Intravitreal sustained-release dexamethasone implant for the treatment of persistent cystoid macular edema in ocular syphilis

With a resurgence of syphilis with human immunodeficiency virus (HIV) infection in last few years, various ocular manifestations of syphilis have been described in literature. This case report described an HIV-positive patient on anti-retroviral therapy who was diagnosed and treated for posterior uveitis secondary to ocular syphilis in the recent past presented to our clinic with cystoid macular edema (CME). CME, which did not respond to periocular corticosteroid, resolved with intravitreal sustained release dexamethasone implant. There was a recurrence CME 9 months later and repeat injection of intravitreal implant showed complete resolution. A long-term follow-up did not reveal reactivation of the infection with intravitreal corticosteroid. Intravitreal sustained release dexamethasone implant can be an effective treatment for refractory CME in patients with regressed syphilitic uveitis.

Tubercular posterior scleritis: A case report and review of literature

A 47-year-old female presented with optic disc oedema, peripapillary subretinal fluid and scattered areas of choroiditis. Her ultrasound B-scan showed sclerochoroidal thickening with widening of sub-Tenon space. Subsequent investigations revealed a positive Mantoux test and high-resolution computed tomography of the chest was suggestive of pulmonary involvement. She responded well to antitubercular treatment and systemic corticosteroid. A review of the literature was conducted to identify additional reports on similar cases and discussed. A high index of suspicion and appropriate laboratory work-up can aid in the diagnosis of tuberculous posterior scleritis.

A case of idiopathic necrotizing scleritis with secondary glaucoma treated successfully with golimumab and Ahmed valve implantation

A 52-year-old woman presented with idiopathic active scleritis not responding to oral cyclophosphamide, azathioprine, and oral steroid. Her intraocular pressure in the left eye was 45 mm of Hg in spite of using combination of brinzolamide 1% and brimonidine 0.2% (thrice a day), timolol maleate 0.5% (twice a day) eye drops in both eyes and oral acetazolamide. She was administered subcutaneous golimumab 50 mg injection every 4 weeks along with oral methotrexate 15 mg/week. The scleral inflammation responded and she underwent Ahmed glaucoma valve implantation after two months of initiation of golimumab therapy. After one week of surgery her IOP in left eye was the reduced to 8 mm of Hg. The index case showed that Golimumab can be a useful drug in the management of necrotizing scleritis refractory to the conventional therapy.

An unusual case of tuberculous optic neuropathy associated with choroiditis

Tuberculous optic neuropathy that includes papillitis, neuroretinitis, and optic nerve tubercle is a rare presentation of ocular tuberculosis. Though contagious spread from choroid following the hematogenous dissemination of the bacilli has been implicated in the optic nerve involvement, unlike neuroretinitis, optic nerve and choroidal involvement are usually considered as two separate clinical entities. We report a case of optic nerve involvement in a 33-year-old male who had concurrent choroidal involvement at present and also in the past. A strong history of contact with patients of pulmonary tuberculosis, positive tuberculin skin test, interferon gamma release assay, and high-resolution computed tomography helped us to clinch the diagnosis. Patients responded to systemic corticosteroid therapy and anti-tuberculosis treatment. Choroidal involvement in a case of inflammatory optic neuropathy should arise suspicion of tuberculous etiology.

Enigma of serpiginous choroiditis

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