Neoplastic masquerade syndromes in patients with uveitis

Vitreoretinal Lymphoma with Intraretinal Infiltration, Simulating Retinal Necrosis

PURPOSE

To describe the clinical features and outcomes of vitreoretinal lymphoma (VRL) with intraretinal infiltration, a pseudonecrotic variant.

DESIGN

Retrospective, comparative analysis.

SUBJECTS

Patients with biopsy-proven VRL at a single center from August 2016 to April 2022.

METHODS

A retrospective record review was conducted for clinical, imaging, and laboratory data.

MAIN OUTCOME MEASURES

Clinical features, visual, and survival outcomes.

RESULTS

We included 67 eyes of 40 patients with biopsy-proven VRL. Pseudonecrotic retinal lesions (PRLs) were found in 24 (35.8%) eyes of 19 patients; these eyes were classified as a pseudonecrotic variant, whereas the remaining 43 (64.2%) eyes were classified as nonnecrotic. Comparison (pseudonecrotic vs. nonnecrotic) revealed that eyes with PRLs at presentation had a worse median best-corrected visual acuity (BCVA; 2.4 vs. 0.5 logarithm of the minimum angle of resolution [logMAR], P < 0.0001) and severe ocular manifestations (P < 0.0001), including optic disc swelling (79.2% vs. 0%), retinal vasculitis (93.8% vs. 4.7%), retinal hemorrhage (83.3% vs. 0%), and retinal detachment (RD) (79.2% vs. 0%). Follow-up data were available for 20 eyes (17 patients) in the pseudonecrotic group and 43 eyes (21 patients) in the nonnecrotic group. An equally worse median BCVA was noted in pseudonecrotic eyes at 6 months after treatment and the final follow-up as compared with nonnecrotic eyes (2.4 vs. 0.3 logMAR, P < 0.0001). The median follow-up period did not differ significantly (16.6 vs. 18.4 months, P = 0.47). Initial BCVA (β = 0.300, P = 0.003), presence of anterior chamber cell (β = 0.472, P = 0.013), and RD (β = 1.137, P < 0.0001) were significantly associated with poor visual outcomes in multivariate linear regression analysis (adjusted R2 = 0.693). There were no significant differences in survival outcomes.

CONCLUSION

Vitreoretinal lymphoma can present as pseudonecrotic retinopathy, with more advanced clinical presentations and worse final visual outcomes.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Unraveling the Spectrum of Uveitis: Insights from an Epidemiological Study in a National Referral Center in Northern Italy

PURPOSE

Uveitis embraces a heterogeneous group of vision-threatening inflammatory conditions. Understanding uveitis epidemiology, etiology, and clinical findings is fundamental for a prompt diagnosis and optimal patient management. The aim of the study is to report the epidemiology of uveitis in a national referral center in Northern Italy and investigate the visual prognosis.

METHODS

This retrospective study was conducted at Uveitis Service (Ospedale San Raffaele) between June 2016 and May 2023. Demographic data, clinical characteristics, and etiological diagnoses of uveitis patients were collected, and visual prognosis was longitudinally explored.

RESULTS

1105 patients with uveitis were included in the study, while 47 patients presented neoplastic masquerade syndrome and have been excluded. The population had a slight majority of females (M/F ratio = 0.76), mean age was 47 years. 25% presented infectious uveitis, primarily due to herpetic etiology, toxoplasmosis, and tuberculosis. Non-infectious uveitis was the most prevalent diagnosis (38%), with sarcoidosis, HLA-B27-associated uveitis, and Fuch's uveitis as prominent causes. Anatomically, anterior segment was most frequently involved (41%). Significant improvement in visual acuity was observed at follow-up, particularly in patients with infectious uveitis.

CONCLUSIONS

Our study sheds light into the epidemiological landscape of uveitis in Northern Italy, reflecting changing patterns due to factors such as migration and changing sexual habits. In particular, higher percentages of syphilis have been observed, compared to other European reports. The distribution of non-infectious uveitis reflects other epidemiological European series. Higher percentages of neoplastic masquerade syndromes support the need of early recognition. Our findings offer precious insights for uveitis epidemiology and daily clinical practice.

Characteristics of Vitreoretinal Lymphoma in B-Scan Ultrasonography: A Case-Control Study

PURPOSE

To explore the characteristics of vitreoretinal lymphoma (VRL) in B-scan ultrasonography.

DESIGN

Single-center case-control study.

PARTICIPANTS

A total of 106 eyes of 56 patients with biopsy-proven VRL and 86 eyes of 59 patients with uveitis were included.

METHODS

B-scan ultrasonography of the included eyes was performed. Evaluated were the ultrasonographic signs as well as a special pattern termed centrifugal condensation, which refers to the peripherally hyperreflective appearance of the vitreous haze in ultrasonography.

MAIN OUTCOME MEASURES

Posterior vitreous detachment, vitreoretinal adhesion, location of vitreous haze, thickening or occupying lesions of the retina, retinal detachment, and centrifugal condensation pattern of vitreous haze were evaluated through B-scan ultrasonography. The incidences of these signs were compared between the 2 groups; odds ratios (ORs) were calculated.

RESULTS

The incidence of vitreoretinal adhesion in patients with VRL (6/106) was lower than in patients with uveitis (20/86; P = 0.001; OR: 0.195; 95% confidence interval [CI]: 0.073-0.522). The incidence of retinal thickening or occupying lesions in patients with VRL (21/106) was higher than that in patients with uveitis (1/86; P = 0.005; OR: 19.068; 95% CI: 2.455-148.265). The incidences of posterior vitreous detachment and retinal detachment were not significantly different between the 2 groups (P = 0.453 and P = 0.310, respectively). The centrifugal condensation pattern was more likely to be observed in patients with VRL (49/106) than in patients with uveitis (13/86; P < 0.001; OR: 4.831; 95% CI: 2.416-9.660).

CONCLUSIONS

B-scan ultrasonography might help to provide clues for the suspicion of VRL. Thickening or occupying lesions of the retina and centrifugal condensation pattern of vitreous haze might be suggestive of VRL.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Uveitis masquerade syndromes: An approach to diagnosis

Uveitis masquerade syndromes are a diverse group of clinical entities which mimic conventional immune-mediated uveitis due to the presence of inflammatory signs but are resistant to anti-inflammatory therapy. Misdiagnosis hinders appropriate management in these conditions and may result in poor outcomes. This review discusses commonly encountered neoplastic and non-neoplastic disease processes that masquerade as intraocular inflammation with a focus on relevant clinical features and adjunctive investigations that are helpful in reaching a correct diagnosis.

Indications and pathologic diagnoses of diagnostic chorioretinal biopsies in the province of Quebec, Canada

OBJECTIVE

To review the clinical usefulness of chorioretinal biopsies in diagnostically undefined cases of intraocular inflammation or chorioretinal lesions.

DESIGN

Retrospective case series.

PARTICIPANTS

Seven patients who underwent chorioretinal biopsies.

METHODS

This case series included all consecutive patients who underwent chorioretinal biopsies in 2 academic tertiary care centres in the province of Quebec between 2014 and 2020.

RESULTS

A total of 7 patients were included in the study. Five patients with intraocular inflammation underwent chorioretinal biopsies to rule out an infectious or neoplastic etiology, whereas 2 patients underwent biopsies for suspicion of neoplastic chorioretinal masses. Final diagnoses included primary chorioretinal lymphoma (n = 2), toxoplasmosis (n = 1), benign choroidal mass (n = 1), nonnecrotizing granuloma (n = 1), and peripheral exudative hemorrhagic chorioretinopathy (n = 1). No specific diagnosis was defined in 1 case of panuveitis with scleritis. No postoperative complications were reported.

CONCLUSIONS

Chorioretinal biopsies clarified the diagnosis in 6 of 7 patients, including a definitive diagnosis of lymphoma in 2 patients. This is a high rate of diagnosis that also represents clinically meaningful results that influence management. Future directions include identifying patients in whom adjuvant chorioretinal biopsy would yield a high rate of diagnosis.

X-Linked Retinoschisis Masquerading Uveitis

X-linked retinoschisis (XLRS) shows features also seen in patients with uveitis and is recognized as an uveitis masquerade syndrome. This retrospective study aimed to describe characteristics of XLRS patients with an initial uveitis diagnosis and to contrast these to patients with an initial XLRS diagnosis. Patients referred to a uveitis clinic, which turned out to have XLRS (n = 4), and patients referred to a clinic for inherited retinal diseases (n = 18) were included. All patients underwent comprehensive ophthalmic examinations, including retinal imaging with fundus photography, ultra-widefield fundus imaging, and optical coherence tomography (OCT). In patients with an initial diagnosis of uveitis, a macular cystoid schisis was always interpreted as an inflammatory macular edema; vitreous hemorrhages were commonly interpreted as intraocular inflammation. Patients with an initial diagnosis of XLRS rarely (2/18; p = 0.02) showed vitreous hemorrhages. No additional demographic, anamnestic, and anatomical differences were found. An increased awareness of XLRS as a uveitis masquerade syndrome may facilitate early diagnosis and may prevent unnecessary therapies.

Inflammatory eye disease for rheumatologists

PURPOSE OF REVIEW

This review provides a framework for understanding inflammatory eye disease diagnosis, differential diagnosis, and management for rheumatologists. Uveitis, scleritis, episcleritis, peripheral ulcerative keratitis, and orbital inflammation are all discussed. The goal is to facilitate the development of approaches to inflammatory eye diseases that will help rheumatologists co-manage these patients with eye care providers specializing in ocular inflammation.

RECENT FINDINGS

In recent years, studies have aimed to advance biologic treatments and define standard-of-care therapy. Inflammatory eye diseases are highly heterogeneous and often rare, which poses significant challenges to their research and the interpretation of existing data. To date, glucocorticoids, mycophenolate, methotrexate, and TNF inhibitors remain the mainstay of treatment options for many of these diseases.

SUMMARY

Patients with inflammatory eye diseases require multidisciplinary care for best outcomes, frequently including rheumatologists. Understanding the differentials, diagnostics, and treatment are essential to preserving vision in these patients. The diverse nature of the disease processes within this field requires focusing on specific disease phenotypes and endotypes in research and clinical practice.

In Vivo Confocal Microscopy of Keratic Precipitates in Vitreoretinal Lymphoma

PURPOSE

To investigate the morphological features of keratic precipitates (KPs) with in vivo confocal microscopy (IVCM) in vitreoretinal lymphoma (VRL).

METHODS

Patients with biopsy-proven VRL were reviewed, and 12 patients (16 eyes) with KPs examined by IVCM were included.

RESULTS

Five distinct KP morphologies on IVCM were observed: dendritic, nibbling, linear, globular, and stippled. Dendritic KPs were discovered in 9 eyes (56.3%), with a hyperreflective core and multiple thin pseudopodia. Nibbling KPs were found in 8 eyes (50.0%), featuring irregularly hyperreflective borders and a mottled reflective interior. Linear, stippled, and globular KPs were self-explanatory and affected nearly all eyes. Globular KPs seem to be formed by hyperreflective cells with large nuclei and prominent nucleoli, similar to atypical lymphocytes in vitreous cytology.

CONCLUSIONS

IVCM could provide more insight into the morphological traits of KPs than clinical observation, highlighting its potential for identifying VRL involving the anterior segment.

Cell-Free DNA Sequencing of Intraocular Fluid as Liquid Biopsy in the Diagnosis of Vitreoretinal Lymphoma

Purpose

To seek novel diagnostic approaches, we improved the workflow of cell-free DNA (cfDNA) sequencing and evaluated its feasibility in vitreoretinal lymphoma (VRL) specimens; the profile of mutations was preliminarily analyzed for potential diagnostic value.

Methods

The study was a diagnostic trial. 23 eyes of 23 patients with VRL and 25 eyes of 25 patients with inflammatory eye diseases were enrolled. Approximate 500μl undiluted vitreous humor and 10ml diluted vitreous fluid was obtained through diagnostic vitrectomy and sent for cytopathological examinations. 500μl of the diluted vitreous fluid was spared for cfDNA sequencing. For cfDNA sequencing, DNA fragmentation procedure was added to the workflow to improve the extraction efficiency; mutations detected were analyzed for potential diagnostic model. The sensitivity and specificity of the cytopathology and cfDNA sequencing were compared. The clinical manifestations were preliminarily analyzed for potential correlations with the genotypes.

Results

CfDNA sequencing was accomplished in 23 eyes with VRL and 20 eyes with inflammatory eye diseases. VRL-related mutated genes included MYD88 (18 eyes, 78%), ETV6 (11 eyes, 48%), PIM1 (11 eyes,48%), BTG2 (7 eyes, 30%), IRF4 (7 eyes, 30%), CD79B (6 eyes, 26%), LRP1B (6 eyes, 26%), etc. Logistic regression based on the mutations of MYD88 and ETV6 was of the potential for the diagnosis of VRL (P<0.001, adjusted R2 = 0.789, sensitivity 0.913, specificity 0.950); by comparison, the sensitivity and specificity of the vitreous cytopathology were 0.826 and 1.000, respectively. Further analysis of the mutation profile showed that patients carrying CD79B mutation tended to have higher intraocular interleukin-10 level (P=0.030), that CARD11 mutation was correlated with younger age at ocular onset (P=0.039), and that patients with intracranial involvement carried more multiple-site mutations in the BTG2 gene (P=0.013).

Conclusions

The improved workflow of CfDNA sequencing is of sound feasibility in a limited amount of vitreous humor. The logistic model based on the mutations could help to provide reliable clues for the diagnosis of VRL.

Advanced OCT Analysis of Biopsy-proven Vitreoretinal Lymphoma

PURPOSE

Although diagnosing vitreoretinal lymphoma (VRL) can be challenging, early detection is critical for visual prognosis. We analyzed the spectrum of optical coherence tomography (OCT) findings in patients with biopsy-proven VRL and correlate these features with clinical parameters.

DESIGN

This retrospective cross-sectional study was a multicenter chart review from 13 retina, uveitis, and ocular oncology clinics worldwide from 2008 to 2019. We included patients with a diagnosis of biopsy-proven VRL imaged with OCT at presentation. Ocular information, systemic information, and multimodal retinal imaging findings were collected and studied. The main outcome measure was the characteristics of VRL on OCT.

RESULTS

A total of 182 eyes of 115 patients (63 women, mean age 65 years) were included in this study. The disease was bilateral in 81 patients (70%), and mean baseline visual acuity was 0.2 ± 0.89 logMAR (Snellen equivalent, 20/32). At baseline, 38 patients (33%) presented with isolated ocular involvement, 54 (45%) with associated central nervous system involvement, and 11 (10%) with other systemic lymphomatous involvement; an additional 12 patients (10%) presented with central nervous system and other systemic involvement. On OCT, tumor infiltration was identified in various retinal layers, including lesions in the subretinal pigment epithelium compartment (91% of eyes), the subretinal compartment (43% of eyes), and the intraretinal compartment (7% of eyes). OCT analysis of eyes with VRL identified 3 main regions of retinal infiltration. Subretinal pigment epithelium location, with or without subretinal infiltration, was the most common pattern of involvement and isolated intraretinal infiltration was the least.

Clinical Manifestations and Implications of Nonneoplastic Uveitis Masquerade Syndrome

PURPOSE

To investigate the clinical manifestations and systemic and ocular implications of nonneoplastic uveitis masquerade syndrome (NNUMS).

DESIGN

Retrospective case series.

METHODS

The clinical data of 830 consecutive patients who presented with uveitis at a tertiary referral center in northern Taiwan between August 2013 and August 2020 were analyzed. The clinical characteristics and outcomes of patients with NNUMS were evaluated.

RESULTS

Overall, 3.7% of patients were determined to have uveitis masquerade syndrome. Among them, 24 patients (77%; 34 eyes) were diagnosed as having NNUMS. The main presenting anatomical location was posterior uveitis (58.8%). In the NNUMS group, a high chorioretinal involvement rate (94.1%) and delayed diagnosis from symptom onset (45.8% cases were diagnosed after more than 90 days) were found. Multimodal imaging was the major decisive diagnostic factor. Systemic condition alterations requiring urgent treatment were noted in 29.2% of cases. Ocular complications were noted in 58.8% of cases; 60% of those were observed on referral. Following appropriate treatment, visual acuity could be maintained in 88.3% of cases. The 5 major categories of NNUMS were retinal vascular disorders, rhegmatogenous retinal detachment, retinal dystrophy, central serous chorioretinopathy, and uveal effusion syndrome.

CONCLUSION

NNUMS is a group of heterogeneous diseases with a complex diagnostic process and significant ocular and systemic effects. High awareness regarding common clinical manifestations is crucial for physicians to make the appropriate diagnosis and management.

A Comprehensive Update on Retinal Vasculitis: Etiologies, Manifestations and Treatments

Retinal vasculitis is characterized by inflammatory involvement of retinal arterioles, venules and/or capillaries and can be associated with a myriad of systemic and ophthalmic diseases. In this review, we have comprehensively discussed the etiologies, clinical manifestations, and presentations of retinal vasculitis. We have also included newer advances in imaging in retinal vasculitis such as OCTA and widefield imaging.

Traumatic Intralenticular Neovascularization in a HLA B27+ Pediatric Patient

(1) Background: Intralenticular tumors are an entity akin to Schrodinger's cat since, although the human crystalline cells themselves are not known to malignly proliferate, various entities can take the appearance and clinical presentation of a tumor originating in the lens. We present the peculiar case of an 11-year-old male patient of African descent, HLA B27+, with a previous history of minor ocular trauma and unilateral anterior uveitis a year before which was admitted to our department with total opacification of the crystalline lens in the right eye and lens neovascularization. During surgery, a vascular, white fibrotic mass measuring 0.1-0.2 cm was discovered inside the lens bag and was excised. (2) Methods: Retrospective case review. (3) Results: The histopathological exam of the excised mass revealed an abundant infiltrate consisting of CD68+ foamy macrophages and lymphoplasmacytic elements. CD68 is a pan-macrophage marker associated with an active inflammatory mechanism soliciting macrophages, and tissue activated macrophages are correlated to increased stromal and serum levels of vascular endothelial growth factor, providing an explanation for lens angiogenesis. (4) Conclusions: The diagnosis is of a "masquerade tumor" resulted from an abnormal inflammatory process in connection with previous ocular trauma and possibly the patient's HLA B27+ status.

Ocular syphilis

Multiple studies around the world suggest that syphilis is re-emerging. Ocular syphilis - with a wide range of presentations, most of which are subtypes of uveitis - has become an increasingly common cause of ocular inflammation over the past 20 years. Its rising incidence, diagnostic complexity, and manifestations that have only recently been characterized make ocular syphilis relevant from the public health, clinical, and scientific perspectives. We review the demographics, epidemiology, clinical features, ocular imaging findings, diagnosis, and medical management of this condition.

Noninfectious Intermediate, Posterior, or Panuveitis: Results from the Retrospective, Observational, International EyeCOPE Study

Introduction

The EyeCOPE study characterized noninfectious intermediate posterior, or panuveitis (NIIPPU) before biologic agents were widely available.

Methods

This retrospective, observational study included adults with NIIPPU attending a routine ophthalmological visit. Data were collected from the study visit and medical records.

Results

Of 565 patients, 58.8% were female, and the mean age was 41.3 years; 33.8% had idiopathic uveitis and 45.8% had panuveitis. The median time from symptom onset to diagnosis and treatment was 27.0 and 30.5 days, respectively. Patients received immunosuppressants and systemic/local corticosteroids. Most patients experienced substantial decline in ocular function (mean best corrected visual acuity, 0.4 logMAR). Mean total work productivity impairment among employed patients was 31.0%. Most patients reported ocular complications (70.8%) such as vision loss and cataracts.

Conclusions

Despite treatment, most patients with NIIPPU experienced a decline in ocular function and ocular complications. There is an unmet need for additional NIIPPU treatment, such as targeted monoclonal antibodies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-021-00351-4.

Intraocular biopsy in uveitis

An intraocular biopsy is performed for diagnostic, prognostic and investigational purposes. Biopsies help to confirm or exclude malignancies and differentiate inflammatory from infectious processes. Histopathological analysis is the final verdict in unresponsive uveitis, atypical inflammation, metastases and masquerade syndromes. Advances and refinement of techniques in cytopathology, immunohistochemistry, microbiological and molecular biologic study offer much more than just diagnosis. They provide prognosis based on cell characteristics and are helpful in planning treatment and intervention. Many biopsy procedures have evolved to provide more safety and minimise complications thus improving the quality of specimens or samples available for analysis. The type of biopsy and technique adopted varies based on the clinical suspicion, size and location of lesions. In uveitis, a working diagnosis of intraocular inflammation is made on clinical examination and laboratory investigations and ancillary tests. Malignancy and uveitis is interlinked and masquerade syndromes are among the commonest indications for biopsy and analysis of specimen. The various types of intraocular biopsies include aqueous tap, fine needle aspiration biopsy, vitreous biopsy, iris and ciliary body, and retinochoroidal biopsy. They will be reviewed in this article with respect to current perspective

Epidemiology of uveitis in Japan: a 2016 retrospective nationwide survey

PURPOSE

To investigate the epidemiology of uveitis in Japan and assess its changes over time.

STUDY DESIGN

Retrospective multicenter study METHODS: Sixty-six hospitals in Japan with uveitis specialty clinics participated in this retrospective nationwide survey. A questionnaire was sent to each hospital to survey the total number of patients who made a first visit to the outpatient uveitis clinic of each hospital between 1 April 2016 and 31 March 2017. The diagnosis of uveitis was based on guidelines when available or on commonly used diagnostic criteria.

RESULTS

In 2016, new patients with uveitis accounted for 3.2% of the total number of new patients with ophthalmic diseases. A total of 5378 patients were enrolled in the survey; 3408 cases could be classified with a specific uveitis entity, and 1970 cases were described as unclassified intraocular inflammation. Among the classified cases, the most frequent disease was sarcoidosis (10.6%), followed by Vogt-Koyanagi-Harada disease (8.1%), herpetic iritis (6.5%), acute anterior uveitis (5.5%), sclerouveitis (4.4%), Behçet's disease (4.2%), malignant disease (2.6%), acute retinal necrosis (1.7%), Posner-Schlossman syndrome (1.7%), and diabetic iritis (1.4%). The rates of sarcoidosis, Vogt-Koyanagi-Harada disease, and Behçet's disease were similar; however, the rate of herpes iritis increased (4.2-6.5%) when compared with the 2009 survey.

CONCLUSIONS

Some changes were observed between the previous nationwide surveys (2002 and 2009) and the present survey. It must be valuable to continue such nationwide epidemiologic surveys at regular intervals.

[The Management of Vitreous Opacities]

The management of symptomatic vitreous opacities is often complicated in daily practice. The technically significantly improved surgical possibilities lead to an increased number of surgical interventions. The Nd:YAG laser vitreolysis is increasingly becoming a therapeutic option. Unfortunately, there are no comparative randomized studies on vitrectomy, Nd:YAG laser vitreolysis and a wait-and-see approach to spontaneous progress. This article gives an overview of this problem.

Das Management von Glaskörpertrübungen

Das Management von symptomatischen Glaskörpertrübungen stellt sich in der täglichen Praxis oft als kompliziert dar. Die Nd:YAG-Laser-Vitreolyse rückt als weitere therapeutische Option immer mehr in den Fokus. Vergleichende randomisierte Studien zur Vitrektomie, Nd:YAG-Laser-Vitreolyse und einer abwartenden Vorgehensweise zum Spontanverlauf gibt es leider nicht. Dieser Beitrag versucht, zu dieser Problematik einen Überblick zu geben.

Lymphoma masquerading as occlusive retinal vasculitis: A case study

Purpose

To describe a case of retinal lymphoma presenting as an occlusive retinal vasculitis without vitritis that was exquisitely responsive to intravitreal dexamethasone implant (IVDI).

Observation

A 66-year old male presented with decreased vision in the right eye and was diagnosed with occlusive retinal vasculitis and prominent cystoid macular edema though he lacked vitritis. A complete systemic workup for infectious, inflammatory, and infiltrative etiologies was unremarkable. Intravenous methylprednisolone and cyclophosphamide had no clinical effect. Due to persistent perivascular exudates and refractory macular edema, IVDI was administered with marked improvement in vision and clinical findings. Subsequent retinal vasculitis in the left eye responded to IVDI as well. The patient remained disease free for months while on weekly adalimumab. He then presented with acute vision loss in the left eye due to a lymphomatous subretinal infiltration and a new lesion in the corpus callosum. He has remained disease free for more than two years after intravitreal methotrexate injections and rituximab with an autologous stem cell transplant.

Conclusion and importance

Lymphoma may present as an occlusive retinal vasculitis without vitritis and can be masked due to its response to IVDI.

A sarcoidosis-lymphoma syndrome revealed by hypopituitarism

SUMMARY

A 26-year-old woman presented with persistent headache and tiredness. Biological investigations disclosed a moderate inflammatory syndrome, low PTH-hypercalcemia and complete anterior hypopituitarism. A magnetic resonance imaging (MRI) of the pituitary gland was performed and revealed a symmetric enlargement with a heterogeneous signal. Ophthalmological examination showed an asymptomatic bilateral anterior and posterior uveitis, and a diagnosis of pituitary sarcoidosis was suspected. As the localization of lymphadenopathies on the fused whole-body FDG-PET/computerized tomography (CT) was not evoking a sarcoidosis in first instance, an excisional biopsy of a left supraclavicular adenopathy was performed showing classic nodular sclerosis Hodgkin's lymphoma (HL). A diagnostic transsphenoidal biopsy of the pituitary gland was proposed for accurate staging of the HL and surprisingly revealed typical granulomatous inflammation secondary to sarcoidosis, leading to the diagnosis of a sarcoidosis-lymphoma syndrome. The co-existence of these diseases constitutes a diagnostic challenge and we emphasize the necessity of exact staging of disease in order to prescribe adequate treatment.

LEARNING POINTS

The possibility of a sarcoidosis-lymphoma syndrome, although rare, should be kept in mind during evaluation for lymphadenopathies. In the case of such association, lymphoma usually occurs after sarcoidosis. However, sarcoidosis and lymphoma can be detected simultaneously and development of sarcoidosis in a patient with previous lymphoma has also been reported. An accurate diagnosis of the disease and the respective organ involvements, including biopsy, is necessary in order to prescribe adequate treatment.

Guidance on Noncorticosteroid Systemic Immunomodulatory Therapy in Noninfectious Uveitis: Fundamentals Of Care for UveitiS (FOCUS) Initiative

TOPIC

An international, expert-led consensus initiative to develop systematic, evidence-based recommendations for the treatment of noninfectious uveitis in the era of biologics.

CLINICAL RELEVANCE

The availability of biologic agents for the treatment of human eye disease has altered practice patterns for the management of noninfectious uveitis. Current guidelines are insufficient to assure optimal use of noncorticosteroid systemic immunomodulatory agents.

METHODS

An international expert steering committee comprising 9 uveitis specialists (including both ophthalmologists and rheumatologists) identified clinical questions and, together with 6 bibliographic fellows trained in uveitis, conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol systematic review of the literature (English language studies from January 1996 through June 2016; Medline [OVID], the Central Cochrane library, EMBASE, CINAHL, SCOPUS, BIOSIS, and Web of Science). Publications included randomized controlled trials, prospective and retrospective studies with sufficient follow-up, case series with 15 cases or more, peer-reviewed articles, and hand-searched conference abstracts from key conferences. The proposed statements were circulated among 130 international uveitis experts for review. A total of 44 globally representative group members met in late 2016 to refine these guidelines using a modified Delphi technique and assigned Oxford levels of evidence.

RESULTS

In total, 10 questions were addressed resulting in 21 evidence-based guidance statements covering the following topics: when to start noncorticosteroid immunomodulatory therapy, including both biologic and nonbiologic agents; what data to collect before treatment; when to modify or withdraw treatment; how to select agents based on individual efficacy and safety profiles; and evidence in specific uveitic conditions. Shared decision-making, communication among providers and safety monitoring also were addressed as part of the recommendations. Pharmacoeconomic considerations were not addressed.

CONCLUSIONS

Consensus guidelines were developed based on published literature, expert opinion, and practical experience to bridge the gap between clinical needs and medical evidence to support the treatment of patients with noninfectious uveitis with noncorticosteroid immunomodulatory agents.

DELINEATION OF CHOROIDAL AND RETINAL LESIONS IN POSTERIOR UVEITIS BY MULTISPECTRAL WIDE-FIELD SCANNING LASER OPHTHALMOSCOPY

PURPOSE

To investigate whether wide-field multispectral scanning laser ophthalmoscopy could assist in determining depth of chorioretinal pathology in posterior uveitis.

METHODS

Cross-sectional retrospective review of patients with birdshot chorioretinopathy (BCR; 42 eyes of 21 patients) or active primary vitreoretinal lymphoma (PVRL; 18 eyes of 10 patients) who had multispectral wide-field scanning laser ophthalmoscopy (Optos) images. Images acquired with 532 nm and 635 nm lasers were analyzed separately using Optos V Vantage Pro Review software.

RESULTS

All 42 eyes with birdshot chorioretinopathy and 8/18 eyes with active primary vitreoretinal lymphoma had lesions on 635 nm imaging, while 26/42 of the birdshot chorioretinopathy eyes and 18/18 eyes with active primary vitreoretinal lymphoma had lesions on 532 nm imaging. The difference between the 2 groups on both 635 nm and 532 nm was statistically significant (P < 0.05).

CONCLUSION

Retinal and choroidal lesions in patients with posterior uveitis can be differentially visualized with Optos 532 nm and 635 nm lasers, respectively, allowing determination of depth of pathology.

Profile of patients with uveitis referred to a multidisciplinary unit in northern Spain

OBJECTIVE

To describe the main characteristics of a cohort of patients with uveitis referred to a multidisciplinary unit in northern Spain.

MATERIAL AND METHODS

Retrospective analysis of clinical records of patients evaluated in the Multidisciplinary Unit of the Navarra Hospital Complex from the period January 2010 until March 2015. An analysis was performed on the demographic characteristics, origin, types of uveitis, laterality, and aetiology. The present series was also compared with 2 previous series from Castilla y León and Barcelona.

RESULTS

A total of 500 patients were identified, with a mean age of 47.9±16.4 years, with 50% women. The most frequent type of uveitis was anterior uveitis (65.4%), followed by posterior uveitis (17.6%), panuveitis (15.2%), and intermediate uveitis (1.8%). The origin was unclassifiable in 31.2%, followed by non-infectious systemic disease in 29.2%. Ankylosing spondylitis was the most frequent cause in 10.8% of patients, followed by herpes infection in 9.2%, and toxoplasmosis in 7.8%, respectively. Compared with the 2other cohorts, the present cohort showed a higher proportion of unilateral anterior uveitis. Furthermore, the patients from the Navarra series had a higher prevalence of unilateral and idiopathic uveitis compared to the series from Barcelona.

CONCLUSIONS

The main characteristics of the present cohort of patients with uveitis are similar to those of patients from other regions of our country. Unilateral anterior uveitis and idiopathic uveitis were the most frequent in our series.

Notch signalling suppresses regulatory T-cell function in murine experimental autoimmune uveitis

Autoimmune uveitis is an intraocular inflammatory disorder in developed countries. Understanding the mechanisms underlying the development and modulation of immune reaction in uveitic eyes is critical for designing therapeutic interventions. Here we investigated the role of Notch signalling in regulatory T-cell (Treg cell) function during experimental autoimmune uveitis (EAU). Using the Foxp3-GFP reporter mouse strain, the significance of Notch signalling for the function of infiltrating Treg cells was characterized in an EAU model. We found that infiltrating Treg cells substantially expressed Notch-1, Notch-2, JAG1 and DLL1 in uveitic eyes. Activation of Notch signalling, represented by expression of HES1 and HES5, was enhanced in infiltrating Treg cells. Treatment with JAG1 and DLL1 down-regulated Foxp3 expression and immunosuppressive activity of isolated infiltrating Treg cells in vitro, whereas neutralizing antibodies against JAG1 and DLL1 diminished Notch ligand-mediated negative effects on Treg cells. To investigate the significance of Notch signalling for Treg cell function in vivo, lentivirus-derived Notch short hairpin RNAs were transduced into in vitro expanded Treg cells before adoptive transfer of Treg cells into EAU mice. Transfer of Notch-1-deficient Treg cells remarkably reduced pro-inflammatory cytokine production and inflammatory cell infiltration in uveitic eyes. Taken together, Notch signalling negatively modulates the immunosuppressive function of infiltrating Treg cells in mouse EAU.

Vitreoretinal lymphomas misdiagnosed as uveitis: Lessons learned from a case series

PURPOSE

To present challenging cases of vitreoretinal lymphoma (VRL) that was misdiagnosed as uveitis because of the apparent intraocular inflammation. At the light of the new classification of intraocular lymphomas, we detail the characteristics that masqueraded the tumors and the clinical aspects that guided us to the correct diagnosis.

MATERIALS AND METHODS

We retrospectively reviewed the patients referred to our uveitis service between January 2006 and December 2014.

RESULTS

Seven patients referred with a presumptive diagnosis of idiopathic uveitis received a final diagnosis of VRL. The median time between the onset of symptoms and definitive diagnosis was 25 months for these complex cases. The median time from presentation at our clinic to final diagnosis was 1 month. The described clinical features including dense vitreous cells and subretinal infiltrates were characteristic and tend to be present in all these chronically ill patients. Vitreous samples were collected, and all demonstrated the pathognomonic tumor cells, the specific immunoglobulin heavy chain gene rearrangements, and an interleukin (IL)-10 to IL-6 ratio >1.

CONCLUSION

VRLs are severe diseases with a poor prognosis that may be misdiagnosed as idiopathic inflammatory conditions of the eye. Treatment with steroids may occult the tumors and delay the correct diagnosis. Appropriate evaluation may prompt to a timely vitreous sampling and therefore to a faster diagnosis in these peculiar cases where the correct diagnosis was delayed by several months.

Autoimmune uveitis: clinical, pathogenetic, and therapeutic features

Autoimmune uveitis (AU), an inflammatory non-infectious process of the vascular layer of the eye, can lead to visual impairment and, in the absence of a timely diagnosis and suitable therapy, can even result in total blindness. The majority of AU cases are idiopathic, whereas fewer than 20 % are associated with systemic diseases. The clinical severity of AU depends on whether the anterior, intermediate, or posterior part of the uvea is involved and may range from almost asymptomatic to rapidly sight-threatening forms. Race, genetic background, and environmental factors can also influence the clinical picture. The pathogenetic mechanism of AU is still poorly defined, given its remarkable heterogeneity and the many discrepancies between experimental and human uveitis. Even so, the onset of AU is thought to be related to an aberrant T cell-mediated immune response, triggered by inflammation and directed against retinal or cross-reactive antigens. B cells may also play a role in uveal antigen presentation and in the subsequent activation of T cells. The management of AU remains a challenge for clinicians, especially because of the paucity of randomized clinical trials that have systematically evaluated the effectiveness of different drugs. In addition to topical treatment, several different therapeutic options are available, although a standardized regimen is thus far lacking. Current guidelines recommend corticosteroids as the first-line therapy for patients with active AU. Immunosuppressive drugs may be subsequently required to treat steroid-resistant AU and for steroid-sparing purposes. The recent introduction of biological agents, such as those targeting tumor necrosis factor-α, is expected to remarkably increase the percentages of responders and to prevent irreversible sight impairment. This paper reviews the clinical features of AU and its crucial pathogenetic targets in relation to the current therapeutic perspectives. Also, the largest clinical trials conducted in the last 12 years for the treatment of AU are summarized and critically discussed.

Uveal melanoma in the peripheral choroid masquerading as chronic uveitis

Purpose

To describe a case of uveal melanoma in the peripheral choroid masquerading as chronic uveitis and to raise awareness about malignant masquerade syndromes.

Case Report

A 36-year-old Chinese woman presented from an outside ophthalmologist with a 6-month history of unilateral chronic uveitis unresponsive to medical therapy in the left eye. She was found to have a uveal melanoma in the retinal periphery and underwent successful enucleation of her left eye. The histopathological diagnosis confirmed the clinical diagnosis.

Conclusions

When uveal melanoma presents in an atypical way, the diagnosis is more difficult. This case highlights the uncommon presentations of malignant melanoma of the choroid. It provides valuable information on how peripheral uveal melanoma can present with clinical signs consistent with an anterior uveitis.

Autoimmune and autoinflammatory mechanisms in uveitis

The eye, as currently viewed, is neither immunologically ignorant nor sequestered from the systemic environment. The eye utilises distinct immunoregulatory mechanisms to preserve tissue and cellular function in the face of immune-mediated insult; clinically, inflammation following such an insult is termed uveitis. The intra-ocular inflammation in uveitis may be clinically obvious as a result of infection (e.g. toxoplasma, herpes), but in the main infection, if any, remains covert. We now recognise that healthy tissues including the retina have regulatory mechanisms imparted by control of myeloid cells through receptors (e.g. CD200R) and soluble inhibitory factors (e.g. alpha-MSH), regulation of the blood retinal barrier, and active immune surveillance. Once homoeostasis has been disrupted and inflammation ensues, the mechanisms to regulate inflammation, including T cell apoptosis, generation of T_reg cells, and myeloid cell suppression in situ, are less successful. Why inflammation becomes persistent remains unknown, but extrapolating from animal models, possibilities include differential trafficking of T cells from the retina, residency of CD8⁺ T cells, and alterations of myeloid cell phenotype and function. Translating lessons learned from animal models to humans has been helped by system biology approaches and informatics, which suggest that diseased animals and people share similar changes in T cell phenotypes and monocyte function to date. Together the data infer a possible cryptic infectious drive in uveitis that unlocks and drives persistent autoimmune responses, or promotes further innate immune responses. Thus there may be many mechanisms in common with those observed in autoinflammatory disorders.