Bilateral Persistent Placoid Maculopathy Following COVID-19 Vaccines: Real or Coincidence?

COVID-19 vaccinations have been accompanied by reports of inflammatory uveitis. Herein, we report the first case of bilateral persistent placoid maculopathy (PPM) following COVID-19 vaccinations in a previously healthy 58-year-old man who presented with bilateral decrease in vision approximately 2 weeks after the second dose of AstraZenaca® ChAdOx1-S/nCoV-19 vaccine. Fundus examination revealed bilateral well-delineated whitish plaque-like macular lesions involving the fovea. Clinical and multimodal imaging findings were suggestive of PPM. Infective and autoimmune screen were all negative except for a raised MPO-ANCA. Medical review excluded systemic autoimmune and infectious diseases. Patient was monitored closely and his visual acuity improved and stabilised after a tapering regime of oral prednisolone. Mycophenolate mofetil was given as long-term steroid sparing immunosuppression. Our case demonstrated a likely localised autoimmune inflammatory response to the COVID-19 vaccine affecting choriocapillaris. Further research is needed to clarify the association between COVID-19 vaccines and inflammatory placoid lesions of the retina.

Feasibility and clinical utility of handheld fundus cameras for retinal imaging.

BACKGROUND/OBJECTIVES: Handheld fundus cameras are portable and cheaper alternatives to table-top counterparts. To date there have been no studies comparing feasibility and clinical utility of handheld fundus cameras to table-top devices. We compare the feasibility and clinical utility of four handheld fundus cameras/retinal imaging devices (Remidio NMFOP, Volk Pictor Plus, Volk iNview, oDocs visoScope) to a table-top camera (Zeiss VisucamNM/FA). SUBJECTS/METHODS: Healthy participants (n = 10, mean age ± SD = 21.0 ± 0.9 years) underwent fundus photography with five devices to assess success/failure rates of image acquisition. Participants with optic disc abnormalities (n = 8, mean age ± SD = 26.8 ± 15.9) and macular abnormalities (n = 10, mean age ± SD = 71.6 ± 15.4) underwent imaging with the top three scoring fundus cameras. Images were randomised and subsequently validated by ophthalmologists masked to the diagnoses and devices used. RESULTS: Image acquisition success rates (100%) were achieved in non-mydriatic and mydriatic settings for Zeiss, Remidio and Pictor, compared with lower success rates for iNview and oDocs. Image quality and gradeability were significantly higher for Zeiss, Remidio and Pictor (p < 0.0001) compared to iNview and oDocs. For cup:disc ratio estimates, similar levels of bias were seen for Zeiss (-0.09 ± SD:0.15), Remidio (-0.07 ± SD:0.14) and Pictor (-0.05 ± SD:0.16). Diagnostic sensitivities were highest for Zeiss (84.9%; 95% CI, 78.2-91.5%) followed by Pictor (78.1%; 95% CI, 66.6-89.5%) and Remidio (77.5%; 95% CI, 65.9-89.0%). CONCLUSIONS: Remidio and Pictor achieve comparable results to the Zeiss table-top camera. Both devices achieved similar scores in feasibility, image quality, image gradeability and diagnostic sensitivity. This suggests that these devices potentially offer a more cost-effective alternative in certain clinical scenarios.

Efficacy of Tacrolimus in Uveitis, and the Usefulness of Serum Tacrolimus Levels in Predicting Disease Control. Results from a Single Large Center.

AIMS: To evaluate the efficacy of tacrolimus in patients with noninfectious uveitis, as well as the usefulness of serum tacrolimus concentration measurements in predicting disease control. METHODS: A retrospective review was carried out on 71 eligible patients from a single specialist uveitis center for minimum 1-year follow-up. Analysis was carried out on disease activity, visual acuity, and trough serum tacrolimus concentrations (STC). RESULTS: At 1-year follow-up, disease control was achieved in 49 patients (69.0%), this was significantly more likely in patients with trough STC levels above 5 ng/mL (88% vs 53%, p = .002). There was a significant reduction in oral prednisolone (dose ≥7.5 mg, 86% vs 54%, p < .0001). Tacrolimus was discontinued in 12 patients (17%) due to side effects. DISCUSSION: In this study cohort, oral tacrolimus was effective and well tolerated in the treatment of noninfectious uveitis. Trough STC between 5 ng/mL and 10 ng/ml was associated with better disease control at 1-year follow-up.

Dietary Polyunsaturated Fatty Acids (PUFAs): Uses and Potential Health Benefits.

PURPOSE OF REVIEW: Polyunsaturated fatty acids (PUFAs) are obtained from various sources, which can be incorporated in the routine diet to maintain the health. They provide protection from several diseases like osteoarthritis, cancer, and autoimmune disorders. Major focus is given to the PUFAs omega-3 (ω-3) and omega-6 (ω-6) fatty acids which are available in both terrestrial and in the marine environment. The main concern of this article is to review the key scientific reports in context with the human health consequences and advantages of the food sources of ω-3 and ω-6 fatty acids. RECENT FINDINGS: ω-3 and ω-6 fatty acids are consumed by the population globally in the form of foods that are rich in fatty acids. Their nutritional effects have the capability to improve the physical functioning and metabolic rate of the body. These PUFAs contribute in various cellular activities like cell signaling, structural integrity and fluidity of cell membrane, the regulation of blood pressure, glucose level, the nervous system, inflammatory reactions, and hematic clotting. Animal and cell-based models represent that ω-3 and ω-6 PUFAs can regulate the skeletal muscle metabolism. The main concern of this article is to review the key scientific reports in context with the human health consequences and advantages of the food sources of ω-3 and ω-6 fatty acids.

An Atypical Presentation of Sympathetic Ophthalmia in an Intact Globe Following Mechanical Fall: A Case Report and Literature Review.

PURPOSE: To describe an atypical case of sympathetic ophthalmia presenting after blunt trauma causing disinsertion of the iris in an intact globe. METHODS: Case report. RESULTS: A 71-year-old lady presented to the Emergency Department following a mechanical fall. On examination, she was noted to have periocular haematoma, subconjunctival haemorrhage, hyphaema, and vitreous haemorrhage in the left eye, but there was no evidence of globe rupture. The presenting visual acuity was 6/18. As the hyphaema and vitreous haemorrhage settled, a complete loss of the iris was noted with normal fundus. She was re-admitted a month later under the medical team with urinary tract infection and reduced vision in both eyes. On examination, there was mild conjunctival injection, keratic precipitates, anterior chamber flare, 180-degree posterior synechiae, and vitritis with no fundal view of the right eye. She was diagnosed with sympathetic ophthalmia and was treated with topical and systemic corticosteroid. Her vision improved gradually with treatment and was stable at 6/6 on the right (sympathising) eye and 6/9 on the left (excited) eye at final follow-up. CONCLUSION: Sympathetic ophthalmia may result from non-penetrating ocular trauma. Comprehensive history of mechanism of injury and ophthalmic examination is essential so that prompt treatment can be given to improve the visual prognosis of affected patients.

Long-term results of intravitreal bevacizumab and dexamethasone for the treatment of punctate inner choroidopathy associated with choroidal neovascularization: A case series.

INTRODUCTION: To present a case series of three female patients with punctate inner choroidopathy. We report the outcomes after an essentially long follow-up period of up to 14 years and provide evidence of the effectiveness of intravitreal injections of bevacizumab and dexamethasone 0.7 mg in punctate inner choroidopathy patients with choroidal neovascular membrane formation. CASE SERIES PRESENTATION: This is a retrospective case series of three female patients with punctate inner choroidopathy who were treated with intravitreal injections anti-vascular endothelial growth factor agent (bevacizumab, 1.25 mg/0.05 mL). Two patients also received intravitreal dexamethasone 0.7 mg. Once a choroidal neovascular membrane developed, the outcome was poor with a best-corrected visual acuity of 6/60 or counting fingers in the affected eyes. The patients were followed up for 5, 14 and 8 years. CONCLUSION: The use of dexamethasone 0.7 mg in punctate inner choroidopathy yielded encouraging results and long periods of stability. When choroidal neovascular membrane complicates the primary disease, the prognosis is unfavourable, especially if the macula integrity has already been considerably affected. On the contrary, aggressive early therapy and continued monthly monitoring can prevent severe fibrosis, as showed in previous reports. Further larger-scale studies are needed to evaluate the efficacy of intravitreal dexamethasone 0.7 mg and bevacizumab as an alternative treatment in non-infectious uveitis.

Safety profile and efficacy of tacrolimus in the treatment of birdshot retinochoroiditis: a retrospective case series review.

AIM: Evaluation of the use of tacrolimus in the treatment of birdshot retinochoroiditis (BRC) at a tertiary referral centre with the aim to describe its safety and efficacy. METHODS: The medical records of 25 patients diagnosed with BRC at uveitis service, Moorfields Eye Hospital, and who had received tacrolimus treatment were retrospectively reviewed. The main outcome measures of the study were (1) safety of tacrolimus in terms of side effects and (2) efficacy, as measured both by control of inflammation and visual function assessed by Humphrey visual fields and electrophysiological testing over at least 6 months and then 1 year. RESULTS: Tacrolimus was commenced in 25 patients (mean age 50.4±10.8 years) and was well tolerated in 21 patients (84%). It was necessary to stop the tacrolimus in four patients. No patient showed major changes in renal function: 3/21 patients (14.28%) showed slightly abnormal (less than 30%) function at the end of the first month of treatment; 1/21 (4.76%) patients at 3 months, but at the end of a 6-month treatment period only 1/21 patients (4.76%) showed minor abnormality in renal function. The mean daily prednisolone dose was 19.7 mg at the beginning of the study, which had fallen to 6.9 mg at the end (t=5.071, p=0.001). Visual acuity mostly remained stable. Visual fields improved over time (mean improvement in Humphrey mean deviation, right eye=1.8±2.4 dB, t=3.821, p=0.004; left eye=1.9±2.7, dB, t=3.06, p=0.007). Electrophysiological function showed improvement in 10 patients, and in four patients an initial deterioration in function improved following tacrolimus dose adjustment. CONCLUSION: Tacrolimus has a good safety profile for long-term use in patients with BRC as a second-line agent enabling steroid sparing and visual function stabilisation or improvement.

The concept of virtual clinics in monitoring patients with age-related macular degeneration.

PURPOSE: To present clinical results regarding the treatment of patients with age-related macular degeneration (neovascular form) after the implementation of a 'virtual' type of follow-up in a single retina service centre. METHODS: Retrospective study based on the clinical records of the Leicester Royal Infirmary Retina department. Two periods were compared, the 2-year period of 2011-2012 and the following one of 2012-2013 when the 'virtual' clinics model applied in the department. Primary outcomes were as follows: the time between two appointments, follow-up or treatment and the number of patients with significant (>15 letters) improvement of their best corrected distance visual acuity. Secondary parameters of interest were as follows: mean number of injections per patient/year and the average duration of a 'virtual' vs. a regular visit. RESULTS: The mean time interval between two appointments was 5.3 weeks following the implementation of the 'virtual' clinics compared to 6.9 weeks in the previous period of regular appointments. Mean visual acuity improvement >15 letters was achieved in 6.9% of the patients compared to 23.1% of the 'virtual' appointments period. The results regarding injections/patient/year were as follows: 5.6 before the model of 'virtual' appointments and 5.9 after the implementation. The average time a patient spent for a conventional visit was 71.4 ± 24.1 min, and the respective time needed in the virtual clinic was 47.3 ± 18.6 min. CONCLUSION: The model of 'virtual' (without actual consultation) follow-up appointments assisted our service to contend with the increased number of patient. In general, the specific pattern of patients' management could be widely considered obviously after comprehensive and all-embracing assessment of its safety and efficiency.

Successful treatment of retinal angiomatous proliferation with intravitreal triamcinolone and ranibizumab injections in a 67-year-old male.

A 67-year-old male who presented to the eye casualty department with deterioration in his vision was diagnosed with retinal angiomatous proliferation. After initial deterioration with ranibizumab intravitreal injections, we have demonstrated successful treatment and stabilised vision with ranibizumab and a single intravitreal triamcinolone injection. Stringent follow-up and top-up ranibizumab injections have stabilised his vision and have shown foveal improvement on optical coherence tomography imaging.

Incidence of Retinal Pigment Epithelial Tears and Associated Risk Factors After Treatment of Age-Related Macular Degeneration with Intravitreal Anti-VEGF Injections.

PURPOSE: To study the incidence and risk factors for retinal pigment epithelium tears following intravitreal anti-vascular endothelial growth factor (VEGF) injections. METHODS: Retrospective longitudinal study. 4027 intravitreal anti-VEGF injections in 628 patients (676 eyes) for choroidal neovascularisation associated with age related macular degeneration in a period of 18 months were studied. RESULTS: Seventeen patients (mean age 83.95±5.84) developed retinal pigment epithelium tears. The incidence rate was 0.4%. Fibrovascular pigment epithelium detachment (PED) was previously observed in all cases. In 88 % (15/17) of AMD patients that had a RPE tear, PED height was found to be less than 400 microns at presentation. In 5 of 7 patients with RPE tear grade <4, continuing of anti-VEGF treatment resulted to improvement of visual acuity. CONCLUSION: Critical risk factors for RPE tears are presence of PED as well as advanced age. Visual improvement appears to depend more on the extent and location of the RPE tear and less on the PED height.

Selective Laser Trabeculoplasty in Pseudophakic Glaucoma.

Glaucoma following cataract operation is more common when complications occur during surgery. Patients who had posterior capsule rupture during cataract surgery usually have a prolonged intraoperative time and manipulation. In such cases, secondary glaucoma may develop due to chronic trabecular damage and prolong topical steroid use. It is usually treated with topical anti-glaucoma medication or surgery. Recently selective laser trabeculoplasty (SLT) has emerged as a relatively new, safe and effective treatment modality. Three cases of pseudophakic secondary glaucoma following complicated cataract surgery treated successfully with 180 degrees SLT treatment are presented. Case 1 responded well to SLT during 5-year available follow-up, along with reduction in topical anti-glaucoma medication. In Cases 2 and 3, SLT was used as adjunctive to topical anti-glaucoma medication and target intra ocular pressure (IOP) was maintained for 4 and 2 years of available follow-up, respectively. To our best knowledge this is the first case series where SLT has been shown effective in cases of pseudophakic secondary glaucoma.

An unusual case of acute angle closure glaucoma following argon laser pan retinal photocoagulation.

Acute angle closure glaucoma (AACG) is a painful, potentially blinding condition with patients frequently presenting within hours of onset with ocular pain, nausea and vomiting. Argon laser pan-retinal photocoagulation (PRP) is one of the commonest ophthalmic outpatient procedures. It is used in the treatment of vascular disorders of the retina; most commonly diabetic retinopathy. AACG following PRP is a recognised, but rarely occurring, complication. Prompt treatment alleviates pain and improves visual prognosis. The authors report a case of AACG following PRP treatment which was initially mistaken for a viral illness.

Neurotrophic keratitis in a patient with dihydroxypyrimidine dehydrogenase deficiency.

We describe a case of neurotrophic keratitis in association with dihydroxypyrimidine dehydrogenase (DHPD) deficiency. Ocular manifestations in patients with DHPD are rare and neurotrophic keratitis has never been reported before. A six-year-old boy who was a known case of DHPD deficiency and born of a consanguineous marriage presented to our clinic with non-healing corneal ulcers in both eyes. Reduced corneal sensations were detected and the patient was started on lubricating eye drops. The patient continues to be on lubricant eye drops and there has been no recurrence of the disease.