Recurrent Choroidal Neovascular Membrane as the Initial Presentation of Mycobacterium chimaera-Associated Serpiginoid Choroiditis.

PURPOSE: To report a rare presentation of a proven case of Mycobacterium chimaera infection presenting as multifocal choroiditis with recurrent choroidal neovascular membrane (CNVM) in one eye, initially misdiagnosed as punctate inner choroidopathy and later developed serpiginous-like choroiditis in the other eye. METHODS: Retrospective case report with a review of existing literature. RESULTS: A 30-year-old women presented with metamorphopsia (OD) and best-corrected visual acuity (BCVA) of 6/24 (OD) and was diagnosed to have punctate inner choroidopathy with CNVM (OD). Since then, she had received four intravitreal anti-vascular endothelial growth factor injections over 3 years. Two years later, she developed a slowly progressing choroidal lesion radiating from the disc in a serpiginoid manner in the left eye. There was no vitritis. Labs revealed a positive QuantiFERON-TB Gold test. High-resolution computed tomography of the thorax showed sub-centimetre noncalcified lymph nodes in subcarinal and perivascular regions, minimal pleural thickening in left lower zone, minimal pericardial effusion, bronchiectatic changes, and fibrotic strands in right middle and left lower lobes. Bronchoalveolar lavage grew M. chimaera intracellularae (matrix-assisted laser desorption/ionization time-of-flight mass spectrometry). She was given a course of clarithromycin, moxifloxacin, rifampicin, and doxycycline for 12 months. Though the right eye remained stable, choroidal lesion in the left eye continued to progress threatening the fovea, requiring oral steroids, methotrexate, and an intravitreal dexamethasone implant. At the last follow-up, her BCVA was 6/18 (OD) and 6/6 (OS). Both eyes were stable. CONCLUSION: This case highlights a rare presentation of proven M. chimaera infection presenting as multifocal choroiditis with recurrent CNVM in one eye and serpiginous-like choroiditis in the other eye, requiring aggressive treatment to salvage the vision.

Clinical profile and treatment outcomes in pediatric uveitis - A series from South India.

PURPOSE: The purpose of the study was to look at the clinical spectrum, treatment options, and visual outcomes in a large cohort of pediatric uveitis from a tertiary eye care center in South India. METHODS: This is a retrospective study carried out at a tertiary eye center in South India. Cases of pediatric uveitis between January 2012 and June 2022 were retrieved from the hospital's medical database. Uveitis was classified according to the Standardization of Uveitis Nomenclature criteria. Demographic details, clinical presentation, complications, medical and surgical management, and visual outcome were evaluated. RESULTS: Two hundred and six eyes of 132 cases were included, with a median age of 12 years. The male to female ratio was 1:1. Bilaterality was seen in 63.1% of cases. The mean duration of uveitis was 11.5 ± 18.5 months, and the mean follow-up period was 20.5 ± 25.1 months. Noninfectious uveitis was seen in 70.45% cases. Most common etiology in the noninfectious group was idiopathic (27.3%), while in the infectious group, it was tuberculosis (TB; 14.4%). Immunomodulators were used in 43.9% and biologics in 10.9% of cases. Most common complications were cataract (25.24%) and posterior synechiae (21.35%). Surgical procedures were done in 12.62%. The mean visual acuity was 0.81 ± 1.14 log of minimum angle of resolution (logMAR) at presentation and 0.49 ± 0.87 logMAR at the end of the study ( P = 0.002). CONCLUSION: Pediatric uveitis poses a challenge in comparison to adult uveitis. Our study highlights the need for early diagnosis and aggressive management to prevent sequelae. Multidisciplinary approach is a key in improving the overall visual prognosis.

Effectiveness and Safety of Biosimilars in Pediatric Non-infectious Uveitis: Real-Life Data from the International AIDA Network Uveitis Registry.

INTRODUCTION: Since many biological drug patents have expired, biosimilar agents (BIOs) have been developed; however, there are still some reservations in their use, especially in childhood. The aim of the current study is to evaluate the efficacy and safety of tumor necrosis factor (TNF) inhibitors BIOs as treatment for pediatric non-infectious uveitis (NIU). METHODS: Data from pediatric patients with NIU treated with TNF inhibitors BIOs were drawn from the international AutoInflammatory Disease Alliance (AIDA) registries dedicated to uveitis and Behçet's disease. The effectiveness and safety of BIOs were assessed in terms of frequency of relapses, risk for developing ocular flares, best-corrected visual acuity (BCVA), glucocorticoids (GCs)-sparing effect, drug survival, frequency of ocular complications, and adverse drug event (AE). RESULTS: Forty-seven patients (77 affected eyes) were enrolled. The BIOs employed were adalimumab (ADA) (89.4%), etanercept (ETA) (5.3%), and infliximab (IFX) (5.3%). The number of relapses 12 months prior to BIOs and at last follow-up was 282.14 and 52.43 per 100 patients/year. The relative risk of developing ocular flares before BIOs introduction compared to the period following the start of BIOs was 4.49 (95% confidence interval [CI] 3.38-5.98, p = 0.004). The number needed to treat (NNT) for ocular flares was 3.53. Median BCVA was maintained during the whole BIOs treatment (p = 0.92). A significant GCs-sparing effect was observed throughout the treatment period (p = 0.002). The estimated drug retention rate (DRR) at 12-, 24-, and 36-month follow-up were 92.7, 83.3, and 70.8%, respectively. The risk rate for developing structural ocular complications was 89.9/100 patients/year before starting BIOs and 12.7/100 patients/year during BIOs treatment, with a risk ratio of new ocular complications without BIOs of 7.1 (CI 3.4-14.9, p = 0.0003). Three minor AEs were reported. CONCLUSIONS: TNF inhibitors BIOs are effective in reducing the number of ocular uveitis relapses, preserving visual acuity, allowing a significant GCs-sparing effect, and preventing structural ocular complications. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT05200715.

In Response to Oyeniran E, Katz D, Kodati S's Isolated Optic Disc Granuloma as a Presenting Sign of Sarcoidosis.

We read with great interest the article by Oyeniran E et al. on "Isolated optic disc granuloma as a presenting sign of sarcoidosis." We would like to share our experience with a similar optic nerve head granuloma secondary to sarcoidosis in the absence of any systemic symptoms and no evidence of signs of periocular/intraocular inflammation. However, our case was refractory to oral steroids and methotrexate and required intravitreal dexamethasone implants and mycophenolate mofetil.

Knowledge and Current Practices in Monogenic Uveitis: An International Survey by IUSG and AIDA Network.

INTRODUCTION: This study aims to explore awareness, knowledge, and diagnostic/therapeutic practices in monogenic uveitis (mU) among uveitis experts. METHODS: This is an explorative, cross-sectional survey study. An anonymous, semi-structured, electronic survey was delivered to uveitis experts from the Autoinflammatory Diseases Alliance (AIDA) Network and International Uveitis Study Group (IUSG). We included respondents answering ≥ 50% of the survey. RESULTS: Seventy-seven participants rated their knowledge of mU as proficient (3.9%), adequate (15.6%), sufficient (16.9%), or poor (63.6%). When asked about the first mU gene they thought of, 60.4% mentioned NOD2, 3.9% mentioned NLRP3 or MEFV, and 49.4% provided incorrect or no answers. Success rates in clinical scenarios varied from 15.6% to 55.8% and were higher for ophthalmologists working in multidisciplinary teams (p < 0.01). Genetic testing was ordered for suspected mU by 41.6% of physicians. The availability of molecular techniques did not significantly differ based on geography (p > 0.05). The public healthcare system ensured a higher percentage of tests prescribed were obtained by patients compared to private insurances (p < 0.00). In terms of disease-modifying anti-rheumatic drugs (DMARDs), tumor necrosis factor-α inhibitors were the most familiar to uveitis experts. The difficulties with off-label therapy procedures were the primary barrier to DMARDs prescription for patients with mU and correlated inversely with the obtained/prescribed drug ratio for interleukin-1 (p < 0.01) and interleukin-6 (p < 0.01) inhibitors. CONCLUSIONS: This survey identifies proficiency areas, gaps, and opportunities for targeted improvements in patients care. The comprehensive outputs may inform evidence-based guidelines, empowering clinicians with standardized approaches, and drive an AIDA Network-IUSG unified effort to advance scientific knowledge and clinical practice.

Multiple sclerosis-associated uveitis - A series from South India.

PURPOSE: To report clinical profiles of multiple sclerosis (MS)-associated uveitis in seven cases from a single tertiary eye care center in South India. METHODS: Retrospective case series 2013-2023. RESULTS: Seven cases of MS-associated uveitis were retrieved from our databases. There were five females and two males. The diagnosis of MS was made by the neurologist in all cases. Bilaterality was seen in all cases. Intermediate uveitis was the most common presentation (five cases). It was associated with peripheral retinal vasculitis (two cases) and disc pallor (two cases). Fuchs heterochromic iridocyclitis (one case) and incomplete Vogt-Koyanagi-Harada (VKH)-like presentation with a peripapillary choroidal neovascular membrane (one case) were the other presentations. In the case with incomplete VKH-like presentation, whole genome sequencing revealed a heterozygous non-synonymous variation (c.1228C>T) in exon 10 of TNFRSF1A, suggestive of susceptibility to multiple sclerosis 5 due to mutation in the TNFRS1A gene on chromosome 12p13.31. All cases received systemic steroids. Azathioprine (three cases) and rituximab (three cases) were the commonly used immunomodulatory drugs. The visual outcome was good in all cases at the last follow-up. CONCLUSION: MS-associated uveitis is underreported in India. This series highlights the clinical profile of MS-associated uveitis in India.

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.

Posterior segment involvement in systemic lupus erythematosus - A series from South India.

Purpose: To report the spectrum of posterior segment manifestations and visual outcomes in a large series of patients with systemic lupus erythematosus (SLE). Methods: Retrospective study at a tertiary referral eye center in south India between 2016 and 2022. Results: Charts of 109 patients diagnosed to have SLE were retrieved from our medical database. Only nine cases of SLE (8.25%) had posterior segment involvement. The male: female ratio was 1:8. The mean age was 28 years. Unilaterality was the most common presentation in eight cases (88.89%). Lupus nephritis was the most common systemic presentation in five cases (55.56%). Antiphospholipid antibodies (APLA) positivity was seen in two cases (22.22%). Ocular manifestations included microangiopathy (cotton wool spots) in one case, occlusive retinal vasculitis with cotton wool spots in four cases (five eyes), optic disc edema with combined venous and arterial occlusion (one case), central retinal vein occlusion with cotton wool spots and hemorrhages (one case), macular edema (four cases), posterior scleritis with optic disc edema and exudative retinal detachment in the posterior pole (one case), and tubercular choroidal granuloma (one case). Treatment included systemic steroids, hydroxychloroquine sulfate (HCQS), and immunosuppression in all cases, blood thinners in two cases, and laser photocoagulation in four cases. HCQS-related retinal toxicity was not seen in any of the 109 cases. Ocular manifestation was the initial presentation of SLE in one case. Visual outcome was poor in three cases. Conclusion: Presence of posterior segment findings in cases with SLE may suggest a severe systemic disease. Early detection and aggressive treatment result in better visual outcomes. Ophthalmologists could play a vital role in guiding systemic therapy.

Peripheral Ulcerative Keratitis in a Young Lady with Systemic Lupus Erythematosus Post Rituximab Infusion-A Case Report.

AIM: We report a new ocular finding of episcleritis (OD) and peripheral ulcerative keratitis (OS) in a 40-year-old lady with a 13-year history of systemic lupus erythematosus (SLE), 3 weeks post-rituximab infusion. MATERIALS & METHODS: Retrospective case report. RESULTS: A 40-year-old lady with a history of SLE and 3 weeks post rituximab infusion developed a new onset episcleritis (OD) and peripheral ulcerative keratitis (OS). As the PUK continued to advance with a leading edge, intravenous methyl prednisolone 1 gm/day was given for 3 days followed by a slow tapering course of oral prednisolone 50 mg/day. Though her ocular inflammation resolved, she developed pneumonia 6 weeks later. At 10 months follow-up, there were no ocular recurrences. She is currently on mycophenolate mofetil 2 gm/day along with oral prednisolone of 10 mg/day. CONCLUSION: This case highlights the new occurrence of episcleritis and PUK in SLE post-rituximab infusion.

Impact of COVID-19 pandemic on uveitis patients receiving immunomodulatory and biological therapies (COPE STUDY).

PURPOSE: To evaluate the change in the ongoing immunomodulatory (IMT) and biological therapies among patients with non-infectious uveitis (NIU), and determine the number of uveitis relapses during the COVID-19 pandemic. METHODS: In this national multicentric prospective case series, data of subjects with NIU receiving corticosteroids, systemic IMT and/or biological agents were analysed. The data collection was performed from 1 March 2020 to 25 June 2020. Main outcome measures included change in the ongoing treatments with corticosteroids, IMT and biological agents, use of alternate therapies and rates of uveitis relapse. RESULTS: In this study, 176 patients (284 eyes) with NIU (mean age: 33±17.1 years; males: 68) were included. A total of 121 eyes (90 patients) were deemed to have active NIU. Of these, seven subjects (7.8%) did not receive intravenous methylprednisolone despite need felt by the treating uveitis experts. In addition, 35 subjects (57.4%) received a rapid tapering dosage of oral corticosteroids despite active disease. A total of 161 (91.5%) subjects were receiving systemic IMT and 25 (14.2%) were on biological therapies. Overall, IMT was altered in 29/161 (18.0%) subjects. Twenty-two eyes were treated with intravitreal therapies in the study period. Fifty-three eyes (32.5%, 29 subjects) developed relapse of NIU, of which 25 subjects (86.2%) were deemed to have reactivation related to altered systemic IMT. No patient developed COVID-19 during follow-up. CONCLUSIONS: During the ongoing COVID-19 pandemic, uveitis specialists may tend to reduce the ongoing systemic IMT, or prefer less aggressive treatment strategies for NIU. These subjects may be at high risk of relapse of uveitis.

Diagnostic Markers in Ocular Sarcoidosis in A High TB Endemic Population - A Multicentre Study.

AIM: To look at markers to differentiate ocular sarcoidosis from ocular tuberculosis in a high TB endemic population. MATERIALS & METHODS: Retrospective multicenter study involving seven tertiary eyecare centers in India between July 2016 to December 2016. Demographic, clinical and laboratory data were retrieved from respective hospital databases. Group A included biopsy-proven ocular sarcoidosis while group B included ocular tuberculosis. RESULTS: Data from 2726 consecutive patients with uveitis were retrieved from the databases. Group A had 61 cases while group B included 307 cases. The mean age in group A was 43 ± 16.55 years while in group B was 38 ± 13.13 years. Females were more common in group A. Uveitis with low Schirmer test (OR-30, CI-95%), candlewax retinal vasculitis (OR-8.69, CI-95%), hilar lymphadenopathy (OR-15.23, CI-95%), fissural nodules (OR-39.11, CI-95%) had higher odds of having ocular sarcoidosis. CONCLUSION: Presence of dry eye, candlewax retinal vasculitis, hilar lymphadenopathy, and fissural nodules if present in a patient with uveitis, could help differentiate ocular sarcoidosis from ocular tuberculosis in a high TB endemic population.

Recommendations for the management of ocular sarcoidosis from the International Workshop on Ocular Sarcoidosis.

AIMS: To establish expert recommendations for the management of ocular sarcoidosis (OS). METHODS: A question-based survey on the management of OS was circulated to international uveitis experts (members of the International Uveitis Study Group and the International Ocular Inflammation Society) electronically. Subsequently, a consensus workshop was conducted at the 7th International Workshop on Ocular Sarcoidosis (IWOS) in June 2019 in Sapporo, Japan as part of the Global Ocular Inflammation Workshops. Statements on the management of OS that were supported by a two-thirds majority of 10 international panel members of the workshop, after discussion and voting, were taken as consensus agreement. RESULTS: A total of 98 participants from 29 countries responded to the questionnaire survey. The subsequent consensus workshop established recommendations for the management of OS in five sections. The first section concerned evaluation and monitoring of inflammation. The second, third and fourth sections described ocular manifestations that were indications for treatment, and the management of anterior uveitis, intermediate uveitis and posterior uveitis. In the fifth section, the use of systemic corticosteroids and systemic immunosuppressive drugs were detailed. CONCLUSIONS: Recommendations for management of OS were formulated through an IWOS consensus workshop.

Clinical Profile in Genetically Proven Blau Syndrome: A Case Series from South India.

Purpose: To report the clinical profile of genetically proven Blau syndrome in seven cases from a single center in South India.Materials & Methods: Retrospective case seriesResults: There were four females and three males. All cases had a history of skin and joint involvement of varying severity. Flexion contractures of the proximal interphalangeal joints were seen in all cases except Case 2. Ocular involvement was bilateral and included keratoconjunctivitis sicca (six cases), granulomatous panuveitis (three cases), granulomatous anterior uveitis (three cases), conjunctival granulomas (three cases), subepithelial corneal opacities (one case), and subretinal granuloma (one case). Other ocular findings included band-shaped keratopathy (five cases) and cataract (three cases). All cases received oral steroids and methotrexate with an addition of mycophenolate mofetil in one case. Visual prognosis was good in all cases.Conclusions: Blau syndrome is underreported in India. This is the largest case series of genetically proven Blau syndrome from South India and highlights the clinical profile of Blau syndrome seen in India.

Orbital Sarcoidosis in a High TB Endemic Country - A Case Series from South India.

Aim: We report a series of orbital sarcoid in a south Indian patient population and their outcome.Materials & Methods: Retrospective interventional case series.Results: Eleven out of 144cases of biopsy-proven sarcoidosis had orbital involvement. The mean age was 50.64 ± 9.52years and was more commonly seen in women (90.91%). Unilateral presentation with right orbit involvement was more common. Bilateral lacrimal gland enlargement (4cases), inferior orbital mass presenting as proptosis (4cases), preseptal mass above upper eyelid (2cases) and orbital mass encasing the globe (1case) were the different types of orbital presentation. All cases had a dry eye and a negative mantoux test. CT thorax was abnormal in 7cases (63.61%). Biopsy in all cases showed noncaseating granulomatous inflammation. Oral steroids were the standard mode of treatment and none of the cases had recurrences.Conclusions: Orbital sarcoidosis is seen in a high TB endemic country like India and is definitely underreported.

The Collaborative Ocular Tuberculosis Study (COTS)-1: A Multinational Review of 447 Patients with Tubercular Intermediate Uveitis and Panuveitis.

Purpose: Tubercular intermediate uveitis (TIU) and panuveitis (TBP) are difficult to manage because of limitations in diagnostic tools and lack of evidence-based treatment guidelines. The Collaborative Ocular Tuberculosis Study (COTS) analyzed treatment regimens and therapeutic outcomes in patients with TIU and TBP.Methods: Multicentre retrospective analysis.Results A total of 138 TIU and 309 TBP patients were included. A total of 382 subjects received antitubercular therapy (ATT) (n = 382/447; 85.4%) and 382 received corticosteroids (n = 382/447; 85.4%). Treatment failure was observed in 78 individuals (n = 78/447; 17.4%), occurring less frequently in patients receiving ATT (n = 66/382; 17.2%) compared to those who did not (n = 12/65; 18.5%). The study did not show any statistically significant therapeutic effect of ATT in patients with TIU and TBP.Conclusion Taking into account the limitations of the retrospective, non-randomized study design, resultant reliance on reported data records, and unequal size of the samples, the current study cannot provide conclusive evidence on the therapeutic benefit of ATT in TIU and TBP.

The Collaborative Ocular Tuberculosis Study (COTS)-1: A Multinational Descriptive Review of Tubercular Uveitis in Paediatric Population.

Purpose: To examine disease profile of tubercular uveitis (TBU) in Paediatric population.Methods: Among 945 patients of the retrospective multinational study by the Collaborative Ocular Tuberculosis Study (COTS)-1, 29 Paediatric patients diagnosed with TBU were analyzed.Results: Mean age of disease presentation was 12.8 (range 4-18 years), with predominance of males (n = 14/20; 70.0%) and Asian ethnicity (n = 25/29; 86.2%). Posterior uveitis (n = 14/28; 50%) was the most frequent uveitis phenotype, with choroidal involvement occurring in 64.7% (n = 11/17). Incidence of optic disc edema and macular edema was higher in children (n = 8/18; 44.4% and n = 5/18; 27.8%, respectively) than in adults (n = 160/942; 16.9% and n = 135/942; 14.3%, respectively). Comparison of optic disc edema between subgroups showed a significant difference (P =.006). All patients received oral corticosteroids, most of them with antitubercular therapy. Treatment failure developed in 4.8% (n = 1/21).Conclusions: Children have a more severe inflammatory response to the disease, and an intensive anti-inflammatory therapeutic regimen is required to achieve a positive treatment outcome.

Viral anterior uveitis.

Viral anterior uveitis (VAU) needs to be suspected in anterior uveitis (AU) associated with elevated intraocular pressure, corneal involvement, and iris atrophic changes. Common etiologies of VAU include herpes simplex, varicella-zoster, cytomegalovirus, and rubella virus. Clinical presentations can vary from granulomatous AU with corneal involvement, Posner-Schlossman syndrome, Fuchs uveitis syndrome, and endothelitis. Due to overlapping clinical manifestations between the different viruses, diagnostic tests like polymerase chain reaction and Goldmann-Witmer coefficient analysis on the aqueous humor may help in identifying etiology to plan and monitor treatment.

Drug-induced uveitis: A review.

Uveitis maybe induced by the use of various medications known as drug-induced uveitis (DIU), though rare it is an important cause of uveitis which one needs to be aware of. The drugs may be administered through any route including systemic, topical, and intravitreal. Ocular inflammation can be in the form of anterior, intermediate, posterior or pan uveitis, and rarely may present as episcleritis and scleritis. Identification of drug as the offending agent of uveitis is important as many a times stopping the drug may help recover the uveitis or the concomitant use of corticosteroids. An extensive literature review was done using the Pubmed. An overview of DIU is provided as it is important for us to be aware of this clinical entity.