The characteristic features of optical coherence tomography in posterior uveitis

Are intravitreal hyperreflective particles alike in eyes with acute toxoplasma chorioretinitis and non-infectious uveitis?

BACKGROUND

To compare distinctive features of hyperreflective particles observed on spectral-domain optical coherence tomography (OCT) sections in eyes with acute toxoplasma chorioretinitis (TC) and non-infectious uveitis (NIU).

METHODS

Medical records and the spectral-domain OCT images of the patients with TC and NIU were retrospectively reviewed. The TC and NIU groups were compared in terms of age, sex, mean OCT image quality, mean central macular thickness (CMT), presence of intraretinal fluid (IRF), presence of subretinal fluid (SRF), number of hyperreflective particles in the posterior vitreous area and mean particle measurement in the posterior vitreous area.

RESULTS

Non-infectious uveitis group included nine patients (60 %) with Behcet's uveitis, five patients (33.3 %) with idiopathic posterior uveitis or panuveitis, and the remaining patient (6.7 %) with HLA-B27 associated uveitis. Comparison of the mean age, sex distribution, mean OCT image quality, mean CMT, presence of IRF, presence of SRF and the mean number of hyperreflective particles in the posterior vitreous area between the two groups showed no statistically significant differences (p = 0.085, p = 0.051, p = 0.748, p = 0.431, p = 0.109, p = 0.080 and p = 0.152, respectively). However, the mean length of the hyperreflective particles in the posterior vitreous area was 27.22 ± 8.60 μm in the TC group, and 21.91 ± 3.58 μm in the NIU group, with a significant difference between the two groups (p = 0.036).

CONCLUSION

This pilot study aimed to assess the hyperreflective particles in the posterior vitreous area using spectral-domain OCT images and image processing software. Despite its limitations, such as the small sample size, limited understanding of the nature of hyperreflective particles, and the absence of differentiation between acute and chronic uveitis, our study points out the potential role of the measurement of the hyperreflective particle length located in the posterior vitreous in differentiating the acute infectious versus non-infectious uveitis as the hyperreflective particles tend to be larger in infectious cases.

Optical coherence tomography findings in fungal uveitis

PURPOSE

The purpose of the study was to describe the vitreal, retinal, and choroidal features of eyes affected by endogenous endophthalmitis (EE) and evaluate the effects of systemic antifungal drug treatment and pars plana vitrectomy by using spectral domain optical coherence tomography (SD-OCT).

METHODS

Medical records and SD-OCT images of eyes diagnosed with EE at a single uveitis tertiary referral center in Brazil were acquired at the time of diagnosis, after 7 days of high-dose antifungal drug treatment, and at follow-up assessments performed 30 days after resolution.

RESULTS

Thirteen eyes were enrolled in the study. All patients showed hyperreflective round-shaped lesions on SD-OCT and pre-retinal aggregates. Five eyes responded to antifungal systemic oral drugs despite showing vitreous opacity. The response to treatment was observable on optical coherence tomography (OCT) images.

CONCLUSION

Fungal endophthalmitis showed typical features on SD-OCT, facilitating early diagnosis and treatment despite the absence of vitreous culture or biopsy. This study suggests that OCT images can be used to support diagnosis by physicians who do not have access to vitreoretinal surgery.

[Acute posterior multifocal placoid pigment epitheliopathy, serpiginous choroiditis and related diseases]

Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE) and serpiginous choroiditis are two diseases classified as "white spot syndromes." Both are inflammatory/autoimmune diseases with suspected primary involvement of the choriocapillaris. The former usually has an excellent prognosis, while the latter can rapidly induce legal blindness. Whereas these diseases are well defined and well known, other entities (such as persistent placoid maculopathy or ampiginous choroiditis) with features of both APMPPE and serpiginous choroiditis have been described more recently. This review aims to describe demographic characteristics and multimodal imaging features to help differentiate between these four diseases.

Relationship between ultra-widefield optical coherence tomography and ophthalmoscopy for detecting posterior inflammation in posterior uveitis and panuveitis

PURPOSE

To confirm the utility of ultra-widefield optical coherence tomography (W-OCT) for diagnosing uveitis.

METHOD

We retrospectively studied patients who had been diagnosed with uveitis and had undergone W-OCT. All patients had visited at Osaka Metropolitan University between January 2019 and January 2022. On W-OCT, vitreous opacity ("W-OCT VO") and the presence of vitreous cells ("W-OCT Cells") were identified by three specialists. We compared findings from ophthalmoscopy ("Ophthalmoscopic findings") and fluorescein angiography ("FAG findings") with those from W-OCT.

RESULTS

This study investigated 132 eyes from 68 patients (34 males, 34 females; mean age, 53.97±22.71 years). Vitreous cells in posterior uveitis and panuveitis differed significantly between "W-OCT Cells" and "Ophthalmoscopic findings" for all cases (P = 0.00014). Vitreous opacities in posterior uveitis and panuveitis did not differ significantly between "W-OCT VO" and "Ophthalmoscopic findings" (P = 0.144) for all cases. Compared to "Ophthalmoscopic findings", "W-OCT Cells" offered 51.1% sensitivity and 66.7% specificity for all cases (p<0.01). Compared to "Ophthalmoscopic findings", "W-OCT VO" offered 78.6% sensitivity and 30% specificity for all cases (p = 0.19). In addition, "W-OCT Cells" did not differ significantly from "FAG findings" for all cases (P = 0.424).

CONCLUSION

W-OCT was shown to offer significantly greater sensitivity than ophthalmoscopy for detecting vitreous cells. The results of this study may add an option for the evaluation of uveitis.

A systematic review of OCT and OCT angiography in retinal vasculitis

BACKGROUND

Retinal vasculitis is a component of uveitis for which the Standardisation of Uveitis Nomenclature (SUN) working group has no standard diagnostic criteria or severity grading. Fluorescein angiography is the gold standard test to assess retinal vasculitis, but is invasive and time-consuming. Optical coherence tomography (OCT) provides non-invasive detailed imaging of retinal structures and abnormalities, including blood vessel architecture and flow with OCT angiography (OCT-A). However, use of OCT in retinal vasculitis beyond assessing macular oedema, is not well established. We conducted a systematic review to understand the features of retinal vasculitis in OCT, Enhanced-depth imaging OCT (OCT-EDI) and OCT-A imaging.

METHODS

The systematic search was done in March 2022 and updated in January 2023, through PubMed, EMBASE and the Web of Science database for studies related to OCT, OCT-EDI and OCT-A findings and retinal vasculitis. Bias assessment was assessed using JBI Critical Appraisal Checklist, and any findings associated with retinal vasculitis were extracted by qualitative analysis.

RESULTS

We identified 20 studies, including 8 articles on OCT, 6 on OCT-EDI and 6 on OCT-A. The studies included analytical retrospective studies, case-series, and a case-control study. Five OCT studies reported secondary complications could be detected, and four reported retinal thickness alteration in retinal vasculitis. Five studies explored choroidal thickness alteration in OCT-EDI, and four explored capillary density alterations in retinal vasculitis using OCT-A. The heterogeneity in the studies' analysis and design precluded a meta-analysis.

DISCUSSION

There were no clear OCT, OCT-EDI or OCT-A findings that demonstrated potential to supersede fluorescein angiography for assessing retinal vasculitis. Some signs of macular structural effects secondary to retinal vasculitis may help prognostication for vision. The OCT signs of inflamed retinal vessels and perivascular tissue is an unexplored area.

Characteristics of Cellular Infiltration into Posterior Vitreous in Eyes with Uveitis on the Classification Basis Assessed Using Optical Coherence Tomography

Purpose

To evaluate the characteristics of posterior vitreous cells in patients with uveitis on the classification basis using spectral domain optical coherence tomography (SD-OCT).

Methods

In this retrospective chart review, all eyes were classified into three groups: infectious uveitis (IFU, n=7), noninfectious granulomatous uveitis (NIGU, n=13), and noninfectious nongranulomatous uveitis (NINGU, n=13). We measured the size, number, and density of vitreous hyperreflective particles in the posterior vitreous area that was defined as the space between the vitreous top and the internal limiting membrane on OCT. The correlations between vitreous haze and vitreous particles were also evaluated.

Results

Thirty-three eyes from 23 patients with active posterior uveitis were included. IFU had significantly more particles than NIGU and NINGU (P=0.03 and P<0.001, respectively). The vitreous particle density was higher in IFU than in NIGU and NINGU (P=0.03 and P=0.003, respectively). The mean largest particle size was greater in IFU and NIGU than in NINGU (P=0.01 and P=0.03, respectively). The median vitreous haze of 2+ in IFU, 1+ in NIGU and NINGU showed no significant difference among three groups (P=0.21). Conversely, the correlation of the largest particle size with vitreous haze was significant at ρ= 0.44 (P=0.01).

Conclusion

SD-OCT may be useful for assessing ocular inflammation based on morphological characteristics of vitreous particles on the uveitis classification basis.

Spectral Domain Optical Coherence Tomography Findings in Vision-Threatening Rhino-Orbital Cerebral Mucor Mycosis-A Prospective Analysis

Rhino-orbital cerebral mucor mycosis is a rare disease entity, where retinal involvement is described in the literature mostly as CRAO. However, pathological studies have shown mucor invading the choroid and retina with a neutrophilic reaction. So, it is pertinent that retinal inflammation secondary to invading mucor has some role in microstructural changes seen in the vitreous and retina of these patients. This novel study aims to describe the vitreal and retinal features of patients with vision-threatening rhino-orbital cerebral mucor mycosis and how they evolve on spectral domain optical coherence tomography (SD-OCT). This study shall also provide insight into the pathophysiology of these vitreoretinal manifestations by in vitro analysis of the exenterated orbital content. Fifteen eyes of fifteen patients with vision-threatening ROCM treated with standard care were enrolled in this study and underwent complete ophthalmic examination, serial colour fundus photography, and SD-OCT for both qualitative and quantitative analysis, at baseline and follow-up visits. SD-OCT on serial follow-up revealed thickening and increased inner-retinal reflectivity at presentation followed by thinning of both, other features such as the loss of the inner-retinal organized layer structure, external limiting membrane (ELM) disruption, necrotic spaces in the outer retina, and hyperreflective foci. Vitreous cells with vitreous haze were also seen. There was a significant reduction in CMT, inner and outer retinal thickness, total retinal thickness (all p < 0.05) with time, the quantum of reduction concentrated primarily to the inner retina. In summary, in vivo and in vitro analysis revealed that early microstructural changes were primarily a result of retinal infarctions secondary to thrombotic angioinvasion. With the late microstructural changes, there was possible sequelae of retinal infarction with some contribution from the inflammation, resulting from mucor invading the choroid and retina.

Measuring Inflammation in the Vitreous and Retina: A Narrative Review

Uveitis consists of a group of syndromes characterised by intraocular inflammation, accounting for up to 15% of visual loss in the western world and 10% worldwide. Assessment of intraocular inflammation has been limited to clinician-dependent, subjective grading. Developments in imaging technology, such as optical coherence tomography (OCT), have enabled the development of objective, quantitative measures of inflammatory activity. Important quantitative metrics including central macular thickness and vitreous signal intensity allow longitudinal monitoring of disease activity and can be used in conjunction with other imaging modalities enabling holistic assessment of ocular inflammation. Ongoing work into the validation of instrument-based measures alongside development of core outcome sets is crucial for standardisation of clinical trial endpoints and developing guidance for quantitative multi-modal imaging approaches. This review outlines methods of grading inflammation in the vitreous and retina, with a focus on the use of OCT as an objective measure of disease activity.

Vitreoretinal interface anomalies in patients with a history of toxoplasmosis retinochoroiditis

PURPOSE

To evaluate vitreoretinal interface anomalies over time in patients diagnosed with toxoplasmosis retinochoroiditis (TRC) and progression of the chronic disease.

STUDY DESIGN

Retrospective clinical study.

METHODS

The clinical records of 36 patients with TRC were studied retrospectively. All patients underwent standard ophthalmological examinations and optical coherence tomography (optical coherence tomography: OCT). Vitreoretinal interface changes and retinal layers in the macula and lesion area were evaluated.

RESULTS

The fovea was involved in 9 (25%) patients. OCT of the scar region showed retinal layer thinning and disorganization in all cases. Complete posterior vitreous detachment (PVD) was detected in 9 (25%) cases, incomplete PVD in 22 (61%) cases and no PVD in 5 (13.8%) cases. In 23 (63%) of the 36 patients with inactive TRC lesions, an epiretinal membrane (ERM) was detected by follow-up OCT, i.e., in 14 (60%) patients with incomplete PVD, 8 (34.7%) with complete PVD, and 1 (4%) with no PVD. Vitreoschisis was found in 5 of 22 patients with incomplete PVD; an ERM developed in 4 of these 5 patients. No ERM developed only in the macula, i.e., independent of the TRC scar region.

CONCLUSIONS

Vitreoretinal interface anomalies are common in patients diagnosed with TRC, including those with incomplete PVD. We observed no progression of vitreoretinal interface anomalies during the follow-up of patients diagnosed with TRC.

Differences between Mycobacterium chimaera and tuberculosis Using Ocular Multimodal Imaging: A Systematic Review

Due to their non-specific diagnostic patterns of ocular infection, differential diagnosis between Mycobacterium (M.) chimaera and tuberculosis can be challenging. In both disorders, ocular manifestation can be the first sign of a systemic infection, and a delayed diagnosis might reduce the response to treatment leading to negative outcomes. Thus, it becomes imperative to distinguish chorioretinal lesions associated with M. chimaera, from lesions due to M. tuberculosis and other infectious disorders. To date, multimodal non-invasive imaging modalities that include ultra-wide field fundus photography, fluorescein and indocyanine green angiography, optical coherence tomography and optical coherence tomography angiography, facilitate in vivo examination of retinal and choroidal tissues, enabling early diagnosis, monitoring treatment response, and relapse detection. This approach is crucial to differentiate between active and inactive ocular disease, and guides clinicians in their decisional-tree during the patients’ follow-up. In this review, we summarized and compared the available literature on multimodal imaging data of M. chimaera infection and tuberculosis, emphasizing similarities and differences in imaging patterns between these two entities and highlighting the relevance of multimodal imaging in the management of the infections.

Foveal reorganization after treatment of acute foveal toxoplasmic retinochoroiditis

Purpose

To report a patient with impaired vision due to foveal involvement of toxoplasmic retinochoroiditis, who was successfully treated with intravitreal clindamycin and dexamethasone and oral therapy with azithromycin, trimethoprim-sulfamethoxazole, and prednisolone and led to successful visual and anatomic recovery.

Case presentation

A 32-year-old man presented with three-day history of gradually decreasing visual acuity, redness, pain and photophobia of the right eye. Anterior chamber cellular reaction, vitritis and a white retinochoroiditis patch with adjacent retinal vasculitis in the fovea was suggestive of the toxoplasmic retinochoroiditis. He was treated with intravitreal clindamycin and dexamethasone injection followed by six-week regimen of azithromycin, trimethoprim-sulfamethoxazole, and prednisolone. In serial optical coherence tomography imaging, retinitis patch changed to cavitary foveal destruction. Fovea reorganized gradually, and visual acuity concurrently improved from counting finger 3 m to 20/25.

Conclusion

In foveal toxoplasmic retinochoroiditis lesions, timely treatment is associated with retinal reorganization and visual improvement.

Optical coherence tomography findings in toxoplasma retinochoroiditis

Purpose:

This study aimed to evaluate the optic coherence tomography (OCT) findings in patients with toxoplasmic retinochoroiditis (TRC).

Methods:

A total of 12 eyes of 12 patients with active TRC were included in the study. At baseline, at the first-month follow-up, at the sixth-month follow-up and at the 1-year follow-up, the TRC lesion OCT and macula OCT were evaluated.

Results:

Hyperreflectivity of the inner retinal layers and an increase in retinal thickness were observed on the OCT examinations of all the patients with an active TRC lesion. The retinal thickness decreased and the reflectivity of retinal layers was disorganized in the OCT images obtained in the follow-up period. Partial posterior hyaloid detachment (PHD) and no PHD were detected in 11 cases and 1 case, respectively. Epiretinal membrane (ERM) had developed in the adjacent region of the scar in 7 patients. With the regression of the lesion, the disruption of the ellipsoid zone (EZ), retinal pigment epithelium (RPE) and external limiting membrane (ELM) improved in the adjacent areas. In all the eyes, ERM and the PHD configuration did progress during the follow-up period. Vitreoschisis was found in 4 of the 11 patients with partial PHD. It was observed that ERM developed in all the patients with vitreoschisis.

Conclusion:

ERM and partial PHD were common in the TRC patients, and there was no progression during the follow-up period. Regeneration of the EZ, RPE and ELM was observed in the follow-up period.

Optical Coherence Tomographic Finding in a Case of Congenital Macular Coloboma at King Abdulaziz University Hospital, Jeddah

Macular coloboma is a rare eye condition that affects around 0.5-0.7/10,000 of live births. Macular coloboma appears as a well-demarcated atrophic lesions that could affect one eye or both eyes on fundus examination. This is a case of a 33-year-old male patient who presented to the outpatient clinic with a history of poor vision in the left eye since childhood. He had a history of strabismus surgery for sensory exotropia (XT) in the left eye. Anterior segment examination of both eyes was normal while the fundus examination of both eyes revealed bilateral chorioretinal lesions in the macula which was larger in the left eye (OS) than the right eye (OD), representing bilateral chorioretinal coloboma. Congenital coloboma is a rare eye condition that leads to non-progressive decrease in visual acuity. Optical coherence tomography (OCT) is the modality of choice in diagnosing and describing macular coloboma.

Multimodal Imaging in Ocular Toxoplasmosis

Multimodal imaging relies on combination of multiple imaging modalities to precisely delineate pathological changes in the posterior segment of the eye associated with a wide range of conditions. This combined application of fundus photography, optical coherence tomography, fundus reflectance/autofluorescence and fundus angiography (with fluorescein, indocyanine green and/or optical coherence tomography) is of great utility for assessment of patients with ocular toxoplasmosis. Multimodal imaging is helpful to characterize the typical pattern of toxoplasmic retinochoroiditis, with primary focal inflammatory involvement of the neurosensory retina, and secondary changes at the level of underlying choroid, retinal blood vessels, vitreous and even optic disc. It may also be valuable to document and follow local complications, including macular edema, vascular occlusions, and choroidal neovascularization, among others.

Imaging in Tubercular Choroiditis: Current Concepts

PURPOSE

Ocular tuberculosis has protean clinical manifestations. Because of its varied clinical presentation, multimodal imaging is very important to characterize the disease activity, presence of inflammation, determining therapeutic response, and detection of complications.

METHODS

Narrative review.

RESULTS

In this review, various imaging modalities employed in the management of ocular tuberculosis including fluorescein angiography (FA), indocyanine green angiography (ICGA), optical coherence tomography (OCT), and optical coherence tomography angiography (OCTA) have been reviewed. Not only do these imaging tools complement each other in providing a comprehensive assessment of the pathology, they also help in gaining valuable insights regarding the evolution of the disease.

CONCLUSIONS

Fundus imaging plays a vital role in the diagnosis and management of patients with posterior uveitis due to tuberculosis. Fundus imaging may have a useful role in defining clinical endpoints for ocular tuberculosis in the future.

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.

Advances in imaging of uveitis

Advances in multimodal imaging have significantly contributed to the management of many uveitis diseases in recent years. The most significant developments include the use of optical coherence tomography to obtain a more accurate and reproducible assessment of ocular inflammation, the application of optical coherence tomography angiography in choroiditis and retinal vasculitis, new possibilities for studying vitritis with ultrawide field imaging, and the most recent applications of fundus autofluorescence in uveitis. In this review, we provide an overview of the most significant advances in multimodal imaging of uveitis achieved in recent years.

Ocular syphilis mimicking Vogt-Koyanagi-Harada disease

The study aimed to present a case of ocular syphilis mimicking Vogt-Koyanagi-Harada (VKH) disease. This is an observational case report. A 59-year-old female with Sicca syndrome and rheumatoid arthritis presented to the ophthalmologic department with blurred vision of the right eye for 5 days accompanied by color sensation loss in both eyes. Bilateral disc hyperemia and serous retinal detachment at the posterior pole were noted in her both eyes by fundus examination. Fluorescein angiography revealed bilateral late dye leakage from the disc and posterior choroid. Optical coherence tomography showed bilateral subretinal fluid and choroidal thickening. The impression of her condition was VKH disease initially. However, she was later diagnosed with bilateral ocular syphilis with optic neuritis which was proved by laboratory data. After appropriate antimicrobial agent treatment, her best-corrected visual acuity, serous retinal detachment, and disc hyperemia improved. There was no recurrent intraocular inflammation even without systemic steroid or immunosuppressive therapy control during the following 1 year. Ocular syphilis can mimic many other ocular inflammatory diseases including VKH disease. It is necessary to differentiate infectious causes from inflammatory origins due to the substantially different treatment and prognosis.

Exploring choroidal angioarchitecture in health and disease using choroidal vascularity index

The choroid is one of the most vascularized structures of the human body and plays an irreplaceable role in nourishing photoreceptors. As such, choroidal dysfunction is implicated in a multitude of ocular diseases. Studying the choroid can lead to a better understanding of disease pathogenesis, progression and discovery of novel management strategies. However, current research has produced inconsistent findings, partly due to the physical inaccessibility of the choroid and the lack of reliable biomarkers. With the advancements in optical coherence tomography technology, our group has developed a novel quantitative imaging biomarker known as the choroidal vascularity index (CVI), defined as the ratio of vascular area to the total choroidal area. CVI is a potential tool in establishing early diagnoses, monitoring disease progression and prognosticating patients. CVI has been reported in existing literature as a robust marker in numerous retinal and choroidal diseases. In this review, we will discuss the current role of CVI with reference to existing literature, and make postulations about its potential and future applications.

Choroidal structural changes correlate with severity of diabetic retinopathy in diabetes mellitus

Background

This study aims to investigate the choroidal thickness and choroidal vascular density parameters and their correlation with severity of diabetic retinopathy (DR) in diabetes mellitus (DM) patients.

Methods

An observational cross-sectional study was conducted of 104 eyes, which were divided into 4 groups: Healthy controls (n = 38), DM with no DR eyes (n = 22), panretinal photocoagulation-untreated non-proliferative DR eyes (PRP-untreated NPDR eyes) (n = 24), PRP-untreated proliferative DR eyes (PRP-untreated PDR eyes) (n = 20). Optical coherence tomography (OCT) was performed. The total choroidal area (TCA), stromal area (SA), the luminal areas (LA) and the ratio of the luminal to choroidal area (L/C ratio) were compared. The choroidal parameters were also compared between PRP untreated and PRP-treated DR eyes.

Results

The L/C ratio values were 0.68 ± 0.06 in controls and 0.63 ± 0.04 in DM eyes (P < 0.001). But there were no statistically significant differences in retinal nerve fiber layer (RNFL) thickness, retinal thickness and subfoveal choroidal thickness (SCT) measurements between the two groups (P = 0.407, P = 0.654 and P = 0.849; respectively). The vessel density values were significantly different in DM with no DR eyes, PRP-untreated NPDR eyes and PRP-untreated PDR eyes (P < 0.001 for SCT, TCA and SA). The L/C ratio values in the three groups were significant different (P = 0.019). There was no significant difference in SCT, TCA, LA, SA and the L/C ratio between PRP-untreated and PRP-treated DR eyes.

Conclusion

Eyes of patients with DM showed the L/C ratio decreased compared with normal controls. The SCT increased, but L/C ratio significantly decreased with severity of DR eyes compared with DM and normal eyes. Changes in the L/C ratio may predict DR development before they are otherwise evident clinically. Choroidal blood flow deficit can be an early pathologic change in DR.

Electronic supplementary material

The online version of this article (10.1186/s12886-019-1189-8) contains supplementary material, which is available to authorized users.

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.

Modulation of three key innate immune pathways for the most common retinal degenerative diseases

This review highlights the role of three key immune pathways in the pathophysiology of major retinal degenerative diseases including diabetic retinopathy, age‐related macular degeneration, and rare retinal dystrophies. We first discuss the mechanisms how loss of retinal homeostasis evokes an unbalanced retinal immune reaction involving responses of local microglia and recruited macrophages, activity of the alternative complement system, and inflammasome assembly in the retinal pigment epithelium. Presenting these key mechanisms as complementary targets, we specifically emphasize the concept of immunomodulation as potential treatment strategy to prevent or delay vision loss. Promising molecules are ligands for phagocyte receptors, specific inhibitors of complement activation products, and inflammasome inhibitors. We comprehensively summarize the scientific evidence for this strategy from preclinical animal models, human ocular tissue analyses, and clinical trials evolving in the last few years.

Clinical and Functional Evaluation of Ocular Inflammatory Disease Using the Model of Experimental Autoimmune Uveitis

Non-infections uveitis in humans is an autoimmune disease of the retina and uvea that can be blinding if untreated. Its laboratory equivalent is experimental autoimmune uveitis (EAU) induced in susceptible rodents by immunization with retinal antigens and described elsewhere in this series (Agarwal et al., Methods Mol Biol, 900:443-469, 2012). Evaluation and quantitation of the disease is usually performed by fundus examination and/or histopathology, which provide limited information on structural and no information on functional changes as disease progresses. Here, we describe methods for systematic evaluation of disease using noninvasive clinical assessments by fundus examination and photography, optical coherence tomography, and functional evaluation by electroretinography, which are then compared to histopathology. Using these methodologies, we demonstrate that clinical variants of disease can be accurately evaluated both clinically and functionally, facilitating longitudinal follow-up and providing information that cannot be obtained by fundoscopy and histology alone. These methodologies can be useful to obtain additional information and to evaluate effects of therapeutic modalities under investigation.

Identification of unique proteins in vitreous fluid of patients with noninfectious uveitis

PURPOSE

Uveitis is a cause for concern in the developing countries like India. Its poor diagnosis and lack of proper therapeutics often cause blindness in children and young adults. Moreover, the exact mechanism of pathogenesis of different types of uveitis is still elusive. Modern proteomic techniques are found to be advantageous for an in-depth understanding of the ocular physiology using proteomic diversity. Our aim was to identify unique proteins involved in the pathogenesis of autoimmune or noninfectious uveitis.

METHODS

Vitreous fluid samples (n = 90) were obtained from infectious (N = 34) and noninfectious (N = 56) uveitis patients, and their protein profiles were compared by analysing sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) and 2D electrophoresis. Unique proteins were identified through matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS) and further studied for pathway analysis.

RESULTS

Protein spots having different molecular weights were observed in noninfectious vitreous fluid samples. Enzymatic digestion of these spots after MALDI-TOF MS analysis revealed different proteins. We identified 25 different proteins through SDS-PAGE and 22 through 2D electrophoresis. 50% of the proteins from SDS-PAGE were associated with heterotrimeric G-protein signalling pathway-rod outer segment phototransduction. 50% proteins from SDS-PAGE and 20% from 2D electrophoresis revealed association with de novo purine biosynthesis. Carbonic anhydrase 1 and serpin B3 were found to be common in both analyses.

CONCLUSION

High-throughput proteomic and pathway analyses have exposed the potential association of these proteins with autoimmune pathogenesis in uveitis. The exact role of most of the proteins in autoimmune uveitis is yet to be unfurled.

SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY FINDINGS IN ENDOGENOUS CANDIDA ENDOPHTHALMITIS AND THEIR CLINICAL RELEVANCE

PURPOSE

To describe vitreal, retinal, and choroidal features of eyes affected by Endogenous candida endophthalmitis (ECE) analyzed by spectral domain optical coherence tomography (SD-OCT) and to evaluate their clinical impact.

METHODS

Medical records and SD-OCT images from eyes diagnosed with ECE at four retina and uveitis tertiary referral centers were retrospectively evaluated. Spectral domain optical coherence tomography images were analyzed to evaluate the structural changes occurring in the vitreous, the retina, and the choroid in areas involved by ECE. Baseline and final best-corrected visual acuity were correlated with SD-OCT findings.

RESULTS

Fifteen eyes from nine patients were enrolled. Vitreous involvement (vitreous cells, posterior hyaloid thickening) was detected in 13/15 eyes. Peculiar hyper-reflective preretinal aggregates obscuring the underlying retina because of a shadowing effect ("rain-cloud" sign) were noticed in all eyes with vitreous involvement. Two patterns of retinal and choroidal findings were identified: the first (six eyes) confined within the inner retinal layers (Intraretinal Pattern), the second (nine eyes) involving both retina (full thickness) and choriocapillaris (Chorioretinal Pattern). None of the eyes showed both patterns. None of the eyes, regardless the pattern, showed choroidal thickening. Baseline best-corrected visual acuity was not associated with OCT pattern (P = 0.09). On the contrary, final best-corrected visual acuity was significantly higher in patients showing Intraretinal Pattern (∼20/25, 0.06 ± 0.08 LogMAR) than in subjects with Chorioretinal Pattern (∼20/50, 0.44 ± 0.30 LogMAR) (P = 0.01).

CONCLUSION

Endogenous candida endophthalmitis showed peculiar features on SD-OCT. Two distinct patterns of chorioretinal involvement influencing the final best-corrected visual acuity were identified. Spectral domain optical coherence tomography could be useful in the diagnosis, management, and outcome prediction in ECE.

Macular serpiginous choroiditis - case report

Serpiginous choroiditis represents an inflammation, often asymmetric, situated at the level of the inner choroid, which is related to the retinal pigment epithelium and the choriocapillaris. It is known as a primarily idiopathic, but there are authors who consider it an autoimmune process. Many times, fundus autofluorescence is the investigation which is guiding the diagnosis, the management, also the follow-up together with the determination of the progressive visual prognosis. Local treatment is proven to be sometimes an adjunctive treatment often effective. Abbreviations: SC = Serpiginous choroiditis; RPE = Retinal pigment epithelium.

Comparing optical coherence tomography findings in different aetiologies of infectious necrotising retinitis

Aims

To compare optical coherence tomography (OCT) features of active necrotising infectious retinitis (NIR) due to toxoplasmosis or herpesviruses and to determine distinctive OCT signs for these two causes of infectious retinitis.

Methods

OCT scans from eyes with active NIR due to varicella zoster virus (VZV), herpes simplex virus (HSV), cytomegalovirus (CMV), and toxoplasmosis (TOXO) were reviewed. All images were evaluated for the presence of previously described OCT findings in TOXO-NIR and compared with the viral group. New OCT findings were recorded and compared. Retinal and choroidal thickness were measured at the site of NIR and compared.

Results

10 eyes diagnosed with TOXO-NIR and 13 eyes affected by viral-NIR (9 CMV and 4 VZV) were analysed. All eyes showed full thickness hyper-reflectivity, disruption of the retina and a variable degree of vitritis. Among previously described OCT signs, hyper-reflective oval deposits and hypo-reflectivity of the choroid had a higher prevalence in TOXO (p=0.018 and p<0.0001, respectively). Among the new signs, hyper-reflective round deposits along the posterior hyaloid, retrohyaloid hyper-reflective spots and a disruption of the choroidal architecture were more frequent in TOXO eyes (all p<0.01). Intra-retinal oedema and hyper-reflective vertical strips within the outer nuclear layer were suggestive of a viral aetiology (p=0.045). Retinal thickness at the site of NIR did not differ between the two groups. Choroidal thickness was significantly higher in TOXO eyes (p=0.01).

Conclusions

The diagnosis of NIR is largely based on clinical and laboratory findings. OCT changes may be useful in differentiating different causes of NIR.

Choroidal and Retinal Anatomical Responses Following Systemic Corticosteroid Therapy in Vogt-Koyanagi-Harada Disease Using Swept-Source Optical Coherence Tomography

PURPOSE

To assess structural changes in retina and choroid after systemic corticosteroid therapy in Vogt-Koyanagi-Harada (VKH) disease using swept-source optical coherence tomography (SS-OCT).

METHODS

SS-OCT was conducted before treatment and during first-month follow-up in 16 eyes treated with systemic corticosteroids for active VKH. Retina was divided into five zones depending on pretreatment choroidal thickness (CT) of <100, >100 to <200, >200 to <300, >300 to <400 and >400μm, and changes in retinal thickness and CT after treatment in these zones were compared with baseline.

RESULTS

Mean CT significantly improved from 83.1±8.75 to 156.4±62.73μm(p = 0.008) in the zone with pre-CT <100μm and significantly decreased from 336.1 ± 17.28 to 266.28 ± 81.39μm(p = 0.008) in the zone with pre-CT > 300μm.

CONCLUSIONS

We have shown choroidal remodeling in VKH. SS-OCT can serve as an important noninvasive tool in assessment of treatment response in patients with VKH disease.

Choroidal Vascularity Index in Vogt-Koyanagi-Harada Disease: An EDI-OCT Derived Tool for Monitoring Disease Progression

Purpose

We assessed the application of the choroidal vascularity index (CVI) in the follow-up of Vogt-Koyanagi-Harada disease (VKH) patients derived from image binarization of enhanced depth imaging optical coherence tomography (EDI-OCT) images with Fiji software. Our secondary objective was to derive the retinochoroidal vascularity index based on en face fundus fluorescein and indocyanine green angiography (FFA and ICGA).

Methods

In this retrospective cohort study, EDI-OCT scans of 18 eyes of 9 patients with VKH were obtained at baseline within 2 weeks of acute presentation, and again at 6 to 12 months. Images with poor quality were excluded. Choroidal thickness (CT) and CVI were analyzed and compared to 13 eyes of 13 healthy controls. En face FFA and ICGA obtained from 12 eyes of 7 patients were segmented to derive retinochoroidal vascularity index.

Results

There was no statistical difference in age or sex between the study group and controls. Choroidal thickness of patients with VKH was 359.23 ± 57.63 μm at baseline, compared to 274.09 ± 56.98 μm in controls (P = 0.003). Follow-up CT in VKH patients was 282.62 ± 42.51 μm, which was significantly decreased from baseline (P = 0.0001). Choroidal vascularity index in VKH patients was 70.03 ± 1.93% at baseline, compared to 64.63 ± 1.92% in controls (P < 0.001). Choroidal vascularity index was 66.94 ± 1.82% at follow-up, significantly reduced from baseline (P < 0.0001). Fundus fluorescein angiography and ICGA retinochoroidal vascularity indices at baseline were 70.67 ± 2.65% and 66.42 ± 2.16%, respectively.

Conclusions

In this small series of VKH patients, EDI-OCT–derived CVI had a statistically significant reduction over time, similar to CT. We propose that OCT, FFA, and ICGA-derived vascularity indices may be potential novel supportive tools in monitoring disease progression in VKH.

Translational Relevance

Choroidal vascularity index can be used potentially to study and analyze the structural changes in choroid. It can be a useful tool to explain the changes in the CT in different retinochoroidal disorders. Choroidal vascularity index also can be used for longitudinal follow-up in patients with VKH disease and other inflammatory disease involving the choroid.

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.

Correlation in retinal nerve fibre layer thickness in uveitis and healthy eyes using scanning laser polarimetry and optical coherence tomography

PURPOSE

To evaluate the correlation of retinal nerve fibre layer (RNFL) thickness measured using spectral domain optical coherence tomography (SD-OCT) and scanning laser polarimetry (SLP) in uveitic eyes compared with healthy eyes.

METHODS

A descriptive, observational, prospective, consecutive, cross-sectional, controlled, monocentre case series was conducted from May to October 2015. Clinical characteristics, best-corrected visual acuity, intraocular pressure, RNFL thickness measurement with SD-OCT and SLP using GDx variable corneal compensation (GDx VCC) were performed for each patient. An evaluation of anterior chamber inflammation with laser flare-cell meter was also carried out. Correlations between SD-OCT and GDx VCC RNFL measurement were evaluated by linear regression analysis.

RESULTS

Fifty-four patients were included and divided into two groups: 50 healthy eyes in 29 patients and 42 uveitic eyes in 25 patients. The mean RNFL thickness was 98.08(±8.42) and 113.21(±20.53) μm in the healthy group and the uveitic group, respectively, when measured with SD-OCT (p<0.001); and 56.43(±5.24) and 58.77(±6.67) μm, respectively, when measured with GDx VCC (p=0.078). There was a strong correlation between total average RNFL thickness measured using SD-OCT and GDX (r=0.48, p<0.001) in healthy eyes but there was no correlation in the uveitic eyes (r=0.2, p=0.19).

CONCLUSIONS

RNFL thickness was significantly greater when measured using SD-OCT in active uveitis as compared with GDx. There was no correlation between the RNFL thickness measurements obtained using the two techniques in uveitic eyes. The discrepancies between the results suggest that for these patients both techniques should be used in conjunction to obtain an accurate measurement of RNFL.

TRIAL REGISTRATION NUMBER

IRB 00008855 Société Française d'Ophtalmologie IRB#1.

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.

Spectral domain optical coherence tomography in the evaluation and management of infectious retinitis

PURPOSE

To describe spectral domain optical coherence tomography (SD-OCT) findings of infectious retinitis, including affected layer of retinal involvement, changes at the vitreoretinal interface, and response to therapy.

METHODS

Observational case series. A retrospective review of five patients with infectious retinitis: one with toxoplasmosis, three with herpetic retinitis secondary to cytomegalovirus, and one with herpetic retinitis secondary to varicella zoster virus. Each patient underwent a complete ophthalmologic examination, fundus photography, and SD-OCT imaging (Heidelberg Spectralis; Heidelberg Engineering, Heidelberg, Germany) of the affected retina at the initial visit with serial fundus photography and SD-OCT imaging at follow-up visits. Approval was obtained from the Institutional Review Board of Northwestern University.

RESULTS

Spectral domain ocular coherence tomography of retinitis associated with Toxoplasma, cytomegalovirus, or varicella zoster virus demonstrates full-thickness disruption of the retinal architecture and overall thickening. This was in contrast to clinically imitating lesions such as cotton-wool spots, which only showed focal swelling of the inner retina. There was a clear demarcation between the area of active retinitis and unaffected retina. Inactivity was apparent when the previously affected thickened area became atrophic. The SD-OCT also demonstrated changes at the vitreoretinal interface where there was frequently a detachment of the posterior hyaloid (four of five cases) associated with overlying vitreous debris and formation of tractional changes. In the case of varicella zoster virus retinitis, this traction subsequently led to a total retinal detachment.

CONCLUSION

In the assessment of infectious retinitides, SD-OCT is a helpful adjunct to clinical examination and fundus photography. It provides high-resolution detail regarding the border of infectious activity, the vitreoretinal interface, and the differentiation of lesions that can clinically mimic active retinitis. Serial SD-OCT also provides further insight into response to therapy and postinfectious retinal changes by highlighting areas that are at greater risk for complications such as retinal detachment.

Birdshot retinochoroidopathy

Birdshot retinochoroidopathy (BSRC) is an uncommon, but well-characterized chronic, bilateral posterior uveitis, which is uniquely associated with the human leukocyte antigen-A29 phenotype. The disease presents predominantly in middle-aged Caucasian females who complain of blurred vision, floaters, photopsias, paracentral scotomas and nyctalopia. While autoimmune mechanisms are thought to play an important role in the pathogenesis of BSRC, its etiology remains unknown. Important questions remain in our understanding of BSRC with respect to its pathogenesis, epidemiology, optimal treatment, and prognosis, including the determinants of remission and relapse, as well as the best strategy for monitoring disease activity, progression and response to therapy with electroretinographic and psychophysical testing, established and emerging imaging modalities, and peripheral cytokines profiles.

Spectrum of morphological and visual changes due to vitreomacular interface disorders encountered in a large consecutive cohort of patients

AIM

Identify the incidence of vitreomacular traction (VMT) and frequency of reduced vision in the absence of other coexisting macular pathology using a pragmatic classification system for VMT in a population of patients referred to the hospital eye service.

METHODS

A detailed survey of consecutive optical coherence tomography (OCT) scans was done in a high-throughput ocular imaging service to ascertain cases of vitreomacular adhesion (VMA) and VMT using a departmental classification system. Analysis was done on the stages of traction, visual acuity, and association with other macular conditions.

RESULTS

In total, 4384 OCT scan episodes of 2223 patients were performed. Two hundred and fourteen eyes had VMA/VMT, with 112 eyes having coexisting macular pathology. Of 102 patients without coexisting pathology, 57 patients had VMT grade between 2 and 8, with a negative correlation between VMT grade and number of Snellen lines (r=-0.61717). There was a distinct cutoff in visual function when VMT grade was higher than 4 with the presence of cysts and sub retinal separation and breaks in the retinal layers.

CONCLUSIONS

VMT is a common encounter often associated with other coexisting macular pathology. We estimated an incidence rate of 0.01% of VMT cases with reduced vision and without coexisting macular pathology that may potentially benefit from intervention. Grading of VMT to select eyes with cyst formation as well as hole formation may be useful for targeting patients who are at higher risk of visual loss from VMT.

Scleral melt following Retisert intravitreal fluocinolone implant

Intravitreal fluocinolone acetonide implant (Retisert) has a high potency, a low solubility, and a very short duration of action in the systemic circulation, enabling the steroid pellet to be small and reducing the risk of systemic side effects. Scleral melt has not been reported as a possible complication of Retisert implant. The authors describe the occurrence of scleral melt 18 months after the implantation of fluocinolone acetonide implant in a 42-year-old Caucasian woman. To the authors' knowledge, this is the first report of this possible complication.

Widespread vitreoretinal traction simulating retinal vasculitis in a patient with uveitis

PURPOSE

To describe a case of uveitis with widespread vitreoretinal traction simulating retinal vasculitis angiographically.

METHODS

Interventional case report.

RESULTS

A 62-year-old woman was examined for low vision in her left eye that persisted for ∼1 year. She had been treated for polymyalgia rheumatica for 1 year. Visual acuity was 20/20 in the right eye and 20/100 in the left eye. There were a few aged vitreous cells in both eyes. On fundus examination, there was mild epiretinal membrane in the left eye. Fluorescein angiography revealed diffuse fluorescein leakage in the late phase of angiography in the macular peripapillary and superior retinal hemisphere in the left eye, which appeared similar to retinal vasculitis. With optical coherence tomography, there was vitreomacular traction on the macular, peripapillary, and major branches of vessels in the left eye. Fundus examination was normal in the right eye. Pars plana vitrectomy was performed in the left eye uneventfully. Visual acuity was 40/100 at the postoperative 1-year follow-up.

CONCLUSION

Vitreoretinal traction can be widespread and can cause diffuse fluorescein leakage resembling vasculitis or other types of uveitis.

Optical coherence tomographic findings at the fixation point in a case of bilateral congenital macular coloboma

Background

Congenital macular coloboma is a rare ocular disease that consists of atrophic lesions in the macula with well-circumscribed borders. We report the findings of spectral domain optical coherence tomography (SD-OCT) at the fixation point in a case of bilateral macular coloboma.

Case report

The subject is a 4-year-old boy. He visited our hospital at age 1 year and 4 months for the evaluation of strabismus. The fundus examination of both eyes showed round-shaped sharply-demarcated atrophic lesions involving the macula with large choroidal vessels and bared sclera at the base. Immunologic tests including toxoplasmosis, rubella, varicella, herpes virus, and human T-cell leukemia virus were all negative. At age 4 years and 1 month, cycloplegic refraction showed insignificant refractive errors and his best corrected visual acuity was 0.6 bilaterally. The SD-OCT showed a crater-like depression accompanying atrophic neurosensory retina, and the absence of retinal pigment epithelium and choroid. Examination of the fixation behavior by visuscope showed steady fixation with an area 0.5° nasal to the nasal edge of the atrophic lesion bilaterally. The SD-OCT findings at fixation area showed remaining normal retinal structures involving inner segment-outer segment (IS/OS) junction line.

Conclusion

The findings of SD-OCT have been shown to be useful in the diagnosis of macular coloboma. In the fixation point, the structure of retina and choroid were well preserved.