The Role of Dexamethasone Implant in the Management of Tubercular Uveitis

Corticosteroids for the Management of Uveitic Macular Edema: A Comprehensive Review

Uveitis, which refers to the inflammation of the uveal tract and surrounding structures in the eye, poses a significant risk of vision impairment, with macular edema (UME) being a prevalent complication. The current statement reviews UME's prevalence, pathogenesis, diagnosis, and management strategies, focusing on the utility of systemic and local corticosteroid therapy. Corticosteroids, with their multifaceted effects on inflammatory pathways, serve as the cornerstone of UME treatment. Various administration routes, including topical, periocular, intraocular, and systemic, are employed based on the anatomical type and severity of inflammation. The efficacy of different corticosteroid formulations, such as difluprednate, triamcinolone acetonide, dexamethasone implant, and fluocinolone acetonide implant, is evaluated through clinical trials and retrospective studies. Additionally, the role of corticosteroid-sparing treatments, including antimetabolites like methotrexate and mycophenolate mofetil, is explored. Emerging techniques, such as suprachoroidal space triamcinolone acetonide administration, offer promising alternatives for managing UME. Through a thorough examination of current evidence, this review provides valuable insights into optimizing the management of UME and improving visual outcomes in patients with uveitis.

Immune recovery uveitis: a focus review

Immune recovery uveitis (IRU) is an intraocular inflammation that typically occurs as part of immune reconstitution inflammatory syndrome (IRIS) in the eye. Typically, it affects human immunodeficiency virus (HIV)-infected patients with recognized or unrecognized cytomegalovirus (CMV) retinitis who are receiving highly active antiretroviral therapy (HAART). IRU is a common cause of new vision loss in these patients, and it manifests with a wide range of symptoms and an increased risk of inflammatory complications, such as macular edema. Recently, similar IRU-like responses have been observed in non-HIV individuals with immune reconstitution following immunosuppression of diverse etiologies, posing challenges in diagnosis and treatment. This review provides an updated overview of the current literature on the epidemiology, pathophysiology, biomarkers, clinical manifestations, diagnosis, differential diagnosis, and treatment strategies for IRU.

The application of dexamethasone implants in uveitis treatment

Uveitis refers to a group of ocular inflammatory diseases that can significantly impair vision. Although systemic corticosteroid therapy has shown substantial efficacy in treating uveitis, extensive use of corticosteroids is associated with significant adverse effects. Recently, a biodegradable, sustained-release implant, namely dexamethasone intravitreal implant (Ozurdex), has been reported for treating non-infectious and infectious uveitis. This review aims to summarize the experiences with Ozurdex treatment across various forms of uveitis and to assist readers in understanding the appropriate timing and potential side effects of Ozurdex in uveitis treatment, thereby maximizing patient benefits in uveitis management.

The Efficacy and Safety of Intravitreal Dexamethasone Implant as Anti-inflammatory Monotherapy in the Management of Tuberculosis-associated Intermediate Uveitis

AIM

To study the long-term efficacy and safety of Ozurdex as anti-inflammatory monotherapy in the management of tuberculosis-associated intermediate uveitis (TBIU).

METHODS

Retrospective analysis of eyes with TBIU that received Ozurdex as anti-inflammatory monotherapy with a follow-up of at least 1 year.

RESULTS

13 eyes (2 pseudophakic) of 11 patients were included. Mean BCVA improved from 0.65 to 0.11 at 3 months (p = .0005) and remained 0.11 at 1 year. Mean central foveal thickness improved from 452.87µ to 187.25µ at 3 months (p = .0009) and 184.62µ at 1 year in 8 eyes with CME. Mean vitreous haze improved from 2.38 to 0.11 at 3 months with no recurrences at 1 year. Mean IOP increased from 13.15mmHg to 15.53mmHg (p = .013) at 2 months and reduced to 12.46mmHg by 1 year. None required antiglaucoma medication. One eye underwent cataract surgery. The mean follow-up was 18.4 months.

CONCLUSION

Ozurdex is safe and efficacious in TBIU as anti-inflammatory monotherapy in conjunction with antitubercular therapy.

A New Era in Ocular Therapeutics: Advanced Drug Delivery Systems for Uveitis and Neuro-Ophthalmologic Conditions

The eye's intricate anatomical barriers pose significant challenges to the penetration, residence time, and bioavailability of topically applied medications, particularly in managing uveitis and neuro-ophthalmologic conditions. Addressing this issue, polymeric nano-based drug delivery systems (DDS) have surfaced as a promising solution. These systems enhance drug bioavailability in hard-to-reach target tissues, extend residence time within ocular tissues, and utilize biodegradable and nanosized polymers to reduce undesirable side effects. Thus, they have stimulated substantial interest in crafting innovative treatments for uveitis and neuro-ophthalmologic diseases. This review provides a comprehensive exploration of polymeric nano-based DDS used for managing these conditions. We discuss the present therapeutic hurdles posed by these diseases and explore the potential role of various biopolymers in broadening our treatment repertoire. Our study incorporates a detailed literature review of preclinical and clinical studies from 2017 to 2023. Owing to advancements in polymer science, ocular DDS has made rapid strides, showing tremendous potential to revolutionize the treatment of patients with uveitis and neuro-ophthalmologic disorders.

Intravitreal immunotherapy in non-infectious uveitis: an update

INTRODUCTION

In the past several years, there have been numerous advances in pharmacotherapeutics for the management of uveitis and other ocular inflammatory diseases, including newer therapeutic agents and ocular drug delivery systems. One of the most attractive modes of drug delivery is the intravitreal route since it has proven to be safe and efficacious and prevents unwanted systemic adverse events related to the agent.

AREAS COVERED

In this review, intravitreal delivery of various pharmacotherapeutic agents for noninfectious uveitis has been described. An extensive review of the literature was performed using specific keywords on the PubMed database to identify clinical studies employing various pharmacotherapeutic agents with intravitreal drug delivery for noninfectious uveitis. The mode of action, safety, efficacy, and tolerability of these drugs have also been elucidated.

EXPERT OPINION

Several agents, including biologic response modifier agents, have been found to be safe and efficacious for various indications of uveitis, such as cystoid macular edema, active uveitis, and other conditions such as retinal vasculitis and vitreous haze. The use of intravitreal biological therapies, especially infliximab, has been fraught with potential safety signals such as photoreceptor toxicity. However, pharmacotherapeutic agents such as corticosteroids and anti-vascular endothelial growth factor agents are now widely used in the clinical management of uveitis and its complications.

The immune response in tubercular uveitis and its implications for treatment: From anti-tubercular treatment to host-directed therapies

Tubercular uveitis (TB-uveitis) remains a conundrum in the uveitis field, which is mainly related to the diverse clinical phenotypes of TB-uveitis. Moreover, it remains difficult to differentiate whether Mycobacterium tuberculosis (Mtb) is present in the ocular tissues, elicits a heightened immune response without Mtb invasion in ocular tissues, or even induces an anti-retinal autoimmune response. Gaps in the immuno-pathological knowledge of TB-uveitis likely delay timely diagnosis and appropriate management. In the last decade, the immunopathophysiology of TB-uveitis and its clinical management, including experts' consensus to treat or not to treat certain conditions with anti-tubercular treatment (ATT), have been extensively investigated. In the meantime, research on TB treatment, in general, is shifting more toward host-directed therapies (HDT). Given the complexities of the host-Mtb interaction, enhancement of the host immune response is expected to boost the effectiveness of ATT and help overcome the rising burden of drug-resistant Mtb strains in the population. This review will summarize the current knowledge on the immunopathophysiology of TB-uveitis and recent advances in treatment modalities and outcomes of TB-uveitis, capturing results gathered from high- and low-burden TB countries with ATT as the mainstay of treatment. Moreover, we outline the recent progress of HDT development in the pulmonary TB field and discuss the possibility of its applicability to TB-uveitis. The concept of HDT might help direct future development of efficacious therapy for TB-uveitis, although more in-depth research on the immunoregulation of this disease is still necessary.

Anti-tubercular therapy in the treatment of tubercular uveitis: A systematic review and meta-analysis

We quantitatively evaluated the efficacy of antitubercular therapy (ATT) in tubercular uveitis (TBU) patients. Main outcome measures include inflammation recurrence, inflammation reduction, complete resolution of inflammation, improved visual acuity (VA), ability to taper corticosteroids to < 10 mg/day without inflammatory progression, and use of adjunctive immunosuppressants while on ATT. This review is prospectively registered in PROSPERO (CRD42020206845). Forty-nine studies reporting data for 4,017 TBU patients were included. In comparative studies, the odds ratio (OR) of inflammatory recurrence was 0.33 (95%CI:0.19-0.60) for TBU patients treated with ATT±corticosteroid versus no ATT. For TBU patients treated with ATT±corticosteroid, the pooled absolute incidences of inflammatory recurrence, inflammatory reduction, complete resolution of inflammation, and visual acuity improvement were 13% (n=310/2,216; 95%CI:9-18), 81% (n=217/276; 95%CI: 62-95), 83% (n=1,167/1,812; 95%CI: 77-89), and 65% (n=347/542; 95%CI:51-78), respectively. Corticosteroids were tapered to <10 mg/day without inflammatory progression in 91% (n=326/395; 95%CI:78-99) of patients, 9% (n=121/1,376; 95%CI:6-13) of whom were administered concomitant immunosuppressive agents alongside ATT. We conclude that treatment of TBU with ATT±corticosteroid is associated with a high level of control or improvement of inflammation. More prospective studies with detailed reporting of ATT regimens, patient subgroups, and outcomes are required to better evaluate ATT effectiveness.

Human Immunodeficiency Virus and Uveitis

Uveitis is one of the most common ocular complications in people living with the Human immunodeficiency virus (HIV) and can be classified into HIV-induced uveitis, co-infection related uveitis, immune recovery uveitis, and drug-induced uveitis. The introduction of antiretroviral therapy has considerably changed the incidence, diagnosis, and treatment of different types of HIV-related uveitis. Furthermore, the specific immune condition of patients infected with HIV makes diagnosing HIV-related uveitis difficult. Recent studies have focused on the growing prevalence of syphilis/tuberculosis co-infection in uveitis. Simultaneously, more studies have demonstrated that HIV can directly contribute to the incidence of uveitis. However, the detailed mechanism has not been studied. Immune recovery uveitis is diagnosed by exclusion, and recent studies have addressed the role of biomarkers in its diagnosis. This review highlights recent updates on HIV-related uveitis. Furthermore, it aims to draw the attention of infectious disease physicians and ophthalmologists to the ocular health of patients infected with HIV.

Tubercular serpiginous choroiditis

Tubercular association with serpiginous choroiditis, also called ‘serpiginous-like choroiditis’ or ‘multifocal serpiginoid choroiditis’ (MSC) is reported from world over, especially from endemic countries. Though the exact mechanism is not yet clear, a direct or indirect infectious trigger by Mycobacterium tuberculosis (MTB) is believed to cause choroiditis.

The link of immune mechanisms with ocular inflammation caused by MTB is emerging, and has been supported by both experimental and human data. The molecular and histopathological findings of tubercular serpiginous-like choroiditis have been demonstrated in clinicopathological reports, as well as in animal models. Young to middle-aged healthy males are more frequently affected. The choroiditis lesions of tubercular serpiginous-like choroiditis evolve as multifocal lesions, affecting the retinal periphery as well as posterior pole. They begin as discrete lesions, and spread in a serpiginoid pattern to become confluent. Fundus imaging including autofluorescence is extremely helpful in monitoring patients for response to therapy. Its diagnosis is essentially clinical. Corroborative evidence is obtained by a positive tuberculin skin test, or a positive QuantiFERON-TB Gold (Cellestis, Carnegie, Victoria, Australia) test, and/or radiological (chest X-ray or chest CT scan) evidence of TB elsewhere in the body. Systemic corticosteroids are the mainstay of therapy to control active inflammation, while ATT helps to reduce recurrence of inflammatory attacks. Immunosuppressive agents are indicated in cases with relentless progression, paradoxical worsening, or recurrent choroiditis.

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.

BTS clinical statement for the diagnosis and management of ocular tuberculosis

The BTS clinical statement for the diagnosis and management of ocular tuberculosis (TB) draws on the expertise of both TB and and ophthalmic specialists to outline the current understanding of disease pathogenesis, diagnosis and management in adults. Published literature lacks high-quality evidence to inform clinical practice and there is also a paucity of data from animal models to elucidate mechanisms of disease. However, in order to improve and standardise patient care, this statement provides consensus points with the currently available data and agreed best practice.

The use of optical coherence tomography angiography in comparing choriocapillaris recovery between two treatment strategies for multifocal choroiditis: a pilot clinical trial

PURPOSE

To compare differences in choriocapillaris flow deficit (CC FD) in multifocal choroiditis (MFC) between two treatment arms using optical coherence tomography angiography (OCTA).

METHODS

In this prospective randomized clinical trial, patients were randomized to either Group 1 which received standard tapering dose of oral corticosteroids, or Group 2 which received additional dexamethasone implant (or intravitreal methotrexate). The patients were followed-up until 12 weeks using OCTA and other imaging tools. CC FD and visual acuity between the two groups were compared at each visit.

RESULTS

Twenty-five subjects (17 males; 25 eyes) were studied (11 eyes in Group 1). There were no differences between the visual acuity or CC FD (1.12 versus 1.08 mm²; p = 0.86) at baseline between the groups. However, patients in Group 2 achieved better visual acuity (0.32 ± 0.23 versus 0.15 ± 0.11; p = 0.025) and CC FD (0.54 versus 0.15 mm²; p = 0.008) at 12 weeks.

CONCLUSIONS

OCTA is a useful tool in monitoring the CC FD recovery after treatment in MFC. Patients receiving intravitreal corticosteroid/methotrexate in addition to systemic corticosteroid showed greater resolution of CC FD on OCTA compared to those receiving only oral corticosteroids.

Tubercular Retinal Vasculitis: Diagnostic Dilemma and Management Strategies

Ocular tuberculosis (OTB) is a rare, extrapulmonary manifestation of systemic TB, which has been a global etiology of uveitis for centuries, though concentrated in the developing world. OTB remains difficult to diagnose clinically despite a plethora of conventional and modern investigations. Tubercular retinal vasculitis (TRV) is a common and specific presentation of OTB but is variably defined in the literature in terms of clinical profile and the investigations essential for diagnosis and treatment. Ironically, the need and duration of antitubercular treatment is uncertain for this manifestation of ocular TB. The rationale and utility for corticosteroids is similarly equivocal for TRV. This review attempts to tease out a commonsense approach from the best available evidence and consensus in the literature to suspect, investigate and diagnose TRV with reasonable certainty, and institute appropriate treatment with due ethnic and geographic considerations.

The clinical presentation and treatment outcomes of ocular tuberculosis: a 5-year experience in an endemic area

PURPOSE

To report the clinical presentations of ocular tuberculosis infection (OTB) and the treatment regimen and outcome in an endemic area.

METHODS

This is a retrospective case series of patients with presumed OTB treated in a tertiary teaching hospital in Hong Kong in 2014-2019.

RESULTS

Among the nineteen patients recruited, the most common clinical presentation of OTB was retinal vasculitis (42.1%), followed by scleritis, intermediate uveitis, and choroidal tuberculoma (15.8% respectively). 94.7% and 94.4% of the subjects were treated with ATT and steroid, respectively, and 31.6% were put on systemic immunosuppressant prior to the initiation of ATT. Apart from those suffering from intermediate uveitis, most demonstrated good clinical response within 8 weeks of ATT initiation.

CONCLUSION

Ocular involvement of TB has been increasingly recognized, especially in endemic regions like Hong Kong. High index of suspicion is recommended for OTB in typical clinical phenotypes or recurrent/resistant ocular inflammation unresponsive to conventional therapy. TB retinal vasculitis was the most common presentation of OTB in this study and OTB generally requires treatment with either regional or systemic steroid together with ATT.

LONGITUDINAL FOLLOW-UP OF TUBERCULAR SERPIGINOUS-LIKE CHOROIDITIS USING OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY

PURPOSE

To analyze and describe serial follow-up of choriocapillaris alterations in tubercular serpiginouslike choroiditis (SLC) using optical coherence tomography angiography (OCTA) and to compare it with multimodal imaging.

METHODS

In this prospective cohort study, patients with active tubercular SLC underwent OCTA using Optovue RTVue XR Avanti and other imaging techniques including enhanced-depth imaging OCT (EDI-OCT) (Heidelberg Spectralis; Heidelberg Engineering, Heidelberg, Germany), fundus autofluorescence, fluorescein angiography, and indocyanine green angiography. Serial imaging was performed for a total follow-up of 3 months. Choriocapillaris alterations at the site of lesions were analyzed on OCTA imaging, and their mean lesion areas were calculated.

RESULTS

Twenty-six eyes (26 patients; 20 males; mean age: 32.68 ± 10.56 years) were included. Fourteen eyes had active multifocal lesions (n = 39), whereas 12 eyes had active placoid lesions (n = 12). At baseline, OCTA showed hyporeflective flow deficit lesions corresponding to the hypofluorescent lesions on indocyanine green angiography in all eyes. In the multifocal type of SLC, the mean lesion area decreased in all eyes compared with baseline, and lesions with a lesion area less than 0.1 mm2 on OCTA showed near-complete resolution with minimal choriocapillaris atrophy. In comparison, all eyes with a placoid type of SLC showed no significant reduction in the lesion area and showed extensive choriocapillaris atrophy.

CONCLUSION

Optical coherence tomography angiography has the unique ability to demonstrate pathological flow impairment at the level of choriocapillaris in active tubercular SLC. Serial OCTA analysis reveals that large tubercular SLC lesions result in choriocapillaris atrophy as the lesions heal, whereas smaller multifocal lesions show resolution of choriocapillaris hypoperfusion with minimal atrophy.

Placoid lesions of the retina: progress in multimodal imaging and clinical perspective

Placoid lesions of the retina may be secondary to a wide spectrum of acquired inflammatory conditions that have been reported as single entities with different presentation and clinical course. These conditions include acute posterior multifocal placoid pigment epitheliopathy, persistent placoid maculopathy, serpiginous choroiditis, serpiginous-like choroiditis, relentless placoid chorioretinitis and acute syphilitic posterior placoid chorioretinitis. In this article, we will group these conditions under the name of 'placoids'. The recognition of the specific condition may be challenging in clinical practice, often resulting in diagnostic and therapeutic delay. Given the complex nature of placoids and their similarities, a systematic approach including differentiating between infectious and non-infectious aetiologies increases the chance of reaching the correct diagnosis. Detailed history and comprehensive clinical examination are the first steps to formulate a diagnostic hypothesis that should be corroborated by multimodal imaging and appropriate investigations. The advent of multimodal imaging has made it possible to extensively study placoids and revealed a constellation of specific findings that may help clinicians in the diagnostic process. The treatment of the conditions other than syphilis is complex and sometimes challenging. Our article is aimed at giving an overview of the individual entities associated with placoids and discussing the differential diagnosis. A practical and systematic approach is then proposed.

Insights into the molecular pathogenesis of ocular tuberculosis

Unclear pathogenic mechanisms underlying the ocular tuberculosis (OTB) has resulted in perplexity related to the diagnosis and management of the disease. Developments in experimental research and innovations in molecular diagnostics have recently provided a new understanding of disease pathogenesis and natural history. The current review focuses on the new insights into OTB pathogenesis, derived from in vivo and in vitro studies on Mycobacterium tuberculosis dissemination and localization into the eye, in combination with histopathological studies on chorioretinal tissue and vascular network. Advances in the knowledge of OTB have influenced disease management in the clinical setting and lead to reconsideration of the role of existing treatments and suggesting potential new therapeutic approaches.

Ocular tuberculosis: Where are we today?

Diagnosis and management of ocular tuberculosis (OTB) poses a significant challenge. Mixed ocular tissue involvement and lack of agreement on best practice diagnostic tests together with the global variations in therapeutic management contributed to the existing uncertainties regarding the outcome of the disease. The current review aims to update recent progress on OTB. In particular, the Collaborative Ocular Tuberculosis Study (COTS) group recently standardized a nomenclature system for defining clinical phenotypes, and also proposed consensus guidelines and an algorithmic approach for management of different clinical phenotypes of OTB. Recent developments in experimental research and innovations in molecular diagnostics and imaging technology have provided a new understanding in the pathogenesis and natural history of the disease.

Intravitreal Dexamethasone Implant as a Sustained Release Drug Delivery Device for the Treatment of Ocular Diseases: A Comprehensive Review of the Literature

Drug delivery into the vitreous chamber remains a great challenge in the pharmaceutical industry due to the complex anatomy and physiology of the eye. Intravitreal injection is the mainstream route of drug administration to the posterior segment of the eye. The purpose of this review is to assess the current literature about the widening use of the intravitreal 0.7 mg dexamethasone (Dex) implant, and to provide a comprehensive collection of all the ocular disorders that benefit from Dex administration. Although anti-vascular endothelial growth-factors (VEGFs) have been largely indicated as a first-choice level, the Dex implant represents an important treatment option, especially in selected cases, such as vitrectomized eyes or patients in whom anti-VEGF failed or are contraindicated. In this article, the safety profile as well as the list of the possible complications related to intravitreal Dex injection are also discussed.

Retinal vasculitis: A framework and proposal for a classification system

Retinal vasculitis, a poorly understood process involving inflammation or ischemia of the retinal vessel wall, may occur in association with a systemic process, although it can also be isolated to the retina. Because of the limited ability to perform histopathological studies on retinal vessels, there is no gold standard for diagnosis. Thus, there is utility in creating a classification system for retinal vasculitis and improving diagnostic strategies for this disease. We provide a framework for understanding retinal vasculitis based on size, location, and etiology. We hope that this information can be implemented in the clinical setting to provide some diagnostic strategies for this often confusing entity.

Management of Intraocular Infections in HIV

Purpose: Overview of treatment options for the most common intraocular opportunistic infections in patients with acquired immunodeficiency syndrome (AIDS), including ocular syphilis, ocular tuberculosis, toxoplasmic chorioretinitis, and viral retinitis. Method: Narrative Review. Results: Despite the huge advances in the development of combined antiretroviral therapy (cART) for the management of patients with human immunodeficiency virus (HIV) infection, opportunistic infections still represent a significant diagnostic dilemma and cause of ocular morbidity in patients with HIV. Conclusion: Although the treatment of intraocular infections in patients with AIDS may be challenging, prompt assessment of the clinical features and appropriate aggressive management of the underlying etiology are critical to avoid life and vision threatening.

Challenges in Treating Intraocular Inflammation in HIV Patients

Purpose: To describe the challenges faced by uveitis specialists when managing human immunodeficiency virus (HIV) -infected patients diagnosed with ocular opportunistic infections. Methods: Narrative Review Results: Management of opportunistic ocular infections in HIV-infected subjects still represents a diagnostic and therapeutic challenge. Atypical and aggressive clinical features can often mislead the correct diagnosis, leading to a delay in therapy and thus, a poor clinical outcome. The reliability of standard serological tests may be affected by the immune system response, further contributing to the diagnostic challenge. Life-long monitoring and long-term antimicrobial maintenance are necessary to avoid recurrences and disease dissemination. Conclusions: A multidisciplinary approach is needed to achieve the best standard of care for HIV patients with ocular opportunistic infections.

Paradoxical reactions in ocular tuberculosis

Paradoxical reactions following initiation of anti-tubercular therapy have been documented most often in extrapulmonary tuberculosis. A combination of factors such as delayed hypersensitivity, decreased suppressor mechanisms, and an increased response to mycobacterial antigens mediated by the host’s immune system have been implicated in the development of these reactions. Similar worsening in patients with ocular tuberculosis while on treatment has been described. It is therefore important for the clinician to be aware of this occurrence, as prompt recognition and timely institution of corticosteroids and immunosuppressants can lead to restoration of vision. In these patients, an alteration or discontinuation of anti-tubercular therapy may not be indicated.

Emerging therapies in the management of macular edema: a review

Macular edema (ME) is a major complication of several vascular and inflammatory retinal diseases. Multiple mechanisms are implicated in its development and lead to visual impairment that could be reversible (the acute stages) or not reversible (long-standing ME). For this reason, an effective approach to the treatment of ME is of paramount importance in order to prevent irreversible damage of visual function. In this review, we discuss the management of ME and, in particular, current data of studies and clinical trials about drugs that have already been evaluated or are under investigation in the management of ME. Although several diseases could lead to the development of ME, we focus on the three main causes: diabetic retinopathy (DR), retinal vein occlusion (RVO), and uveitis. The introduction into clinical practice of anti-vascular endothelial growth factor injections (ranibizumab and aflibercept) and dexamethasone implants has revolutionized the treatment of ME secondary to DR and RVO. However, new drugs are needed in the treatment of resistant forms of ME secondary to DR and RVO. A fluocinolone acetonide implant has been approved by the US Food and Drug Administration for the treatment of diabetic ME but not for RVO. Furthermore, brolucizumab and abicipar pegol have been shown to be effective in preliminary studies and have the chance to be approved soon for diabetic ME treatment. In ME secondary to uveitis, a crucial role is played by corticosteroids and non-biologic immunomodulatory drugs. However, several new biologic agents are under investigation in different clinical trials and could be important new therapeutic options in cases with a low response to first-line therapy. However, only a few of these drugs will enter the market after proving their safety and efficacy. Only after that will we be able to offer a new therapeutic option to patients affected by uveitic ME.

Enigma of serpiginous choroiditis

Serpiginous choroiditis (SC) is an asymmetrically bilateral inflammation of the choroid that leads to loss of choriocapillaris atrophy or loss of overlying retinal pigment epithelium. Over the last few decades, SC has passed through a long evolution of nomenclature, etiologies and morphological variations. Initially diagnosed in patients with tuberculosis and syphilis, SC was predominantly considered as autoimmune process. With the advancement of molecular diagnosis, a new aspect of infectious subtypes of SC has emerged out. The terminologies such as serpiginous-like choroiditis (SLC) and multifocal serpiginoid choroiditis are now used to denote the subtypes of SC which are associated with infectious etiologies especially tuberculosis. In a country endemic for tuberculosis such as India, it is very important to differentiate between classic SC and SLC before initiating aggressive immunomodulatory therapy. Also, management of paradoxical worsening of the clinical condition with antitubercular treatment is another challenge in SLC and ophthalmologists should be aware of such situations. With advent of newer imaging modalities, monitoring the patient with choroiditis and identification of complications such as choroidal neovascular membrane have become much easier. This article aims to review the existing literature on SC with a special emphasis on management of SC and SLC.

Dexamethasone intravitreal implant (OZURDEX®) for macular edema secondary to noninfectious uveitis: a review of the literature

Macular edema (ME) is the leading cause of visual loss in uveitis and may persist long after ocular inflammation has been resolved. Local steroids are the first line treatment for uveitis and uveitic ME. Dexamethasone intravitreal implant (OZURDEX®; Allergan, Inc., CA, USA) has been used to treat diabetic ME and ME secondary to retinal vein occlusion. Recent studies have also demonstrated that Ozurdex may be effective treatment for patients with persistent uveitic ME. In this review, we present the results of the real word studies concerning the efficacy and safety of Ozurdex for the treatment of uveitic ME.

Update in treatment of uveitic macular edema

Macular edema (ME) represents the most common cause for visual loss among uveitis patients. The management of uveitic macular edema (UME) may be challenging, due to its often recalcitrant nature. Corticosteroids remain the mainstay of treatment, through their capability of effectively controlling inflammation and the associated ME. Topical steroids may be effective in milder cases of UME, particularly in edema associated with anterior uveitis. Posterior sub-Tenon and orbital floor steroids, as well as intravitreal steroids often induce rapid regression of UME, although this may be followed by recurrence of the pathology. Intra-vitreal corticosteroid implants provide sustained release of steroids facilitating regression of ME with less frequent injections. Topical nonsteroidal anti-inflammatory drugs may provide a safe alternative or adjuvant therapy to topical steroids in mild UME, predominantly in cases with underlying anterior uveitis. Immunomodulators including methotrexate, mycophenolate mofetil, tacrolimus, azathioprine, and cyclosporine, as well as biologic agents, notably the anti-tumor necrosis factor-α monoclonal antibodies adalimumab and infliximab, may accomplish the control of inflammation and associated ME in refractory cases, or enable the tapering of steroids. Newer biotherapies have demonstrated promising outcomes and may be considered in persisting cases of UME.

Infectious uveitis: an Asian perspective

Several intraocular infections can present with protean manifestations posing major diagnostic and management challenges. Infections such as tuberculosis, dengue and chikungunya fever have continued to remain major endemic diseases that are associated with uveitis in the Asia Pacific region. These entities often require a high index of clinical suspicion and laboratory analysis including assays of ocular fluids and/or tissues for confirmation of the diagnosis. Infectious uveitis caused by tuberculosis, dengue and chikungunya can present with characteristic clinical features and imaging findings on ancillary investigations; that may provide clue to the early diagnosis. Use of modern imaging modalities such as enhanced-depth imaging optical coherence tomography, optical coherence tomography angiography and ultra-wide field fundus photography greatly aid in the evaluation of these conditions. In the current review, we have discussed the epidemiology, clinical phenotypes, imaging characteristics, diagnosis and management of uveitis caused by tuberculosis, dengue and chikungunya.