Surgically induced necrotizing scleritis (SINS): Is it a standalone condition or a variant of necrotizing scleritis?

PURPOSE: To report the clinical pattern of surgically induced necrotizing scleritis (SINS) in a tertiary eye care center in Southern India. METHODS: Retrospective analysis of all SINS cases visiting the uveitis clinic of a tertiary eye institute between January 2009 and April 2019. RESULTS: In total, 15 patients with a median age of 65 (IQR:52-70) years were included in the study. Male (53%) predominance was noted, and SINS was unilateral (100%) in all cases. Most (87%) of the patients developed SINS after a single surgical procedure, with a median onset period of 251 (IQR:127-1095) days. None of these patients had any evidence of systemic association. Ocular hypertension (n = 3, 20%), and cataract (n = 5, 33%) were the most common complications. When compared with a cohort of patients with idiopathic necrotizing scleritis, the index study did not find any statistically significant difference between SINS and idiopathic scleritis. CONCLUSION: SINS is idiopathic necrotizing scleritis rather than an independent entity of scleritis.

An Analysis of the clinical and investigative profile of uveitis in the elderly: First case series from India.

PURPOSE: To evaluate the spectrum of uveitis occurring after 60 years of age in elderly patients who presented to a tertiary care eye center in India. METHODS: Retrospective study of patients who visited a tertiary eye care institute between January 2010 and July 2020. RESULT: Eighty-seven patients developed uveitis after 60 years, with only 44.8% having sufficient follow-up documentation and were included in the final analysis. The median age of these patients was 64 (IQR: 62-70) years, and 69% of them were male. Among the identifiable causes of uveitis, infectious uveitis (36%) was the most common and noninfectious uveitis was noted in 23% of patients. The most common subtype of uveitis was anterior uveitis (52%), followed by intermediate uveitis (32%), panuveitis (11%), and posterior uveitis (7%). Tuberculosis (28%) was the most common cause in our cohort, followed by HLA B27 (10%), sarcoid (8%), and Vogt-Koyanagi-Harada disease (5%). In 41% of patients, a definitive diagnosis of uveitis could not be achieved, and the anterior uveitis group had the highest number of undifferentiated uveitis cases. There were no undifferentiated cases of uveitis in the posterior and panuveitis category. The median follow-up period of these patients was 52 (15-91) months and 66% of eyes had recurrence. A statistically significant improvement in vision was seen in anterior uveitis and panuveitis groups, whereas the median visual acuity of the intermediate uveitis group remained stable throughout the follow-up period. CONCLUSION: Uveitis in the elderly can have a higher recurrence rate; however, the lack of follow-up in these groups of patients is a major challenge.

Visual outcome in pediatric uveitis: A retrospective data review in 277 children.

Purpose: This study aimed to describe visual outcomes in cases of pediatric uveitis in an Indian population and to analyze various factors affecting these outcomes. Methods: Single-center, retrospective chart review of 277 cases of uveitis in patients under the age of 18 years. Variables assessed included age and sex distribution, anatomical location of uveitis, systemic associations, complications, and various treatment strategies used, including long-term immunomodulation and surgical management of complications if required. The main outcome was the final visual acuity. Results: At the final visit, 51.5% of the eyes showed improvement in the final visual acuity, while vision remained stable in 28.7% and 19.7% of the eyes showed worsening of vision at the final follow-up. A total of 19.4% of patients were blind in at least one eye at the final visit, and 16 patients (5.77%) remained bilaterally blind at the final follow-up. The presence of cataract (p = 0), posterior uveitis (p = 0.005), and retinal detachment (p = 0.014) were the most significant risk factors for predicting worse visual outcomes. More than half (65.7%) of patients reported a complication at some point in their follow-up, and the most common complication was cataract. In total, 50.9% of patients required long-term immunomodulatory therapy. Conclusion: Pediatric uveitis remains a challenging condition to treat and follow-up, and the visual outcome remains guarded for most patients.

Clinical profile of patients with anterior nodular scleritis in India.

PURPOSE: To report the clinical profile of a series of anterior nodular scleritis in Indian population. METHODS: We conducted a retrospective review of medical records of 140 eyes of 123 consecutive patients with nodular scleritis who presented to a tertiary eye care institute between 2007 and 2018. RESULTS: The mean age at presentation was 46.8 ± 13.1 years and 70.7% of the patients were female. Bilateral involvement was observed in 14% patients. The most common presenting symptom was redness (92.6%) and ocular pain (69.1%). Twenty-seven patients (22%) had some systemic association and rheumatoid arthritis (5%) was the most common autoimmune disease. Presumed ocular tuberculosis was diagnosed in 13% patients. Methotrexate was the most common immunosuppressive used in these patients and an additional immunosuppressive was required in 6.5% patients. Recurrence of inflammation was observed in 74.8% patients. Deterioration of vision noted in 2.8% eyes. CONCLUSION: Tuberculosis remains an important cause of nodular scleritis in India. Recurrence of scleritis is common in nodular scleritis and cases with non infectious nodular scleritis often require treatment with immune suppressives.

Phacotrabeculectomy in Eyes With Uveitic Glaucoma: A Retrospective Case-Control Study.

PRECIS: Phacotrabeculectomy with adjunctive mitomycin C is a good option for the management of coexisting cataract and glaucoma. Strict preoperative control of inflammation and close follow-up are essential in the management of eyes with uveitic glaucoma (UG). PURPOSE: The purpose of this study was to compare the outcomes of phacotrabeculectomy with adjunctive antimetabolites in the management of patients with UG and patients with primary open-angle glaucoma (POAG). MATERIALS AND METHODS: A retrospective case-control study of 112 patients with UG and 120 patients with POAG who underwent phacotrabeculectomy with mitomycin C and had a follow-up of ≥12 months between January 2000 and June 2015 was performed. Patients who had undergone intraocular surgery or cyclodestructive procedures earlier were excluded. The primary outcome was intraocular pressure (IOP) control; secondary outcomes included visual acuity and complication rates. RESULTS: IOP control was similar at the final visit in the UG group (14.52±6.74 mm Hg) and the POAG group (14.39±4.18 mm Hg) (P=0.867). Kaplan-Meier survival analysis showed a cumulative probability of survival (IOP: 6 to 18 with or without medications) in 71% and 77% at the end of 5 years (P=0.094) in the UG and POAG groups, respectively. Visual outcomes were worse in the UG group (0.5±0.68 logMAR units), as compared with the POAG group (0.27±0.47 logMAR units) (P=0.002). Complications such as cystoid macular edema (P=0.025) and posterior capsular opacification (P=0.004) were more common in the UG group. Recurrence of inflammation occurred in 34 eyes (30.04%) in the UG group. CONCLUSION: Meticulous control of perioperative and postoperative inflammation could have contributed to the favorable long-term outcomes of phacotrabeculectomy in UG, as compared with POAG.

Incidence and Management of Glaucoma in Vogt Koyanagi Harada Disease.

PURPOSE: To analyse the prevalence, incidence, and risk factors of glaucoma in Vogt Koyanagi Harada (VKH) disease and study the changes in visual acuity and intraocular pressure (IOP) with treatment. MATERIALS AND METHODS: Retrospective chart analysis of 448 eyes of 224 patients of Indian origin diagnosed with VKH disease from January 1990 to December 2013, who had a minimum follow-up of 3 months was performed. RESULTS: Seventy-one eyes (15.8%) developed sustained elevation in IOP. The prevalence of glaucoma at presentation was 15.8% and the cumulative incidence of glaucoma was 11.7%. The mechanisms of glaucoma were open-angle glaucoma in 46 eyes, (64.8%), angle closure in 21 eyes (29.6%), and of combined mechanisms in the remainder (4 eyes, 5.6%). Acute angle-closure crisis developed in 9 eyes (12.6%). Uveal effusion (odds ratio 9.47; confidence interval, 4.08-20.03) and increased number of recurrences (odds ratio 1.31; confidence interval, 1.13-1.53) were found to be significant risk factors for the development of glaucoma. Successful control of IOP was achieved in 64% at 12 months using medical/ laser treatment for glaucoma and was 50 % at 12 months following surgical management. CONCLUSIONS: Glaucoma is a frequent complication of uveitis in VKH disease. Presence of uveal effusion and increased number of recurrences of inflammation are significant risk factors.

Ocular lesions in 1,000 consecutive HIV-positive patients in India: a long-term study.

BACKGROUND: Ocular lesions in patients on highly active antiretroviral therapy (HAART) have shown changes in disease prevalence and pattern. Although they have been described in the Western population, there are not many such studies in the HAART era from India. This study aims to present the clinical profile, systemic correlation, and visual outcome in HIV-positive patients in relation to HAART in comparison with pre-HAART Indian studies and current Western data. Ocular findings and systemic correlation in 1,000 consecutive patients with HIV seen at a tertiary eye care center were analyzed. This study uses a prospective observational case series design. RESULTS: Age range of the patients was 1.5 to 75 years. Ocular lesions were seen in 68.5% of the patients (cytomegalovirus (CMV) retinitis was the commonest). The commonest systemic disease was pulmonary TB. Mean interval between HIV diagnosis and onset of ocular lesions was 2.43 years. CD4 counts range from 2 to 1,110 cells/mm3. Immune recovery uveitis (IRU) was seen in 17.4%. Interval between HAART initiation and IRU was 4 months to 2.5 years. Recurrence of ocular infection was seen in 2.53% (post-HAART) and > 20% (pre-HAART). Overall visual outcome showed improvement in about 14.3% and was maintained in 71.6% of the patients. CONCLUSIONS: CMV retinitis is the commonest ocular opportunistic infection in India, even in the HAART era. Newer manifestations of known diseases and newer ocular lesions are being seen. In contrast to Western studies, in our patients on HAART, ocular lesions do not always behave as in immunocompetent individuals. Ocular TB needs to be kept in mind in India, as well as other neuro-ophthalmic manifestations related to cryptococci, especially in gravely ill patients. Occurrence and frequency of various ocular opportunistic infections in developing nations such as India have significant variations from those reported in Western literature and need to be managed accordingly.