Book Review

Uveitis: Fundamentals and clinical practice

N Engl J Med 1996; 334:1552June 6, 1996

Article

Uveitis: Fundamentals and clinical practice
Second edition. By Robert B. Nussenblatt, Scott M. Whitcup, and Alan G. Palestine. 413 pp., illustrated. St. Louis, Mosby, 1995. $99. ISBN: 0-8151-6446-7

Since its first publication in 1989, Uveitis: Fundamentals and Clinical Practice has been the preeminent textbook of clinical ocular immunology. The extensively rewritten second edition includes a third author (Dr. Whitcup) and an excellent new selection of color photographs, but it retains the basic format of the first edition. The book has five sections, on fundamentals and pathogenesis, diagnosis, medical and surgical therapy, and infectious and noninfectious uveitis syndromes. The three authors, from the National Eye Institute, have prepared a highly readable book with a consistent style and approach. The bibliography is comprehensive.

The book is directed toward the specialist in uveitis more than the general ophthalmologist, since the focus is on less common and more complicated diseases. Anterior uveitis, for example, which constitutes the vast majority of cases of uveitis seen by most ophthalmologists, is accorded roughly the same amount of space as uveitis caused by parasitic diseases. Nonetheless, the well-written sections on history taking, diagnostic testing, and critical evaluation of the literature would be of value to anyone with an interest in ophthalmology or clinical immunology. It is interesting to note that tests for immune complexes, which in the 1980s were thought to play an important part in the pathogenesis of uveitis, are now “better left unordered.” On the other hand, the importance of tests for antineutrophil cytoplasmic antibodies in the diagnosis of Wegener's granulomatosis, which were not available 10 years ago, is emphasized. This is no reflection on the excellence of the book, but it is disappointing to realize that our understanding of ocular inflammation at the molecular level has advanced considerably, whereas our understanding of many diseases has not. Conditions such as serpiginous choroidopathy, the white-dot syndromes, and pars planitis remain ill-defined, with no major therapeutic advances in the past decade. The new drugs available to treat uveitic diseases either have limited therapeutic indications (cidofovir and foscarnet for cytomegalovirus retinitis, atovaquone for ocular toxoplasmosis) or have yet to have much clinical impact (tacrolimus, also known as FK 506).

There are disadvantages to a textbook based on the perspective of a single institution. As is consistent with the clinical focus at the National Eye Institute, the section on the surgical treatment of uveitis emphasizes diagnostic rather than therapeutic procedures and is perhaps unduly conservative. Extracapsular cataract extraction is recommended in older patients with posterior synechiae, whereas with current techniques and pupil expanders, phacoemulsification can almost always be performed safely in such patients. A more extensive discussion of the preoperative and postoperative management of these cases would have been helpful. The authors consider cyclosporine rather than alkylating agents the immunosuppressive drug of choice in uveitis unresponsive to corticosteroids, a view not all experts share. The toxicity of cytotoxic drugs such as cyclophosphamide is emphasized, but a problem sometimes associated with cyclosporine therapy — namely, the tendency for the disease to recur when the drug is discontinued — is not adequately addressed. Scleritis and ocular cicatricial pemphigoid, two conditions commonly treated with cyclophosphamide by uveitis specialists, are not discussed.

The authors have done an admirable job of keeping the book as up-to-date as possible. The section on ocular complications of AIDS, for example, lists many recent studies of the treatment of cytomegalovirus retinitis. Newly recognized diseases, such as progressive outer retinal necrosis and acute zonal occult outer retinopathy, are covered in detail, as is the ganciclovir intraocular device that was recently approved by the Food and Drug Administration. Experimental treatments of uveitis, including the use of monoclonal antibodies and oral tolerance, are also mentioned.

James P. Dunn, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 21205