Serpiginous choroiditis and infectious multifocal serpiginoid choroiditis

Long-Term Outcomes of Adalimumab Treatment in Conventional Treatment-Resistant Serpiginous Choroiditis

BACKGROUND/OBJECTIVES

To investigate the long-term efficacy and safety of adalimumab(ADA) in the treatment of patients with serpiginous choroiditis (SC) refractory to conventional therapy through quantitative parameters.

SUBJECTS/METHODS

A retrospective analysis was conducted on patients diagnosed with SC clinically and through fundus autofluorescence(FAF). Patients receiving ADA treatment were included. Demographic and clinical characteristics of the patients, association with tuberculosis (TB) infection, number of immunosuppressive therapies, recurrences, best corrected visual acuity (BCVA) change, and ADA-related side effects were recorded. The progression rate before and after ADA was calculated based on the area involved by FAF.

RESULTS

Sixteen eyes of 8 patients (3 female/5 male) were enrolled to the study. The median (IQR) age was 53.5 (16.5) years. Diagnosis was SC in 4, ampiginous choroiditis in 3, and TB-related serpiginous-like choroiditis in 1 patient. Peripapillary involvement was present in 10 of 16 eyes. The area involved by FAF continued to progress under ADA treatment, however the progression rate was decreased (p = 0.143).The BCVA was preserved (p = 0.772). The number of systemic and local treatments decreased with ADA (p = 0.025 and 0.019, respectively). Additionally, the number of recurrences was reduced with ADA (p = 0.002). Median (IQR) follow-up was 45(28.75) months. Two patients experienced ADA-related side effects (pulmonary TBand rash).

CONCLUSIONS

Our findings suggest a promising role for ADA in halting the progression of SC and have implications for improving outcomes. Despite the evidence in the literature at the level of case reports, ADA can be used effectively with close monitoring for potential risks.

Peripapillary fluid: Obvious and not so obvious!

Intraretinal or subretinal fluid in the peripapillary area can be clinically visualized in conditions such as peripapillary choroidal neovascularization, optic disc pit maculopathy, and optic nerve head tumors and granulomas. Optical coherence tomography (OCT) helps to visualize peripapillary fluid in many other chorioretinal conditions such as peripapillary pachychoroid syndrome, posterior uveitis, central retinal vein occlusion, malignant hypertension, hypotonic maculopathy as well as neuro-ophthalmological conditions such as glaucoma, microcystic macular edema and disc edema due papilledema, non-arteritic anterior ischemic optic neuropathy, neuroretinitis, and diabetic papillopathy. Often, the differential diagnosis of peripapillary fluid is a bit tricky and may lead to misdiagnosis and improper management. We describe a diagnostic algorithm for peripapillary fluid on OCT and outline the salient features and management of these conditions.

Primary Tubercular Chorioretinitis Without a Pulmonary Focus: A Case Report

Ocular tuberculosis (TB) can affect various eye structures and may manifest independently of systemic TB. Typically, it arises from hematogenous dissemination from a primary focus; however, in exceptional instances, it may originate as a primary infection after epithelial injury. Diagnosing TB in an extrapulmonary site presents a significant clinical challenge. We present the case of a 33-year-old Bangladeshi female who presented with a deteriorating loss of vision in her left eye. A thorough neurologic examination and serological tests, the tuberculin skin test, a CT scan of the chest, ocular fundus photography, and optical coherence tomography were performed. Based on the clinical features and the outcome of appropriate tests, a presumptive diagnosis of ocular TB was made and later confirmed after initiating antitubercular therapy, which resulted in a marked improvement in the patient's vision a week later. This case is an illustration of the rare nature and unusual presentation of extrapulmonary TB in the form of tubercular chorioretinitis, diagnosed in a resource-limited setting. Tubercular chorioretinitis, characterized by inflammation of the choroid and retina due to TB infection, presents a diagnostic challenge, especially in resource-limited environments where access to advanced diagnostic tools may be restricted. Therefore, this case highlights the importance of considering TB as a potential cause of ocular manifestations, even in settings where TB prevalence might not be high, and underscores the need for increased awareness and diagnostic capacity for extrapulmonary TB in resource-limited areas. This case exemplifies the infrequent occurrence and atypical manifestation, presenting a learning opportunity for future clinicians.

A retrospective study describing the effective exchange of total blood plasma for disease control in the exacerbation of serpiginous choroiditis

INTRODUCTION

Serpiginous choroiditis presents with large yellow-white exudative lesions that occur near the optic nerve papillae, that progresses slowly with repeated relapses and cures. Although infection and autoimmunity have been implicated, the cause is unknown.

METHODS

A man was diagnosed with serpiginous choroiditis on clinical and other examinations. He started treatment with oral corticosteroids, cyclophosphamide, adalimumab, azathioprine, rituximab, and mycophenolate mofetil. Only the steroids and cyclophosphamide had a therapeutic effect. Plasma exchange was initiated, and the lesions quickly resolved.

RESULTS

Disease control has been maintained by plasma exchange and cyclophosphamide during flare-ups in the fall and winter, suggesting that plasma exchange is effective in the treatment of serpiginous choroiditis.

CONCLUSION

The reproducible response with each recurrence suggests a strong association between the disease and autoimmunity. Furthermore, that some, as yet unknown, autoantibodies are involved in the pathogenesis of serpiginous choroiditis.

Tubercular Serpiginous-Like Choroiditis in Patients with Negative TB-Immunoreactivity Tests

BACKGROUND

Serpiginous-like choroiditis (SLC) denotes ocular tuberculosis (TB), in the presence of positive tuberculin skin test (TST) or interferon gamma release assay (IGRA).

METHODS

Retrospective review of SLC patients from a TB-endemic country, with negative TST and IGRA tests, but responsive to anti-TB therapy.

RESULTS

Fifteen patients (13 bilateral) with active SLC  were included.   Eleven (73.3%) patients had received corticosteroids ± immunosuppressive therapy prior to presentation. Chest radiographic abnormalities were found in four (26.7%) patients. We treated all patients with a combination of anti-TB therapy (ATT) and corticosteroids. Paradoxical worsening was noted in nine (60%) patients, complete resolution of lesions in 12 (80%), persistent inflammation (post-ATT) in one, while two were yet to complete ATT. None had recurrence after complete resolution of lesions (median follow-up of 71 weeks [range 15-676 weeks]).

CONCLUSIONS

TB-SLC may present with negative TST and IGRA tests but may still have clinical appearance, and treatment response, like test-positive disease.

Clinical association and visual morbidity in uveitis with systemic diseases: An analysis from a tertiary ophthalmic center

AIM

The aim of this study was to identify the incidence, etiology, most common presentations, complications, and the causes of visual loss in posterior uveitis (PU).

MATERIALS AND METHODS

A retrospective study was conducted on a cohort of 125 patients with PU with a minimum follow-up of 6 months. Ocular evaluation consisted of slit-lamp examination, indirect ophthalmoscopy, tonometry, and refraction. Ancillary ophthalmic investigations such as fundus fluorescein angiography, optical coherence tomography, and B-scan ultrasonography were done. Laboratory tests were performed on blood on all patients and in aqueous humor samples obtained by anterior chamber paracentesis in cases of diagnostic dilemmas. All the data were analyzed using SPSS program.

RESULTS

PU occurred in 61%. Infections were noted in 34% and autoimmune diseases in 27%. The most frequent presentation was choroiditis. The most common etiologies were tubercular uveitis in 50%, Toxoplasma retinochoroiditis in 23%, and autoimmune category of serpiginous choroiditis in 56% of patients. Complications occurred in 27% and were most commonly cystoid macular edema and macular scarring. Polymerase chain reaction (PCR), nested PCR, and real-time PCR on ocular fluids were required for diagnosis in 30%. A combination of laboratory investigations on blood and aqueous humor samples were confirmation in 88%.

CONCLUSION

PU and its sequelae are known to be sight threatening and are associated with systemic diseases. They have diverse etiologies and presentations. Identification of etiology is important as management is diametrically opposite in infections and autoimmune diseases.

Retinitis Pigmentosa Masquerades: Case Series and Review of the Literature

Retinitis pigmentosa (RP) displays a broad range of phenotypic variations, often overlapping with acquired retinal diseases. Timely recognition and differentiation of RP masquerades is paramount due to the treatable nature of many such conditions. This review seeks to present examples of pseudo-RP cases and provide a comprehensive overview of RP masquerades. We first present two pseudo-RP cases, including comprehensive clinical histories and multimodal retinal imaging, to highlight the important role of accurate diagnoses that subsequently steered effective intervention. Subsequently, we conduct an in-depth review of RP masquerades to provide valuable insights into their key distinguishing features and management considerations. The recent approval of ocular gene therapy and the development of investigational gene-based treatments have brought genetic testing to the forefront for RP patients. However, it is important to note that genetic testing currently lacks utility as a screening tool for inherited retinal diseases (IRDs), including RP. The integrity of a precise clinical assessment remains indispensable for the diagnosis of both RP and RP masquerade conditions, thereby facilitating prompt intervention and appropriate management strategies.

[Acute posterior multifocal placoid pigment epitheliopathy, serpiginous choroiditis and related diseases]

Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE) and serpiginous choroiditis are two diseases classified as "white spot syndromes." Both are inflammatory/autoimmune diseases with suspected primary involvement of the choriocapillaris. The former usually has an excellent prognosis, while the latter can rapidly induce legal blindness. Whereas these diseases are well defined and well known, other entities (such as persistent placoid maculopathy or ampiginous choroiditis) with features of both APMPPE and serpiginous choroiditis have been described more recently. This review aims to describe demographic characteristics and multimodal imaging features to help differentiate between these four diseases.

Diagnosis of Optic Disc Oedema: Fundus Features, Ocular Imaging Findings, and Artificial Intelligence

Optic disc swelling is a manifestation of a broad range of processes affecting the optic nerve head and/or the anterior segment of the optic nerve. Accurately diagnosing optic disc oedema, grading its severity, and recognising its cause, is crucial in order to treat patients in a timely manner and limit vision loss. Some ocular fundus features, in light of a patient's history and visual symptoms, may suggest a specific mechanism or aetiology of the visible disc oedema, but current criteria can at most enable an educated guess as to the most likely cause. In many cases only the clinical evolution and ancillary testing can inform the exact diagnosis. The development of ocular fundus imaging, including colour fundus photography, fluorescein angiography, optical coherence tomography, and multimodal imaging, has provided assistance in quantifying swelling, distinguishing true optic disc oedema from pseudo-optic disc oedema, and differentiating among the numerous causes of acute optic disc oedema. However, the diagnosis of disc oedema is often delayed or not made in busy emergency departments and outpatient neurology clinics. Indeed, most non-eye care providers are not able to accurately perform ocular fundus examination, increasing the risk of diagnostic errors in acute neurological settings. The implementation of non-mydriatic fundus photography and artificial intelligence technology in the diagnostic process addresses these important gaps in clinical practice.

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.

Subretinal Hyperreflective Material (SHRM) as biomarker of activity in Exudative and Non- exudative inflammatory choroidal neovascularization

AIM

To analyze the structural features and therapeutic response in clinical and subclinical inflammatory choroidal neovascularization (i-CNV) detected inside subretinal hyperreflective material (SHRM) using swept-source optical coherence tomography (SS-OCT) and SS-OCT angiography (SS-OCTA).

METHODS

In this prospective interventional study, subjects with quiescent posterior uveitis presenting with SHRM on SS-OCT and CNV network on SS-OCTA were included. Subjects with intraretinal fluid/subretinal fluid (IRF/SRF) received intravitreal antivascular endothelial growth factor (anti-VEGF) injections, while those with no IRF/SRF either received treatment or observation for 6 months until they developed IRF/SRF or decrease in best-corrected visual acuity (BCVA)/metamorphopsia. Serial comparisons included SHRM width and height and intrinsic flow signal on OCTA.

RESULTS

28 eyes of 22 subjects (12 males; mean age: 29.52 ± 12.56 years) were evaluated. Subjects with IRF/SRF at baseline (n = 6 eyes; termed as exudative iCNVs) receiving treatment showed significant improvement in BCVA (p = .017), SHRM width/height and flow signal (p < .05). Among eyes with no IRF/SRF (n = 22; termed as non-exudative iCNVs), 7 received treatment and showed significant improvement in SHRM parameters and BCVA (p < .05). 4/15(26.67%) eyes that received no treatment developed IRF/SRF upon 6-month follow-up.

CONCLUSION

SHRM may act as a useful biomarker to monitor activity and response to therapy in eyes with iCNV.

Application of metagenomic next-generation sequencing in suspected intraocular infections

PURPOSE

To evaluate the efficacy of metagenomic next-generation sequencing (mNGS) and to explore its value in the diagnosis of intraocular infection.

METHODS

A retrospective case-series study of patients with suspected intraocular infection was performed. Intraocular fluid samples were collected from all the patients and sent for mNGS. Detailed clinical data, the results of mNGS and other laboratory examinations, the sequencing data of mNGS, and the final diagnosis were recorded.

RESULTS

Fifteen eyes of 15 patients were included in the study. Eight samples were identified as positive for different kinds of pathogens by mNGS, which were all confirmed by other laboratory examinations or effective diagnostic treatment. The mNGS results were negative in seven samples. The final diagnosis was still intraocular infection in four of the seven negative results. Of these, one patient was diagnosed with fungal endophthalmitis according to the clinical characteristics and good treatment response to the anti-fungal therapy, one patient underwent vitrectomy and the bacterial culture of the vitreous sample was positive for Brucella melitensis, and two patients were diagnosed with ocular tuberculosis according to the positive T-SPOT test and effective anti-tuberculous treatments.

CONCLUSIONS

mNGS could be helpful in determining pathogens in cases of suspected intraocular infection. The mNGS protocols should be optimized for the detection of intracellular bacterial and fungal pathogens.

Multifocal Serpiginoid Choroiditis Due to Mycobacterium Mageritense following Laparoscopic Hysterectomy in an Immunocompetent Host

PURPOSE

To report nontubercular choroiditis, caused by Mycobacterium mageritense isolated using MALDI-TOF MS, following laparoscopic hysterectomy in an immunocompetent patient.

CASE REPORT

A 42-year-old female presented with gradual, painless diminution of vision in the right eye for six weeks. She had undergone laparoscopic hysterectomy two months back. BCVA was 2/60 OD. Clinical presentation and imaging all pointed to a diagnosis of serpiginous-like choroiditis. Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry (MALDI-TOF MS) had led to isolation of Mycobacterium mageritense. Patient was treated with systemic antibiotics. At 3 months follow up, BCVA improved to 6/60; fundus showed healed choroiditis and chorioretinal thinning.

CONCLUSION

Atypical mycobacterial infections associated with laparoscopic surgeries can rarely lead to debilitating systemic bacteremia resulting in profound visual impairment. The importance of timely diagnosis using specific and sophisticated methods such as MALDI-TOF MS as well as maintaining aseptic precautions perioperatively during major surgeries cannot be overemphasized.

Relentless placoid chorioretinitis: A review of four cases in pediatric and young adult patients with a discussion of therapeutic strategies

Introduction

Relentless placoid chorioretinitis (RPC) is a rare, bilateral disease of the retinal pigment epithelium. The clinical course is prolonged and relapsing. No standard treatment has been established to date. The purpose of this case series is to report four cases of RPC in pediatric and young adult patients in which varying treatments were used, comparing them to previously published cases.

Methods

A literature review was conducted to investigate currently published presentations and treatment options for RPC. A multicenter retrospective chart review was also performed on four consecutive patients. These patients were diagnosed with RPC because of new chorioretinitis lesions continuing to appear without or despite therapy for 5-36 months (2 patients), with a clinical course prolonged and relapsing, or because of the atypical location of the multiple lesions (>50) extending from the posterior pole to the equator and mid-peripheral retina (all four patients), which were not consistent with other entities like acute posterior multifocal placoid pigment epitheliopathy and serpiginous choroiditis.

Results

All four cases of RPC received oral or IV steroids acutely, and three of these patients were transitioned to a steroid-sparing agent and biologic therapy: anti-TNF alpha or anti-IL-6. Quiescence of the chorioretinitis lesions was obtained after 7 months, 1 month, and 36 months; however, the latter had issues with treatment adherence. Mycophenolate mofetil was insufficient to control the disease in one patient, but tocilizumab and infliximab thereafter were effective after cessation of adalimumab due to side effects. Adalimumab when started the first month after the presentation was effective in controlling the disease in one patient. After the failure of interferon-alpha-2a, one patient displayed long-term control with infliximab. One patient did not require a steroid-sparing agent after oral prednisone taper as there was no evidence of progression or recurrence.

Conclusion

This case series adds to the current knowledge regarding potential treatments for RPC, specifically the use of anti-TNF-alpha treatment and anti-IL-6 tocilizumab. In this case study, relapses of RPC were found among patients on mycophenolate mofetil and interferon-alpha-2a, and one case did not relapse on oral steroids without a steroid-sparing agent. Our findings suggest that adalimumab, infliximab, and tocilizumab may be useful medications to obtain quiescence of RPC.

An excursion into ocular tuberculosis

Till today, ocular tuberculosis (OTB) presents clinicians with significant challenges in diagnosis and management. There is no one-size-fits-all approach to a heterogeneous disease like OTB, and clinicians often have to consider a multitude of factors when initiating treatment, such as tuberculosis endemicity, the probability of a true OTB diagnosis in the setting of nonspecific ocular features, the effective duration of treatment, and the likelihood of vision-threatening complications in the patient. It is no wonder that treatment protocols are widely varied globally. There have been recent developments in the standardization of nomenclature and therapeutic strategies for OTB, as established by the Collaborative OTB Study Working Group. In this review, we referred to findings in retrospective studies, international clinical guidelines, and OTB consortiums, to explore the clinical presentations, investigations, and updated management principles for patients with presumed tubercular uveitis.

Choriocapillaris Flow Deficit in Tubercular Serpiginous-Like Choroiditis with and without Paradoxical Worsening

PURPOSE

The aim is to analyze automated quantification of choriocapillaris flow deficit (CCFD) on swept-source (SS)-optical coherence tomography angiography (OCTA) in tubercular serpiginous-like choroiditis (TBSLC).

METHODS

In this prospective study, automated CCFD calculations were performed on SS-OCTA and compared with CCFD areas on indocyanine green angiography (ICGA). Patients were divided into two groups based on the occurrence of paradoxical worsening (PW).

RESULTS

Twenty-nine eyes (29 subjects; 18 males; mean age: 33±12 years) were included. The mean CCFD at baseline was 34.9 ± 4.3% on OCTA in eyes without PW and 35.4 ± 5.0% on SS-OCTA with PW (p = .77). At 4 and 12 weeks, CCFD on SS-OCTA improved to 30.6 ± 3.9% and 28.0 ± 4.2% (p < .001) without PW, respectively, and increased to 42.9 ± 4.4% and 48.8 ± 4.1% (p < .001) with PW, respectively. The SS-OCTA CCFD correlated well with ICGA (r = 0.48; p < .001).

CONCLUSIONS

Automated quantitative serial assessment of CCFD on SS-OCTA can serve as a useful biomarker of disease activity in eyes with TBSLC.

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.

Navigating the White Dot Syndromes with Optical Coherence Tomography (OCT) and OCT Angiography (OCT-A)

INTRODUCTION

White dot syndromes are a heterogeneous group of diseases that affect different layers in the retina and choroid. Multimodal imaging is fundamental in the diagnosis, but also can be crucial in unveiling the pathogenesis of these entities.

MATERIAL AND METHODS

Literature review.

RESULTS

Optical coherence tomography (OCT) provides depth-resolved, histological grade images of the vitreous, retina, and choroid. This technology is very useful to localize the primary nature and level of pathology of the various white dot syndromes. En face OCT can provide additional information regarding the interrelationship of lesion types. Vascular involvement at the level of the retina, choriocapillaris or choroid can be assessed by en face OCT angiography (OCT-A) and is not limited by masking, leakage or staining as can occur with conventional angiography (fluorescein or indocyanine green angiography) which requires dye injection.

CONCLUSION

OCT and OCTA are fundamental in the diagnosis and follow-up of white dots syndromes.

BILATERAL SERPIGINOUS-LIKE CHORIORETINITIS ASSOCIATED WITH CILIOCHOROIDAL MELANOMA: A Clinicopathologic Correlation

PURPOSE

To report the clinicopathologic correlation of a case of bilateral serpiginous-like chorioretinitis (SLC) associated with unilateral ciliochoroidal melanoma.

METHODS

A 71-year-old white woman was diagnosed with progressive SLC in both eyes associated with ciliochoroidal melanoma in the right eye. Clinical findings and imaging before and after enucleation in the right eye were correlated to histologic and immunohistochemistry sections.

RESULTS

Examination and imaging identified a peripheral bilobed amelanotic lesion with low reflectivity on B-scan ultrasound with an associated exudative detachment in the right eye. Additionally, multiple areas of new SLC lesions in the macula and peripapillary region in the right eye and along the inferior arcade in the left eye were observed. Oncologic evaluation confirmed a Class 2, ciliochoroidal melanoma, and the eye was enucleated. Autoimmune and infectious laboratory evaluations for the etiology of the SLC lesions were negative. Histopathology of the enucleated eye confirmed the diagnosis of uveal melanoma with lymphocytic inflammation at the edges of the tumor itself and in the areas of discrete SLC lesions. Immunohistochemistry identified similar predominantly CD3 and CD8 T cells and fewer CD20 B cells in both regions.

CONCLUSION

Serpiginous-like chorioretinitis may present as a paraneoplastic, predominantly T-lymphocyte inflammation associated with intraocular tumor such as uveal melanoma.

Mechanisms, Pathophysiology and Current Immunomodulatory/Immunosuppressive Therapy of Non-Infectious and/or Immune-Mediated Choroiditis

Non-infectious choroiditis comprises immune-mediated diseases resulting from diverse pathophysiological mechanisms. These conditions are sub-divided into two main groups, (1) diseases of the choriocapillaris and (2) diseases of the choroidal stroma. The purpose of this study is to expose the pathophysiology of the most common diseases of both these groups and recommend the optimal immunomodulatory/immunosuppressive therapy of each analyzed condition based on literature data and data from our own centers. Material and Methods: Narrative review. In the group of choriocapillaritis entities or primary inflammatory choriocapillaropathies (PICCPs) including multiple evanescent white dot syndrome (MEWDS), acute posterior multifocal placoid pigment epitheliopathy (APMPPE), idiopathic multifocal choroiditis (MFC) and serpiginous choroiditis (SC), as well as secondary choriocapillaritides including acute syphilitic posterior multifocal placoid chorioretinitis (ASPMPC) and tuberculosis-related SC (TB-SC), were analyzed. In the group of stromal choroidites, HLA-A29 birdshot retinochoroiditis (BRC) and Vogt-Koyanagi-Harada (VKH) disease were included. For each entity a literature search, in the PubMed database, on treatment was performed and analyzed and the therapeutic attitudes of our own centers were presented. Management of immune-mediated choroiditis implies vigorous immunosuppressive therapy given in a prompt and prolonged fashion in most of these entities.

Infectious Posterior Uveitis - Toxoplasmosis, Treponema, Tuberculosis (TTT)

Toxoplasma gondii, Treponema pallidum and Mycobacterium tuberculosis are the most important infectious causes of posterior uveitis. The epidemiology, clinical picture, diagnostic and treatment strategies of these diseases are presented.

Idiopathic multifocal choroiditis with serpiginous-like peripapillary chorioretinal atrophy

PURPOSE

To report nine cases of multifocal choroiditis with serpiginous-like peripapillary chorioretinal atrophy.

METHODS

A retrospective observational case series of eyes with multifocal choroiditis with serpiginous-like peripapillary chorioretinal atrophy. Multimodal imaging findings were reviewed and presented.

RESULTS

Fifteen eyes of 9 patients (6 women and 3 men), mean age 48.1 years (median 46 years, range 23-74 years), presented with multifocal choroiditis serpiginous-like peripapillary chorioretinal atrophy. All fifteen eyes presented with serpiginoid peripapillary changes and had discrete patches of atrophy or punched out scars in the posterior pole or periphery. Eleven eyes (73.3%) had cone-shaped retinal pigment epithelium (RPE) elevations on optical coherence tomography (OCT), 10 eyes (66.7%) had mild vitritis, and four eyes (26.7%) had peripheral curvilinear streak lesions. Three eyes (20%) had choroidal neovascularization. All patients responded well to treatment with systemic immunosuppression, local corticosteroid injections, and/or intravitreal anti-vascular endothelial growth factor injections.

CONCLUSION

Multifocal choroiditis may present with peripapillary chorioretinal changes resembling a serpiginous-like choroiditis in addition to the classic findings of patches of atrophy or punched-out scars in the posterior pole or periphery, cone-shaped RPE elevated on optical coherence tomography, and peripheral curvilinear streak lesions.

The use of optical coherence tomography angiography in comparing choriocapillaris recovery between two treatment strategies for multifocal choroiditis: a pilot clinical trial

PURPOSE

To compare differences in choriocapillaris flow deficit (CC FD) in multifocal choroiditis (MFC) between two treatment arms using optical coherence tomography angiography (OCTA).

METHODS

In this prospective randomized clinical trial, patients were randomized to either Group 1 which received standard tapering dose of oral corticosteroids, or Group 2 which received additional dexamethasone implant (or intravitreal methotrexate). The patients were followed-up until 12 weeks using OCTA and other imaging tools. CC FD and visual acuity between the two groups were compared at each visit.

RESULTS

Twenty-five subjects (17 males; 25 eyes) were studied (11 eyes in Group 1). There were no differences between the visual acuity or CC FD (1.12 versus 1.08 mm²; p = 0.86) at baseline between the groups. However, patients in Group 2 achieved better visual acuity (0.32 ± 0.23 versus 0.15 ± 0.11; p = 0.025) and CC FD (0.54 versus 0.15 mm²; p = 0.008) at 12 weeks.

CONCLUSIONS

OCTA is a useful tool in monitoring the CC FD recovery after treatment in MFC. Patients receiving intravitreal corticosteroid/methotrexate in addition to systemic corticosteroid showed greater resolution of CC FD on OCTA compared to those receiving only oral corticosteroids.

Clinical profile, multimodal imaging, and treatment response in macular serpiginous choroiditis

Purpose:

To describe the clinical profile, multimodal imaging, and treatment response in macular serpiginous choroiditis (MSC).

Methods:

Clinical records of 16 eyes (14 patients) with MSC presenting to a tertiary eye care institute between 2015 and 2019 were analyzed retrospectively.

Results:

Mean age of 14 patients presenting with MSC was 33 ± 13 yrs with 64% males and 36% females. Mean visual acuity of the eyes with MSC at presentation was 0.43 ± 0.46 (logMAR) improving to 0.16 ± 0.28 (logMAR) at final visit. Thirteen eyes (81.3%) had active lesion at presentation. Mantoux test was positive in seven patients (50%) and QuantiFERON TB gold test positive in 10 patients (71%). HRCT chest showed latent tuberculosis in seven patients (50%). All patients underwent multimodal imaging. All patients received oral steroids as treatment therapy; 11 patients also received immunosuppressives, nine patients received additional anti-tubercular therapy (ATT). Mean duration of follow-up for the patients was 18 ± 10 months. A total of eight (50%) eyes had recurrence of lesions after an average duration of 14 ± 14 (3-36) months and were restarted on the treatment as per the requirement. At final follow-up, all eyes showed a good response to treatment and had healed lesions. Comparing the final BCVA to the initial BCVA, 38% (n = 6) showed improvement, 56% (n = 9) remained stable, and 6% (n = 1) eyes worsened at the final follow-up.

Conclusion:

Clinical profile and presentation of MSC is similar to that of CSC, and combination treatment with intravenous methyl prednisolone (IVMP), steroids, immunosuppressives, and ATT can salvage vision. A high suspicion of associated tuberculosis in endemic regions should be kept in mind.

Serpiginous Choroiditis Complicated with Choroidal Neovascular Membrane Detected using Optical Coherence Tomography Angiography: A Case Series and Literature Review

Serpiginous choroiditis (SC) is a rare, chronic, recurrent, progressive disease of unknown origin. The inflammatory process of SC can disrupt Bruch’s membrane, allowing occasional choroidal vascular growth, leading to significant visual loss even in the healed stages of the disease. Optical coherence tomography angiography (OCTA) can help in the detection of choroidal neovascular membrane (CNV), leading to a definitive diagnosis and thereby guide the initiation of intravitreal anti-vascular endothelial growth factor (anti-VEGF) treatment. We report herein two cases of SC complicated with a CNV detected with OCTA and treated with a series of anti-VEGF injections.

Expanded Spectrum of Optical Coherence Tomography Findings in Patients with Ocular Toxoplasmosis

Purpose: To describe the optical coherence tomography (OCT) findings of toxoplasmic retinochoroiditis at different stages of activity.Methods: Observational case series.Results: A total of 32 eyes of 31 patients were included; 43 sets of OCT were reviewed. A total of 14 lesions were classified as active, 13 as partially active, and 16 as inactive. All active lesions demonstrated increased retinal thickness and reflectivity with blurring of details of retinal layers. Choroidal granuloma was detected in eight (61.5%) and serous retinal detachment in nine (64%). In partially active lesions, sustained thickening and/or attachment of posterior hyaloid face with fine epiretinal membrane was the hallmark. Scarified lesions showed decreased retinal and choroidal thickness starting from the periphery. Characteristic signs for decreased activity of a lesion seen in majority of both partially active and inactive lesions were RPE changes and retina-RPE approximation. We called this unique feature 'hourglass configuration'.Conclusion: Features in OCT are helpful to specify and monitor the activity of toxoplasmic retinochoroiditis.

Longitudinal study of serpiginous choroiditis and serpiginous like choroiditis using wide field OCT angiography

PURPOSE

To assess the ability of wide field Swept Source OCTA (SS-OCTA) imaging to detect morphological variations in Serpiginous Choroiditis (SC) and Serpiginous Like Choroiditis (SLC) in response to treatment and also analyze these findings quantitatively using Image J software.

METHODS

Retrospective observational case series of nine eyes with clinical diagnosis of active SC and SLC, who underwent SS-OCTA and fundus autofluorescence (FAF) imaging at baseline and each follow up visit till 6 months. Morphological analysis was done by two independent graders and quantitative analysis to measure the size and intensity of lesion was done using publicly available Image J software at baseline and each follow up visit.

DESIGN

Retrospective observational case series.

RESULTS

Using SS-OCTA, all the active lesions followed a characteristic healing pattern. Active lesions appear well defined hypo flow void patches and as healing progressed, lesion became more ill-defined and iso-hyper- intense. Significant increase in mean intensity of the lesion could be apparent after 1 and 6 month of treatment. There was reduction in the size of lesions during follow up however this difference was not statistically significant.

CONCLUSION

SS-OCTA could be a useful noninvasive tool to study the treatment response in SC/SLC both morphologically as well as quantitatively. Quantitative parameters need to be designed in further research studies to aid in uniform management and follow up of uveitis cases.

Peripapillary Halo in Inflammatory Papillitis of Birdshot Chorioretinopathy

Purpose

Peripapillary halos (PPH) are peripapillary changes observed surrounding the optic nerve head in normal eyes and eyes with different disorders. Recognizing the microstructure and mechanism of development of these halos will help clinicians understand the different associated retinal and optic nerve head pathologies. We describe the in vivo histological characteristics of PPH in birdshot chorioretinopathy (BSCR).

Patients and Methods

This was a prospective observational case-series in a single tertiary referral center. Six eyes of three patients with PPH associated with BSCR were determined through clinical examination, fundus photography, and fundus autofluorescence (FAF). Patients underwent swept-source optical coherence tomography (SS-OCT) imaging of the optic nerve head and peripapillary region.

Results

In SS-OCT B-scans across the area of PPH, we observed thinning and interruption of retinal pigment epithelium (RPE)-Bruch’s membrane complex. These halos are a circumferential form of alpha zone RPE-associated crescentic peripapillary atrophy (PPA), unlike the PPH observed with myopia and normal aging.

Conclusion

PPH in BSCR patients may be a sign of prior inflammatory optic neuropathy.

Evaluation of change in the vascular density of choriocapillaris on optical coherence tomography angiography in eyes with serpiginous choroiditis

Purpose:

Serpiginous choroiditis (SC) is primarily an inflammation of choriocapillaris leading to nonperfusion. A quantitative assessment of choriocapillaris perfusion can be done by measuring the flow-density by OCT-Angiography (OCTA). This study measures a change in the flow-density of choriocapillaris with the resolution of inflammation.

Methods:

The OCTA images of a choriocapillaris slab of 30 eyes with active SC were subjected to binarization and vessel density was measured at baseline and final visits and compared.

Results:

Upon comparing the vessel density of the affected areas by OCTA of choriocapillaris-slab at baseline and final visits, there was statistically significant (P < 0.0001) improvement after the resolution of inflammation. The vessel density of a demarcated normal area was significantly higher when compared to that of lesions at baseline (P < 0.0001) and final visit (P < 0.0001).

Conclusion:

OCTA is a useful tool to assess reduction in the inflammatory activity on treatment in SC. This study shows that with treatment the perfusion of choriocapillaris improves; however, it remains lower than normal.

Serpiginous Choroiditis Presenting in Association With Clostridium difficile Infection and Ulcerative Colitis

Purpose:

This work reports a case of serpiginous choroiditis (SC) in association with ulcerative colitis and Clostridium difficile infection.

Methods:

A case report is discussed.

Results:

A 35-year-old man with a history of ulcerative colitis and recently treated C difficile infection presented with a rapid decline in central visual acuity in both eyes. Examination findings included geographic creamy-white lesions extending from the peripapillary region in both eyes. Multimodal imaging and negative infectious workup results supported the diagnosis of SC. Visual acuity and examination findings improved after initiation of systemic prednisone therapy. Adalimumab was initiated as a steroid-sparing treatment. At the last follow-up, 5 months after the initial presentation, SC and ulcerative colitis both remain in remission.

Conclusions:

SC has been previously described in patients with systemic disorders, including autoimmune conditions. This patient developed SC following C difficile infection and in the context of active ulcerative colitis. To our knowledge, this is the first report of SC in association with these entities.

Chlorambucil combination therapy in refractory serpiginous choroiditis: A cure?

Purpose

To find a remedy for serpiginous choroiditis refractory to oral prednisone and chlorambucil treatment.

Observations

Eight eyes of four patients (all female) with advanced macular involvement secondary to serpiginous choroiditis were included in the study. The average age of the patients was 45.2 years. One eye of each patient was legally blind and the lesion was close to the fovea in the other eye. All four patients failed oral prednisone and chlorambucil therapy. However, case 1 responded to chlorambucil treatment after intravitreal dexamethasone implant implantation and discontinuation of oral prednisone. Case 2 responded to chlorambucil therapy when oral prednisone was stopped in combination with infliximab therapy. Due to long follow-up period of more than four years, these two cases are considered to be cured. Case 3 and case 4 were not able to achieve remission with chlorambucil and immunomodulatory therapy. They refused intravitreal steroid implant due to side effects profile.

Conclusions and importance

The stability of WBC counts within toxic levels close to normal or lower limits of normal (3000–4500 cells/μl) during treatment with chlorambucil is an essential factor for the success of this therapy. A combination of dexamethasone intravitreal implant with chlorambucil therapy can be an effective and promising regimen in inducing and maintaining remission in refractory serpiginous choroiditis patients who fail a combination of systemic corticosteroid and chlorambucil therapy.

•

Serpiginous choroiditis may be recurrent or refractory to chlorambucil in conjunction with systemic corticosteroids.

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The stability of WBC counts within lower limits of normal is an essential factor for the success of chlorambucil therapy.

•

This can be achieved with dexamethasone intravitreal implant or systemic immunomodulatory without systemic corticosteroid therapy.

Placoid lesions of the retina: progress in multimodal imaging and clinical perspective

Placoid lesions of the retina may be secondary to a wide spectrum of acquired inflammatory conditions that have been reported as single entities with different presentation and clinical course. These conditions include acute posterior multifocal placoid pigment epitheliopathy, persistent placoid maculopathy, serpiginous choroiditis, serpiginous-like choroiditis, relentless placoid chorioretinitis and acute syphilitic posterior placoid chorioretinitis. In this article, we will group these conditions under the name of 'placoids'. The recognition of the specific condition may be challenging in clinical practice, often resulting in diagnostic and therapeutic delay. Given the complex nature of placoids and their similarities, a systematic approach including differentiating between infectious and non-infectious aetiologies increases the chance of reaching the correct diagnosis. Detailed history and comprehensive clinical examination are the first steps to formulate a diagnostic hypothesis that should be corroborated by multimodal imaging and appropriate investigations. The advent of multimodal imaging has made it possible to extensively study placoids and revealed a constellation of specific findings that may help clinicians in the diagnostic process. The treatment of the conditions other than syphilis is complex and sometimes challenging. Our article is aimed at giving an overview of the individual entities associated with placoids and discussing the differential diagnosis. A practical and systematic approach is then proposed.

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.

Serpiginous choroiditis presenting after SARS-CoV-2 infection: A new immunological trigger?

INTRODUCTION

To report the first case of a serpiginous choroiditis presenting after SARS-CoV-2 infection in a previously healthy young woman.

CASE DESCRIPTION

A 41-year-old woman reported blurry vision OS 1 month after a mild SARS-CoV-2 infection. Left eye fundus examination revealed multiple peripapillary atrophic lesions, adjacent to a larger diffuse, ill-defined, yellow-whitish deep amoeboid-like patch, involving the peripapillary region and extending temporally to the fovea. Multimodal imaging including fluorescein angiography, indocyanine-green angiography, fundus autofluorescence and optical coherence tomography was consistent with serpiginous choroiditis. A complete systemic work-up was performed to exclude potential infectious or inflammatory etiologies. The active choroidal lesions responded to high dose corticosteroids, with functional improvement. Immunomodulatory therapy with methotrexate was initiated for long-term management.

CONCLUSION

Serpiginous choroiditis is a rare but important sight-threatening condition that has been previously associated to viral infections, which seem to have a role in the induction and/or perpetuation of choroidal inflammation. SARS-CoV-2 infection appears to have played a role as a possible trigger for intraocular inflammation in this case. Therefore, COVID-19 patients reporting visual symptoms should be carefully evaluated in order to obtain adequate ophthalmological management to avoid irreversible visual damage.

Clinical and Imaging Factors Associated With the Outcomes of Tubercular Serpiginous-like Choroiditis

PURPOSE

To analyze baseline clinical and imaging risk factors associated with poor outcome in patients with tubercular serpiginous-like choroiditis (TB SLC).

DESIGN

Retrospective clinical study.

METHODS

Charts and fundus photographs of consecutive patients with active TB SLC seen at a single tertiary referral center with 6 months follow-up after initiation of treatment were reviewed. Logistic mixed models were performed to determine the clinical and imaging factors associated with the response to therapy, including the opacity of choroiditis graded according to a 3-point scale.

RESULTS

This study included 203 eyes of 183 patients with active TB SLC. Poor initial best-corrected visual acuity (BCVA) and foveal and optic disc involvement were associated with poor response to therapy at 6 months (odds ratio [OR] 4.489, 95% confidence interval [CI]: 1.92-10.47; P = .001; OR 2.892, 95% CI: 1.23-6.81; P = .015; OR 11.633, 95% CI: 3.17-42.71; P < .001, respectively). The high opacity grades (2 and 3) were also associated with poor outcomes OR 9.541; 95% CI: 2.94-30.91; P = .001). Poor baseline BCVA and high grade of opacity of the lesions were the composite risk factors for paradoxical worsening of TB SLC (OR 7.555, 95% CI: 1.78-32.02; P = 0.006; OR 7.434, 95% CI: 1.34-41.18; P =0.021, respectively).

CONCLUSIONS

TB SLC with higher grades of lesion opacity at baseline may be associated with greater risk of poor therapeutic response and paradoxical worsening. Grading of baseline lesion opacity may be used in future prospective studies to predict the biological behavior of the lesions and may serve as a guide to therapeutic interventions.

Imaging in Tubercular Choroiditis: Current Concepts

PURPOSE

Ocular tuberculosis has protean clinical manifestations. Because of its varied clinical presentation, multimodal imaging is very important to characterize the disease activity, presence of inflammation, determining therapeutic response, and detection of complications.

METHODS

Narrative review.

RESULTS

In this review, various imaging modalities employed in the management of ocular tuberculosis including fluorescein angiography (FA), indocyanine green angiography (ICGA), optical coherence tomography (OCT), and optical coherence tomography angiography (OCTA) have been reviewed. Not only do these imaging tools complement each other in providing a comprehensive assessment of the pathology, they also help in gaining valuable insights regarding the evolution of the disease.

CONCLUSIONS

Fundus imaging plays a vital role in the diagnosis and management of patients with posterior uveitis due to tuberculosis. Fundus imaging may have a useful role in defining clinical endpoints for ocular tuberculosis in the future.

Recommendations statement on the immunosuppressive treatment of non-infectious, non-neoplastic, non-anterior uveitis

OBJECTIVE

To generate recommendations on the use of immunomodulators in patients with non-infectious, non-neoplastic intermediate uveitis (IU), posterior uveitis (PU) and panuveitis (PanU) based on best evidence and experience.

METHODS

A multidisciplinary panel of 5 experts was established, who defined the scope, users, and sections of the document. A systematic literature review (SLR) was performed to assess the efficacy and safety of immunomodulatory drugs in patients with non-infectious, non-neoplastic, non-anterior uveitis. The results of the SLR were presented and discussed during an expert meeting in which 34 recommendations were generated. The level of agreement with the recommendations was also tested in 25 additional experts following a Delphi process. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of the experts voted ≥7. The level of evidence and grade or recommendation were assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence.

RESULTS

The SLR included 33 articles. The 34 recommendations were accepted after 2 Delphi rounds (3 of them were modified after the first round). They include specific recommendations on patients with non-infectious, non-neoplastic, PU and PanU, as well as different treatment guidelines.

CONCLUSIONS

In patients with non-infectious, non-neoplastic, non-anterior uveitis these recommendations might help treatment decision making, due to the lack of robust evidence or other globally accepted algorithms.

Ocular tuberculosis: Where are we today?

Diagnosis and management of ocular tuberculosis (OTB) poses a significant challenge. Mixed ocular tissue involvement and lack of agreement on best practice diagnostic tests together with the global variations in therapeutic management contributed to the existing uncertainties regarding the outcome of the disease. The current review aims to update recent progress on OTB. In particular, the Collaborative Ocular Tuberculosis Study (COTS) group recently standardized a nomenclature system for defining clinical phenotypes, and also proposed consensus guidelines and an algorithmic approach for management of different clinical phenotypes of OTB. Recent developments in experimental research and innovations in molecular diagnostics and imaging technology have provided a new understanding in the pathogenesis and natural history of the disease.

Multimodal imaging reveals pathological edges of disease activity in tuberculosis-associated multifocal serpiginoid chorioiditis

Tuberculosis associated serpiginous-like choroidopathy can lead to significant vision loss. The anatomical cause for this visual decline can be elucidated using multimodal retinal imaging. Imaging modalities used in this case, most notably, optical coherence tomography angiography (OCTA), demonstrated specific atrophy of the choriocapillaris.

Simultaneous mutually exclusive active tubercular posterior uveitis

Ocular tuberculosis (TB) is a form of extra-pulmonary TB, which can involve almost any intraocular structure or ocular adnexa. Posterior uveitis, the commonest form of intraocular TB manifests as choroidal tubercles, choroidal tuberculoma, subretinal abscess, neuroretinitis, or serpiginous-like choroiditis. These forms of posterior tubercular lesions can be broadly classified into two groups based on their pathophysiology and morphology. One group of lesions is related to the direct invasion and reactivation of the bacilli in the choroidal tissue, whereas the other is a result of hypersensitivity reaction to the bacilli. Simultaneous bilateral active posterior uveitis with such varying morphology and pathophysiology in either eye of the same patient is an extremely rare presentation. We report a case with pulmonary TB on Anti-tubercular therapy (ATT), who presented to us with two mutually exclusive and distinctly different forms of tubercular posterior uveitis in either eye simultaneously. Both lesions were active at the time of presentation.

OCT Angiography and En Face OCT Reflectance Aid in Monitoring Subclinical Inflammation in Serpiginous Choroidopathy

Introduction. We present a case of serpiginous choroidopathy (SC) with novel OCTA and en face OCT reflectance findings which help identify subclinical disease progression. Case Presentation. En face OCT reflectance images demonstrated outer retinal tubules (ORT) at the serpiginous lesion margins of affected and unaffected retina on multimodal imaging. OCTA findings demonstrate variable dropout of choriocapillaris in “normal” retina beyond lesion borders which was not visible on standard imaging and which demonstrated a clear transition zone beyond the ORT. Discussion. This is the first report of choriocapillaris atrophy identified on OCTA not identified on traditional multimodal imaging in serpiginous choroidopathy. Damage to vasculature only visible with OCTA may help characterize the distribution of inflammation, aiding in monitoring of suppression not illustrated by traditional imaging and which may threaten the central macula. ORT in SC suggest death and reorganization of outer segments from dysfunction of the choriocapillaris and RPE, as well as serve to demarcate the area of chronic or old inflammation, supporting the hypothesis that the choriocapillaris is the primary site of inflammation in SC. Based on these findings, we recommend OCTA on all patients with serpiginous choroidopathy to monitor underlying state of inflammation and help determine immunosuppressive threshold.

MULTIMODAL IMAGING OF CHOROIDAL LESIONS IN DISSEMINATED MYCOBACTERIUM CHIMAERA INFECTION AFTER CARDIOTHORACIC SURGERY

PURPOSE

To explore morphologic characteristics of choroidal lesions in patients with disseminated Mycobacterium chimaera infection subsequent to open-heart surgery.

METHODS

Nine patients (18 eyes) with systemic M. chimaera infection were reviewed. Activity of choroidal lesions were evaluated using biomicroscopy, fundus autofluorescence, enhanced depth imaging optical coherence tomography, fluorescein angiography/indocyanine green angiography, and optical coherence tomography angiography. Relationships of choroidal findings to systemic disease activity were sought.

RESULTS

All 9 male patients, aged between 49 and 66 years, were diagnosed with endocarditis and/or aortic graft infection. Mean follow-up was 17.6 months. Four patients had only inactive lesions (mild disease). In all five patients (10 eyes) with progressive ocular disease, indocyanine green angiography was superior to other tests for revealing new lesions and active lesions correlated with hyporeflective choroidal areas on enhanced depth imaging optical coherence tomography. One eye with a large choroidal granuloma developed choroidal neovascularization. Optical coherence tomography angiography showed areas with reduced perfusion at the inner choroid. All 5 patients with progressive ocular disease had evidence of systemic disease activity within ±6 weeks' duration.

CONCLUSION

Choroidal manifestation of disseminated M. chimaera infection indicates systemic disease activity. Multimodal imaging is suitable to recognize progressive ocular disease. We propose ophthalmologic screening examinations for patients with M. chimaera infection.

Management of Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE): Insights from Multimodal Imaging with OCTA

A 28-year-old man presented to the emergency room with blurred vision in the right eye for two days. He reported a preceding flu-like illness one week earlier. His best-corrected visual acuity (BCVA) was 20/40 in the right eye and 20/25 in the left eye. There was no anterior chamber inflammation or vitritis in either eye. He presented multiple yellowish-white placoid lesions in the posterior pole, some involving the foveal area, bilaterally. General examination and systemic investigation were unremarkable. Multimodal evaluation with fluorescein angiography, indocyanine green angiography, and spectral domain and optical coherence tomography angiography (OCTA) were consistent with the diagnosis of acute posterior multifocal placoid pigment epitheliopathy. Due to centromacular involvement with decreased BCVA, treatment with oral methylprednisolone was started after infectious causes were ruled out. After two weeks, the patient presented functional and anatomical improvement. OCTA showed partial reperfusion of the choriocapillaris in the affected areas, in both eyes.

Prevalence of Positive QuantiFERON-TB Gold In-Tube Test in Uveitis and its Clinical Implications in a Country Nonendemic for Tuberculosis

PURPOSE

To report on the prevalence and clinical implications of positive QuantiFERON-Gold (QFT-G) test results in the diagnostic evaluation of a large cohort of consecutive patients with uveitis in the Netherlands.

DESIGN

Retrospective cross-sectional study.

METHODS

This study included 710 consecutive patients who all underwent evaluation for uveitis including QFT-G testing. The ocular features, comorbidity, and abnormalities in diagnostic imaging and laboratory tests were registered for QFT-G-positive patients with uveitis.

RESULTS

Of all patients, 13% (92/710) were positive for QFT-G. Previously treated tuberculosis (TB) was documented in 2 patients. Of all 92 QFT-G-positive patients, culture-proven active TB was observed in 1 case. The proportion of patients with uveitis of unknown etiology was higher in QFT-G-positive than in the QFT-G-negative patients (54/92, 59% vs 238/618, 39%; P = .0004). The uveitis features of QFT-G-positive patients were mainly nonspecific. Of all QFT-G-positive patients with uveitis, 17 patients had chest imaging changes suggesting either TB or sarcoidosis. Twenty-nine QFT-G-positive patients with otherwise unexplained uveitis completed antituberculous therapy (29/710; 4% of all included patients) with beneficial effect in most cases.

CONCLUSION

The QFT-G tested positive in 13% of patients with uveitis in the Netherlands, whereas only sporadic patients had a documented previous or active TB infection. The proportion of patients with unexplained uveitis was higher in QFT-G-positive patients. Though the association between uveitis and a positive QFT-G test might be coincidental, the majority of treated QFT-G-positive patients with otherwise unexplained severe uveitis cause had a beneficial response to antituberculous therapy.