Diagnostic and therapeutic results of aqueous real-time polymerase chain reaction in infectious uveitis.

OBJECTIVE: This study was aimed primarily at describing the results of aqueous real-time polymerase chain reaction (RT-PCR) and reporting the rate of therapeutic modifications directly attributable to this procedure (profitability). Our secondary outcome was to compare demographic and clinical characteristics between patients with RT-PCR positivity and those with RT-PCR negative results. DESIGN: Retrospective observational study conducted at the Uveitis Service of San Raffaele Hospital (Milan, Italy) between November 2016 and July 2022. PARTICIPANTS: Patients with infectious uveitis suspect (anterior, intermediate, posterior uveitis, or panuveitis). METHODS: Patients with suspected infectious uveitis underwent aqueous RT-PCR for detection of herpes simplex 1 (HSV-1), herpes simplex 2 (HSV-2), varicella zoster virus (VZV), cytomegalovirus (CMV), and Toxoplasma gondii. RESULTS: Sixty-five eyes of 61 patients (60 ±16 years of age; 54% males) were included. Aqueous RT-PCR tested positive in 58% and negative in 42% of patients. CMV and HSV-1 were the most frequently detected pathogens. RT-PCR confirmed clinical suspicion in 38% of patients and altered the presumed etiologic diagnosis and treatment in 20% of patients. Profitability was associated with CMV positivity. HSV-1 positivity was related to iris atrophy. CMV positivity was correlated with keratic precipitates. Vitritis and retinitis were related to VZV, CMV, and T. gondii detection. Synechiae, retinitis, and neuritis were related to positive tests regardless of the pathogen investigated. Early complications related to paracentesis were rarely reported. CONCLUSION: Aqueous RT-PCR was a safe semi-invasive tool to confirm a presumptive diagnosis and to change initial suspicion in ambiguous cases of herpetic uveitis. Thus aqueous RT-PCR may alter therapeutic management.

A case of Vogt-Koyanagi-Harada-like uveitis secondary to dabrafenib/trametinib therapy for advanced melanoma.

We report a case of ocular drug toxicity consistent with bilateral Vogt-Koyanagi-Harada (VKH) like disease in a patient with cutaneous melanoma treated with Dabrafenib/Trametinib therapy. A 53-year-old man with a history of metastatic cutaneous melanoma, treated with Dabrafenib/Trametinib, developed a severe acute panuveitis with granulomatous anterior uveitis and multiple serous retinal detachments. The ocular inflammatory reaction was classified as a bilateral Vogt-Koyanagi-Harada disease. Intraocular inflammation resolved after discontinuation of chemotherapeutic agents and aggressive topical and systemic corticosteroid therapy. The present case outlines the importance of recognizing VKH-like syndrome as a possible consequence of therapy with dabrafenib and trametinib.

Predictive factors of radio-induced complications in 194 eyes undergoing gamma knife radiosurgery for uveal melanoma.

BACKGROUND AND PURPOSE: To report the factors predictive of radio-induced complications (i.e. radiation retinopathy [RR], radiation papillopathy [RP] and neovascular glaucoma [NVG]) in uveal melanoma (UM) patients undergoing gamma knife radiosurgery (GKR). MATERIALS AND METHODS: Longitudinal cohort study on patients with UM treated at the Ocular Oncology Service, San Raffaele Scientific Institute, Milan, between June 1994 and November 2018. Data were retrospectively reviewed. Rates of GKR-related complications were reported. Variables associated with each complication were investigated using multivariable Cox models and confirmed by logistic regression analysis. Hazard ratio (HR) and 95% confidence intervals (CI) were reported for significant associations. RESULTS: One hundred ninety-four patients (99 males, 51%) were included, and 184 tumours were primarily located in the choroid (95%). Median follow-up was 57 months (range 6-286). Local control was achieved in 182 eyes (94%), and 152 eyes (78%) experienced at least one radiation-induced complication. Radiation retinopathy was documented in 67 eyes (35%) after a median of 23 months. Older age (HR = 0.97, 95% CI = 0.95-0.99, p = 0.02) had a protective effect for RR. Radiation papillopathy was diagnosed in 35 eyes (18%) after a median of 14 months after GKR. Macular or peripapillary location (HR = 3.06, 95% CI = 1.52-6.16, p = 0.002) was associated with increased risk of RP, while older age was protective (HR = 0.95, 95% CI = 0.93-0.98, p = 0.001). New-onset NVG was found in 53 eyes (27%), and median onset was 28 months. Tumour thickness (HR = 4.41, 95% CI = 2.23-8.72, p < 0.001) and peripapillary location (HR = 2.78, 95% CI = 1.46-5.27, p = 0.002) were the main risk factors associated with NVG. CONCLUSION: Understanding factors predictive for radiation-related complications in patients undergoing GKR might help for better counselling and treatment planning.

The "Sponge sign": A novel feature of inflammatory choroidal neovascularization.

INTRODUCTION: To investigate choroidal thickness changes related to the clinical activity of inflammatory choroidal neovascularization in punctate inner choroidopathy/multifocal choroiditis as compared to myopic choroidal neovascularization. MATERIALS AND METHODS: Consecutive inflammatory choroidal neovascularization secondary to punctate inner choroidopathy/multifocal choroiditis, and myopic choroidal neovascularization were retrospectively reviewed. By means of enhanced-depth imaging optical coherence tomography, choroidal thickness was assessed at the same location before choroidal neovascularization development, at choroidal neovascularization onset (baseline), and after treatment. RESULTS: Eleven eyes with inflammatory choroidal neovascularization and 11 eyes with myopic choroidal neovascularization were analyzed. Choroidal thickness beneath inflammatory choroidal neovascularization significantly increased at baseline and decreased after therapy ("Sponge sign"), reaching preclinical values. In particular, mean choroidal thickness under inflammatory choroidal neovascularization was 145 ± 85 µm at the preclinical stage, increased to 210 ± 103 µm at baseline (p = 0.006), and decreased to 136 ± 87 µm after treatment (p = 0.017). Conversely, no significant choroidal thickness changes were disclosed in myopic choroidal neovascularization eyes, under any location. CONCLUSION: Optical coherence tomography-based choroidal thickness evaluation may represent an additional useful tool to monitor inflammatory choroidal neovascularization activity. Moreover, choroidal thickness under choroidal neovascularizations could be used to discriminate the origin of choroidal neovascular membrane, either inflammatory or myopic, in doubtful cases and guide the therapeutic management.

Ophthalmic Shingles with Simultaneous Acute Retinal Necrosis in the Opposite Eye.

Purpose: To report a case of acute retinal necrosis (ARN) occurring in the opposite eye to the ophthalmic shingles eruption.Design: Case report.Methods: Clinical examination and multimodal imaging review, including ultra-widefield photography and fluorescein angiography (FA).Results: A 49-years-old man attended the Uveitis Service for concurrent acute visual loss in the right eye and ophthalmic shingles skin eruption of the left ophthalmic trigeminal branch. Fundus examination of the right eye revealed multiple yellowish patchy areas of retinitis in the peripheral retina consistent with ARN. Multimodal imaging and laboratory tests confirmed the diagnosis.Discussion: Herpes Zoster Ophtalmicus (HZO) represents the 10-20% of Herpes Zoster (HZ) cases and ARN is a rare but sight-threatening complication due to the viral widespread along the retina. By definition, the reactivation of Varicella Zoster virus (VZV) has a unilateral clinical expression, due to the centrifugal neural pathway followed by the virus from the neural ganglia, and HZO, as well, results located on the same side of the skin affection. The case presented contradicted this postulate.Conclusion: prompt diagnosis, through fundus examination and FA, and proper antiviral therapy were the mainstays to counteract the posterior uveitis. Nowadays, vaccination is a safe weapon to efficaciously reduce the ZVZ incidence among general population.

Gamma Knife Radiosurgery for Uveal Melanoma: A Retrospective Review of Clinical Complications in a Tertiary Referral Center.

INTRODUCTION: Gamma knife radiosurgery (GKR) has shown promising results in the treatment of intraocular uveal melanoma (UM) in terms of local tumor control. However, GKR is not free from potentially sight-threatening side effects, including cataract, dry eye disease, vitreous hemorrhage, radiation retinopathy (RR), radiation maculopathy (RM), optic neuropathy, and neovascular glaucoma. The aim of this paper is to report our 20-year experience in UM management with GKR focusing on the rate of clinical treatment-induced complications. METHODS: Single-center, retrospective, observational study, including all patients with UM treated at the Ocular Oncology and Uveitis Service, in the Department of Ophthalmology of the San Raffaele Scientific Institute, Milan from September 1993 to September 2018. Clinical charts comprised complete ophthalmological examination with measurement of best-corrected visual acuity, slit-lamp biomicroscopy, intraocular pressure measurement, gonioscopy, and indirect ophthalmoscopy at each visit. B-scan ultrasound (Aviso S, 10 MHz probe; Paris, France), optical coherence tomography (Heidelberg Spectralis; Heidelberg Engineering, Heidelberg, Germany), retinography, and fundus fluorescein angiography (standard or ultra-widefield [UWF; California, Optos, Dunfermline, Scotland, UK]) were performed aiding in the diagnosis of complications. RESULTS: Overall, 194 patients (100 males, 51.6%) were reviewed. The median age at the time of the treatment was 65 years (range 27-89) and all participants were Caucasian. In 185 eyes (95.4%), the tumor was primarily located at the choroid. The median follow-up was 57.6 months; radiation-induced complications were found in 145 eyes (74.7%). Radiation-induced cataract and RR were the most frequent events, with a relative incidence of 41.2 and 34.5%, respectively, followed by neovascular glaucoma (27.3%), optic neuropathy (18.6%), RM (11.4%), vitreous hemorrhage (14.4%), phthisis bulbi (7.7%), hyphema (0.5%), and corneal melting (0.5%). The shorter onset of side effects involved the optic nerve (median 14.9 months) and the macula (median 13.7 months). CONCLUSION: Despite modern and advanced strategies introduced to limit GKR side effects, cataract and RR still represent a serious limitation of this treatment. Incidence of RR was higher in our cohort compared to other reports, probably due to increased diagnosis rate permitted by UWF retinal imaging.

3D WrapTM Ultra-Widefield Reconstruction in Stereotactic Radiosurgery for Choroidal Melanoma.

Choroidal melanoma (CM) is the most commonly diagnosed primary intraocular malignancy in adults. Gamma knife radiosurgery (GKR) has demonstrated reliable results in the treatment of CM, but it is limited by the risk of radiation-induced ocular complications. To optimize the dose of radiation focused on the tumor, and limit side effects, the eye should be properly immobilized before treatment. A recently released ultra-widefield imaging instrument (Optomap California; Optos, Dunfermline, Scotland, UK) allows for an interactive three-dimensional (3D) virtual reconstruction of the globe, called 3D WrapTM. The authors share their experience with this rapid, reliable, and relatively easy support in planning globe positioning before GKR treatment.

Retinal and Choroidal Changes of Vitreoretinal Lymphoma from Active to Remission Phase after Intravitreal Rituximab.

To identify main qualitative and quantitative changes by spectral-domain optical coherence tomography (SD-OCT) in eyes with vitreoretinal lymphoma (VRL) shifting form active to remission phase, after intravitreal rituximab (IVR).SD-OCT scans retrospectively assessed for: hyperreflective retinal dots (HRD), intraretinal infiltration, subretinal infiltration, outer retina (OR) fuzzy borders, and pigment epithelium detachments (PED).Central macular thickness (CMT) and choroidal thickness (CT) were measured. These features were examined in active and in remission phase.Eighteen eyes of nine patients enrolled. Patients received 5.3 ± 2.1 IVR according to a 2-weekly or monthly schedule. In remission phase, presence of HRD (p = 0.02), intraretinal infiltration (p = 0.02), OR fuzzy borders (p = 0.01) significantly reduced. Treatment frequency did not influence rate of disappearance of these features. CMT (p = 0.04) and CT (P = 0.004) became thinner.Signs referable to lymphoma-induced inflammation (CMT, CT, HRD) and infiltration (intraretinal infiltrates, OR fuzzy borders) decreased in remission phase. Further comparative studies needed to identify the specific role of IVR in inducing these changes.

Ocular Toxicity of Mirvetuximab.

PURPOSE: To report the clinical features and outcomes of corneal toxicity following mirvetuximab soravtansine therapy. METHODS: Five patients who were treated with mirvetuximab soravtansine were evaluated in our hospital for ocular symptoms during a period of 5 months between December 2017 and April 2018. A complete ophthalmologic examination, including anterior segment infrared reflectance (AS-IR) and anterior segment optical coherence tomography (AS-OCT), was performed. RESULTS: All 5 patients were female (average age, 62.4 ± 5.5 years) and being treated for advanced epithelial ovarian cancer, primary peritoneal cancer, or fallopian tube cancer. Both eyes were involved in each case. Patients complained of blurred vision (n = 5), ocular pain (n = 2), tearing (n = 5), foreign-body sensation (n = 4), and photophobia (n = 4). Slit-lamp examination demonstrated fine corneal subepithelial opacities, mainly involving the corneal periphery migrating toward the center. AS-IR revealed the presence of hyporeflective dots on the cornea, suggesting that they were cystic. AS-OCT confirmed the subepithelial location of lesions. In all patients, the cornea cleared, and visual acuity recovered fully with a short course of topical steroids and lubricants. CONCLUSIONS: Mirvetuximab soravtansine therapy can cause transient corneal toxicity. A short course of topical steroids can reduce the patient symptoms.