Choroidal lesions in varicella zoster virus uveitis

Purpose

To evaluate choroidal lesions with spectral domain optical coherence tomography (SD-OCT) scan in varicella zoster virus (VZV) uveitis.

Methods

VZV-uveitis cases which underwent OCT scan for choroidal lesions were studied. SD-OCT scan passing through these lesions was studied in detail. Subfoveal choroidal thickness (SFCT) during active and resolved stages was studied. Angiogaphic features were studied where available.

Results

Thirteen out of 15 cases had same-sided herpes zoster ophthalmicus skin rashes. All except three patients had old or active kerato-uveitis. All eyes demonstrated clear vitreous and a single or multiple hypopigmented orangish-yellow choroidal lesions. The number of lesions remained unchanged during the follow-up on clinical examination. SD-OCT over lesions (n = 11) showed choroidal thinning (n = 5), hyporeflective choroidal elevation during active inflammation (n = 3), transmission effects (n = 4), and ellipsoid zone disruption (n = 7). The mean change in SFCT (n = 9) after resolution of the inflammation was 26.3 μm (range: 3-90 μm). Fundus fluorescein angiography showed iso-fluorescence over lesions in all (n = 5), but indocyanine green angiography (n = 3) showed hypofluorescence at lesions. Mean follow-up was 1.38 years (range: 3 months-7 years). De-novo appearance of choroidal lesion during the first relapse of VZV-uveitis was captured in one case.

Conclusion

VZV-uveitis can cause focal or multifocal hypopigmented choroidal lesions with thickening or scarring of choroidal tissue, depending on the disease activity.

COVID-19 vaccination, dengue hepatitis, and recurrent unilateral anterior uveitis

A 36-year-old Asian Indian male presented with redness and pain in his right eye of 1 week duration. He was diagnosed to have right acute anterior uveitis and had a history of being admitted at a local hospital for dengue hepatitis a month earlier. He had been on adalimumab 40 mg three weekly once and oral methotrexate 20 mg/week for human leucocyte antigen (HLA) B27 spondyloarthropathy and recurrent anterior uveitis. Our patient had re-activation of his anterior chamber inflammation on three distinct occasions: first, 3 weeks following recovery from coronavirus disease 2019 (COVID-19), the second after the second dose of COVID-19 vaccination, and the third after recovery from dengue fever-associated hepatitis. We propose molecular mimicry and bystander activation as the postulated mechanisms for the re-activation of his anterior uveitis. In conclusion, patients with auto-immune diseases can have recurrent ocular inflammation following COVID-19 or its vaccination or dengue fever as seen in our patient. The anterior uveitis is usually mild and responds to topical steroids. Additional immuno-suppression may not be needed. Mild ocular inflammation following vaccination should not deter individuals from getting COVID-19 vaccination.

Pole-to-pole involvement of varicella zoster virus reactivation following COVID-19 vaccination

The aim of this study is to report the clinical features, imaging findings including confocal imaging, corneal nerve fiber analysis, and management outcomes in a series of three cases of varicella zoster virus (VZV) reactivation following one dose of coronavirus disease 2019 (COVID-19) vaccination. This was a retrospective and observational study. All the patients who developed uveitis post-vaccination were pooled together. Patients who had VZV reactivation were included. Two cases had polymerase chain reaction positive for VZV from aqueous humor. At the time of presentation, IgG and IgM spike protein antibodies for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) were tested. Out of this pool, three patients with classical features to describe pole-to-pole manifestations were chosen. A 36-year-old lady with post-vaccination sclerokeratouveitis associated with reactivation of herpes zoster ophthalmicus, a 56-year-old lady with post-vaccination acute anterior uveitis associated with herpes zoster ophthalmicus, and a 43-year-old gentleman with post-vaccination acute retinal necrosis were included. We present a possible link between anti-SARS-CoV-2 virus vaccination and varicella zoster reactivation in these patients and also describe the clinical features, imaging findings including confocal imaging, corneal nerve fiber analysis, and management with detailed discussion.

Systemic investigations in dry eye disease

The incidence of dry eye disease has increased manifold in the past few years with more patients presenting with these complaints to our clinics every day. In the more severe forms of disease, it is important to evaluate for any systemic association which could be driving the disease such as in Sjogren's syndrome. Understanding the possible varied etiopathogenesis and knowing when to evaluate, form an important part of treating this condition effectively. In addition, it is sometimes confusing as to which investigations to order and how to prognosticate the disease in these situations. This article simplifies this into an algorithmic approach with insights from the ocular and systemic point of view.

UTILITY OF EN FACE OPTICAL COHERENCE TOMOGRAPHY IN INTRAOCULAR LYMPHOMA

PURPOSE

To report the en face optical coherence tomography (OCT) features of intraocular lymphoma.

METHODS

Retrospective, observational case report.

RESULTS

A 59-year-old man, a known case of primary testicular carcinoma, complained of right eye blurred vision since 1 week. He had previously undergone systemic intravenous chemotherapy (R-CHOP regimen), orchiectomy, and external beam radiotherapy for the primary malignancy. His right eye vision was 20/30, 6/6 reduced Snellen. The right eye anterior segment examination was normal. Fundus examination showed vitreous cells 1+ and a large, bumpy, subretinal dull-yellow lesion sparing the fovea with multiple discrete yellow retinal lesions at the posterior pole. Magnetic resonance imaging of the brain was normal. Multimodal imaging was used to document the clinical features. On the en face OCT, multiple hyperreflective lesions were identified on the superficial, deep, and outer retinal slabs of the scan corresponding to the vertical hyperreflective lesions extending from the retinal nerve fiber layer to the retinal pigment epithelium. The subretinal pigment epithelium lesion can be well delineated in the choriocapillaris segment. He was treated with multiple injections of intravitreal methotrexate 400 μg/0.1 mL along with systemic chemotherapy in conjunction with the oncologist. At the 6-month follow-up, fundus lesions had regressed. In addition, resolution of the lesions was noted on the OCT and en face OCT scans.

CONCLUSION

En face OCT imaging can be considered for monitoring the therapeutic efficacy after intravitreal chemotherapy in intraocular lymphoma.

Unilateral Acute Idiopathic Maculopathy following Severe Acute Respiratory Syndrome Corona Virus (SARS-CoV-2) Infection

AIM

To report a case of unilateral acute idiopathic maculopathy (UAIM) following SARS-CoV-2 virus infection.

CASE DESCRIPTION

A 44-year-old male patient, infected with SARS-CoV-2 virus previously, presented to the retina department with complaints of sudden blurring of vision in right eye. His presenting visual acuity in right eye was 20/30, N8. Fundus showed an irregular area of yellowish-white subretinal lesion at the macula involving the fovea with reddish-brown pigment clumps. Retinal imaging findings were consistent with the diagnosis of UAIM. No treatment was given.

RESULTS

The imaging findings showed improvement at day 7 post-presentation with improvement in vision to 20/20, N6. At final visit (5-week post presentation), visual acuity was maintained at 20/20, N6 and there was no recurrence of findings.

EXPERT OPINION

Unilateral acute idiopathic maculopathy might be associated with SARS-CoV-2 virus infection.

CONCLUSION

Infection with SARS-CoV-2 virus might be associated with UAIM. Such an association has not yet been described in the literature.

Systemic Markers in Ophthalmic Manifestations of Post Corona Virus Disease-19 (COVID-19)

INTRODUCTION

Corona virus disease (COVID-19) has been associated with ophthalmic manifestations which can occur during or following the infection.

PURPOSE

To explore the systemic status in ophthalmic patients who had a recent history of COVID-19 or those with positive COVID-19 antibody status.

METHODS

Retrospective case series.

RESULTS

30 patients with history of COVID-19 infection and positive COVID-19 antibodies were included in the study. The median age was 49 years (mean 48.7 ± 13.7 years), 20 were males (66.7%) and 10 (33.3%) were females. Patients with VA>/= 6/60 were included in group 1 and those with VA<6/60 were included in group 2. D-dimer/serum Ferritin levels were raised in group 2 compared to group 1with (p=0.013)/(p=0.018) respectively.

CONCLUSION

Serum D-dimer and ferritin levels were statistically significant and were higher in patients with sight threatening ocular manifestations. ESR and CRP were raised even after recovery from COVID-19 although they were not statistically significant.

Monitoring Weil-Felix test in epidemic retinitis

Purpose

The objective was to study the positivity of the Weil-Felix test (WFT) in epidemic retinitis (ER) during the course of the disease.

Methods

This is a retrospective, observational case series of patients diagnosed with ER and presented to a tertiary eye care hospital in south India. Patients with positive WFT at the presentation, and who underwent a follow-up WFT during or after the resolution of ER were studied from September 2019 to March 2022. Patient's demographics, timings of clinical presentation and resolution, and investigation details with a special focus on WFT positivity and its duration were noted.

Results

Sixteen patients were studied. Patients presented after 5 weeks of the fever (range: 2-12 weeks, median: 4). After 1-2 months, WFT was still positive in eight patients (50%). Only in one patient titers increased after 1 month, while in others, the titers decreased (n = 11) or remained the same (n = 4). Repeated tests in those patients (n = 6) after 3-4 months turned negative. Resolution of ER was seen at 1.35 months (range: 1-3 months) after the presentation. The mean duration for WFT to turn negative was 2 months from the presentation (range: 1-4 months) or 3.2 months of the fever (range: 1.5-6 months).

Conclusion

In contrast to the reported physician's observation of increasing titers of WFT after rickettsial fever, ophthalmologists may observe decreasing WFT titers in ER. The clinical resolution of ER may precede the normalization of WFT. Follow-up WFT titers should be studied in larger series in confirmed cases of rickettsial-ER to validate the affordable and readily available WFT in India.

Reactivation of varicella zoster infection presenting as acute retinal necrosis post COVID 19 vaccination in an Asian Indian male

PURPOSE

To present the clinical features of a rare case of varicella zoster infection following one dose of Coronavirus Disease 2019 (COVID-19) vaccination in an elderly Asian Indian male.

METHODS

Retrospective observational case report.

RESULTS

A 71-year-old gentleman presented to us with complaints of reduced vision associated with redness and pain in his right eye for 1 week. On examination he revealed a right eye pan uveitis picture with circumcorneal congestion, multiple fine keratic precipitates, anterior chamber cells and flare, vitritis and widespread areas of acute retinal necrosis. His left eye was within normal limits. Ten days prior to the presentation he had received the first dose of COVID-19 vaccine following which he had developed fever for 2 days that preceded the red eye. The patient's aqueous sample tested positive for varicella zoster virus (VZV) by nested polymerase chain reaction (PCR) method. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in reverse transcriptase polymerase chain reaction (RT-PCR) assay from the aqueous and also from the nasopharyngeal swab was negative.

CONCLUSION AND SIGNIFICANCE

To the best of our knowledge this is the earliest description of a case that has a viral reactivation following COVID-19 vaccination. Elderly people with pre-existing comorbidities, may be at a risk of both primary coronavirus infection and unconceivable risk of aberrant immune reactions leading to a different virus infection or reactivation need to be kept in mind. We present a possible link between SARS-CoV-2 virus vaccination and varicella zoster reactivation in this patient.

Bacillary Layer Detachment in Unilateral Acute Idiopathic Maculopathy: A Report of 2 Cases

AIM

To report the presence of bacillary layer detachment (BLD) in unilateral acute idiopathic maculopathy (UAIM).

CASE DESCRIPTION

Two patients diagnosed with UAIM based on the clinical and imaging features showed the characteristic splitting of the ellipsoid layer on spectral domain optical coherence tomography (SDOCT). This has been termed as bacillary layer detachment.

RESULTS

No treatment was given. In both cases, there was a complete spontaneous resolution of the SDOCT findings 14-days post-presentation in Case 1 and 5-days post-presentation in Case 2 with improvement in visual acuity to 20/20, N6 in both cases.

CONCLUSION

BLD in UAIM is not a commonly reported SDOCT finding and can serve as an imaging biomarker.

Vitiligo Iridis in a Patient With a History of Smallpox

This case report describes a diagnosis of vitiligo iridis in a patient in their late 50s who was noted to have bilateral atrophic patches on the iris during routine ophthalmic care.

Topical interferon therapy in uveitic macular edema

Purpose

To evaluate efficacy of topical interferon alfa-2b (IFN) in the treatment of uveitic macular edema (UME).

Methods

This is a prospective, interventional case study of patients with UME. Injection IFN was reconstituted into eye drops and a four times/day (QID) application was prescribed. Central macular thickness (CMT) on optical coherence tomography (OCT) scan was evaluated. Improvement in CMT by ≥50 μm from the baseline was studied in eyes with presenting CMT ≥400 μm.

Results

Twenty eyes of 20 patients with UME were studied: anterior uveitis (n = 3), anterior + intermediate uveitis (n = 5), posterior uveitis (n = 3), retinal vasculitis (n = 3), and panuveitis (n = 6). Mean CMT at the presentation was 423.3 μm (range: 270-604 μm), which improved at 1 month (n = 16), 2 months (n = 10), and ≥3 months (n = 11) follow-up, to 415.3 μm (range: 247-579 μm) (P = 0.411), 364.4 μm (range: 258-566 μm) (P = 0.099), 344 μm (range: 258-484 μm) (P = 0.001), respectively. Twelve eyes of 12 patients had presenting CMT ≥400 μm. In these cases, decrease in CMT by ≥50 μm was seen in 4/10, 4/5, and 5/6 eyes at 1 and 2 months and ≥3 months follow-up. Mean follow-up was 4 months (range: 1-17 months). Complete resolution of UME was seen only in three eyes. No ocular or systemic side effects were observed.

Conclusion

Topical IFN therapy in QID doses is safe but may have limited role in UME. Long-term therapy may improve its efficacy. Larger studies with dose modification, combination with other drugs, and with homogeneous uveitis population are recommended.

COVID-19 vaccination and recurrent anterior uveitis

A 35-year-old Asian Indian female previously diagnosed with bilateral anterior uveitis and on oral methotrexate developed bilateral anterior uveitis following first/second dose of coronavirus disease 2019 (COVID-19) vaccination. She had skipped her weekly dose of oral methotrexate following first dose of vaccination. Following the second dose, she reduced her oral methotrexate from 25 to 15 mg on her own, but did not stop like the previous occasion. She had extensive workup for her uveitis in the past with only positive severe acute respiratory syndrome coronavirus (SARS-CoV-2) antibodies. She developed unilateral anterior uveitis after she had COVID-19 in July 2022, which resolved with topical steroids and continuation of immunosuppression. This report illustrates that COVID-19 or its vaccination may presumably play a role in triggering the immune system and can cause recurrent ocular inflammation even in the absence of an extraocular inflammation.

Current concepts in granulomatosis poly angiitis and the eye

Purpose of review

Granulomatosis with polyangiitis (GPA), a multisystem disease with diverse systemic and protean ocular manifestations. Its pathophysiology, spectrum of the ocular manifestations, changing paradigms in the diagnosis of the disease, recent updates in the treatment patterns are clinically relevant to the treating clinician. They are described in this review.

Recent findings

Summary

The changing trends in the diagnosis, treatment can be adapted to real time clinical practice to provide the best quality of life to patients with GPA.

Bilateral Post Fever Retinitis With Retinal Vascular Occlusions Following Severe Acute Respiratory Syndrome Corona Virus (SARS-CoV2) Infection

INTRODUCTION

As the world fights the pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), several reports of retinal manifestations of the disease are emerging. Post fever retinitis is a well reported ocular inflammatory reaction to multiple invasive agents, be it virus, bacteria or other microbial agent.

PURPOSE

We report an interesting case of bilateral multifocal retinitis with multiple vascular occlusions in a patient, three weeks after a febrile illness.

RESULTS

Investigations to ascertain the cause of fever resulted in identifying ephemeral seropositivity for several different Ribonucleic acid (RNA) viruses. The retinitis was managed with systemic steroids, doxycycline and anticoagulants with improvement in vision.

CONCLUSION

High and persistent seropositive response against (SARS-CoV-2) helped us to narrow it as the causative agent but the cross reactivity of SARS-CoV-2 with other viruses can be misleading and needs careful interpretation.

Epidemic Retinitis with Positive or Negative Weil Felix Test - a Comparative Study and Outcome with Doxycycline

PURPOSE

To compare clinical manifestations and disease outcomes in Epidemic Retinitis (ER) with positive or negative Weil Felix Test (WFT).

METHODS

Retrospective, observational, comparative study. WFT positive or negative patients formed Group 1 and 2, respectively. Patients receiving oral doxycycline monotherapy formed subgroup A and B. Duration of resolution of macular edema and retinitis was compared.

RESULTS

Novel finding of "ring retinitis" was observed equally in group 1 and 2. Complete resolution of macular edema took 41.3 days (range: 30-60 days) and 43.68 days (range: 20-105 days) (p = .668) and retinitis lesions resolved in 34.3 days (range: 14-65 days) and 34 days (range: 12-60 days) (p = .875) in group A and B, respectively. All (n = 14) eyes with retinitis within 1 disc diameter of fovea improved better than 20/80 except 1.

CONCLUSION

No significant difference with respect to clinical, imaging findings and the treatment outcome was observed in WFT positive or negative cases.

Unilateral recurrent central serous chorioretinopathy (CSCR) following COVID-19 vaccination- A multimodal imaging study

Corona virus disease-19 (COVID-19) vaccines have been approved for emergency use. Ocular adverse effects following the vaccines have been reported.

Purpose

To report an unique case of recurrent central serous chorioretinopathy following both doses of COVID-19 vaccine.

Observations

A 40-year-old male presented with blurring of vision in the left eye during 2 days following COVISHIELD™ (Serum Institute of India). He had a previous history of central serous chorioretinopathy in the right eye 2 years back and was treated with micropulse laser. Ocular examination showed a best corrected visual acuity of 20/20 right eye and 20/60 left eye. Fundus evaluation of left eye showed central serous chorioretinopathy. Spectral domain optical coherence tomography of the left eye revealed neurosensory detachment. Fundus fluorescein angiography of the left eye showed multiple window defects and ink-blot appearance in the macula. Oral eplerenone 50mg once a day for a month showed significant reduction in the subretinal fluid. Patient developed central serous chorioretinopathy in the left eye 3 days after 2nd dose of COVISHIELD™.

Conclusion and Importance

CSCR following vaccination may be a temporal event. In our patient it occurred following the vaccination. This is the first case of a recurrent CSCR after either dose of COVID-19 vaccination. Ocular symptoms after vaccination warrant a thorough eye evaluation.

Intensive topical interferon therapy in uveitic macular edema

Purpose

To evaluate the efficacy of intensive topical interferon alfa-2b (IFN) therapy in uveitic macular edema (UME).

Methods

This is a prospective, interventional case study of eyes with UME. Commercially available injection IFN for subcutaneous use was reconstituted to form eye drops and a dose of 6 times/day for 2 weeks, 5 times/day for next 2 weeks, followed by 4, 3, 2, 1 taper per month was prescribed. Optical coherence tomography (OCT) and clinical examination was done at 0, 2, 4, 8 weeks, and further as required.

Results

Nine eyes of 9 patients with UME were studied. Mean central macular thickness (CMT) at presentation was 522.2 μm (range: 408-803 μm). At 2-week, 1-month, and 2-month follow-up, mean CMT decreased to 451.6 μm (range: 322-524 μm), 375.8 μm (range: 287-480 μm), and 360.3 μm (range: 260-485 μm), respectively. Four eyes which showed inadequate response to previous topical IFN therapy (4 times/day) showed significant improvement with intensive therapy at 1 month follow-up. In 4 eyes, UME resolved completely with mean CMT 285.5 μm (range: 260-312 μm) at 7.5 weeks (range: 4-12 weeks). Study exit was seen in 2 cases due to inadequate response and relapse of uveitis. Mean follow up was 3.38 months (range: 1-5 months).

Conclusion

Intensive topical IFN therapy can be an alternative therapeutic option in the treatment of UME. Study of intraocular penetration, combination with other drugs, and the efficacy of IFN separately for different uveitic entities may explore new avenues in treatment of UME.

Reactivation of juvenile idiopathic arthritis associated uveitis with posterior segment manifestations following anti-SARS-CoV-2 vaccination

Background/purpose

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in the pediatric population and anterior uveitis is its commonest extra-articular manifestation. Typically the uveitis presents as chronic anterior uveitis and there is limited literature of the posterior segment manifestations of the disease. Similar to other vaccines, anti-SARS-CoV-2 vaccination that began as an urgent measure to control the spread of the SARS-CoV-2 pandemic has not been without adverse events. We are reporting a 19-year-old Asian Indian female who was diagnosed and treated for JIA associated anterior uveitis that was unilateral and was under anti-inflammatory control but showed worsening of uveitis with posterior segment inflammation in both eyes following anti-SARS-CoV-2 vaccination.

Case report

A 19-year-old Asian Indian female with a history of juvenile idiopathic arthritis on treatment with methotrexate, presented with right eye chronic anterior uveitis with peripheral subclinical retinal vasculitis and macular edema which was brought under control following administration of adalimumab. She was inflammation free for 6 months until she received anti-SARS-CoV-2 vaccination and developed new onset floaters in both eyes that were initially noted after the first dose and increased after the second dose. Clinical examination revealed presence of keratic precipitates and grade 1+ anterior chamber inflammation along with vitiritis in both eyes. Fundus fluorescein angiography revealed angiographically active retinal vasculitis without the presence of macular edema in both eyes. This was managed with a short course of topical difluprednate and continuation of systemic immunosuppressive therapy with adalimumab and methotrexate.

Conclusion

JIA associated uveitis results from an autoimmune process which can be controlled with timely immunosuppressive treatment. It is important to be aware of the potential risk of flare up of uveitis with posterior segment manifestations following anti- SARS-CoV-2 vaccination.

"Acute Bilateral Neuroretinitis and Panuveitis in A Patient with Coronavirus Disease 2019: A Case Report"- Few Comments

During the Coronavirus Disease 2019 (COVID-19) pandemic, we have witnessed increase in number of reports of a known uveitic entity being associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Causal relation is yet to be proven for many reports. Perhaps, occurrence of a previously known region-specific endemic disease or closely resembling manifestations of a known disease in a non-endemic region during the COVID-19 pandemic might suggest a causal relationship. Epidemic retinitis (ER) or post fever retinitis is such condition with geographic variation. Occurrence of ER or ER-like manifestations in a non-endemic country during the pandemic should instigate further studies to consider SARS-CoV-2 as a causative organism.

Epidemic retinitis - Factors associated with poor visual outcomes

Purpose:

To identify factors other than macular edema and retinitis location responsible for poor visual outcomes in epidemic retinitis (ER).

Methods:

A retrospective, observational, comparative study. Eyes with corrected distant visual acuity (CDVA) 20/200 or worse at resolution formed Group A. Eyes with central macular thickness (CMT) 600 μm or worse and retinitis within 1500 μm to foveal center at the presentation, but improved to CDVA 20/200 or better at the resolution formed Group B. The patient’s history, clinical presentation, imaging, and treatment outcomes were studied and the factors responsible for the final visual outcomes were compared in both groups.

Results:

Groups A and B included 25 eyes each. The mean CDVA at the presentation was 20/400 (range: 20/125–20000) and 20/320 (range: 20/80–20000), and mean CMT at the presentation was 948.5 μm (range: 520–1553) and 912.2 μm (range: 615–1250) in Groups A and B, respectively. All eyes except 1 (Group A) had retinitis lesions within 1500 μm of foveal center. The mean CDVA at the resolution was 20/400 (range: 20/200–20/20000) and 20/40 (range: 20/20–20/80) in Groups A and B, respectively. Older age, male gender, diabetic status, delayed presentation, poor presenting CDVA, bilaterality, presence of keratic precipitates, disk pallor, retinal thinning, and subfoveal deposits had a statistically significant association, whereas the absence of skin rash, ellipsoid zone loss, negative WIDAL, Weil-Felix test, and delayed doxycycline therapy or use of steroids without doxycycline had a statistically insignificant association with poor visual outcomes.

Conclusion:

Apart from presenting CMT and location of retinitis, multiple demographic, clinical, and imaging factors can be implicated for poor visual outcomes.