Role of multicolour imaging in post-fever retinitis involving posterior pole

PURPOSE

To describe composite multicolour (MC) imaging features along with the monocoloured fundus reflectance images in active and resolving stages of post-fever retinitis (PFR).

METHODS

Retrospective image analysis of cases of PFR who underwent dilated retinal clinical examination followed by optical coherence tomography and MC imaging.

RESULTS

Twenty-five eyes of 18 patients diagnosed with PFR were included. There were 11 males and 7 females. Mean age of patients was 30.63 years. The retinitis lesion appeared bright white on MC image and white mainly on blue and green reflectance images during the active stages of PFR. The lesion appeared dull-grey to greyish white during the resolving stages and as dull-green in resolved cases. The active stages showed the presence of intraretinal/subretinal fluid which appeared as green colour on MC images and less green to normal during resolving stages. Hard exudates were seen as bright yellow- or orange-coloured spots on MC image during the resolving stages of the disease.

CONCLUSION

The different stages of PFR show different colour on multicolour image and different reflectance patterns on individual colour reflectance channels. Hence, multimodal fundus imaging with different wavelength can be helpful for differentiation of activity in PFR.

Topical interferon in recurrent inflammatory macular edema following a cat bite

INTRODUCTION

Treating chronic macular edema (CME) post endophthalmitis is a challenge. Use of steroids may reactivate the infection and repeated intravitreal therapy with anti-vascular growth factor inhibitors (Anti-VEGF) puts the patient again at the risk of exacerbation of inflammation or endophthalmitis. We describe a case of CME post traumatic endophthalmitis successfully treated with topical interferon therapy.

CASE DESCRIPTION

A 34-year-old Asian Indian lady with a history of cat bite to her right eye and treated elsewhere as traumatic endophthalmitis with recurrent macular edema, presented to us 1 year after the injury. She had received anti-VEGF injection for same. Her medical history was non-contributory except for close contact with her cat. Therapeutic trials with oral doxycycline followed by oral albendazole with steroids, as well as repeated anti-VEGF therapy failed to prevent recurrence of CME. Patient's steroid responsiveness and reluctance for injections, made us to opt for a novel topical Interferon therapy. Macular edema resolved in 2 months. Interruption of interferon therapy due to COVID-lock down resulted in recurrence of the CME, which again responded well to interferon monotherapy.

CONCLUSION

Topical interferon may have a role in the treatment of inflammatory macular edema and can serve as a, safer, economical and non-invasive treatment option compared to intravitreal steroids and anti-VEGFs.

"Post Coronavirus Disease (COVID-19) Reactivation of a Quiescent Unilateral Anterior Uveitis"

Coronavirus disease (COVID-19) can be associated with ophthalmic manifestations like conjunctivitis, retinal haemorrhages, retinal vascular occlusions, papillophlebitis, and Adie’s syndrome. We herein report for a case of a unilateral acute anterior uveitis which was quiescent for 13 years and was reactivated post COVID-19 infection in a 43-year-old Asian Indian male. He had a past history of recurrent unilateral granulomatous anterior and intermediate uveitis in the right eye (RE), and all the investigations done 14 years ago were negative and had been on treatment with topical and oral steroids. He developed cataract 6 months later in the RE and underwent surgery. Patient was in remission for the past 13 years. Uveitis investigations for the present episode were all negative. Topical steroid and cycloplegic helped in resolution of the uveitis. This may be the first instance of reactivation of a quiescent unilateral anterior uveitis following COVID-19 infection.

Epidemic retinitis and community outbreaks

Purpose:

The objective of this study was to correlate seasonal variation of epidemic retinitis (ER) with concurrent community outbreaks.

Methods:

This is a retrospective, observational, comparative study conducted in a tertiary care eye hospital in south India. Monthly variation in number of ER cases in comparison with reported community outbreaks by Integrated Disease Surveillance Program (IDSP) from 2009 to 2020 in the same region were studied. Month-wise graphs against number of patients were plotted for ER and for each community outbreak.

Results:

ER was diagnosed in 163 patients. Diagnosis of presumed rickettsial ER was made in 48 cases (29.44%), chikungunya in 5, dengue in 3 and typhoid in 6 cases, while in other cases the etiological diagnosis remained uncertain (n = 101). Multiple positive serological tests were seen in 6 patients (Weil Felix Test (WFT) with WIDAL in 4 and chikungunya IgM with WFT in 2 patients). Relevant reported outbreaks by IDSP were: Pyrexia of unknown origin (PUO) (n = 5148), Chikungunya (n = 6577), Dengue (n = 7350), Measles (n = 1422), Mumps (n = 881), Rubella (n = 288), Malaria (n = 2262), Chicken Pox (n = 2385), Typhoid (n = 597), Kyasanur Forest Disease (n = 381), Scrub Typhus (n = 13), Typhus fever (n = 4), Japanese Encephalitis (n = 15). None of the outbreak graphs pattern was identical or similar to the graph of ER. Inverse relation of the graph of dengue outbreak with ER was observed.

Conclusion:

Inverse correlation between dengue and ER should be further studied for causation, which we believe may prove dengue as least common cause. Reporting of rickettsial outbreaks should be enhanced by undertaking statewide awareness and procurement of gold standard tests.

"Old wine in a new bottle" - post COVID-19 infection, central serous chorioretinopathy and the steroids

INTRODUCTION

Corona virus disease (COVID-19) pandemic can cause myriad of ocular manifestations. We report a case of unilateral multi focal central serous retinopathy, post COVID-19 infection in an Asian Indian female.

CASE PRESENTATION

A 42-year-old female presented to us with unilateral blurring, in the right eye (OD), 12 days after COVID-19 infection. She had fever, chills, shortness of breath and cough with tiredness and was COVID- RT PCR positive. She was administered intravenous and oral antibiotics with injection heparin/remdesivir, during her 7 day stay at the hospital. She was also on steroid inhalers. She had no systemic history of note. On ocular evaluation, her corrected distance visual acuity was 20/40 in OD and 20/20 in left eye (OS). Anterior segment was normal. Anterior vitreous was clear. Fundus examination of the OD showed central serous retinopathy (CSCR) with OS being normal.

CONCLUSION

CSCR can occur post COVID-19 due to steroid administration and physicians administering it should be aware of this and refer the patients to an ophthalmologist earlier.

Post COVID-19 Ophthalmic Manifestations in an Asian Indian Male

Introduction: The Ocular manifestations of coronavirus disease 2019 (COVID-19) reported include conjunctivitis, conjunctival hyperemia, chemosis, epiphora, episcleritis, retinal manifestations included cotton wool spots (CWS), micro-hemorrhages, papillophlebitis and neuro-ophthalmic manifestations.Purpose: To report post COVID-19 ophthalmic manifestations using multimodal imaging.Results: A 66-year-old Asian Indian male presented to us with bilateral blurring of vision, RE>LE, of 3 days following a diagnosis of COVID-19 disease. Corrected distance visual acuity were 20/2666 and 20/25 in the right (RE) and left (LE) eyes respectively. He had bilateral anterior chamber inflammation with a relative afferent pupillary defect in the RE. RE showed central retinal artery occlusion(CRAO) with CWS, few flame-shaped retinal hemorrhages and disc edema and hyperemia. LE had disc edema and hyperemia, few flame-shaped retinal hemorrhages, cystoid changes and CWS. A diagnosis of bilateral panuveitis and papillitis with CRAO in the RE was made.Conclusion: Our patient developed a vascular occlusion with panuveitis, which possibly represents an immune mediated event following COVID-19. Patients should be warned about possible ophthalmic sequelae even after recovery.

Role of Ocular Imaging in Diagnosis and Determining Response to Therapeutic Interventions in Posterior and Panuveitis

ABSTRACT

This review provides a comprehensive description and careful interpretation of various ocular imaging techniques to visualize the different ocular structures in posterior and panuveitis. This can help in the diagnosis, follow-up, and monitoring the response to treatment in patients with different posterior and panuveitic entities.

Multimodal Imaging in Ocular Sarcoidosis

Aim: Ocular sarcoidosis presents a diagnostic challenge because of its varied clinical presentations. It is important to distinguish sarcoidosis from other uveitis diseases. Multimodal imaging provides useful data to be introduced into clinical practice. Methods: This is a review article. Conclusions: This review article highlights the role of fundus fluorescein angiography (FA), indocyanine green angiography (ICG), optical coherence tomography (OCT), and optical coherence tomography angiography (OCTA) in the diagnosis and management of ocular sarcoidosis. This review article highlights the role of fundus fluorescein angiography (FA), indocyanine green angiography (ICG), optical coherence tomography (OCT), and optical coherence tomography angiography (OCTA) in the diagnosis and management of ocular sarcoidosis.

Role of secukinumab in ankylosing spondylitis with tubercular uveitis

We present the case of a 32-year-old Indian male one-eyed individual with a history of unilateral panuveitis with HLA B 27 positive spondyloarthropathy on systemic immunosuppressant (Adalimumab). He developed recurrent inflammation in the same eye in a span of 2 years, later complicated with retinal vasculitis. On evaluation, he was diagnosed with tubercular uveitis and started on antitubercular treatment along with systemic steroids. Inview of Increased IOP due to steroid response, Inj. Secukinumab ( IL 17 A inhibitor) was started and significant improvement was noted.

Floral Pattern of Keratic Precipitates in Vitreoretinal Lymphoma on In Vivo Confocal Microscopy

PURPOSE

To describe the morphological patterns of keratic precipitates (KPs) in vitreoretinal lymphoma (VRL) using in vivo confocal microscopy (IVCM).

METHODS

Six eyes of three biopsy-proven VRL patients were included. KPs were identified and analyzed on IVCM.

RESULTS

On examination, pigmented KPs in four eyes, white central KPs in two eyes and anterior chamber cells with flare in six eyes and pseudo hypopyon in one eye were identified. A typical floral pattern of KPs on IVCM was noted in all eyes. Three eyes each showed the complete and incomplete floral patterns, respectively. Resolution of KPs on IVCM was noted after chemotherapy.

CONCLUSION

In addition to the routinely used clinical and imaging markers like the visual acuity, presence of lymphomatous cells in the vitreous and optical coherence tomography findings, the presence and appearance of KPs on IVCM can also be considered as a useful, diagnostic and treatment monitoring marker in VRL.

Diagnostic and Therapeutic Challenges in Ocular Histoplasmosis - A Case Report

Purpose: To report a rare case of skin biopsy proven Histoplasma panuveitis.Method: Observational case report of a 76-year-old Asian Indian man presented as panuveitis. Clinical course, diagnostic and treatment difficulties and confocal microscopy findings were studied.Result: Patient presented with mild anterior uveitis, membranous vitritis and large chorio-retinal lesions in peripheral fundus with a small macular scar in the right eye. Positive quantiferon test along with chest and adrenal findings initially misled ophthalmologist and pulmonologist to commence anti-tubercular treatment with steroids which further worsened the inflammation and the fungus involved iris and scleral tissue. Skin biopsy from the lesions on thigh revealed histoplasma spores and confocal microscopy showed similar cystic lesions on endothelium. Prolonged course of anti-fungal with steroids resulted in resolution of the infection.Conclusion: Histoplasma uveitis can worsen with steroids only treatment and may invade iris and scleral tissue which may require prolonged treatment with antifungal agents.

Post-fever retinitis - Newer concepts

Post-fever retinitis (PFR) is an infectious or para-infectious uveitic entity caused by bacterial or viral agents and seen mainly in tropical countries. Systemic symptoms such as joint pain, skin rash are common during the febrile stage. On the basis of only clinical presentation, it is difficult to pin-point the exact etiology for PFR. Serological investigations, polymerase chain reaction, and knowledge of concurrent epidemics in the community may help to identify the etiological organism. Bacterial causes of PFR such as rickettsia and typhoid are treated with systemic antibiotics, with or without systemic steroid therapy, whereas PFR of viral causes such as chikungunya, dengue, West Nile virus, and Zika virus have no specific treatment and are managed with steroids. Nevertheless, many authors have advocated mere observation and the uveitis resolved with its natural course of the disease. In this article, we have discussed the clinical features, pathogenesis, investigations, and management of PFR.

HLA-B27-related uveitis and seasonal variation-an Indian perspective

Purpose:

To study seasonal variation and systemic associations in HLA-B27 related uveitis (HBU).

Methods:

This was a retrospective, observational chart review conducted in a single, tertiary eye care hospital, from January 2015 to December 2019. New cases presented from January 2017 to December 2019 were studied for incidence patterns (Group X). Cases with ≥1-year follow-up were studied for systemic association (Group Y) and cases with ≥4 episodes of active uveitis were studied for recurrence pattern (Group Z). A year was divided into 3 segments of the year (SoY): 1. November–February, 2. March–June, 3. July–October.

Results:

We found 157 cases of HBU from January 2015 to December 2019. The incidence in Group X (n = 105) was found to be least in SoY 2 in all 3 years (2017–2019). In Group Y (n = 85), 39 cases (45.88%) were diagnosed as spondyloarthropathies, among which 20 were of ankylosing spondylitis (23.52%). More than 1/2 the total number of episodes occurring in the same SoY (SoY Max), in Group Z (n = 25), was seen in 14 (56%) cases. SoY Max was the first segment (SoY 1) for most of these cases (n = 7). In Group Z, 8 (32%) patients were on immunomodulatory therapy at presentation.

Conclusion:

Our study confirms seasonal variation in HBU patients by documenting the least incidence from March to June and identifies 56% of patients that can have a maximum number of recurrences in a specific season of the year. Outcomes of surgical interventions planned accordingly, and responsible environmental factors for HBU should be studied further.