Clinical profile of uveitis patients developing central serous chorioretinopathy: An experience at a tertiary eye care center in India

Purpose: To evaluate clinical profile of patients with uveitis who developed central serous chorioretinopathy (CSC). Methods: Retrospective case series of consecutive patients of uveitis with CSC managed at a tertiary eye care center in India between 1994 and 2014. The data about clinical features, investigations, treatment, and outcomes were obtained from their medical records. Results: A total of 31 eyes of 26 patients with uveitis with a diagnosis of CSC between June 1994 and May 2014 were included in the study. The mean age of presentation was 42.8 � 9.2 years, and 88.4% of the patients were male. CSC was bilateral in 19.2% of the patients, and in 38.4% patients uveitis was because of infectious etiology. CSC developed in 23 (88.5%) patients when they were on oral corticosteroid. The most common cause of uveitis in our study was choroiditis (48.4%), followed by retinal vasculitis (12.9%). The mean time for resolution of CSC was relatively less in patients with uveitis because of infectious etiology. In 10% eyes vision remained the same and deterioration of vision was noted in 19% eyes. Best corrected visual acuity of the patients at the time of presentation with CSC was 0.56 � 0.34 and after the resolution of CSC was 0.48 � 0.5 (P < 0.0005). Conclusion: Patients with choroidal inflammations are more prone to develop CSC compared with other subtypes of uveitis. Management of CSC in uveitis can be challenging.

Familial Blau syndrome:First molecularly confirmed report from India

Blau syndrome (BS) is a rare autoinflammatory disorder characterized by the clinical triad of arthritis, uveitis, and dermatitis due to heterozygous gain-of-function mutations in the NOD2 gene. BS can mimic juvenile idiopathic arthritis (JIA)-associated uveitis, rheumatoid arthritis, and ocular tuberculosis. We report a family comprising a mother and her two children, all presenting with uveitis and arthritis. A NOD2 mutation was confirmed in all the three patients – the first such molecularly proven case report of familial BS from India.

Visual rehabilitation of patients with low vision in uveitis

Purpose: To elucidate the clinical profile of visual impairment (VI) and rehabilitation of the uveitic patients with irreversible low vision. Methods: Retrospective analysis of visual rehabilitation of patients with uveitis suffering from poor vision with low vision devices (LVD). Results: Most common cause of uveitis was choroiditis (46.29%), followed by retinitis (25.92%), retinochoroiditis (18.51%), and chronic panuveitis sequelae (9.25%). Of these 54 cases, 35.18% had moderate VI, 25.92% had severe VI, 20.37% had mild VI, and 18.51% had profound VI or blindness. Statistically significant improvement (P < 0.05) in near vision was seen in choroiditis (52%) and retinitis (72%), whereas clinically significant improvement in distance vision was found in patients with choroiditis. Most commonly prescribed LVD was half-eye prismatic spectacle magnifier (22.2%). Conclusion: Rehabilitation of the uveitic patients with low vision is challenging. LVD may be a beneficial tool in these patients to help them perform their day-to-day activities independently.

Real-time polymerase chain reaction for diagnosis and management of HIV-induced uveitis

Intraocular (IO) inflammation in patients with Human immune deficiency virus (HIV) infection can be due to opportunistic infections, immune recovery uveitis, drugs used in the management or a primary manifestation of HIV itself. We studied the role of RT-PCR for HIV RNA in confirming the diagnosis of HIV induced uveitis and its useful in the management and follow-up of these patients.

Antineutrophil cytoplasmic antibody-positive scleritis: Clinical profile of patients from a tuberculosis-endemic region

Purpose: To report the clinical profile of a series of antineutrophil cytoplasmic antibody (ANCA)-associated scleritis in Indian population. Methods: We conducted a retrospective review of medical records of 33 eyes of 26 consecutive patients with scleritis, who tested positive for either antibody to proteinase 3 [anti-PR3/cytoplasmic antineutrophil cytoplasmic antibody (cANCA)] or myeloperoxidase [anti-MPO/perinuclear anti-neutrophil cytoplasmic antibody (pANCA)] between 2006 and 2015. Results: The mean age at presentation was 54.1 (11.1) years and 61.5% of the patients were female. Underlying systemic disorder was found in 46.2% of patients and includes granulomatosis with polyangitis (30.8%) and tuberculosis (15.4%). Necrotizing scleritis (48.5%) was the most common scleritis observed, followed by diffuse anterior scleritis (42.4%). Positive cANCA was found in 65.4% of patients and 34.6% was found positive for pANCA. Four of the six patients with positive Mantoux test were started on anti-tuberculosis treatment (ATT) by pulmonologist. Cyclophosphamide was the most common immunosuppressive and 11.5% of the patients required combination of two immunosuppressives. Seventeen eyes developed cataract and four eyes required patch graft. Female gender was more frequently associated with pANCA-associated scleritis than cANCA (P = 0.037). Incidence of necrotizing scleritis was higher in patients with positive cANCA, but this difference was not statistically significant (P = 0.806). cANCA-positive patients had statistically significant higher association with systemic rheumatic diseases (P = 0.021). Conclusion: Necrotizing scleritis is the most common subtype of scleritis in ANCA-positive individuals and even in the absence of systemic involvement. All patients with ANCA positivity should be thoroughly screened to rule out any evidence of tuberculosis, especially in tuberculosis-endemic region before planning aggressive immunomodulatory therapy.

Toxoplasma retinitis following intravitreal injection of triamcinolone acetonide: A case report and review of literature

The aim of this study was to report a case of atypical toxoplasma retinochoroiditis following intravitreal triamcinolone acetonide (IVTA) injection and to review the literature pertaining to toxoplasma retinochoroiditis following intravitreal injection of corticosteroid. Clinical data were collected from a 64-year-old male who developed toxoplasma retinitis 2 months after IVTA. A review of the literature was conducted to identify additional reports on similar cases. A 64-year-old male, known diabetic with nonproliferative diabetic retinopathy in both the eyes and optic atrophy in the left eye, presented with atypical retinitis inferior to the disc following IVTA. Real-time polymerase chain reaction and serology confirmed the toxoplasma etiology, and the patient was started on anti-toxoplasma therapy along with oral corticosteroid leading to regression of the lesion by 3 months. A high index of suspicion and proper microbiological diagnosis with appropriate antimicrobial therapy can aid in the management of toxoplasma retinochoroiditis following intravitreal injection of corticosteroid.

Vernal keratoconjunctivitis in human immunodeficiency virus – The possible role of T-helper 1–T-helper 2 shift

Human immunodeficiency virus infection (HIV) is associated with a reduced T-helper (Th) 1 response, and vernal keratoconjunctivitis (VKC) occurs secondary to a heightened Th2 response. VKC has been reported to occur in patients with HIV. In all probability, a Th1–Th2 shift occurs in the immune response in progressive HIV patients with a decreasing CD4 count. This shift could be the probable cause for the initiation and gradual worsening of the VKC in our patient that corresponded to the dropping CD4 counts. VKC resolved only after a change in antiretroviral therapy for HIV that caused a demonstrable increase in the CD4 counts possibly by reversing the shift.

Idiopathic intracranial hypertension associated with anaemia, secondary to antiretroviral drug in a human immunodeficiency virus positive patient

Papilledema in a patient with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome is an alarming finding. Any condition giving rise to raised intracranial tension (ICT) can cause papilledema, and in these patients, it could be secondary to opportunistic infections like meningitis to neoplasm. We report a case of a 28-year old female with HIV on antiretroviral therapy, who presented to us, with papilledema. Her fundus examination revealed superficial hemorrhages and Roth's spots along with papilledema. Patient was diagnosed with idiopathic intracranial hypertension (IIH), and all other possible systemic associations were ruled out. Her blood tests showed severe anemia. The papilledema and retinal changes resolved with treatment of anemia. This is a rare presentation of IIH in HIV positive patient due to anemia, secondary to zidovudine adverse effect.

Laboratory support in the diagnosis of uveitis.

Intraocular inflammations are still a diagnostic challenge for ophthalmologists. It is often difficult to make a precise etiological diagnosis in certain situations. Recently, there have been several advances in the investigations of uveitis, which has helped the ophthalmologists a lot in the management of such clinical conditions. A tailored approach to laboratory diagnosis of uveitic cases should be directed by the history, patient's symptoms and signs, and clinical examination. This review summarizes various modalities of laboratory investigations and their role in the diagnosis of uveitis.

Current approach in the diagnosis and management of posterior uveitis.

Posterior uveitic entities are varied entities that are infective or non-infective in etiology. They can affect the adjacent structures such as the retina, vitreous, optic nerve head and retinal blood vessels. Thorough clinical evaluation gives a clue to the diagnosis while ancillary investigations and laboratory tests assist in confirming the diagnosis. Newer evolving techniques in the investigations and management have increased the diagnostic yield. In case of diagnostic dilemma, intraocular fluid evaluation for polymerase chain testing for the genome and antibody testing against the causative agent provide greater diagnostic ability.

Introduction and immunopathogenesis of acquired immune deficiency syndrome.

India has a large number of patients with acquired immune deficiency syndrome (AIDS), the third largest population of this group in the world. This disease was first described in patients with Pneumocystis pneumonia in 1981. Ocular lesions can occur at any stage of the disease but are more commonly seen at the late stages. Human immunodeficiency virus (HIV), the causative agent of AIDS is a retrovirus with RNA genome and a unique 'Reverse transcriptase enzyme' and is of two types, HIV-1 and 2. Most human diseases are caused by HIV-1. The HIV-1 subtypes prevalent in India are A, B and C. They act predominantly by reducing the CD4+ cells and thus the patient becomes susceptible to opportunistic infections. High viral titers in the peripheral blood during primary infection lead to decrease in the number of CD4+ T lymphocytes. Onset of HIV-1-specific cellular immune response with synthesis of HIV-1 specific antibodies leads to the decline of plasma viral load and chronification of HIV-1 infection. However, the asymptomatic stage of infection may lead to persistent viral replication and a rapid turnover of plasma virions which is the clinical latency. During this period, there is further decrease in the CD4+ counts which makes the patient's immune system incapable of controlling opportunistic pathogens and thus life-threatening AIDS-defining diseases emerge. Advent of highly active antiretroviral treatment (HAART) has revolutionized the management of AIDS though there is associated increased development of immune recovery uveitis in a few of these patients.

Anterior segment manifestations of human immunodeficiency virus/acquired immune deficiency syndrome.

Ocular complications are known to occur as a result of human immunodeficiency virus (HIV) disease. They can be severe leading to ocular morbidity and visual handicap. Cytomegalovirus (CMV) retinitis is the commonest ocular opportunistic infection seen in acquired immune deficiency syndrome (AIDS). Though posterior segment lesions can be more vision-threatening, there are varied anterior segment manifestations which can also lead to ocular morbidity and more so can affect the quality of life of a HIV-positive person. Effective antiretroviral therapy and improved prophylaxis and treatment of opportunistic infections have led to an increase in the survival of an individual afflicted with AIDS. This in turn has led to an increase in the prevalence of anterior segment and adnexal disorders. Common lesions include relatively benign conditions such as blepharitis and dry eye, to infections such as herpes zoster ophthalmicus and molluscum contagiosum and malignancies such as squamous cell carcinoma and Kaposi's sarcoma. With the advent of highly active antiretroviral therapy, a new phenomenon known as immune recovery uveitis which presents with increased inflammation, has been noted to be on the rise. Several drugs used in the management of AIDS such as nevirapine or indinavir can themselves lead to severe inflammation in the anterior segment and adnexa of the eye. This article is a comprehensive update of the important anterior segment and adnexal manifestations in HIV-positive patients with special reference to their prevalence in the Indian population.

Analysis of juvenile idiopathic arthritis associated uveitis in India over the last 16 years.

AIM: Juvenile idiopathic arthritis (JIA) associated uveitis is one of the most common causes of visual morbidity in children. We report the systemic, clinical and investigational features of a cohort of all cases of JIA associated uveitis seen at our referral uveitis clinic between 1988 and 2004. STUDY DESIGN: Retrospective case series MATERIALS AND METHODS: All patients of JIA seen at the uveitis clinic of tertiary eye care hospital, between 1988 and 2004 with minimum follow up of 3 months were included. Complete history and ophthalmic evaluation and findings on each visit were noted. Ocular complications were identified and recorded. Results of laboratory investigations and diagnostic as well as therapeutic procedures were analyzed. A rheumatologist managed systemic status. RESULTS: There were 40 patients (64 eyes) with JIA. Thirty four patients (85%) had pauciarticular type and 6 patients (15%) had polyarticular type of JIA. Complicated cataract and band shaped keratopathy were seen in 38 eyes (63%) and 37 eyes (62%) respectively. Twenty-two patients (17 bilateral and 5 unilateral) were treated with immunosuppressives and in 19 of these patients, the disease went into remission. Twenty-three eyes (38%) had improvement in visual acuity while in 27 eyes (45%), the vision remained stable and in 10 eyes (17%), vision deteriorated despite therapy. CONCLUSION: In India, JIA associated uveitis commonly presented in pauciarticular type with preponderance in males. Rheumatoid arthritis factor and anti nuclear antibodies were not as common as compared to the western population. Among long-term treatment options, immunosuppressives are a better choice. Ocular surgery was performed when mandatory for visual rehabilitation.