Nonglaucomatous localized retinal nerve fiber layer defects in Behçet uveitis

Bilateral acute multifocal retinitis and retinal vasculitis secondary to Rickettsia typhi infection

PURPOSE

To describe a case of acute multifocal retinitis (AMR) and retinal vasculitis associated with Rickettsia typhi.

METHODS

Case report.

RESULTS

A 37-year-old previously healthy female presented with acute bilateral panuveitis that was preceded by a febrile illness with pneumonitis and transaminitis. On exam she had bilateral multifocal small white retinal lesions, vascular sheathing, and hemorrhages. The retinal lesions, which appeared consistent with infiltrates and/or ischemia, were confined within the inner or middle retinal layers on optical coherence tomography (OCT) and corresponded to late leakage on fluorescein angiography (FA). There was no evidence of choroidal involvement on indocyanine green angiography (ICGA). Based on the imaging findings and history, the diagnosis of AMR with associated small vessel retinal vasculitis was made and the patient was started empirically on doxycycline. Workup was positive for R. typhi. At follow-up, there was resolution of visual symptoms and nearly all retinal lesions.

CONCLUSIONS

Rickettsial disease should be highly suspected in a patient with AMR and occlusive small vessel vasculitis. Retinal lesions may be either infiltrative or ischemic in nature. Diagnosis, which can be aided by multimodal retinal imaging, is essential for prompt initiation of appropriate antibiotic therapy.

Indocyanine green angiography reveals choroidal hypoperfusion in subacute sclerosing panencephalitis (SSPE)

We report the choroidal findings on indocyanine green angiography (ICGA) in two cases of subacute sclerosing panencephalitis (SSPE). The two immunocompetent patients (31-year-old and 30-year-old Asian Indian males) presented with acute-onset rapidly progressing vision loss with findings of necrotizing retinitis involving the central macula. Both patients tested negative for serological evidence of herpes or varicella, and toxoplasma antibodies. The patients demonstrated high serum and cerebrospinal fluid titers of anti-measles antibody (and abnormal electroencephalogram in one patient) leading to the diagnosis of SSPE. ICGA of both patients revealed distinct "dark dots" which showed hypofluorescence in the early and late phases suggestive of choroidal involvement/hypoperfusion. Choroidal involvement in SSPE has not been evaluated before and must be considered in the pathological manifestations of the disease.

Outbreak of Rift Valley Fever Retinitis in Rwanda: Novel Imaging Findings and Response to Treatment with Corticosteroids

PURPOSE

To describe the clinical and epidemiological characteristics of the first epidemic of Rift Valley Fever retinitis in Rwanda and to report novel imaging findings and a possible role for corticosteroids.

METHODS

Retrospective analysis of all patients who presented with presumed Rift Valley Fever retinitis at the Rwanda Charity Eye Hospital over a period of 4 months in 2022. Multimodal images are reviewed including optical coherence tomography, fluorescein angiography, color, infrared, red-free, and autofluorescence photography.

RESULTS

The newly identified arciform hyporeflective pattern on infrared imaging was present in 100% of patients. Out of 9 patients treated with oral corticosteroids, 7 (78%) experienced a visual acuity increase of at least 0.2 during follow-up, in comparison to only 4 (28%) out of 14 of untreated patients. Out of four patients treated with a subtenon corticosteroid injection, only one (25%) reached this threshold. Post-hoc pairwise comparison with Bonferroni correction revealed a significant difference in average visual acuity improvement (p = 0.034) between patients receiving oral corticosteroids (0.35 ± 0.07) versus no treatment (0.11 ± 0.04).

CONCLUSION

The identified arciform hyporeflective pattern on infrared imaging appears to be characteristic of Rift Valley Fever retinitis and should be known to clinicians working in endemic regions. Compared to a historical cohort and to untreated patients in this non-randomized study, there appears to be a benefit of treatment with oral corticosteroids.

Evaluation of optic coherence tomography findings in patients with inflammatory bowel disease

BACKGROUND

Ocular complications are known to appear in inflammatory bowel disease (IBD). Among these, posterior segment complications can lead to substantial morbidity. The aim of the study is to evaluate the retinal nerve fiber layer (RNFL), ganglion cell-inner plexiform layer (GCIPL), and macula thickness measurement in patients with IBD.

METHODS

A total of 118 patients with IBD (42 Crohn's disease (CD), 76 ulcerative colitis (UC)) and 52 healthy subjects were included in the study. RNFL, GCIPL, and macula thickness were measured using spectral-domain optical coherence tomography (SD-OCT).

RESULTS

The central macular thickness was increased, mean and all superior quadrants of GCIPL thickness measurements were significantly decreased, but RNFL thickness wasn't changed in CD compared to healthy subjects. Although the central macular thickness increased, no change was observed in mean RNFL and GCIPL in UC compared to healthy subjects. Mean RNFL, GCIPL, and macular thickness did not differ during the remission and active phases of the disease in IBD. There was no difference in RNFL, GCIPL, and macular thicknesses in CD patients in terms of the location and behavior of the disease. A significant thickness increase was found in extensive type UC for inferior RNFL value compared to the left side and proctitis.

CONCLUSIONS

IBD may cause an increase in macular thickness. This finding may be related to the inflammation or ischemia of the retina. The use of SD-OCT in ophthalmologic examination in patients with IBD may enable early detection of retinal changes and alert the clinician to complications of IBD.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY BIOMARKERS AND MICROPERIMETRY FEATURES IN BEHÇET'S UVEITIS

PURPOSE

To evaluate the parafoveal macular microvasculature and the macular function in patients with retinal vasculitis associated with Behçet's uveitis.

METHODS

In 14 patients with inactive Behçet's uveitis and 26 control individuals (13 with nonocular Behçet's syndrome and 13 healthy subjects), we analyzed the retinal nerve fiber layer, ganglion cell layer, full retinal thickness, foveal avascular zone area and sectorial parafoveal vascular density in the superficial vascular plexus, intermediate capillary plexus, and deep capillary plexus using SPECTRALIS optical coherence tomography (OCT) 2 and OCT angiography. Macular sensitivity was analyzed using an MP-3 microperimeter.

RESULTS

Eighteen eyes (78%) had a best-corrected visual acuity ≥ 20/25. Significant differences were found in Behçet's uveitis in comparison with the controls on the OCT and OCT angiography: 14.8%, 22.4%, and 14.9% ganglion cell layer thinning in the global, nasal, and inferior sectors, respectively; 6%, 13.2%, and 7.5% full retinal thickness thinning in the superior, nasal, and inferior sectors; and 16.8%, 14.9%, 23.6%, 15.8%, and 12.6% mean deep capillary plexus density reduction in the global, superior, nasal, inferior, and temporal sectors. Microperimetry data demonstrated significant mean reductions of 21% and 23.6% in central and average macular sensitivities and 28.8%, 40.4%, 27.7%, and 24.2% in the superior, nasal, inferior, and temporal sectors, respectively. Outer plexiform layer elevations were observed in Behçet's uveitis (69.6%).

CONCLUSION

Behçet's uveitis presented structural and functional macular damage despite good best-corrected visual acuity, mainly affecting the nasal sector and the deep capillary plexus. On OCT and OCT angiography, quantitative and qualitative changes can be valuable biomarkers of ocular involvement in Behçet's syndrome.

Swept-source Optical Coherence Tomography Angiography in Active and Scarred Toxoplasmic Retinochoroiditis

PURPOSE

To describe optical coherence tomography angiography (OCTA) findings in eyes with active and scarred toxoplasmic retinochoroiditis.

METHODS

OCTA scans in active (25 eyes) and scarred (17 eyes) retinochoroiditis were retrospectively reviewed.

RESULTS

In active lesions, OCTA findings included a non-detectable flow signal area in retinal vascular plexuses and choriocapillaris in all 25 eyes (100%), an abnormal intraretinal vascular process in 2 eyes (8%), and an associated area of retinal flow deficit secondary to branch retinal artery occlusion in one eye (4%). In scarred lesions, OCTA findings included a flow deficit area in retinal vascular plexuses and choriocapillaris in all 17 eyes (100%), a visibility of larger deeper choroidal vessels at the level of choriocapillaris in 9 eyes (53%), and a well-defined intraretinal vascular network in one eye (5.9%). Peripapillary scars were associated on OCTA with wedge-shaped loss of radial peripapillary capillaries with corresponding localized retinal nerve fiber layer defect and visual field loss.

CONCLUSION

OCTA allows to non-invasively detect retinal and choroidal vascular changes in active and scarred toxoplasmic retinochoroiditis.

Behçet's Disease Uveitis

Uveitis in Behçet's disease (BD) is frequent (40% of cases) and is a major cause of morbidity. The age of onset of uveitis is between 20 and 30 years. Ocular involvement includes anterior, posterior, or panuveitis. Uveitis may be the first sign of the disease in 20% of cases or it may appear 2 or 3 years after the first symptoms. Panuveitis is the most common presentation and is more commonly found in men. Bilateralization usually occurs on average 2 years after the first symptoms. The estimated risk of blindness at 5 years is 10-15%. BD uveitis has several ophthalmological features that distinguish it from other uveitis. The main goals in the management of patients are the rapid resolution of intraocular inflammation, the prevention of recurrent attacks, the achievement of complete remission, and the preservation of vision. Biologic therapies have changed the management of intraocular inflammation. The aim of this review is to provide an update to a previous article by our team on pathogenesis, diagnostic approaches, and the therapeutic strategy of BD uveitis.

Stepwise approach for fundus imaging in the diagnosis and management of posterior uveitis

An array of retinochoroid imaging modalities aid in comprehensive evaluation of the immunopathological changes in the retina and choroid, forming the core component for the diagnosis and management of inflammatory disorders such as uveitis. The recent technological breakthroughs have led to the development of imaging platforms that can evaluate the layers of retina and choroid and the structural and functional alteration in these tissues. Ophthalmologists heavily rely on imaging modalities such as dye-based angiographies (fluorescein angiography and indocyanine green angiography), optical coherence tomography, fundus autofluorescence, as well as dye-less angiography such as optical coherence tomography angiograph,y for establishing a precise diagnosis and understanding the pathophysiology of the diseases. Furthermore, these tools are now being deployed with a 'multimodal' approach for swift and accurate diagnosis. In this comprehensive review, we outline the imaging platforms used for evaluation of posterior uveitis and discuss the organized, algorithmic approach for the assessment of the disorders. Additionally, we provide an insight into disease-specific characteristic pathological changes and the established strategies to rule out disorders with overlapping features on imaging.

Behçet uveitis: Current practice and future perspectives

Described as early as Hippocrates in his “Third Book of Endemic Diseases,” Behçet's Disease (BD), also known as “The Silk Road Disease” following its initial demographics, consists of a triad of recurrent oro-genital ulcers and associated uveitis. Current demographics and rising percentages of patients seen far beyond the Silk Road in Ocular Inflammatory Disease and Uveitis Clinics list BD uveitis as one of the frontliners of non-infectious autoinflammatory eye diseases. Clinical features of BD and juvenile-onset BD are detailed alongside various approaches in classification and suggested algorithms for diagnosis that are outlined in this review. With the ongoing Human Microbiome Project and studies such as the MAMBA study, the role of the human microbiome in BD is highlighted in the pathophysiology of BD to include the current research and literature perspective. Furthermore, with the advancement of recent diagnostic and investigative techniques, especially in the field of Optical Coherence Tomography (OCT), disease-related characteristics are updated to encompass SD, EDI and OCT-angiography characteristics of BD. Having entered the era of biologic therapy, the role of various specific cytokine-blocking biologic drugs, such as TNF-α inhibitors (e.g., adalimumab, infliximab), interferon α-2a inhibitors, IL-6 and IL-1 inhibitors are presented and contrasted alongside the conventional immunosuppressant drugs and the classic old gold standard: corticosteroids (systemic or local). Finally, with the ongoing SARS-CoV-2 pandemic, it was not possible to conclude the review without reviewing the latest evidence-based literature reporting BD morbidity in this era, the observed pattern and treatment recommendations as well as those related to reported post-vaccine complications and emergence of BD.

Old and New Challenges in Uveitis Associated with Behçet's Disease

Behçet’s disease (BD) is a systemic vasculitis disease of unknown origin occurring in young people, which can be venous, arterial or both, classically occlusive. Ocular involvement is particularly frequent and severe; vascular occlusion secondary to retinal vasculitis may lead to rapid and severe loss of vision. Biologics have transformed the management of intraocular inflammation. However, the diagnosis of BD is still a major challenge. In the absence of a reliable biological marker, diagnosis is based on clinical diagnostic criteria and may be delayed after the appearance of the onset sign. However, therapeutic management of BD needs to be introduced early in order to control inflammation, to preserve visual function and to limit irreversible structural damage. The aim of this review is to provide current data on how innovations in clinical evaluation, investigations and treatments were able to improve the prognosis of uveitis associated with BD.

Advances and potential new developments in imaging techniques for posterior uveitis. Part 1: noninvasive imaging methods

The aim of this review was to identify the imaging methods at our disposal to optimally manage posterior uveitis at the present time. The focus was put on methods that have become available since the 1990s, some 30 years after fluorescein angiography had revolutionized imaging of posterior uveitis in particular imaging of the retinal vascular structures in the 1960s. We have focussed our review on precise imaging methods that have been standardized and validated and can be used universally thanks to commercially produced and available instruments for the diagnosis and follow-up of posterior uveitis. The first part of this imaging review will deal with noninvasive imaging methods, focusing on fundus autofluorescence and optical coherence tomography as well as recent developments in imaging of the posterior segment.

Sequential bilateral Behçet's neuroretinitis associated with prepapillary vitreous exudate: case report

Objective

To describe a case of Behçet disease (BD) uveitis manifesting with sequential bilateral neuroretinitis associated with prepapillary inflammatory vitreous exudate (PIVE).

Material and methods

A single case report documented with multimodal imaging.

Results

A 37-year-old man developed neuroretinitis with associated PIVE in the left eye. He was diagnosed with ocular toxoplasmosis and treated accordingly based on positive serologic testing and negative work-up for other entities, including BD. The disease course was favorable, but 1 year later a similar neuroretinitis developed in the right eye. Extraocular features of BD became evident only at the time of the second eye involvement, and the patient received corticosteroid and immunosuppressive therapy.

Swept source (SS) OCT showed at the acute phase in both eyes a typical “mushroom-shaped” prepapillary hyperreflectivity of the PIVE. SS OCT angiography (OCTA) demonstrated a corresponding prepapillary hypointense area due to shadowing effect, decreasing in size while scanning deeper layers. It also detected peripapillary retinal hypervascularity in both eyes and a sectoral area of flow signal loss in the first involved left eye. Visual acuity improved following the resolution of the PIVE and associated acute inflammatory changes in both eyes. The left eye showed residual optic disc pallor and retinal nerve fiber layer defects.

Conclusion

Sequential bilateral neuroretinitis associated with PIVE may occur before other clinical features of BD become evident. SS OCT and OCTA can provide useful information for the diagnosis and management of this rare, but typical, ocular manifestation of BD uveitis.

Relationship between changes in retinal nerve fiber layer thickness measured by SD-OCT and changes in visual field parameters in birdshot chorioretinopathy

PURPOSE

To describe the structure-function relationship in birdshot chorioretinopathy (BSCR) using visual field data and peri-papillary retinal nerve fiber thickness (RNFL).

METHODS

A total of 21 patients (34 eyes) with BSCR were evaluated prospectively from 2014 to 2018 (IMAGE-EYE cohort). Functional tests included measurement of visual acuity and visual field (30-2 SITA standard). Anatomical tests included fluorescein angiography, indocyanine green angiography, and spectral domain optical coherence tomography.

RESULTS

Most of the patients were female (57%) with a mean age of 62 ± 8 years. Mean follow-up was 2.3 ± 0.6 years. Structural examination results were significantly modified in contrast to functional test results, with a significant reduction in mean RNFL (2.49 μm, p < 0.01), temporal RNFL (- 1.68 μm; p = 0.03) and lower nasal RNFL (- 2.83 μm; p = 0.003). A significant linear relationship was found (p = 0.001) between the visual field deficit (mean deviation (MD)) and the Napierian logarithm of the mean RNFL thickness.

CONCLUSION

We found a subtle structural deterioration of the optic nerve (RNFL) during the follow-up, but not of the visual field. The significant relationship between structural (RNFL thickness) and functional measures (mean deviation) also supports the idea that RNFL thickness measurements could be useful for the mid-term monitoring of BSCR patients.

Uveitis as a Confounding Factor in Retinal Nerve Fiber Layer Analysis Using Optical Coherence Tomography

PURPOSE

To investigate the retinal nerve fiber layer thickness (RNFLT) in uveitic eyes and search for the associations with uveitis activity, etiology and location.

METHODS

The files of 76 patients with uveitis and 76 controls were scanned. Associations of RNFLT were analyzed using generalized linear models.

RESULTS

The RNFLT was significantly higher in patients with uveitis (p < .001). Active uveitis patients had a thicker RNFL than the controls and the patients with quiescent uveitis (p < .001). Anterior uveitis was associated with thinner RNFL in global and inferotemporal quadrant (p = .011 and 0.013, respectively). Thickening of RNFL was associated with posterior uveitis and Behçet's disease in all quadrants (p < .001) and idiopathic uveitis in the superonasal and nasal quadrants (p = .001).

CONCLUSION

Active uveitis, as well as posterior uveitis and Behcet's disease-associated uveitis, is a major confounding factor in RNFL analysis and therefore detection of glaucoma.

Behçet's Uveitis: Current Diagnostic and Therapeutic Approach

Behçet's disease is a chronic, multisystem inflammatory disorder characterized by relapsing inflammation. Although its etiopathogenesis has not yet been clarified, both the adaptive and innate immune systems, genetic predisposition, and environmental factors have all been implicated. It is more frequent and more severe in males in the third and fourth decades of life. The eye is the most frequently involved organ in the course of the disease. Ocular involvement (Behçet's uveitis) is characterized by bilateral recurrent non-granulomatous panuveitis and occlusive retinal vasculitis. Recurrent inflammatory episodes in the posterior segment may lead to permanent vision loss due to irreversible retinal damage and complications such as macular scarring, macular atrophy, and optic atrophy. Early and aggressive immunomodulatory treatment and the use of biologic agents when needed are crucial for preventing recurrences and improving visual prognosis.

Quantitative measurements with optical coherence tomography angiography in Behçet uveitis

PURPOSE

The aim of this study was to evaluate the quantitative measurements obtained by optical coherence tomography angiography in patients with Behçet uveitis.

METHODS

A total of 22 consecutive patients with Behçet uveitis and 19 age-matched healthy individuals were included in the study. Quantitative analysis of optical coherence tomography angiography images was performed. Comparisons between the patients and the control groups and correlation analysis between optical coherence tomography angiography results and age, visual acuity, duration of uveitis, central macular thickness, and fluorescein angiography scores in the patient group was performed.

RESULTS

The mean superficial foveal avascular zone area was 283.040 ± 113.003 µm² in the patient group and 254.268 ± 75.813 µm² in the control group (p = 0.821). The mean deep foveal avascular zone area was 317.657 ± 116.225 µm² in the patient group and 332.954 ± 94.783 µm² in the control group (p = 0.775). The foveal avascular zone area could not be calculated in eight eyes with macular atrophy in the patient group because of unclear foveal avascular zone borders. Both superficial and deep capillary vessel density in all regions were lower in the patient group than in the control. Superior, inferior, and temporal capillary vessel density were correlated with fluorescein angiography score (Pearson's r = -0.380, 0.392, and -0.384, p < 0.05 in superficial plexus; r = -0.357, -0.401, and -0.321, p < 0.05 in deep plexus, respectively). The foveal avascular zone area was correlated with central macular thickness in both superficial and deep plexus (r = -0.387 and -0.331, p < 0.05, respectively).

CONCLUSION

Recurrent uveitis attacks affecting the macula are associated with a decrease in capillary vessel density and expansion in the foveal avascular zone area in Behçet disease. The qualitative evaluation of the optical coherence tomography angiography findings may be more valuable in patients with macular atrophy.

Neurodegeneration in systemic lupus erythematosus: layer by layer retinal study using optical coherence tomography

Background

Systemic lupus erythematosus (SLE) is a chronic, autoimmune and multisystemic disease. Recent studies with functional and structural magnetic resonance imaging and cognitive tests report an unexpectedly high frequency of central nervous system involvement, even in patients with asymptomatic SLE. The purpose of this study was to identify early signs of retinal neurodegeneration by comparing the thickness of the peripapillary retinal nerve fiber layer (pRNFL) and all macular layers between patients with SLE without ophthalmologic manifestations and healthy controls. The effect of disease duration and systemic comorbidities was also studied.

Methods

Cross-sectional study, in which all participants underwent a complete ophthalmologic evaluation including retinal segmentation analysis with spectral domain-optical coherence tomography. Patients with SLE also received a detailed autoimmune disease specialist evaluation to assess the disease activity state and systemic involvement. For pRNFL thickness, the global and six peripapillary sectors were determined. Each macular layer thickness was determined in the nine Early Treatment Diabetic Retinopathy Study (ETDRS) subfields. A multiple linear regression analysis was performed to control for the effect of potential demographic, ophthalmic and systemic confounders. A second multivariable analysis, including patients with SLE only, was performed to assess the effect of disease-specific variables on the outcome measures.

Results

Sixty-eight eyes of 68 patients with SLE and 50 eyes of 50 healthy controls were considered. The pRNFL was significantly thinner in the SLE group globally (p = 0.026) and in the temporal superior (p = 0.007) and temporal (p = 0.037) sectors. In patients with SLE, chronic medication for hypercholesterolemia, hypertension and anticoagulants were associated with a significant thinning of the pRNFL. Patients with SLE presented significant thinning in the photoreceptor layer in five ETDRS areas (p < 0.05). Shorter disease duration was associated with greater photoreceptor thinning in all ETDRS subfields. Neuropsychiatric SLE, higher disease activity and cardiovascular risk factors were associated with a thinner photoreceptor layer. No differences were observed in overall retinal thickness or the remaining macular layers.

Conclusion

Patients with SLE present early signs of retinal neurodegeneration, as evidenced by a reduction in the photoreceptor layer and pRNFL. These signs are more pronounced in patients with higher cardiovascular risk burden or neuropsychiatric involvement.

An Algorithm for the Diagnosis of Behçet Disease Uveitis in Adults

Purpose: To develop an algorithm for the diagnosis of Behçet's disease (BD) uveitis based on ocular findings.Methods: 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.Results: 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.Conclusion: This study provides a diagnostic tree for BD uveitis that needs to be validated in future studies.

Outer Plexiform Layer Elevations as a Marker for Prior Ocular Attacks in Patients With Behcet's Disease

Purpose

Patients with Behcet's disease frequently have abnormal focal outer plexiform layer (OPL) bumps, which compress the inner nuclear layer. This study investigates the clinical relevance of these OPL elevations in Behcet's disease patients.

Methods

Thirty-one consecutive patients (59 eyes) with Behcet's disease in remission and with available optical coherence tomography (OCT) images were included. The number of OPL bumps was counted using spectral-domain OCT images. The relationships between the number of bumps and visual acuity (VA), retinal thickness, choroidal thickness, disease duration, number of prior ocular attacks, and photoreceptor layer status (including external limiting membrane [ELM] and ellipsoid zone [EZ] continuity) were examined.

Results

Eyes with more severe EZ or ELM disruptions had lower VA, more ocular attacks, and thinner retinas. Additionally, EZ line and ELM line status were significantly correlated with the number of OPL elevations. Eyes with OPL elevations had poorer VA, longer disease duration, more ocular attacks, and thinner retinas than those without OPL elevations. Additionally, the number of OPL elevations was strongly correlated with the number of ocular attacks in eyes with a preserved photoreceptor layer (R = 0.720, P < 0.0001).

Conclusions

The number of OPL elevations was associated with the number of prior ocular attacks in eyes with preserved photoreceptor layers. Therefore, OPL elevations may be a marker of prior posterior ocular attacks, which is important when determining how best to manage Behcet's uveitis.

The role of optical coherence tomography in therapeutics and conditions, which primarily have systemic manifestations: a narrative review

Optical coherence tomography is designed to evaluate in vivo qualitative and quantitative changes of the anterior segment, optic nerve and the retina. Initial applications of this technology were confined mainly to ophthalmic diseases. However recently, numerous studies have evaluated its use in systemic conditions and in therapeutics where, optic nerve and retinal architecture can be assessed to monitor progression of systemic conditions and its response to treatment. This is a narrative review aimed at evaluating the debate surrounding the role of spectral domain optical coherence tomography, in systemic conditions where optic nerve affection can be measured and be used in the diagnosis, monitoring and assessment of treatment effect as a non-invasive, quick, novel technique.

Retinal nerve fiber layer analysis in cocaine users

Cocaine is a well-known factor of tissue ischemia and may be related to thinning of the inner retinal layers. The present study aimed to evaluate and determine whether cocaine users show retinal nerve fiber layer (RNFL) thinning by means of spectral-domain optical coherence tomography. A group of 17 cocaine users and 18 non-users were recruited for complete ophthalmologic examination. Spectral domain optical coherence tomography (Cirrus OCT) was used to evaluate peripapillary RNFL and macular thickness. The average RNFL measurement in the cocaine users group was significantly thinner compared to the control group. Subjects in the cocaine users group showed significant thinning in the nasal, superior and inferior quadrant. There were no significant differences in macular thickness or in the temporal quadrant between the two groups. This study supports further research with larger sample sizes to precisely determine the effect of cocaine on the RNFL.

Ability of MultiColor scanning laser ophthalmoscope to detect non-glaucomatous retinal nerve fiber layer defects in eyes with retinal diseases

PURPOSE

To compare the ability of ocular fundus images obtained by Spectralis MultiColor scanning laser ophthalmoscope (MC-SLO) to that obtained by conventional color fundus images (CF) in detecting non-glaucomatous nerve fiber layer defects (NFLDs).

METHODS

A cross-sectional, retrospective study. Patients with retinal diseases who had ocular examination with both the MC-SLO and CF instruments at the Kagoshima University from December 2016 to February 2017 were studied. Eyes that had NFLDs with non-glaucomatous optic discs were analyzed. The visibility of the NFLDs was classified into three grades: grade 0, not visible; grade 1, barely visible; and grade 2, clearly visible. The NFLD grade for blue, green, and red scanning lights of the MC-SLO, merged images with three wavelengths and the color and red-free images were determined by two ophthalmologists. These scores were compared by Steel-Dwass tests.

RESULTS

Thirty-one eyes of 26 patients with a mean age of 63.1 ± 11.2 years were studied. There were 14 eyes with diabetic retinopathy, 11 eyes with age-related macular degeneration, 3 eyes with a branch retinal vein occlusion, and 3 eyes with an epiretinal membrane/macular hole. Both the intra-rater (0.631-0.790) and inter-rater (0.637-0.733) agreements were good. NFLDs were detected by the blue wavelength in all cases and by green wavelength and merged wavelengths in 90.3% of the images. The mean NFLD grade was 1.58 ± 0.49 for blue light images, 1.13 ± 0.54 for green light images, 0.07 ± 0.24 for red light images, and 1.16 ± 0.56 for merged images. The NFLD score for blue wavelength was significantly higher than that for green and red wavelength images (P < 0.05 and P < 0.01) but not significantly higher than that for the merged images. NFLDs were detected in 12 eyes (38.7%) in the color images and 16 eyes (51.6%) in the red-free images. The NFLD score for the CF and the red-free image was 0.41 ± 0.55 and 0.70 ± 0.67 which is significantly lower than that of blue MC-SLO images.

CONCLUSION

The images obtained by MC-SLO are superior to that obtained by CF in detecting NFLDs in eyes with retinal diseases. We recommend MC-SLO imaging to screen for NFLDs in eyes with retinal diseases.

Acute multifocal retinitis: a retrospective review of 35 cases

Background

Acute multifocal retinitis is a rare condition that has been considered to be often idiopathic. The purpose of this study was to analyze clinical features and causes of acute multifocal retinitis.

Results

This study is a retrospective review of the charts of 35 patients with acute multifocal retinitis. Patients with three or more retinal lesions in at least one eye, with at least one lesion of less than 500 μm in size were included. All patients had complete ophthalmological examination, fundus photography, and fluorescein angiography. Twelve patients (34.3%) had optical coherence tomography. An extensive work-up was performed including a detailed comprehensive medical history, examination by an internist and an infectious disease specialist, a chest X-ray, Mantoux test, and laboratory tests for syphilis, human immunodeficiency virus, Bartonella, and Rickettsia. Of the 35 patients, 25 (71.4%) had bilateral involvement and 10 (28.6%) had unilateral involvement (total number of eyes: 60). Mean best-corrected visual acuity (BCVA) was 20/25 (range, 20/1000–20/20). Retinal lesions ranged from 3 to more than 20 in number in at least 1 eye, and from 150 to 1500 μm in size. Associated findings included mild anterior chamber inflammation in 5 eyes (8.3%), mild vitritis in 46 eyes (76.7%), optic disc swelling in 9 eyes (15%), macular star in 4 eyes (6.7%), exudative retinal detachment in 6 eyes (10%), and branch retinal artery occlusion in 6 eyes (10%). Acute multifocal retinitis was found to be caused by Rickettsia conorii infection in 20 patients (57.1%), Rickettsia typhi infection in 4 patients (11.4%), cat-scratch disease in 8 patients (22.9%), and syphilis in 1 patient (2.9%). It was idiopathic in two patients (5.7%). Retinal lesions resolved without scarring in 3 to 12 weeks in all but three eyes (5%), in which residual retinal pigment epithelial changes were noted.

Conclusion

Rickettsial disease was the most common cause of acute multifocal retinitis. Other identified causes included cat-scratch disease and syphilis, and a very small subset of patients was diagnosed with idiopathic multifocal retinitis.

In Vivo Confocal Microscopic Evaluation of Corneal Nerve Fibers and Dendritic Cells in Patients With Behçet's Disease

Central and peripheral nervous system involvement may occur during the course of Behçet’s disease (BD). In vivo corneal confocal microscopy (CCM) can detect corneal small fiber damage and immune cell density. The aim of this study was to assess central corneal sensitivity, corneal subepithelial nerve plexus morphology and dendritic cell (DC) density in patients with BD. Forty-nine consecutive patients with BD and 30 healthy control subjects were included in this cross-sectional study conducted at a tertiary referral university hospital. Central corneal sensitivity was measured using the contact corneal esthesiometer (Cochet-Bonnet; Luneau, France). The laser scanning CCM (Heidelberg, Germany) was used to quantify corneal nerve fiber density (NFD), nerve branch density (NBD), nerve fiber length (NFL), and DC density. There was a significant reduction in NFD (P = 0.001) and NFL (P = 0.031) and an increase in DC density (P = 0.038) in patients with BD compared to healthy controls, whereas corneal sensitivity (P = 0.066) and NBD (P = 0.067) did not differ significantly. There was no difference in corneal sensitivity, corneal nerve parameters, or DC density between BD patients with [n = 18 (36.7%)] and without a previous history of uveitis (P > 0.05 for all). Disease duration [median (IQR), 6.5 (4.0–14.5) years] correlated with corneal sensitivity (ρ = −0.463; P = 0.001) and NFD (ρ = −0.304; P = 0.034) and corneal sensitivity correlated with NFD (ρ = 0.411; P = 0.003) and NFL (ρ = 0.295; P = 0.039) in patients with BD. CCM demonstrates corneal sub-basal nerve fiber loss and increased DC density, providing a non-invasive ophthalmic means to identify peripheral neuropathy and inflammation in patients with BD.

Prevalence of retinal nerve fiber layer defects: The Korea National Health and Nutrition Examination Survey 2008-2012

Purpose

To investigate the prevalence and associated factors of retinal nerve fiber layer defects (RNFLDs) in a Korean population.

Methods

The Korea National Health and Nutrition Examination Survey (KNHANES) is a population-based study using a complex, stratified, multistage, probability-cluster survey. We performed a review of 2008–2012 data from the KNHANES. Two masked ophthalmologists evaluated fundus photography to detect RNFLDs. All participants underwent ocular and systemic evaluations.

Results

A total of 28,637 subjects aged ≥ 19 years with at least one evaluable fundus photograph were enrolled. The estimated prevalence of RNFLDs in this Korean population was 4.8% (95% confidence interval, 4.4%–5.3%). The estimated percentages of glaucomatous RNFLD and non-glaucomatous RNFLD subjects were 34.4% and 65.6%, respectively. In a multivariate analysis, the prevalence of RNFLDs was significantly associated with older age (P < 0.001), male gender (P = 0.047), glycosylated hemoglobin (P = 0.048), disc hemorrhage (P = 0.016), ISNT rule (P < 0.001), and vertical cup to disc ratio (P < 0.001).

Conclusions

The prevalence of RNFLDs in a large Korean population-based sample with a minimum age of 19 years was 4.8%. RNFLD prevalence was associated with old age, male gender, glycosylated hemoglobin, disc hemorrhage, and glaucomatous optic disc.

Systemic vasculitis and the eye

PURPOSE OF REVIEW

The primary systemic vasculitides represent a spectrum of rare but life-threatening conditions that may also affect the eye in various forms. This article reviews recently published data on ocular manifestations of systemic vasculitis.

RECENT FINDINGS

Early diagnosis and timely treatment has led to better visual outcomes in giant cell arteritis (GCA). Gene expression from orbital tissues could distinguish granulomatosis with polyangiitis (GPA) from sarcoidosis and Graves disease, but not from idiopathic orbital inflammation. Rituximab was an effective therapeutic option in ocular GPA. An ocular attack severity scoring system, flare levels, fluorescein angiography and optical coherence tomography parameters have been suggested as predictors of visual prognosis in Behçet disease. Efficacy of tumor necrosis factor-alpha inhibitors, interferon α and anti-interleukin-1 agents was shown in noncontrolled studies of ocular Behçet disease.

SUMMARY

Widely used fast-track pathway care as well as ocular imaging to detect subclinical involvement may enable earlier diagnosis of GCA and prevention of permanent visual loss. Orbital inflammation may not remain idiopathic with advances in gene expression profiling of orbital tissues. With an increased availability and the use of biologic agents, visual prognosis will improve in patients with severe ocular complications of systemic vasculitides.

Efficacy of cataract surgery in patients with uveitis: A STROBE-compliant article

To evaluate the visual outcomes of cataract surgery in patients with uveitis, and to determine risk factors for the recurrence of uveitis and postoperative complications.Eighty patients with uveitis who underwent phacoemulsification with intraocular lens (IOL) implantation were included in this retrospective study. We analyzed the following data: patient characteristics, medications used, visual acuity, and complications of cataract surgery.The mean ± standard deviation time from cataract surgery to the last visit was 20.8 ± 10.4 months. Best-corrected visual acuity improved significantly after surgery (P < .001). The visual outcome was worse in patients with Behçet disease than in patients with other etiologies of uveitis. Gender (P = .018) and IOL type (P = .020) were significantly associated with recurrent uveitis after surgery. The incidence of recurrent inflammation was not significantly different between patients who did or did not receive systemic therapy (P = .43). Perioperative systemic therapies (P = .011) and recurrent uveitis within 3 months of surgery (P = .043) were associated with posterior capsular opacification. Perioperative systemic therapies (P = .026) and recurrent uveitis after surgery (P = .006) were also significantly associated with cystoid macular edema.Patients with uveitis could benefit from cataract surgery. Patients with Behçet disease had worse postoperative prognosis than patients with other etiologies of uveitis. A heparin-surface-modified IOL may reduce the incidence of recurrent inflammation.

Asymptomatic Progression of Ocular Behçet's Disease

BACKGROUND AND OBJECTIVE

To emphasize the importance of auxiliary exams to detect progression of ocular Behçet's disease (BD) in asymptomatic patients.

PATIENTS AND METHODS

This was a retrospective review of the clinical records of a consecutive series of patients with BD and asymptomatic visual deterioration, imaged on fundus photograph (FP), visual field (VF), fluorescein angiography (FA), and optical coherence tomography (OCT).

RESULTS

Patients presented with no clinical findings or with mild inflammation on ophthalmic examination. However, during follow-up, VF examination indicated a progressive enlargement of previously visualized scotomas. On FA, the authors detected leakage and ischemia. On OCT, there was macular anatomical disruption, and the FP showed areas of atrophic retina.

CONCLUSION

In patients with ocular BD, the visual acuity deterioration may be asymptomatic and progressive. This should justify the importance of early and sequential ancillary exams in the management of BD patients to detect subclinical ocular involvement. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:18-25.].

Analysis of Clinical Factors Associated with Retinal Morphological Changes in Patients with Primary Sjögren's Syndrome

Purpose

To investigate clinical factors associated with abnormal retinal morphologies in patients with primary Sjögren's syndrome (pSS).

Methods

One-hundred-thirty patients with pSS who underwent immunoserological tests, minor salivary gland biopsies, and optical coherence tomography examinations were retrospectively analyzed. Risk factors for abnormally reduced peripapillary retinal nerve fiber layer (pRNFL) and macular ganglion cell–inner plexiform layer (mGCIPL) thicknesses were evaluated, as well as the correlation between clinical factors and pRNFL and mGCIPL thicknesses.

Results

Anti-Sjögren's syndrome type B (SSB) antibody positivity (P = 0.048) was identified as a risk factor associated with abnormally reduced pRNFL thickness, and anti-SSB positivity (P = 0.005) and erythrocyte sedimentation rate (ESR) level (P = 0.031) were identified as risk factors associated with an abnormally reduced mGCIPL thickness as revealed by multivariate logistic regression analysis. There was a significant negative correlation between anti-SSB antibody levels and the thickness of pRNFL and mGCIPL. The thicknesses of pRNFL and mGCIPL were significantly reduced in anti-SSB–positive eyes when compared to anti-SSB–negative eyes (P < 0.05). However, histopathologic grading was not associated with the pRNFL and mGCIPL thicknesses.

Conclusion

Anti-SSB antibody positivity and ESR levels may be useful for predicting an abnormally reduced pRNFL or mGCIPL thickness in patients with pSS. Our results may provide clinical evidence to substantiate the association between aberrant autoimmunity and inner retinal changes in patients with pSS.