Systemic and Bilateral Severe Ocular Toxoplasmosis Resembling Autoimmune Phenomena: A Case Report

PURPOSE

To present an atypical case of severe bilateral ocular toxoplasmosis with systemic involvement that initially mimicked an autoimmune etiology, posing challenges to its diagnosis and treatment.

CASE REPORT

A 39-year-old immunocompetent male was admitted to the hospital due to a presumed pulmonary thromboembolism concomitant with an abrupt onset of vision loss. Initial differential diagnoses included antiphospholipid syndrome and systemic lupus erythematosus, prompting the administration of corticosteroid pulses and rituximab. Despite observing a partial systemic response, there was no improvement in visual acuity. Subsequent aqueous humor polymerase chain reaction confirmed Toxoplasma gondii infection, leading to the introduction of oral antibiotic therapy. The patient's condition showed a partially favorable response; however, the treatment could not reverse the permanent retinal damage.

CONCLUSION AND IMPORTANCE

This case underscores the importance of ruling out an infectious etiology in all cases of uveitis. Additionally, it alerts clinicians to the possibility that elevated positive autoantibodies may result from a severe inflammatory reaction caused by pathogens rather than an autoimmune or autoinflammatory disease, particularly in instances of poor treatment response or atypical clinical presentation.

Autoimmune Liver Disease Associated Uveitis: An Extrahepatic Manifestation or a Polyautoimmunity Phenomenon? Case Reports

PURPOSE

To report two cases of non-granulomatous unilateral anterior uveitis in two female patients associated with autoimmune liver diseases (ALD), emphasizing the possibility of this rare coexistence as a polyautoimmunity phenomenon.

CASE DESCRIPTIONS

Case 1: An 18-year-old female with a history of congenital renal hypoplasia and metabolic syndrome presented with anterior uveitis in OS and a history of jaundice, blood elevated hepatic enzymes, and cholangioresonance compatible with primary sclerosing cholangitis (PSC). Laboratory work-up for additional autoimmune and infective causes were within normal limits. Case 2: An 58-year-old female presented an episode of anterior uveitis in OD and a history of Sjögren syndrome diagnosed at the age of 53, primary biliary cholangitis (PBC), systemic sclerosis, Raynaud's phenomenon, bilateral sacroiliitis, and vitiligo, consistent with polyautoimmunity and multiple autoimmune syndrome.

CONCLUSIONS

Uveitis rarely coexists with ALD. However, it is essential to recognize the possibility of polyautoimmunity in patients presenting with ophthalmic manifestations and a previous diagnosis of ALD, such as PSC or PBC.

Colombian Ocular Diseases Epidemiology Study (CODES): Prevalence and Sociodemographic Characterization of Refractive Errors in Colombian Eye Care Consultations

PURPOSE

To estimate the prevalence and demographic characteristics of uncorrected refractive errors (URE) in people who attended eye care consultations in Colombia between 2015 and 2019, using the National Health Registry data.

METHODS

We identified ICD codes for myopia (H-52.1), degenerative myopia (H-44.2), hyperopia (H-52.0), and astigmatism (H-52.2) from the Integrated Social Protection Information System. Crude prevalence rates by age and sex were calculated for the population attending eye care services during these years. Additionally, we developed a standardized morbidity map across county departments.

RESULTS

In Colombia, the prevalence of URE among eye care consultations was 30.26%, increasing from 30.39% in 2015 to 35.14% in 2019. Of the 1,579,778 cases analyzed, 60.9% were females. Astigmatism emerged as the most prevalent URE, predominantly seen in individuals under 40 years old. Myopia showed the highest prevalence in the 10-30 age group, whereas hyperopia was most prevalent in the first decade of life. Geographically, the Andean region recorded most of URE cases, while more remote areas have seen a rising morbidity risk in recent years.

CONCLUSIONS

The rising trend of URE in Colombia and its demographic and geographical variations underscores the urgent need for health professionals and government authorities to acknowledge and address this issue. This study provides crucial insights into the refractive error landscape across the country, highlighting the necessity for prevention programs specifically designed to cater to the country's unique needs.

Epidemiology, clinical features, and classification of 3,404 patients with uveitis: Colombian Uveitis Multicenter Study (COL-UVEA)

PURPOSE

To describe the epidemiology, clinical features, and classification of uveitis in a large cohort of Colombian patients.

METHODS

Data were collected from seven ophthalmological referral centers in the four main cities in Colombia. The study included patients with a confirmed diagnosis of uveitis from January 2010 to December 2022. Information on demographics, ophthalmic examination findings, uveitis classification, and etiology was recorded.

RESULTS

The study reviewed 3,404 clinical records of patients with uveitis. The mean age at diagnosis was 41.1 (SD 19.0) years, and 54.2% of the patients were female. Overall, 1,341(39.4%) were infectious, 626 (18.4%) non-infectious, and four masquerade syndromes (0.1%). The most common types of uveitis were unilateral (66.7%), acute (48.3%), and non-granulomatous (83%). Anterior uveitis was the most common anatomical localization (49.5%), followed by posterior uveitis (22.9%), panuveitis (22.3%), and intermediate uveitis (5.2%). A diagnosis was established in 3,252 (95.5%) cases; idiopathic was the most common cause (27.7%), followed by toxoplasmosis (25.3%) and virus-associated uveitis (6.4%). The age group between 30 and 50 exhibited the highest frequency of uveitis.

CONCLUSION

This multicenter study comprehensively describes uveitis characteristics in Colombian patients, providing valuable insights into its demographic and clinical features. The study findings emphasize the need to continue updating the changing patterns of uveitis to improve diagnosis and treatment strategies for diseases associated with intraocular inflammation.

Prevalence and clinical characteristics of uveitic glaucoma: multicentric study in Bogotá, Colombia

OBJECTIVES

To describe the clinical features of patients diagnosed with uveitic glaucoma (UG) and ocular hypertension secondary to uveitis (OHT-SU).

METHODS

A multicentric cross-sectional study using medical records of patients with uveitis between 2013 and 2021. Uveitis and glaucoma specialists examined all patients. Variables were analyzed using the chi-square or Fisher's exact test for categorical variables. Additionally, t test, Mann-Whitney, and Kruskal-Wallis variance analysis were used for continuous variables. Finally, a Kaplan-Meier survival analysis for UG and OHT-SU development over time was done.

RESULTS

Of the 660 clinical records reviewed of patients with uveitis, 191 (28.9%) had OHT-SU in at least one visit, and 108 (16.4%) of them developed UG. In all ages, females were more affected than males. Anterior uveitis was the main anatomic localisation, and non-granulomatous, recurrent, and inactive uveitis were the most frequent clinical features. The mean final visual acuity was 0.3 (0.0-1.0) LogMAR. Also, 95.8% of the patients had additional sequelae related to uveitis regardless of UG and OHT-SU. Interestingly, males had earlier affection, with statistical significance in OHT for adults (P = 0.036) and UG for children (P = 0.04). Of all patients, 81.1% received topical hypotensive treatment and 29.8% required a surgical procedure.

CONCLUSIONS

UG and OHT-SU are common complications of uveitis in the Colombian population. These sight-threatening conditions were more common and appeared sooner in men at any age. Our results suggest that earlier and more aggressive treatment with topical hypotensive agents could positively influence the visual outcomes and the requirement of surgical procedures.

Uveitis and Dry Eye Disease in Children: A Cross-Sectional Comparative Study

PURPOSE

This study aims to evaluate the ocular surface characteristics in children diagnosed with uveitis and explore the association between uveitis and dry eye disease (DED).

METHODS

We included 84 children, 42 with uveitis and 42 healthy children. We performed the OSDI questionnaire and several ocular surface tests, including osmolarity, NITBUT, Schirmer test, and vital staining. We used Fisher's exact test and Mann-Whitney to compare variables and a binomial logistic regression to determine the factors associated with DED.

RESULTS

The difference in the prevalence of DED between uveitis (54.8%) and healthy (31%) groups was statistically significant (p < 0.05). Most patients with uveitis had mixed DED, and none of the healthy subjects had a severe form of the disease. There were no statistically significant differences in most of the tear film tests. However, all parameters tended to worsen in the uveitis group, and lipid layer thickness was thinner (p < 0.036). The uveitis group exhibited significantly more symptoms (p < 0.05). In the multivariate logistic regression, uveitis was associated with an odds ratio (OR) of 3.0 (95% CI: 1.07-8.42, p < 0.05) for DED.

CONCLUSIONS

Our findings demonstrate a significantly higher prevalence of DED in children with uveitis compared to their healthy counterparts. Furthermore, our analysis indicates that the risk of DED in pediatric patients with uveitis is threefold higher than in healthy children. Therefore, it is crucial for clinicians to vigilantly monitor the development of DED in pediatric patients with uveitis and consider the implementation of preventive treatments.

Quantitative changes in the corneal endothelium and central corneal thickness during anterior chamber inflammation: A systematic review and meta-analysis

PURPOSE

To establish the effects of anterior chamber inflammation (ACI) on the corneal endothelium parameters and central corneal thickness (CCT).

METHODS

We conducted a comprehensive literature review using medical databases (PubMed, EMBASE, VHL, and medRxiv) on March 8, 2023, for studies that included patients with ACI who had undergone specular microscopy or pachymetry. Case series with >10 patients, cross-sectional, case-control, and cohort studies were included. The risk of bias was assessed using CLARITY tools and validated scales such as those by Hassan Murad et al. and Hoy et al. A narrative synthesis and a quantitative standardized mean difference meta-analysis, I2 heterogeneity assessment, and publication bias tests were conducted. The study was registered in PROSPERO (CRD42023420148) and approved by the Universidad del Rosario ethical committee (DVO005 2277- CV1712).

RESULTS

Thirty-four studies, encompassing 1,388 eyes with ACI, were included. Compared with healthy controls, overall, ACI eyes show significant mean differences in endothelial parameters (endothelial cell density (ECD), coefficient of variation (CV), and hexagonality (HEX)) (P < 0.05). In the subgroup analysis compared with healthy controls, both active and chronic-recurrent ACI demonstrated a reduced ECD. An increased CV was observed in active, inactive, and chronic-recurrent ACI. Lower HEX was evident in inactive, acute, and chronic-recurrent ACI, while both active and acute ACI exhibited high CCT.

CONCLUSION

ACI leads to significant alterations in endothelial parameters and CCT. The primary contributors to these changes are increased IOP, uveitis duration, and intraocular surgeries. Further studies are needed to explore the impact of ACI etiology on the endothelium, potential biases in IOP measurements during acute ACI episodes, and the potential necessity for monitoring the endothelial parameters and CCT in patients with chronic ACI.

Colombian Ocular Inflammatory Diseases Epidemiology Study (COIDES): Optic Neuritis Incidence Between 2015-2020

PURPOSE

To estimate the incidence of Optic Neuritis (ON) in Colombia using data from the national health registry between January 1, 2015, and December 31, 2020.

METHODS

A population-based study was conducted using the Integrated Social Protection Information System from the Colombian Ministry of Health and the International Classification of Diseases-10 code for ON to estimate the incidence of ON from 2015 to 2020. We also evaluated the impact of the COVID-19 lockdown on the epidemiology of the disease in 2020. Finally, a standardized morbidity rate map was created to assess a country's ON geographic distribution.

RESULTS

From 2015 to 2019, 2,463 new cases of ON were reported. The overall 5-year incidence rate was 1.56 cases per 100,000 inhabitants per year, 66% of the patients were females. The peak of presentation in males was the quinquennium of 50-54 years, and in females, it was 45-49 years. In 2020, coinciding with the COVID-19 pandemic, there was a reduction in the incidence of ON by approximately 0.15 cases per 100,000 inhabitants. The regions with a high number of cases and an increasing risk of new cases were Bogotá, Antioquia, and Valle del Cauca.

CONCLUSIONS

The incidence of ON in Colombia is lower compared to countries in the northern hemisphere, with women under 50 years being predominantly affected. The onset of the COVID-19 pandemic corresponded with a reduction in identifying new ON cases. This underscores governments' need to implement effective diagnostic strategies in the future.

Colombian Ocular Inflammatory Diseases Epidemiology Study (COIDES): Prevalence, Incidence, and Sociodemographic Characterization of Uveitis in Colombia, 2015-2020

PURPOSE

To describe the prevalence, incidence, and sociodemographic characteristics of uveitis in Colombia based on the National Health Registry of Colombia, the Integrated Social Protection Information System database (SISPRO).

METHODS

We performed a cross-sectional study using SISPRO. Along with the International Classification of Diseases, we were able to identify cases of general uveitis (GU), anterior (AU), and posterior uveitis (PU) from 2015 to 2019. For 2020, we used a statistical model for spatial data to predict the prevalence/incidence of the diseases and compared it to the data retrieved in SISPRO.

RESULTS

The average prevalence of GU was 14.66 cases per 100,000 inhabitants, while the average incidence rate of GU during the same period was 13.61 cases per 100,000 inhabitants per year. In 2020, there was a noticeable decrease in the incidence and prevalence of GU. Similar trends were observed when analyzing the incidence and prevalence of AU and PU separately. Females accounted for most reported cases, and there was a notable shift towards older age groups (over 50 years) for uveitis occurrence in males and females. Regions such as Bogotá, Antioquia, Valle del Cauca, and the Andean region had higher numbers of cases and a more significant disease burden.

CONCLUSIONS

Our study represents Colombia's first population-based characterization of GU, AU, and PU epidemiology. Our results highlight the importance of understanding disease patterns according to sociodemographic factors intrinsic to distinct geographic locations to design better preventive, diagnostic, and treatment approaches in the Colombian population.

Immunogenicity of Adalimumab in Patients with Non-Infectious- Uveitis: Systematic Review and Meta-Analysis

OBJECTIVE

To review the prevalence, incidence, and risk factors for developing anti-drug antibodies (AAA) in patients with non-infectious uveitis (NIU) treated with Adalimumab (ADA).

METHODS

A systematic literature search was performed on PubMed, EMBASE, Virtual Health Library, Cochrane, and medRxiv. Meta-analysis was performed using random effects.

RESULTS

Nine out of 2,373 studies were included. The prevalence of AAA in NIU patients treated with ADA was 9% (95% CI: 2% to 37%, I2 = 95% with a P<0.01), it was significantly higher in real-life scenarios (observational studies) than in clinical trials. The pooled incidence at 12 months was 27% (CI 95% 16%-42% I2 = 0%). Several factors have been associated with AAA generation in NIU patients, including the non-use of concomitant immunosuppressants, presence of autoimmune systemic disease, female gender, etc.

CONCLUSION

This study showed that AAA prevalence is higher in real-life scenarios compared to clinical trials. Further research is needed to elucidate the factors that trigger AAA generation in NIU patients.

Acute Retinal Necrosis: Experience in a Reference Center in Santander - Colombia

INTRODUCTION

Acute retinal necrosis (ARN) is a severe eye disease demanding swift treatment to prevent blindness. Early action involving antiviral medications and corticosteroids is crucial for optimal visual outcomes.

OBJECTIVE

We present an ARN case series showcasing treatment experience and results.

METHODOLOGY

Patients diagnosed with ARN based on SUN Working Group 2021 criteria were included; all underwent comprehensive eye exams, PCR analysis, and imaging.

RESULTS

 Eight patients were studied; PCR confirmed ARN in six. Induction treatment, either oral valacyclovir (5/8) or intravenous acyclovir (3/8), lasted 10-14 days. Maintenance included oral valacyclovir (6/8), oral valganciclovir (2/8) for six months, along with intravitreal ganciclovir. Visual outcomes were similar for oral and intravenous therapies; poor baseline acuity and macular involvement tend to result in a worse final acuity.

CONCLUSIONS

Swift treatment is vital to ARN management. Our findings emphasize effective treatment strategies' role in visual prognosis.

ABBREVIATIONS

ACV: Acyclovir; BCVA: Best Corrected Visual Acuity; CMV: Cytomegalovirus; EBV: Epstein Barr Virus; FTA-ABS: Fluorescent treponemal antibody absorption test; HSV 1-2: Herpes simplex virus 1-2; HIV: Human Immunodeficiency Virus; IV-ACV: Intravenous- Acyclovir; PCR: Polymerase Chain Reaction;Tg: Toxoplasma gondii; VZV: Varicella Zoster Virus; VCV: Valacyclovir; VDRL: Venereal disease research laboratory test.

Clinical relationship between dry eye disease and uveitis: a scoping review

This scoping review examined the relationship between Dry Eye Disease (DED) and Uveitis. We searched Pubmed, Embase, and LILACS databases for articles in which at least one patient had DED and uveitis concomitantly. The search produced 2381 records, and 24 studies were included in the qualitative synthesis. We concluded that DED and uveitis of any etiology could appear concomitantly in patients of any age. However, both diseases seem to coexist more frequently in middle-aged women and cases of anterior uveitis. Therefore, it is crucial that ophthalmologists actively look for the coexistence of ocular surface abnormalities, especially in patients with these characteristics. Future studies should establish and quantify the risk factors and pathophysiological mechanisms of this coexistence to achieve an early diagnosis of both etiologies and comprehensive management of these patients.

Colombian ocular infectious epidemiology study (COIES): presumed ocular tuberculosis incidence and sociodemographic characterization, 2015-2020

PURPOSE

This study aims to describe the incidence and geographical distribution of presumed ocular tuberculosis (POTB) in Colombia between 2015 and 2020 based on the Colombian Ministry of Health and Social Protection data.

METHODS

We conducted a claims-based study using the Integrated Social Protection Information System database from the Colombian Ministry of Health. We used the specific code of the International Classification of Diseases for Ocular Tuberculosis (A18.5) and tuberculosis from 2015 to 2020 to estimate the incidence and the demographic status of the disease in Colombia. We used STROBE guidelines.

RESULTS

During the 6 years of study, the crude unadjusted incidence was 0.2 new cases of POTB in one million consulting patients and 55 new cases of POTB in 100,000 patients with TB showing a decreasing pattern of the disease. From the 28 new cases, the mean age of presentation was 41.4 years (SD ± 25.3) with a female predominance (60.7% of the cases). Distribution by age shows a higher proportion of cases in groups 15-19 (14%), 20-24 (11%), 55-59 (11%), and 60-64 (11%) years of age. The geographic analysis showed a higher number of cases in Andean region, followed by the Caribbean and Pacific regions.

CONCLUSIONS

This is the first study that determines the incidence of POTB in a developing country from Latin America. POTB incidence in Colombia is lower than the reported worldwide. It could be attributed to a low burden of Tuberculosis in Colombia, underdiagnosis, and a low rate of immigration from countries with a high burden of TB.