|Year : 2017 | Volume
| Issue : 3 | Page : 252-254
Hilda K Nixon
Fellow in Cornea and Phaco, Ophthalmology Department, Little Flower Hospital and Research Centre, Angamaly, Eranakulam, Kerala, India
|Date of Web Publication||30-Jan-2018|
Hilda K Nixon
Fellow in Cornea and Phaco, Ophthalmology Department, Little Flower Hospital and Research Centre, Angamaly, Eranakulam, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Nixon HK. Journal Review. Kerala J Ophthalmol 2017;29:252-4
| Risk Factors for Secondary Glaucoma in Herpetic Anterior Uveitis|| |
Hoeksema L, Jansonius NM, Los LI. Risk Factors for Secondary Glaucoma in Herpetic Anterior Uveitis. Am J Ophthalmol. 2017 Jun 27. pii: S0002-9394(17) 30258-1.
Elevated intraocular pressure (IOP) and secondary glaucoma (IOP-related damage to the optic nerve head and accompanying visual field loss) are major ocular complications in uveitis. The main objective of this study is to determine the incidence of elevated IOP and secondary glaucoma in herpetic anterior uveitis (AU), due to either herpes simplex virus (HSV) or varicella zoster virus (VZV), using the standardization of uveitis nomenclature (SUN) criteria. The second objective is to identify risk factors for the development of glaucoma. This is a retrospective, observational cohort study conducted by Ophthalmology Department of the University Medical Center Groningen. All patients with herpetic AU, due to HSV or VZV, were included in the study. Patients with multiple causes of AU including a possibly herpetic uveitis and patients who had an elevated IOP or glaucoma before the onset of the uveitis were excluded from the study. Seventy-three herpetic AU patients were analyzed. The median age of onset of uveitis was 50 (range: 5–85) years. Fifty-four (74%) patients had a presumably HSV-associated AU and 19 (26%) patients had a presumably VZV-associated AU. The median age of HSV patients was 48 (range: 5–85) years and of VZV patients 60 (range: 24–85) years, P = 0.03. There were 28 (38%) female patients. All patients had a unilateral AU, the fellow eye was affected in none of the patients. Ocular complications most commonly seen during follow-up for uveitis, these were elevated IOP (75%), keratitis (59%), dry eyes (34%), posterior synechiae (34%), cataract (32%), and glaucoma (15%). The majority of patients with elevated IOP (91%) had elevated IOP at the start of one or more uveitis episodes. Glaucoma developed during follow-up for uveitis after a median interval of 3.9 (range: 0.2–22.7) years. None of the patients with glaucoma in the eye with uveitis developed glaucoma in their fellow eye. There was no significant difference in the incidence of glaucoma between HSV and VZV patients. Overall, the patients were treated with systemic antiviral medication. Glaucoma patients, in comparison to nonglaucoma patients, are more often characterized by a higher number of IOP peaks during follow-up for uveitis. Sixty-four percent of patients received IOP-lowering medication at least once, most commonly used type was a β-blocker. Forty-eight percent of patients needed two or more IOP-lowering agents simultaneously. Forty-five percent of whom were treated with IOP-lowering medication solely and 19% needed a surgical pressure-reducing intervention, consisting mainly of an implantation of a Baerveldt glaucoma drainage device (79%). The median interval between the first uveitis episode and the pressure-reducing intervention was 5.4 (range: 0.01–25.6) years. In addition, all patients were treated with topical corticosteroids at the time of active uveitis, with a maximum of 16 drops a day. In case of a persistent and severe uveitis, additional oral corticosteroids or periocular corticosteroid injections were given. Using the SUN criteria, this study confirmed that elevated IOP and secondary glaucoma are major complications in herpetic AU patients. The incidence of secondary glaucoma in our study was 15% after a median follow-up of 7.9 years. In the majority of the patients, the elevated IOP was measured at the start of a uveitis episode. Risk factors for the development of glaucoma were the number of IOP peaks. Furthermore, use and prolonged use of IOP-lowering medication and the number of IOP-lowering agents used simultaneously were higher in glaucoma patients. A large proportion of patients needed a surgical pressure-reducing intervention. Since it is a retrospective study done in tertiary referral center, this population may not represent that the general uveitis population is a drawback of this study. Most patients were diagnosed by their clinical presentation is another shortcoming related to this study. However, information on specific aspects of the elevated IOP that influences the development of secondary glaucoma and regarding diurnal-to-nocturnal change of habitual IOP is lacking in this study.
| Recombinant Interferon Alpha 2b for Ocular Surface Squamous Neoplasia: an Efficient and Cost-Effective Treatment Modality in Asian Indian Patients|| |
Kaliki S, Singh S, Iram S, Tripuraneni D. Recombinant Interferon Alpha 2b for Ocular Surface Squamous Neoplasia: An Efficient and Cost-effective Treatment Modality in Asian Indian Patients. Indian J Ophthalmol. 2016 Oct; 64(10):702-9.
Ocular surface squamous neoplasia (OSSN) includes a spectrum from mild/moderate/severe dysplasia to carcinoma in situ to invasive squamous cell carcinoma involving the conjunctiva and/or cornea. The purpose was to study the efficacy of interferon alpha 2b (INF-α 2b) in the treatment of ocular surface squamous neoplasia (OSSN) and analyze its cost-effectiveness in India. It is a retrospective study conducted by L. V. Prasad Eye Institute. The patients with extensive tumor (>20 mm basal dimension or >6 h involvement of limbus, with flat tumor configuration), OSSN limited to the corneal surface, recurrent tumor postsurgical excision, and/or mitomycin C and those with microscopic tumor residue postexcision biopsy were treated with INF-α 2b. Patients with OSSN treated with INF-α 2b with a minimal follow-up of 3 months were included in the study. The primary tumor was classified based on the American Joint Committee Classification. The patients with only corneal OSSN were advised topical INF-α 2b eye drops (1 MIU/cc) four times/day for immunoreduction/immunotherapy. The patients with conjunctival or conjunctivo-limbal-corneal lesions were given a combination of topical INF-α 2b eye drops (1 MIU/cc) four times/day and perilesional INF-α 2b injection (5 MIU/cc) once a month for immunoreduction/immunotherapy. Those patients with Tis, who had undergone excision biopsy of the lesion and showed carcinoma in situ at one or more surgical margins on histopathology review, were advised topical INF-α 2b eye drops (1 MIU/cc) four times/day for immunoprevention. Every patient was reviewed once a month during the treatment period. Tumor details were recorded during each visit. If the patient had a residual tumor, the patient was advised to continue topical medication until complete tumor regression and 3 months beyond complete tumor regression. Topical INF-α 2b 1 MIU/cc drops were freshly prepared and dispatched every month as needed. The additional perilesional injection was repeated every month in suitable cases. After complete tumor regression had been achieved, topical drops were continued for another 3 months. If there were tumor residue after six cycles of topical INF-α 2b eye drops and three perilesional injections of INF-α 2b, the lesion was surgically excised. After complete tumor regression had been achieved, the patients were reviewed once in 3 months in the 1st year and every 4 months in the 2nd year. The outcome was also analyzed based on maximum tumor dimension on presentation. The patients were divided into three groups; Group 1, with no clinical evidence of tumor (Tis, INF-α 2b used to prevent tumor recurrence in those with histopathology evidence of residual tumor at margins postexcision biopsy); Group 2, with maximum basal diameter of tumor <10 mm; and Group 3, with maximum basal diameter of tumor >10 mm at presentation. The number of cycles of INF-α 2b (topical drops ± perilesional injections) per patient was recorded. The total treatment cost of INF-α 2b per patient was recorded. The side effects of treatment and any event of tumor recurrence were noted. Two hundred and fifty-four patients with OSSN were examined. Of these, thirty patients treated with INF-α 2b were included in this study. The tumor involved cornea (n = 9, 30%), conjunctivo-limbal-corneal surface (n = 19, 63%), or bulbar conjunctiva (n = 2, 7%). The mean basal dimension of the tumor was 16 mm. The tumors belonged to Tis (n = 6, 20%) or T3 (n = 24, 80%) based on the American Joint Committee Classification, 7 edition. In the six patients with Tis, three cycles of topical INF-α 2b were used for immunoprevention. In the remaining 24 patients, INF-α 2b was advised for immunoreduction, but served as immunotherapy with 100% tumor regression in 22 (92%) cases, and resulted in 95% immunoreduction in 2 (6%) cases. Complete tumor regression by immunotherapy (n = 22) was achieved with a mean number of three topical INF-α 2b cycles and two perilesional injections. All these 22 patients received three additional topical INF-α 2b cycles after complete tumor regression. For immunoreduction (n = 2), both patients received six cycles of topical INF-α 2b which was three perilesional INF-α 2b injections. The mean total treatment cost per patient with INF-α 2b was INR 9164 ($US 137). Based on maximum basal diameter of tumor at presentation, the mean total treatment cost per patient with INF-α 2b was INR 4866 ($US 73) for eyes with microscopic evidence of tumor residue (n = 6), INR 9607 ($US 143) for tumors ≤10 mm (n = 13), and INR 10,985 ($US 164) for tumors >10 mm (n = 11), with two patients needing additional surgical excision for complete tumor control. This study showed that no tumor recurrence was noted in any patient at a mean follow-up period of 9 months. INF-α 2b has fewer side effects than other topical agents used in OSSN. Thus, this study proved that INF-α 2b is an effective alternative to surgery in suitable cases and can be used for immunoreduction, immunotherapy, or immunoprevention of OSSN. The limitations of the study include retrospective nature of the study, lack of histopathologic documentation of diagnosis in all cases, smaller patient cohort, and shorter duration of follow-up. The cost-effectiveness of treatment has been calculated by taking into account only the cost of INF-α 2b syringe. However, the patient has additional costs of frequent follow-up visits with INF-α 2b medical treatment is more compared to primary surgery.
| Changes of Choroidal Structure After Intravitreal Aflibercept Therapy for Polypoidal Choroidal Vasculopathy|| |
Daizumoto E, Mitamura Y, Sano H, Akaiwa K, Niki M, Yamanaka C, Kinoshita T, Egawa M, Sonoda S, Sakamoto T. Changes of Choroidal Structure After Intravitreal Aflibercept Therapy for Polypoidal Choroidalvasculopathy. Br J Ophthalmol. 2017 Jan; 101(1):56-61.
Earlier studies using enhanced depth imaging optical coherence tomography (EDI-OCT) showed that the central choroid was thicker in eyes with polypoidal choroidal vasculopathy (PCV), and the central choroidal thickness was reduced after antivascular endothelial growth factor (anti-VEGF) therapy. There have been no reports quantifying the changes of the luminal and stromal areas of the choroid in eyes with PCV after anti-VEGF therapy. In this study, they reported that the EDI-OCT images can be converted to binary images which can then be used to quantify the luminal and stromal areas of the choroid. Thus, the purpose of this study was to quantify the changes of the luminal and stromal areas of the inner and outer choroid after intravitreal aflibercept (IVA) injections for PCV.
This was a retrospective, observational case series of 40 eyes of 40 consecutive treatments at the Tokushima University Hospital between October 2013 and November 2015. The patients were examined by EDI-OCT before and 3 months and 12 months after the initial IVA. The exclusion criteria included a myopic refractive error >−6.0 diopters and other ocular diseases that might affect the clinical findings. Twenty-one untreated healthy fellow eyes and 38 age-matched, sex-matched, and refractive error-matched normal controls were also examined. All 40 eyes underwent three consecutive monthly IVA injections (2.0 mg) as a loading dose and received additional IVAs given as needed. The EDI-OCT images were binarized by ImageJ software. The cross-sectional luminal and stromal areas of the inner and outer subfoveal choroid of 1500 mm width were quantified. In this study, the stromal but not the luminal area of the inner choroid was significantly decreased at 3 months and 12 months after the IVA (stromal area, both P = 0.050). On the other hand, the luminal but not the stromal area of the outer choroid was significantly decreased at 3 months and 12 months (luminal area, both P = 0.050). The Pachychoroid Index, ratio of luminal/stromal area (L/S ratio) of the outer choroid divided by the L/S ratio of the inner choroid, was significantly decreased at 3 months and 12 months (both P < 0.050). This is the first study that evaluated the changes in the choroidal structures in eyes undergoing IVA for PCV. This study proved that binarization of the EDI-OCT images can be used to quantify the activity of PCV and to predict the prognosis after IVA. Limitation of this study was small sample size, it is a retrospective study and hence can have sampling biases. The follow-up of 1 year may not be long enough. Manual segmentation of the inner and outer choroid is not completely objective is also the shortcoming related to this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.