Characteristics and outcomes of the duration of treatment with adjunctive corticosteroids in intraocular tuberculosis

Introduction

Intraocular tuberculosis (IOTB) is a common site of extrapulmonary tuberculosis and a main cause of infectious uveitis. It can result in severe visual morbidity if not recognized and treated properly. The clinical manifestations of IOTB are varied, and the duration of treatment is unclear. This study describes the clinical characteristics and outcomes of patients with IOTB and compares the duration of antituberculosis therapy (ATT) and steroid use.

Method

An 8-year retrospective study of IOTB patients in an endemic area of a tertiary hospital in Thailand. All patients had a complete treatment of ATT at least for 6 months.

Results

Forty-three patients with 57 eyes and a mean age of 43.72 years were included. Panuveitis (38.6 %), retinal phlebitis (31.6 %), and posterior uveitis (15.8 %) were common clinical characteristics. A significant difference between initial and final best corrected visual acuity (BCVA) after ATT in 6 months for therapy and at least 9 months for therapy was observed (p = 0.004, 0.003, respectively). Ninety point nine percent of patients who received ATT for 9 months achieved a successful treatment outcome, while 66.7 % of patients who received ATT for 6 months did (p = 0.056). Patients who received systemic and/or regional corticosteroids therapy during treatment had a higher rate of treatment failure (p < 0.001).

Conclusion

IOTB had a variety of clinical manifestations, including nongranulomatous inflammation. Patients who completed treatment with ATT for at least 6 months improved their final BCVA. There was no difference in treatment outcomes regarding the duration of treatment. Combined treatment with systemic and/or regional corticosteroids was significantly associated with failed treatment outcomes.

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.

Characteristics, Etiologies, and Outcomes of Peripheral Ulcerative Keratitis in a Tertiary Referral Hospital in Thailand: A 10-Year Study

PURPOSE

To evaluate characteristics, etiologies, and outcomes of peripheral ulcerative keratitis (PUK) in Thailand.

METHODS

Retrospective study.

RESULTS

Forty-three eyes from 34 patients were enrolled, with a mean age of 53.44 ± 15.48 years. PUK affected women more than men (1.6:1) and resulted in unilateral lesions more frequently than bilateral lesions (2.8:1). Redness (56.3%) was the most common presenting symptom followed by pain (43.8%) and irritation (40.6%). The three most common etiologies were Mooren's ulcer (52.9%), rheumatoid arthritis (20.6%), and Graves' disease (8.8%). Corneal thinning was significantly more common in unilaterality (p = 0.004) and less common when the lesion was located in the superior cornea (p = 0.031). Surgery was also more frequently performed in case of unilateral PUK (p = 0.026). Perforation was observed in 5 eyes (11.6%) and recurrence after treatment was identified in 8 eyes (18.6%).

CONCLUSION

Nearly half of PUK cases are associated with several systemic causes. Accordingly, careful physical examination and investigation are important. Unilateral lesions could serve as potential risk factors in identifying patients at risk of thinning and perforation, which could prevent further damage to the eye and vision loss.

Pigmentary retinopathy and nodular granuloma associated with acute retinal necrosis from varicella zoster virus and human herpes virus type 6: Case report

RATIONALE

Acute retinal necrosis (ARN) caused by human herpes virus type 6 (HHV-6) is uncommon. We described a case of consecutive bilateral ARN, which was found to be a coinfection of varicella zoster virus (VZV) and HHV-6 in a 50-year-old woman, not well responded with systemic acyclovir. We showed the atypical findings with corresponding fundus and optical coherence tomography imaging.

PATIENT CONCERNS

She presented with anterior segment inflammation with peripheral retinitis and vasculitis in the left eye with disease progression despite of initial antiviral treatment, end up with retinal detachment. The right eye, subsequently, developed focal retinitis.

DIAGNOSIS

ARN was diagnosed by clinical fundus picture, confirmed by polymerase chain reaction (PCR).

INTERVENTIONS

Initially, she was treated with intravenous acyclovir and intravitreal ganciclovir for left eye. Retinal necrosis progressed, followed by retinal detachment. Pars plana vitrectomy with silicone oil was performed. The right eye, subsequently, developed focal retinitis. Medication was switched to intravenous ganciclovir and then oral valganciclovir.

OUTCOMES

Retinitis was resolved, generalized hyperpigmentation appeared as a salt-and-pepper appearance in the right eye. The left eye presented preretinal deposits on silicone-retina interphase along retinal vessels. Spectral-domain optical coherence tomography (SD-OCT) showed multiple hyperreflective nodules on retinal surface.

LESSONS

ARN from coinfection of VZV and HHV-6 is rare. Preretinal granulomas and generalized hyperpigmentation could be one of the HHV-6 features. HHV-6 should be in the differential diagnosis for ARN. It responds well to systemic ganciclovir.

Sarcoidosis developing after COVID ‐19: A case report

COVID‐19 has been implicated in the development of a range of autoimmune diseases and medical consequences. Sarcoidosis is an inflammatory disease with sustained granulomatous inflammation. The possible main pathogenesis of sarcoidosis is a dysregulation between immune response and certain environmental antigens. We present a case of sarcoidosis as an interesting sequela of COVID‐19. The patient was hospitalized due to SARS‐CoV‐2 without complication. Ten weeks after the illness, his chest computed tomography (CT) showed bilateral hilar, paratracheal and subcarinal lymph node enlargement. Endobronchial ultrasound with transbronchial needle aspiration (EBUS‐TBNA) was performed; pathologic findings were that of well‐formed non‐necrotizing granulomas. Complete eye examination reported panuveitis and papillitis in both eyes. On the basis of these findings, sarcoidosis was diagnosed. Therefore, sarcoidosis developing after COVID‐19 was suggested as a possible link between the viral infection and dysregulation of the inflammation process. However, further studies are needed to confirm this association.

Fluorescein angiographic findings and Behcet's disease ocular attack score 24 (BOS24) as prognostic factors for visual outcome in patients with ocular Behcet's disease

Purpose

To determine the application of fluorescein angiographic (FA) findings and Behcet’s disease ocular attack score 24 (BOS24) scoring system in predicting poor visual outcome in patients with ocular Behcet’s disease.

Study design

Retrospective cohort study.

Methods

We included 73 eyes of 38 patients with ocular Behcet’s disease who underwent FA and reviewed FA images, anterior chamber cells, vitreous opacity, retinal and optic disc lesions, which are parameters in BOS24. The correlation between FA findings, BOS24, and visual acuity was assessed.

Results

Optic disc hyperfluoresence (74%), diffuse posterior pole leakage (52%) and diffuse peripheral leakage (52%) were the three most common findings. Common complications were peripheral capillary nonperfusion (29%), arterial narrowing (22%), and macular ischemia (19%). BOS24 scores of ≥ 6 (p < 0.0001), arterial narrowing (p < 0.0001), and severe posterior pole leakage (p = 0.004) were significantly associated with poor visual outcome. Combining significant FA findings: arterial narrowing and severe posterior pole leakage, to BOS24 ≥ 6 results in an increased relative risk of developing poor visual acuity from 7.30 to 10.43 and 1.89 to 2.02 respectively.

Conclusion

Fluorescein angiography is an important investigation for predicting poor visual outcome. BOS24 may be a useful alternative when fluorescein angiographic is unavailable.

Combined central retinal vein, central retinal artery and cilioretinal artery occlusion with ischemic macular hole secondary to severe orbital cellulitis after black fly bite

Background: Orbital cellulitis is an infection of the ocular adnexal and orbital tissues behind the orbital septum. The complications are poor prognosis. This paper is to describe some severe rare complications of orbital cellulitis.

Case presentation: A case of 32-year-old female presented with acute severe progressive orbital cellulitis on the right eye after a black fly (Simuliidae spp.) bite. Orbital imaging with computed tomography and magnetic resonance imaging showed eyelid abscess with orbital abscess formation and superior ophthalmic vein thrombosis. She was promptly treated with intravenous vancomycin, piperacillin and had surgical procedures to release orbital pressure including lateral canthotomy, lateral cantholysis, and eyelid with orbital abscess drainage. Pus collection culture was positive for Staphylococcus aureus. Even though she responded well to antibiotics treatment, progression involved severe orbital inflammation with marked increased orbital pressure, and her visual acuity was such that she had no light perception. Combined central retinal vein, central retinal artery and cilioretinal artery occlusion were identified. Fundus examination showed retinal whitening at the posterior pole and a few scattered flame-shaped retinal hemorrhages. The cilioretinal artery presented with perivascular retinal whitening. A fundus fluorescein angiogram revealed cilioretinal and retinal artery filling delay and also delayed arteriovenous transit time. She also developed an ischemic macular hole after a week of treatment. We demonstrate an optical coherence tomography image showing the intact posterior hyaloid membrane that represents no traction on the macula to support the ischemic cause.

Conclusion: Multiple retinal vascular occlusion and ischemic macular hole could be an early complication of severe orbital cellulitis from increased orbital pressure; therefore, close monitoring of visual acuity with IOP, and prompt treatment when indicated might reduce the risk of consequent blindness.

Characteristics and Clinical Outcomes of Hypertensive Anterior Uveitis

OBJECTIVE

The objective of this article is to determine characteristics and outcome of hypertensive anterior uveitis and prevalence of the Herpesviridae family. Study: Retrospective cohort study.

METHODS

A total of 64 anterior uveitis participants with increased intraocular pressure and Herpesviridae family polymerase chain reaction (PCR) analysis results were included.

RESULTS

The prevalence of Herpes family was 53.1% (6.3% for herpes simplex virus, 10.9% for varicella-zoster virus, 34.4% for cytomegalovirus, and 1.6% for Epstein-Barr virus), Posner-Schlossman syndrome 25%, Fuchs uveitis syndrome 7.8%, and idiopathic 14.1%. The recurrence rate was 70.3%. Age in PCR-proven infection group (52.7 ± 15.3) was older than the PCR-negative group (44.4 ± 12.5) (p = 0.021). Glaucoma in PCR-proven infection group (44.1%) was more than in PCR-negative group (16.7%) (p = 0.018). Corneal endothelial cell count in PCR-proven infection group (1879.3 ± 952.3) was lower than in PCR-negative group (2532.9 ± 540.4) (p = 0.004).

CONCLUSION

Viral infection was found in one half of hypertensive anterior uveitis. The complications of PCR-proven infectious case were more severe than PCR-negative case.

Herpesviridae prevalence in aqueous humor using PCR

Objective

The aim of this study was to determine the prevalence of Herpesviridae family in aqueous humor and the prevalence of antibodies against Herpesviridae family in serum.

Methods

Participants undergoing cataract surgery were included in the study. Serum for viral serology including herpes simplex virus (HSV), varicella zoster virus (VZV), Epstein-Barr virus (EBV), and cytomegalovirus (CMV) was collected. Aqueous humor specimen was tapped for PCR analysis.

Results

Ninety-two participants were included with a mean age of 67.67 years (SD ±12.51). The prevalence of positive serology tests was 83.3% for HSV, 94.0% for VZV, 98.8% for EBV, and 97.6% for CMV. A total of 66 aqueous humor specimens were negative for PCR of Herpesviridae family.

Conclusion

This study showed previous HSV, VZV, EBV and CMV infections in >90% of the Thai population, while no viral presence was detected in aqueous humor. Thus, the serology test is unrelated to the presence of virus in the eye. We suggest that PCR is a valuable tool to diagnose intraocular viral infection and detect virus presenting active infection.

Efficacy and safety of an extemporaneous preparation of 2% ganciclovir eye drops in CMV anterior uveitis

Background

To evaluate the efficacy and safety of an extemporaneous preparation of 2% ganciclovir topical eye drops in cytomegalovirus (CMV) anterior uveitis because many studies have confirmed the benefits of topical ganciclovir in varying concentrations.

Design

The study employed a retrospective cohort design.

Methods

This study enrolled 11 eyes (11 patients) with CMV anterior uveitis. All cases were proved by positive PCR for CMV DNA from aqueous tapping and received topical 2% ganciclovir, applied every 2 hours daily as induction therapy then tapered off and stopped based on clinical response. Outcome measures were best-corrected visual acuity, anterior chamber cell, coin-shaped and other keratic precipitates, intraocular pressure (IOP), the number of antiglaucoma drugs used, the frequency of steroid eye drops used daily and side effects over a 12-month follow-up period. Side effects after applying topical 2% ganciclovir were recorded using questionnaires and eye examination.

Results

Mean age was 49.0±17.8 years. IOP, number of antiglaucoma drugs used and keratic precipitates decreased significantly at first week (p<0.013, p<0.024 and p<0.031, respectively) followed by decreased anterior chamber cells and significantly reduced frequency of applying steroid eye drops at 4 weeks (p<0.034 and p<0.017, respectively). Visual acuity significantly improved at 5 months continuously. All clinical improvement was maintained to 12 months, and keratic precipitates were eliminated in 90% of all cases. However, in 27% of discontinued medicine cases, inflammation was recurrent. No significance was observed in all factors between recurrent and non-recurrent groups. The most common side effect was eye irritation (27.27%). No severe complications from the medicine was detected.

Conclusion

Extemporaneous preparation topical 2% ganciclovir was effective and safely controlled CMV anterior uveitis. The medication is non-invasive, economical and convenient for hospitals where commercial topical ganciclovir is unavailable.

The efficacy of preoperative posterior subtenon injection of triamcinolone acetonide in noninfectious uveitic patients with secondary glaucoma undergoing trabeculectomy

Objective

The aim of this study was to evaluate the efficacy and safety of preoperative posterior subtenon injection of triamcinolone acetonide (PSTA) in noninfectious uveitic patients with secondary glaucoma undergoing primary trabeculectomy with mitomycin C.

Design

This was a retrospective study.

Patients and methods

We reviewed the medical records of 10 noninfectious uveitic patients, who had received a single preoperative PSTA 40 mg/1 mL, with secondary glaucoma undergoing primary trabeculectomy with mitomycin C. We collected data before and after surgery on intraocular pressure (IOP), anterior chamber (AC) cells, best-corrected visual acuity (BCVA), morphologic characteristics of the filtering bleb and complications.

Results

The mean time between injection and surgery was 7.8±3.88 days. Postoperative IOP level was significantly lower than preoperative level (31.3±11.44 mmHg) at all visits (P<0.02). Antiglaucoma medications were decreased from preoperative (4.9±0.88) to 12-month postoperative (0.8±1.31; P-value <0.001) and also discontinued in seven eyes (70%). About 12 months after surgery, eight eyes (80%) with qualified success and two eyes (20%) with failed treatment were recorded. AC cells and BCVA did not differ significantly from baseline; however, all inflammations were controlled successfully. Most desirable bleb morphology was shown at 12 months as well. Complications were blepharoptosis and hypotony maculopathy in two eyes (20%).

Conclusion

A preoperative PSTA may be an effective and safe option in controlling intraocular inflammation and maintaining bleb function after trabeculectomy in noninfectious uveitic patients with secondary glaucoma during a 12-month period.

Necrobiotic xanthogranuloma scleritis in a case of granulomatosis with polyangiitis (Wegener's granulomatosis)

The purpose of this study was to describe a case of necrobiotic xanthogranuloma scleritis in a 53-year-old male with unilateral progressive visual loss, scleritis, prolonged fever, and multiple mononeuropathy. Scleral biopsy showed necrosis with small abscess, and the pathological tissues revealed submucosal infiltration of mononucleated foamy histiocytes (xanthoma cells), hemosiderin-laden macrophages, neutrophils, lymphocytes, plasma cells, and erythrocytes without Touton giant cells or cholesterol clefts. Serum protein electrophoresis showed polyclonal gammopathy. All infectious investigations were negative. Afterward, this patient was diagnosed with granulomatosis with polyangiitis based on granuloma found in scleral tissue, vasculitis seen in sural nerve biopsy and positive serologies (C-ANCA and anti-PR3 antibody). He was treated with high-dose corticosteroid and later with intravenous cyclophosphamide monthly. He responded well to treatment, both eye and systemic conditions. Necrobiotic xanthogranuloma scleritis could be an early presentation of granulomatosis with polyangiitis.

Normal flora of conjunctiva and lid margin, as well as its antibiotic sensitivity, in patients undergoing cataract surgery at Phramongkutklao Hospital

OBJECTIVE

This study aimed to evaluate the normal flora of conjunctiva and lid margin, as well as its antibiotic sensitivity.

DESIGN

This was a prospective cross-sectional study.

PATIENTS AND METHODS

A prospective study was conducted on 120 patients who underwent cataract surgery at the Phramongkutklao Hospital from September 2014 to October 2014. Conjunctival and lid margin swabs were obtained from patients before they underwent cataract surgery. These swabs were used to inoculate blood agar and chocolate agar plates for culturing. After growth of the normal flora, the antibiotic sensitivity method using tobramycin, moxifloxacin, levofloxacin, and cefazolin was applied.

MAIN OUTCOME MEASURES

Normal flora of conjunctiva and lid margin, along with its antibiotic sensitivity, from patients who underwent cataract surgery was assessed.

RESULTS

A total of 120 eyes were included in this study, and bacterial isolation rates were identified. Five bacteria from the lid margin were cultured, namely, coagulase-negative staphylococcus (58.33%), Streptococcus spp. (2.5%), Corynebacterium (1.67%), Micrococcus spp. (1.67%), and Staphylococcus aureus (0.83%). Two bacteria from the conjunctiva were cultured, namely, coagulase-negative staphylococcus (30%) and Streptococcus spp. (0.83%). Results of antibiotic sensitivity test showed that all isolated bacteria are sensitive to cefazolin 100%, tobramycin 98.67%, levofloxacin 100%, and moxifloxacin 100%.

CONCLUSION

Coagulase-negative staphylococci are the most common bacteria isolated from conjunctiva and lid margin.

A case report of Epstein-Barr virus-associated retinal vasculitis: successful treatment using only acyclovir therapy

The purpose of this study was to describe a presumed case of Epstein–Barr virus (EBV)-associated retinal vasculitis in a 42-year-old female with sudden unilateral vision loss and successful treatment with acyclovir therapy. Diagnostic vitreous biopsy of the right eye was performed to test for EBV and other known infectious causes of retinitis and evaluate vitreous cells and serological testing. Vitreous polymerase chain reaction viral DNA testing result was positive for EBV but negative for herpes simplex virus, varicella-zoster virus, and cytomegalovirus. Serologic testing was negative for toxoplasma gondii, syphilis, tuberculosis, and HIV. Histopathologic analysis of vitreous cells revealed atypical lymphocytes. Fluorescein angiography showed disk leakage, occluded retinal artery, peripheral vascular leakage, and ischemic area of the right eye. Intravenous acyclovir, 10 mg/kg/d, was prescribed for 14 days followed by oral acyclovir for 3 months. All lesions have become quiet. EBV may be a cause of retinal disease, and intravenous acyclovir is a successful treatment choice.