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.

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.

The retinal vascular growth rate in babies with retinopathy of prematurity could indicate treatment need.

Purpose: To analyze the weekly rate of retinal vascular growth in treatment-naïve babies with various stages of retinopathy of prematurity (ROP) and validate if this could be a predictor of treatment need. Methods: Retrospective review of medical charts and retinal images of babies with various stages of ROP. The images were enhanced using red-green image enhancement software. Using the length of the horizontal disc diameter (DD) of each eye, the vessel growth was measured from the disc margin up to the vessel tip in fixed quadrants. The rate of vessel growth was the ratio of vessel length to the number of weeks it took to reach this length. The babies were divided into treatment warranting ROP (group 1), low-risk pre-threshold (type II) ROP (group 2,), and no-ROP (group 3) for analysis. The "no-ROP" group acted as normal control. Group 1 was further subdivided into 1A (threshold ROP), IB (aggressive posterior ROP), 1C (hybrid ROP), and ID (high-risk pre-threshold ROP). Results: Out of 436 eyes, groups 1, 2, and 3 had 238, 108, and 90 eyes, respectively. The mean rate of vascular outgrowth along with 95% confidence interval (CI) was 0.490 [0.487,0.520], 0.612 [0.599, 0.638], and 0.719 [0.703, 0.740] DD/week, respectively, for babies with "treatment warranting," "low risk pre-threshold" and "no ROP" groups, respectively. In our estimate, more than 80% of eyes with a vessel growth rate of 0.54 DD/week or less required treatment. Conclusion: A rate of retinal vascular growth less than 0.54 DD/week can be used to determine treatment requirements in babies with ROP.

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.

Eye: the door to undiagnosed chronic myeloid leukaemia.

Chronic myeloid leukaemia (CML) is a myeloproliferative neoplasm that can present in varied ways from incidental finding on haemogram to symptomatic presentation such as splenomegaly. We report an interesting case of a 22-year-old man who presented with loss of vision in right eye for 1 month. There were no pre-existing ocular or systemic diseases. On detailed ocular examination, a diagnosis of right eye rubeosis iridis, hyphaema, cataract and vitreous haemorrhage with left eye suspected leukaemic retinopathy was made. Routine haemogram revealed high leucocytosis. Systemic evaluation with investigations confirmed the diagnosis of CML and the patient was started on appropriate therapy.

Chronic myeloid leukaemia-associated retinopathy.

A 38-year-old man presented with mild blurring of vision in both eyes for the past 1 week. On examination, the retinal vessels were dilated and tortuous, along with multiple dot blot haemorrhages all over the fundus with yellowish white focal retinal infiltrates at the macula temporal to the fovea. The salmon pink discolouration of the blood column made us look at the peripheral blood smear, which was suggestive of chronic myeloid leukaemia, leading to a diagnosis of leukaemic retinopathy in both the eyes.

Posterior Subhyaloid Precipitates: 'KPs' of the Posterior Segment.

Purpose: To describe the course of posterior subhyaloid precipitates (PSPs) accompanying active retinitis. Methods: Retrospective study of three retinitis cases associated with PSPs and literature review. Results: Cases 1 and 2 were Toxoplasma retinochoroiditis. Case 3 had bilateral retinitis post-febrile illness. PSPs were yellowish-white spherical lesions seen in the presence of partial posterior hyaloid detachment (PVD) in the retro-hyaloid space lining the inferior PVD margin. In all 3 cases, PSPs resolved during treatment for primary disease. Resolution of PSPs preceded resolution of retinitis. Literature review revealed similar lesions in CMV retinitis and syphilis in addition to Toxoplasma retinochoroiditis. Conclusion: PSPs were seen in the presence of active retinitis and partial PVD when inflammatory aggregates gravitate inferiorly in the subhyaloid space. They were observed during active retinitis and their resolution preceded the resolution of retinitis, thus providing a potential marker for disease resolution.

Retinopathy of prematurity care in peripheral districts in Odisha, India: Pilot for a sustainable model.

The outcome of a retinopathy of prematurity (ROP) program initiated in five districts of Odisha over 3 years with partnerships between the government and non-government organizations was prospectively analyzed. The mentoring partners trained the district ophthalmologists and neonatal care providers; the program was handed over when the trainees were considered competent enough to diagnose and treat babies with ROP. During the project period (July 2016-June 2019), 3058 babies were examined; ROP was detected in 33.81% (n = 1034) and 5.06% (n = 159) babies required treatment. At the end of the project, ROP screening was possible in all five districts, and treatment was possible in three districts. ROP care nodal centers were built in one government medical college. To strengthen the initial gain, we recommend creating an Odisha Retinopathy of Prematurity (OD-ROP) steering committee with private-public partnerships to support the program and monitor its progress in other districts of Odisha.

Characteristics of 'sawtooth shunt' following anti-vascular endothelial growth factor for aggressive posterior retinopathy of prematurity.

OBJECTIVE: To explore the characteristics of 'sawtooth shunts (STS)' following intravitreal anti-vascular endothelial growth factors (anti-VEGF) for aggressive posterior retinopathy of prematurity (AP-ROP). DESIGN: Prospective observational study. METHODS: In a prospective observational study, 45 eyes of 24 babies receiving intravitreal anti-VEGF for AP-ROP or hybrid ROP were analyzed. Anti-VEGF molecule and doses: bevacizumab (0.62 mg or ½ IVB, n = 30 eyes; 0.25 mg or 1/5IVB, n = 9 eyes; 0.12 mg or 1/10 IVB, n = 1 eye); or ranibizumab (0.25 mg or ½IVR, n = 3 eyes; 0.1 mg or 1/5IVR, n = 2 eyes). They were followed every 1-2 week till disease regression with or without laser treatment. Development of STS, its variants, characteristics, timeline, and final outcomes was analyzed. RESULTS: STS occurred in 26 (57.7%) eyes at 1-6 weeks following anti-VEGF injections and persisted for 1-14 weeks. While the shunt regressed spontaneously in half of the treated eyes (n = 13) with anti-VEGF alone, the other half (n = 13) required additional laser because of either non-compliance (n = 9) or recurrence (n = 4). CONCLUSION: The STS was observed to be an important retinal vascular change seen in infants treated with intravitreal anti-VEGF at half adult doses. It warrants further studies to explore the association between STS and its association with disease recurrence or regression.