Publications by authors named "Radgonde Amer"

62 Publications

The Association Between Vitamin D and Uveitis: A Comprehensive Review.

Surv Ophthalmol 2021 Jul 31. Epub 2021 Jul 31.

Department of Ophthalmology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Israel.

Vitamin D plays an important role in both the innate and adaptive immune systems. We review published data on the relationship between uveitis and vitamin D levels, or vitamin D-associated gene polymorphisms. A search of the PubMed and Medline databases was conducted to identify relevant articles concerning vitamin D and uveitis. Sixteen studies were included in this review, and the evidence they present, linking low vitamin D levels with uveitis, is compelling. The uveitic entities shown to be modulated by hypovitaminosis D include, but are not limited to, HLA-B27-associated acute anterior uveitis, Vogt-Koyanagi-Harada (VKH) disease, sarcoidosis-associated uveitis, and juvenile idiopathic arthritis-associated uveitis. Specific polymorphisms of vitamin D family genes were found to correlate with uveitis in ankylosing spondylitis, Behçet's disease, VKH, and HLA B27-positive patients. Further understanding of the role of vitamin D, a known regulator of inflammatory processes, in noninfectious uveitis may advance capabilities in the fields of disease prevention and treatment.
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http://dx.doi.org/10.1016/j.survophthal.2021.07.006DOI Listing
July 2021

Autoimmune phenomena following SARS-CoV-2 vaccination.

Int Immunopharmacol 2021 Jul 10;99:107970. Epub 2021 Jul 10.

Department of Medicine, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Israel; Rheumatology Unit, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Israel. Electronic address:

Vaccines represent an attractive possible solution to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic. Widespread vaccine distribution has yet to occur in most countries, partially due to public concerns regarding possible side effects. While studies indicate the vaccine is exceptionally safe, rare systemic side effects remain possible. In Israel, where a large percentage of the population has been rapidly vaccinated, such adverse events may be more apparent. We report a series of patients presenting with de-novo or flares of existing autoimmune conditions associated with the Pfizer BNT162b2 mRNA SARS-CoV-2 vaccine. All patients were assessed in our tertiary care center in Israel and had no history of previous SARS-COV-2 infection. We observed that while immune phenomena may occur following vaccination, they usually follow a mild course and require modest therapy. We briefly expound on the theoretical background of vaccine related autoimmunity and explore future research prospects.
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http://dx.doi.org/10.1016/j.intimp.2021.107970DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8270741PMC
July 2021

Bilateral Endogenous Methicillin-Resistant Endophthalmitis in a Young Athlete: A Story of Full Recovery

Turk J Ophthalmol 2021 06;51(3):177-180

Hadassah Medical Center, Department of Ophthalmology, Jerusalem, Israel

Endogenous endophthalmitis (EE) is an ophthalmological emergency. We report the long-term outcome of bilateral methicillin-resistant EE in a 23-year-old healthy immunocompetent athlete who presented with EE secondary to pelvic abscess and remained with excellent vision.
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http://dx.doi.org/10.4274/tjo.galenos.2021.83809DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8251677PMC
June 2021

Anti-tumor necrosis factor-alpha therapy for refractory uveitic optic disk neovascularization in active non-infectious posterior and panuveitis.

Int Ophthalmol 2021 Jun 24. Epub 2021 Jun 24.

Department of Ophthalmology, Hadassah Medical Center, POB 12000, 91120, Jerusalem, Israel.

Purpose: Neovascularization of the optic disk (NVD) is mainly a complication of ischemic retinal disorders and of uveitis with vascular occlusion. Rarely, NVD may develop in patients with uveitis in the absence of retinal ischemia. This report aims to present our long-term experience of treating refractory uveitic NVD (uNVD) with adalimumab in three patients with active non-infectious posterior or panuveitis.

Methods: Observational case series was collected from institutional tertiary referral center. Patients with chronic refractory uNVD who completed 24 months of follow-up were included.

Results: uNVD was diagnosed on first presentation in all patients (3 eyes). Mean age at presentation was 29 years (median 20, range 18-49). Mean duration of complaints before presentation was 18.7 weeks (median 24, range 4-28). Uveitis was idiopathic in two patients and secondary to Behçet disease in one. All eyes had concomitant cystoid macular edema. Additional posterior segment signs included optic disk hemorrhage, preretinal hemorrhage and vitreous hemorrhage. All eyes showed retinal vascular leakage and macular leakage with no evidence of capillary non-perfusion. All patients were treated with systemic steroids and steroid-sparing agent. Because of NVD refractoriness, anti-TNF-α therapy was introduced at a mean of 24.7 weeks after first presentation (median 20, range 14-40). Complete regression of NVD was observed at a mean of 34.7 weeks (median 32, range 8-64) following adalimumab institution. Mean follow-up time after starting anti-TNF-α agents was 31.3 months.

Conclusions: Our results suggest that targeting TNF-α achieves long-term control of uveitic NVD refractory to conventional treatments.
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http://dx.doi.org/10.1007/s10792-021-01919-6DOI Listing
June 2021

Endogenous fungal endophthalmitis: risk factors, clinical course, and visual outcome in 13 patients.

Int J Ophthalmol 2021 18;14(1):97-105. Epub 2021 Jan 18.

Department of Ophthalmology, Hadassah Medical Center, Jerusalem 91240, Israel.

Aim: To analyze the risk factors, ophthalmological features, treatment modalities and their effect on the visual outcome in patients with endogenous fungal endophthalmitis (EFE).

Methods: Data retrieved from the medical files included age at presentation to the uveitis clinic, gender, ocular symptoms and their duration before presentation, history of fever, eye affected, anatomical diagnosis and laboratory evidence of fungal infection. Medical therapy recorded included systemic antifungal therapy and its duration, use of intravitreal antifungal agents and use of oral/intravitreal steroids. Surgical procedures and the data of ophthalmologic examination at presentation and at last follow-up were also collected.

Results: Included were 13 patients (20 eyes, mean age 58y). Ten patients presented after gastrointestinal or urological interventions and two presented after organ transplantation. In one patient, there was no history of previous intervention. Diagnostic vitrectomy was performed in 16 eyes (80%) and vitreous cultures were positive in 10 of the vitrectomized eyes (62.5%). In only 4 patients (31%), blood cultures were positive. All patients received systemic antifungal therapy. Sixteen eyes (80%) received intravitreal antifungal agent with voriconazole being the most commonly used. Visual acuity (VA) improved from 0.9±0.9 at initial exam to 0.5±0.8 logMAR at last follow-up (=0.03). A trend of greater visual improvement was noted in favor of eyes treated with oral steroids (±intravitreal dexamethasone) than eyes that were not treated with steroids. The most common complication was maculopathy. Twelve eyes (60%) showed no ocular complications.

Conclusion: High index of suspicion in patients with inciting risk factors is essential because of the low yield of blood cultures and the good general condition of patients at presentation. Visual prognosis is improved with the prompt institution of systemic and intravitreal pharmacotherapy and the immediate surgical intervention. Oral±local steroids could be considered in cases of prolonged or marked inflammatory responses in order to hasten control of inflammation and limit ocular complications.
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http://dx.doi.org/10.18240/ijo.2021.01.14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7790672PMC
January 2021

Progressive Visual Loss Without Retinal Detachment in Stickler Syndrome: An Uncommon and Novel Presentation.

Turk J Ophthalmol 2020 12;50(6):387-389

Hadassah-Hebrew University Medical Center, Department of Ophthalmology, Jerusalem, Israel.

Stickler syndrome is known to cause visual handicap due to the high incidence of retinal detachment. We aim to present an unusual case of a child with Stickler syndrome who had progressive visual loss secondary to atrophy of the outer retinal layers not associated with retinal detachment. This is a descriptive case report of a 9-year-old child with ocular history of high myopia who presented to our institution with suboptimal visual acuity in both eyes. After 2 years of follow up, he developed unilateral progressive visual loss with marked atrophy of the outer retinal layers and peripheral vascular leakage. Such a presentation has not been previously described in the literature to the best of our knowledge.
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http://dx.doi.org/10.4274/tjo.galenos.2020.33858DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802100PMC
December 2020

Catastrophic Antiphospholipid Syndrome: Skin, Eye and Brain Involvement.

Ocul Immunol Inflamm 2020 Nov 13:1-3. Epub 2020 Nov 13.

Department of Ophthalmology, Hadassah Medical Center, Jerusalem, Israel.

Purpose: To report on a patient with probable catastrophicantiphospholipid syndrome (CAPS) with eye, brain and skin involvement.

Methods: Descriptive presentation of the case and of the relevant clinical photographs.

Results: A 17-year-old girl presented with fatigue, loss of appetite, arthralgia, lower limb skin ulcers and livedo reticularis. Workup showed anemia, elevated ESR, CRP, and positive anti-phospholipid antibodies. Right eye funduscopy showed cotton-wool spots along the inferotemporal arcade with arteriolar occlusion, perivascular retinal hemorrhages, and diffuse retinal ischemia in the temporal peripheral retina. Fluorescein angiogram confirmed the widespread retinal ischemia. Brain MRI revealed several white matter lacunar infarcts, minute cortical/subcortical hemorrhages and subarachnoidal insular hemorrhage. The patient was treated with immunomodulatory therapy, Enoxaparin and retinal laser photocoagulation. Within 2 months of treatment, the facial livedo reticularis resolved and the leg ulcers markedly improved.

Conclusion: CAPS causes multiple organ thrombosis and is associated with high rate of mortality.
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http://dx.doi.org/10.1080/09273948.2020.1830122DOI Listing
November 2020

Uveitis Induced by Biological Agents Used in Cancer Therapy.

Ocul Immunol Inflamm 2020 Jun 16:1-5. Epub 2020 Jun 16.

Department of Ophthalmology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.

Purpose: To report cases of uveitis induced by biological therapy given for cancer.

Methods: Retrospective review of medical charts of patients.

Results: Included were six patients aged 14-81 years. Three were treated with vemurafenib and one each with nivolumab, ipilimumab, and osimertinib. The oncological diagnoses were metastatic thyroid carcinoma, pleomorphic xanthoastrocytoma, metastatic melanoma, adenocarcinoma of the lung, and metastatic breast cancer. Ocular manifestations appeared 4-82 weeks after the biological treatment was initiated. The most common ocular presentation was anterior uveitis. Onset was sudden in all cases. The median duration of uveitis was 70 weeks. Treatment included topical or systemic corticosteroids; one patient received a single intravitreal steroid injection in one eye.

Conclusions: Uveitis may rarely be induced by treatment with biological agents for cancer. Both oncologists and ophthalmologists should be aware of this potential side effect. Early detection and management can prevent permanent complications and save the patient's vision.
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http://dx.doi.org/10.1080/09273948.2020.1760310DOI Listing
June 2020

Ophthalmology practice during the COVID-19 pandemic.

BMJ Open Ophthalmol 2020 19;5(1):e000487. Epub 2020 Apr 19.

Ophthalmology Department, Hadassah Medical Center, Jerusalem, Israel.

Objective: To present an established practice protocol for safe and effective hospital-setting ophthalmic practice during the coronavirus disease 2019 (COVID-19) pandemic.

Methods And Analysis: Literature was reviewed to identify articles relevant to COVID-19 pandemic and ophthalmology. The following keywords were used: COVID-19, SARS-CoV-2 and telemedicine, combined with eye, ophthalmology, conjunctivitis and tears. Data were extracted from the identified manuscripts and discussed among subspecialists to obtain consensus evidence-based practice.

Results: A protocol for ophthalmic practice in the era of COVID-19 pandemic was established. The protocol covered patient screening, clinic flow, required personal protective equipment and modifications of ophthalmic equipment for improved safety.

Conclusion: Important literature emerged with respect to the practice of ophthalmology in the era of COVID-19. An evidence-based ophthalmic practice protocol was established and should be modified in the future to accommodate new insights on the COVID-19 pandemic.
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http://dx.doi.org/10.1136/bmjophth-2020-000487DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7222613PMC
April 2020

Implications of pars planitis-associated cystoid macular edema on visual outcome and management in children.

Graefes Arch Clin Exp Ophthalmol 2020 Aug 28;258(8):1803-1811. Epub 2020 Apr 28.

Department of Ophthalmology, Hadassah Medical Center, POB 12000, 91120, Jerusalem, Israel.

Purpose: Pars planitis is a commonly observed type of pediatric uveitis. The aim of this study was to evaluate the implications of pars planitis-associated cystoid macular edema (CME) on visual outcome and treatment modalities.

Methods: A retrospective review of medical records in a single center with academic practice.

Results: Included were 33 children (mean age 8 years, 58 eyes). Eighteen eyes developed CME (31%): in 67% of them, CME was diagnosed at presentation and in 33%, it developed at a mean of 57 months after presentation. Anterior and posterior segment complications were more prevalent in eyes with CME. Papillitis was significantly associated with the development of CME (OR 12.4, 95% CI 2.3 to 65.6, p = 0.003). Patients with CME were 1.7 times more likely to be treated with systemic therapy. By the last follow-up, 50% of patients who never developed CME were without systemic therapy compared with 13% of patients who developed CME (p = 0.034). LogMAR visual acuity improvement between presentation and month 36 was 0.41 for eyes with CME compared with 0.14 for eyes that never developed CME (p = 0.009).

Conclusion: Pars planitis-associated CME entailed higher prevalence of ocular complications, more frequent use of immunomodulatory therapy, and a lower rate of remission.
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http://dx.doi.org/10.1007/s00417-020-04696-7DOI Listing
August 2020

An Algorithm for the Diagnosis of Behçet Disease Uveitis in Adults.

Ocul Immunol Inflamm 2020 Apr 14:1-10. Epub 2020 Apr 14.

Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.

: To develop an algorithm for the diagnosis of Behçet's disease (BD) uveitis based on ocular findings.: Following an initial survey among uveitis experts, we collected multi-center retrospective data on 211 patients with BD uveitis and 207 patients with other uveitides, and identified ocular findings with a high diagnostic odds ratio (DOR). Subsequently, we collected multi-center prospective data on 127 patients with BD uveitis and 322 controls and developed a diagnostic algorithm using Classification and Regression Tree (CART) analysis and expert opinion.: We identified 10 items with DOR >5. The items that provided the highest accuracy in CART analysis included superficial retinal infiltrate, signs of occlusive retinal vasculitis, and diffuse retinal capillary leakage as well as the absence of granulomatous anterior uveitis or choroiditis in patients with vitritis.: This study provides a diagnostic tree for BD uveitis that needs to be validated in future studies.
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http://dx.doi.org/10.1080/09273948.2020.1736310DOI Listing
April 2020

Lens-induced uveitis: an update.

Graefes Arch Clin Exp Ophthalmol 2020 Jul 6;258(7):1359-1365. Epub 2020 Jan 6.

Department of Ophthalmology, Hadassah Medical Center, POB 12000, 91120, Jerusalem, Israel.

Ocular inflammation resulting from a lens pathology is rare in the absence of a cataract or lens trauma because of the lens' immune privilege. The lens can be a source of ocular inflammation when the capsule is broken or when lens proteins leak out through an intact capsule. These uveitides are termed lens-induced uveitis (LIU) and are often associated with advanced cataracts. Cataracts are part of the normal aging process, and in today's world, cataract surgery is a safe and affordable means of vision restoration in the developed world. In patients with neglected cataracts and in the developing world where cataract surgery rates are lower, LIU rates are higher together with the associated complications. In this literature review, we intend to equip the armamentarium of the practicing ophthalmologist with an updated knowledge on the demographic features, clinical characteristics, treatment options, and outcomes of LIU. This is to highlight the need for timely management of cataracts before the development of advanced cataracts and LIU.
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http://dx.doi.org/10.1007/s00417-019-04598-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223998PMC
July 2020

Standardization of Nomenclature for Ocular Tuberculosis - Results of Collaborative Ocular Tuberculosis Study (COTS) Workshop.

Ocul Immunol Inflamm 2019 Dec 10:1-11. Epub 2019 Dec 10.

Department of Ocular Pathology, Uveitis & Neuro-Ophthalmology Services; Sankaradeva Nethralaya, Guwahati, India.

: To standardize a nomenclature system for defining clinical phenotypes, and outcome measures for reporting clinical and research data in patients with ocular tuberculosis (OTB).: Uveitis experts initially administered and further deliberated the survey in an open meeting to determine and propose the preferred nomenclature for terms related to the OTB, terms describing the clinical phenotypes and treatment and reporting outcomes.: The group of experts reached a consensus on terming uveitis attributable to tuberculosis (TB) as tubercular uveitis. The working group introduced a SUN-compatible nomenclature that also defines disease "remission" and "cure", both of which are relevant for reporting treatment outcomes.: A consensus nomenclature system has been adopted by a large group of international uveitis experts for OTB. The working group recommends the use of standardized nomenclature to prevent ambiguity in communication and to achieve the goal of spreading awareness of this blinding uveitis entity.
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http://dx.doi.org/10.1080/09273948.2019.1653933DOI Listing
December 2019

Laser-induced CNV following hair removal procedure.

Rom J Ophthalmol 2019 Jul-Sep;63(3):281-286

Department of Ophthalmology, Hadassah Medical Center, Jerusalem, Israel.

To describe the chronological features of choroidal neovascular membrane (CNV) development subsequent to accidental firing of diode laser into the eye of a young female during hair epilation. Descriptive case report. The patient presented one week after the laser injury to a local ophthalmologist complaining of RE (right eye) blurred central vision. Snellen's visual acuity (VA) was 6/ 7.5. Optical coherence tomography (OCT) showed focal disruption of the ellipsoid and the interdigitation zones. Four weeks later, she presented with worsening symptoms and RE VA 6/ 15. Funduscopy revealed a perifoveal grayish lesion with adjacent retinal hemorrhage, which, on fluorescein angiography, was leaking, compatible with CNV. OCT showed a dome-shaped sub-retinal pigment epithelium lesion with extension into the subretinal space and little subretinal fluid. The patient was treated with one intravitreal bevacizumab injection. There was rapid regression of the CNV and improvement of VA to 6/ 7.5 at one-month visit and to 6/ 6 at 6-month visit. All the laser procedures should be conducted with intensive care for both the patient and the laser surgeon since inadvertent effects are constantly being reported due to lack of adherence to safety measures.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6820499PMC
December 2019

VASOPROLIFERATIVE TUMORS IN INTERMEDIATE UVEITIS.

Retina 2020 Sep;40(9):1765-1773

Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania.

Purpose: To describe patients with intermediate uveitis complicated by vasoproliferative tumors (VPTs).

Methods: Data were collected at seven Uveitis/Ocular Oncology centers on demographic, ophthalmic findings at baseline and at follow-up, and on imaging. The therapeutic intervention, final visual acuity, and duration of follow-up were recorded.

Results: A total of 36 eyes from 34 patients (12 men, 22 women; mean age 35.3 ± 14.2 years) were included in this study. Visual acuity at presentation ranged from 20/40 to counting fingers. At the time of VPT diagnosis, intermediate uveitis was active in all eyes. The mean VPT thickness was 3.06 ± 0.86 mm. Local treatment to the VPT was provide in 22 eyes (61.1%) and no local treatment to the VPT in 14 eyes (38.9%). After the VPT was detected, systemic or local treatment for the inflammation was initiated and on follow-up FAs 94.4% of the eyes showed resolution of the vascular leakage. During follow-up of 35.8 months, the 22 VPTs treated locally had a reduction in the tumor thickness to 1.25 mm, whereas the 14 VPTs untreated remained stable (final mean tumor thickness 2.65 mm).

Conclusion: The presence of active intermediate uveitis accompanied by VPTs suggests the need for an aggressive uveitis treatment.
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http://dx.doi.org/10.1097/IAE.0000000000002656DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7108969PMC
September 2020

Endophthalmitis Masquerading as Panuveitis After an Imperceptible Ocular Trauma

Turk J Ophthalmol 2019 02;49(1):44-46

Hadassah University Hospital, Ophthalmology Clinic, Jerusalem, Israel

Endophthalmitis after a penetrating trauma occurs in 3% to 30% of cases. Prompt recognition and treatment are paramount to avoid irreversible visual loss. We present a case of severe panuveitis following ocular trauma with a tree branch that did not cause any evident ocular wound and discuss the difficulties in achieving a diagnosis that can allow proper treatment. A healthy 21-year-old man presented with acute anterior uveitis. He was managed elsewhere with oral acyclovir and topical steroids for presumed herpetic uveitis. He subsequently developed severe panuveitis with profound decrease in vision. Diagnostic vitrectomy was performed and vitreous samples were positive for . Systemic and intravitreal antibiotic therapy was initiated and after 5 days, the patient recovered with a remarkable improvement in visual acuity to 6/12. Post-traumatic endophthalmitis can result from an imperceptible trauma with no obvious compromise of the globe.
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http://dx.doi.org/10.4274/tjo.galenos.2018.44520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6416482PMC
February 2019

Visual and Clinical Outcome of Macular Edema Complicating Pediatric Noninfectious Uveitis.

Am J Ophthalmol 2019 06 15;202:72-78. Epub 2019 Feb 15.

Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Purpose: To investigate the clinical course and visual outcome of macular edema (ME) in pediatric patients with chronic noninfectious uveitis.

Design: Retrospective case series.

Methods: The databases of the uveitis clinics of 4 tertiary medical centers in Israel and the UK were searched for all children treated for uveitic ME in the years 2005-2015. Data were collected from the medical records as follows: demographics, diagnosis, visual acuity, clinical and imaging findings, and treatment given specifically for ME. Findings at baseline and at 3, 6, 12, and 24 months were evaluated.

Results: The cohort included 25 children (33 eyes) of mean age 8.5 ± 3.4 years. The most common diagnosis was intermediate uveitis, in 14 children (7 idiopathic, 7 pars planitis). Uveitis was active at ME diagnosis in 28 eyes (84.8%). Median duration of follow-up was 48 months. Median time to resolution of ME was 6 months, with complete resolution in 25 eyes (75.8%) by 24 months. Baseline visual acuity was ≥20/40 in 8 eyes (24.2%), increased to 57.6% at 3 months (P < .0001), and remained stable thereafter. Treatment regimens included corticosteroids (systemically and/or locally), immunosuppression, and biologic therapies. No correlation was found between outcome and either structural characteristics of ME or specific treatment strategy.

Conclusions: The prognosis of pediatric uveitic ME is favorable despite its chronic course. Larger randomized controlled trials are needed to define differences among treatment regimens.
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http://dx.doi.org/10.1016/j.ajo.2019.02.011DOI Listing
June 2019

Psoriasis-associated progressive necrotizing posterior scleritis: A 6-year follow-up.

Eur J Ophthalmol 2020 May 14;30(3):NP7-NP10. Epub 2019 Jan 14.

Department of Ophthalmology, Hadassah Medical Center, Jerusalem, Israel.

Purpose: Posterior scleritis is the least frequent form of scleritis accounting for around 2%-8% of all scleritis cases. We aim to present the 6-year clinical course of a 62-year-old female patient with bilateral progressive necrotizing posterior scleritis who suffered from concurrent active psoriasis and psoriatic arthritis.

Methods: Descriptive case report.

Results: A middle-aged female patient was referred to our clinic because of left eye peripheral progressively enlarging white retinochoroidal lesions. Her previous work-up ruled out infectious and malignant etiologies. A second diagnostic vitrectomy was performed because of the slowly progressive and the atypical nature of the sectoral retinochoroidal patches in the retinal periphery. Again malignancy was ruled out. With the onset of cystoid macular edema and diffuse retinal vasculitis, which occurred concurrently with the reactivation of psoriasis and psoriatic arthritis, treatment was initiated with systemic immunosuppressants which initially included oral steroids and methotrexate and at the last follow-up 6 years after the first presentation included also cyclosporin and golimumab. Vision was preserved with quiescent uveitis and posterior scleritis.

Conclusion: Posterior scleritis is an uncommon condition and it is even rarer in the setting of psoriasis. The necrotizing inflammation observed in the present case and by others revealed sectoral progressive chorioretinitis as a clinical manifestation which may initially raise the suspicion of masquerade malignant and infectious etiologies. Detailed thorough history-taking remains the cornerstone in identifying the possible systemic associations even when occult or subclinical.
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http://dx.doi.org/10.1177/1120672118823121DOI Listing
May 2020

Demographic and Clinical Features of Pediatric Uveitis in Israel.

Ocul Immunol Inflamm 2020 17;28(1):43-53. Epub 2018 Oct 17.

Department of Ophthalmology, Hadassah Medical Center, The Hebrew University Hadassah Medical School, Jerusalem, Israel.

: To report the epidemiology, etiology, ocular characteristics, treatment and visual outcome of pediatric uveitis in Israel.: Retrospective study from two tertiary uveitis centers.: Included were 107 patients (182 eyes), 55% females. Mean age at diagnosis 8.8 years. Uveitis was predominantly anterior, idiopathic, bilateral, and chronic. Systemic associations were seen in 36% of patients of which the most common disease was juvenile idiopathic arthritis. Infectious uveitis accounted for 37% of posterior uveitis cases of which toxoplasmosis was the most common cause. Anterior segment complications were commonly observed at presentation (41%); the most predominant were posterior synechiae, cataract, and band keratopathy. The most common posterior segment complications were papillitis, epiretinal membrane, and macular atrophy/scar. Ninety-three percent of eyes had visual acuity >20/40 at last follow-up.: The pattern of pediatric uveitis in Israel is similar to that in the western world. Visual outcome was good in most eyes.
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http://dx.doi.org/10.1080/09273948.2018.1535079DOI Listing
December 2020

Herpetic Anterior Uveitis - Analysis of Presumed and PCR Proven Cases.

Ocul Immunol Inflamm 2019 12;27(2):211-218. Epub 2018 Oct 12.

b Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel.

Purpose: To describe the demographics and clinical characteristics of patients with herpetic anterior uveitis (HAU), and compare characteristics by pathogen, recurrence, and association to iris atrophy.

Methods: Multicenter, retrospective study of AU patients diagnosed clinically and by polymerase chain reaction (PCR).

Results: The study included 112 eyes in 109 patients: 54 (48.2%) HSV, 34 (30.4%) VZV, 2 (1.8%) CMV, and 22 (19.6%) unspecified diagnosis. HSV eyes, compared to VZV, had a higher recurrence rate, corneal involvement, KPs, iris atrophy, elevated IOP and posterior synechia (p < 0.05). VZV patients had more frequent immunomodulatory treatments and history of systemic herpetic disease (p < 0.05). Fifty-nine (52.7%) eyes had recurrent disease. Iris atrophy was associated with a higher prevalence of posterior synechia, dilated distorted pupil, and high IOP (p < 0.05).

Conclusion: Different HAU-causing Herpesviridae produce common clinical findings; therefore, PCR should be used more often to confirm specific diagnosis. Iris atrophy was associated with more severe disease.
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http://dx.doi.org/10.1080/09273948.2018.1483521DOI Listing
January 2020

Cilioretinal artery hypoperfusion and its association with paracentral acute middle maculopathy.

Br J Ophthalmol 2019 08 26;103(8):1137-1145. Epub 2018 Sep 26.

Stein Eye Institute, University of California, Los Angeles, California, USA.

Background/aims: To study the multimodal imaging findings of a large series of eyes with cilioretinal artery obstruction (CILRAO) and describe the systemic associations.

Methods: Multicentre, retrospective chart review from 12 different retina clinics worldwide of eyes with CILRAO, defined as acute retinal whitening in the distribution of the cilioretinal artery, were identified. The clinical, systemic information and multimodal retinal imaging findings were collected and analysed.

Results: A total of 53 eyes of 53 patients with CILRAO were included in the study. In 100% of eyes, fundus photography illustrated deep retinal whitening corresponding to the course of the cilioretinal artery. Twenty-eight patients (52.8%) presented with isolated CILRAO (baseline best-corrected visual acuity (BCVA) 20/50, final BCVA 20/25) associated with nocturnal hypotension, 23 patients (43.4%) with CILRAO secondary to central retinal vein occlusion (CRVO) (baseline BCVA 20/40, final BCVA 20/20) and two patients with CILRAO due to biopsy-proven giant cell arteritis (GCA) (baseline BCVA 20/175, final BCVA 20/75). With spectral domain optical coherence tomography (SD-OCT), a hyper-reflective band involving the inner nuclear layer (ie, paracentral acute middle maculopathy or PAMM) was noted in 51 eyes (28/28 eyes with isolated CILRAO and 23/23 eyes with CILRAO+CRVO) corresponding to the retinal whitening. In the two eyes with CILRAO+GCA, SD-OCT illustrated hyper-reflective ischaemia of both the middle and inner retina.

Conclusions: Isolated CILRAO and CILRAO secondary to CRVO are the result of hypoperfusion or insufficiency, rather than occlusion, of the cilioretinal artery and are associated with PAMM or selective infarction of the the inner nuclear layer. With GCA, there is complete occlusion of the cilioretinal artery producing ischaemia involving both the middle and inner retina associated with worse visual outcomes.
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http://dx.doi.org/10.1136/bjophthalmol-2018-312774DOI Listing
August 2019

Cat-scratch disease: ocular manifestations and treatment outcome.

Acta Ophthalmol 2018 Jun 5;96(4):e524-e532. Epub 2018 Mar 5.

Infectious Disease Unit and The Bernard Pridan Laboratory for Molecular Biology of Infectious Diseases, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Purpose: To characterize cat-scratch disease (CSD) ocular manifestations and visual outcome and evaluate the effect of systemic antibiotics and corticosteroids on final visual acuity (VA).

Methods: Multicentre retrospective cohort study. Medical records of 86 patients with ocular disease (107 eyes) of 3222 patients identified in a national CSD surveillance study were reviewed.

Results: Mean age was 35.1 ± 14.2 years. Median follow-up was 20 weeks (range 1-806 weeks). Of 94/107 (88%) eyes with swollen disc, 60 (64%) had neuroretinitis at presentation, 14 (15%) developed neuroretinitis during follow-up, and 20 (21%) were diagnosed with inflammatory disc oedema. Optic nerve head lesion, uveitis, optic neuropathy and retinal vessel occlusion were found in 43 (40%), 38 (36%), 34 (33%) and 8 (7%) eyes, respectively. Good VA (better than 20/40), moderate vision loss (20/40-20/200) and severe vision loss (worse than 20/200) were found in 26/79 (33%), 35/79 (44%) and 18/79 (23%) eyes at baseline and in 63/79 (80%), 11/79 (14%) and 5/79 (6%) eyes at final follow-up, respectively (p < 0.001). Significant VA improvement (defined as improvement of ≥3 Snellen lines at final follow-up compared to baseline) occurred in 12/24 (50%) eyes treated with antibiotics compared with 14/16 (88%) eyes treated with antibiotics and corticosteroids (p = 0.02). Multivariate logistic regression was suggestive of the same association (odds ratio 7.0; 95% CI 1.3-37.7; p = 0.024).

Conclusion: Optic nerve head lesion is a common and unique manifestation of ocular CSD. Most patients improved and had final good VA. Combined antibiotics and corticosteroid treatment was associated with a better visual outcome.
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http://dx.doi.org/10.1111/aos.13684DOI Listing
June 2018

The effect of anti-tumor necrosis factor alpha agents on the outcome in pediatric uveitis of diverse etiologies.

Graefes Arch Clin Exp Ophthalmol 2018 Apr 18;256(4):801-808. Epub 2018 Feb 18.

Department of Ophthalmology, Rabin Medical Center-Beilinson Hospital, Petach Tikva, Israel.

Purpose: This study aimed to report the clinical outcome of children with uveitis treated with anti-tumor necrosis factor alpha (TNF-α) agents.

Methods: This included a retrospective cohort study. Children with uveitis treated with infliximab or adalimumab in 2008-2014 at five dedicated uveitis clinics were identified by database search. Their medical records were reviewed for demographic data, clinical presentation, ocular complications, and visual outcome. Systemic side effects and the steroid-sparing effect of treatment were documented.

Results: The cohort included 24 patients (43 eyes) of whom 14 received infliximab and 10 received adalimumab after failing conventional immunosuppression therapy. Mean age was 9.3 ± 4.0 years. The most common diagnosis was juvenile idiopathic arthritis-related uveitis (n = 10), followed by Behçet's disease (n = 4), sarcoidosis (n = 1), and ankylosing spondylitis (n = 1); eight had idiopathic uveitis. Ocular manifestations included panuveitis in 20 eyes (46.5%), chronic anterior uveitis in 19 (44.2%), and intermediate uveitis in 4 (9.3%). The duration of biologic treatment ranged from 6 to 72 months. During the 12 months prior to biologic treatment, while on conventional immunosuppressive therapy, mean visual acuity deteriorated from 0.22 to 0.45 logMAR, with a trend of recovery to 0.25 at 3 months after initiation of biologic treatment, remaining stable thereafter. A full corticosteroid-sparing effect was demonstrated in 16 of the 19 patients (84.2%) for whom data were available. Treatment was well tolerated.

Conclusions: Treatment of pediatric uveitis with anti-TNF-α agents may improve outcome while providing steroid-sparing effect, when conventional immunosuppression fails. The role of anti-TNF-α agents as first-line treatment should be further investigated in controlled prospective clinical trials.
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http://dx.doi.org/10.1007/s00417-018-3928-6DOI Listing
April 2018

Leucine-Rich α-2-Glycoprotein-1 (LRG-1) Expression in Retinoblastoma.

Invest Ophthalmol Vis Sci 2018 02;59(2):685-692

Department of Ophthalmology, Hadassah Medical Center, Jerusalem.

Purpose: Retinoblastomas' growth rate is dependent on their ability to induce neovascularization. Leucine-rich α-2-glycoprotein-1 (LRG-1) was recently reported to be upregulated in human retinal disease with neovascular pathology. The purpose of the study was to determine LRG-1 expression in human retinoblastoma and to correlate it with clinical and histopathologic parameters and to assess how its expression correlates with vascular endothelial growth factor (VEGF) expression.

Methods: LRG-1 expression was immunohistochemically evaluated in 34 retinoblastoma sections. Immunofluorescence for LRG-1/VEGF-A, LRG-1/TGF-β1/CD31, and LRG-1/Ki67 was performed. Quantitative RT-PCR analysis for the expression of LRG-1 was also done.

Results: LRG-1 was found to be extensively and robustly expressed in retinoblastoma tumors (88%) irrespective of the degree of invasiveness, differentiation, iris neovascularization, and anterior segment involvement. LRG-1 immunoreactivity was predominantly observed in the central tumor vasculature and in the surrounding rim of ischemia. The higher frequency of LRG-1 expression in the presence of optic nerve infiltration, vitreous seeding, and necrosis was not statistically significant. Colocalization was observed between LRG-1 and VEGF-A staining, and no difference in their counts was detected. Quantitative RT-PCR analysis showed that LRG-1 gene expression was significantly upregulated (4.8-fold increase, P = 0.01).

Conclusions: LRG-1 was highly expressed in human retinoblastoma sections, thus providing new insights into the molecular mechanism of retinoblastoma pathogenesis, and suggests a possible new therapeutic target. LRG-1 is a novel oncogene-associated protein shown to be vital to the progression of human cancers. Inhibiting tumor vasculature is progressively evolving as a target in anticancer therapy.
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http://dx.doi.org/10.1167/iovs.17-22785DOI Listing
February 2018

Complications in Intermediate Uveitis: Prevalence, Time of Onset, and Effects on Vision in Short-Term and Long-Term Follow-Up.

Ocul Immunol Inflamm 2019 25;27(3):447-455. Epub 2018 Jan 25.

a Department of Ophthalmology , Hadassah Medical Center , Jerusalem , Israel.

: To study the prevalence and time of onset of ocular complications in intermediate uveitis (IU) and to assess their effects on visual outcome in short-term and long-term follow-up. : A retrospective cohort study of patients with IU who had a minimal follow-up of one year. : 96 patients (174 eyes, 70% females) were included with a mean age at presentation of 30 years. Children constituted 38% of all patients. Mean follow- up was 64.9 months. Pars planitis was the most common form followed by sarcoidosis and multiple sclerosis. Cystoid macular edema (CME), cataract, epiretinal membrane and posterior synechiae were the most prevalent complications. Posterior synechiae, band keratopathy, cataract and papillitis at presentation were associated with worse presenting visual acuity (VA). Of the late-onset complications, glaucoma/ocular hypertension (OHT) was the most significantly associated with worse long-term VA. Most sight-threatening complications (namely CME and glaucoma) were diagnosed at presentation while late complications predominantly affected the posterior segment and included among others peripheral retinal elevations, vasoproliferative tumors, and vitreous hemorrhage. Median LogMAR VA improved at short-term and long-term follow-up, from 0.2 to 0.1 (p<0.001). Subgroup analysis revealed significant VA improvement for eyes with all the different complications except for eyes with glaucoma/OHT. : IU is a chronic low-grade uveitis that may be associated with protean early and late complications of the anterior or posterior segments or both. Optimal treatment regimens are imperative for the strict control of inflammation and proper management of complications thus allowing a favorable long-term prognosis.
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http://dx.doi.org/10.1080/09273948.2017.1420203DOI Listing
December 2019

Ophthalmic manifestations of bartonella infection.

Curr Opin Ophthalmol 2017 Nov;28(6):607-612

aDepartment of Ophthalmology, Hadassah Medical Center, Jerusalem bDepartment of Ophthalmology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey.

Purpose Of Review: The eye is commonly affected in disseminated cat scratch disease (CSD) caused by Bartonella species. This article reviews recently published data on epidemiology of CSD, clinical features of ocular involvement, diagnosis and treatment.

Recent Findings: The annual incidence of CSD has been estimated as 4.7 per 100 000 in the United States. It occurs predominantly in the southern states, with a peak in January, and disproportionately affects children. Retinal infiltrates, neuroretinitis and branch retinal artery occlusions have been reported as common manifestations of ocular bartonellosis in recent series. The use of different antigens for serodiagnosis and new real-time PCR assays for molecular diagnosis have been described. Despite lack of a standard treatment, good visual outcomes were generally reported in patients with ocular bartonellosis.

Summary: Bartonella infections continue to be a burden worldwide and epidemiologic features may guide preventive measures in high-risk regions and populations. An increased awareness of diverse posterior segment manifestations will lead to an early diagnosis of ocular bartonellosis. Laboratory diagnostic methods continue to evolve and may be applied to the investigation of ocular fluids for a definitive diagnosis of ocular bartonellosis. Well designed clinical trials are required to establish the optimum treatment of especially sight-threatening manifestations.
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http://dx.doi.org/10.1097/ICU.0000000000000419DOI Listing
November 2017

Exudative retinal detachment.

Surv Ophthalmol 2017 Nov - Dec;62(6):723-769. Epub 2017 May 13.

Department of Ophthalmology, University of Ankara, Ankara, Turkey.

Exudative retinal detachment develops when fluid collects in the subretinal space. The subretinal space between the photoreceptors and the retinal pigment epithelium is the remnant of the embryonic optic vesicle. In the developed eye the subretinal space is of minimal size, but it can reopen under pathological conditions that disrupt the integrity of blood-retinal barrier. Inflammatory, infectious, infiltrative, neoplastic, vascular, and degenerative conditions may be associated with blood-retinal barrier breakdown and the sequential development of exudative retinal detachment. We elaborate on the pathogenesis and the differential diagnosis of exudative retinal detachment and specifically discuss the spectrum of diseases associated with exudative retinal detachment in uveitis clinics.
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http://dx.doi.org/10.1016/j.survophthal.2017.05.001DOI Listing
December 2017

Pattern and causes of visual loss in Behçet's uveitis: short-term and long-term outcomes.

Graefes Arch Clin Exp Ophthalmol 2017 Jul 10;255(7):1423-1432. Epub 2017 Apr 10.

Department of Ophthalmology, Hadassah Medical Center, Jerusalem, Israel.

Background: To analyze the pattern and causes of visual loss in patients with Behçet's uveitis and to report on the short-term outcome at 6 months and at last follow-up visit. Also, to analyze the pattern of visual acuity changes in eyes with and without macular involvement at the specified time points.

Methods: This is a retrospective cohort study of a single-center in an academic practice. Fifty-three patients with Behçet's uveitis evaluated between 2004 and 2014 were included. Data on patients diagnosed with Behçet's uveitis were entered retrospectively into a database and analyzed.

Results: Included were 93 eyes with Behçet's uveitis involving the posterior segment. Frequencies of ≤20/50 and of ≤20/200 VA at presentation were 23.7% and 37.6%, respectively. Retinitis, macular inflammatory infiltrate, and dense vitritis were significantly associated with worse vision. Eyes with macular atrophy and macular inflammatory infiltrate sustained the worst logMAR VA at presentation (1.87 and 1.73, respectively) compared to eyes with cystoid macular edema and epiretinal membrane (0.76 and 0.63, respectively). Eyes with no macular involvement had the best VA at presentation. Mean difference in logMAR VA between presentation and the specified time points was greatest for eyes with macular inflammatory infiltrate.

Conclusions: Behçet's disease affected mostly young males with a male-to-female ratio of 4.8:1. Panuveitis and posterior uveitis were the predominant forms and they were intrinsically associated with sight-threatening potential and breadth of ocular complications for which aggressive immunosuppressive therapy was essential.
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http://dx.doi.org/10.1007/s00417-017-3667-0DOI Listing
July 2017

Uveitic Glaucoma: Long-term Clinical Outcome and Risk Factors for Progression.

Ocul Immunol Inflamm 2017 Dec 12;25(6):740-747. Epub 2016 Dec 12.

a Department of Ophthalmology , Rabin Medical Center, Beilinson Hospital , Petach Tikva , Israel.

Purpose: To study the long-term clinical outcomes of uveitic glaucoma and to identify risk factors for progression.

Methods: Retrospective study of uveitic glaucoma patients in two tertiary medical centers in 2003-2015. Patient- and disease-related data was retrieved. Clinical parameters and visual fields measured at predetermined time points were recorded. Outcome measures included maintaining intraocular pressure ≤21 mmHg and preserving visual fields.

Results: Included were 34 patients (53 eyes), with a mean follow-up of 7 years. Idiopathic anterior uveitis and open-angle glaucoma were most common. In total, 62% of eyes were steroid responders. Higher IOP was associated with posterior synechiae, peripheral-anterior synechiae, steroidal, and immunomodulatory therapy (p<0.05). Glaucomatous field defects developed in 49%, with most showing no progression, despite elevation of cup-to-disc ratio (p<0.05).

Conclusions: Chronic severe uveitis, expressed by structural complications and immunomodulatory therapy, was associated with high IOP and the need for more IOP lowering medications, but was unrelated to glaucomatous damage.
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http://dx.doi.org/10.1080/09273948.2016.1255341DOI Listing
December 2017

Ocular Siderosis Subsequent to a Missed Pars Plana Metallic Foreign Body that Masqueraded as Refractory Intermediate Uveitis.

Ocul Immunol Inflamm 2018 16;26(4):598-600. Epub 2016 Nov 16.

a Department of Ophthalmology , Hadassah Medical Center , Jerusalem , Israel.

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http://dx.doi.org/10.1080/09273948.2016.1240206DOI Listing
June 2019
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