Multifocal Evanescent White Dot Syndrome-like Phenotypes Associated with Inflammatory and Myopic Choroidal Neovascularization.

PURPOSE: To present the observation of multifocal evanescent white dot syndrome (MEWDS)-like phenotypes developing in association with the onset of choroidal neovascularization (CNV) in a series of patients. METHODS: Patients presenting to tertiary-care centers with MEWDS-like phenotypes and CNV were identified. RESULTS: Five patients presented for the management of CNV in the context of previous diagnoses of punctate inner choroidopathy (PIC) and/or myopia. In time-periods ranging from 0 days to 12 weeks from the diagnosis of active CNV, MEWDS-like changes were observed. Treatment with anti-VEGF agents were instituted in four cases, in an as-required protocol. 1 patient received systemic steroid. CONCLUSIONS: The development of MEWDS-like phenotypes in association with CNVM can occur in eyes with either inflammatory or non-inflammatory CNVM, and in those who were or were not treated with anti-VEGF therapy. The association suggests an inflammatory event, which causes RPE changes and probably induces the development of the CNV.

Real-Life Evidence for Using a Treat-and-Extend Injection Regime for Patients with Central Retinal Vein Occlusion.

INTRODUCTION: To report the 52-week treatment outcomes with intravitreal injections of aflibercept using a treat-and-extend regimen for treating macular edema secondary to central retinal vein occlusion (CRVO). METHODS: A retrospective analysis of patients newly diagnosed with CRVO was performed. Patients receiving aflibercept between 1 December 2016 and 31 March 2017 were included in the analysis. Data on age, gender, visual acuity measured on Early Treatment of Diabetic Retinopathy Study charts, presence of macular and peripheral ischemia, anatomical changes observed on spectral domain-optical coherence tomography examination and the number of injections needed were recorded. RESULTS: The mean gain in vision was 17.8 ± 19.1 (± standard deviation) letters and 15.1 ± 20.2 letters at weeks 24 and 52 of follow-up, respectively. The proportion of patients who gained ≥ 15 letters in best-corrected visual acuity was 52.9% at week 24 and 50% at week 52. The mean reduction in central subfield macular thickness was 331.5 and 311.6 at weeks 24 and week 52, respectively. For the patients completing 52 weeks of follow-up, the mean number of treatments was 4.9 ± 1.3 injections in the first 26 weeks and 3.2 ± 2.0 injections in the second 26 weeks. CONCLUSIONS: The Moorfields protocol for treating macula edema in CRVO achieves a quick response to treatment without over- or under-treating patients with a fixed protocol. Overall, our individualized treat-and-extend protocol achieved real-life outcomes approaching those of clinical trials. As there are currently no such trials using this practically useful regimen, our study provides real-world evidence for using a treat-and-extend protocol for aflibercept in CRVO.

What does IGRA testing add to the diagnosis of ocular tuberculosis? A Bayesian latent class analysis.

BACKGROUND: To evaluate the contribution made to the diagnostic work-up for patients with suspected ocular tuberculosis (TB) by QuantiFERON-TB Gold In-Tube (QFT) tests using latent class analysis model. METHODS: A single centre retrospective cohort study. A Bayesian latent class model was constructed on the basis of demographics, phenotypes and test results from patients attending a tertiary referral center in the UK. This estimated the probability of ocular TB for each patient in two versions, first with and then without QFT. The estimated probability of ocular TB was compared with treatment failure. RESULTS: From a database of 365 patients with clinical signs suggestive of ocular TB, 267 patients who had QFT and complete data were evaluated. Mean age was 45.0 ± 15.4 years with 141 (52.9%) male and 148 (50.5%) of Asian ethnicity. QFT was positive in 208 (70.1%) patients and ATT was instituted in 145 (49.5%) patients with 100 (34.1%) patients also having concurrent systemic corticosteroid therapy. The best estimate of a QFT level separating TB-positive and TB-negative patients was extremely low. This weak discrimination between TB and non-TB groups was reflected in poor positive and negative predictive values for treatment failure. CONCLUSIONS: The latent class model did not successfully predict treatment failure, despite taking all variables into account. The threshold between TB and non-TB in QFT values was implausibly low and removing QFT from the model made prediction slightly worse. A larger prospective study is required to establish the role of all tests, demographics and phenotypes in diagnosis.

Spectrum of Choroidal Involvement in Presumed Ocular Tuberculosis: Report from a Population with Low Endemic Setting for Tuberculosis.

OBJECTIVE: To describe the clinical spectrum and outcome of patients with presumed tubercular uveitis and choroidal involvement. METHODS: A retrospective case series nested in a cohort study was enrolled at a tertiary referral eye care center in the UK. Failure was defined as recurrence of lesion within 6 months of completion of antitubercular therapy (ATT) or corticosteroid therapy. RESULTS: Seventy-seven patients with presumed ocular tuberculosis and choroidal involvement were included in the study. Mean age was 45.5 ± 15.7 years, 44 (57.1%) patients were male, and 51 (66.2%) presented with bilateral disease. Choroidal granuloma was the most frequent clinical presentation (n = 27, 35.07%), followed by multifocal choroiditis (n = 24, 31.17%) and serpiginous-like choroiditis (n = 18, 23.38%). Quantiferon Gold in Tube Test (QFT) was positive in 64 (83.11%) patients. Fifty (64.94%) patients received ATT. CONCLUSIONS: Choroidal involvement in presumed ocular tuberculosis can present with a variable spectrum. Treatment failure rates were equivalent between ATT and non-ATT treated groups.

PERIPHERAL RETINAL VASCULITIS: Analysis of 110 Consecutive Cases and a Contemporary Reappraisal of Tubercular Etiology.

PURPOSE: Describe the clinical features and outcomes of patients with peripheral retinal vasculitis (RV) and describe clinical characteristics of presumed tubercular RV in a nonendemic setting. METHODS: Retrospective cohort study of 110 consecutive patients with peripheral RV at a tertiary referral eye care center in the United Kingdom. Retinal vasculitis was defined as RV with vitritis associated with peripheral retinal ischemia. Patients who also had positive Quantiferon Gold in Tube test, positive tuberculin skin test, and/or other evidence of systemic tuberculosis such as biopsy were labeled with presumed tubercular RV. Treatment success was defined as resolution of inflammation, and successful tapering of oral corticosteroids to less than 10 mg/day or topical steroids to less than twice a day. RESULTS: Mean age of the study population was 42.69 ± 14.95 years. Patients were predominantly Asian (49.1%) and Male (67.0%). A total of 73.2% had bilateral involvement. Sixty-nine (62.72%) patients had presumed tubercular RV. A total of 52.8% patients received antitubercular therapy, 65.5% received oral corticosteroids, and 17.3% required steroid-sparing oral immunosuppressive agents. A total of 85.19% of patients with presumed tubercular RV achieved treatment success with concurrent antitubercular therapy as against 75.61% of patients with nontubercular RV. CONCLUSION: This is the largest study of the epidemiology, clinical features, and outcomes of both peripheral RV and presumed tubercular RV to date. Presumed tubercular RV commonly seems to affect young males of Asian descent and had vitreous hemorrhage as common clinical findings and also demonstrated a good treatment outcome with antitubercular therapy.

Predictive factors for treatment failure in patients with presumed ocular tuberculosis in an area of low endemic prevalence.

AIM: To assess the impact of antitubercular therapy (ATT), oral steroids and steroid sparing immunosuppressive treatment on treatment success in cases with presumed ocular tuberculosis in an area of low endemic prevalence. METHODS: A retrospective cross-sectional study was performed for 213 patients with presumed ocular tuberculosis from a database from a tertiary referral eye hospital in the UK. A logistic regression model was constructed incorporating demographics, baseline characteristics and different cut-offs of QuantiFERON-TB Gold In-Tube test (QFT-G) to identify significant factors accounting for the variability of the response variable ('failure') across the whole group. Treatment failure was defined as the recurrence of inflammation or inability to taper steroids within 6 months of completion of ATT or after at least 6 months of treatment in the non-ATT group. RESULTS: There were 126 patients who had at least 6 months of ATT. Patients with QFT-G values >1.50 (OR=0.20, 95% CI 0.09 to 0.48, p<0.001) had less risk of treatment failure as against those with QFT-G values between 0.35 and 1.50. Steroid sparing immunosuppressive agents reduced the chances of treatment success (OR=24.10, 95% CI 6.75 to 86.11, p<0.001). This effect persisted even after adjusting for potential confounding factors. CONCLUSIONS: Patients with higher values of QFT-G (>1.5) are more likely to have treatment success with ATT. In our model, steroid sparing immunosuppressive agents reduced the chances of success in both ATT and non-ATT-treated patients. It is unclear whether this effect reflects the intrinsic underlying severity of disease (ie, study bias), or whether steroid sparing immunosuppressive agents mitigate against successful ATT.

The role of anti-tubercular therapy in patients with presumed ocular tuberculosis.

OBJECTIVE: To analyze the factors affecting the treatment outcome in patients with presumed ocular tuberculosis on anti-tubercular therapy (ATT). METHODS: Retrospective chart review of patients with presumed ocular tuberculosis seen at a tertiary referral eye care center in the United Kingdom. Failure was defined as recurrence of inflammation within 6 months of completion of ATT. RESULTS: There were a total of 175 patients with presumed ocular tuberculosis who had ATT. Patients with intermediate uveitis or panuveitis and those on immunosuppressive therapy had higher odds of treatment failure (p < 0.05) while those with more than 9 months of ATT (77, 79.38%) had less likelihood of failure. CONCLUSION: We present the largest case series of patients with presumed ocular tuberculosis in a low endemic area treated with ATT. Longer duration of treatment resulted in reduced risk of recurrence of inflammation, whereas immunosuppression adversely affected the final treatment outcome.

Desegmentation of Ozurdex implant in vitreous cavity: report of two cases.

PURPOSE: To report two cases of desegmentation or fracture of the Ozurdex implant observed immediately after routine intravitreal implantation for macular oedema. PATIENTS: In two patients receiving intravitreal Ozurdex implant injection, a rare complication of fracture of implant was noted immediately after the injection. No additional complication was noted in either of the patients. On follow-up, the macular oedema had resolved and there were no further complications. DISCUSSION: We shared our experience with the manufacturer, and it was confirmed that, during the normal degradation process, the implant may become soft and break into pieces. Allergan shared their unpublished data on in vivo and in vitro drug release profile of one piece versus three pieces of implant, which is presented in this case report. CONCLUSIONS: With more and more microsurgical implantation procedures, clinicians should be well aware of these unusual although rare complications. Even though the desegmented implants do not appear to cause more intraocular complications compared with single-piece implants, patients with defragmented implants should be followed up carefully to monitor for unexpected complications.

A case of panuveitis with hypopyon due to presumed ocular leishmaniasis in a HIV patient.

BACKGROUND: Post-kala-azar dermal leishmaniasis is a well-known immunologic cutaneous reaction. There are few case reports of ocular leishmaniasis. It is a sight-threatening condition that needs to be rapidly recognized and treated to avoid permanent visual loss. Ocular leishmaniasis panuveitis can present with severe inflammation in patients with highly active anti-retroviral therapy (HAART)-induced immune reconstitution syndrome. FINDINGS: A case of a 40-year-old man, human immunodeficiency virus (HIV) positive on HAART, with a presumed diagnosis of ocular leishmaniasis, is presented. He had a past history of visceral leishmaniasis and was referred to the uveitis service with rapidly worsening panuveitis and counting fingers vision in both eyes. On empirical anti-leishmania therapy and systemic steroids, the visual acuity of the left eye improved to 6/9 but remained poor in the right eye. Based on the medical history, improvement with therapy and the exclusion of other common infections, a presumed diagnosis of ocular leishmaniasis-related panuveitis was made. CONCLUSIONS: A major immune reaction against lingering parasites may play a key role in the pathogenesis of this sight-threatening and rapidly progressive condition. Both the infection and the immune reaction should be treated.