (13 females, 10 males). The average age at presentation was 29.5±9.24 years old. Ocular pain and blurred vision were the two most common complained symptoms by patients. Anterior scleritis occurred in 12 patients, which was confirmed by ultrasound biomicroscopy (UBM) examination. Despite all patients displaying serous retinal detachment in their macula, no fluorescein leakage was observed in the macular area. Optic disc swelling was documented in 10 of the 23 eyes. From B-scan ultrasound examination, the PCT in creased with fluid in Tenon's capsule demonstrated as a typical T-sign. The average PCT was 2.51±0.81 mm in the PS-affected eyes and only 1.09±0.29 mm in the unaffected eye (P<0.0001). The subfoveal CT was 442.61 ±55.61 μm, which correlated with axis length (r=-0.65, P=0.001) and PCT (r=0.783, P<0.001). The BCVA and IOP did not correlate with either CT or PCT.CONCLUSION: PS with serous retinal detachment presented a variety of symptoms, such as pain, visual loss, and physical indicators. Typical T-sign detected by B-scan ultrasound is a useful confirmatory sign for PS diagnosis. Pathological increases in CT might be a potential predictive factor for inflammation.

Molecular pathobiology of scleritis and its therapeutic implications

Scleritis and other autoimmune diseases are characterized by an imbalance in the levels of pro-inflammatory and anti-inflammatory molecules with the balance tilted more towards the former due to the failure of recognition of self. The triggering of inflammatory process could be ascribed to the presence of cytoplasmic DNA/chromatin that leads to activation of cytosolic DNA-sensing c GAS-STING(cyclic GMP-AMP synthase linked to stimulator of interferon genes) pathway and enhanced expression of NF-κB that results in an increase in the production of pro-inflammatory bioactive lipids. Bioactive lipids gamma-linolenic acid(GLA), dihomoGLA(DGLA), prostaglandin E1(PGE1), prostacyclin(PGI2) and lipoxin A4, resolvins, protectins and maresins have antiinflammatory actions, bind to DNA to render it non-antigenic and are decreased in autoimmune diseases. These results suggest that efforts designed to enhance the production of anti-inflammatory bioactive lipids may form a new approach to autoimmune diseases. Local injection or infusion of lipoxins, resolvins, protectins and maresins or their precursors such as arachidonic acid may be exploited in the prevention and management of autoimmune diseases including scleritis, uveitis and lupus/rheumatoid arthritis.

Methotrexate for chronic non-necrotizing anterior scleritis in Chinese patients

AIM:To evaluate the effectiveness and corticosteroidsparing capabilities of methotrexate(MTX)in the treatment of chronic non-necrotizing anterior scleritis in Chinese patients.METHODS:A retrospective chart review of all patients with active anterior scleritis between January 2015 and June 2019 was conducted.All patients received 10 to 15 mg/wk MTX orally,and corticosteroids(10 to 40 mg/d prednisolone or equivalent methylprednisolone)with slow tapering.Topical corticosteroid eye drops(1%prednisolone actate,0.1%dexmathosone or 0.1%fluoromethalone)were applied to control comorbid anterior uveitis at presentation or during follow up.The main outcomes were inflammation control and corticosteroid-sparing success,and secondary outcomes were reduction of immunosuppression load and best-corrected visual acuity(BCVA).RESULTS:Thirty-two eyes(22 patients)were included.The proportion of patients who achieved corticosteroidsparing success was 50.0%at 3mo and 77.3%at 12mo[8(36.4%)patients discontinued corticosteroid].The proportion of eyes that achieved inflammation control was 59.4%at 3mo and 78.1%at 12mo.The immunosuppression load was 5.14±0.87 at presentation and 2.76±2.34 at 12mo(P<0.01).BCVA maintained unchanged or improved in 29(90.6%)of all affected eyes.One patient discontinued MTX treatment because of an abnormal liver function test,and no other serious adverse effects were observed.CONCLUSION:According to this pilot study,low dose MTX appear to be a well-tolerated and effective treatment for chronic non-necrotizing anterior scleritis patients in the Chinese population.

Intravitreal dexamethasone implant — a new treatment for idiopathic posterior scleritis: A case report

BACKGROUND Posterior scleritis is one of the most easily missed and misdiagnosed diseases in ophthalmology.In this case we treated a patient with intravitreal dexamethasone implant that has not been extensively studied before.CASE SUMMARY A 40-year-old female patient who had anxiety,palpitation,and insomnia presented with eye pain and decreased vision in the left eye.An eye examination indicated that her visual acuity(VA)was 40/100.Her left eye presented conjunctival edema,mild exophthalmos,clear cornea,KP(-),and clear aqueous humor.In the fundus,there was a cinerous retinal protuberance.Ultrasonography showed“T-sign”and no systemic association was detected in laboratory examination.One month after injection of dexamethasone implant,the patient exhibited VA of 20/20,fundus serous retinal detachment disappeared,and intraocular pressure of both eyes was at the normal level.CONCLUSION Intravitreal injection of dexamethasone implant may be a safe and effective treatment for patients with idiopathic posterior scleritis.

Novel diagnostic imaging techniques and applications in anterior uveitis,intermediate uveitis,and scleritis

Uveitis can cause significant visual morbidity and often affects younger adults of working age.Anterior uveitis,or inflammation limited to the anterior chamber(AC),iris,and/or ciliary body comprises the majority of uveitis cases.Current clinical biomarkers and conventional grading scales for intraocular inflammation are mostly subjective and have only a moderate degree of interobserver reliability,and as such they have significant limitations when used in either clinical practice or research related to uveitis.In recent years,novel imaging techniques and applications have emerged that can supplement exam findings to detect subclinical disease,monitor quantitative biomarkers of disease progression or treatment effect,and provide overall a more nuanced understanding of disease entities.The first part of this review discusses automated algorithms for optical coherence tomography(OCT)image processing and analysis as a means to assess and describe intraocular inflammation with higher resolution than that afforded by conventional AC and vitreous cell ordinal grading scales.The second half of the review focuses on anterior segment OCT and OCT angiography(OCTA)in scleritis and iritis,especially with regards to their ability to directly image and characterize the pathologic structures and vasculature underlying these diseases.Finally,we briefly review experimental animal research with promising but more distant human clinical applications,including in vivo molecular microscopy of inflammatory markers and investigation of gold nanoparticles as a potential contrast agent in OCT imaging.Imaging modalities are discussed in the broader context of trends within the field of uveitis towards greater objectivity and quantifiable outcome measures and biomarkers.

A case of nodular posterior scleritis simulating intraocular tumor

Dear Editor,I am Dr. Yukiko Shibata, from the Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University. I write to present the case of posterior scleritis simulating intraocular tumor.

Reactive uveitis, retinal vasculitis and scleritis as ocular end-stage of Acanthamoeba keratitis: a histological study

We analysed histologically two Acanthamoeba keratitis(AK) eyes with anterior and posterior segment inflammation and blindness. Two enucleated eyes of 2 patients(age 45 and 51y) with AK(PCR of epithelial abrasion positive) were analysed. Histological analysis was performed using hematoxylin-eosin, periodic acid-Schiff and G?m?rimethenamine silver staining. We could not observe Acanthamoeba trophozoites or cysts neither in the cornea nor in other ocular tissues. Meanwhile, we found uveitis, retinal vasculitis and scleritis in these eyes, due to the long-standing, recalcitrant AK. So in this stage of AK, systemic immune suppression may be necessary for a longer time period.

Monocular posterior scleritis presenting as acute conjunctivitis:A case report

BACKGROUND Posterior scleritis is a rare inflammatory ocular disease,characterized by severe and painful inflammation of the sclera.It is often misdiagnosed or underdiagnosed,due to its general and varying clinical presentation profile,which primarily involves pain and visual impairment but which can include eyelid edema,choroidal folds,serous retinal detachment,disc edema,hard exudates in fovea and subretinal mass.We report here a case of posterior scleritis,with symptoms of eye pain and red eye,initially misdiagnosed as acute conjunctivitis.CASE SUMMARY A 56-year-old man presented to a local hospital with complaint of pain and redness in the right eye.The initial diagnosis was acute conjunctivitis and he was given antibiotic eyedrops.Upon week-long continuance of the symptoms despite treatment,he presented to our hospital.Initial examination revealed a shallow anterior chamber in the right eye and vision reduction to 0.6.Further testing by optical coherence tomography,ultrasound biomicroscopy,and fundus photography indicated diagnosis of posterior scleritis.The patient was given methylprednisolone(oral)on a tapered reduction schedule(starting with 70 mg/d).According to the peaks and troughs of symptoms,compound betamethasone injection was administered into the bulb,culminating in discontinuation of the oral corticosteroid.Subsequent optical coherence tomography showed the subretinal fluid near the optic disc to be completely absorbed after treatment.CONCLUSION Posterior scleritis should be among the differential diagnosis of eye pain and redness,and diagnosis requires further ophthalmic accessory examination,such as by optical coherence tomography.

Bilateral posterior scleritis presenting as acute primary angle closure:A case report

BACKGROUND Scleritis is a rare disease and the incidence of bilateral posterior scleritis is even rarer.Unfortunately,misdiagnosis of the latter is common due to its insidious onset,atypical symptoms,and varied manifestations.We report here a case of bilateral posterior scleritis that presented with acute eye pain and intraocular hypertension,and was initially misdiagnosed as acute primary angle closure.Expanding the literature on such cases will not only increase physicians’awareness but also help to improve accurate diagnosis.CASE SUMMARY A 53-year-old man was referred to our hospital to address a 4-d history of bilateral acute eye pain,headache,and loss of vision,after initial presentation to a local hospital 3 d prior.Our initial examination revealed bilateral cornea edema accompanied by a shallow anterior chamber and visual acuity reduction,with left-eye amblyopia(>30 years).There was bilateral hypertension(by intraocular pressure:28 mmHg in right,34 mmHg in left)and normal fundi.Accordingly,acute primary angle closure was diagnosed.Miotics and ocular hypotensive drugs were prescribed,but the symptoms continued to worsen over the 3-d treatment course.Further imaging examinations(i.e.,anterior segment photography and ultrasonography)indicated a diagnosis of bilateral posterior scleritis.Methylprednisolone,topical atropine,and steroid eye drops were prescribed along with intraocular pressure-lowering agents.Subsequent optical coherence tomography(OCT)showed gradual improvements in subretinal fluid under the sensory retina,thickened sclera,and ciliary body detachment.CONCLUSION Bilateral posterior scleritis can lead to secondary acute angle closure.Diagnosis requires ophthalmic accessory examinations(i.e.,ultrasound biomicroscopy,Bscan,and OCT).

Necrotizing Scleritis Associated with 5-Fluorouracil and Sub-Tenon’s Block in Patient with Previous Trabeculectomy: A Case Report

Necrotizing scleritis is the most severe form of scleritis with a significant threat to vision and globe integrity. It can be infectious, surgically induced necrotizing scleritis (SINS) or systemic autoimmune associated. We report a case of necrotizing scleritis associated with 5-fluorouracil (5-FU) at the site of sub tenon’s block in a patient with previous trabeculectomy. To our knowledge, this is the first reported case of necrotizing scleritis associated with 5-FU. This may implicate alternative approaches to local anaesthetic techniques when using adjunctive 5-FU.

Bacillary layer detachment presenting with posterior scleritis:case report

Background:Bacillary layer detachment(BALAD)is a phenomenon characterized by fluid accumulation at the myoid region of the inner photoreceptor segments identifiable on optical coherence tomography(OCT)imaging.This finding has been recently described in patients with diverse primary diagnoses which share the common feature of serous exudation in the posterior pole.However,thus far there have been very few reports in the literature of BALAD in patients with posterior scleritis.Case Description:A 16-year-old male presented with unilateral vision changes that acutely worsened overnight to significant unilateral vision loss.He was eventually diagnosed with idiopathic posterior scleritis with associated BALAD on OCT.Similar to other reported cases of BALAD,he experienced anatomic restoration of the outer retina followed by good visual recovery after treatment with high dose steroid,ultimately with complete recovery of both retinal anatomy and vision within 4 months.Conclusions:This case provides further evidence that posterior scleritis can be a cause of BALAD.The rapid presentation and excellent visual and anatomical outcome of this case is entirely consistent with known descriptions of BALAD in a variety of other conditions,further supporting the categorization of BALAD as an entity which retinal specialists should be able to recognize as distinct from other forms of intraretinal fluid,retinal detachment,and retinoschisis.

Ocular Manifestations in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is the most common autoimmune disease. Ocular manifestations of this autoimmune disease vary and are mainly keratoconjunctivitis sicca, episcleritis, scleritis and keratitis. Their appearance, as well as their severity are related to RA chronicity and resistance to therapy. The treatment consists of corticosteroids, NSAIDs and cytotoxic drugs, depending on the type of ocular manifestations and the patient’s response to treatment.

Short-term observation of management of sclera patch grafts used in the scleral defects

Background:To explore the safety and effectiveness of Sclera patch grafts in the management of scleral defects.Methods:This is a retrospective uncontrolled study.Medical records were retrospectively reviewed for 8 eyes of 8 patients with sclera patch grafts.Two patients had necrotizing scleritis,2 patients had scleral melting/perforation secondary to thermal burns,4 patients had scleral staphyloma secondary to surgery.Sclera was reconstructed with allogenic sclera patch grafts,6 in 8 patients combined autologous conjunctival pedicle flap,1 patient combined partial medial rectus translocation,1 patient combined autologous pedicle tenon graft,simultaneously.Treatment outcomes were evaluated using structural integrity,best corrected visual acuity(BCVA),scleritis remission,sclera rejection and melt,and ocular symptoms.Results:Eight patients were reviewed.In all of these cases,satisfactory anatomic and functional outcomes were achieved.In the at least half a year follow-up,the BCVA of all the eight patients were no worse than that of preoperative.No eye pain,foreign body sensation and other discomforts showed in all the patients,except one woman,who showed sclera rejection and melt 1 month postoperative.In addition,one patient showed high intraocular pressure(28 mmHg),which can be controlled by a kind of medicine.Conclusions:In this series,sclera patch grafts is an effective method for management scleral defects in the at least half a year following-up.Attention should be paid to the sclera patch rejection and melt post operatively.