Profiling of human leukocyte antigens in Eales' disease

Bacille Calmette-Guérin: An ophthalmic perspective

Vaccines such as bacille Calmette-Guérin (BCG) are known for their heterologous effects mediated through a number of mechanisms, including trained immunity constituted by monocyte-macrophage based innate immunity. Other events such as direct hematogenous spread and induction of autoimmunity are also described. There has been a resurgent interest in harnessing some of the benefits of trained immunity in the management of COVID-19, even as several specific vaccines have been approved. We summarize the current knowledge of ocular effects of BCG. Potential effect of granulomatous inflammation on angiotensin converting enzyme activity and accentuation of cytokine storm that may result in undesirable ocular and systemic effects are also discussed.

Pediatric vitreous hemorrhage: A narrative review

Vitreous hemorrhage is one of the most common causes of sudden, painless loss of vision in adults. This is probably one of the reasons why it has been extensively studied and reported in literature. However, the same cannot be said when it comes to vitreous hemorrhage in the pediatric age group. The causes of vitreous hemorrhage in children tend to differ from those of adults. Not much data exist regarding their presentation and management. In addition to trauma, certain spontaneous causes such as pediatric tumors and congenital conditions assume importance while considering the differential diagnosis of vitreous hemorrhage in the pediatric age group. However, it is natural that the treating ophthalmologist is faced with challenges when a child presents with vitreous hemorrhage. In this narrative review, we have attempted to analyze the retrospective observational studies regarding pediatric vitreous hemorrhage reported in English literature till date. The article sheds some light on the prevailing epidemiology, management strategies employed and the visual outcome among different regions of the world.

[Eales' disease]

The syndrome of recurrent vitreous hemorrhages in young men was described for the first time by Henry Eales in 1880. The association with a clinical manifestation of ocular inflammation was reported 5years later. Eales disease affects young adults who present with ischemic retinal vasculitis, with the peripheral retina most commonly affected. Most cases have been reported in South Asia. Although the etiology of this abnormality is unknown, it may be related to an immune sensitivity to Mycobacterium tuberculosis antigens. Its pathogenesis is related to extensive ischemia that affects the retina, secondary to an obliterative retinal vasculopathy with release of angiogenic factors of the VEGF type. Involvement of the retina is the hallmark of the disease, which manifests as follows: periphlebitis, retinal capillary ischemia most often affecting the periphery with secondary proliferative retinopathy and retinal and/or papillary neovascularization, recurrent vitreous hemorrhages and tractional retinal detachment. These complications are potentially blinding. The natural history of Eales disease varies, with temporary or permanent remission in some cases and continuous progression in others. Progression is often bilateral, which necessitates regular follow-up. The treatment of Eales disease depends on the stage of the disease and is not well defined. Observation only, pars plana vitrectomy surgery and/or intravitreal injections of anti-VEGF are recommended in cases of vitreous hemorrhage, associated with corticosteroids when retinal vasculitis is present. Laser pan-retinal photocoagulation is necessary when neovascularization is present.

Vitreous hemorrhage in children and adolescents in India

PURPOSE

To report the clinical profile, etiologies, treatment modalities, and outcomes for vitreous hemorrhage in patients <18 years of age in India.

METHODS

The medical records of patients presenting with vitreous hemorrhage between January 2000 and January 2010 were retrospectively reviewed.

RESULTS

A total of 261 eyes of 246 patients (201 males) were included. Of these patients, 231 (94%) were unilateral. Trauma was the leading cause of injury in 179 eyes (68.5%); blunt trauma was more common than penetrating trauma in both males (64.7%) and females (57.7%). Wooden sticks were the most common cause of trauma (20.7%). Spontaneous causes accounted for 82 (31.5%) eyes, including 33 eyes (40%) with Eales disease, and 16 eyes (19.7%) with sequelae of retinopathy of prematurity. Trauma was most common cause of vitreous hemorrhage in all age groups, except in children <4 years of age, in whom spontaneous hemorrhage predominated. Overall, the most common management was surgery, performed in 173 (66.2%) eyes; 63 (24.1%) eyes were observed. Male sex, age >8 years, unilateral presentation, surgical treatment (P < 0.001), and blunt trauma (P = 0.047) were associated with severe visual loss. Mean follow-up was 636.5 ± 802.0 days overall, 597.0 ± 749.0 days for eyes observed and 638.8 ± 802.6 days for eyes that underwent surgery.

CONCLUSIONS

Posttraumatic vitreous hemorrhage comprises almost two-thirds of children and adolescents presenting with vitreous hemorrhage. Blunt trauma is more common than penetrating trauma. Male sex, age >8 years, unilateral presentation, and surgical treatment were all significantly associated with severe visual loss.

Profile of retinal vasculitis in a tertiary eye care center in Eastern India

Aims:

To provide a fact file on the etiology, clinical presentations and management of retinal vasculitis in Eastern India.

Materials and Methods:

Retrospective, record based analysis of retinal vasculitis cases in a tertiary care center in Eastern India from January 2007 to December 2009.

Results:

One hundred and thirteen eyes of 70 patients of retinal vasculitis were included in this study. Sixty (85.7%) patients were male (mean age 33± 11.1 years) and 10 (14.3%) were female (mean age 32.4 ± 13.6 years). Vasculitis was bilateral in 43 (61.4%) and unilateral in 27 (38.6%) patients. Commonest symptoms were dimness of vision (73; 64.6%) and floaters (36; 31.9%). Vascular sheathing (82; 72.6%) and vitritis (51; 45.1%) were commonest signs. Mantoux test was positive in 21 (30%) patients but tuberculosis was confirmed in only four (5.71%) patients. Raised serum angiotensin-converting enzyme level and positive antinuclear antibody level were reported in four (5.71%) patients each. Human leukocyte antigen B5 (HLA B5) marker was present in one (1.4%) patient. However, none of the total 70 patients were found to have a conclusively proven systemic disease attributable as the cause of retinal vasculitis. Oral corticosteroid (60; 85.7%) was the mainstay of treatment. Forty-eight (42.5%) eyes maintained their initial visual acuity and 43 (38%) gained one or more line at mean follow-up of 16.6± 6.3 months.

Conclusion:

Retinal vasculitis cases had similar clinical presentations and common treatment plan. There was no systemic disease association with vasculitis warranting a careful approach in prescribing investigations.

Retinal Vasculitis

Retinal vasculitis is a sight-threatening intraocular inflammation affecting the retinal vessels. It may occur as an isolated ocular condition, as a manifestation of infectious or neoplastic disorders, or in association with a systemic inflammatory disease. The search for an underlying etiology should be approached in a multidisciplinary fashion based on a thorough history, review of systems, physical examination, and laboratory evaluation. Discrimination between infectious and noninfectious etiologies of retinal vasculitis is important because their treatment is different. This review is based on recently published articles on retinal vasculitis and deals with its clinical diagnosis, its link with systemic diseases, and its laboratory investigation.

Eales' disease: the great masquerader

BACKGROUND

Eales' disease, also known as idiopathic retinal periphlebitis, is a diagnosis of exclusion, mainly affecting men in the second through fourth decades of life. Although less common in the United States, Eales' disease is widespread in India and certain areas of the Middle East.

CASE REPORT

A healthy, 42-year-old Filipino man presented with reduced vision in the right eye of 2 days' duration and had recently had a nonrhegmatogenous retinal detachment diagnosed. Clinical findings included angle neovascularization, posterior vitritis, intraretinal hemorrhages, and retinal vascular sheathing in that eye. Systemic evaluation did not disclose an underlying etiology. Eales' disease was diagnosed. Treatment included topical steroids and cycloplegia, along with intravitreal triamcinolone acetonide injection, which yielded an improvement in the vasculitis and vitritis with subsequent visual improvement and stabilization.

CONCLUSION

Eales' disease should be considered as a differential diagnosis in patients with vasculitis and vitritis.

Proinflammatory cytokines and angiogenic and anti-angiogenic factors in vitreous of patients with proliferative diabetic retinopathy and eales' disease

PURPOSE

To investigate the mechanism of angiogenesis in proliferative diabetic retinopathy (PDR) and Eales' disease (ED) on the basis of the levels of proinflammatory cytokines, angiogenic growth factor, and antiangiogenic factor in the vitreous humor.

METHODS

Twenty-five patients with PDR, 10 patients with ED, and 25 with macular hole (MH) as control subjects were studied. The concentration of the proinflammatory cytokines interleukin-6 (IL-6), IL-8, IL-1 beta; chemokine-monocyte chemoattractant protein-1 (MCP-1); angiogenic factor-vascular endothelial growth factor (VEGF); and antiangiogenic factor-pigment epithelium derived factor (PEDF) in the vitreous fluid obtained from the eyes during vitrectomy were measured by sandwich enzyme linked immunosorbent assay (ELISA).

RESULTS

IL-6, IL-8, MCP-1, and VEGF levels in the vitreous were significantly higher in PDR (P < 0.0001) and ED (P < 0.0001) than in MH patients. Conversely, the vitreous level of PEDF was significantly reduced in PDR (P < 0.0001) but not in ED. A significant correlation was observed between VEGF and IL-6 in ED patients.

CONCLUSION

The authors demonstrate the importance of VEGF in retinal neovascularization of ED which is an idiopathic inflammatory venous occlusion. Further study is required to understand the interrelationship between VEGF and inflammatory cytokines in PDR and ED.

Treatment of neuro-ophthalmologic manifestations of tuberculosis

In the absence of obvious pulmonary or disseminated tuberculosis, ocular and central nervous system (CNS) tuberculosis may represent a significant diagnostic challenge. Refinements in polymerase chain reaction techniques and neuroimaging have strengthened the battery of tests used to diagnose CNS and ocular tuberculosis, yet in many cases, the diagnosis remains one of exclusion; it may ultimately be determined through exacerbation by anti-inflammatory therapy with subsequent improvement by antitubercular medication treatment. Because of emerging drug resistance, at least a two-drug regimen is required for therapeutic testing and treatment of isolated ocular tuberculosis. If pulmonary or miliary disease coexists, a 6-month, four-drug regimen with isoniazid, rifampin, pyrazinamide, and ethambutol is required for treatment. Tubercular meningitis is treated with the same four-drug regimen for at least 9 to 12 months. Burden of therapeutic compliance rests on the treating physician and public health sector. Best compliance is realized with directly observed therapy.

Full panretinal photocoagulation and early vitrectomy improve prognosis of retinal vasculitis associated with tuberculoprotein hypersensitivity (Eales' disease)

BACKGROUND/AIMS

Eales' disease is an uncommon vasoproliferative retinal disease affecting otherwise healthy young men that is characterised by obliterative retinal periphlebitis, with sequelae such as recurrent vitreous haemorrhage and traction retinal detachment. This study was undertaken to determine whether visual prognosis of Eales' disease could be improved by appropriate medical and surgical treatment.

METHODS

The authors retrospectively studied 30 patients (46 eyes) who were treated from 1992 to 2001. Recorded data included patient age, sex, race, medical history, medications, results of the ophthalmological examination, results of diagnostic laboratory evaluation, and details of systemic and surgical treatments. The mean follow up was 10.6 months.

RESULTS

19 patients (23 eyes) who presented with active periphlebitis received systemic steroids and antituberculous therapy. Extensive full panretinal photocoagulation was performed in 21 eyes that presented with new vessel formation and peripheral capillary closure with or without vitreous haemorrhage. Vitrectomy and endolaser panretinal photocoagulation was necessary in 15 eyes, for severe non-clearing vitreous haemorrhage in 11 eyes and vitreous haemorrhage with traction retinal detachment in four eyes. Complete regression of the disease was achieved in all eyes. Vitrectomy resulted in a significant visual improvement with 14 of the 15 eyes (93.3%) achieving > or =20/200 visual acuity. Overall, the distribution of visual acuities among eyes improved from presentation to final follow up, with 36.4% of eyes having 20/40 or better acuity at presentation compared with 63.6% of eyes by final follow up.

CONCLUSIONS

These results suggest that aggressive treatment of Eales' disease with systemic steroids and antituberculous therapy, full panretinal photocoagulation and early vitrectomy, when necessary, may result in improving the anatomic and visual outcome.

Eales disease--an update

Eales disease, first described by Henry Eales in 1880, remains an enigma. The disease, observed more commonly in the Indian subcontinent than in the rest of the world, occurs in young healthy adult males, initially presenting as retinal periphlebitis and later as retinal ischemia that may lead to vascular alterations and neovascularization. Recurrent vitreous hemorrhage with or without retinal detachment is the common sequelae. In recent years, immunological, molecular biological, and biochemical studies have indicated the role of human leukocyte antigen, retinal autoimmunity, mycobacterium tuberculosis genome, and free radical mediated damage in the etiopathogenesis of this disease. However, its etiology appears to be multifactorial. The management depends on the stage of the disease and consists of medical treatment with oral corticosteroids in the active inflammatory stage and laser photocoagulation in the advanced retinal ischemia and neovascularization stages. The results of vitreoretinal surgery have been found to be satisfactory in case of vitreous hemorrhage with or without retinal detachment.