Unilateral Toxoplasma retinochoroiditis with frosted branch angiitis: a multimodal imaging study

A woman in her late 30s presented with sudden diminution of vision, redness and pain in the right eye (OD) of 10 days' duration. Best corrected visual acuity (BCVA) was 20/160 in OD and 20/20 in the left eye (OS). Anterior segment of OD showed keratic precipitates, flare 3+, cells 2+ and a festooned pupil. Vitreous haze and cells were seen in OD. Frosted branch angiitis (FBA) was seen in all quadrants in OD and old Toxoplasma scar was seen in both eyes. Serum toxoplasma immunoglobulin G (IgG) was positive and IgM negative, and PCR of an aqueous humour sample was negative for Toxoplasma She was diagnosed with toxoplasa retinochoroiditis in OD and treated with intravitreal clindamycin injections, oral anti-Toxoplasma antibiotics and steroids. Three months later, her BCVA in OD was 20/40 with resolving inflammation. She presented 2 months later with a new focus of retinochoroiditis without FBA and an old Toxoplasma scar.

Bilateral retinal vasculitis due to presumed sarcoidosis with rickettsial retinitis

OBJECTIVE

To describe a case of bilateral retinal vasculitis due to presumed sarcoidosis and rickettsial retinitis complicated with neovascularization with tear biomarker analysis.

METHODS

A retrospective case report.

RESULTS

A 16-year-old male presented with bilateral retinal vasculitis and retinitis in both eyes with inferotemporal quadrant neovascularization in the right eye. Multimodal imaging revealed the presence of active inflammation in both eyes. Weil Felix test was positive with raised ACE levels. This patient was treated with local and systemic steroids, doxycycline, and laser photocoagulation followed by oral methotrexate therapy which resulted in clinical resolution with recovery of visual acuity. Tear biomarker analysis showed raised sICAM-1 and MMP-9 levels in both eyes which significantly reduced following treatment.

CONCLUSION

Ocular sarcoidosis with rickettsial infection is a rare association. Tear biomarkers correlated well with clinical and imaging manifestations. High index of suspicion and aggressive anti-inflammatory therapy can help control inflammation and restore good vision.

Choroidal and central macular thickness before and after treatment in post fever retinitis

PURPOSE

To study the choroidal thickness (CT) and central macular thickness (CMT) in post-fever retinitis (PFR) and their correlation with visual acuity and treatment.

METHODS

A retrospective, observational study of patients presenting with PFR from 2013 to 2021 and with spectral domain optical coherence tomography (SD-OCT) (Heidelberg®, SpectralisTM, Heidelberg, Germany) images were included. The CT and CMT were measured at presentation and at the final visit. The CT was measured subfoveally and at points 2000 µm superior, inferior, medial, and lateral from the fovea using the caliper tool.

RESULTS

Seventy-nine eyes of 65 patients were included for this study. The mean age was 39.03 (±16.00) years with female preponderance of 53.84% (n = 35). Mean follow-up duration was 30 days. Mean CT at presentation and at follow-up was 254.12 µm and 241.51 µm, respectively. CT was decreased in majority of the eyes 67.1% (n = 53) from their baseline value. Mean CMTs at presentation and final visit were 454.8 µm and 223.7 µm, respectively. Best corrected visual acuity had a positive correlation with CMT (r = 0.340; P = 0.002) and negligible correlation with CT. A significant decrease in the mean CT was noted in patients who received doxycycline either alone or in combination with a steroid as compared to those who did not receive any treatment (P < 0.001). The significance of which is unknown presently.

CONCLUSION

CMT has a greater role in determining the final visual outcome than CT. CT can be reduced post-treatment with no effect on vision.

Quantitative and comparative analysis of thermography parameters in posterior scleritis, choroiditis, and controls

PURPOSE

To compare various ocular thermography parameters in posterior scleritis (PS), choroiditis (choroidal granuloma [CG], Vogt-Koyanagi-Harada [VKH] syndrome), central serous chorioretinopathy (CSCR), and healthy controls.

METHODS

This retrospective, observational, comparative study evaluated cases undergoing ocular thermography between April 2017 and October 2023. The study groups included cases of PS, CG, and VKH, while the control group comprised CSCR cases and healthy individuals. Various thermography parameters were assessed, which were as follows: Ocular surface temperature (OST), central corneal temperature (CCT), average scleral temperature (ST), nasal scleral temperature (nST), temperature difference between both the eyes (Dt), and difference between scleral and corneal temperatures (ST - CCT, nST - CCT).

RESULTS

It was found that Dt was significantly higher in the PS group compared to the CG (P = 0.005), CSCR (P = 0.0001), and control groups (dilated control: P =0.006, undilated control: P = 0.0001). ST - CCT and nST - CCT were significantly higher in the undilated control and CSCR groups and significantly lower in the PS group. ST - CCT and nST - CCT showed less difference in the affected eyes compared to contralateral healthy eyes of PS and CG cases. OST, CCT, ST, and nST displayed statistically insignificant differences across all groups.

CONCLUSION

It is advisable to focus on temperature differences between the affected and healthy eyes, or the difference between the central corneal and scleral temperature of the affected eye, utilizing parameters such as ∆t, ST - CCT, and nST - CCT. These composite parameters offer a more effective approach than individual measurements like OST, CCT, ST, and nST. Thermography can serve as a screening tool to suspect and differentiate PS.

Evolving Fuchs' uveitis - A diagnostic challenge

PURPOSE

To study cases of Fuchs' uveitis (FU) diagnosed as uveitis other than FU at initial visits.

METHODS

A retrospective, observational chart review. Details of clinical presentation, initial diagnosis, treatment details, and follow-up before and after the diagnosis of FU was studied.

RESULT

Twenty eyes of 19 patients finally diagnosed with FU. Mean total follow-up was 39 months (range: 3-120 months, median: 30 months) and follow-up after diagnosis of FU was 18 months (range: 0-84 months, median: 11 months). Most of the cases were diagnosed with anterior plus intermediate uveitis at the presentation (n = 8, 42.1%) and received steroid treatment. Keratic precipitates (KPs) typical of FU developed after mean 5.4 months of presentation (range: 1-18 months, median: 2 months). Altered iris pattern was noted after 17 months of presentation (range: 2-70 months, median: 8.5). Vitritis of grades 1-2 was present in all eyes. Overlap of uveitis of other etiology (retinal vasculitis, presumed tubercular intermediate uveitis) was found in three patients. Systemic immune disease (systemic lupus erythematosus, pulmonary sarcoidosis) was present in two patients. No treatment for the ocular inflammation was given after the diagnosis of FU in any patient and no change in the pattern of FU was observed during further follow-up.

CONCLUSION

Evolving FU may lead to misdiagnosis and mismanagement. We suggest a conservative approach, withholding steroid treatment, allowing FU to evolve, in otherwise asymptomatic patients with white eye, mild to moderate anterior chamber (AC) and vitreous inflammation, absent posterior synechiae and normal fundus examination or fundus examination suggestive of resolved uveitis.

Systemic and Ophthalmic Manifestations of Chikungunya Fever

PURPOSE

Chikungunya is a re-emerging viral infection across the globe. The purpose of this article is to review the systemic and ophthalmic manifestations associated with chikungunya fever.

METHOD

A review of literature was conducted using online databases.

RESULTS

In this report, we have reviewed the presently available literature on uveitis caused by chikungunya and highlighted the current knowledge of its clinical manifestations, imaging features, laboratory diagnostics, and the available therapeutic modalities from the systemic and ophthalmic standpoint.

CONCLUSIONS

Ocular involvement in chikungunya infection may occur at the time of systemic manifestations or it may occur as a delayed presentation many weeks after the fever. Treatment relies on a supportive therapy for systemic illness. Treatment of ocular manifestation depends on the type of manifestations and usually includes a combination of topical and oral steroids.

Ocular manifestations following COVID-19 vaccination

BACKGROUND

Immunologic and inflammatory adverse effects following vaccination against COVID-19 are being reported. While some reactions may develop denovo others concern its immunogenic effect in patients with pre-existing inflammatory conditions.

METHODS

Retrospective consecutive patients diagnosed with ocular inflammatory manifestations within 8 weeks of receiving COVID-19 vaccination who presented to a tertiary eye care centre in South India.

RESULTS

Ninety-eight eyes of 67 patients presenting with ocular inflammatory manifestations within 8 weeks following COVID-19 vaccination were studied. The mean age was 43 years (+/- 14.82; range 19-80 years). The most common presentations were anterior uveitis (n = 31, 31.7%), followed by panuveitis (n = 24, 24.5%). The mean time to onset of symptoms was 25 days (+/- 15.48; range 2-55 days) following a dose of vaccine. Among all patients, 39 (58.2%) had a previous history of ocular inflammation. Mean presenting visual acuity was 0.4 (0-4) logMAR units and mean final visual acuity was 0.2 (0-4) logMAR units. The causes for reduced vision included of cystoid macular edema (n=2, 2%), chorioretinal atrophy (n=2.2%), optic atrophy (n=1.1%), retinal vascular occlusion (n=1.1%) and acute retinal necrosis (n=1.1%).

CONCLUSION

Infective and immunogenic adverse events should be watched out for after COVID-19 vaccination. It is difficult to establish causality for such manifestations, nevertheless, most of them were mild and had good final visual outcomes.

Visual Fields in Epidemic Retinitis

AIM

The aim of the study is to analyze visual fields defects (VFDs) in epidemic retinitis (ER).

METHODS

Patients with ER and Humphrey's visual field (HFA) 30-2 performed after resolution were studied. VFD severity grading was performed. Patients treated with oral doxycycline (Group-A) versus doxycycline-steroids (group-B) were compared.

RESULTS

Thirty-five eyes of 25 patients were studied. Nasal, inferior, temporal and central VFD were seen in 19 (54.2%), 13 (37.1%), 7 (20%) and 6 (17.1%) eyes, respectively. Grade 0, 1, 2 and 3 VFDs were seen in 4 (11.4%), 15 (42.8%), 12 (34.2%) and 4 (11.4%) eyes respectively. Seven eyes with ≥1 year of follow-up post-resolution also showed grade 0-3 scotomas. Mean severity of scotoma was grade 1.15 (Median: 1) and 1.42 (Median: 1.5) in groups A (n = 13) and B (n = 14), respectively (p = .637).

CONCLUSION

ER can cause VFD persisting long after resolution. Treatment with oral doxycycline without steroids was non-inferior to combined treatment with respect to VFD.

Scleritis and Episcleritis following Coronavirus Disease (COVID-19) Vaccination

INTRODUCTION

Coronavirus disease (COVID-19) vaccines have been reported to have ocular side effects including scleritis and episcleritis.

PURPOSE

To report scleritis and episcleritis within a month following administration of COVID-19 vaccine.

METHODS

Retrospective case series.

RESULTS

15 eyes of 12 consecutive patients with scleritis and episcleritis from March 2021 to September 2021 were included. The mean time of onset of symptoms in patients with scleritis was 15.7 days (range, 4-30) and for episcleritis it was 13.2 days (range 2-30). Patients received COVISHIELD™ (10 patients) and COVAXIN™ (2 patients). Five patients had denovo inflammation and seven had recurrent inflammation. Episcleritis patients were treated with topical steroids and systemic COX2 inhibitors while patients with scleritis were treated with topical steroids/oral steroids/antiviral medications depending on the aetiology.

CONCLUSION

Scleritis and episcleritis following COVID-19 vaccination are milder and do not require intensive immunosuppression except in rare cases.

Coronavirus disease 19 (COVID-19) and viral keratouveitis - unraveling the mystery

To demonstrate viral proteins/inflammatory cytokines in a patient with unilateral keratouveitis. Retrospective case report. A 70-year-old Asian-Indian male presented with acute onset of blurring of vision in the left eye (OS) of 2 days duration. He had was coronavirus disease 2019 (COVID-19)-positive 3 months earlier. He had undergone cataract surgery/retinal laser photocoagulation in both the eyes. The corrected distance visual acuity (CDVA) (Snellen) in the right eye (RE) (OD) and left eye (LE) (OS) was 20/20 and 20/80, respectively. OS showed decreased corneal sensation, Descemet's folds, mild stromal edema, and fine and pigmented keratic precipitates with anterior chamber 1+ flare and 1+ cells. Fundus evaluation showed scattered laser marks in the OD and temporal sectoral laser marks in OS. He was diagnosed with viral keratouveitis in OS. Tear samples were collected on Schirmer's strips and tear wash for mass spectrometry and cytokines, which had 368 and 451 viral proteins in the RE and LE, respectively, using nano liquid chromatography-mass spectrometry, which were more than controls. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and varicella zoster virus proteins were detected. Cytokine analysis using flow cytometer analysis showed higher inflammation in OS as compared to OD. The patient was treated with oral acyclovir and topical steroids and resulted in resolution of his keratouveitis. SARS-CoV-2 proteins were present in the tear sample 3 months after COVID-19. The presence of viral proteins does not indicate causality.

Comments on 'Presumed Post-COVID Infection Retinitis - Clinical and Tomographic Features of Retinitis as a Post-COVID Syndrome'

Characteristics and course of known seasonal diseases of pre-coronavirus disease (COVID-19) pandemic era may or may not change during the pandemic. Labelling COVID-19 as a novel etiology for those seasonal diseases or considering it as coinfection is debatable. Appropriate investigations are required to rule out previously known etiologies before correlating it with COVID-19. Epidemic retinitis (ER) or post fever retinitis is one such entity with seasonal variation. Multiple seropositivity for various organisms has been reported for ER during pre-pandemic era. This may significantly increase during the pandemic as the possibility of coinfection with COVID-19 is high. In the absence of gold-standard tests to exclude previously reported causes of ER, one should not undermine the possible coinfection before considering ER as post-COVID-19 syndrome. A study of incidence and pattern of seasonal variation of ER before and during the pandemic is needed before presumptively associating it with COVID-19.

Epidemic retinitis during the COVID-19 pandemic

Purpose

To study the impact of the novel coronavirus disease-2019 (COVID-19) pandemic on incidence, seasonal variation, clinical presentation, and disease outcome of epidemic retinitis (ER) and to compare clinical outcomes with positive and negative COVID-19 serology.

Methods

This is a retrospective, observational study conducted at a tertiary eye care hospital from August 2020 to June 2022. A graph of ER cases against the month of presentation was compared with the graph of the COVID-19 pandemic in the same region. Cases presented before COVID-19 vaccination, with positive COVID-19 serology (Group 1) were compared with cases with negative serology (Group 2).

Results

One hundred and thirty-two cases of ER were seen. The least number of cases were seen during and immediately after the peak of the pandemic (May 2021-August 2021). COVID-19 serology was positive in 13 (22 eyes)/60 (21.6%) unvaccinated cases. Along with COVID-19, positive serology for other ER etiologies was seen in 5/13 cases (38.4%). All patients received oral doxycycline with/without steroids. Groups 1 and 2 included 22 and 21 eyes of 13 cases each. Macular edema resolved in 43.6 and 32 days in groups 1 and 2, respectively. Retinitis resolved at 1 month in both groups. Corrected distant visual acuity was 20/50 and 20/70 at the presentation, which improved to 20/20 and 20/25 in groups 1 and 2, respectively. Mean and median follow-up was 6 months and 4.5 months, respectively, in both groups. No complications or recurrences were seen.

Conclusion

No significant impact of the COVID-19 pandemic on ER was observed.

Epidemic retinitis during pregnancy

Purpose

To study the clinical presentation and treatment outcome of epidemic retinitis (ER) during pregnancy.

Methods

This is a retrospective, observational chart review of pregnant patients diagnosed with ER from January 2014 to February 2023. Demographic details, month of pregnancy at the onset of ocular symptoms, history of present illness, clinical manifestations, and treatment outcomes were studied.

Results

In 9 years, ER was seen in 86 females, of whom 12 (13.9%) were pregnant. Twenty-one eyes of those 12 patients were studied. Most of the patients presented in the sixth month of pregnancy (range: 5-9 months, mean: 6.3 months). Physicians diagnosed viral exanthematous fever in six, typhoid in three, and suspected rickettsia in one patient. Medical termination of pregnancy (MTP) was performed in two patients before presentation. Weil-Felix test was positive in five, Brucella in one, WIDAL in three, and coronavirus disease 2019 (COVID-19) IgG and dengue IgG in one patient each. Oral antibiotics were given in five patients (two post-medical termination of pregnancy [MTP]) for the retinitis. All except four received oral steroids. Mean presenting corrected distant visual acuity (n = 21) was 20/125 (range: 20/20-20/20,000), which improved to (n = 18) 20/30 (range: 20/20-20/240). Macular edema (n = 11) resolved in 33.18 days (range: 20-50 days), and retinitis (n = 13) resolved in 58 days (range: 30-110 days). Ocular and systemic examination of newborn was possible in two and the babies were normal.

Conclusion

ER is seen commonly at the beginning of the third trimester. Lack of antibiotics may delay the resolution of retinitis. Ocular health needs to be assessed in larger series to conclude absence of retinal involvement in newborns.

Choroidal Involvement and Chronic Macular Edema in Acute Retinal Necrosis: A Novel Finding and a Novel Treatment

Acute retinal necrosis (ARN) as the term suggests is recognized as necrotic inflammation of retina, in contrast to toxoplasma retinochoroiditis where involvement of choroid can be appreciated as choroidal thickening on optical coherence tomography scan during active stage. Secondly, sequelae of ARN, such as chronic anterior uveitis and cystoid macular edema, could be challenging to manage as steroid use in various forms poses a risk of virus reactivation. We present a case of ARN caused by varicella zoster virus with an initial confusing clinical picture with toxoplasma retinochoroiditis, documented with choroidal involvement. The patient also developed a chronic anterior uveitis with macular edema after resolution of ARN which was treated with topical interferon (IFN) alfa 2b therapy with successful outcome. This report supports the recently described choroidal involvement in ARN and suggests topical IFN as a novel treatment in management of chronic macular edema post ARN.

Choroidal lesions in varicella zoster virus uveitis

Purpose

To evaluate choroidal lesions with spectral domain optical coherence tomography (SD-OCT) scan in varicella zoster virus (VZV) uveitis.

Methods

VZV-uveitis cases which underwent OCT scan for choroidal lesions were studied. SD-OCT scan passing through these lesions was studied in detail. Subfoveal choroidal thickness (SFCT) during active and resolved stages was studied. Angiogaphic features were studied where available.

Results

Thirteen out of 15 cases had same-sided herpes zoster ophthalmicus skin rashes. All except three patients had old or active kerato-uveitis. All eyes demonstrated clear vitreous and a single or multiple hypopigmented orangish-yellow choroidal lesions. The number of lesions remained unchanged during the follow-up on clinical examination. SD-OCT over lesions (n = 11) showed choroidal thinning (n = 5), hyporeflective choroidal elevation during active inflammation (n = 3), transmission effects (n = 4), and ellipsoid zone disruption (n = 7). The mean change in SFCT (n = 9) after resolution of the inflammation was 26.3 μm (range: 3-90 μm). Fundus fluorescein angiography showed iso-fluorescence over lesions in all (n = 5), but indocyanine green angiography (n = 3) showed hypofluorescence at lesions. Mean follow-up was 1.38 years (range: 3 months-7 years). De-novo appearance of choroidal lesion during the first relapse of VZV-uveitis was captured in one case.

Conclusion

VZV-uveitis can cause focal or multifocal hypopigmented choroidal lesions with thickening or scarring of choroidal tissue, depending on the disease activity.

COVID-19 vaccination, dengue hepatitis, and recurrent unilateral anterior uveitis

A 36-year-old Asian Indian male presented with redness and pain in his right eye of 1 week duration. He was diagnosed to have right acute anterior uveitis and had a history of being admitted at a local hospital for dengue hepatitis a month earlier. He had been on adalimumab 40 mg three weekly once and oral methotrexate 20 mg/week for human leucocyte antigen (HLA) B27 spondyloarthropathy and recurrent anterior uveitis. Our patient had re-activation of his anterior chamber inflammation on three distinct occasions: first, 3 weeks following recovery from coronavirus disease 2019 (COVID-19), the second after the second dose of COVID-19 vaccination, and the third after recovery from dengue fever-associated hepatitis. We propose molecular mimicry and bystander activation as the postulated mechanisms for the re-activation of his anterior uveitis. In conclusion, patients with auto-immune diseases can have recurrent ocular inflammation following COVID-19 or its vaccination or dengue fever as seen in our patient. The anterior uveitis is usually mild and responds to topical steroids. Additional immuno-suppression may not be needed. Mild ocular inflammation following vaccination should not deter individuals from getting COVID-19 vaccination.

Pole-to-pole involvement of varicella zoster virus reactivation following COVID-19 vaccination

The aim of this study is to report the clinical features, imaging findings including confocal imaging, corneal nerve fiber analysis, and management outcomes in a series of three cases of varicella zoster virus (VZV) reactivation following one dose of coronavirus disease 2019 (COVID-19) vaccination. This was a retrospective and observational study. All the patients who developed uveitis post-vaccination were pooled together. Patients who had VZV reactivation were included. Two cases had polymerase chain reaction positive for VZV from aqueous humor. At the time of presentation, IgG and IgM spike protein antibodies for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) were tested. Out of this pool, three patients with classical features to describe pole-to-pole manifestations were chosen. A 36-year-old lady with post-vaccination sclerokeratouveitis associated with reactivation of herpes zoster ophthalmicus, a 56-year-old lady with post-vaccination acute anterior uveitis associated with herpes zoster ophthalmicus, and a 43-year-old gentleman with post-vaccination acute retinal necrosis were included. We present a possible link between anti-SARS-CoV-2 virus vaccination and varicella zoster reactivation in these patients and also describe the clinical features, imaging findings including confocal imaging, corneal nerve fiber analysis, and management with detailed discussion.

Systemic Markers in Ophthalmic Manifestations of Post Corona Virus Disease-19 (COVID-19)

INTRODUCTION

Corona virus disease (COVID-19) has been associated with ophthalmic manifestations which can occur during or following the infection.

PURPOSE

To explore the systemic status in ophthalmic patients who had a recent history of COVID-19 or those with positive COVID-19 antibody status.

METHODS

Retrospective case series.

RESULTS

30 patients with history of COVID-19 infection and positive COVID-19 antibodies were included in the study. The median age was 49 years (mean 48.7 ± 13.7 years), 20 were males (66.7%) and 10 (33.3%) were females. Patients with VA>/= 6/60 were included in group 1 and those with VA<6/60 were included in group 2. D-dimer/serum Ferritin levels were raised in group 2 compared to group 1with (p=0.013)/(p=0.018) respectively.

CONCLUSION

Serum D-dimer and ferritin levels were statistically significant and were higher in patients with sight threatening ocular manifestations. ESR and CRP were raised even after recovery from COVID-19 although they were not statistically significant.

Monitoring Weil-Felix test in epidemic retinitis

Purpose

The objective was to study the positivity of the Weil-Felix test (WFT) in epidemic retinitis (ER) during the course of the disease.

Methods

This is a retrospective, observational case series of patients diagnosed with ER and presented to a tertiary eye care hospital in south India. Patients with positive WFT at the presentation, and who underwent a follow-up WFT during or after the resolution of ER were studied from September 2019 to March 2022. Patient's demographics, timings of clinical presentation and resolution, and investigation details with a special focus on WFT positivity and its duration were noted.

Results

Sixteen patients were studied. Patients presented after 5 weeks of the fever (range: 2-12 weeks, median: 4). After 1-2 months, WFT was still positive in eight patients (50%). Only in one patient titers increased after 1 month, while in others, the titers decreased (n = 11) or remained the same (n = 4). Repeated tests in those patients (n = 6) after 3-4 months turned negative. Resolution of ER was seen at 1.35 months (range: 1-3 months) after the presentation. The mean duration for WFT to turn negative was 2 months from the presentation (range: 1-4 months) or 3.2 months of the fever (range: 1.5-6 months).

Conclusion

In contrast to the reported physician's observation of increasing titers of WFT after rickettsial fever, ophthalmologists may observe decreasing WFT titers in ER. The clinical resolution of ER may precede the normalization of WFT. Follow-up WFT titers should be studied in larger series in confirmed cases of rickettsial-ER to validate the affordable and readily available WFT in India.

Reactivation of varicella zoster infection presenting as acute retinal necrosis post COVID 19 vaccination in an Asian Indian male

PURPOSE

To present the clinical features of a rare case of varicella zoster infection following one dose of Coronavirus Disease 2019 (COVID-19) vaccination in an elderly Asian Indian male.

METHODS

Retrospective observational case report.

RESULTS

A 71-year-old gentleman presented to us with complaints of reduced vision associated with redness and pain in his right eye for 1 week. On examination he revealed a right eye pan uveitis picture with circumcorneal congestion, multiple fine keratic precipitates, anterior chamber cells and flare, vitritis and widespread areas of acute retinal necrosis. His left eye was within normal limits. Ten days prior to the presentation he had received the first dose of COVID-19 vaccine following which he had developed fever for 2 days that preceded the red eye. The patient's aqueous sample tested positive for varicella zoster virus (VZV) by nested polymerase chain reaction (PCR) method. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in reverse transcriptase polymerase chain reaction (RT-PCR) assay from the aqueous and also from the nasopharyngeal swab was negative.

CONCLUSION AND SIGNIFICANCE

To the best of our knowledge this is the earliest description of a case that has a viral reactivation following COVID-19 vaccination. Elderly people with pre-existing comorbidities, may be at a risk of both primary coronavirus infection and unconceivable risk of aberrant immune reactions leading to a different virus infection or reactivation need to be kept in mind. We present a possible link between SARS-CoV-2 virus vaccination and varicella zoster reactivation in this patient.

Topical interferon therapy in uveitic macular edema

Purpose

To evaluate efficacy of topical interferon alfa-2b (IFN) in the treatment of uveitic macular edema (UME).

Methods

This is a prospective, interventional case study of patients with UME. Injection IFN was reconstituted into eye drops and a four times/day (QID) application was prescribed. Central macular thickness (CMT) on optical coherence tomography (OCT) scan was evaluated. Improvement in CMT by ≥50 μm from the baseline was studied in eyes with presenting CMT ≥400 μm.

Results

Twenty eyes of 20 patients with UME were studied: anterior uveitis (n = 3), anterior + intermediate uveitis (n = 5), posterior uveitis (n = 3), retinal vasculitis (n = 3), and panuveitis (n = 6). Mean CMT at the presentation was 423.3 μm (range: 270-604 μm), which improved at 1 month (n = 16), 2 months (n = 10), and ≥3 months (n = 11) follow-up, to 415.3 μm (range: 247-579 μm) (P = 0.411), 364.4 μm (range: 258-566 μm) (P = 0.099), 344 μm (range: 258-484 μm) (P = 0.001), respectively. Twelve eyes of 12 patients had presenting CMT ≥400 μm. In these cases, decrease in CMT by ≥50 μm was seen in 4/10, 4/5, and 5/6 eyes at 1 and 2 months and ≥3 months follow-up. Mean follow-up was 4 months (range: 1-17 months). Complete resolution of UME was seen only in three eyes. No ocular or systemic side effects were observed.

Conclusion

Topical IFN therapy in QID doses is safe but may have limited role in UME. Long-term therapy may improve its efficacy. Larger studies with dose modification, combination with other drugs, and with homogeneous uveitis population are recommended.

COVID-19 vaccination and recurrent anterior uveitis

A 35-year-old Asian Indian female previously diagnosed with bilateral anterior uveitis and on oral methotrexate developed bilateral anterior uveitis following first/second dose of coronavirus disease 2019 (COVID-19) vaccination. She had skipped her weekly dose of oral methotrexate following first dose of vaccination. Following the second dose, she reduced her oral methotrexate from 25 to 15 mg on her own, but did not stop like the previous occasion. She had extensive workup for her uveitis in the past with only positive severe acute respiratory syndrome coronavirus (SARS-CoV-2) antibodies. She developed unilateral anterior uveitis after she had COVID-19 in July 2022, which resolved with topical steroids and continuation of immunosuppression. This report illustrates that COVID-19 or its vaccination may presumably play a role in triggering the immune system and can cause recurrent ocular inflammation even in the absence of an extraocular inflammation.

Bilateral Post Fever Retinitis With Retinal Vascular Occlusions Following Severe Acute Respiratory Syndrome Corona Virus (SARS-CoV2) Infection

INTRODUCTION

As the world fights the pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), several reports of retinal manifestations of the disease are emerging. Post fever retinitis is a well reported ocular inflammatory reaction to multiple invasive agents, be it virus, bacteria or other microbial agent.

PURPOSE

We report an interesting case of bilateral multifocal retinitis with multiple vascular occlusions in a patient, three weeks after a febrile illness.

RESULTS

Investigations to ascertain the cause of fever resulted in identifying ephemeral seropositivity for several different Ribonucleic acid (RNA) viruses. The retinitis was managed with systemic steroids, doxycycline and anticoagulants with improvement in vision.

CONCLUSION

High and persistent seropositive response against (SARS-CoV-2) helped us to narrow it as the causative agent but the cross reactivity of SARS-CoV-2 with other viruses can be misleading and needs careful interpretation.

Epidemic Retinitis with Positive or Negative Weil Felix Test - a Comparative Study and Outcome with Doxycycline

PURPOSE

To compare clinical manifestations and disease outcomes in Epidemic Retinitis (ER) with positive or negative Weil Felix Test (WFT).

METHODS

Retrospective, observational, comparative study. WFT positive or negative patients formed Group 1 and 2, respectively. Patients receiving oral doxycycline monotherapy formed subgroup A and B. Duration of resolution of macular edema and retinitis was compared.

RESULTS

Novel finding of "ring retinitis" was observed equally in group 1 and 2. Complete resolution of macular edema took 41.3 days (range: 30-60 days) and 43.68 days (range: 20-105 days) (p = .668) and retinitis lesions resolved in 34.3 days (range: 14-65 days) and 34 days (range: 12-60 days) (p = .875) in group A and B, respectively. All (n = 14) eyes with retinitis within 1 disc diameter of fovea improved better than 20/80 except 1.

CONCLUSION

No significant difference with respect to clinical, imaging findings and the treatment outcome was observed in WFT positive or negative cases.

Unilateral recurrent central serous chorioretinopathy (CSCR) following COVID-19 vaccination- A multimodal imaging study

Corona virus disease-19 (COVID-19) vaccines have been approved for emergency use. Ocular adverse effects following the vaccines have been reported.

Purpose

To report an unique case of recurrent central serous chorioretinopathy following both doses of COVID-19 vaccine.

Observations

A 40-year-old male presented with blurring of vision in the left eye during 2 days following COVISHIELD™ (Serum Institute of India). He had a previous history of central serous chorioretinopathy in the right eye 2 years back and was treated with micropulse laser. Ocular examination showed a best corrected visual acuity of 20/20 right eye and 20/60 left eye. Fundus evaluation of left eye showed central serous chorioretinopathy. Spectral domain optical coherence tomography of the left eye revealed neurosensory detachment. Fundus fluorescein angiography of the left eye showed multiple window defects and ink-blot appearance in the macula. Oral eplerenone 50mg once a day for a month showed significant reduction in the subretinal fluid. Patient developed central serous chorioretinopathy in the left eye 3 days after 2nd dose of COVISHIELD™.

Conclusion and Importance

CSCR following vaccination may be a temporal event. In our patient it occurred following the vaccination. This is the first case of a recurrent CSCR after either dose of COVID-19 vaccination. Ocular symptoms after vaccination warrant a thorough eye evaluation.

Intensive topical interferon therapy in uveitic macular edema

Purpose

To evaluate the efficacy of intensive topical interferon alfa-2b (IFN) therapy in uveitic macular edema (UME).

Methods

This is a prospective, interventional case study of eyes with UME. Commercially available injection IFN for subcutaneous use was reconstituted to form eye drops and a dose of 6 times/day for 2 weeks, 5 times/day for next 2 weeks, followed by 4, 3, 2, 1 taper per month was prescribed. Optical coherence tomography (OCT) and clinical examination was done at 0, 2, 4, 8 weeks, and further as required.

Results

Nine eyes of 9 patients with UME were studied. Mean central macular thickness (CMT) at presentation was 522.2 μm (range: 408-803 μm). At 2-week, 1-month, and 2-month follow-up, mean CMT decreased to 451.6 μm (range: 322-524 μm), 375.8 μm (range: 287-480 μm), and 360.3 μm (range: 260-485 μm), respectively. Four eyes which showed inadequate response to previous topical IFN therapy (4 times/day) showed significant improvement with intensive therapy at 1 month follow-up. In 4 eyes, UME resolved completely with mean CMT 285.5 μm (range: 260-312 μm) at 7.5 weeks (range: 4-12 weeks). Study exit was seen in 2 cases due to inadequate response and relapse of uveitis. Mean follow up was 3.38 months (range: 1-5 months).

Conclusion

Intensive topical IFN therapy can be an alternative therapeutic option in the treatment of UME. Study of intraocular penetration, combination with other drugs, and the efficacy of IFN separately for different uveitic entities may explore new avenues in treatment of UME.

Reactivation of juvenile idiopathic arthritis associated uveitis with posterior segment manifestations following anti-SARS-CoV-2 vaccination

Background/purpose

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in the pediatric population and anterior uveitis is its commonest extra-articular manifestation. Typically the uveitis presents as chronic anterior uveitis and there is limited literature of the posterior segment manifestations of the disease. Similar to other vaccines, anti-SARS-CoV-2 vaccination that began as an urgent measure to control the spread of the SARS-CoV-2 pandemic has not been without adverse events. We are reporting a 19-year-old Asian Indian female who was diagnosed and treated for JIA associated anterior uveitis that was unilateral and was under anti-inflammatory control but showed worsening of uveitis with posterior segment inflammation in both eyes following anti-SARS-CoV-2 vaccination.

Case report

A 19-year-old Asian Indian female with a history of juvenile idiopathic arthritis on treatment with methotrexate, presented with right eye chronic anterior uveitis with peripheral subclinical retinal vasculitis and macular edema which was brought under control following administration of adalimumab. She was inflammation free for 6 months until she received anti-SARS-CoV-2 vaccination and developed new onset floaters in both eyes that were initially noted after the first dose and increased after the second dose. Clinical examination revealed presence of keratic precipitates and grade 1+ anterior chamber inflammation along with vitiritis in both eyes. Fundus fluorescein angiography revealed angiographically active retinal vasculitis without the presence of macular edema in both eyes. This was managed with a short course of topical difluprednate and continuation of systemic immunosuppressive therapy with adalimumab and methotrexate.

Conclusion

JIA associated uveitis results from an autoimmune process which can be controlled with timely immunosuppressive treatment. It is important to be aware of the potential risk of flare up of uveitis with posterior segment manifestations following anti- SARS-CoV-2 vaccination.

"Acute Bilateral Neuroretinitis and Panuveitis in A Patient with Coronavirus Disease 2019: A Case Report"- Few Comments

During the Coronavirus Disease 2019 (COVID-19) pandemic, we have witnessed increase in number of reports of a known uveitic entity being associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Causal relation is yet to be proven for many reports. Perhaps, occurrence of a previously known region-specific endemic disease or closely resembling manifestations of a known disease in a non-endemic region during the COVID-19 pandemic might suggest a causal relationship. Epidemic retinitis (ER) or post fever retinitis is such condition with geographic variation. Occurrence of ER or ER-like manifestations in a non-endemic country during the pandemic should instigate further studies to consider SARS-CoV-2 as a causative organism.

Epidemic retinitis - Factors associated with poor visual outcomes

Purpose:

To identify factors other than macular edema and retinitis location responsible for poor visual outcomes in epidemic retinitis (ER).

Methods:

A retrospective, observational, comparative study. Eyes with corrected distant visual acuity (CDVA) 20/200 or worse at resolution formed Group A. Eyes with central macular thickness (CMT) 600 μm or worse and retinitis within 1500 μm to foveal center at the presentation, but improved to CDVA 20/200 or better at the resolution formed Group B. The patient’s history, clinical presentation, imaging, and treatment outcomes were studied and the factors responsible for the final visual outcomes were compared in both groups.

Results:

Groups A and B included 25 eyes each. The mean CDVA at the presentation was 20/400 (range: 20/125–20000) and 20/320 (range: 20/80–20000), and mean CMT at the presentation was 948.5 μm (range: 520–1553) and 912.2 μm (range: 615–1250) in Groups A and B, respectively. All eyes except 1 (Group A) had retinitis lesions within 1500 μm of foveal center. The mean CDVA at the resolution was 20/400 (range: 20/200–20/20000) and 20/40 (range: 20/20–20/80) in Groups A and B, respectively. Older age, male gender, diabetic status, delayed presentation, poor presenting CDVA, bilaterality, presence of keratic precipitates, disk pallor, retinal thinning, and subfoveal deposits had a statistically significant association, whereas the absence of skin rash, ellipsoid zone loss, negative WIDAL, Weil-Felix test, and delayed doxycycline therapy or use of steroids without doxycycline had a statistically insignificant association with poor visual outcomes.

Conclusion:

Apart from presenting CMT and location of retinitis, multiple demographic, clinical, and imaging factors can be implicated for poor visual outcomes.

"Bilateral Sequential Acute Macular Neuroretinopathy in an Asian Indian Female with β Thalassemia Trait following (Corona Virus Disease) COVID-19 Vaccination and Probable Recent COVID Infection- Multimodal Imaging Study."

INTRODUCTION

Corona virus disease (COVID-19) has been associated with a variety of ophthalmic manifestations including acute macular neuroretinopathy and paracentral middle maculopathy. Posterior segment manifestations after post COVID-19 vaccinations have been reported.

CASE REPORT

A 25- year-old Asian Indian female developed sequential bilateral AMN following a single dose of COVISHIELD™ vaccine. On investigations she was found to have a β thalassemia trait. Presentation started unilaterally and progressed to the other eye after a month. On clinical examination, the fundus was apparently normal in both eyes. Significant changes suggestive of AMN were seen on multimodal imaging of the posterior segment of the respective eye at the time of involvement which resolved spontaneously in due course.

CONCLUSION

We report a temporal association of COVID-19 vaccination and AMN.

Trends in teleconsultations for uveitis during the COVID-19 lockdown

Purpose:

To study the use of teleophthalmology as a tool to manage patients with uveitis and to describe the experience of teleconsultation for uveitis at a tertiary eye care hospital in India during the two waves of the COVID-19 pandemic.

Methods:

A prospective observational case series of uveitis patients seeking teleconsultations during the first (March 25–May 2020) and second lockdown (April 27 to June 21, 2021) in a tertiary eye care center were analyzed.

Results:

There were 79 teleconsultations in the first and 89 teleconsultations in the second lockdown. A majority of the patients presented in the age group of 41–60 years in both the lockdowns. There were both new or primary consultations and follow-up patients (6% vs. 94%) in the first lockdown, and similarly in the second lockdown (8% new vs. 92% follow-up). The majority of patients resided in Bengaluru city (78% in the first and 76% in the second lockdown). After evaluation through video consultation, only 15% required a hospital referral in the first lockdown, whereas in the second lockdown, 21.3% were referred to the hospital. During the second lockdown, 20% presented with COVID-19 infection-related ailments.

Conclusion:

Based on our preliminary experience using a customized smartphone-based application for teleconsultation, we found it to be an alternative option to provide continuation of ophthalmic care to uveitis patients. Given the current COVID-19 situation, it can help avoid physical visits of uveitis patients to the hospital.

Posterior segment manifestations and imaging features post-COVID-19

Background

To report the posterior segment (uvea and retinal) manifestations and imaging characteristics of eyes of patients with and after coronavirus disease 2019 (COVID-19).

Methods

We searched the PubMed/MEDLINE database to identify relevant articles using the following search terms: COVID-19, SARS-CoV-2, retina, uvea, optic nerve, retinal findings, posterior segment manifestations, and endophthalmitis. Articles published from December 1, 2019, to May 30, 2021, and indexed in PubMed/ MEDLINE were screened.

Results

For the purpose of this review, we included clinical features of 26 case reports and 8 case series. The posterior segment manifestations reported included cotton wool spots, retinal hemorrhages, central serous retinopathy, papillophlebitis, optic neuritis, panuveitis, multifocal retinitis, necrotizing retinitis, central retinal artery/vein occlusion, and Purtschner like retinopathy. In this review, we have also included optical coherence tomography angiography (OCTA) features that have been described in COVID-19 patients with pneumonia.

Conclusions

COVID-19 patients can experience uveo-retinal manifestations even after recovery. These patients, even if asymptomatic for eye symptoms, should undergo an eye evaluation to rule out posterior segment involvement. OCTA performed in these patients revealed microvascular changes in the superficial and deep retinal plexuses. Some of these patients may require anticoagulant or antiplatelet therapy.

Optical coherence tomography angiography (OCTA) of retinal vasculature in patients with post fever retinitis: a qualitative and quantitative analysis

Post fever retinitis is a heterogenous entity that is seen 2-4 weeks after a systemic febrile illness in an immunocompetent individual. It may occur following bacterial, viruses, or protozoal infection. Optical coherence angiography (OCTA) is a newer non-invasive modality that is an alternative to fundus fluorescein angiography to image the retinal microvasculature. We hereby describe the vascular changes during the acute phase of post fever retinitis on OCTA. Imaging on OCTA was done for all patients with post fever retinitis at presentation with 3 × 3 mm and 8 × 8 mm scans centred on the macula and corresponding enface optical coherence tomography (OCT) scans obtained. A qualitative and quantitative analysis was done for all images. 46 eyes of 33 patients were included in the study. Salient features noted were changes in the superficial (SCP) and deep capillary plexus (DCP) with capillary rarefaction and irregularity of larger vessels in the SCP. The DCP had more capillary rarefaction when compared to the SCP. The foveal avascular zone (FAZ) was altered with an irregular perifoveal network. Our series of post fever retinitis describes the salient vascular features on OCTA. Although the presumed aetiology was different in all our patients, they developed similar changes on OCTA. While OCTA is not useful if there is gross macular oedema, the altered FAZ can be indicative of macular ischemia.

Topical interferon - A novel treatment for pseudophakic macular edema

Purpose:

The aim of this study was to evaluate the efficacy of topical interferon (IFN) therapy in pseudophakic cystoid macular edema (P-CME).

Methods:

This is a prospective, interventional case series of patients with P-CME. Patients presenting with P-CME were given the option of topical IFN therapy against conventional treatment with oral, topical, intravitreal, and periocular steroid therapy and antivascular growth factors. Patients who consented for the same were advised to use the IFN drops four times/day. Commercially available injection IFN alfa-2b was reconstituted to prepare the eye drops (1 MIU/ml). Optical coherence tomography (OCT) was done at the baseline and on each review visit until complete resolution of P-CME.

Results:

Eight eyes of eight patients diagnosed with P-CME were studied. Mean central macular thickness (CMT) on OCT at the presentation (n = 8) and at 4 weeks post topical IFN therapy (n = 6) was 560.1 μm (range: 349–702 μm) and 344.33 μm (range: 250–390 μm), respectively. All eyes except one had posterior capsular rent (PCR). Five patients had regular follow-up until resolution. The mean duration of complete first resolution of P-CME was 5 weeks (range: 4–7.1 weeks) in those patients. Relapse was seen in three patients who responded after resuming or continuing the therapy. Case 1 had 9 months follow-up after completion of IFN therapy, and no recurrence was noted. No ocular or systemic side effects related to the topical IFN therapy were noted clinically, except papillary conjunctivitis in one patient.

Conclusion:

Topical IFN therapy can be a noninvasive, economical, and effective choice of treatment for P-CME, especially in the case of PCR, and where steroids are contraindicated.

Choroidal Thickness in Multifocal Dendritic and Placoid Serpiginous-Like Choroiditis: A Comparative Study

BACKGROUND AND OBJECTIVE

To study spectral-domain optical coherence tomography (SD-OCT) characteristics in multifocal advanced dendritic serpiginous-like choroiditis (D-SLC) and placoid serpiginous-like choroiditis (P-SLC).

PATIENTS AND METHODS

Retrospective, comparative study. SD-OCT features were studied in both the groups. Area of involvement (AoI) due to SLC lesions was calculated, and cases with comparable AoI from both the groups were subclassified into Group A (subgroup D-SLC) and Group B (subgroup P-SLC). Central choroidal thickness (CT) was measured, and comparative analysis was performed.

RESULTS

Thirty-four eyes (15 D-SLC, 19 P-SLC) of 28 patients were studied. Mean AoI for Group A (n = 10) and for Group B (n = 12) was 197,066.50 units (range: 139,602 to 267,151 units) and 203,407.33 units (range: 148,156 to 285,048 units), respectively (P = .553). Mean central CT was 217.92 µm for DSLC and 152 µm for P-SLC (P = .01).

CONCLUSIONS

The choroid was significantly thinner at the resolution in P-SLC than in D-SLC form. P-SLC renders more choroidal destruction and may warrant aggressive treatment. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:438-442.].

Role of multicolour imaging in post-fever retinitis involving posterior pole

PURPOSE

To describe composite multicolour (MC) imaging features along with the monocoloured fundus reflectance images in active and resolving stages of post-fever retinitis (PFR).

METHODS

Retrospective image analysis of cases of PFR who underwent dilated retinal clinical examination followed by optical coherence tomography and MC imaging.

RESULTS

Twenty-five eyes of 18 patients diagnosed with PFR were included. There were 11 males and 7 females. Mean age of patients was 30.63 years. The retinitis lesion appeared bright white on MC image and white mainly on blue and green reflectance images during the active stages of PFR. The lesion appeared dull-grey to greyish white during the resolving stages and as dull-green in resolved cases. The active stages showed the presence of intraretinal/subretinal fluid which appeared as green colour on MC images and less green to normal during resolving stages. Hard exudates were seen as bright yellow- or orange-coloured spots on MC image during the resolving stages of the disease.

CONCLUSION

The different stages of PFR show different colour on multicolour image and different reflectance patterns on individual colour reflectance channels. Hence, multimodal fundus imaging with different wavelength can be helpful for differentiation of activity in PFR.

Topical interferon in recurrent inflammatory macular edema following a cat bite

INTRODUCTION

Treating chronic macular edema (CME) post endophthalmitis is a challenge. Use of steroids may reactivate the infection and repeated intravitreal therapy with anti-vascular growth factor inhibitors (Anti-VEGF) puts the patient again at the risk of exacerbation of inflammation or endophthalmitis. We describe a case of CME post traumatic endophthalmitis successfully treated with topical interferon therapy.

CASE DESCRIPTION

A 34-year-old Asian Indian lady with a history of cat bite to her right eye and treated elsewhere as traumatic endophthalmitis with recurrent macular edema, presented to us 1 year after the injury. She had received anti-VEGF injection for same. Her medical history was non-contributory except for close contact with her cat. Therapeutic trials with oral doxycycline followed by oral albendazole with steroids, as well as repeated anti-VEGF therapy failed to prevent recurrence of CME. Patient's steroid responsiveness and reluctance for injections, made us to opt for a novel topical Interferon therapy. Macular edema resolved in 2 months. Interruption of interferon therapy due to COVID-lock down resulted in recurrence of the CME, which again responded well to interferon monotherapy.

CONCLUSION

Topical interferon may have a role in the treatment of inflammatory macular edema and can serve as a, safer, economical and non-invasive treatment option compared to intravitreal steroids and anti-VEGFs.

"Post Coronavirus Disease (COVID-19) Reactivation of a Quiescent Unilateral Anterior Uveitis"

Coronavirus disease (COVID-19) can be associated with ophthalmic manifestations like conjunctivitis, retinal haemorrhages, retinal vascular occlusions, papillophlebitis, and Adie’s syndrome. We herein report for a case of a unilateral acute anterior uveitis which was quiescent for 13 years and was reactivated post COVID-19 infection in a 43-year-old Asian Indian male. He had a past history of recurrent unilateral granulomatous anterior and intermediate uveitis in the right eye (RE), and all the investigations done 14 years ago were negative and had been on treatment with topical and oral steroids. He developed cataract 6 months later in the RE and underwent surgery. Patient was in remission for the past 13 years. Uveitis investigations for the present episode were all negative. Topical steroid and cycloplegic helped in resolution of the uveitis. This may be the first instance of reactivation of a quiescent unilateral anterior uveitis following COVID-19 infection.