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

Characteristics, Etiology, and Clinical Outcome of Retinal Vasculitis in Tertiary Hospital in Thailand

OBJECTIVE

To analyze characteristics, etiology, and outcome of retinal vasculitis in Central Thailand.

METHODS

A retrospective cohort study.

RESULTS

Retinal vasculitis was found in 10% of uveitis, 74 from 741 uveitis, noninfectious (64.9%) and infectious group (35.1%). The most common cause was Behcet's disease (48.6%). Behcet's disease was the most common cause of all types of vascular leakage on angiography, including capillary (80.4%), venous (56.3%), and arterial leakage (56%). Final visual acuity was 0.86 ± 0.97 logMAR. Cataract was the most frequent complication (42.5%). Acute clinical course (p = .025) and retinal neovascularization (p = .031) were associated with infectious group. Forty-three percent of vasculitis complicated by ischemia required photocoagulation (33%) and anti-VEGF injection (17%). Furthermore, 17% of vasculitis underwent vitrectomy.

CONCLUSION

One-half of the retinal vasculitis in Central Thailand were Behcet's disease. Acute onset and retinal neovascularization may suggest infectious etiology. Retinal ischemia should be cautious and undergo early interventions to prevent sight-threatening complications.

A Comparative Study between Occlusive and Non-occlusive Retinal Vasculitis: Data from a Referral Center in Tunisia, North Africa

PURPOSE

To compare clinical profile and visual outcomes of occlusive versus non-occlusive retinal vasculitis (RV).

METHODS

A retrospective comparative study.

RESULTS

284 patients were enrolled, including 124 patients with occlusive RV (ORV) and 160 patients with non-occlusive RV (NORV). Patients with ORV were older (p ≤ 10-3), predominantly male (p ≤10-3), with less bilateral involvement (31.5% vs 53,4%; p ≤ 10^-3). Infectious RV was more frequently diagnosed in the ORV group than in the NORV group (48.8% vs 32.9%, p = .006). Behçet disease and ocular tuberculosis were the leading causes of ORV. Idiopathic RV, Behçet disease, and sarcoidosis were the most common causes of NORV. Independent predictive factors of poor visual outcome were worse baseline visual acuity in both groups (p = .006 and p ≤ 10-3, respectively), and retinal hemorrhages (p = .048) and optic atrophy (p = .040) in the ORV group.

CONCLUSION

Occlusive and non-occlusive RV have distinctive clinical and etiological profile.

The Clinical Characteristics of Noninfectious Occlusive Retinal Vasculitis

PURPOSE

To characterize the clinical features of occlusive retinal vasculitis (ORV).

DESIGN

Retrospective case series.

PARTICIPANTS

Forty-two patients with ORV.

METHODS

A retrospective chart review identified all patients with ORV seen at the University of Colorado uveitis service between January 2013 and April 2020. All included patients demonstrated noninfectious uveitis and evidence of vascular occlusion in the presence of retinal vascular inflammation on widefield fluorescein angiography.

MAIN OUTCOME MEASURES

Demographic data, visual acuity, clinical findings, and fluorescein angiography findings.

RESULTS

We identified 73 eyes from 42 patients (15 men, 27 women) with ORV. Thirty-one of 42 patients had bilateral disease. Most eyes (54/73) showed mixed arteriolar and venous vasculitis compared with primarily arteriolar (6/73) or venous (15/73) vasculitis. Thirteen of 42 patients had an underlying systemic condition, most commonly granulomatosis with polyangiitis; however, bilaterality was not associated with a systemic condition. Retinal nonperfusion was present equally in zone 2 (28/73) and zone 3 (28/73) compared with zone 1 (16/73). Retinal or iris neovascularization was present in 25 of 73 eyes. Eighteen of 42 patients required more than 1 immunosuppressive medication (average, 1.33) to prevent progressive vascular occlusive disease.

CONCLUSIONS

Occlusive retinal vasculitis is a heterogeneous entity with significant risk of visual impairment. Systemic disease was more prevalent in this specific cohort compared with cohorts from prior studies of retinal vasculitis.

Comparison of fundus fluorescein angiography, optical coherence tomography and optical coherence tomography angiography features of macular changes in Eales disease: a case series

Purpose

To study the macular features in Eales disease patients observed with fundus fluorescein angiography (FA), optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA).

Methods

A cross-sectional study was done on treatment naïve 31 eyes (23 patients) with Eales disease. Baseline parameters such as Best-corrected visual acuity (BCVA), slit-lamp bio microscopy (SLB), indirect ophthalmoscopy, FA, spectral-domain OCT {quantitative (central macular thickness [CMT]) and qualitative analysis on SD-OCT} and OCTA were performed. Any media opacity precluding the above investigations was excluded.

Results

Macular findings comprised of- epiretinal membrane, macular exudation, full thickness macular hole, sub internal limiting membrane bleed, cystoid macular oedema, neurosensory detachment and retinal thickening. Sixteen (51.6%) of our patients had macular changes as seen on all modalities together. SLB and indirect ophthalmoscopy missed macular findings in 50% patients and FA in 18.8% patients. OCT and OCTA diagnosed all macular findings. On comparison of mean BCVA in patients with macular involvement on FA, OCT and OCTA, compared to those without macular involvement, patients with macular involvement had lower BCVA (p 0.000, 0.01 and 0.001 respectively). Thus, FA missed many patients who had significant macular involvement and hence less vision.

Conclusion

Eales disease though described in literature as classically being peripheral retina disease process, also has macular involvement. OCT and OCTA are useful guides to evaluation of macular involvement in these patients. The latter seems to be superior to FA in detecting macular abnormalities in this ailment. OCTA is non-invasive and shows deep capillary plexus changes which are not shown by any other modality.

Comparison of montage with conventional stereoscopic seven-field photographs for assessment of ETDRS diabetic retinopathy severity

Background

The ETDRS stereoscopic seven-field (7F) has been a standard imaging and grading protocol for assessment of diabetic retinopathy (DR) severity score in many clinical trials. To the best of our knowledge, the comparison between montage and stereoscopic 7F has not been reported in the literature. Therefore, the main purpose of this study is to compare agreement between montage and stereoscopic seven-field (7F) photographs in the assessment of DR severity.

Methods

Stereoscopic 7F photographs were captured from subjects with DR. Montages of monoscopic 7F images were created using Adobe Photoshop CS6 Extended©. The best quality image of each stereo pair was selected and placed on a 150 × 125-inch canvas field according to the standard location from field 1 to 7. All the fields were aligned following the vessels and overlaid using the built-in blending tool. The resulting montage was utilized for grading and compared with grading on stereoscopic 7F photographs. Three independent graders were asked to assess DR severity on stereoscopic 7F photographs and montage. Severity level agreement between stereo 7F and montage was cross-tabulated and the agreement of DR severity levels between stereoscopic 7-field images and montage was analyzed using κ intergrader agreement; statistical significance was set at p < 0.05.

Results

A total of 50 eyes were included in the study. There was a substantial agreement between stereoscopic 7F and montage (κ = 0.745, κ_weighted = 0.867) in assessment of DR severity. Of 50 eyes, 80% of the cases showed complete agreement, and 100% of the cases had agreement within one-step. There was a moderate agreement among graders, and κ-value ranged from 0.4705 to 0.5803.

Conclusion

In this study, we found a substantial agreement in assessing DR severity score employing non-stereoscopic montage and stereoscopic 7F photographs.

Ultra-Wide Field Imaging Characteristics of Primary Retinal Vasculitis: Risk Factors for Retinal Neovascularization

Aim: To evaluate patterns of retinal vasculitis with ultra-wide field imaging (UWF) and ascertain the risk factors for retinal neovascularization. Methods: Consecutive patients of retinal vasculitis were included prospectively. Patients with retinal vasculitis secondary to uveitis were excluded. UWF was done for all the patients. Retinal involvement was classified into three zones and area of capillary non-perfusion was stratified into clock hours. Results: Two hundred patients were included, 85% (n = 170) were male. Mean age was 28.99 ± 10.56 years. Clinical examination revealed 65% cases (n = 130) to be bilateral, while UWF angiography detected 72.5% (n = 145) to have bilateral involvement. Retinal neovascularization was present in 47% (n = 188).Presence of posterior disease had very high odds ratio for development of retinal neovascularization as compared to cases restricted to retinal periphery (OR = 45.03, CI = 6.10-332.30, p = < 0.001). Conclusion: UWF imaging is useful in detecting retinal vasculitis, which is otherwise obscure to clinical examination and assessing risk factors for retinal neovascularization.

Pediatric Eales Disease: An Indian Tertiary Eye Center Experience

PURPOSE

To report the clinical profiles, etiologies, treatment modalities, and outcomes for Eales disease in patients younger than age 16 years in India.

METHODS

Retrospective review of medical records of patients with Eales disease who had a minimum 5-year follow-up period.

RESULTS

A total of 25 eyes of 13 patients were included. Of these 13 patients, 12 (94%) had bilateral Eales disease and 11 (84.6%) were men. Mean patient age was 14.1 years (range: 11 to 16 years). Diminution of vision (36%) was the most common presenting complaint, followed by both diminutions of vision and floaters (32%). Sclerosed vessels were seen in all eyes, and 21 (84%) eyes had active periphlebitis at presentation. Neovascularization elsewhere was seen in 20 (80%) eyes and neovascularization of the optic disc was seen in 1 (4%) eye. Veno-venous shunts were found in 12 (48%) eyes, and 18 (72%) eyes had vitreous hemorrhage. All eyes received photocoagulation; 84.6% of patients received oral steroids, with 7.7% of patients treated with azathioprine and 38.4% treated with anti-tubercular therapy. Vitrectomy was performed in 36% of eyes for non-clearing vitreous hemorrhage and tractional retinal detachment. Vision improved in 7 (28%) eyes, was stable in 12 (48%) eyes, and worsened in 6 (24%) eyes. Recurrence of the disease more than five times during the 5-year follow-up period occurred in 20% of patients.

CONCLUSIONS

Recurrent vasculitis and vitreous hemorrhage in children should raise the suspicion of pediatric Eales disease. [J Pediatr Ophthalmol Strabismus. 2018;55(4):270-274.].

Spectral domain optical coherence tomography evaluation of macular changes in Eales disease

Purpose:

The purpose of the study was to describe macular changes in treatment-naïve eyes with Eales disease using spectral domain optical coherence tomography (SD-OCT).

Methods:

A cross-sectional study was done on 79 eyes of 66 patients with Eales disease. Best-corrected visual acuity (BCVA), slit-lamp biomicroscopy (SLB), indirect ophthalmoscopy, fundus fluorescein angiography (FFA), and quantitative (central macular thickness [CMT]) and qualitative analysis on SD-OCT were performed.

Results:

Forty-six (58.2%) eyes had macular involvement as assessed with SD-OCT, while in 33 (41.8%) eyes, macula was not affected. Macular edema was the most common feature when macula was affected followed by epiretinal membrane. Mean CMT was higher (315.3 ± 102.3 μm) in eyes with macular involvement than those without it (243.8 ± 19.3 μm). Eyes with active vasculitis involving larger vessels and neovascularization had greater chance of macular involvement. SLB and FFA alone missed 28.3% and 50% eyes with macular abnormalities on SD-OCT, respectively.

Conclusion:

While the clinical description of Eales disease points mainly to a peripheral location, macular involvement can be commonly picked up when SD-OCT is used. Macular involvement when present is associated with a poorer BCVA.

Clinical Features and Incidence Rates of Ocular Complications in Patients With Retinal Vasculitis

PURPOSE

To describe the incidence rates of visual loss and ocular complications in patients with retinal vasculitis (RV).

DESIGN

Retrospective cohort study.

METHODS

Clinical data were collected for 96 patients (175 eyes) diagnosed with RV from 2003 to 2013. Main outcome measures included rates of visual loss and ocular complications. Comparison of outcomes in patients with a relapsing vs nonrelapsing disease also were analyzed.

RESULTS

Over a median follow-up of 44 months (range: 1-153 months), the rate of visual loss to 20/50 or worse was 0.13 per eye-year (/EY, 95% confidence interval [CI], 0.09/EY to 0.18/EY) and to 20/200 or worse was 0.06/EY (95% CI, 0.04/EY to 0.08/EY). The most common complications were cataract (0.31/EY), epiretinal membrane (0.16/EY), and recurrent macular edema (0.09/EY). Patients with a relapsing course (median number of relapses = 1, range: 1-6) appeared to have greater risk for visual loss to 20/50 (odds ratio [OR] = 2.07; 95% CI, 0.88-4.90, P = .09) and 20/200 or worse (OR = 2.49; 95% CI, 0.98-6.30, P = .05). Immunosuppressive drug therapy lowered the risk of visual loss, independent of relapsing disease course (OR = 0.79; 95% CI, 0.66-0.94, P = .01 and OR = 0.73; 95% CI, 0.57-0.93, P = .01 for the 20/50 or worse and 20/200 or worse thresholds, respectively).

CONCLUSIONS

Rates of visual loss and complications among patients with RV were similar to reported rates in noninfectious uveitides. Treatment with immunosuppressive drugs lowered the risk of visual loss. A relapsing course suggested an increased risk for visual loss but was not statistically significant, perhaps owing to low numbers of recurrences.

Ischemic retinal vasculitis and its management

Ischemic retinal vasculitis is an inflammation of retinal blood vessels associated with vascular occlusion and subsequent retinal hypoperfusion. It can cause visual loss secondary to macular ischemia, macular edema, and neovascularization leading to vitreous hemorrhage, fibrovascular proliferation, and tractional retinal detachment. Ischemic retinal vasculitis can be idiopathic or secondary to systemic disease such as in Behçet's disease, sarcoidosis, tuberculosis, multiple sclerosis, and systemic lupus erythematosus. Corticosteroids with or without immunosuppressive medication are the mainstay treatment in retinal vasculitis together with laser photocoagulation of retinal ischemic areas. Intravitreal injections of bevacizumab are used to treat neovascularization secondary to systemic lupus erythematosus but should be timed with retinal laser photocoagulation to prevent further progression of retinal ischemia. Antitumor necrosis factor agents have shown promising results in controlling refractory retinal vasculitis excluding multiple sclerosis. Interferon has been useful to control inflammation and induce neovascular regression in retinal vasculitis secondary to Behçet's disease and multiple sclerosis. The long term effect of these management strategies in preventing the progression of retinal ischemia and preserving vision is not well understood and needs to be further studied.

Intravitreal methotrexate in the management of presumed tuberculous serpiginous-like choroiditis

PURPOSE

To report on the use of intravitreal methotrexate (IVT MTX) as part of treatment of presumed tuberculous serpiginous-like choroiditis progressing despite the use of tuberculostatics.

METHODS

Case series of patients suffering from serpiginous-like choroiditis with positive tuberculin skin test who received IVT injections of MTX as part of treatment. Ocular disease was active despite the use of systemic tuberculostatic (isoniazid, rifampicin, pyrazinamide, and ethambutol), and choroidal lesions showed signs of progression. A single injection of IVT MTX (400 μg/0.1 mL) was administered in the eye with macular-threatening features. Change in visual acuity, appearance of the lesion, and staining patterns on angiography were among the main outcome measurements.

RESULTS

Three eyes from two patients were included. Both cases presented bilateral involvement with mild vitritis. In all three eyes, choroidal lesions healed within the first month after an IVT MTX injection with visual acuity improvement in two. No adverse reaction was related to the medication or to the procedure. Patients were followed for a mean of 13.5 months after being injected.

CONCLUSION

The use of IVT MTX seems effective in the management of the inflammatory component of tuberculous serpiginous-like choroiditis, whereas systemic tuberculostatics are aimed at controlling the infectious one.

Clinical features and etiology of retinal vasculitis in Northern Thailand

PURPOSE

To report on the clinical features and etiology of patients with retinal vasculitis (RV).

MATERIALS AND METHODS

We reviewed medical records of 47 patients (75 affected eyes) diagnosed with RV. Clinical presentations, ocular complications, associated systemic diseases, and treatment regimens were registered.

RESULTS

Etiology of RV included infectious causes in 10/47, (21%) while an association with systemic and/or ocular non-infectious disorders was noted in 22/47 (47%). Eales' disease and Behcet's disease represented the most common clinical entities in non-infectious group while tuberculosis-associated RV was diagnosed in 6/10 (60%) among those with infectious disorders. RV was bilateral in 28/47 (60%) patients. Retinal veins were most commonly affected (72%, 34/47). Involvement of arteries was present in 12/47 (25%) and was associated with viral infections and Behcet's disease. Ocular complications developed in 60/75 (80%) eyes. The most common complications were elevated intraocular pressure and/or glaucoma (33/75, 44%). Retinal detachment, vitreous hemorrhage, and cystoid macular edema developed in similar percentages (15%).

CONCLUSIONS

RV in Thailand manifested mostly in male patients, was typically bilateral and involved mostly veins. Involvement of arteries was observed in patients with viral infections and Behcet's disease. Tuberculosis was the most common infectious cause.

Profile of serpiginous choroiditis in a tertiary eye care centre in eastern India

Purpose:

To study the clinical profile of serpiginous choroiditis in eastern India.

Materials and Methods:

Ninety-one eyes of 54 patients with serpiginous choroiditis presenting to a tertiary care centre in eastern India between January 2006 and December 2010 were included in the study. Clinical presentation, treatment given, and visual outcome of the eyes were studied.

Results:

Thirty-five (64.8%) patients were male and 19 (35.2%) were female in the age group of 13-62 years (mean age: 34.1 ± 18.7 years). Blurring of vision (71; 78%) and floaters (36; 39.5%) were commonest symptoms. In 75 (82.4%) eyes, choroiditis started from optic nerve head and spreading centrifugally. Overall, 38 (41.75%) eyes had macular involvement at first visit. Mantoux test reading was 10 mm or more (Group A) in 12 (22.22%) patients and less than 10 mm (Group B) in 42 (77.77%) patients. Difference between Groups A and B in macular involvement at first visit (10; 50% vs. 28; 39.4%) and rate of recurrence (3; 15% vs. 14; 19.7%) was not statistically significant (P = 0.37 and 0.68). Oral steroid (51; 94.4%) was the commonest mode of treatment. Fifty-one (56%) eyes had two lines or more improvement in vision.

Conclusions:

The present study details the clinical presentation, treatment, and visual outcome of serpiginous choroiditis. Mantoux test reading does not affect the clinical presentation or the treatment outcome in these eyes.