Vogt-Koyanagi-Harada Disease in Pre-school Children

PURPOSE

To report the management and outcome of VKH disease in a 4-year-old boy with a review of literature on VKH in preschool children (3 to 5 years).

METHOD

Retrospective chart and literature review.

RESULT

A 4-year-old boy presented with visual acuity of light perception in both eyes with panuveitis, secondary cataracts and intraocular pressure (IOP) of ≥40 mmHg in both eyes. He was started on oral corticosteroid, immunosuppressive and underwent glaucoma filtering surgery and lensectomy with vitrectomy after adequate control of intraocular inflammation. Over time his IOP was again uncontrolled even with maximum anti-glaucoma medications, and he underwent Ahmed glaucoma valve (AGV) implantation, and he gained a visual acuity of 20/60 in both eyes with aphakic correction at the last visit.

CONCLUSION

Paediatric VKH follows an aggressive disease phase and requires a comprehensive multispeciality management approach.

Extranodal Rosai-Dorfman disease manifesting as Sjögren's syndrome combined with panuveitis and hypertrophic pachymeningitis: a case report and review of literature

Rosai-Dorfman disease (RDD) is a rare non-Langerhans cell histiocytosis characterized by massive lymphadenopathy and systemic extranodal lesions. We present the case of a 28-year-old woman who presented with recurrent blurred vision in her right eye for 3 months. She developed blindness and atrophy in her left eye a decade prior to presentation. She subsequently developed headache, fever, and impaired mental status. Cranial magnetic resonance imaging indicated hypertrophic pachymeningitis (HP), and 18F-fluoro-2-deoxy-2-d-glucose (FDG) positron emission tomography/computed tomography revealed significant FDG uptake in the left dura mater. Autoimmune testing revealed elevated anti-nuclear, anti-SS-A, and anti-SS-B antibody levels. Incisional biopsy of the atrophic eyeball revealed RDD with marked polyclonal plasmacytosis. The patient was diagnosed with RDD accompanied by multisystem involvement, including Sjögren's syndrome (SS), panuveitis, and HP. Treatment with methylprednisolone for several weeks resulted in significant improvement. This is the first reported case of RDD presenting with SS in combination with panuveitis and HP. Although RDD is rarely diagnosed in young patients, interdisciplinary collaboration is essential to prevent a delayed diagnosis.

Ocular syphilis masquerading as CMV retinitis in a transplanted patient

BACKGROUND

Syphilis has historically been referred to as "the great imitator", for the extent of disease manifestations secondary to infection. Ocular manifestations include a wide range of intra-ocular inflammation.

METHODS

In this study, we report the case of a 52 years-old male patient with syphilitic hemorrhagic necrotizing retinitis.

RESULTS

The patient presented to the emergency room for rapid and progressive vision loss and ocular redness lasting three weeks and was under immunosuppressive treatment. The diagnosis was syphilitic hemorrhagic necrotizing retinitis mimicking the typical clinical picture of retinitis caused by Cytomegalovirus infection in immunocompromised patients.

CONCLUSIONS

The presented case highlights the need to consider ocular syphilis as a great masquerader even in the presence of atypical presentations such as hemorrhagic retinitis. Syphilis should be tested for treponemal and non-treponemal tests, and it should be ruled out as an etiological agent in every case of new-onset intra-ocular inflammation.

A case of panuveitis caused by caterpillar setae

INTRODUCTION

Panuveitis is a serious inflammatory disease. Setae are fibers produced by many insects and plants. Many case reports have described caterpillar and spider fibers entering the eye. These hairs are covered with tiny barbs that help them enter and migrate into the eye tissue, leading to severe inflammation. Normally, they are buried mainly in the conjunctiva and cornea. However, in the present case, they entered the posterior segment of the eye, which is very rare.

CASE DESCRIPTION

A female patient presented with a complaint of repeated foreign body sensation, redness, pain, and photophobia in the left eye for 9 years following initial exposure to caterpillars. She visited the doctor in January after aggravation of symptoms. Slit-lamp examination, ultrasound biomicroscopy, ultrasound B-scan, fluorescein angiography, and indocyanine green angiography revealed the presence of a foreign body in the vitreous, which caused discomfort in the patient's left eye and subsequently, panuveitis of the left eye. The symptoms improved significantly after foreign body removal using vitrectomy. Microscopic examination revealed that the foreign body was caterpillar setae.

CONCLUSION

Clinicians should be more vigilant about history of contact with caterpillars while examining uveitis that has recurred for many years. Identification of the root cause of the disease can ensure better treatment.

Isolated Depo-Medrol Administration under Tenon's Capsule for Post-COVID-19 Uveitis in a Child: A Case Report and Literature Review

Coronavirus disease 2019 (COVID-19) can manifest with ocular symptoms. These symptoms can be divided into isolated events attributed to COVID-19, and those occurring in multisystem inflammatory syndrome in children (MIS-C), a newly diagnosed disease entity associated with COVID-19 infection. Currently, the literature lacks specific guidelines and treatment regimens for COVID-19 ocular symptoms, especially in children. The authors present the case of a 14-and-a-half-year-old boy with bilateral uveitis of the anterior and posterior segments along with vasculitis and optic neuritis associated with SARS-CoV-2 infection. The authors also perform an up-to-date review of all available publications on the treatment of post-COVID-19 uveitis in children described in the literature between 2020 and 2023. In the case described by the authors, the treatment involved a Depo-Medrol 40 mg/mL injection uder the Tenon capsule, with two subconjunctival injections of epinephrine, topical steroid therapy and non-steroidal anti-inflammatory drugs: dexamethasone 0.1%; diclofenac eye drops. In addition, acetylsalicylic acid (150 mg) and pentoxifylline (100 mg, orally) were administered throughout the course of the disease as well as up to 12 months after its termination, until a complete improvement in visual acuity and the withdrawal of ocular lesions were achieved. It can be assumed that this type of treatment is far more beneficial for pediatric patients, with an effect comparable to systemic steroid administration with a preserved improvement in retinal-vascular circulation, without exposing the child to systemic post-steroid complications.

Clinical Features and Course in Patients Diagnosed with Ocular Sarcoidosis without Previously Known Systemic Disease at a Tertiary Referral Center in Turkey

PURPOSE

To evaluate the ocular features, course, and prognosis of uveitis in the ocular sarcoidosis (OS) subgroups without previously known systemic sarcoidosis.

METHODS

Ninety-one eyes of 49 patients were included. Definite OS patients were classified as group 1 (n = 15), presumed OS patients as group 2 (n = 15), and probable OS patients as group 3 (n = 19).

RESULTS

 The most common presentation of OS was panuveitis in all groups. During the follow-up, bilateral ocular involvement was observed in 85.7% of the patients. The most common extraocular involvement was pulmonary involvement, which was detected in 61.2% of the patients at the time of diagnosis.

CONCLUSION

Ophthalmologists should be aware that uveitis may be the first sign of systemic sarcoidosis. In all subgroups of OS, uveitis tends to be bilateral and the most common type is panuveitis. Therefore, the eye without obvious clinical findings should be carefully evaluated clinically and angiographically.

Long-Term Visual Outcome of Patients with Blau Syndrome

PURPOSE

To document the long-term visual outcomes in patients with Blau syndrome.

METHODS

A retrospective institutional cohort study was conducted, and 13 patients with genetically confirmed Blau syndrome were included. Demographic and clinical data were collected from standardised medical charts. Baseline was defined as the first detected uveitis and data were recorded onwards at intervals of 1, 3, 5, 10, 15 and 20 years.

RESULTS

Anterior uveitis was the most common classification at baseline (57.1%). Among patients with documented uveitis lasting 10 years or more, all of them developed panuveitis. Median logMAR visual acuity at baseline was 0 (range -0.5; 0.7), 0.19 (range 0; 1.5) at year 5, and 0.7 (range 0.1 - no perception of light) at year 20, as recorded in 13, 16, and 10 eyes, respectively. All patients received treatment with topical and oral steroids, and multiple systemic immunosuppressants including biologics. Disease control, defined as having cells <1+ in both eyes and using topical steroid eye drops less than twice daily, was achieved in 14.3% to 37.5% of patients at the different time points. Cataract surgery was performed in 12 eyes of 8 patients, 3 eyes of 3 patients necessitated glaucoma surgery, and 4 eyes of 4 patients required surgery for retinal detachment.

CONCLUSION

Uveitis associated with Blau syndrome commonly leads to severe, chronic panuveitis, requiring long-term systemic immunosuppression. Early diagnosis and timely initiation of biologics may prevent significant visual impairment.

Vogt-Koyanagi-Harada Disease: The Clinical Spectrum and Management of Case Series in a Tertiary Eye Centre in Northern Part Of Malaysia

AIMS

We present the clinical spectrum, the initial clinical presentation with management trends in treating 14 Vogt-Koyanagi-Harada (VKH) disease cases in a tertiary center in the Northern part of Malaysia.

CASE SERIES

There were 14 cases of Vogt-Koyanagi-Harada (VKH) disease retrospectively reviewed over five years (from 2015 to 2020). The mean age at presentation was 37.7 years (range 21-64 years), with female predominance (85.7%). All cases presented with acute uveitic stage and bilateral eye involvement. Of them, 11 (78.6%) were probable VKH, and three (21.4%) were incomplete VKH. All patients attended with acute panuveitis at first presentation. The main posterior segment involvement was disc edema in 57.1% (16 out of 28 eyes) and exudative retinal detachment (ERD) in 35.7% (10 out of 28 eyes). Most of them presented with blindness (3/60 and worse) and moderate visual impair- ment (6/18-6/60); 35.71% each, followed by mild visual impairment (6/12-6/18), and severe visual impairment (6/60-3/60); 7.1% each. Ten patients (71.4%) required combination second-line immunomodulatory treatment during subsequent visits, and only four patients (28.6%) responded well to corticosteroid therapy. Most of the cases achieved no visual impairment (64.3%), followed by mild visual impairment (21.4%) and moderate visual impairment (14.3%), and none were severe or blind at the end of follow-up.

CONCLUSION

VKH is a potentially blinding illness if there is inadequate control of the disease in the acute stage. Most of our patients achieved good visual outcomes with early immunomodulatory treatment and systemic corticosteroids.

Efficacy and Safety of Adalimumab in Patients with Behçet Uveitis: A Systematic Review and Meta-Analysis

PURPOSE

To examine the long-term efficacy and safety of adalimumab (ADA) in patients with Behçet uveitis (BU).

METHODS

A systematic review and meta-analysis of observational studies was performed. Pooled results are presented as mean difference or standardized mean difference (std diff) and 95% confidence intervals (CI). Visual acuity (VA), intraocular inflammation grade, central macular thickness, corticosteroid (CS) sparing effect and adverse events were evaluated.

RESULTS

Ten studies were included finally for quantitative and qualitative synthesis. ADA therapy resulted in 0.124 (95%CI: 0.084, 0.165) logMAR improvement in VA. In addition, ADA therapy resulted in decreased grade of intraocular inflammation [std diff, -1.187 (95%CI: -1.508, -0.866)] and macular thickness [std diff, -0.564 (95%CI: -0.843, -0.286)] and caused a decrease in CS dosage [std diff, -1.809 (95%CI: -2.420, -1.198)]. The pooled rate of overall adverse events for ADA in 301 patients was 8.5% (95%CI: 0.039, 0.177).

CONCLUSION

ADA is an efficient therapy that improves VA and controls intraocular inflammation, macular edema and retinal vasculitis. As the disease exposure time increased, improvement in VA was less. The safety and CS-sparing effect of ADA were demonstrated with few adverse effects. The results provided evidence that ADA can be used safely and efficiently as the first-line drug in patients with BU.

Fulminant endogenous endophthalmitis caused by Brucella melitensis, a case report

Key Clinical Message

Ocular brucellosis is a potential cause of endogenous endophthalmitis in endemic areas, which can be associated with sight-threatening complications.

Abstract

To report a patient with unusual fulminant endogenous endophthalmitis due to Brucella melitensis. A 25-year-old woman with a history of fever and right shoulder pain from 4 months ago and a positive Wright test presented with acute panuveitis in her right eye. All laboratory tests were unremarkable except for the positive polymerase chain reaction (PCR) test of the vitreous sample for B. melitensis. Despite the therapeutic efforts, including multiple vitreoretinal surgeries, and intravitreal and systemic antibiotics, the patient's final follow-up examination after 6 months revealed hand motion vision, hypotonia, and pre-phthisis bulbi status. The fellow eye was entirely normal. Brucella endogenous endophthalmitis can be fulminant and result in poor visual outcomes. It is suggested to consider ocular brucellosis as a potential cause of endogenous endophthalmitis in endemic areas.

Protothecosis in four dogs in New Zealand

CASE HISTORIES

Medical records of four dogs diagnosed with protothecosis in New Zealand were reviewed. The dogs were aged between 4 and 9 years and three of the four dogs were female. Breeds were one Labrador, one Miniature Schnauzer and two crossbreeds. The reasons for initial veterinary evaluation were a cough and opaque appearance of the right eye (Case 1), diarrhoea (Cases 2 and 3), and cutaneous disease (Case 4).

CLINICAL FINDINGS

The ocular signs were characterised by panuveitis, retinal detachment and secondary glaucoma. Gastrointestinal signs included chronic haemorrhagic diarrhoea due to colitis. Three cases had disseminated infection and developed both bilateral, blinding, ocular disease and chronic gastrointestinal disease. Cutaneous signs consisted of draining fistulae over the olecranon, multifocal cutaneous nodules, and ulceration and tracts of the foot pads. Disseminated protothecosis was confirmed by histopathology of biopsied ocular tissues in Cases 1 and 2 and by gastrointestinal biopsies in Case 3. Prototheca spp. were also identified in cytological specimens from Cases 1 and 4 and recovered by culture in Cases 2 and 4. Cutaneous protothecosis was diagnosed in Case 4 initially by cytology and histopathology of skin lesions, and Prototheca zopfii was confirmed by PCR of cultured organisms.

TREATMENT AND OUTCOME

Prior to diagnosis of protothecosis, a variety of treatments were prescribed to treat the gastrointestinal and ocular signs. After diagnosis, only Cases 2 and 4 received medication aimed at treating the protothecal infection, which was itraconazole in both cases. Following the progression of clinical signs and concerns about quality of life, all four dogs were euthanised.

DIAGNOSIS

Disseminated protothecosis in three dogs, cutaneous protothecosis in one dog.

CLINICAL RELEVANCE

Canine protothecosis is rarely reported, despite the ubiquity of the causal algae, and the disease usually carries an extremely grave prognosis when infection is generalised. In New Zealand, protothecosis should be considered as a differential diagnosis in dogs with panuveitis, chorioretinitis or retinal detachment, colitis, or nodular, ulcerative or fistulating cutaneous lesions.

Regarding Kaya P et al. "Predictive Factors for the Prognosis of Vogt-Koyanagi-Harada Disease"

INTRODUCTION

VKH is a primary stromal choroiditis. Studies with indocyanine green angiography (ICGA) have shown that inflammation begins at the choroid and may persist without clinically apparent inflammation. Thus, systemic therapy must target choroidal inflammation and be maintained until the choroiditis resolves, as proven by ICG and/or EDI-OCT imaging studies.

DISCUSSION

Aggressive therapy with oral corticosteroids, with or without "pulsed" intravenous methylprednisolone, has been the mainstay of VKH therapy in the acute phase for many years. However, there is convincing evidence that corticosteroid monotherapy is insufficient to prevent progression onto the chronic recurrent form of the disease, which is associated with poor visual outcomes.

CONCLUSION

Numerous studies suggest that combined therapy with systemic corticosteroids and immunosuppressants is necessary to prevent the progression toward chronic recurrent disease, avoiding complications, get a better control of inflammation and visual outcomes in VKH patients seen at the uveitic phase of the disease.

Vogt-Koyanagi-Harada-like Syndrome Induced by Checkpoint Inhibitor Cemiplimab

Checkpoint inhibition targeting programmed cell-death protein 1 has demonstrated efficacy for a wide range of indications including cutaneous malignancy. However, immune-related adverse events (irAEs), including infrequent but visually impactful ocular irAEs, require careful consideration of treatment options, including medication withdrawal, local corticosteroids, or rarely immunomodulation. This case presents a 53-year-old woman who developed uveitis and mucous membrane ulcers after treatment for numerous cutaneous neoplasms, primarily squamous cell carcinoma, with the programmed cell-death protein 1 inhibitor cemiplimab. Ophthalmic examination revealed diffuse choroidal depigmentation consistent with a Vogt-Koyanagi-Harada-like syndrome. Topical and periocular steroids were used to treat the intraocular inflammation, and cemiplimab was discontinued. Because of ongoing severe uveitis, systemic corticosteroids and corticosteroid-sparing immunosuppression were initiated. Specifically, azathioprine and methotrexate were introduced, but each was stopped due to side effects, prompting the initiation of adalimumab (ADA) treatment. While ADA controlled intraocular inflammation, the squamous cell carcinomas were noted to progress, resulting in the discontinuation of ADA. However, a uveitis recurrence was observed. After a discussion of risks and benefits of biologic immunosuppressive therapy, including the risk of vision loss, ADA was restarted with successful disease quiescence at a 16-month follow-up. The cutaneous neoplasms were managed with topical and intralesional therapies, such as 5-fluorouracil. Recent dermatologic examinations suggested no new cutaneous lesions. This scenario presents the effective use of ADA in an ocular irAE that balances the management of sight-threatening ocular inflammation with the risk of promoting recurrent or de novo neoplastic disease.

A Systematic Review of Clinical Trials in Uveitis: Lessons Learned

PURPOSE

Clinical trials in uveitis have led to the expansion of therapeutic options for the management of non-infectious uveitis. The purpose of this systematic review is to investigate why some clinical trials have yielded successful results and regulatory approval of new therapies, and some have not.

METHODS

A systematic literature search of the Pubmed/MEDLINE database and clinicaltrials.gov was performed from 2006 to 2021, according to the PRISMA guidelines. Phase III clinical trials of systemic and local therapies in adults with non-infectious intermediate, posterior, and panuveitis were included.

RESULTS

A total of 79 clinical trials were collected from ClinicalTrials.gov and PubMed/MEDLINE database search. Based on the inclusion and exclusion criteria, 14 clinical trials were included.

CONCLUSION

This review summarizes the study design, outcome measures, and results of recent phase III trials in non-infectious uveitis, in the interest of understanding limitations and rethinking new methods of defining endpoints in clinical trial design.

Multimodal Imaging of Panuveitis with Multifocal Retinitis Resulting from Post-Streptococcal Uveitis Syndrome

BACKGROUND

Post-streptococcal uveitis syndrome is a rare inflammatory sequela following streptococcus infection most commonly occurring in young patients. Patients most typically present with bilateral anterior nongranulomatous uveitis, but posterior involvement occurs frequently.

CASE PRESENTATION

We report an immunosuppressed patient presenting with asymmetrically bilateral acute onset, panuveitis with diffuse multifocal retinitis resulting from post-streptococcal uveitis syndrome.

CONCLUSION

Post-streptococcal uveitis syndrome can present as a panuveitis with multifocal retinitis. A high clinical suspicion is needed for this diagnosis especially in patients under the age of 30 years old with bilateral non-granulomatous uveitis.

Penicillin Responsive Presumed Seronegative Ocular Syphilis in a Patient with Human Immunodeficiency Virus: A Case Report and Review of the Literature

Ocular and systemic syphilis are well known to mimic other clinical entities making them challenging to diagnose in many cases. Syphilis testing plays an important role in diagnosis and timely treatment. Here we describe a patient with untreated human immunodeficiency virus (HIV) infection who presented with bilateral panuveitis with repeatedly negative syphilis serologies. In light of worsening retinitis while on aggressive anti-viral treatment and in consideration of the clinical suspicion for syphilitic uveitis, intravenous penicillin was initiated empirically. The patient demonstrated significant improvement subjectively and objectively after treatment. We also review and discuss syphilis testing reliability generally and in HIV co-infected patients in particular. Empiric intravenous penicillin should be considered in patients with clinical features of ocular syphilis despite negative serologic testing, especially in those with HIV co-infection.

A Case of Lyme Disease Presenting as Bilateral Panuveitis

Here, we describe a case of Lyme disease presenting as bilateral panuveitis. A 25-year-old woman presented to our clinic with decreased visual acuity of 20/320 and 20/160 in the right and left eye, respectively. An ophthalmic examination revealed the presence of anterior chamber cells 3+, vitreous cells 1+, vitreous haziness 2+/1+, and retinal infiltration in both eyes. She also had fever, headache, and difficulty in breathing. An initial blood analysis did not detect infection; however, high levels of erythrocyte sedimentation rate and C-reactive protein were noted. Pleural and pericardial effusions, and multiple reactive arthritis lesions were observed on chest computed tomography and bone scans, respectively. Oral steroids (30 mg/day) and steroid eye drops were initiated. Ten days later, she was diagnosed with Lyme disease, based on an indirect immunofluorescence antibody test. Ceftriaxone (2 g) was intravenously administered for 2 weeks followed by administration of oral trimethoprim-sulfamethoxazole (400 mg/80 mg/day) for 1 week. Thereafter, she received a 4-week course of doxycycline (100 mg) twice daily. Her symptoms and ocular findings improved; however, a gradually increasing dose of oral steroid was needed to control retinal lesions for some time, since multiple retinitis lesions developed in the peripheral retina after tapering the oral steroid dose to 5 mg/day. In conclusion, panuveitis can occur in patients with Lyme disease and can be treated with systemic antibiotics and steroids.

Bilateral Exudative Retinal Detachments and Panuveitis in a Patient with Multiple Myeloma

PURPOSE

To report a case of bilateral exudative retinal detachments and panuveitis in a patient with multiple myeloma (MM).

CASE REPORT

A 54-year-old patient with non-proliferative diabetic retinopathy was referred with blurred vision and scotomas in both eyes (OU). Three months prior to the onset of ocular symptoms, he was diagnosed with systemic MM and was receiving chemotherapy. Clinical examination revealed best-corrected visual acuities of 20/80 OU, rare anterior chamber cell, 2+ vitreous cell, diffuse intraretinal hemorrhages, and exudative retinal detachments (RD). Optical coherence tomography of the macula showed central subretinal fluid with cystic intraretinal fluid OU. The findings were consistent with panuveitis and exudative RD in the setting of MM. He reported symptomatic improvement after plasmapheresis and oral prednisone initiation.

CONCLUSION

Extensive, bilateral exudative RD and panuveitis are rare but potentially sight-threatening findings in patients with MM.

Presence of Choroidal Caverns in Patients with Posterior and Panuveitis

Choroidal caverns (CCs) have been described in association with age-related macular degeneration and pachychoroid disease. However, it is unknown if caverns are found in patients with chronic non-infectious uveitis (NIU). Herein, we evaluated patients with NIU who had optical coherence tomography and indocyanine green angiography for CCs. Clinical and demographic characteristics were extracted from the chart review. Univariate and multivariate mixed-effects logistical models were used to assess the association between clinical and demographic factors and the presence of CCs. One hundred thirty-five patients (251 eyes) met the inclusion criteria: 1 eye had anterior uveitis, 5 had intermediate uveitis, 194 had posterior uveitis, and 51 had panuveitis. The prevalence of CCs was 10%. CCs were only observed in patients with posterior and panuveitis, with a prevalence of 10.8% and 7.8%, respectively. Multifocal choroiditis (MFC) was the type of uveitis where CCs were most frequently observed, with 40% of eyes with MFC having CCs. In addition, male sex (p = 0.024) was associated with CCs. There was no significant difference in the degree of intraocular inflammation or mean subfoveal choroidal thickness between CC+ and CC- eyes. This is the first study to describe CCs in uveitis. Overall, these findings suggest that caverns may be a sequela of structural and/or vascular perturbations in the choroid from uveitis.

Conjunctival Inflammation and Panuveitis as Manifestations of Ig-G4-Related Disease: A Case Report

PURPOSE

To report a case of isolated conjunctival inflammation as initial manifestation of IgG4-related disease and subsequent development of panuveitis.

CASE REPORT

A 75-year-old female presented with a diffuse mass lesion in the temporal area of the left eye, involving the conjunctiva, and an abscessed corneal ulcer. An incisional biopsy was diagnostic of IgG4-related disease with an elevated IgG4/IgG ratio (>40%) and the presence of >10 cells that tested positive for IgG4/CGA. No other ocular, orbital or systemic manifestations were noted at the time of diagnosis. After a year of treatment with topical dexamethasone, oral prednisone, and methotrexate, the patient developed panuveitis, which was controlled by increasing steroids and switching to rituximab.

CONCLUSION

IgG4-related disease is a rare entity that can be particularly challenging to diagnose if it manifests in an atypical manner. Continuous follow-up of patients is crucial as relapses and worsening of symptoms can occur despite treatment.

Uveitis in Sarcoidosis - Clinical Features and Comparison with Other Non-infectious Uveitis

PURPOSE

Comparison of sarcoid uveitis with other non-infectious uveitis treatment and visual outcomes.

METHODS

Retrospective study of 287 eyes with sarcoid uveitis and 1517 eyes with other non-infectious uveitis (15,029 eye-years follow-up).

RESULTS

Sarcoid uveitis patients presented at age 43.1 ± 0.8 years, and 66.2% were female. Panuveitis was the most frequent presentation (48.3%), and 90.1% were bilateral. Moderate visual loss (≤20/50) developed in 19 eyes (6.6%), and severe visual loss (≤20/200) in 13 eyes (4.5%). Sarcoid uveitis had better visual outcomes than other non-infectious uveitis (10-year BCVA anterior uveitis 0.06 vs 0.24 p = .002; posterior disease 0.17 vs 0.38 p = .001). Oral corticosteroid use was more common with sarcoid uveitis (anterior uveitis 45.9% vs 16.4% p < .0005; posterior disease 64.0% vs 61.7% p = .635), but second-line immunosuppression was required less frequently (p = .008).

CONCLUSIONS

Compared to other non-infectious uveitis, sarcoid uveitis has better visual acuity outcomes and is less likely to require second-line immunosuppression.

Seasonal Patterns of Vogt-Koyanagi-Harada Disease

PURPOSE

To identify the relationship between the incidence of Vogt-Koyanagi-Harada (VKH) disease and seasonality.

METHODS

A retrospective cohort study was performed, including patients with a confirmed diagnosis of VKH whose month of disease onset was available. Information on patients was entered retrospectively into a database and analyzed according to the month and season.

RESULTS

Twenty-four patients who met the inclusion criteria were included in the analysis. There was a statistically significant deviation from expected values in the incidences of VKH per season (P = .043). The most common season for the onset of VKH was fall, with 50% of the patients presenting in this season, while spring was the least common season for VKH presentation, with 12.5% of the patients presenting in this season.

CONCLUSION

Our study suggests that the onset of VKH in Puerto Rico follows a seasonal pattern, with most cases occurring during the fall.

Infectious Sclerouveitis in an Immunocompetent Patient: A Probable Case of Simultaneous Ocular Tuberculosis and Toxoplasmosis

Simultaneous infections of tuberculosis and toxoplasmosis are uncommon in immunocompetent patients. We report a case of a 30-year-old male who presented with right eye redness and blurring of vision for one month. The visual acuities were hand movement and Snellen 20/30 in the right and left eyes, respectively. Panuveitis and scleritis were found in the right eye, together with dense vitritis and a large choroidal lesion that extended from the inferonasal to the superotemporal quadrants. B-scan ultrasonography of the right eye showed a choroidal detachment with scleral thickening and subtenon fluid. His IgM anti-Toxoplasma antibody was detected, and his QuantiFERON Gold testing was positive. Magnetic resonance imaging (MRI) of the orbit revealed an enhancing intraocular mass at the lateral and inferior aspects of the right globe. The diagnosis of right eye sclerouveitis with presumed tuberculosis and toxoplasmosis co-infections was made. He was treated with a course of oral azithromycin and anti-tubercular therapy along with systemic prednisolone and a topical steroid. The treatment reduced the inflammation; however, the patient suffered from a sequela of chronic uveitis with prolonged hypotony. Medical treatment alone may be insufficient in treating severe infective sclerouveitis, hence surgical intervention might be warranted to provide favorable clinical outcomes.

Cytopathology of Vitreous Specimens in Acute Retinal Necrosis

PURPOSE

To report the cytopathology of vitreous biopsy samples in patients with acute retinal necrosis (ARN) who underwent pars plana vitrectomy (PPV). We also describe two patients with unique clinical courses, cytopathologic findings, and immune response.

METHODS

A retrospective review of patients with ARN who developed retinal detachment (RD) and underwent PPV from 22011 to 2019 at the Emory Eye Center was performed to assess cytopathology findings of vitreous biopsy samples. Patient demographics and laboratory testing including aqueous humor PCR for viral pathogens were recorded. Additional clinical details abstracted included intravitreal injections, surgical procedures, and vitreous cytopathological reports including immunohistochemistry findings.

RESULTS

Fourteen eyes of 12 patients with RD were reviewed. Ten eyes showed HSV DNA (71%) and 4 demonstrated VZV DNA (29%). All eyes received intravitreal antivirals (i.e. ganciclovir or foscarnet) with a median of 8.5 intravitreal injections per eye. Diagnoses prompting PPV included tractional RD in 14 eyes (100%), rhegmatogenous RD in 8 eyes (57%), vitreous hemorrhage in 4 eyes (29%) and vitreous opacity in 4 (29%). Ophthalmic pathology reports showed lymphocyte populations in 10 eyes (71%) with a CD3 + T-cell predominance in two patients where immunohistochemistry of CD3+ and CD20+ for T- and B-cell populations was performed. Observed immune cell populations included macrophages or histiocytes (11 eyes, 79%) and polymorphonuclear cells in 4 eyes (29%). Initial median VA was 2.5 (IQR 2.0-3.0) and improved to 2.0 (IQR 1.48-3.00, p = .48) at 6-months and 1.8 (IQR 1.2-3.0, p = .45) at 12 months follow-up.

CONCLUSIONS

Our cohort of ARN patients undergoing PPV show a spectrum of immunologic findings with the majority demonstrating a lymphocytic response. Histiocytes, macrophages, and PMNs were also observed. Cytopathologic and immunologic studies suggest that both innate and adaptive immunity are responsible for the clinical disease findings observed in ARN. The variability of the response to treatment in patients with ARN may reflect patient-to-patient differences in their antigen-specific immune response. Understanding the immunologic response associated with ARN may provide valuable information regarding the dosing and timing of treatment.

A Unique Case of Syphilitic Hypopyon Panophthalmitis

Purpose

This work reports a unique case of syphilitic hypopyon panophthalmitis.

Methods

A case report is presented.

Results

A 25-year-old man with a history of HIV and intravenous (IV) drug use presented to an outside hospital with blurred vision and swelling of the right eye. Computed tomography was concerning for orbital cellulitis. On examination, he had limited extraocular motility, relative exophthalmos, periocular edema, 4+ anterior chamber cell, an irregular layering hypopyon, and no view of the fundus. Magnetic resonance imaging showed enhancement of the sclera, lateral rectus muscle, and lacrimal gland concerning for infectious or inflammatory panophthalmitis. The patient's history and presentation were concerning for bacterial or fungal etiologies from an endogenous source. He began antimicrobial therapy. Diagnostic vitrectomy was unrevealing. Syphilis testing was positive. The patient showed improvement with IV antiluetic therapy.

Conclusions

We present a case of syphilitic hypopyon panophthalmitis, a new constellation of findings in syphilitic ocular disease.

Sympathetic ophthalmia: A comprehensive update

Sympathetic ophthalmia is a rare, bilateral, granulomatous, panuveitis following penetrating trauma or surgery to one eye. Clinical presentation commonly occurs within the first year of trauma occurrence but can be delayed by several years. It manifests as acute/chronic granulomatous uveitis with yellowish-white choroidal lesions or Dalen-Fuchs nodules. Initially, patients respond rapidly to corticosteroid therapy, but a majority require long-term use of corticosteroid-sparing agents to prevent recurrences. The purpose of this review is to elaborate on the current understanding of the pathophysiology, the importance of multimodal imaging in early diagnosis, and the role of newer immunomodulatory and biological agents in recalcitrant cases.

Sympathetic Ophthalmia - An Overview

INTRODUCTION

Sympathetic ophthalmia (SO) is rare, bilateral granulomatous panuveitis that typically occurs following penetrating or perforating ocular trauma or surgery. This review aims to provide an update on the etiopathogenesis, clinical presentations, diagnosis and treatment of SO.

METHODS

Reports cited in MEDLINE database, that analyzed SO in at least 5 patients, published prior to December 1st, 2021 were included.

RESULTS

Initially, SO was associated with penetrating ocular trauma, however, various studies reported an increased incidence of SO after surgical procedures including vitreoretinal surgeries. Multimodal imaging including fluorescein and indocyanine green angiography, optical coherence tomography (OCT) and OCT angiography have added further insights into the understanding of SO. While pulse dose corticosteroids & immunosuppressive drugs are still the treatment of choice, TNF-α blockers & other biologic drugs represent new promising agents.

CONCLUSION

There is a growing pool of evidence in understanding the pathogenesis of SO. Novel treatment options have provided better prognosis for this potentially blinding condition.

Pattern of uveitis from a tertiary eye care center in Himalayan belt of North India

Purpose:

To study the clinical characteristics of uveitis in patients presenting to a tertiary care institute in the northern part of India, predominantly serving the population of Himalayan belt.

Methods:

In this retrospective descriptive case series, data of 141 eyes of 102 patients diagnosed between January 2019 and January 2021 were analyzed. Patients were diagnosed, named, and meshed as per the Standardization of Uveitis Nomenclature. A panel of investigations (systemic and ocular ancillary investigations) were done, which was individualized according to the clinical picture.

Results:

The mean age of presentation was 39.1 ± 14.62 years. A male predominance (62.7%) was noted. Unilateral presentation was seen in 61.8% of patients. Specific etiological diagnosis was not reached in 56.7% of cases. The incidence of infectious and noninfectious uveitis was 23.4% and 19.9%, respectively. The frequency of anterior, intermediate, posterior, and panuveitis was 23.4%, 11.3%, 46.8%, and 18.5%, respectively. Posterior uveitis was the most frequent anatomical location (46.8%). Tuberculous uveitis was the most common definitive etiology irrespective of location (18.5%). Anterior, intermediate, and posterior uveitis were more frequently idiopathic in origin. Sympathetic ophthalmitis was the most common cause for panuveitis.

Conclusion:

Uveitis significantly affected the working age group population. Despite the evolution of diagnostic investigations, etiology remained unknown in many cases of uveitis. Infectious etiology was more common. Posterior uveitis as the most frequent anatomical location in our study may be attributed to the tertiary care referral bias.

Bilateral Granulomatous Panuveitis in A Patient with COVID-19

PURPOSE

To present a case of panuveitis with granulomatous intraocular inflammation and vasculitis related to coronavirus disease 2019 (COVID-19).

CASE REPORT

A 46-year-old female patient had blurred vision in both eyes during 8 days after COVID-19 symptoms. Anterior segment examination revealed anterior chamber cells in the both eyes, mutton fat keratic precipitates and posterior synechiae in the left eye. Small peripheral iris nodules and mild vitritis were accompanying in both eyes. Fundus examination revealed multiple superficial retinal infiltrate lesions in the peripheral retina with retinal periphlebitis in both eyes. Spectral domain optical coherence tomography showed hyperreflective superficial retinal infiltrates. Fluorescein angiography (FA) and indocyanine green angiography demonstrated hypofluorescent foci due to blockade of retinal infiltrates. Peripheral vascular leakage was detected on FA in both eyes.

CONCLUSION

This case showed that COVID-19 infection can cause granulomatous panuveitis. Autoimmune mechanisms related to COVID-19 may lead to ocular inflammation.

Rescue Treatment with Infliximab for a Bilateral, Severe, Sight Threatening Frosted Branch Angiitis Associated with Concomitant Acute Onset of Presumed Dermatomyositis

PURPOSE

To report a severe bilateral frosted branch angiitis associated with acute onset of systemic dermatomyositis.

METHOD

History and clinical examination, laboratory evaluation, fundus' and skin's color pictures, fluorescein angiography (FA), optical coherence tomography (OCT).

RESULTS

A 32-year-old female was referred for a bilateral frosted branch angiitis and vitreitis, with skin rash, muscle pain, weakness, severe headache, compatible with dermatomyositis. After an initial improvement following an aggressive treatment by systemic steroids and mycophenolate mofetil, she was switched to intravenous infliximab (RemicadeTM, Janssen Biotech, Inc. USA) due to lack of efficacy. Nine months later, her visual acuity was improved up to 20/20 in OU, with both retinal vasculitis and vitreitis being solved.

CONCLUSION

Dermatomyositis is a severe multiorgan disease which might severely involve eye structures. Anti-TNF-Alpha agents, particularly Infliximab, might offer a rapid control and long-term remission.

Bilateral Panuveitis with Occlusive Vasculitis following Coronavirus Disease 2019 Vaccination

PURPOSE

To report a case of bilateral panuveitis and occlusive vasculitis following COVID-19 vaccination.

STUDY DESIGN

Case report.

RESULTS

A 41-year-old otherwise healthy male presented with progressive vision loss and floaters starting 48 hours after a first dose of COVID-19 vaccine. Examination initially showed bilateral anterior uveitis, but this evolved into bilateral panuveitis with occlusive vasculitis despite topical corticosteroids over two weeks. The patient underwent extensive testing for other etiologies which were excluded. He was successfully treated with a gradual taper of topical and systemic corticosteroids leading to improvement of signs and symptoms. Follow-up is maintained for observation of avascular zones with possible neovascularization which could require laser as needed.

CONCLUSIONS

The temporal association between vaccine and presentation makes this a plausible etiology. This remains a rare adverse event, but clinicians should be aware of this possibility to include it in their differential diagnosis when confronted with idiosyncratic ocular presentations.

Varicella Zoster Reactivation Causing Acute Retinal Necrosis following mRNA COVID-19 Vaccination in a Young Immunocompetent Man

BACKGROUND

Varicella zoster reactivation is an increasingly recognised event following mRNA COVID-19 vaccination. In addition, various ocular inflammatory and infectious adverse events following COVID-19 vaccination have been described in the literature. This case report describes acute retinal necrosis (ARN) secondary to varicella zoster virus (VZV) reactivation following COVID-19 mRNA vaccination.

CASE DESCRIPTION

A 42-year-old immunocompetent man developed left ARN 12 days following first dose of Pfizer BioNTech mRNA COVID-19 vaccination. Aqueous and vitreous tap polymerase chain reaction testing was positive for VZV. Good visual outcome was achieved with combination therapy, including intravitreal foscarnet, oral valaciclovir and prednisolone, topical dexamethasone and atropine, and barrier retinal laser. Second dose of the vaccine is planned under cover of high-dose oral valaciclovir therapy.

CONCLUSION

This case illustrates the possible association between COVID-19 vaccination and potentially blinding VZV reactivation. Therefore, prompt ophthalmic assessment is recommended in patients with visual disturbance following COVID-19 vaccination.

An unusual case of eosinophilic uveitis in a cat

An 8-year-old female spayed domestic short-haired cat was examined for recurrent unilateral anterior uveitis of 5 month's duration. No underlying cause was found on infectious disease screening. The cat also had a 4-year history of allergic or immune-mediated skin disease that was controlled with corticosteroid injections followed by long-term oral cyclosporine therapy. Medical management with frequent topical anti-inflammatory drugs (prednisolone acetate 1% suspension, diclofenac 0.1% solution) controlled the intraocular inflammation; however, the uveitis would relapse when therapy was discontinued. Eventually, secondary glaucoma developed OD and the eye was enucleated. At the time of surgery, a complete blood count showed a mild eosinophilia. Histopathology revealed a marked panuveitis characterized by an abundant accumulation of mixed inflammatory cells, with a predominantly eosinophilic infiltrate in the anterior chamber, iris, ciliary body, and choroid. No etiologic agents were found on serial sections, and there were no cellular criteria for malignancy noted. Nine months after enucleation, the chronic dermatitis appeared to be in remission despite no further medical management. This is the first known report of a primarily eosinophilic uveitis in a cat with chronic allergic skin disease and may be considered an ocular variant of feline eosinophilic granuloma complex.

Uveitis and autoimmune hepatitis, a real entity? A case report with review of the literature

A 63-year-old man presented with a 10-day history of severe pain, redness of the right eye, and reduced vision in both eyes. In addition, he had been diagnosed incidentally with liver cirrhosis and splenomegaly 1 week before he was admitted to our center. The patient was found to have severe intraocular inflammation that initially involved the right eye and then progressed to bilateral panuveitis. The presenting visual acuity was 20/60 for the left eye and lumbar puncture (LP) for the right eye. Vitreous tap revealed a nonturbid, yellow fluid that was negative for organism culture, polymerase chain reaction (PCR), and tumor markers. Oral prednisolone significantly improved the clinical status of both ocular and hepatic inflammation. During the admission period, the patient developed several medical comorbid complications that temporarily altered the management of our case. After a full evaluation of uveitis causes, the patient was diagnosed with biopsy-proven autoimmune hepatitis. In addition to a high-dose oral steroid, azathioprine was given for 3 months before the patient developed decompensated liver failure, which was successfully managed with a liver transplant. The patient was stable for 1 year following the transplant but eventually developed blindness of the right eye and visual acuity of 20/30 in the left eye.

Efficacy of intravitreal dexamethasone implant in patients with Vogt-Koyanagi-Harada Disease and bilateral panuveitis: Two case reports

INTRODUCTION

Vogt-Koyanagi-Harada (VKH) disease is a multisystemic disorder characterized by intraocular inflammation associated with serous retinal detachment, optic disc edema, uveitis, and vitritis, and is often associated with neurologic and cutaneous manifestations. Diagnosis can be assisted by fluorescein angiography and optical coherence tomography that can help evaluate changes in the retina. Therapy relies mainly on the use of corticosteroids, administrated through oral or intravenous high-dose pulses, and immunosuppressants. The purpose of our study was to assess the outcome of VKH disease with bilateral panuveitis treated with dexamethasone intravitreal implant.

PATIENT CONCERNS

Two patients without underlying disease had severe vision deterioration, eye pain, following flu-like symptoms.

DIAGNOSIS

At initial diagnosis, macular edema and sub-retinal fluid lobulated accumulation were noted under SD-OCT exam. FAG revealed multiple pinpoint leakage around macula and pooling of dye within sub-retinal space.

INTERVENTIONS

All two patients received intravenous pulse methylprednisolone at the diagnosis, followed by oral prednisolone and cyclosporine. One patient received bilateral eye dexamethasone intravitreal implant two weeks after diagnosis, while the other received left eye dexamethasone intravitreal implant at the time of diagnosis.

OUTCOMES

Vision and macular structure recovered more rapidly after receiving dexamethasone implants in the short-term follow-up. All macular structures recovered to normal, and vision recovered to 20/20 in both eyes. One patient, receiving bilateral dexamethasone implant, didn't relapse during the 13-month follow-up; the other, receiving left eye dexamethasone implant, didn't relapse during the 6-month follow-up. None of them required intravenous high-dose steroids again.

CONCLUSION

VKH disease is a multisystemic disorder; intravenous pulse steroid therapy and oral prednisolone can control systemic inflammation. In addition to systemic prednisolone treatment of VKH disease in the acute phase, dexamethasone implants can enhance short-term and long-term control of intraocular anti-inflammation.

Vogt-Koyanagi-Harada disease during prolonged intermittent steroid therapy for chronic obstructive pulmonary disease: a case report

Vogt-Koyanagi-Harada Disease (VKHD) is a rare systemic granulomatous autoimmune condition that affects melanocyte-rich organs including the eyes, inner ears, meninges, skin, and hair. VKHD causes chronic uveal inflammation and a loss in visual acuity in some patients. Patients generally respond well to steroid therapy. In our patient, we evidenced VKHD in the chronic recurrent stage at the time of presentation while the patient was on intermittent systemic steroid therapy. To date, no cases of VKHD have been reported in patients who were taking immunosuppressive medications. This study sheds light on the possibility that, in addition to the complex multisystem autoimmune phenomenon, other variable factors may also be implicated in the etiopathogenesis of this disease. Also, if a patient presents with subacute vision loss and an acute onset headache and encephalopathy, this differential diagnosis should be kept in mind, and the patient should be treated as soon as possible if the diagnosis is confirmed.

Vogt Koyanagi Harada syndrome in a 15-year-old girl, steroids side effects and recurrences

BACKGROUND

Vogt-Koyanagi-Harada Syndrome is rare in childhood and is usually seen between the 2nd and 5th decades. We present a 15-year-old girl with findings of incomplete Vogt-Koyanagi-Harada Syndrome.

CASE

In the first visit, anterior chamber inflammation, vitritis, serous retinal detachment and papillitis were observed in her both eyes. She also had neurological symptoms such as a headache. During the systemic treatment period, some of the side effects related to steroids emerged. Additionally, the symptoms and findings of the disease relapsed while the steroid dose was reduced.

CONCLUSION

Early diagnosis and selection of an individualized appropriate treatment provided good clinical and visual results without any serious complications in our case.

Acute Bilateral Neuroretinitis and Panuveitis in A Patient with Coronavirus Disease 2019: A Case Report

Purpose: Herein, we report a case of bilateral neuroretinitis and panuveitis in a patient recovered from coronavirus disease 2019 (COVID-19).Case presentation: A 37-year-old male patient with a history of recovered COVID-19, which was confirmed with nasopharyngeal reverse transcriptase polymerase chain reaction (RT-PCR) for Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), about one-month ago was referred with one-week history of bilateral severe vision loss. Visual acuity was counting fingers, and bilateral retinitis and panuveitis were revealed in ocular examination. The result of the vitreous sample using RT-PCR was positive for SARS-CoV-2 and negative for Herpesviridae viruses and mycobacterium tuberculosis. The patient was successfully treated with corticosteroid.Conclusion: We report a case of bilateral neuroretinitis and panuveitisin a recovered COVID-19 patient and positive RT-PCR of the vitreous sample. It is suggested to apply intraocular sampling and evaluation for COVID-19 in patients with the new-onset of uveitis and/or retinitis during the pandemic.

Long-term Management of Panuveitis and Choroidal Mass Associated with Rosai Dorfman Disease with Pegylated Interferon

Purpose: To present a patient with Rosai-Dorfman Disease (RDD), a histiocytic proliferative disorder typified by lymphadenopathy with rare ocular manifestations, who developed panuveitis that responded to pegylated interferon.Methods: Descriptive case report of a patient with RDD with multi-organ involvement including ocular manifestations including bilateral panuveitis with choroidal masses.Results: A 54-year-old African American woman with known systemic RDD of the breast, lung, and gastrointestinal tract presented with panuveitis with choroidal masses in both eyes. Her systemic and ocular disease initially responded well to oral and topical steroid therapy. Later, however, her systemic disease progressed with multiple muscular and bony lesions. Systemic therapy was switched to pegylated interferon, a cytokine with antiviral, antitumor and immunomodulatory activity. After 14 months of therapy with pegylated interferon, the patient's systemic and ocular disease stabilized.Conclusion: Rosai-Dorfman disease may be complicated by panuveitis and choroidal masses that may respond to pegylated interferon with stabilization of systemic and ocular manifestations. A multi-disciplinary approach is essential given the unique diagnostic and management challenges of RDD.

Widefield Fundus Fluorescein Angiography Features of Uveitis Associated with Juvenile Idiopathic Arthritis

PURPOSE

To evaluate the wide-field fundus fluorescein angiography (WFA) characteristics of uveitis associated with juvenile idiopathic arthritis (JIA-uveitis).

METHODS

Retrospective review of records. WFA with Spectralis (Heidelberg) of JIA-uveitis patients were analyzed using the scoring system by Angiography Scoring for Uveitis Nomenclature.

RESULTS

Thirty-seven eyes of 20 patients were studied. A total score of at least 1 was noted in 27 eyes (72.97%). WFA features included optic disc hyperfluorescence (51.35%), macular leakage (27.03%), retinal vascular staining/leakage at posterior pole (27.03%) and peripheral retina (64.86%), capillary leakage at the posterior pole (37.84%), and peripheral retina (59.46%). A decision to change the management plan was made in 8 of 9 patients with bilateral quiet anterior chambers after WFA results.

CONCLUSION

More than 70% of JIA-uveitis eyes showed some WFA-evidence of posterior segment inflammation, which changed the course of therapy for a major proportion of patients with no clinically active anterior chamber inflammation.

Tattoo Granulomas With Uveitis

Bilateral intraocular inflammation and simultaneous development of tattoo granulomas has been described in several case reports. The pathophysiology of this process is poorly understood, and it has been hypothesized that it could be a similar mechanism to systemic sarcoidosis versus a delayed hypersensitivity response. Granulomatous tattoo reaction with associated uveitis can manifest with or without evidence of systemic sarcoidosis, and it is usually responsive to immunosuppression and/or tattoo removal. We present a patient with no prior diagnosis of sarcoidosis who developed bilateral panuveitis and tattoo changes suggestive of tattoo granulomas with uveitis (TAGU). The patient was initially managed with intraocular steroids and systemic steroids with minimal improvement of symptoms. The patient later required steroid sparing therapy with a tumor factor inhibitor to achieve remission. There is a growing prevalence of tattooing among the general population and a low reported rate of tattooing complications. Granulomatous tattoo reaction with associated uveitis should be a consideration in patients with tattoos presenting with “idiopathic” uveitis.

Granulomatous panuveitis associated with Hodgkin lymphoma: A case report with review of the literature

BACKGROUND

Intraocular lymphoma (IOL) is an uncommon ophthalmic malignancy and poses a diagnostic challenge. Uveitis associated with systemic lymphoma (USL) has been predominantly attributed to non-Hodgkin lymphoma (NHL) and rarely reported with Hodgkin lymphoma (HL) in the literature.

METHODS

Case report with review of the literature.

RESULTS

A 25-year-old healthy male presented with bilateral granulomatous panuveitis including vasculitis and discrete chorioretinal yellowish-white lesions. Macular optical coherence tomography (OCT) of both eyes revealed a disruption of ellipsoid and interdigitation zones over the areas of subretinal lesions as well as a small sub-retinal pigment epithelium (RPE) deposit in one eye. Thorough uveitis workup revealed clavicular, axillary and cervical lymphadenopathy, and biopsy of lymph nodes confirmed the diagnosis of nodular lymphocyte-predominant (NLP) HL. Six months later and after receiving chemotherapy, all symptoms and most of clinical signs resolved.

CONCLUSIONS

Clinical features of USL do not differ between HL and NHL. However, the age of presentation may be much younger in HL. Ocular manifestations can precede systemic HL diagnosis, as shown in our patient. Therefore, USL should be part of the differential diagnosis of panuveitis. Paraneoplastic inflammation is thought be the cause of uveitis associated with HL. The sub-RPE deposit and disruption of ellipsoid and interdigitation zones on OCT have not been documented before as a manifestation of uveitis secondary to HL. In addition, the NLP subtype of HL was reported in only 1 case with uveitis in the literature.

Endogenous Tuberculous Endophthalmitis and Panophthalmitis: A Systematic Review of Case Reports and Case Series

Purpose

To systematically review the characteristics of patients with endogenous tuberculous (TB) endophthalmitis and panophthalmitis in an effort to help clinicians with diagnosis and treatment.

Patients and Methods

We conducted a systematic literature search in MEDLINE/PubMed, EMBASE and Web of Science from inception to August 2020. References and abstracts were screened independently by two authors. Included studies were case reports and case series reporting endogenous TB endophthalmitis and panophthalmitis secondary to Mycobacterium tuberculosis complex (MTBC). Available-case analysis was employed to handle missing data.

Results

A total of 1343 articles were found using the search strategy. Following abstract screening, 51 articles were selected for full text-review, from which 26 were deemed eligible for inclusion in the study. Forty-four cases from 26 articles were included in the quantitative analysis. The median age of presentation was 29.5 (range: 1 to 81), and 11/44 patients (25.0%) were pediatric. Immunosuppression was seen in 9/36 cases (25.0%). Most patients (24/38, 63.2%) had no prior history of tuberculosis. Systemic symptoms were absent in half of the patients (16/32, 50.0%). Visual acuity was poor, with 23/27 cases (85.2%) being 20/200 or worse at presentation. Poor organ and visual outcomes were reported: 36/43 cases (83.7%) resulted in enucleation/evisceration or exenteration. Intraocular tumors were suspected in 5/34 cases (14.7%). Pulmonary tuberculosis was seen in 15/35 cases (42.8%), and miliary tuberculosis was seen in 7/35 cases (20.0%). The earliest source of TB diagnosis was through histopathologic specimen after eye removal in 32/44 cases (72.7%), vitreous specimen in 6/44 cases (13.6%) and aqueous specimen in 3/44 cases (6.8%).

Conclusion

TB endophthalmitis is a rare and sight-threatening manifestation of ocular tuberculosis. It can occur in apparently healthy individuals and can mimic intraocular tumors and other infectious etiologies. Diagnosis remains a significant challenge, which, often delayed, leads to profound visual loss. Early detection and treatment of intraocular tuberculosis may be associated with better ocular and systemic outcomes.

IgA Nephropathy-Associated Uveitis: A Case Presentation

Purpose: To describe a case of bilateral panuveitis in the setting of IgA nephropathy. Methods: Retrospective review of clinical records, fundus, and optical coherence tomographic (OCT) images, and fluorescein angiography. Results: A 36-year-old female presented with IgA nephropathy and contemporaneous ocular manifestations of one-year duration. Clinical exam demonstrated bilateral panuveitis, 3+ anterior chamber (AC) cell in the right eye (OD), and 0.5+ AC cell in the left eye (OS). Funduscopic exam demonstrated diffuse yellow drusenoid deposits bilaterally (OU), accentuated on fundus autofluorescence as focal areas of hyperautofluorescence. Deposits correlated with retinal pigment epithelium hyper-reflectivity on OCT, and choroidal hypo-fluorescence on fluorescein angiography. The patient was managed with oral prednisone. Conclusion: IgA nephropathy is a systemic autoimmune disease that may be associated with uveitis. Immunosuppression with corticosteroids appears to be an effective therapy.

Panuveitis and Optic Neuritis as a Possible Initial Presentation of the Novel Coronavirus Disease 2019 (COVID-19)

OBJECTIVE

To describe the ocular manifestations in a case of novel coronavirus disease 2019 (COVID-19).

MATERIAL AND METHODS

A case of unilateral panuveitis and optic neuritis as initial presentation of COVID-19.

RESULTS

As it is published, angiotensin-converting-enzyme-2 receptors can be found in many organs, such as the eyes, nerves, and vessels, so extrapulmonary involvement would be expected. According to current evidence and clinical characteristics of the patient, uveitis and optic neuritis could be produced by the virus.

CONCLUSIONS

It is fundamental to consider panuveitis and optic neuritis as an unusual presentation of ocular involvement in COVID-19 so proper care can be given to the patients.

Panuveitis in Sweet syndrome

Ocular manifestations of Sweet syndrome, or acute febrile neutrophilic dermatosis, are usually limited to the anterior segment. We report the case of a patient with bilateral panuveitis and retinal vasculitis associated with Sweet syndrome. A 45-year-old Asian female with an undiagnosed febrile illness with rash presented with bilateral panuveitis with haemorrhagic occlusive retinal vasculitis. Skin biopsy confirmed Sweet Syndrome. Intraocular inflammation resolved with a combination of topical and systemic corticosteroids as well as intravenous cyclophosphamide, with resulting permanent severe right visual impairment. Although an uncommon condition, Sweet syndrome should be considered in any febrile patient with skin lesions and uveitis.

Ocular Syphilis Presenting as Acute Necrotizing Retinitis in a Human Immunodeficiency Virus-Positive Patient

The incidence of ocular syphilis is increasing in the developing world even in the era of effective human immunodeficiency virus (HIV) treatment, as there is a potential increase of high-risk sexual behavior. Ocular involvement in the form of uveitis is seen in all stages of syphilis. Diagnosis begins with ophthalmologic examination, but requires serologic testing for confirmation. Ocular syphilis presents with unusual presentations or mimics other diseases and is identified by serological screening. It is curable with a relatively short course of antibiotic treatment, making its recognition a priority. All ophthalmic manifestations of syphilis should be treated with a Centers for Disease Control and Prevention-approved neurosyphilis regimen. In this report, we present a case of necrotizing retinitis with no response to antiviral treatment. On subsequent serological testing it was proved as syphilis in a HIV-positive patient who responded well to intravenous antibiotics with rapid visual recovery. Hence, awareness of this disease will promote early diagnosis and treatment.

Approach to Cataract Surgery in an Ebola Virus Disease Survivor with Prior Ocular Viral Persistence

A 46-year-old patient with previously documented Ebola virus persistence in his ocular fluid, associated with severe panuveitis, developed a visually significant cataract. A multidisciplinary approach was taken to prevent and control infection. Ebola virus persistence was assessed before and during the operation to provide safe, vision-restorative phacoemulsification surgery.

A Case Report of Sweet's Syndrome with Panuveitis and Rhegmatogenous Retinal Detachment

Purpose: To report a case of a patient who suffered from Sweet's syndrome with panuveitis in both eyes.Materials & Methods: Retrospective interventional case report.Results: A 54-year-old Chinese male patient complained of fever, painful skin lesions and blurry vision in both eyes lasting for 4 days. His visual acuity was hand motion in both eyes. Slit-lamp examination showed the hypopyon and severe vitreous opacification in both eyes. A skin pathology from head skin lesion demonstrated diffuse neutrophilic infiltration in the dermis with karyorrhexis. Based on the inspection above, the patient was diagnosed with Sweet's syndrome and given systemic corticosteroids therapy. However, he developed secondary rhegmatogenous retinal detachment in the right eye during his treatment.Conclusion: The association of bilateral uveitis with Sweet's syndrome has been described in this report.