Iris Crystals: A Rare Clinical Finding in Chronic Anterior Uveitis

Iris crystals are a rare clinical entity seen in cases of chronic anterior uveitis (CAU). We report one such case with crystal deposition on iris as well as corneal endothelium and anterior lens capsule. No significant change in the crystals was seen over a period of 11 years despite multiple episodes of exacerbation and resolution. Anterior segment optical coherence tomography (AS-OCT) showed crystals as hyperreflective deposits over the corneal endothelium. On confocal microscopy, the crystals were seen as ill-defined hyperreflective lesions on endothelium between 525 and 604 μm. Reduction in the number of crystals was seen after cataract surgery. In conclusion, AS-OCT and confocal microscopy can be used as additional diagnostic tools to analyze iris crystals in CAU.

Topiramate-induced acute angle closure with severe panuveitis: A challenging case report

A 36-year-old female presented with the complaints of pain, photophobia, redness, and sudden diminution of vision in both the eyes following topiramate for migraine treatment. On examination, there was panuveitis with angle-closure glaucoma in both the eyes with fibrinous exudate with pigments in the anterior chamber of the left eye. B scan revealed increased choroidal thickness in both the eyes. Serial anterior segment optical coherence tomography scans were done in the left eye to demonstrate the gradual resolution of the fibrin material from the anterior chamber. There was complete resolution of inflammation in both eyes following discontinuation of topiramate and treatment with systemic and topical steroids. There was an improvement in visual acuity in the left eye following complicated cataract surgery.

Multimodal Imaging of the Normal Eye

Multimodal imaging is the concept of "bundling" images obtained from various imaging modalities, viz., fundus photograph, fundus autofluorescence imaging, infrared (IR) imaging, simultaneous fluorescein and indocyanine angiography, optical coherence tomography (OCT), and, more recently, OCT angiography. Each modality has its pros and cons as well as its limitations. Combination of multiple imaging techniques will overcome their individual weaknesses and give a comprehensive picture. Such approach helps in accurate localization of a lesion and understanding the pathology in posterior segment. It is important to know imaging of normal eye before one starts evaluating pathology. This article describes multimodal imaging modalities in detail and discusses healthy eye features as seen on various imaging modalities mentioned above.

Increased Aqueous Humor CD4+/CD8+ Lymphocyte Ratio in Sarcoid Uveitis

Purpose: To determine aqueous humor CD4+/CD8+ T-lymphocyte ratio changes in sarcoid and non-sarcoid uveitis with anterior chamber involvement. Methods: The case-control study includes 61 patients with either anterior uveitis, intermediate uveitis with anterior spill, or panuveitis. A total of 21 of them were categorized as sarcoid uveitis and 40 as non-sarcoid uveitis according to diagnostic criteria. CD4+/CD8+ ratio in the aqueous humor was determined using flow cytometry. Results: Significantly higher CD4+/CD8+ ratio in the aqueous humor was observed in patients with sarcoid uveitis (6.3 ± 1.4; mean ± SEM) compared to non-sarcoid uveitis (1.6 ± 0.1; mean ± SEM). Whole blood CD4+/CD8+ ratio was not elevated in subjects with sarcoid and non-sarcoid uveitis. Aqueous humor CD4+/CD8+ ratio >3.5 was observed to be associated with sarcoid uveitis (OR 38, 95% CI 7.0-205.2). Conclusion: Increased aqueous humor CD4+/CD8+ ratio in sarcoid uveitis. Immunophenotyping of localized lymphocytosis in aqueous humor could be utilized as an additional confirmatory marker for ocular sarcoidosis.

Epidemic Retinitis

Purpose: To study demography, seasonal variation, clinical presentation, and treatment outcome of "retinitis post febrile illness." (RpFI) Method: Case records of patients diagnosed as RpFI, from July 2009 to May 2017 were studied retrospectively. Patients with complete follow up were evaluated for treatment and visual outcomes. Results: Two hundred and five eyes of 119 patients were studied. The peak incidence of RpFI was from November to March each year. Diagnosis of fever largely remained unknown. Chikungunya IgM, Dengue IgM, and Weil-Felix test was positive in 22.22%, 15.38%, and 39.75%, respectively, in investigated cases. The mean visual acuity at presentation and at resolution was 20/63 and 20/32, respectively, in 122 eyes with complete follow up. Conclusion: We suggest a term "Epidemic Retinitis" for RpFI due to its seasonal variation and to differentiate it from other sporadic forms of retinitis. Although RpFI has aggressive presentation, it resolves over 3-4 months and the overall visual outcome is satisfactory.

Personality and uveitis

Background

Psycho-immunology is an emerging branch of science which studies the interaction between the brain and the immune system. The purpose of this study is to identify the types of personality factors in patients with non-infectious uveitis and to find its association with a particular uveitic entity if any.

This is a prospective, observational, case-control study of 186 patients with non-infectious uveitis (group A) and controls from general ophthalmology outpatient department (group B). “Global 5/SLOAN” personality questionnaire was used which is based on the five-factor theory of personality which describes personality factors based on the presence or absence of five primary dimensions, viz extroversion, orderliness, emotional stability, accommodation, and intellectual curiosity. Personality factors of patients from groups A and B were compared. History of present illness, clinical diagnosis, details of systemic ailment, and demographic information were collected.

Results

Group A comprised HLA-B27-related uveitis (n = 30), uveitis due to sarcoidosis (n = 10), Vogt-Koyanagi-Harada syndrome (n = 5), sclero-kerato-uveitis due to rheumatoid arthritis (n = 5), and idiopathic uveitis in rest. Forty-five patients with uveitis had associated systemic ailment. Uveitis patients (n = 56) showed positive personality trait: S (social), C (calm), O (organized), A (accommodative), and I (inquisitive). In contrast, the control group (group B) which mainly comprised patients with non-pathological refractive error and visually insignificant cataract showed more number of negative personality traits (n = 62): R (reserved), L (limbic), U (unstructured), E (egocentric), and N (non-curious). This difference between the uveitis and control group was found to be statistically significant (p ≤ 0.001). The difference was also statistically significant for O (p = 0.008), U (p = 0.004), and C (p = 0.022) with chi-square test. Calm personality was found to be significantly associated with HLA-B27-related uveitis (p = 0.002). N, S, and A traits were seen almost equal in numbers in both the groups. U trait was absent in group A, whereas I trait had negligible presence in group B.

Conclusions

Our finding of an association between organized personality type and uveitis and calm personality and HLA-B27-related uveitis warrants further studies to understand the complex mechanism of psycho-immunology in uveitis.

Rickettsial retinitis-an Indian perspective

BACKGROUND

Though rickettsiosis is common in India, there is paucity of rickettsial retinitis (RR) reports from India. Moreover, rickettsial sub-types and their association with retinitis have not been studied. We are reporting a case series of presumed RR with their course of the disease, visual outcome, and association with rickettsial sub-type based on Weil-Felix test.

FINDINGS

This is a retrospective study of 19 eyes of 10 patients presented to a single institution. Cases diagnosed with presumed RR were identified from our database from March 2006 to October 2014 and studied retrospectively for patient's demography, clinical presentation, and treatment. Patients with history of fever, retinitis, and a positive Weil-Felix test and a negative chikungunya and dengue serology were diagnosed as presumed rickettsial uveitis. One patient was diagnosed to have epidemic typhus, and four were diagnosed to have Indian tick typhus. Nine patients had bilateral presentation. One patient had history of dog tick bite, and four patients had skin rashes. All the patients presented between 2 and 4 weeks after a fever.

CONCLUSIONS

Retinitis on posterior pole with recent history of fever with or without skin rash and a positive Weil-Felix test may suggest a rickettsial etiology. Its ocular manifestation could be an immune response to recent systemic rickettsial infection. Indian tick typhus and epidemic typhus could be the common sub-types seen in our population. Although it has aggressive presentation, it has a good visual prognosis.

Combined depth imaging of choroid in uveitis

Background

Understanding the changes that occur in the choroid is of paramount importance in various uveitis entities. B-scan ultrasonography and indocyanine green angiography can be used to study choroid. Currently, spectral-domain optical coherence tomography is used as the standard noninvasive technique to study the choroid by enhanced depth imaging.

Our aim was to study the structural visibility of the choroid using spectral-domain optical coherence tomography in the same area of interest in patients with uveitis with posterior segment manifestations using conventional, enhanced depth imaging (EDI), and combined depth imaging (CDI) techniques.

Results

Fifty-eight (58) eyes of 48 patients between age group 9 and 82 years were confirmed cases of uveitis. Out of the 48 patients, 21 (43.75%) were males while 27 (56.25%) were females. Sixteen eyes (27.59%) had intermediate uveitis, 33 (56.9%) had posterior uveitis, and 9 eyes (15.51%) had panuveitis.

For posterior vitreous, there was substantial agreement for all the three groups (kappa value of 0.77, 0.73, and 0.72 in groups 1, 2, and 3, respectively). For vitreo retinal interface and inner choroid, there was perfect interobserver agreement, and for outer choroid, there was substantial to almost perfect interobserver agreement (kappa value of 0.71, 0.81, and 0.86 in groups 1, 2, and 3, respectively).

Chi-squared test was done to compare the three groups. The method of scanning had a significant effect on the visualization of posterior vitreous and the outer choroid (p < 0.01) and did not have an effect on the visualization of vitreoretinal interface, inner retina, outer retina, and inner choroidal layers (p > 0.05).

Conclusion

The CDI technique alone might provide a good structural visibility compared to normal and EDI scanning done separately in patients with uveitis with posterior segment pathology. CDI OCT technique is thus able to visualize all posterior structures in a single image in patients with uveitis with posterior segment manifestations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12348-014-0018-8) contains supplementary material, which is available to authorized users.

Ocular toxoplasmosis associated with scleritis

We report an atypical presentation of Toxoplasma retinochoroiditis with associated scleritis in a young and immunocompetent patient. The diagnosis was done on the basis of Polymerase chain reaction of vitreous sample, and the clinical response to specific treatment. This case highlights the unusual presentation of ocular toxoplasmosis as scleritis.