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.

Systemic lupus erythematosus (SLE) associated uveitis in India - A case series.

PURPOSE: To report the uveitic manifestations of patients with systemic lupus erythematosus (SLE). METHODS: This was a retrospective analysis of all SLE cases with ocular manifestations seen by a single ophthalmologist between 2015 and December 2021. RESULTS: In total, seven patients with a median age of 40 (range 18-50) years were included in the study. Female (85.7%) predominance was noted. Ocular findings were bilateral in 71% (five patients) of cases. Majority (10 eyes, 83%) of the patients had retinal vasculitis as the common finding. Antinuclear antibodies were positive in all the patients. The vision improved in two (16.6%) eyes, was stable in eight (66%) eyes, and worsened in one (8%) eye. All the patients were treated with oral steroids along with immunosuppressive agents. CONCLUSION: Though SLE is rare cause of uveitis, it can be associated with significant ocular morbidity. Hence, early diagnosis and treatment can salvage vision in many cases.

Age-Related Alterations of the Macular Choroid in Healthy Eyes Assessed by Swept-Source Optical Coherence Tomography Angiography.

OBJECTIVE: To analyze age-related changes in the choroid in healthy eyes using swept-source optical coherence tomography angiography (SS-OCTA). PATIENTS AND METHODS: This was a cross-sectional, prospective, observational study enrolling 222 eyes of 116 healthy participants. SS-OCTA images were captured using the PLEX Elite 9000 (Carl Zeiss Meditec) with a 6 x 6 mm pattern centered on the fovea. Subfoveal choroidal thickness (CT) and choroidal volume (CV) were generated automatically through manufacturer tools available in the Advanced Retinal Imaging (ARI) hub network. Choroidal vascularity index (CVI) and choriocapillaris flow deficits (CCFD) were computed using ImageJ. RESULTS: CV was found to be significantly higher in women than men. Overall, there was a significant positive correlation between CVI and CCFD, and a significant negative correlation between CT and CV with age. The relationship, however, was more complex, as a decade-wise analysis showed that CT and CV increased until the second decade, followed by a decrease until the sixth decade, and then an increase again in the seventh and eighth decades. CVI was highest in the seventh decade. In contrast, CCFD increased consistently with age and in all the Early Treatment of Diabetic Retinopathy Study (ETDRS) rings. CONCLUSION: The choroidal blood flow and its thickness reduces as the age advances. While the choroidal flow deficits show a consistent increase with age and the distance from the foveal center, the relationship of other parameters with age is more complex. Having a normative database from healthy subjects is imperative for understanding the changes taking place in diseased states. Choroidal parameters can show significant variations with age. These differences are not uniform or consistent with age, highlighting the importance of a normative reference database to assess the significance of choroidal alterations associated with disease. [Ophthalmic Surg Lasers Imaging Retina 2023;54:526-534.].

Fractal analysis of the macular region in healthy eyes using swept-source optical coherence tomography angiography.

PURPOSE: This cross-sectional observational study evaluated the relationship between retinal vascular fractal dimension (FD) and age, as well as other vascular parameters in healthy eyes using swept-source optical coherence tomography angiography (SS-OCTA). METHODS: The study cohort consisted of 222 eyes of 116 healthy participants with no ocular or systemic disease. SS-OCTA images were captured and analyzed using the Plex Elite 9000 and software tools available in the advanced retinal imaging (ARI) network hub. The retinal vascular layers were defined by the instrument's automatic retinal layer segmentation. The fractal analysis was performed on the superficial capillary plexus (SCP), deep capillary plexus (DCP), and the whole retina. Grayscale OCTA images were standardized and binarized using ImageJ and fractal box-counting analyses were performed using Fractalyse software. Pearson's correlation was used to analyze the correlation between FD and retinal vascular parameters. RESULTS: The results showed that FD values were significantly higher in the 6 mm ring and the whole 6 × 6 scan region when compared to the 1 mm ETDRS central subfield. The correlation between age and FD was weak with a significant positive correlation between age and FD of the SCP in the 6 mm ring and between age and FD of the DCP in the 1 mm ring. Overall, differences in FD values in these healthy eyes were extremely small regardless of age or macular location. CONCLUSION: FD values in normal eyes show little variation with age and are relatively stable across the macula. This suggests that FD values may not need adjustment for age or location when evaluated in the context of retinal disease.

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 Scleritis Presenting for the First Time in the Elderly.

PURPOSE: To analyze clinical characteristics of scleritis in elderly patients and also compare the data with relatively younger patients with scleritis (<60 years). METHOD: Retrospective analysis of medical records of patients with scleritis who visited a tertiary eye care centre between 2008 and 2018. RESULT: Scleritis in ≥60 years accounted for 3% of the total scleritis cases. The mean age of the patients was 67 ± 6 years, and a female (66%) predominance was noted. Of the 44 elderly patients with scleritis, 48% were 66-70 years of age and 20% were above 70 years of age. Diffuse scleritis was the most common subtypes followed by necrotizing scleritis (35%). Overall, 32% of elderly patients with scleritis had underlying disease and the most common systemic association was granulomatous with polyangiitis. When compared with a subset of patients (<60 years of age), the elderly group showed higher rate of recurrences and complications. CONCLUSION: Scleritis in elderly patients is relatively rare but can have a higher recurrence rate with a increased complications.

Clinical profile, treatment, and visual outcome of scleritis: A single ophthalmologist experience.

PURPOSE: The purpose of this study was to analyze the clinical profile of patients with scleritis managed by a single ophthalmologist in a tertiary eye care center. METHODS: This was a retrospective analysis of 107 eyes of 96 patients with scleritis from January 2007 to December 2018. RESULTS: Female predominance (68%) with a relatively young-onset (46 ± 14 years) of scleritis was observed. Diffuse anterior scleritis (41%) was the most common subtype of scleritis, and the most common systemic association was rheumatoid arthritis (18%). Three-fourth of patients received immunosuppressive treatment (74%) along with corticosteroids. The mean follow-up period was 3 ± 2.5 (range: 0.6-10) years. Necrotizing scleritis was at a 3.5 times higher risk of developing ocular complications. Eighty percent of patients maintained the same vision. Recurrence of scleritis was noted in 25 eyes (23%). CONCLUSION: Diffuse scleritis is the most common scleritis in our population. Tuberculosis was commonly seen with diffuse scleritis. The likelihood of developing ocular complications (cataract and glaucoma) was higher in necrotizing scleritis, thus requiring periodic monitorization.

Age-related assessment of foveal avascular zone and surrounding capillary networks with swept source optical coherence tomography angiography in healthy eyes.

AIM: To assess the macular capillary networks and foveal avascular zone (FAZ) with swept-source optical coherence tomography angiography in healthy eyes. METHODS: This cross-sectional, prospective, observational study enrolled 222 eyes of 116 healthy participants with no ocular or systemic disease. SS-OCTA images were captured using the PLEX Elite 9000 (Carl Zeiss Meditec Inc., Dublin, CA, USA) with a 6 × 6 mm pattern centered on the foveal center. Vessel length density (VLD), perfusion density (PD), and FAZ parameters were analyzed using the manufacturer's automated software. RESULTS: A significant negative correlation was observed between age and average VLD in the superficial plexus, and average PD in both the superficial plexus and the whole retina. A significant positive correlation between age and foveal avascular zone perimeter and area was also noted. Age-wise comparisons showed a trend for an increase in VLD and PD until 40 years of age, with a subsequent decrease in the older age in the macular region. The central subfield showed a decrease in the vessel density measurements in the 21-40 age group. FAZ area and perimeter were the mirror inverse of the central subfield vessel density measurements with a numerically greater area and perimeter in the 21-40 age group compared to the 0-20 and 41-60 age groups. FAZ circularity was significantly reduced after 40 years of age. CONCLUSION: Age-related changes in the vessel density and FAZ parameters in the healthy macula are complex and vary with the macular location. These results carry significance when interpreting the data from diseased eyes.

Retino-choroidal evaluation of the macular region in eyes with tubercular serpiginous-like choroiditis using swept-source optical coherence tomography angiography.

AIM: To analyse the alterations in retino-choroidal angioarchitecture in eyes with active tubercular serpiginous-like choroiditis (TB-SLC) using swept-source optical coherence tomography angiography (SS-OCTA). METHODS: This prospective cross-sectional study enrolled 34 eyes diagnosed with TB-SLC and 34 age-matched healthy controls. Data acquisition with SS-OCTA using the PLEX Elite 9000 (Carl Zeiss Meditec Inc., Dublin, CA, USA) with a 6 × 6 mm pattern centered on the foveal center was done. Automated retinal vessel length density (VLD) and perfusion density (PD) and foveal avascular zone architecture were obtained from the ARI hub. Choroidal vascularity index (CVI) and choriocapillaris flow deficits (CCFD) were obtained using Image J. RESULTS: Eyes with TB-SLC showed significantly reduced vessel indices in all retinal layers (P < 0.05), decreased CVI (P = 0.001) and increased CCFD (P = 0.001) as compared to healthy eyes. CCFD was increased significantly in the involved quadrants in eyes with TB-SLC when compared with the uninvolved quadrants and corresponding healthy quadrants in control subjects. CCFD showed a significant negative correlation with visual acuity (r = - 0.46, P = 0.006). CONCLUSION: Eyes with TB-SLC manifest reduced VLD and PD, decreased CVI and increased CCFD. The CCFD alterations are non-uniform in these eyes, mainly located under the regions with disease activity.

Clinical profile, multimodal imaging, and treatment response in macular serpiginous choroiditis.

PURPOSE: To describe the clinical profile, multimodal imaging, and treatment response in macular serpiginous choroiditis (MSC). METHODS: Clinical records of 16 eyes (14 patients) with MSC presenting to a tertiary eye care institute between 2015 and 2019 were analyzed retrospectively. RESULTS: Mean age of 14 patients presenting with MSC was 33 ± 13 yrs with 64% males and 36% females. Mean visual acuity of the eyes with MSC at presentation was 0.43 ± 0.46 (logMAR) improving to 0.16 ± 0.28 (logMAR) at final visit. Thirteen eyes (81.3%) had active lesion at presentation. Mantoux test was positive in seven patients (50%) and QuantiFERON TB gold test positive in 10 patients (71%). HRCT chest showed latent tuberculosis in seven patients (50%). All patients underwent multimodal imaging. All patients received oral steroids as treatment therapy; 11 patients also received immunosuppressives, nine patients received additional anti-tubercular therapy (ATT). Mean duration of follow-up for the patients was 18 ± 10 months. A total of eight (50%) eyes had recurrence of lesions after an average duration of 14 ± 14 (3-36) months and were restarted on the treatment as per the requirement. At final follow-up, all eyes showed a good response to treatment and had healed lesions. Comparing the final BCVA to the initial BCVA, 38% (n = 6) showed improvement, 56% (n = 9) remained stable, and 6% (n = 1) eyes worsened at the final follow-up. CONCLUSION: Clinical profile and presentation of MSC is similar to that of CSC, and combination treatment with intravenous methyl prednisolone (IVMP), steroids, immunosuppressives, and ATT can salvage vision. A high suspicion of associated tuberculosis in endemic regions should be kept in mind.

Clinical Profile of Patients with Scleritis in Bangladesh.

Purpose: To analyze clinical profile of the patients with scleritis in a tertiary care eye hospital in Bangladesh.Method: Retrospective analysis of 111 eyes of 79 patients of scleritis between January 2012 and May 2018.Result: The study observed a relative younger mean age and equal gender distribution. Diffuse anterior scleritis (43%) was the most common type of scleritis. Rheumatoid arthritis (10%) was the most common systemic disease followed by granulomatosis with polyangiitis (5%) and tuberculosis (2.5%). Fifty-eight patients (73.4%) required immunosuppressive agents.Conclusion: The current study highlighted a distinct pattern and profile of scleritis patients in Bangladesh.

Choroidal Tuberculoma Manifesting in A Patient of Eales Disease 6 Years after Initial Presentation.

Purpose: To describe a case of choroidal tubercle in a patient with Eales disease after 6 years, whose initial work-ups were negative for systemic diseases.Methods: A retrospective chart reviewResults: This case report describes a 39-year-old male with a 6-year history of Eales disease characterized by recurrent inflammations and vitreous hemorrhages in his both eyes. His systemic work-up at the initial presentation was normal which included a negative Mantoux test and a normal chest X-ray. On a follow-up visit after 6 years, fundus examination of the right eye revealed a choroidal tuberculoma and subsequent investigations revealed a positive Mantoux test, QuantiFERON TB Gold test and lymphadenopathy in high-resolution computerized tomography. The choroidal tuberculoma responded well to anti-tubercular treatment and oral steroid.Conclusions: Ocular tuberculosis can be associated with Eales disease and often manifest later in the course of the disease.

Retinal Vasculitis in a Patient with Ankylosing Spondylitis: A rare Association.

PURPOSE: To report a case of retinal vasculitis in a patient with ankylosing spondylitis. BACKGROUND: Posterior segment involvement in HLA B-27-associated uveitis is uncommon but we report a case wherein retinal vasculitis was associated with HLA-B 27 uveitis. CASE: A 36-year-old male, a diagnosed case of ankylosing spondylitis, presented to us with severe anterior segment inflammation associated vitritis in both the eyes. He received topical, oral steroid and immunosuppressive and 3½-month after the control of his uveitis, he underwent cataract surgery in his left eye. Fundus evaluation following cataract surgery revealed sclerosed retinal vessels and wide-field fundus fluorescein angiography confirmed retinal vascular involvement in both the eyes. CONCLUSION: Retinal vasculitis, though rare can occur in patients with ankylosing spondylitis especially in conditions which present with panuveitis-like picture.