Treatment of presumed trematode-induced granulomatous anterior uveitis among children in rural areas of Egypt

Clinical Insights: Antimicrobial Therapy for Infectious Uveitis

Infectious uveitis is a major global cause of vision impairment. Despite the eye's immune privilege, afforded by the blood-ocular barrier that restricts microbial entry, several pathogens such as bacteria, viruses, fungi, and parasites can still infiltrate and cause ocular infections and complications. Clinicians often encounter significant challenges in treating infectious uveitis due to limited or ineffective treatment options. Modern molecular techniques and imaging can aid in diagnosing and assessing intraocular infections. Various antimicrobial therapies exist, spanning topical and systemic treatments, but these are constrained by issues like drug concentration, penetration, effective duration, toxicity, and side effects. Treatment approaches also differ based on the infection's etiology. This review provides recent updates on antimicrobial therapies from a clinical perspective, covering topical, systemic, and regional treatments for infectious uveitis.

Demographic and Clinical Profile of Pediatric Uveitis in Delta Region, Egypt

PURPOSE

Pediatric uveitis poses unique challenges, characterized by difficulties in performing comprehensive examinations, potential delays in diagnosis, and a heightened risk of ocular complications. This study evaluate the etiologic and clinical characteristics of uveitis in children presenting to the Mansoura Ophthalmic Center, Mansoura, Egypt.

METHODS

A cross-sectional observational study was undertaken involving children diagnosed with uveitis attending the uveitis outpatient clinic at Mansoura University Ophthalmic Center. Comprehensive clinical evaluations were carried out, including detailed history taking and exhaustive ophthalmological examinations. Whenever deemed necessary, Spectral Domain Optical Coherence Tomography (OCT) and Fluorescein Fundus Angiography (FFA) were utilized to secure retinal images. An extensive systemic evaluation was also conducted to discern the diverse causes of uveitis among the participants.

RESULTS

The cohort comprised 63 children, impacting 97 eyes. Bilateral involvement was seen in 54% of cases, with a male predominance of 58.7%. The predominant etiologies of uveitis were presumed trematode-induced (36.7%), Juvenile Idiopathic Arthritis (JIA) accounting for 28.6%, and in 12.7% of cases, the cause remained undetermined. Anterior uveitis emerged as the primary presentation in 79.4% of cases. Regarding visual loss, cataract was the leading cause at 56.4%, followed by vitritis at 38.4%, and macular edema at 20.5%.

CONCLUSION

Anterior uveitis was the most frequent presentation in our pediatric cohort. Despite the challenges, the majority of children with uveitis exhibited no significant visual impairment, with most causes of visual loss being reversible.

Metagenomic analysis of the ocular toxoplasmosis in children uveitis from Fayoum governorate, Egypt

Granulomatous anterior uveitis with single or numerous gelatinous nodules was found in children living in rural Egypt. All ocular diseases were originally thought to be water-born and related to digenic flukes. The current study sought to learn more about the causes of anterior granulomatous uveitis in Egyptian youngsters who used to swim in rural water canals. 50 children with eye lesions that had not responded to medical treatment were recruited. Four samples were surgically extracted and examined using real-time PCR, transmission electron microscopy (TEM), and shotgun metagenomic sequencing (SMS). Toxoplasma gondii was detected free within the syncytium's distal section, while the proximal part exhibited active synthesis of a presumably extra-polymeric material, possibly released by the microbial population. Toxoplasma gondii was found in 30 samples. Serologically, distinct anti-Toxoplasma antibodies were not found in 91.6% of patients. SMS showed that the T. gondii ME 49 strain had the greatest percentage (29-25%) in all samples within an Acinetobacter-containing microbial community. These findings suggested that these bacteria entered the body via the exterior route rather than the circulatory route. The lack of genetic evidence for subsequent parasite stages invalidates the prior findings about the assumed trematode stage.

Infectious eye disease in the 21st century-an overview

Infectious diseases affecting the eye often cause unilateral or asymmetric visual loss in children and people of working age. This group of conditions includes viral, bacterial, fungal and parasitic diseases, both common and rare presentations which, in aggregate, may account for a significant portion of the global visual burden. Diagnosis is frequently challenging even in specialist centres, and many disease presentations are highly regional. In an age of globalisation, an understanding of the various modes of transmission and the geographic distribution of infections can be instructive to clinicians. The impact of eye infections on global disability is currently not sufficiently captured in global prevalence studies on visual impairment and blindness, which focus on bilateral disease in the over-50s. Moreover, in many cases it is hard to differentiate between infectious and immune-mediated diseases. Since infectious eye diseases can be preventable and frequently affect younger people, we argue that in future prevalence studies they should be considered as a separate category, including estimates of disability-adjusted life years (DALY) as a measure of overall disease burden. Numbers of ocular infections are uniquely affected by outbreaks as well as endemic transmission, and their control frequently relies on collaborative partnerships that go well beyond the remit of ophthalmology, encompassing domains as various as vaccination, antibiotic development, individual healthcare, vector control, mass drug administration, food supplementation, environmental and food hygiene, epidemiological mapping, and many more. Moreover, the anticipated impacts of global warming, conflict, food poverty, urbanisation and environmental degradation are likely to magnify their importance. While remote telemedicine can be a useful aide in the diagnosis of these conditions in resource-poor areas, enhanced global reporting networks and artificial intelligence systems may ultimately be required for disease surveillance and monitoring.

Outcome of cataract surgery in children with presumed trematode-induced granulomatous anterior uveitis

PURPOSE

To examine the 6-month visual outcomes and complications following cataract surgery in patients with persumed trematode induced granulomatous anterior uveitis.

SETTING

Assiut university hospital, Assiut, Egypt.

DESIGN

This is a retrospective non comparative case series study.

METHODS

Patients presenting with significant cataract secondary to uveitis caused by trematode induced anterior chamber granuloma were included in this study. Cases with active anterior uveitis, within the last 3 months preceding surgery, and those with a history of trauma, were excluded from this study. Data collected included demographic characteristics, history of the condition including when uveitis started, treatment received and history of other health conditions that may be relevant to uveitis.Complete opthalmologic examination including assessment of best corrected visual acuity (BCVA) and OCT macula, if possible, were done. These was repeated 1 week, 1 month, 3 months and 6 months after surgery. Specular microscopy was performed preoperatively and 3 months after surgery. Patients underwent cataract surgery with posterior chamber intra ocular lens and statistical analysis was performed to compare preoperative and postoperative BCVA and corneal endothelial cell counts. Postoperative complications were recorded.

RESULTS

Five eyes of 5 patients were included in the study. All study eyes showed improvement in the post-operative visual acuity. A statistically significant improvement was observed in VA in the sixth postoperative month compared to the baseline measurements (p = 0.004). No statistically significant difference was observed between the preoperative and postoperative endothelial cell counts (p = 0.696). Cystoid macular edema did not occur as a postoperative complication.

CONCLUSION

Visual outcomes of cataract surgery in eyes with persumed trematode induced granulametous anterior uveitis are favorable. No sight threatening complication was observed in our series.

Posterior Segment Involvement in Childhood Presumed Trematode Induced Granulomatous Anterior Uveitis

PURPOSE

To outline posterior segment characteristics of presumed-trematode induced granulomatous uveitis.

DESIGN

A cross-sectional case series.

METHODS

The study included 56 patients (60 eyes) presented with anterior chamber (AC) granulomas. Involvement of the posterior segment structures has been documented and reported.

RESULTS

The mean age of the patients was 11.8 years (range 6-14 years). Posterior segment findings were vitritis in 9 eyes (15%), optic disc granuloma in 2 eyes (3.3%), optic disc hyperaemia in one eye (1.7%), macular oedema in 2 eyes (3.3%), epiretinal membrane in 3 eyes (5%), retinal vasculitis in one eye, a peripheral focus of retinitis in one eye (1.7%), and choroid thickening in 10 eyes (6.7%), with localised choroidal granuloma in one eye (1.7%).

CONCLUSION

Presumed trematode-induced anterior chamber (AC) granuloma is not only restricted to the anterior segment of the eye, but posterior segment associations that may threaten vision should also be considered.

Management of presumed trematode-induced granulomatous intermediate uveitis

PURPOSE

To describe the surgical management of presumed trematode-induced granulomatous intermediate uveitis (PTIGIU) not responding to medical treatment in controlling the inflammation.

METHODS

A prospective, interventional, single-center study in which patients with a history of fresh canal water contact and PTIGIU were enrolled. All patients underwent lensectomy-pars plana vitrectomy (PPV) and post-operative control of inflammation, functional and anatomical outcomes were assessed.

RESULTS

Fifteen eyes of 12 patients were included in the study with median age of 11.6 ± 4 yrs. Six months following lensectomy-PPV, inflammation was well controlled in all patients. The eyes were divided into two groups: Group A: 10 patients with an attached retina while Group B: 5 patients who were in the cicatricial stage with tractional retinal detachment. All patients in group A had CDVA of 20/40 or better, unlike patients in group B who failed to achieve a CDVA better than 20/70 throughout their follow-up. In group B, final anatomical success was achieved in only 40% with hypotony occurring in 20%.

CONCLUSION

PTIGIU is associated with the presence of ciliary body granuloma which, if left untreated, can lead to drastic outcomes. Early lensectomy-PPV represents a viable management option in cases resistant to medical treatment, with a favorable outcome.

Surgical outcomes of complicated cataract with pediatric trematode granulomatous uveitis

AIM

To describe the clinical characteristics and surgical outcomes of complicated cataract with pediatric trematodal granulomatous uveitis (TGU).

METHODS

Patients of cataract with TGU in the membranous (inactive) stage underwent cataract surgery with intraocular lens (IOL) implantation. Preoperative history and ophthalmic examination were conducted for all cases, whereas Schimphlug imaging and corneal topography were done for some patients. Postoperative follow up was done on the 1^st, 2^nd, and 5^th postoperative days after surgery. Then, it was done at least at one, three, and six months postoperatively. Intraoperative and postoperative complications and the methods of their management were reported.

RESULTS

Twelve eyes of 12 male children were included in this study ranging from 8 to 16y. The mean best corrected Snellen visual acuity (BCVA) was significantly improved from 0.09±0.06 preoperatively to 0.37±0.11 at the final visit 6mo postoperatively (P<0.001). Schimphlug imaging and corneal topography showed flattening of the anterior surface of the inferior cornea. Intraoperative difficulties and complications included the poor dilatability of the drown down pupil, strong posterior synechia between the anterior lens capsule and the iris at the site of the inferior retrocorneal vascularized membrane and hyphema. All cases underwent primary hydrophobic IOL implantation.

CONCLUSION

Surgery for this type of cataract is relatively safe and effective. It is associated with some specific difficulties and complications that should be considered during surgery and follow up.

Characteristics of Childhood Presumed Trematode-Induced Granulomatous Anterior Uveitis Using Ultrasound Biomicroscopy

PURPOSE

To investigate the UBM characteristics of presumed trematode-induced granulomatous uveitis.

DESIGN

Prospective case series.

METHODS

Thirty patients who presented with anterior chamber (AC) granuloma were included. UBM Imaging included Cornea, iris, AC angle, posterior chamber, ciliary body, and vitreous base.

RESULTS

Thirty eyes were included with a mean age of 12.4 ± 2.5 years. UBM findings were retrocrneal membrane (33%), sub conjunctival nodule (10%), AC granuloma (100%); peripheral anterior synechia, granuloma-like lesion in posterior chamber; ciliary body edema with localized granuloma at specific site (100%), cataract in 30% either localized or generalized, and dot or thread-like high reflection on vitreous base in (20%).

CONCLUSION

Presumed trematode-induced AC granuloma is common among children living in the rural areas of Egypt. UBM examinations can demonstrate various pathologic changes of anterior segment of the eye and provide objective evidence for the exact origin of those granulomas.

Argon laser photocoagulation for treatment of presumed trematode-induced granulomatous anterior uveitis in children

Background/Aims

To assess the safety and efficacy of argon laser photocoagulation as a new modality for the treatment of presumed trematode-induced granulomatous anterior uveitis (PTGAU) in children.

Methods

Forty-eight eyes of 48 children with PTGAU with pearl-like nodule(s) in the anterior chamber were included in this prospective non-randomised controlled clinical trial. The patients were divided into two groups: those in Group A (23 eyes) were treated with one session of argon laser applied to the anterior chamber nodules and those in Group B (25 eyes) received medical treatment in the form of topical steroid and cycloplegic eye drops with trans-septal triamcinolone injections. All cases were followed up for 3 months with measurement of visual acuity (VA), assessment of the anterior chamber reaction and measurement of the pearl-like nodule size.

Results

In Group A, 22 eyes (95.65%) showed regression of the pearl-like nodules with resolution of the anterior chamber reaction (flare and cells) and improvement in visual acuity from 0.52±0.12 to 0.06±0.08 logMAR (p<0.001). Such improvement was maintained within the 3-month follow-up period. In Group B, 23 eyes (92%) showed initial regression of the granulomas, which was maintained in only 14 eyes (56%),with nine eyes experiencing recurrence after 3 months of follow-up.

Conclusion

Argon laser photocoagulation is a safe and effective novel treatment for PTGAU with pearl-like nodules in the anterior chamber in children. Larger studies with longer follow-up periods are needed to confirm these results.

Aqueous humor cytokines and cellular profiles in pediatric ocular granulomas caused by theTrematode Fluke Procerovum sp

Background: Children from coastal areas of South India develop granulomatous eye disease after swimming in their village ponds, the causative organism being trematode Procerovum.Aim: To understand the pathogenesis by analyzing the cellular profile, cytokines, and chemokines of aqueous fluid.Methods: This was a prospective study over 1 year on pediatric patients with ocular granuloma caused by a Trematode Fluke Procerovum sp. Granuloma was aspirated along with 100 µl volume of aqueous humor. Immunohistochemical analysis of granuloma was performed. Bio-Plex Pro™ Human Cytokine 17-plex Assay (M5000031YV) was used to measure cytokine and chemokines.Results: The immunohistochemistry revealed predominantly eosinophils, followed by macrophages (CD68+) and T - lymphocytes (CD4+). Both T-helper (Th) 1 and 2 mediated cytokines and chemokine levels were significantly high. As the disease duration increased, direct Th1 response reduced and was replaced by IL-12 and IL-17 mediated secondary Th1 response.Conclusion: Procerovum associated granulomatous disease is immunologically characterized by Th1 and Th2 cell-mediated responses. A balance between both arms maintains the eyes between granulomatous inflammation and healing by fibrosis.

Argon Laser Photocoagulation for Treatment of Presumed Trematode-induced Granulomatous Anterior Uveitis in Children.. [DOI: 10.1101/2020.12.30.20248850]

Background/Aims

To assess the safety and efficacy of argon laser photocoagulation as a new modality for the treatment of presumed trematode-induced granulomatous anterior uveitis (PTGAU) in children.

Methods

Forty-eight eyes of 48 children with PTGAU with pearl-like nodule(s) in the anterior chamber were included in this prospective non- randomised controlled clinical trial. Patients were divided into two groups: group A (23 eyes) was treated with one session of argon laser applied to the anterior chamber nodules, and group B (25 eyes) received medical treatment in the form of topical steroid and cycloplegic eye drops with trans-septal triamcinolone injection.All cases were followed up for 3 monthswith measurement of VA, assessment of anterior chamber reaction, and size of the pearl-like nodules.

Results

In group A, 22 eyes (95.65%) showed regression of the pearl- like nodules with resolution of the anterior chamber reaction (flare and cells) and improvement in visual acuity from 0.52±0.12 to 0.06 ± 0.08logMAR (p value <0.001). Such improvement was maintained within the 3-month follow-up period. In group B, 23 eyes (92%) showed initial regression of the granulomas,whichwas maintained in only 14 eyes (56%),with 9 eyes experiencing recurrence after 3 months of follow-up.

Conclusion

Argon laser photocoagulation is a safe and effective novel treatment for PTGAU with pearl-like nodules in the anterior chamber in children. Larger studies with longer follow-up periods are needed to confirm these results.

PRECIS

Argon laser photocoagulation is a novel non-invasive line of treatment that can be added to the armamentarium for presumed trematode-induced granulomatous anterior uveitis in children.

Anterior chamber granuloma: conservative treatment versus surgical intervention

PURPOSE

A distinct pattern of granulomatous anterior uveitis, with white anterior chamber (AC) granuloma, has been reported in certain endemic areas. The aim of this work was to compare the outcome of conservative treatment to surgical intervention for the treatment of large AC granulomas presenting with moderate-severe anterior uveitis. The secondary outcome is ultrasound biomicroscopy (UBM) characterization of AC granulomas.

METHODS

This is a prospective randomized interventional study including 41 eyes of 39 patients with active AC granuloma ≥3 mm (flare & cells ≥ +2). Patients were randomly assigned to either conservative treatment in the form of topical prednisolone and cycloplegic drops with orbital floor (transseptal) injection of Triamcinolone acetonide (20 eyes) or surgery in the form of granuloma excision and AC wash (21 eyes). As a perioperative care, topical steroids and cycloplegic drops were given few days before surgery and tapered gradually over 6 weeks. Patients were followed up at first day, 2 weeks, 1 and 3 months.

RESULTS

Thirty-seven patients were males, and 2 were females (13.0 ± 3.5 years). After 2 weeks, disappearance/healing of granuloma was achieved in 20 eyes in the surgical group versus 2 eyes in the conservative group (p < 0.0001). This effect was maintained throughout the follow-up period, for the surgical group and reached up to 70%, for the medical group. At every follow-up, BCVA was better in the surgical group, but this was only statistically significant at 1 and 3 months. The granuloma appeared as a homogenous hyperreflective lesion in examined eyes (16 eyes of 15 patients).

CONCLUSION

Surgical treatment of large granulomas leads to a more complete and rapid resolution of inflammation.