Infectious causes of posterior uveitis

Presentation of Ocular Syphilis with Bilateral Optic Neuropathy

A 60-year-old otherwise healthy male presented with a 1 year history of bilateral progressive visual loss. His best-corrected visual acuity was counting fingers at 2 m with his right eye and counting fingers at 0.5 m with his left eye. Visual field testing revealed bilateral near-total loss of visual fields. Slit-lamp examination was unremarkable, apart from bilateral grade two nuclear sclerotic cataracts. Both optic discs were pale-looking with some retinal pigment epithelial alterations at the left papillomacular region. Enhanced depth imaging optical coherence tomography depicted punctate hyperreflective dots at the inner choroidal level corresponding to the retinal pigment epithelial changes in the left eye. Fundus autofluorescence imaging revealed patchy hyper-autofluorescent and hypo-autofluorescent areas, and there was mild staining in the early and late phases of the fluorescein angiogram at the papillomacular region in the left eye. A diagnosis of bilateral optic neuropathy was made. A full systemic work-up was carried out, and serological tests pointed out the presence of syphilis with normal cranial magnetic resonance imaging. He was treated accordingly. Our case clearly demonstrates the importance of a high clinical suspicion for syphilis in cases of optic neuropathy.

Uveitis in children: Epidemiological, clinical and prognostic characteristics

PURPOSE

The purpose of this study is to describe the characteristics and prognostic factors of pediatric uveitis in a French university referral hospital.

METHODS

We performed a retrospective study of all cases of all pediatric uveitis seen at our institution over a 7-year period.

RESULTS

A total of 141 eyes of 86 children were included. The mean age was 10.7 years, and 61.6% were girls. The uveitis was bilateral in 64.0% of cases. Anterior uveitis (41.0%) and intermediate uveitis (32.0%) were the most frequent forms. The most frequent etiologies were idiopathic (27.9%), juvenile idiopathic arthritis (25.6%) and pars planitis (18.6%). During the follow-up period, systemic corticosteroids were received by 43.0% of children, immunosuppressive drugs by 31.4% and biological agents by 18.6%. At the final examination, complications were present in 67.0% of patients: 18.0% had cataracts, and 11.3% had intraocular hypertension. Posterior synechiae were present in 27.6% of eyes, optic disc edema in 10.5% and macular edema in 16.2%. At the last visit, visual acuity was better than 20/200 in 97.0% of cases. The presence of band keratopathy, cataract or glaucoma was an independent predictor of impaired visual outcomes at follow-up.

CONCLUSION

Juvenile idiopathic arthritis is one of the most frequent and severe pediatric uveitides. Close monitoring and early treatment could prevent complications.

MULTIMODAL IMAGING OF ACUTE MULTIFOCAL HEMORRHAGIC RETINAL VASCULITIS: A CASE REPORT

PURPOSE

To report a case of acute multifocal hemorrhagic retinal vasculitis and demonstrate the multimodal imaging.

METHODS

Interventional case report.

RESULTS

A 54-year-old woman without significant past medical history complained of redness and blurred vision in both eyes. Her visual acuity was counting fingers and 20/60. Mild conjunctival injection, anterior chamber cells, and vitreous haze were noted. Fundus showed multifocal intraretinal hemorrhages. Fluorescein angiography revealed vasculitic process with intraretinal hemorrhage blocking defects and retinal ischemic changes in both eyes. Anterior chamber tap fluid polymerase chain reaction for varicella zoster virus, herpes simplex virus I/II, cytomegalovirus, and Epstein-Barr virus was unremarkable. Rheumatology was consulted and systemic vasculitis was ruled out. Her vision improved to 20/50 and 20/20 after pulse methylprednisolone therapy, oral methotrexate, and prednisolone treatment.

CONCLUSION

Acute multifocal hemorrhagic retinal vasculitis can occur in an immunocompetent patient. Multimodal Imaging is useful in the diagnosis and follow-up. Patients could benefit from early and aggressive immunosuppressive therapy.

Risk of anxiety and depression in patients with uveitis: a Meta-analysis

AIM

To quantitatively evaluate the risk of anxiety and depression in patients with uveitis via performing a Meta-analysis.

METHODS

Three electronic database (PubMed, Embase, and Cochrane Library databases) were searched for studies recording data about uveitis and anxiety as well as depression simultaneously up to January 2021. The incidence rate and standard mean difference (SMD) with a 95% confidence interval (95%CI) were calculated to analyse the association using random-effects models based on heterogeneity tests.

RESULTS

In total, 12 observational studies containing 874 patients with uveitis were included. The results showed that there was a significant association between uveitis and anxiety (SMD=0.97, 95%CI: 0.39 to 1.54, P=0.0009) and depression (SMD=0.79, 95%CI: 0.51 to 1.07, P<0.00001). The overall morbidities of anxiety and depression in patients with uveitis were 39% and 17%, respectively. With subgroup analysis, the heterogeneity actually came from different kinds of uveitis. Specifically, the incidence rates of both anxiety and depression were relatively low in patients with anterior uveitis (33% and 15%), moderate in patients with infectious uveitis (46% and 22%), and high in patients with unspecified uveitis (59% and 35%).

CONCLUSION

It is preliminarily indicated that patients with uveitis may have a high risk of anxiety and depression. Ophthalmologists and psychologists should pay more attention to the psychological state when dealing with patients with uveitis. Further high-quality studies with detailed direct data are needed to draw more precise conclusions.

Automated detection of retinal exudates and drusen in ultra-widefield fundus images based on deep learning

BACKGROUND

Retinal exudates and/or drusen (RED) can be signs of many fundus diseases that can lead to irreversible vision loss. Early detection and treatment of these diseases are critical for improving vision prognosis. However, manual RED screening on a large scale is time-consuming and labour-intensive. Here, we aim to develop and assess a deep learning system for automated detection of RED using ultra-widefield fundus (UWF) images.

METHODS

A total of 26,409 UWF images from 14,994 subjects were used to develop and evaluate the deep learning system. The Zhongshan Ophthalmic Center (ZOC) dataset was selected to compare the performance of the system to that of retina specialists in RED detection. The saliency map visualization technique was used to understand which areas in the UWF image had the most influence on our deep learning system when detecting RED.

RESULTS

The system for RED detection achieved areas under the receiver operating characteristic curve of 0.994 (95% confidence interval [CI]: 0.991-0.996), 0.972 (95% CI: 0.957-0.984), and 0.988 (95% CI: 0.983-0.992) in three independent datasets. The performance of the system in the ZOC dataset was comparable to that of an experienced retina specialist. Regions of RED were highlighted by saliency maps in UWF images.

CONCLUSIONS

Our deep learning system is reliable in the automated detection of RED in UWF images. As a screening tool, our system may promote the early diagnosis and management of RED-related fundus diseases.

A review of diseases of the retina for neurologists

Diseases of the retina are common and numerous, with causes ranging over inherited, inflammatory, vascular, infectious, neoplastic, traumatic, toxic, and idiopathic etiologies. A key issue in the diagnosis of retinal disease is the duration of symptoms, which can be acute, chronic, or acute presentations of chronic disease. Clinical examination with direct ophthalmoscopy or, even better, biomicroscopy with a slit lamp and condensing lens, is a key component of diagnosis, which can be enhanced through investigational methods such as fluorescein angiography, optical coherence tomography, or electroretinography. Consideration of the history, visual acuity and visual field, and fundoscopic findings is usually sufficient to determine whether patients need referral on an emergency, urgent, or routine basis. Emphasis is given to vascular disease, age-related macular degeneration, diabetic retinopathy, genetic eye disease, and retinal detachment.

Blocking the inflammasome: A novel approach to treat uveitis

Uveitis is a complex ocular inflammatory disease often accompanied by bacterial or viral infections (infectious uveitis) or underlying autoimmune diseases (non-infectious uveitis). Treatment of the underlying infection along with corticosteroid-mediated suppression of acute inflammation usually resolves infectious uveitis. However, to develop more effective therapies for non-infectious uveitis and to better address acute inflammation in infectious disease, an improved understanding of the underlying inflammatory pathways is needed. In this review, we discuss the disease aetiology, preclinical in vitro and in vivo uveitis models, the role of inflammatory pathways, as well as current and future therapies. In particular, we highlight the involvement of the inflammasome in the development of non-infectious uveitis and how it could be a future target for effective treatment of the disease.

Ocular manifestations of people living with HIV in Tunisia

Background

Ocular involvement is a common complication of human immunodeficiency virus (HIV). Knowledge about this topic in Tunisia is limited.

Objective

To investigate ophthalmic manifestations in patients living with HIV in Tunisia.

Method

This was an observational study, performed between January 2007 and December 2016. We included patients with ocular disorders related to HIV. The data were recorded retrospectively from chart review.

Results

Amongst 98 people living with HIV (PLWH), 36 participants (55 eyes) had ocular manifestations. The mean age was 32.2 ± 5.6 years. Twenty-four patients were men and 12 were women. The mean value of CD4+ T-cell count was 156.5 ± 4.2 cells/µL. Bilateral lesions were found in 19 eyes. Best corrected visual acuity was better than 6/12 in 36 eyes. The most common ocular finding was dry eye syndrome (22%), cotton-wool spots (20%) and retinal haemorrhage (16%) followed by cytomegalovirus (CMV) retinitis (9%), anterior uveitis (7%), toxoplasmosis (4%) and tuberculosis retinochoroiditis (7%) Herpetic keratitis (5%), Herpes zoster ophthalmicus (2%) and syphilitic chorioretinitis (2%). Papilledema was found in three eyes (5%). Panuveitis was observed in four eyes (7%): three of them were associated with chorioretinal toxoplasmosis, syphilitic chorioretinitis and CMV retinitis. The fourth was attributable to immune recovery uveitis. A CD4+ T-cell count of ≤ 200 cells/µL was found to be an independent risk factor for developing posterior segment manifestations.

Conclusion

Various ophthalmic manifestations were observed in PLWH. The most common lesion was retinopathy. Ocular involvement can be serious leading to poor visual prognosis, which requires close collaboration between the ophthalmologist and infectious disease physician.

Epidemiology of Uveitis in a tertiary care centre in Portugal

Purpose: Evaluate the prevalence and incidence, demographic characteristics, anatomical classification, concomitant complications and treatment of uveitis, as well as its association with systemic diseases in the northern Portuguese population referred to a tertiary care centre (São João Hospital, Porto).Methods: A retrospective observational study of 545 consecutive uveitis cases was performed between 12th April 2012 and the 26th October 2017. Uveitis was classified according to Standard Uveitis Nomenclature, while aetiology and complications were diagnosed by specific clinical and laboratory testing.Results: Prevalence was calculated to be 12,4 cases per 100,000 people while incidence was 3.9 cases per 100,000 people annual incidence. The ratio of females to males was 1.32:1 and the mean age at diagnosis was 47,86 years. Anterior uveitis was the most common classification making up 47.5%, followed by non-infectious posterior uveitis 18,0%, infectious posterior uveitis 8,4%, intermediate uveitis 5,5% and panuveitis 4,2%. Extra-uveal entities made up the rest of the causes (16.4%). In terms of aetiology, the majority of uveitis was idiopathic (32,1%) followed by axial spondylarthritis (12.1%), Behçet's disease (8,8%), sarcoidosis (6,1%), tuberculosis (5,5%), herpes (5,1%), toxoplasmosis (3,1%) among other less frequent causes.Conclusion: In our referral region, 72% of uveitis cases were correctly identified surpassing other studies. There was a higher rate of intermediate uveitis and lower number of panuveitis cases when compared to a previous Portuguese study. Extensive monitoring of the development of uveitis by international multicentre prospective studies could be useful for increasing practitioner awareness and diagnostic approach.

Evaluation of a Multiplex Strip PCR Test for Infectious Uveitis: A Prospective Multicenter Study

PURPOSE

A novel multiplex polymerase chain reaction (PCR) test (Strip PCR) for 24 common ocular infectious disease pathogens was established. Solid-phase techniques provide stable, prompt, and accurate results while using less sample amount with lower cost than conventional quantitative real-time PCR (qPCR). Strip PCR for infectious uveitis was optimized and evaluated using intraocular samples.

DESIGN

Evaluation of diagnostic testing.

METHODS

We examined 722 samples at 14 institutions. Genomic DNA from aqueous humor and vitreous fluid was analyzed by qPCR and Strip PCR. Clinical diagnosis was determined based on symptoms, clinical findings, and laboratory tests. MainOutcomeMeasures: The diagnostic parameters of the Strip PCR were based on qPCR results.

RESULTS

Strip PCR showed low intra- and inter-institutional variability even when performed by technicians with various PCR skill levels. The targets of Strip PCR for infectious uveitis were optimized for 9 major pathogens (herpes simplex virus [HSV] 1, HSV2, varicella-zoster virus, human T-cell lymphotropic virus 1, human herpesvirus 6, Epstein-Barr virus, cytomegalovirus, Toxoplasma gondii, and Treponema pallidum) with 772 intraocular samples. The Strip PCR successfully detected pathogen DNA at concentrations ranging from 10⁰ to 10⁹ copies/mL in 252 of the 255 qPCR-positive samples. It yielded negative results for all the 191 qPCR-negative samples. Strip PCR had higher sensitivity (98.8%), specificity (98.5%), positive predictive value (98.8%), and negative predictive value (98.5%) than qPCR, with distinct primers. The Strip PCR results had strong correlation with that of the qPCR (r = 0.838) and they were consistent with the clinical diagnosis.

CONCLUSIONS

Easy-to-use Strip PCR is recommended for rapid diagnosis of infectious uveitis, as its results are equivalent to that of conventional qPCR.

Real-Time Multiplex PCR Analysis in Infectious Uveitis

Introduction: Infectious uveitis is a serious inflammatory condition that often causes grave ocular morbidity including permanent vision loss and damage to the structures of the eye. The most common causes of infectious uveitis include herpesviruses and Toxoplasma gondii. Traditionally, these infections have been identified and differentiated based on characteristic clinical examination findings; however, there is often overlap between these presentations and the unique cause of a given patient's infection is not always clear. Therefore, a reliable and fast method for definitively diagnosing infectious uveitis would be helpful and potentially sight-saving. Several groups have recently found experimental success with real-time multiplex polymerase chain reaction (PCR) techniques. Methods: A comprehensive review of the literature was undertaken to further understand the current state of real-time multiplex PCR and its clinical use. Search terms including "real time multiplex PCR", "infectious uveitis", and "uveitis diagnosis" were used. Appropriate English-language articles were included in this review. Results: Publications from four main groups (two from the United States, one from Japan, and one from India) citing success with real-time multiplex PCR were compared and contrasted. All four groups used the same technique to develop a highly sensitive and specific multiplex PCR analysis and found that their tests maintained high sensitivity and specificity during validation testing. These tests confirmed clinical suspicions in the majority of cases of infectious uveitis, but there were also cases of clinical misdiagnosis that were corrected based on molecular pathogen detection. These patients were then initiated on appropriate antimicrobial therapy with subsequent clinical improvement. Discussion: Real-time multiplex PCR is a highly sensitive and specific laboratory assay that allows for rapid and reliable molecular diagnosis of causative agents in infectious uveitis. This in turn facilitates swift initiation of effective therapy and prevents long-term ocular damage and vision loss.

Aurora borealis and string of pearls in vitreoretinal lymphoma: patterns of vitreous haze

Aims

Peculiar retinal signs of vitreoretinal lymphoma (VRL) have been identified. However, limited information on the vitreous features of VRL is available. This study aims to characterise the vitreous involvement in VRL with the help of multimodal imaging.

Methods

In this retrospective, observational study, we reviewed charts and imaging of all patients with biopsy-proven VRL seen from January 2016 to April 2018 at a single referral centre. These included ultrawide-field imaging, ophthalmic ultrasonography and slit-lamp photography. The main outcome measures were patterns of vitreous haze of VRL, as observed by combining clinical and multimodal imaging information.

Results

Twenty-six eyes of 13 patients were included. At presentation, vitreous haze was present in 24 eyes (92%) and was the only sign of VRL in 4 eyes (15%). Three patterns of vitreous haze were identified in VRL. An aurora borealis pattern was present in 12 eyes and showed linear opacities with a myriad of cells aligned along the vitreous fibrils. A string of pearls pattern was present in two eyes at baseline and developed in other four eyes after vitrectomy, showing fine fibrils connecting bunches of inflammatory material. A non-specific pattern was observed in 10 eyes. Ophthalmic ultrasound showed corpuscular material correlating with the grading of vitreous haze.

Conclusion

VRL shows different patterns of vitreous haze. Multimodal imaging, including ultrawide-field imaging and slit-lamp photography, helps in recognising these patterns, raising suspicion for VRL.

UVEOGENE: An SNP database for investigations on genetic factors associated with uveitis and their relationship with other systemic autoimmune diseases

Uveitis is an intraocular inflammatory disease which can lead to serious visual impairment. Genetic factors have been shown to be involved in its development. However, few databases have focused on the information of associations between single nucleotide polymorphisms (SNPs) and uveitis. To discover the exact genetic background of uveitis, we developed an SNP database specific for uveitis, “UVEOGENE,” which includes 370 genes and 918 SNPs covering 14 uveitis entities and 40 populations from 286 PubMed English‐language papers. Stratification analyses by gender, HLA status, and different clinical features were also extracted from the publications. As a result, 371 associations were judged as “statistically significant.” These associations were also shared with Global Variome shared Leiden Open Variation Database (LOVD) (https://databases.lovd.nl/shared/genes). Based on these associations, we investigated the genetic relationship among three widely studied uveitis entities including Behcet's disease (BD), Vogt–Koyanagi–Harada (VKH) disease, and acute anterior uveitis (AAU). Furthermore, “UVEOGENE” can be used as a reliable and informative resource to identify similarities as well as differences in the genetic susceptibility among uveitis and other autoimmune diseases. UVEOGENE is freely accessible at http://www.uvogene.com.

Opportunistic ocular infections in the setting of HIV

PURPOSE OF REVIEW

The aim of this review is to highlight recent changes in opportunistic ocular infections (OOIs) in the era of modern combination antiretroviral therapy (cART), in the setting of HIV-infected patients.

RECENT FINDINGS

Improvements in modern cART has led to a progressive decline in the incidence of OOIs and mortality among patients with AIDS. Not only has there been a decreasing incidence of cytomegalovirus (CMV) retinitis, but there also has been a decline in progression of such retinitis when it does occur in AIDS patients, since the introduction of cART. Nevertheless, CMV retinitis remains the major cause of vision loss in AIDS patients. Although the incidence of CMV retinitis has declined overall, the incidence of ocular syphilis has increased during the cART era. Moreover, the impact of having HIV plays a role with respect to multidrug-resistant (MDR) tuberculosis and has resulted in a high prevalence of presumed ocular tuberculosis in HIV/MDR-TB co-infected patients. Although immune reconstitution uveitis (IRU) has been an important cause of visual deficits in developed countries, OOIs remain an important cause of blindness in the developing world.

SUMMARY

Reconstituting the immune system with effective cART while increasing accessibility of screening examinations is key to the success of blindness prevent in HIV-infected individuals, particularly in developing countries.

Acute multifocal hemorrhagic retinal vasculitis in a child: a case report

Background

Acute Multifocal Hemorrhagic Retinal Vasculitis (AMHRV) is a rare disease with unknown incidence that presents with abrupt onset of visual loss associated with retinal vasculitis, retinal hemorrhage, non-confluent posterior retinal infiltrates, vitreous cellular inflammation and papillitis in, otherwise, healthy adult individuals. The reported treatment options for Acute Multifocal Hemorrhagic Retinal Vasculitis are oral corticosteroids, intravitreal ganciclovir and laser photocoagulation or vitrectomy. We report a child with Acute Multifocal Hemorrhagic Retinal Vasculitis who was treated with aggressive immunosuppressive therapy resulting in a favorable visual outcome.

Case presentation

A retrospective case report of a 10-year-old African American girl who developed unilateral Acute Multifocal Hemorrhagic Retinal Vasculitis, which later on progressed bilaterally. We conducted a review of the clinical, laboratory and photographic records to evaluate her functional and anatomic outcome after aggressive immunosuppressive treatment. During the first 4 months of treatment of OD with intravitreal ganciclovir, intravitreal dexamethasone and systemic prednisone, the change in vision in OD improved from light perception (LP) to counting fingers (CF). During the next 18 months of aggressive systemic treatment of OD and the newly affected left eye (OS), the change in vision improved from CF in OD and CF in OS to 20/200 in OD and 20/80 in OS. Management during the 18-month interval included rituximab infusions, cyclophosphamide/methylprednisolone infusions, prednisone and mycophenolate.

Conclusions

This is the first reported case of Acute Multifocal Hemorrhagic Retinal Vasculitis occurring in a child. Ophthalmologists should be aware of the need to treat severe Acute Multifocal Hemorrhagic Retinal Vasculitis with aggressive immunosuppressive agents in collaboration with rheumatologists to obtain the best possible visual outcome.

The Great Imitator: Ocular Syphilis Presenting as Posterior Uveitis

Patient: Female, 34

Final Diagnosis: Ocular syphilis

Symptoms: Painful unilateral vision loss

Medication: Benzylpenicillin

Clinical Procedure: Lumbar puncture

Specialty: Infectious Diseases • Ophthalmology

Pharmacotherapy for uveitis: current management and emerging therapy

Uveitis, a group of conditions characterized by intraocular inflammation, is a major cause of sight loss in the working population. Most uveitis seen in Western countries is noninfectious and appears to be autoimmune or autoinflammatory in nature, requiring treatment with immunosuppressive and/or anti-inflammatory drugs. In this educational review, we outline the ideal characteristics of drugs for uveitis and review the data to support the use of current and emerging therapies in this context. It is crucial that we continue to develop new therapies for use in uveitis that aim to suppress disease activity, prevent accumulation of damage, and preserve visual function for patients with the minimum possible side effects.

Management of pediatric uveitis

Pediatric uveitis is a topic of special interest not only because of the unique diagnostic and therapeutic challenges but also because of the lifetime burden of vision loss if the problem is not adequately treated, as well as the economic and psychological toll on the family. Often, uveitis in children is discovered as part of a routine eye exam; this silent, insidious inflammation can be difficult to treat and can lead to further complications if not handled skillfully. Corticosteroids have long been the mainstay of therapy; however, the significant associated side effects mandate a corticosteroid-sparing therapeutic regimen in pursuit of remission. In this review, we cover the therapeutic options for pediatric uveitis, specifically focusing on the most common non-infectious varieties, juvenile idiopathic arthritis-associated uveitis and pars planitis.

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.

Pediatric uveitis: new and future treatments

PURPOSE OF REVIEW

Pediatric uveitis is relatively uncommon, accounting for only 5-10% of all patients with uveitis. However, owing to high prevalence of complications and devastating outcomes, its lifetime burden can be significant.

RECENT FINDINGS

Immunomodulatory therapy has been associated with better outcomes in noninfectious pediatric uveitis. However, effective treatments are limited by medication-related complications, including multiorgan toxicities and systemic side effects.

SUMMARY

We review the current therapies available to treat pediatric uveitis, discuss novel and future therapies, and provide clinical recommendations utilizing these new agents. The consideration for treatment regimens in noninfectious pediatric uveitis is multifactorial. Understanding past, present, and future technology will aid in treatment of a complex and refractory disease.