Challenges in posterior uveitis-tips and tricks for the retina specialist

PURPOSE

Posterior uveitis is a common chorioretinal pathology affecting all ages worldwide and is a frequent reason for referral to the retina clinic. The spectrum of etiologies for uveitis is very broad and includes infectious and auto-immune diseases. Inflammation can be confined to the eye or may be a part of systemic disease. A useful outline is therefore proposed to aid in the correct diagnosis of these challenging entities. The situation is further complicated by the fact that many neoplastic conditions resemble features of posterior uveitis; they are known as "masqueraders of uveitis". Here, we summarize different posterior uveitides that present with rare findings, along with masqueraders that can be difficult to distinguish. These conditions pose a diagnostic dilemma resulting in delay in treatment because of diagnostic uncertainty.

METHODS

An extensive literature search was performed on the MEDLINE/PUBMED, EBSCO and Cochrane CENTRAL databases from January 1985 to January 2022 for original studies and reviews of predetermined diagnoses that include posterior uveitic entities, panuveitis and masquerade syndromes.

RESULTS

We described conditions that can present as mimickers of posterior uveitis (i.e., immune check-points inhibitors and Vogt-Koyanagi-Harada-like uveitis; leukemia and lymphoma associated posterior uveitis), inflammatory conditions that present as mimickers of retinal diseases (i.e., Purtscher-like retinopathy as a presentation of systemic lupus erythematosus; central serous chorioretinopathy masquerading inflammatory exudative retinal detachment), and uveitic conditions with rare and diagnostically challenging etiologies (i.e., paradoxical inflammatory effects of anti-TNF-α; post vaccination uveitis; ocular inflammation after intravitreal injection of antiangiogenic drugs).

CONCLUSION

This review of unique posterior uveitis cases highlights the overlapping features of posterior uveitis (paradoxical inflammatory effects of anti -TNF α and uveitis; Purtscher-like retinopathy as a presentation of systemic lupus erythematosus, …) and the nature of retinal conditions (ischemic ocular syndrome, or central retinal vein occlusion, amyloidosis, inherited conditions like retinitis pigmentosa, autosomal dominant neovascular inflammatory vitreoretinopathy (ADNIV), etc.…) that may mimic them is represented. Careful review of past uveitis history, current medications and recent vaccinations, detailed examination of signs of past or present inflammation, eventually genetic testing and/ or multimodal retinal imaging (like fluorescein angiography, EDI-OCT, OCT-angiography for lupus Purtscher-like retinopathy evaluation, or ICG for central serous retinopathy, or retinal amyloid angiopathy) may aid in correct diagnosis.

Bilateral, chronic, bacterial conjunctivitis in giant fornix syndrome

Giant fornix syndrome (GFS) results in chronic, relapsing conjunctivitis in elderly patients with enophthalmos and enlarged fornices, in which infectious material collects and perpetuates inflammation. A 98-year-old woman presented with persistent, bilateral, purulent conjunctivitis; corneal epithelial defects and progressive blepharospasm that did not respond to artificial tears, topical antibiotics and steroids and amniotic membrane grafts. Additional findings of deep-set orbits with enlarged upper fornices were diagnostic of GFS. Over the next 2 months, she responded to a combination of topical and systemic antibiotics, autologous serum eye drops, povidone-iodine forniceal rinses, and hypochlorous acid treatment of the eyelashes. GFS is an important diagnostic consideration in elderly patients with chronic conjunctivitis and deep-set orbits.

Herpes Simplex Virus 2 Blepharokeratoconjunctivitis

PURPOSE

To retrospectively review the clinical characteristics of patients with herpes simplex virus type 2 (HSV-2) blepharokeratoconjunctivitis.

METHODS

Laboratory-proven HSV-2 blepharokeratoconjunctivitis cases were reviewed between 1995 and 2021.

RESULTS

Ten of 725 (1.4%) patients had HSV-2 infection. Data were available for nine patients. Associated conditions included neonatal herpes (1/9, 11%), severe atopy (1/9, 11%), genital herpes (2/9, 22%), and systemic immune disorders (2/9, 22%). The most common presenting finding was pain and blurred vision (55.5%). Two patients (22%) had dendritic lesions and one patient (11%) had reduced corneal sensation. Complete resolution was reported in four patients (44.5%). Recurrence was noted in four patients (44.5%) despite antiviral prophylaxis. Corneal complications included scarring and neovascularization. The visual acuity at the last follow-up was 20/40 or worse in four patients (44.5%).

CONCLUSIONS

HSV-2 is an uncommon cause of keratitis. Dendrites and loss of corneal sensation were uncommon. Recurrence was noted despite antiviral prophylaxis.

FLASH: A Novel Tool to Identify Vision-Threating Eye Emergencies

BACKGROUND

Two million patients visit emergency departments due to eye complaints annually in the United States, yet nearly one-quarter of these visits are for non-urgent ocular problems. Other patients often present a significant length of time after the onset of their symptoms, which may cause progression to irreversible vision loss. A major reason for this discrepancy is that many patients are unsure what symptoms constitute eye emergencies. The challenge is helping patients understand what constitutes a vision-threatening eye emergency, as well as the risks and complications that are associated with delaying their visit to the ophthalmologist or Emergency Department.

OBJECTIVES

To describe relevant literature on incidence, prevalence, presentation times, associated prognoses, risks, and complications of individual vision-threating eye emergencies, and present a novel acronym, FLASH (Floaters and flashes, Loss of vision, Aching pain, Second Image, Help), to better educate patients at risk for these conditions, fostering better symptom recognition and timely care. This manuscript is aimed at reaching public health departments, educational institutions, primary care offices and eye care centers as part of a dedicated patient education effort for vision-threatening eye emergencies.

DESIGN / METHODS

Narrative overview of the available literature on specific eye conditions presenting with the aforementioned symptoms, synthesizing findings retrieved from searches of computerized databases and authoritative texts.

CONCLUSIONS

In each condition presented in this article, symptom interval significantly impacts treatment prognoses. The cited literature demonstrates that patients often present late in emergent eye conditions resulting in vision loss.

Fractal dimension of microbead assemblies used for protein detection

We use fractal analysis to calculate the protein concentration in a rotating magnetic assembly of microbeads of size 1 μm, which has optimized parameters of sedimentation, binding sites and magnetic volume. We utilize the original Forrest-Witten method, but due to the relatively small number of bead particles, which is of the order of 500, we use a large number of origins and also a large number of algorithm iterations. We find a value of the fractal dimension in the range 1.70-1.90, as a function of the thrombin concentration, which plays the role of binding the microbeads together. This is in good agreement with previous results from magnetorotation studies. The calculation of the fractal dimension using multiple points of reference can be used for any assembly with a relatively small number of particles.

Bead assembly magnetorotation as a signal transduction method for protein detection

This paper demonstrates a proof-of-principle for a new signal transduction method for protein detection called Bead Assembly Magnetorotation (BAM). BAM is based on using the target protein to mediate the formation of aptamer-coated 1 μm magnetic beads into a bead assembly, formed at the bottom of a 1 μL hanging droplet. The size, shape and fractal dimension of this bead assembly all depend on the protein concentration. The protein concentration can be measured in two ways: by magnetorotation, in which the rotational period of the assembly correlates with the protein concentration, or by fractal analysis. Additionally, a microscope-free magnetorotation detection method is introduced, based on a simple laser apparatus built from standard laboratory components. In this paper, we chose to focus on the protein thrombin, a popular choice for proof-of-principle work in this field.

Colorectal cancer epidemiology in minorities: a review

Colorectal cancer is the second leading cause of cancer death in the United States. In 1997, more than 131,000 new cases and more than 54,000 deaths were estimated. Racial and ethnic disparities in incidence, mortality and survival rates, and trends exist for this disease. Differences in colorectal cancer screening, early detection, and treatment in minority communities are related to therapeutic outcomes. Age-adjusted incidence rates for men with colorectal cancer are highest for Alaskan native men, followed by Japanese, then African-American men. For women, the incidence is highest for Alaskan native women, followed by African-American, then Japanese women. Mortality rates in men are highest for African Americans, followed by Alaskan natives and then Hawaiians. In women, mortality rates are highest for Alaskan natives, then African Americans and whites. Colorectal cancer screening rates vary by race, income, and education. It is interesting that, when compared with whites, African-American men demonstrate the higher reported rate of screening for this disease. In addition, site specificity is different for African Americans compared with whites. Findings also reveal that stage at diagnosis is an influential factor with regard to mortality and survival. This may be related in part to socioeconomic factors, differences in anatomic site, and treatment differences in African Americans. Risk factor data for this disease are scarce for minority populations. Documented differences in colorectal cancer incidence, mortality, and survival rates exist between minorities and whites. Additional research is needed on risk factors specific to African Americans and other minorities, differences in treatment, and the role of socioeconomic status.

Socioeconomic factors and breast carcinoma in multicultural women

Breast carcinoma is the most common cancer in women in the U.S. and the second leading cause of cancer death in women. Furthermore, there are racial differences in breast carcinoma incidence, mortality, and survival rates. Social and economic factors within racial/ethnic groups are being examined as risk factors not only for breast carcinoma mortality and survival but also as determinants of the rate of incidence. Social and economic factors have been associated in the literature predominantly with cancer mortality and survival. When socioeconomic status (SES) is considered, certain studies suggest that racial disparities in breast carcinoma are smaller than when social and economic factors are examined alone, but these disparities still persist. Sources of data for this discussion include the National Cancer Institute (NCI) (the Surveillance, Epidemiology, and End Results [SEER] program, a group of population-based cancer registries that cover up to 14% of the U.S. population. SEER reports cancer incidence, mortality, and survival rates), the U.S. Bureau of the Census, the National Center for Health Statistics (NCHS), and numerous articles from the scientific literature. Socioeconomic factors or SES can be considered "cross-cutting risk factors" (i.e., they can be related to the risk of developing breast carcinoma [rate of incidence] as well as to the risk of dying [mortality] from this disease). They also are the risk factors that "cut across" racial and ethnic populations. Socioeconomic factors are related to breast carcinoma mortality and survival rates in multicultural women. Racial disparities in breast carcinoma mortality and survival rates can be explained partially by stage distribution at the time of diagnosis, which may be related to SES. For example, African-American women present with more advanced stage distributions for breast carcinoma than white women. Similarly, women of lower SES present with higher stage disease than women of upper SES who present with more localized breast carcinoma. The lack of data regarding the SES of cancer patients limits our understanding of the contributions of SES to cancer incidence and mortality rates. SES appears to be related to breast carcinoma incidence, mortality, and survival rates. Breast carcinoma mortality is higher in women of lower SES. Additional research on SES, race, culture, and the relation of these factors to cancer incidence rate is needed.