Malingering or simulation in ophthalmology-visual acuity

Simulation can be defined as malingering, or sometimes functional visual loss (FVL). It manifests as either simulating an ophthalmic disease (positive simulation), or denial of ophthalmic disease (negative simulation). Conscious behavior and compensation or indemnity claims are prominent features of simulation. Since some authors suggest that this is a manifestation of underlying psychopathology, even conversion is included in this context. In today's world, every ophthalmologist can face with simulation of ophthalmic disease or disorder. In case of simulation suspect, the physician's responsibility is to prove the simulation considering the disease/disorder first, and simulation as an exclusion. In simulation examinations, the physician should be firm and smart to select appropriate test(s) to convince not only the subject, but also the judge in case of indemnity or compensation trials. Almost all ophthalmic sensory and motor functions including visual acuity, visual field, color vision and night vision can be the subject of simulation. Examiner must be skillful in selecting the most appropriate test. Apart from those in the literature, we included all kinds of simulation in ophthalmology. In addition, simulation examination techniques, such as, use of OCT (optical coherence tomography), frequency doubling perimetry (FDP), and modified polarization tests were also included. In this review, we made a thorough literature search, and added our experiences to give the readers up-to-date information on malingering or simulation in ophthalmology.     

Ocular malingering and hysteria: diagnosis and management

Confronted with a claim of poor vision in the absence of any apparent pathology, the ophthalmologist must consider the possibility that the patient is malingering or hysterical. The authors define four categories of such patients, and recommend diagnostic approaches for each. Specific diagnostic tests are described, as are methods of managing patients once the diagnosis of malingering or hysteria has been made.     

New pharmacotherapy options for noninfectious posterior uveitis

International Ophthalmology - Noninfectious inflammation of the posterior eye segment represents an important cause of visual impairment. It often affects relatively young people and causes a...     

Anti-inflammatory treatment of uveitis with biologicals: new treatment options that reflect pathogenetic knowledge of the disease

Background  

Endogenous uveitis is a sight-threatening disease. In addition to corticosteroids, immunosuppressive agents are commonly used to treat patients with severe course. Immunosuppressive drugs act nonspecifically, rather than providing a specific interaction with the critical pathogenetic pathways of uveitis. Better knowledge of the basic mechanisms underlying uveitis and of the molecules that are important for regulating inflammation has helped to create new and more specific treatment approaches. Biological therapy for inflammatory diseases employs substances that interfere with specific molecules or pathways induced in the body during the inflammatory process.     

Glaucoma and uveitis. Causes of and treatment options for increased intraocular pressure in cases of inflammatory ophthalmology

Uveitic secondary glaucoma poses one of the most difficult problems for differential diagnostics and therapeutics in the field of clinical glaucomatology. The prevalence of glaucoma among uveitis patients ranges between 5 and 20% with great fluctuations depending on the underlying disease, duration of the disease, and the patient's age. Based on slit-lamp examination, uveitis can be classified as granulomatous and non-granulomatous. The effects of uveitic glaucoma on the quality of life and central visual acuity are particularly serious during childhood. Surgical reduction of eye pressure in cases of uveitic secondary glaucoma should only be performed if medical treatment of the underlying disease or ocular inflammation does not lower the eye pressure level and if in the presence of glaucomatous damage to the optic nerve the level of intraocular pressure is so high that a drastic decrease in pressure that cannot be achieved by medication becomes necessary.     

视网膜母细胞瘤的治疗方案选择

视网膜母细胞瘤的治疗需根据不同的患者情况制定个性化的治疗方案.早期肿瘤患者可选择眼局部治疗,如冷冻治疗、激光光凝治疗、经瞳孔温热疗法治疗、局部放射治疗等;中期肿瘤选择化学减容治疗联合眼局部治疗;晚期肿瘤患者选择眼球摘除和全身化疗.如果出现肿瘤眼球外生长,还要追加眼眶部放射治疗;肿瘤全身转移患者一般通过强化的全身化疗联合自体干细胞移植等方法治疗.     

Simvastatin-induced rhabdomyolysis following cyclosporine treatment for uveitis

The purpose of this study was to heighten awareness of a potentially life-threatening drug interaction in patients with chronic uveitis treated with cyclosporine. A 69-year-old female with chronic posterior uveitis was treated with cyclosporine while on concomitant oral simvastatin for hypercholesterolemia. Rhabdomyolysis developed with acute renal failure from the probable interaction between these drugs. Discontinuation of simvastatin and cyclosporine resulted in resolution of rhabdomyolysis and normalization of renal function. Statins are associated with a small, dose-related risk of myopathy, myositis, and rhabdomyolysis. Cyclosporine is a potent inhibitor of simvastatin metabolism, and may therefore facilitate simvastatin-induced rhabdomyolysis. Concomitant use of statins and cyclosporine should be avoided.     

Ganciclovir for the treatment of anterior uveitis

Background: Ganciclovir, administered systemically or intraocularly, is effective in controlling cytomegalovirus (CMV) retinitis in immunocompromised patients. The efficacy of therapy with this antiviral substance was investigated in an immunocompetent patient with CMV uveitis causing secondary glaucoma. Methods: To identify the presence of an intraocular viral infection, anterior chamber taps to detect the intraocular synthesis of IgG antibodies and PCR testing were carried out. Clinically, the degree of intraocular inflammation and the intraocular pressure (IOP) values were monitored. During this time, the patient was treated systemically with ganciclovir administered orally and intravenously. Results: The intraocular synthesis of IgG antibodies specific for CMV was found in two samples of aqueous humor, but negative for other viruses. PCR testing was negative for HSV, VZV and CMV at each time. During this time, the patient was treated systemically with ganciclovir administered either intravenously or orally. As a response to therapy with ganciclovir, the elevated IOP values decreased to normal and the intraocular inflammation declined. After cessation of ganciclovir administration, the inflammation and secondary glaucoma recurred. Conclusion: In this case of anterior uveitis presumably caused by CMV inducing secondary glaucoma, treatment with ganciclovir led to a decrease of the inflammation and normalization of IOP. It appears that continuous administration may be required to control the infection in an immunocompetent patient. Received: 17 February 2000 Revised: 11 May 2000 Accepted: 8 June 2000     

Surgical treatment options for paralytic lagophthalmos

Facial nerve palsy may result from a broad spectrum of causes, which is largely due to its topographic complexity. Different types of cross plastic surgery and nerve autografting and muscle transplantation and transposition are used to recover nerve function. Lagophthalmos is a most severe sequel of facial nerve palsy. Blephorrhaphy and tarsorrhaphy, operations for removal of lower eyelid ectropion, and different types of palpebral fissure narrowing are used widely to correct lagophthalmos and to prevent corneal complications. Various weight implants and special springs are employed to modify upper eyelid mobility. The lengthening of the upper eyelid levator and the administration of hyaluronic acid gel and botulotoxin type A are proposed for additional upper eyelid descent.     

Current treatment options for corneal ectasia

PURPOSE OF REVIEW: The approach to the management of various forms of corneal ectasia is changing, with the advent of new surgical and nonsurgical options. The purpose of this review is to summarize and evaluate relevant studies on new treatments for keratoconus, postrefractive surgery keratectasia, and peripheral ectatic corneal disorders. RECENT FINDINGS: Various alternatives to corneal transplantation for the management of keratoconus aim to enhance corneal rigidity by means of nonsurgical collagen cross-linking, or with the use of intrastromal corneal ring segments, and studies suggest that these treatments may reduce astigmatism or ectatic progression to varying degrees. Recent developments in anterior lamellar keratoplasty enable targeted replacement or augmentation of corneal stroma without replacement of endothelium, and include procedures such as deep anterior lamellar keratoplasty, microkeratome or laser-assisted anterior lamellar surgery, and peripheral tectonic lamellar keratoplasty procedures demonstrate successful reinforcement of peripheral stroma to reduce astigmatism. SUMMARY: These new forms of surgery are viable alternatives to conventional penetrating keratoplasty and bring added safety profiles for long-term visual rehabilitation and restoration of tectonic integrity in central and peripheral forms of corneal ectasia.     

Clinical outcomes of cyclosporine treatment for noninfectious uveitis

Purpose

To assess the clinical outcomes of cyclosporine treatment for noninfectious uveitis.

Methods

A retrospective review of medical records was completed for 182 noninfectious uveitis patients who were treated with cyclosporine between January 2001 and August 2010. Data was obtained relevant to demographic characteristics, anatomic classification, and laterality of uveitis, associated systemic disorder, dosage of cyclosporine and prednisolone, usage of other immunosuppressive drugs, visual acuity (VA), control of uveitic activity, and adverse effects during the cyclosporine use.

Results

Uveitic activity was controlled to a level of minimal inflammation in 89.0% and completely in 78.6% of patients by the median duration of 49 and 98 days, respectively. Prednisolone-sparing (dose ≤10 mg) control of inflammation equal to or less than the minimal activity was achieved in 75.3% of patients. VA was aggravated more than 0.2 logarithm of the minimum angle of resolution in 17.3% of eyes in spite of cyclosporine treatment for the mean follow-up of 698.4 days. Dose reduction and cessation of cyclosporine was required only in 3.3% and 9.3%, respectively, due to the intolerable toxicity, although 44.0% of patients experienced mild to moderate adverse effects.

Conclusions

Cyclosporine combined with corticosteroids or other immunosuppressive drugs as needed is an effective treatment for noninfectious uveitis, thus minimizing the adverse effects of corticosteroids and other toxic drugs. However, careful monitoring for the toxicity of cyclosporine is needed, because a small group of patients cannot tolerate its toxicity.     

Increased intraocular pressure during treatment for chronic uveitis

Objectives: (1) To prospectively evaluate the incidence of increased intraocular pressure (IOP) in patients suffering from chronic uveitis. (2) To identify the main factors responsible for an increase in the IOP among these patients. Methods: Two hundred and one patients suffering from chronic uveitis were included. Enrolled patients had an initial IOP of 8–18 mmHg. The patients were treated and clinically monitored during a period of 4 years. The IOP was measured at each visit and its changes followed prospectively. All patients were followed up for at least 12 months after enrollment. Results: Twenty-four (12%) of the 201 patients had IOP higher than 24 mmHg at two or more consecutive visits. Of these 24 patients, 19 suffered from bilateral uveitis and 5 had unilateral disease. Four of the 19 patients with bilateral uveitis developed a constant IOP higher than 24 mmHg in both eyes, while in 15 patients an IOP higher than 24 mmHg persisted only in one eye. A close association between the increased IOP and the use of corticosteroids was found in 18 of the 24 cases (75%). This association was ascertained in 16 of these patients by the decrease in IOP levels on discontinuation of the corticosteroid regimen and the renewed increase in IOP on rechallenge. The increased IOP was due to pupillary block in three cases (12.5%), to iris and angle neovascularization in two (8.3%), and to the inflammatory process per se in one case only (4.2%). Conclusions: This study demonstrates that a persistent elevation of the IOP in patients suffering from chronic uveitis is, in the majority of cases, associated with the use of corticosteroids.     

重视葡萄膜炎药物治疗研究,提高葡萄膜炎药物治疗效果

各类非感染性葡萄膜炎的治疗,糖皮质激素是首选药物.但单一药物治疗对慢性或复发性葡萄膜炎的疗效欠佳,长期应用又具有明显的毒副作用,因此部分患者需辅助以免疫抑制剂或生物制剂治疗.不同类型免疫抑制剂和生物制剂的作用机制不完全相同,因此各自的适应证、疗效和毒副作用也不尽一样.在临床实践中,应根据葡萄膜炎的类型选择敏感的免疫抑制剂或生物制剂治疗,同时密切观察其疗效和毒副作用.葡萄膜炎治疗中的常用药物类型、疗效以及存在的问题值得我们进一步关注和深入研究,以提高葡萄膜炎药物治疗的效果.     

非感染性葡萄膜炎药物治疗进展

糖皮质激素及其他免疫抑制剂是非感染性葡萄膜炎的主要治疗方案,新型生物可降解缓释玻璃体植入剂临床应用前景广阔,生物制剂显示出独特疗效.目前应用的局部糖皮质激素包括氟西奈德植入剂、地塞米松玻璃体植入剂等.免疫抑制剂包括抗代谢药甲氨蝶呤、硫唑嘌呤、霉酚酸酯等;T细胞抑制剂环孢霉素、他克莫司、雷帕霉素等;烷化剂环磷酰胺、苯丁酸...