Ocular involvement and visual outcome of herpes zoster ophthalmicus: review of 45 patients from Tunisia, North Africa.

BACKGROUND: Ocular complications of herpes zoster ophthalmicus (HZO) may lead to substantial visual impairment. The purpose of this study was to characterize and analyze ocular involvement and visual outcome of HZO in patients from Tunisia, North Africa. This study is a retrospective chart review of 51 eyes of 45 patients with HZO. RESULTS: Mean age was 44.5 years. Thirty patients (66.7%) were aged over 50 years. Twenty-four patients (53.3%) were male and 21 patients were female (46.7%). There was no statistically significant difference in gender distribution. Initial mean best corrected visual acuity (BCVA) was 20/50. Ocular manifestations included adnexal involvement (58.8%), keratitis (31.4%), keratouveitis (31.4%), isolated anterior uveitis (AU) (29.4%), intraocular pressure elevation (23.5%), oculomotor nerve palsy (5.8%), and optic neuritis (1.9%). Isolated AU (p < 0.001), isolated keratitis (p = 0.001), and intraocular pressure elevation (p = 0.013) were more likely to be concomitant to HZO active skin disease, while keratouveitis occurred more likely more than 1 month after HZO eruption (p < 0.001). AU and keratouveitis were more likely to be associated with age ≥ 50 years (p = 0.001 and p = 0.02, respectively). Ocular complications included neurotrophic keratopathy (1.9%), corneal opacity (5.9%), secondary glaucoma (7.8%), optic atrophy (1.9%), and postherpetic neuralgia (13.3%). Mean follow-up was 12 months. Mean final BCVA was 20/32; it was ≥ 20/40 in 78.4% of the eyes. CONCLUSIONS: Our study provided epidemiologic and clinical data of HZO in a Tunisian population. AU and keratitis were the most common ocular complications. Neurotrophic keratopathy was scarce. The overall visual outcome is good, with about three quarters of the treated patients maintaining VA of 20/40 or better.

Herpesvirus detection and cytokine levels (IL-10, IL-6, and IFN-γ) in ocular fluid from Tunisian immunocompetent patients with uveitis.

Human herpesviruses (HHVs) are involved in the pathogenesis of different types of uveitis. Cytokine response plays an important role in virus-induced immunopathology. This study aimed to investigate the incidence of HHVs in aqueous humor samples of immunocompetent patients with suspected viral uveitis and cytokine (IL-10, IL-6, and IFN-γ) expression profiling. Forty-seven aqueous humor samples were collected from immunocompetent patients with viral uveitis. Samples were assayed for HHV-1 to HHV-8 by in-house real-time polymerase chain reactions. IL-6, IL-10, and IFN-γ were quantified with a cytometric bead array. Relations between viral detection, cytokine profiles, and clinical data were studied. At least one viral genome was detected in 21 aqueous humor samples analyzed. Varicella-zoster virus (VZV) was detected in 14 of the positive samples, cytomegalovirus (CMV) in 8, HSV-1 in 1, Epstein-Barr virus (EBV) in 4, and HHV-6 in 2. More than one viral genome was detected in seven aqueous humor samples. Aqueous humor samples positive for HHV-DNA contained significant levels of IL-6, IL-10, and IFN-γ, compared to HHV-DNA negative samples. High levels of IL-6 were detected in patients with CMV-DNA in their aqueous humor samples. Significantly higher levels of IL-10 and IFN-γ were found in positive samples for VZV, EBV, and HHV-6 DNA than in negative aqueous humor ones. VZV was the principal etiologic agent of uveitis in this Tunisian series, with CMV the second most common agent. Knowledge of immunoregulatory interactions and dynamic changes in viral uveitis may be a key to understand the pathogenesis leading to more-effective treatments.

Branch retinal artery occlusion associated with posterior uveitis.

BACKGROUND: The purpose of this study is to report the clinical features and visual outcome of branch retinal artery occlusion (BRAO) associated with posterior uveitis. This is a retrospective study including the 18 eyes of 18 patients. All patients underwent a complete ophthalmic evaluation. Fundus photography, fluorescein angiography, and visual field testing were performed in all cases. RESULTS: Diseases associated with BRAO included active ocular toxoplasmosis in 7 patients, rickettsiosis in 4, Behçet's uveitis in 2, West Nile virus infection in 1, idiopathic retinal vasculitis in 1, Crohn's disease in 1, ocular tuberculosis in 1, and idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome in 1 patient. The mean initial visual acuity was 20/50. BRAO involved the first order retinal artery in 33.3% of the eyes, the second order retinal artery in 33.3%, an arteriole in 27.8%, and a cilioretinal artery in 5.5%. The macula was involved in 44.4% of the eyes and an acute focus of retinitis or retinochoroiditis was associated to BRAO in 55.5%. Repermeabilization of the occluded artery occurred in all patients with permanent scotomas in the corresponding visual field. The mean visual acuity at last visit was 20/32. CONCLUSIONS: BRAO, with subsequent visual impairment, may occur in the eyes with posterior uveitis. Physicians should be aware of such vision-threatening complication of infectious and inflammatory eye diseases.

Supratarsal injection of triamcinolone acetonide and childhood allergic keratoconjunctivitis.

To evaluate the efficacy and safety of supratarsal injection of triamcinolone acetonide in the treatment of refractory allergic keratoconjunctivitis in childhood. Thirty-five patients (70 eyes) with severe allergic keratoconjunctivitis were included in this study. Fifteen patients (42.8%) had atopic keratoconjunctivitis (AKC) and 20 (57.2%) had vernal keratoconjuncivitis (VKC). All patients underwent a bilateral supratarsal injection of 20 mg triamcinolone acetonide. Mean follow-up was 28 months (range 14-38). All patients showed a significant symptomatic improvement and partial resolution of clinical features of keratoconjunctivitis within the first 2 weeks. Corneal complications related to keratoconjunctivitis disappeared in all patients. One patient with VKC experienced ocular hypertension. No patient with AKC showed side-effects. Severe relapse of the disease was noted in 10% of eyes with VKC and in 6.7% of eyes with AKC after a mean follow-up of 9 and 11 months, respectively. Supratarsal injection of triamcinolone acetonide is effective and safe in patients with severe chronic allergic keratoconjunctivits to relieve severe inflammation associated with this disease.

Branch retinal artery occlusion associated with Behçet disease.

PURPOSE: To report 2 cases of branch retinal artery occlusion (BRAO) associated with Behçet disease (BD). DESIGN: Small case series. METHODS: Review of two patients' charts, fluorescein angiography, and optical coherence tomography (OCT). RESULTS: The authors report two young patients, diagnosed with BD, who developed decreased vision secondary to BRAO for the first patient and cilioretinal artery occlusion associated with branch retinal vein occlusion for the second patient. In the two cases, artery occlusion was associated with active intraocular inflammation. CONCLUSIONS: BRAO, with subsequent transient or permanent visual impairment, is an additional ocular complication of BD.

Clinical characteristics of intermediate uveitis in Tunisian patients.

To analyze the pattern of intermediate uveitis (IU) in a referral center in Tunisia, North Africa. A retrospective, descriptive study of 87 consecutive patients (145 eyes) examined at the Department of Ophthalmology of Monastir (Tunisia) from January 1996 to August 2008. All patients underwent an extensive ocular and systemic history, a complete ophthalmic examination, and fluorescein angiography. Standard diagnostic criteria of IU were employed. The mean follow-up period was 43.2 months (range, 4-65 months). The mean age at diagnosis of IU was 29.1 years (range, 5-54 years). The male-to-female ratio was 1:1.6. Both eyes were affected in 58 patients (66.7%). The best-corrected visual acuity at onset of uveitis ranged from light perception to 20/20 (mean, 20/32). The most frequent ocular findings were vitritis (100%), snowballs (53.8%), and retinal vasculitis (28.3%). Concurrent anterior uveitis was noted in 38.6% of affected eyes. Intermediate uveitis was most commonly idiopathic (86.2%). Systemic associations were found in 13.8%; sarcoidosis (9.2%) and multiple sclerosis (2.3%) were the most common systemic diseases. The ocular complications that developed during the follow-up period included cystoid macular edema (39.3%), cataract (31.7%), inflammatory optic disc involvement (26.2%), and glaucoma or ocular hypertension (9%). One hundred-twelve affected eyes (77.2%) had a final visual acuity more than or equal to 20/40. Factors of poor visual outcome were initial VA less than 20/40 (P = 0.00011), CME (P = 0.0016), and vitritis more than 3+ cells (P = 0.023). In a hospital population in Tunisia, intermediate uveitis started frequently at the 3rd decade. This type of uveitis was most commonly idiopathic. Cystoid macular edema and cataract were the most frequent complications. Visual prognosis appeared to be fairly good.

Pattern of uveitis in Behçet's disease in a referral center in Tunisia, North Africa.

The purpose of this study was to analyze the pattern of uveitis in Behçet's disease in Tunisia, North Africa. We retrospectively reviewed the clinical records of 62 patients (111 eyes) diagnosed with Behçet's uveitis (BU) at the Department of Ophthalmology, Fattouma Bourguiba University Hospital, Monastir, Tunisia, between January 1995 and December 2006. Forty-seven of 62 patients (75.8%) were men and 15 (24.2%) were women. Mean age at onset was 29.3 years. The average follow-up was 75.6 months. The most common extraocular clinical manifestations were recurrent oral ulcer in all patients and pseudofolliculitis in 52 patients (83.9%). Uveitis was bilateral in 79%. Initial best-corrected visual acuity was > or =20/40 in 41 affected eyes (36.9%) and <20/200 in 49 affected eyes (44.2%). Panuveitis (68 eyes, 61.3%) and posterior uveitis (38 eyes, 34.2%) were the most common forms, followed by anterior uveitis (five eyes, 4.5%). Retinal vasculitis was found in 89 eyes (80.2%). Most common complications included posterior synechiae (32.4%), cataract (31.5%), and cystoid macular edema (19.8%). Systemic corticosteroids were administered in 58 patients (93.5%). Immunosuppressive drugs were used in 22 patients (35.5%). Fifty-six affected eyes (50.5%) had final visual acuity > or =20/40 and 34 affected eyes (30.6%) had final visual acuity <20/200. In Tunisia, BU affects predominantly young men. Bilateral panuveitis associated with retinal vasculitis was the most common ocular manifestation. More than 50% of patients maintained a visual acuity of 20/40 or better, and immunosuppressive therapy probably contributed to the improvement of visual prognosis of these patients.

Serous retinal detachment secondary to choroidal osteoma successfully treated with transpupillary thermotherapy.

PURPOSE: To report a case of serous retinal detachment (SRD) associated with choroidal osteoma successfully treated with transpupillary thermotherapy (TTT). METHODS: A 21-year-old woman presented with a 1-month history of blurred vision in the right eye. RESULTS: Visual acuity was 20/50 in the right eye and 20/20 in the left eye. Fundus examination of the right eye revealed a suprapapillary choroidal osteoma associated with SRD extending to the macula. Fluorescein angiography showed diffuse mottled hyperfluorescence of the tumor associated with a moderately leaking area at its inferior border within the area of SRD. There were neither obvious features of choroidal neovascularization nor typical focal retinal pigment epithelial leaks. TTT, applied to the leaking area in one session using an 810-nm diode laser, resulted in resolution of subretinal fluid and subsequent improvement in visual acuity to 20/25. CONCLUSION: TTT can be considered as treatment for patients with choroidal osteoma complicated by SRD.

A prospective evaluation of factors associated with chorioretinitis in patients with West Nile virus infection.

PURPOSE: To identify factors associated with the development and severity of chorioretinitis (CR) in patients with West Nile virus (WNV) infection. METHODS: Prospective study of 38 patients with WNV infection. RESULTS: Simple analysis showed that diabetes (p = 0.027) and age older than 45 years (p = 0.03) were significantly associated with CR. When controlling for age, only association between diabetes and CR remains statistically significant. Diabetic patients' eyes were more likely to have macular involvement (p < 0.0001), 20 or more chorioretinal lesions (p < 0.001), and lesion size 500 microm or more (p < 0.01). CONCLUSIONS: Diabetes was a risk factor for the development and severity of WNV-associated CR.

Acute choroidal ischemia associated with toxoplasmic retinochoroiditis.

PURPOSE: To describe eight patients with active toxoplasmic retinochoroiditis (RC) who had features suggestive of acute choroidal ischemia. METHODS: A retrospective review of the clinical records of 23 consecutive patients with acute toxoplasmic RC was performed. All patients underwent detailed ophthalmic examination at presentation and throughout follow-up, including dilated biomicroscopic fundus examination, fundus photography, fluorescein angiography, and indocyanine green (ICG) angiography. RESULTS: Of 23 patients, 8 (34.8%) had a large area of retinal whitening surrounding a small focus of RC. Fluorescein as well as ICG angiography showed a well demarcated geographic area of early choroidal hypofluorescence that extended beyond the clinical borders of the white retinal lesion, particularly by ICG angiography. Associated findings for these 8 patients included old retinochoroidal scars (7 [87.5%]), serous retinal detachment (3 [37.5%]), retinal hemorrhages (1 [12.5%]), and multiple satellite dark dots by ICG angiography (6 [75%]). Seven of eight patients were treated using a combination of antitoxoplasmic drugs and corticosteroids. All findings seen at the acute stage resolved in 2 weeks to 6 weeks. A small atrophic retinochoroidal scar replaced the active toxoplasmic lesion and was surrounded with mild or moderate retinal pigment epithelium changes that were associated with decreased final visual acuity in 2 patients (25%). CONCLUSION: Patients with toxoplasmic RC may develop features suggestive of choroidal ischemia that can result in a transient or permanent decrease in vision. Choroidal ischemia can only be suspected clinically, and fluorescein angiography and ICG angiography are required to establish the definitive diagnosis.

Orbital sarcoidosis manifesting with enophthalmos.

PURPOSE: To describe a case of orbital sarcoidosis manifesting with enophthalmos. METHODS: A 60-year-old woman presented with right enophthalmos. She had a palpable mass in her anterior orbit inferiorly. She underwent a complete ophthalmic evaluation, magnetic resonance imaging, and histopathologic examination. RESULTS: A magnetic resonance imaging scan disclosed an orbital, extraconal mass, with displacement of the orbital floor. A biopsy specimen of the mass demonstrated a granulomatous inflammation without caesation necrosis. Workup revealed hilar lymphadenopathy, pleural nodule, and splenomegaly. The patient was treated with corticosteroids, with subsequent involution of the mass and disappearance of enophthalmos. CONCLUSION: Although orbital sarcoidosis usually manifests with proptosis or palpebral swelling, enophthalmos should be considered as ophthalmic manifestation of sarcoidosis.

Pattern of childhood-onset uveitis in a referral center in Tunisia, North Africa.

PURPOSE: To analyze the pattern of childhood uveitis in a referral center in Tunisia, North Africa. METHODS: The study included 64 patients with uveitis examined at the Department of Ophthalmology of Monastir (Tunisia) from January 1994 to July 2005. All patients had a comprehensive ocular and systemic history, including an extensive review of medical systems. Complete ophthalmic examination was performed in all cases, including best-corrected Snellen visual acuity, slit-lamp examination, applanation tonometry, and dilated fundus examination with 3-mirror lens. Standard diagnostic criteria were employed for all syndromes or entities of uveitis. RESULTS: The mean age at onset of uveitis was 12.4 years. The male-to-female ratio was 0.68. The process was unilateral in 51.6% of patients. Mean follow-up was 43.2 months. Anterior and intermediate uveitis each represented 31.25% of cases, posterior uveitis 20.3%, and panuveitis 17.2%. Noninfectious uveitis (75%) was the most frequent type of inflammation. Idiopathic uveitis was found in 50% of patients. Infectious uveitis was responsible for 25% of the cases, with toxoplasmosis (14.1%) being the most frequent cause. Twenty percent of the patients had systemic associations; juvenile idiopathic arthritis was found in 6.25%. Ocular complications occurred in 74.7% of affected eyes, of which the most common were posterior synechiae (28.4%), cataract (17.9%), cystoid macular edema (19%), and optic disc edema (32.6%). Fifty-seven affected eyes (60%) had a final visual acuity more than 20/40 and nine (9.5%) had a final visual acuity less than 20/200. CONCLUSIONS: In a hospital population in Tunisia, a specific cause of uveitis in children was found in half the patients. Idiopathic intermediate uveitis was the leading cause of uveitis in our study, followed by idiopathic anterior uveitis and toxoplasmosis. Uveitis associated with juvenile idiopathic arthritis was rare. Visual prognosis appeared to be good.

Ocular neovascularization in a patient with Fanconi anemia.

CASE REPORT: An 11-year-old girl diagnosed with Fanconi anemia was referred to us for redness and pain in her right eye. Findings in the right eye included visual acuity of counting fingers, neovascular glaucoma, vitreous hemorrhage, optic disc neovascularization, and features of peripheral ischemic retinopathy. Findings in the left eye included peripheral retinal neovascularization and areas of retinal capillary nonperfusion. COMMENTS: Patients with Fanconi anemia may develop ocular neovascularization with subsequent severe visual loss due to vitreous hemorrhage or neovascular glaucoma. Regular ophthalmic examination, including ophthalmoscopy and fluorescein angiography in selected cases, is recommended in such patients.

Primary intravitreal triamcinolone acetonide for diabetic massive macular hard exudates.

PURPOSE: To evaluate the efficacy of intravitreal triamcinolone acetonide as treatment for massive macular hard exudates in diabetic patients. METHODS: The study was a prospective, noncomparative, interventional case series of 12 eyes (12 patients) with massive hard exudates involving the fovea that had no previous focal laser treatment. A single intravitreal injection of 4 mg of triamcinolone acetonide in 0.1 mL was performed. Visual acuity and evolution of hard exudates and fluorescein leakage were assessed. Potential complications were monitored, including ocular hypertension and endophthalmitis. RESULTS: The follow-up period ranged from 6 to 12 months (mean, 8.25 months). Visual acuity improved significantly at examinations performed 7 days (P = 0.036), 1 month (P = 0.008), 3 months (P = 0.008), and 6 months (P = 0.003) after the injection. Visual acuity improved by at least 2 Snellen lines in 4 patients (33%). However, no eyes with initial visual acuity worse than 20/100 improved to better than 20/100. Foveal hard exudates resolved completely in 6 eyes (50%) and partially in 6 eyes (50%). Fluorescein leakage decreased and a variable proportion of microaneurysms disappeared in all cases. Intraocular pressure elevation occurred in 3 eyes (25%) and was successfully treated by topical medication. No other complications, such as endophthalmitis, were recorded. CONCLUSION: Intravitreal injection of triamcinolone acetonide appears to be beneficial for reducing hard exudates, decreasing fluorescein leakage, and significantly improving visual acuity in patients with diabetic massive hard exudates. Visual improvement may not be important due to profound anatomical impairment caused by hard exudate deposition. Further studies with a larger number of patients are required to assess the long-term efficacy and safety and the need for retreatment.

Posterior segment manifestations of Rickettsia conorii infection.

PURPOSE: To characterize and analyze the posterior segment manifestations of Mediterranean spotted fever (MSF), an infectious disease caused by Rickettsia conorii. DESIGN: Prospective, noncomparative case series. PARTICIPANTS: Thirty patients (60 eyes) with serologically proven MSF at the acute stage. METHODS: Patients underwent complete ophthalmic examination, including dilated biomicroscopic fundus examination, fundus photography, and fluorescein angiography. Sequential follow-up examinations were performed in patients with evidence of posterior segment involvement. RESULTS: Of 30 patients, 25 (83.3%) had unilateral (n = 5) or bilateral (n = 20) posterior segment involvement related to MSF. Of those 25 patients, 16 (64%) had no ocular symptoms, and 9 (36%) had ocular complaints. Findings included mild vitreous inflammation (45 eyes [75%]), white retinal lesions (18 eyes [30%]), focal vascular sheathing (5 eyes [8.3%]), multiple arterial plaques (1 eye [1.7%]), intraretinal hemorrhages (14 eyes [23.3%]), white-centered retinal hemorrhages (2 eyes [3.3%]), subretinal hemorrhages (2 eyes [3.3%]), serous retinal detachment (3 eyes [5%]), macular star (2 eyes [3.3%]), cystoid macular edema (1 eye [1.7%]), optic disc edema (1 eye [1.7%]), branch retinal artery occlusion (1 eye [1.7%]), optic disc staining (30 eyes [50%]), retinal vascular leakage (27 eyes [45%]), delayed filling in a branch retinal vein (1 eye [1.7%]), and multiple hypofluorescent choroidal dots (10 eyes [16.7%]). One eye (1.7%) had retinal neovascularization at the 6-month follow-up examination. All posterior segment findings at the acute stage resolved in 3 to 10 weeks, and the final visual acuity was 20/20 in 42 of 45 affected eyes (93.3%). Retinal pigment epithelium changes developed in 9 eyes (15%), with resolved full-thickness white retinal lesions. No other abnormalities were noted in the eye with retinal neovascularization over a further follow-up of 6 months. CONCLUSION: Posterior segment involvement, frequently asymptomatic, is common in patients with acute MSF. Because the diagnosis can be easily overlooked, a careful dilated funduscopic examination, complemented by fluorescein angiography in selected cases, is recommended. Mild vitritis, retinal vasculitis, optic disc staining, white retinal lesions, retinal hemorrhages, and multiple hypofluorescent choroidal dots are the most common manifestations of MSF. Posterior segment changes in a patient with fever and/or skin rash living in or returning from a specific endemic area, especially during the spring or summer, strongly suggest R. conorii infection.