Optical coherence tomography in the diagnosis and management of uveitis

Review for Disease of the Year Clinical Features and Ocular Imaging in Intermediate Uveitis and Pars Planitis

Intermediate uveitis is a relatively common form of intraocular inflammation that can be seen at any age. The vitreous is the primary site of inflammation; and the presence of snowballs or snowbank defines its subtype, pars planitis. Since it is a clinical diagnosis, it is important to recognize the typical clinical features and associated ocular complications. Recent advances in ocular imaging have made significant contributions to the clinical appraisal and studies of intermediate uveitis. This narrative review includes clinical signs, ocular complications, and ocular imaging of intermediate uveitis and pars planitis.

Optical coherence tomography features in vitreoretinal lymphoma compared with non-infectious uveitis

BACKGROUND

Vitreoretinal lymphoma (VRL) is a rare intraocular malignancy that poses a diagnostic challenge due to the non-specific clinical presentation that resembles uveitis. The use of spectral domain optical coherence tomography (SD-OCT) has emerged as a valuable imaging tool to characterize VRL. Therefore, we sought to determine the specific OCT features in VRL compared to the uveitides.

METHODS

Retrospective chart review of patients who were seen at Mayo Clinic from January 1, 2010 through December 31, 2022. The medical records and SD-OCT images at time of initial presentation were reviewed in patients with biopsy-proven VRL, intermediate uveitis, or biopsy-confirmed sarcoid posterior uveitis. Patients with VRL or similar uveitides including intermediate uveitis or sarcoid posterior uveitis were included.

RESULTS

There were 95 eyes of 56 patients in the VRL group and 86 eyes of 45 patients in the uveitis group, of whom 15 (33.3%) were diagnosed with intermediate uveitis and 30 (66.7%) with sarcoid chorioretinitis. The SD-OCT features more commonly seen at initial presentation in VRL patients (vs. uveitis) included preretinal deposits (31.6% vs. 9.3%, p = 0.002), intraretinal infiltrates (34% vs. 3.5%, p < 0.001), inner retinal hyperreflective spots (15.8% vs. 0%, p < 0.001), outer retinal atrophy (22.1% vs. 2.3%, p < 0.001), subretinal focal deposits (21.1% vs. 4.7%, p = 0.001), retinal pigmented epithelium (RPE) changes (49.5% vs. 3.5%, p < 0.001), and sub-RPE deposits (34.7% vs. 0%, p < 0.001). Features more frequently seen in uveitis included epiretinal membrane (ERM) (82.6% vs. 44.2%, p < 0.001), central macular thickening (95.3% vs. 51.6%, p < 0.001), cystoid macular edema (36% vs. 11.7%, p < 0.001), subretinal fluid (16.3% vs 6.4%, p = 0.04), and subfoveal fluid (16.3% vs. 3.2%, p = 0.003). Multivariate regression analysis controlling for age and sex showed absence of ERM (OR 0.14 [0.04,0.41], p < 0.001) and absence of central macular thickening (OR 0.03 [0,0.15], p = 0.02) were associated with VRL as opposed to uveitis.

CONCLUSION

OCT features most predictive of VRL (vs. uveitis) included absence of ERM and central macular thickening.

Insights into the diagnosis and management of sarcoid uveitis: A review

Sarcoidosis is a leading cause of non-infectious uveitis that commonly affects middle-aged individuals and has a female preponderance. The disease demonstrates age, sex and ethnic differences in clinical manifestations. A diagnosis of sarcoidosis is made based on a compatible clinical presentation, supporting investigations and histologic evidence of non-caseating granulomas, although biopsy is not always possible. Multimodal imaging with widefield fundus photography, optical coherence tomography and angiography can help in the diagnosis of sarcoid uveitis and in the monitoring of treatment response. Corticosteroid remains the mainstay of treatment; chronic inflammation requires steroid-sparing immunosuppression. Features on multimodal imaging such as vascular leakage may provide prognostic indicators of outcome. Female gender, prolonged and severe uveitis, and posterior involving uveitis are associated with poorer visual outcomes.

The Role of the Retinal Nerve Fiber Layer Thickness on OCT in the Evaluation of Papillitis in Childhood Uveitis

PURPOSE

To investigate the diagnostic value of using retinal nerve fiber layer thickness measured on optical coherence tomography (OCT-RNFL) to diagnose papillitis in pediatric uveitis.

DESIGN

Retrospective cohort study.

METHODS

Demographic and clinical data were collected retrospectively for 257 children with uveitis (with 455 affected eyes). Receiver operating characteristic (ROC) analysis was performed to compare fluorescein angiography (FA, the diagnostic gold standard for papillitis) to OCT-RNFL in a subgroup of 93 patients. An ideal cut-off value for OCT-RNFL was then determined by calculating the highest Youden index. Finally, a multivariate analysis was applied to the clinical ophthalmological data.

RESULTS

Based on a subset of 93 patients who underwent both OCT-RNFL and FA, the ideal cut-off OCT-RNFL for diagnosing papillitis was >130 µm, with 79% sensitivity and 85% specificity. Among the entire cohort, the prevalence of OCT-RNFL >130 µm was 19% (27/141), 72% (26/36), and 45% (36/80) in patients with anterior uveitis, intermediate uveitis, and panuveitis, respectively. Our multivariate analysis of the clinical data revealed that OCT-RNFL >130 µm was associated with a higher prevalence of cystoid macular edema, active uveitis, and optic disc swelling on fundoscopy, with odds ratios of 5.3, 4.3, and 13.7, respectively (all P < .001).

CONCLUSIONS

OCT-RNFL can be a useful noninvasive additional imaging tool for diagnosing papillitis in pediatric uveitis with relatively high sensitivity and specificity. OCT-RNFL was >130 µm in approximately one-third of all children with uveitis and was particularly prevalent in cases of intermediate uveitis and panuveitis.

The Effect of Plasma Rich in Growth Factors on Microglial Migration, Macroglial Gliosis and Proliferation, and Neuronal Survival

Plasma rich in growth factors (PRGF) is a subtype of platelet-rich plasma that has being employed in the clinic due to its capacity to accelerate tissue regeneration. Autologous PRGF has been used in ophthalmology to repair a range of retinal pathologies with some efficiency. In the present study, we have explored the role of PRGF and its effect on microglial motility, as well as its possible pro-inflammatory effects. Organotypic cultures from adult pig retinas were used to test the effect of the PRGF obtained from human as well as pig blood. Microglial migration, as well as gliosis, proliferation and the survival of retinal ganglion cells (RGCs) were analyzed by immunohistochemistry. The cytokines present in these PRGFs were analyzed by multiplex ELISA. In addition, we set out to determine if blocking some of the inflammatory components of PRGF alter its effect on microglial migration. In organotypic cultures, PRGF induces microglial migration to the outer nuclear layers as a sign of inflammation. This phenomenon could be due to the presence of several cytokines in PRGF that were quantified here, such as the major pro-inflammatory cytokines IL-1β, IL-6 and TNFα. Heterologous PRGF (human) and longer periods of cultured (3 days) induced more microglia migration than autologous porcine PRGF. Moreover, the migratory effect of microglia was partially mitigated by: 1) heat inactivation of the PRGF; 2) the presence of dexamethasone; or 3) anti-cytokine factors. Furthermore, PRGF seems not to affect gliosis, proliferation or RGC survival in organotypic cultures of adult porcine retinas. PRGF can trigger an inflammatory response as witnessed by the activation of microglial migration in the retina. This can be prevented by using autologous PRGF or if this is not possible due to autoimmune diseases, by mitigating its inflammatory effect. In addition, PRGF does not increase either the proliferation rate of microglial cells or the survival of neurons. We cannot discard the possible positive effect of microglial cells on retinal function. Further studies should be performed to warrant the use of PRGF on the nervous system.

[Application of high-resolution optical coherence tomography for visualization of eye structures in uveitis of different localization]

The article presents an analysis of publications in main Russian and foreign journals devoted to the use of optical coherence tomography in intravital visualization of the structures of the eye for diagnosis, assessment of the changes during relapses, recovery and remission stages, as well as the effectiveness of treatment for uveitis of different localization. It describes in detail the results of studies conducted using spectral optical coherence tomography, changes in the anterior chamber and cornea in uveitis of the anterior localization, morphological changes in the vitreous body, vitreomacular interface, retina, choroid and optic disc in the anterior and posterior localization of inflammation, and presents the features of OCT diagnosis in a number of nosological forms of uveitis based on the literature data.

Clinical features of uveitis in elderly patients in central Tokyo (2013-2018)

PURPOSE

To clarify the clinical features of uveitis in elderly patients in central Tokyo.

METHODS

We retrospectively identified 1424 patients with uveitis who visited the Uveitis Clinic of the University of Tokyo Hospital between January 2013 and December 2018. The patients were categorized into two groups based on their ages at the time of disease onset: patients aged 65 years or older were included in Group A, whereas those younger than 65 years were included in Group B. The etiological classification of uveitis and its causes were investigated for each group.

RESULTS

Group A presented significantly higher rates of infectious uveitis (35.5% vs. 17.8%, p < 0.0001) and masquerade syndromes (17.9% vs. 5.0%, p < 0.0001) than Group B. Furthermore, Group A had significantly higher rates of sarcoidosis (23.1% vs. 9.3%, p < 0.0001), intraocular lymphoma (16.6% vs. 4.6%, p < 0.0001), cytomegalovirus iritis (11.0% vs. 5.6%, p = 0.0043), and cytomegalovirus retinitis (5.2% vs. 1.5%, p = 0.0020) than Group B.

CONCLUSION

Our results demonstrate a clear difference in the causative diseases of uveitis between elderly and non-elderly patients. These findings may support ophthalmologists in their diagnostic process for elderly patients with uveitis.

Ocular sarcoidosis: new diagnostic modalities and treatment

PURPOSE OF REVIEW

Ocular involvement in sarcoidosis is present in up to 80% of patients and is frequently manifested before diagnosis of the underlying systemic disease. Considering the therapeutic consequences, early diagnosis of the underlying disease is advantageous in patients presenting with ocular inflammation. There are several ocular findings suggestive of underlying sarcoidosis, such as granulomatous keratic precipitates, iris nodules, cells in the vitreous humor known as snowballs and snowbanks, and retinal periphlebitis. High suspicion is crucial for the diagnosis of sarcoidosis. This review on ocular sarcoidosis will mainly focus on new diagnostic and treatment modalities.

RECENT FINDINGS

Recent studies found possible new diagnostic indicators for the diagnosis of ocular sarcoidosis which include not only serum profiles but also vitreous sample analysis. Ophthalmologic imaging techniques have improved to investigate the ocular structure in detail. Results from recent uveitis clinical trials have included sarcoidosis as an underlying cause and have reported positive results.

SUMMARY

The diagnosis of ocular sarcoidosis can be challenging in some cases. High suspicion is important to diagnose ocular sarcoidosis with various laboratory and ophthalmic tools. There are many possible options for the treatment of ocular sarcoidosis including various biologic agents.

Evaluation of hyperreflective foci as a prognostic factor of visual outcome in retinal vein occlusion

AIM

To evaluate the potential role of hyperreflective foci (HF) as a prognostic indicator of visual outcome in patients with macular edema (ME) due to retinal vein occlusion (RVO).

METHODS

We retrospectively reviewed 50 eyes of 50 patients with ME due to ischemic central retinal vein occlusion (CRVO), non-ischemic CRVO and branch retinal vein occlusion (BRVO) who were treated with anti-vascular endothelial growth factor (anti-VEGF) at Beijing Tongren Eye Center from January 2013 to July 2016. All patients underwent best-corrected visual acuity (BCVA), spectral domain optical coherence tomography (SD-OCT) at baseline and follow-up. Such factors were evaluated and compared among three groups as baseline and final BCVA, central retinal thickness (CRT), external limiting membrane (ELM) status and the numbers of HF in different position. Multiple linear regression analysis was employed to analyze the relationship between baseline HF and final BCVA. Changes of HF before and after treatment were evaluated too.

RESULTS

Among three groups, HF could be located in each retinal layers, as well as in vitreous cavity. The mean HF in outer retinal layer (ORL) at baseline was 5.29±8.48 in ischemic CRVO with intact ELM, 1.93±2.76 in non-ischemic CRVO, and 1.75±2.05 in BRVO. With disrupted ELM, the mean HF in ORL increased. There was statistically difference of HF in ORL between intact and disrupted ELM. The numbers of HF in ORL were associated with poor visual outcome among three groups. However, HF in inner retinal layer (IRL) and vitreous cavity were not associated with poor visual outcome. Meanwhile, the baseline HF in ORL and vitreous cavity reduced significantly in non-ischemic CRVO and BRVO after anti-VEGF treatment.

CONCLUSION

The numbers of HF in ORL are prognostic factors associated with the final BCVA in patients with ME due to RVO after anti-VEGF treatment.

Analysis of clinical features and visual outcomes of pars planitis

PURPOSE

To evaluate the demographic characteristics, clinical features, treatment and outcomes of patients with pars planitis in a tertiary referral center in Turkey.

METHODS

Medical records of patients with pars planitis were retrospectively reviewed. The data including demographic and ocular features and treatment outcomes were recorded. The distribution of clinical findings and complications were evaluated according to age and gender groups. The changes in final BCVA compared to the initial BCVA were noted. Statistical analysis was performed using SPSS software (Version 18.0, SPSS Inc., Chicago, USA).

RESULTS

Twenty-seven patients (54 eyes) were included in this study. 16 patients were male (59.3%), and 11 were female (40.7%). Mean age at diagnosis was 12.84 ± 8.26 (range 4-36) years. Mean follow-up period was 61.3 ± 52.15 (range 9-172) months. Mean BCVA was 0.58 ± 0.36 (range 0.03-1.00) (0.40 ± 0.45 logMAR) at presentation, and 0.81 ± 0.28 (range 0.10-1.00) (0.14 ± 0.27 logMAR) at final visit (P = 0.001). Vitreous inflammation (100%), vitreous haze (92.6%), snowballs (74.1%), snowbanks (66.7%), anterior chamber cells (66.7%) and peripheral retinal vascular sheathing (48.1%) were the most common presentations. Ocular complications included vitreous condensation (51.9%), cystoid macular edema (22.2%), cataract (18.5%), inferior peripheral retinal detachment (11.1%), glaucoma (5.6%) and vitreous hemorrhage (3.7%). Treatments included topical, periocular, intravitreal and systemic corticosteroids, immunosuppressives, peripheral laser photocoagulation and pars plana vitrectomy when needed.

CONCLUSIONS

Pars planitis is an idiopathic chronic intermediate uveitis mostly affecting children and adolescents. In spite of its chronic nature with high potential of causing ocular complications, adequate treatment and close follow-up lead to favorable visual outcomes.

Algorithm for the Measure of Vitreous Hyperreflective Foci in Optical Coherence Tomographic Scans of Patients With Diabetic Macular Edema

IMPORTANCE

Developing a noninvasive measure of diabetic retinopathy disease progression may provide physicians with information needed for patient-specific intervention.

OBJECTIVE

To develop an algorithm to measure vitreous hyperreflective foci (VHRF) from standard, 3-dimensional optical coherence tomographic (OCT) images in an unbiased manner.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively analyzed OCT scans from 97 patients who were evaluated at the Kellogg Eye Center, University of Michigan. Patients with diabetes mellitus without signs of retinopathy (n =  9) and patients with diabetic macular edema (DME) (n = 31) were compared with healthy control participants (n = 37). The algorithm was used to determine whether the VHRF score is associated with DME and may serve as a noninvasive measure of inflammation. The study was conducted from November 14, 2011, to August 5, 2015. Data analysis was performed from May 15, 2014, to August 13, 2015.

MAIN OUTCOMES AND MEASURES

An algorithm was developed to enhance the vitreous imaging from OCT to allow automated quantification of VHRF and calculation of a VHRF score. This score was compared between the healthy control, diabetes without retinopathy, and DME groups.

RESULTS

In the 97 scans evaluated, VHRF scores, reported as mean (SD), were increased in patients with DME by 2.95-fold (5.60 [8.65]) compared with healthy controls (1.90 [3.42]; 95% CI, 0.75-7.45; P = .012) and by 6.83-fold compared with patients with diabetes without retinopathy (0.82 [1.26]; 95% CI, 1.46-8.82; P = .005).

CONCLUSIONS AND RELEVANCE

Scores obtained using the VHRF algorithm may be obtained from OCT images that include the vitreous and could provide a rapid, noninvasive clinical correlate for ocular inflammation. Higher VHRF scores in patients with DME compared with controls and diabetic patients without retinopathy warrant further population-based and longitudinal studies to help determine the value of the VHRF score in selecting therapeutic intervention.

Pars Planitis: Epidemiology, Clinical Characteristics, Management and Visual Prognosis

Pars planitis is an idiopathic chronic intermediate uveitis which predominantly affects children and adolescents, and accounts for 5-26.7% of pediatric uveitis. Although an autoimmune process with a genetic predisposition has been suggested, its etiology still remains unknown. The most common presenting symptoms are floaters and blurred vision. Diffuse vitreous cells, haze, snowballs and snowbanks are typical findings of pars planitis. Peripheral retinal vasculitis, optic disc edema and anterior segment inflammation are other well-known findings. Although pars planitis is known to be a benign form of uveitis in most cases, it may become a potentially blinding disease due to complications including cataract, cystoid macular edema, vitreous opacities and optic disc edema. Cystoid macular edema is the most common cause of visual morbidity. Band keratopathy, epiretinal membrane formation, vitreous condensation, neovascularizations, vitreous hemorrhage, retinal detachment, cyclitic membranes, glaucoma and amblyopia may develop as a consequence of the chronic course of the disease. Exclusion of infectious and non-infectious causes which may present with intermediate uveitis is of utmost importance before starting treatment. Treatment of pars planitis has been a controversial issue. There is no consensus specifically for treatment of cases with minimal inflammation and relatively good visual acuity. However, current experience shows that pars planitis may cause severe inflammation and needs an aggressive treatment. A stepladder approach including corticosteroids, immunosupressive agents, anti-tumor necrosis factor-alpha and pars plana vitrectomy and/or laser photocoagulation is the most commonly used method for treatment of pars planitis. Adequate control of inflammation and prompt detection of associated complications are crucial in order to improve the overall prognosis of the disease.

Choroidal Vascularity Index (CVI)--A Novel Optical Coherence Tomography Parameter for Monitoring Patients with Panuveitis?

PURPOSE

To compute choroidal vascularity index (CVI) using an image binarization tool on enhanced depth imaging (EDI)-optical coherence tomography (OCT) scans as a non-invasive optical tool to monitor progression in panuveitis and to investigate the utility of volumetric data from EDI-OCT scans using custom image analysis software.

MATERIALS AND METHODS

In this retrospective cohort study, segmented EDI-OCT scans of both eyes in 19 patients with panuveitis were taken at baseline and at 3-month follow-up and were compared with EDI-OCT scans of normal eyes. Subfoveal choroidal area was segmented into luminal (LA) and stromal interstitial area (SA). Choroidal vascularity index (CVI) was defined as the proportion of LA to the total circumscribed subfoveal choroidal area (TCA).

RESULTS

The mean choroidal thickness was 265.5±100.1μm at baseline and 278.4±102.6μm at 3 months follow up (p = 0.06). There was no statistically significant difference in TCA between study and control eyes (p = 0.08). CVI in the control group was 66.9±1.5% at baseline and 66.4±1.5% at follow up. CVI was 74.1±4.7% at baseline and 69.4±4.8% at 3 months follow up for uveitic eyes (p<0.001). The % change in CVI was 6.2 ±3.8 (4.3 to 8.0) for uveitic eyes, which was significantly higher from % change in CVI for control eyes (0.7±1.1, 0.2 to 1.3, p<0.001).

CONCLUSION

The study reports composite OCT-derived parameters and CVI as a possible novel tool in monitoring progression in panuveitis. CVI may be further validated in larger studies as a novel optical tool to quantify choroidal vascular status.

A Brazilian report using serological and molecular diagnosis to monitoring acute ocular toxoplasmosis

Background

Toxoplasmosis was recently included as a neglected disease by the Center for Disease Control. Ocular toxoplasmosis is one clinical presentation of congenital or acquired infection. The laboratory diagnosis is being used worldwide to support the clinical diagnosis and imaging. The aim of this study was to evaluate the use of serology and molecular methods to monitor acute OT in immunocompetent patients during treatment.

Methods

Five immunocompetent patients were clinically diagnosed with acute OT. The clinical evaluation was performed by ophthalmologic examination using the Early Treatment Diabetic Retinopathy Study, best-corrected visual acuity, slit lamp biomicroscopy, fundoscopic examination with indirect binocular ophthalmoscopy color fundus photography, fluorescein angiography and spectral optical coherence tomography (OCT). Serology were performed by ELISA (IgA, IgM, IgG) and confirmed by ELFA (IgG, IgM). Molecular diagnoses were performed in peripheral blood by cPCR using the Toxoplasma gondiiB1 gene as the marker. Follow-up exams were performed on day +15 and day +45.

Results

Only five non-immunocompromised male patients completed the follow up and their data were used for analysis. The mean age was 41.2 ± 11.3 years (median: 35; range 31–54 years). All of them were positive for IgG antibodies but with different profiles for IgM and IgA, as well as PCR. For all patients the OCT exam showed active lesions with the inner retinal layers being abnormally hyper-reflective with full-thickness disorganization of the retinal reflective layers, which assumed a blurred reflective appearance and the retina was thickened.

Conclusions

The presence of IgA and IgM confirmed the acute infection and thus was in agreement with the clinical evaluation. Our results show the adopted treatment modified the serological profile of IgM antibodies and the PCR results, but not the IgG and IgA antibodies and that imaging is a good tool to follow-up patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1650-6) contains supplementary material, which is available to authorized users.