Anterior Non-Necrotizing Scleritis with Active Uveitis in Cases of Ocular Syphilis.

PURPOSE: To study clinical characteristics and management outcomes of cases of ocular syphilis co-presenting with scleritis and active uveitis. METHODS: A retrospective analysis of cases diagnosed with ocular syphilis between January 2020 and December 2023 was conducted at a tertiary eye care centre. Clinical records, investigations, and outcomes were reviewed to identify cases with scleritis with active uveitis. Demographic data, clinical features, treatment modalities, and resolution patterns were analyzed. RESULTS: Among the 135 eyes of 95 cases of ocular syphilis studied, scleritis with uveitis was observed in 3.70% of eyes (five eyes). All cases with scleritis and uveitis were unilateral and male, with ages ranging from 32 to 61 years. Concurrent features included placoid chorioretinitis, retinal vasculitis, and anterior uveitis. Misdiagnosis with subsequent oral steroid therapy precipitated scleritis as an exacerbation in two cases. Three cases, which were previously undiagnosed, were found to be HIV-positive. Scleritis manifested as anterior, non-necrotizing inflammation, often accompanied by chemosis, and responded rapidly to antibiotic and non-steroidal anti-inflammatory therapy. Scleritis resolution preceded that of chorioretinitis and retinal vasculitis. CONCLUSIONS: Non-necrotizing anterior scleritis with chemosis can be a rare presentation of active syphilitic uveitis. Large placoid chorioretinitis lesions, preceding inadvertent oral steroid and/or undiagnosed HIV status were the possible risk factors for the development of concurrent scleritis.

Efficacy, Safety and Immunogenicity of Sun's Ranibizumab Biosimilar in Neovascular Age-Related Macular Degeneration: A Phase 3, Double-Blind Comparative Study.

INTRODUCTION: The study aimed to evaluate comparability in terms of efficacy, safety and immunogenicity of Sun's ranibizumab biosimilar with reference ranibizumab in patients with neovascular age-related macular degeneration (nAMD). METHODS: This prospective, randomised, double-blind, two-group, parallel-arm, multicentre, phase 3 comparative study included patients with nAMD ≥ 50 years, randomised (in a 2:1 ratio) in a double-blind manner to receive 0.5 mg (0.05 mL) intravitreal injection of either Sun's ranibizumab or reference ranibizumab in the study eye every 4 weeks until week 16 (total of four doses). RESULTS: Primary endpoint results demonstrated equivalence in the proportion of patients who lost fewer than 15 letters from baseline best-corrected visual acuity (BCVA) to the end of week 16 (99% of patients in Sun's ranibizumab and 100% in reference ranibizumab; p > 0.9999), with the proportional difference (90% confidence interval) at -1% (-2.51, +0.61) lying within a pre-specified equivalence margin. Visual acuity improved by 15 or more letters in 43% of Sun's ranibizumab group and 37% of the reference ranibizumab group (p = 0.4267). The mean increase in BCVA was 15.7 letters in Sun's ranibizumab group and 14.6 letters in the reference ranibizumab group (p < 0.001 within both groups and p = 0.5275 between groups). The mean change in central macular thickness was comparable between groups (p = 0.7946). Anti-ranibizumab antibodies were found in one patient of the reference ranibizumab group, while neutralising antibodies were not found in any patients. Both products were well tolerated. CONCLUSION: Sun's ranibizumab biosimilar is found to be therapeutically equivalent to reference ranibizumab in patients with nAMD. There were no additional safety or immunogenicity concerns. TRIAL REGISTRATION: CTRI/2020/09/027629, registered on 07 September 2020.

Macular Punctate Lesions Presenting as a Primary Manifestation of Ocular Toxoplasmosis.

PURPOSE: To study clinical features and outcomes of primary ocular Toxoplasmosis (OT) cases presenting as macular punctate lesions. METHODS: Retrospective review of three cases of OT with positive Toxoplasma serology. RESULTS: We describe three cases presenting as primary OT with no evidence of old retinochoroidal scar in either eye. All the cases had multiple foveal or extrafoveal, punctate, inner/outer, or combined lesions at macula with minimal vitreous reaction. During the first/primary episode, all the lesions resolved with 1. retinal atrophy, thinning (n = 1) or 2. Progressed to limited full-thickness retinitis lesions (n = 2). Recurrence as typical retinochoroiditis was seen in one eye. More than four-fold IgG positivity was seen in all cases while IgM positivity was seen in two cases. CONCLUSIONS: Macular punctate lesions (inner/outer/combination) can be the primary manifestation of ocular toxoplasmosis in the absence of old retinochoroiditis scars in either eye.

Role of IgG avidity in eyes with active Toxoplasma retinochoroiditis.

PURPOSE: To study the role of Toxoplasma IgG avidity in evaluating the stage of systemic infection during manifestation as toxoplasma retinochoroiditis and its clinical implications in eastern India. METHODS: Retrospective chart review of Toxoplasma retinochoroiditis cases with Toxoplasma serology for IgG, IgM, and IgG avidity. RESULTS: Included in this study were 17 eyes of 17 patients who had active retinitis located in the macula (14), mid-periphery (2), or periphery (1). They were either primary lesions (12) or reactivations (5). All the cases had Toxoplasma IgG positive; one case had IgM positivity, while all the cases had high IgG avidity values. IgG avidity had a positive correlation with the duration of symptoms. CONCLUSION: We observed high IgG avidity values in active retinochoroiditis in both primary ocular Toxoplasmosis and reactivation subgroups. These results indicate a late ocular manifestation after initial systemic infection with a possible incubation period ranging from 5 weeks to 5 months.

Central retinal artery occlusion following pediatric blunt ocular trauma.

BACKGROUND: To analyze the clinical profile, presentation, possible pathophysiology, and outcomes of central retinal artery occlusion (CRAO) following blunt trauma in pediatric subjects. METHODOLOGY: The medical charts of subjects aged 18 years or less with a diagnosis of CRAO following blunt ocular trauma were analyzed retrospectively for demography, details of the trauma, ocular findings, additional imaging reports if any, and final outcome. A Medline search was done (key words like central retinal artery occlusion, blunt trauma, children, pediatric subjects, and adolescents) to gather information available in the literature on the subject. RESULTS: A total of 11 patients (11 eyes), mean age of 14.3 ± 3.4 years, and 100% male preponderance, with an average time duration from trauma to presentation to the hospital of 8.1 days were included. Visual acuity ranged from no light perception (four eyes) to finger count at a 1 m distance. Intraocular pressure was raised in three patients, of which two were suffering from sickle cell disease. In two eyes, the CRAO coexisted with optic nerve avulsion and the cilioretinal artery was spared. Disk pallor was seen in six eyes as early as 12 days from the trauma. None of the cases revealed any bony fracture in the CT scan. CONCLUSION: CRAO was observed to be an important primary or contributory cause of visual loss in children following blunt trauma, reflex vasospasm being the most common etiology. Early onset disk pallor could suggest an underlying vascular compromise of both retinal and optic disk circulation in addition to direct disk damage.

Tubercular Serpiginous-Like Choroiditis in Patients with Negative TB-Immunoreactivity Tests.

BACKGROUND: Serpiginous-like choroiditis (SLC) denotes ocular tuberculosis (TB), in the presence of positive tuberculin skin test (TST) or interferon gamma release assay (IGRA). METHODS: Retrospective review of SLC patients from a TB-endemic country, with negative TST and IGRA tests, but responsive to anti-TB therapy. RESULTS: Fifteen patients (13 bilateral) with active SLC were included. Eleven (73.3%) patients had received corticosteroids ± immunosuppressive therapy prior to presentation. Chest radiographic abnormalities were found in four (26.7%) patients. We treated all patients with a combination of anti-TB therapy (ATT) and corticosteroids. Paradoxical worsening was noted in nine (60%) patients, complete resolution of lesions in 12 (80%), persistent inflammation (post-ATT) in one, while two were yet to complete ATT. None had recurrence after complete resolution of lesions (median follow-up of 71 weeks [range 15-676 weeks]). CONCLUSIONS: TB-SLC may present with negative TST and IGRA tests but may still have clinical appearance, and treatment response, like test-positive disease.

Beaded Pearls Appearance in Syphilitic Chorioretinitis.

PURPOSE: To report an atypical case of bilateral syphilitic chorioretinitis. METHODS: A case report. RESULTS: A young male presented with bilateral pigmentary retinal changes along with multifocal chorioretinal lesions along the blood vessels giving a "beaded pearl" appearance. He was a hitherto undiagnosed case of human immunodeficiency virus infection and was diagnosed to have syphilis. He had a favourable visual and anatomical outcome following treatment. CONCLUSION: Multifocal chorioretinal lesions along blood vessels forming a "beaded pearls" appearance can be a rare and unique presentation of syphilis.

Retinal Pigment Epithelial Characteristics in Acute and Resolved Vogt-Koyanagi-Harada Disease.

Vogt-Koyanagi-Harada (VKH) disease is an auto-immune inflammatory disease of choroidal origin. During the acute stage, optical coherence tomography (OCT), however, may not be able to assess the entire choroid. The aims of the paper were to evaluate the role of retinal pigment epithelium (RPE) as a biomarker of inflammation in acute VKH. This was a retrospective observational study done in 55 eyes of 29 patients with acute VKH. RPE thickness, total choroidal thickness, and RPE reflectivity before and after resolution were analyzed using image J software. Correlations between several baseline and post-resolution parameters were performed, and factors affecting change in visual acuity were analyzed. A significant decrease in RPE thickness and a significant increase in RPE reflectivity were seen following resolution of the disease. Furthermore, there was a significant correlation between RPE and choroidal thickness during the acute stage of the disease. Baseline visual acuity and the presence of bacillary detachment at baseline were the only factors responsible for changes in visual acuity. We propose the utility of RPE layer as a surrogate biomarker of choroidal activity and inflammation in terms of RPE reflectivity and RPE thickness during the acute stage of VKH, especially when there is poor imaging of the choroid.

Microsporidia-Associated Anterior Uveitis After Keratoconjunctivitis.

OBJECTIVE: The aim of this study was to describe the clinical features and management of uveitis associated with microsporidial keratoconjunctivitis (MKC). METHODS: The medical records of clinically diagnosed or microbiologically proven patients with MKC between July 2016 and August 2021 were reviewed. Patients with documented evidence of keratic precipitates (KPs) or anterior chamber cells were analyzed for their demography, clinical features, and treatment. Patients with microsporidial stromal keratitis and herpes simplex virus keratouveitis were excluded from the study. RESULTS: Of the 2212 patients reviewed within the study period 171 of 172 eyes (7.7%) had documented evidence of KPs and/or anterior chamber cells. The patients' mean age was 43.8 ± 13.8 years, and there were more men (n = 120). The mean duration of appearance of KPs was 6.9 ± 5.5 days, and 28% (n = 48 of 171) appeared on the day of presentation. Superficial punctate keratitis was central and diffuse in 48 and 49 patients, respectively. The treatment was either lubricant alone (45.3%; 78 eyes) or combined with topical steroids (54.7%; 94 eyes). The mean duration of the resolution was longer in the "corticosteroid" than "no corticosteroid" group: KPs: 15.3 ± 6.5 days versus 12.3 ± 5.8 days ( P = 0.007) and superficial punctate keratitises: 15.4 ± 9.4 days versus 11.7 ± 6.2 days ( P = 0.01). The presenting visual acuity with a pinhole was 0.26 ± 0.26 (logMAR) and it improved to 0.03 ± 0.07 on resolution ( P < 0.0001, paired t test). CONCLUSIONS: Uveitis after MKC is a self-limiting entity that often resolves without corticosteroid. One must exercise caution in using steroids in the presence of active corneal lesions.

Clinical and imaging characteristics of outer retinal folds in eyes with retinitis.

Purpose: To describe clinical and imaging characteristics of the outer retinal folds (ORF) in cases of retinitis, retinochoroiditis, and chorioretinitis. Methods: Retrospective review of retinitis cases with presence of ORFs either at presentation or during follow up. Results: ORFs were seen adjacent to retinitis lesions in 16 eyes of 14 cases (retinitis post-febrile illness n = 10, toxoplasma retinochoroiditis n = 2, fungal chorioretinitis n = 2) either at presentation (n = 2) or during follow up (n = 14). Optical coherence tomography (OCT) appearance was outer retinal vertical stout lesions involving ellipsoid, external limiting membrane, and outer nuclear layer. All the cases had a presence of past or concurrent subretinal fluid and/or subretinal hyperreflective material when ORF was seen. ORF resolved with variable outer retinal atrophy over a mean period of 2.86 months. Conclusion: ORF is observed in cases of retinitis with subretinal fluid either at presentation or during resolution. It is not specific to any etiological disease. Differentiation of this sign from vertical outer retinal stripes in viral retinitis on OCT is important to avoid misinterpretation.

Anti-tubercular therapy alone for treatment of isolated tubercular retinal vasculitis.

PURPOSE: To compare the time to resolution of perivascular infiltrates in tubercular retinal vasculitis (TRV) between anti-tubercular therapy (ATT) alone, and in combination with systemic corticosteroids. METHODS: Observational retrospective cohort study in a tertiary eye centre in eastern India. Patients with TRV who were treated with anti-tubercular therapy (ATT) alone (Group A), or in combination with systemic corticosteroids (Group B) were included in the study. Eyes with additional inflammatory signs (cystoid macular oedema, vitritis ≥2+, optic disc oedema) were excluded. Resolution was defined as complete disappearance of perivascular infiltrates on seven-field fundus photographs. Descriptive statistics were used for demographic data. A linear mixed effects model was applied to adjust for intereye correlations, in patients with bilateral disease. The primary outcome measure was time to resolution of perivascular infiltrates. Secondary outcome measure was need for laser or surgical intervention for management of complications of TRV. RESULTS: Fifty eyes of 39 patients (Group A 21/18 and Group B 29/21) were included. Both groups had similar demographics and severity of vasculitis. All patients had complete resolution of TRV. On adjusting for intereye correlation, the mean difference in time to resolution between the two groups (Group A, 3.24 [95% CI 2.69-3.77] months, and Group B, 4.76 [95% CI 3.52-5.99] months) was not statistically significant (0.96 weeks [-0.52 to 2.45] p = 0.21). Vaso-occlusive complications and healing patterns were similar in both groups. CONCLUSIONS: ATT alone, may be sufficient for resolution of perivascular infiltrates, in TRV without additional inflammatory signs.

Anti-TB monotherapy for choroidal tuberculoma: an observational study.

BACKGROUND: Choroidal tuberculoma is possibly the most unequivocal manifestation of ocular infection with Mycobacterium tuberculosis. Here, we investigate the need for adjunctive corticosteroids in the management of this infection. We have compared the efficacy of anti-tubercular therapy (ATT) with or without oral corticosteroids, in management of choroidal tuberculoma. METHODS: We report a retrospective, observational study of patients treated with ATT for choroidal tuberculoma. Group A patients were treated with standard 6-month ATT alone, and Group B with ATT and oral corticosteroids, with/without intravitreal triamcinolone/ bevacizumab injections. Primary outcome measure was time to complete resolution of lesions. Secondary measures were time to first sign of resolution and change in best corrected visual acuity (BCVA) at final visit. RESULTS: Fourteen patients were included in the study-seven in Group A and seven in Group B. Both groups had similar duration of symptoms and size of lesions but not baseline BCVA (p = 0.02). Perilesional fluid was noted in all eyes in each group. Mean time to complete resolution in group A was 1.89 ± 0.28 (range 1.25-2) months, significantly lesser than group B (5.17 ± 2.64 [range 2-9] months, p = 0.005, Mann-Whitney test). Mean time to first sign of resolution (range from 5 days to 10 weeks, p = 0.35) and mean change in BCVA between presentation and final follow up (p = 0.2) were comparable between both groups. CONCLUSION: Anti-TB monotherapy alone, may be sufficient for resolution of at least, select cases of choroidal tuberculoma, without the need for adjunctive corticosteroids.

Punctate Inner Retinal Toxoplasmosis: Case Series and Review of Literature.

PURPOSE: To describe clinical and multimodal imaging characteristics of punctate inner retinal toxoplasmosis (PIRT) as an atypical presentation of ocular toxoplasmosis (OT). METHODS: Retrospective review of OT cases with PIRT lesions and review of the literature. We describe five cases (6 eyes). RESULTS: PIRT lesions were seen adjacent to active/healed toxoplasma retinochoroiditis. The appearance of PIRT was creamy yellowish-white, inner retinal, punctate, and sub-centimetric lesions. The depth of these lesions on optical coherence tomography was till the outer plexiform layer. Co-existing punctate outer retinal toxoplasmosis (PORT) was found in three eyes and recurrent retinochoroiditis in three. The fate of PIRT was resolution with minimal retinal thinning or progression to a full-thickness retinochoroiditis. CONCLUSION: PIRT was noted in association with typical toxoplasma retinochoroiditis and PORT lesions, and had equal chances of resolution or progression to full-thickness lesions.