Sympathetic ophthalmia: A comprehensive update.

Sympathetic ophthalmia is a rare, bilateral, granulomatous, panuveitis following penetrating trauma or surgery to one eye. Clinical presentation commonly occurs within the first year of trauma occurrence but can be delayed by several years. It manifests as acute/chronic granulomatous uveitis with yellowish-white choroidal lesions or Dalen-Fuchs nodules. Initially, patients respond rapidly to corticosteroid therapy, but a majority require long-term use of corticosteroid-sparing agents to prevent recurrences. The purpose of this review is to elaborate on the current understanding of the pathophysiology, the importance of multimodal imaging in early diagnosis, and the role of newer immunomodulatory and biological agents in recalcitrant cases.

Optical coherence tomography angiography versus fluorescein angiography in diagnosing choroidal neovascularization in chronic central serous chorioretinopathy.

Purpose: Diagnosis of choroidal neovascular membrane (CNVM) is difficult in chronic central serous chorioretinopathy (CCSC) due to overlapping features of both on conventional dye angiography. Optical coherence tomography angiography (OCTA) allows a quick and noninvasive detection of CNVM in these eyes. We compared the fluorescein angiography (FA) features of CNVM with those of OCTA to assess the role of FA in detecting CNVM in CCSC eyes. Methods: Patients with CCSC undergoing FA, spectral domain (SD)-OCT, and OCTA were identified (March 2015-June 2015). Four retina specialists individually reviewed FA images (without OCTA and SD-OCT) to determine whether CNVM was present. In parallel, two other retina specialists reviewed all images (FA/SD-OCT/OCTA) for CCSC features and confirmed whether CNVM was present using OCTA as the gold standard. The inter- and intraobserver variability was measured by Kappa (k) coefficient. The FA features of CNVM were compared and correlated with those on OCTA. Results: Of 43 eyes (26 patients, mean age 45.6 ± 8.5 years, all males), a definite CNVM (detected by OCTA) was present in nine (20.9%) eyes. FA alone detected CNVM in 13 (30.2%) eyes [sensitivity 44.4% (95% confidence interval (CI): 11.9-76.9), specificity 73.5% (95% CI: 58.7-88.3), positive and negative predictive values 30.8% and 83.3%, respectively, and accuracy 67.44% (95% CI: 53.4-81.4)]. Conclusion: When compared with OCTA, the FA was unable to characterize CNVM in CCSC (with a very low sensitivity and moderate specificity) as none of the specific dye leakage patterns on FA correlated with CNVM seen on OCTA, limiting its usefulness and accuracy in detecting CNVM in these eyes.

OCT angiography demonstrates retinal angiomatous proliferation and chorioretinal anastomosis of type 3 neovascularization.

PURPOSE: To report the OCT angiography findings of type 3 neovascularization. METHODS: Two cases (one each with retinal angiomatous proliferation and chorioretinal anastomosis) are reported, in which the conventional fundus fluorescein angiography and spectral-domain optical coherence tomography findings were inconclusive. RESULTS: OCT angiography demonstrated flow within the abnormal anastomotic network and delineated the extent of the lesion with respect to the retinal layers. CONCLUSION: OCT angiography enables a quick diagnosis of type 3 neovascularization by demonstrating a supranormal flow within the lesion and delineates the lesion within different retinal layers.

Safety and Outcome of Microincision Vitreous Surgery in Uveitis.

PURPOSE: To report the outcome of microincision vitreous surgery (MIVS) in uveitis. METHODS: In total, 103 patients (106 eyes) underwent diagnostic MIVS between March 2012 and April 2015. Postoperative evaluation included vitreous haze grading from clinical/electronic records, best-corrected visual acuity (BCVA), and complications. RESULTS: Mean age was 36.8 ± 13.9 years (range: 8-80 years). Mean follow-up after MIVS was 12.2 ± 7.2 months (median 12 months). Mean vitreous haze grading was 2.39 ± 0.98 (preoperatively), 0.36 ± 0.73 postoperatively (1 week), and 0.02 ± 0.2 at 1 month (p < 0.001). Mean BCVA was 1.5 ± 1.0 logMAR preoperatively and 0.72 ± 0.68 logMAR at 1 month (p = 0.000). Postoperative complications included cataract (14.6%), rise in intraocular pressure (13.2%), vitreous hemorrhage (4.7%), hypotony (3.2%), retinal detachment (2.8%), epiretinal membrane (2.8%), and worsening of inflammation (0.9%). CONCLUSIONS: MIVS is safe and may have a therapeutic role in uveitis.

Role of Ultra-Wide Field Imaging in the Management of Tubercular Posterior Uveitis.

PURPOSE: To assess the utility of ultra-wide field (UWF) versus conventional fundus imaging in the management of tubercular (TB) posterior uveitis. METHODS: Twenty-two consecutive patients (33 eyes) diagnosed with TB posterior uveitis in a tertiary care center who underwent UWF fundus photography and fluorescein angiography (FA) between July 2014 and March 2015 were included. Complete clinical and imaging records of the patients were retrospectively reviewed. A circle simulating the central 75-degree field was drawn on UWF pseudocolor and fluorescein angiography images. Findings within the circle were compared with the information yielded by the complete image and its impact on patient management was noted. RESULTS: The clinical manifestations of posterior tubercular uveitis included retinal vasculitis (17 eyes), multifocal serpiginoid choroiditis (13 eyes), choroidal granulomas (2 eyes) and intermediate uveitis (1 eye). UWF imaging revealed additional capillary non-perfusion areas, neovascularization, active vasculitis, and peripheral choroiditis lesions in 30/33 eyes (90.9%), which influenced treatment decision in 15 eyes (45.5%). CONCLUSIONS: UWF imaging is useful in the detection of peripheral pathologies in tubercular posterior uveitis that may influence management decisions, such as addition of immunosuppressive therapy or scatter laser photocoagulation.

Detection of Mycobacterium tuberculosis genome in vitreous fluid of eyes with multifocal serpiginoid choroiditis.

PURPOSE: To compare 3 different molecular techniques to detect the Mycobacterium tuberculosis genome in vitreous fluid of eyes with multifocal serpiginoid choroiditis (MSC). DESIGN: Prospective, interventional case series. PARTICIPANTS: Eleven patients (11 eyes) with active MSC in at least 1 eye underwent diagnostic pars plana vitrectomy (PPV) between October 2012 and December 2013. METHODS: Vitreous fluid samples were subjected to multitargeted polymerase chain reaction (PCR) for a M. tuberculosis assay, the Gene Xpert MTB/RIF assay (Cepheid, Sunnyvale, CA), and a line probe assay (GenoType MTBDRplus; Hain Lifescience, GmbH, Nehren, Germany). The samples with positive results were subjected to rpoB gene sequencing to demonstrate rifampicin resistance. The clinical details, digital fundus imaging, and treatment details and outcomes also were noted. MAIN OUTCOME MEASURES: Detection of the M. tuberculosis genome and rifampicin resistance in the vitreous samples. RESULTS: Of the 11 eyes subjected to PPV, the multitargeted PCR results for tuberculosis were positive for 10 eyes, the MTBDRplus assay results were positive in 6 eyes, and the Gene Xpert MTB/RIF assay results were positive in 4 eyes. Rifampicin resistance was detected in 3 eyes by rpoB gene sequencing, in 3 eyes by the MTBDRplus assay, and in 1 eye by the Gene Xpert MTB/RIF assay. CONCLUSIONS: We detected the M. tuberculosis genome in the vitreous fluid of eyes with MSC using 3 different molecular techniques. Rifampicin resistance was detected for the first time in eyes with MSC.

Comparison of event-based analysis of glaucoma progression assessed subjectively on visual fields and retinal nerve fibre layer attenuation measured by optical coherence tomography.

The purpose is to study the ability of an event-based analysis of retinal nerve fibre layer (RNFL) attenuation measured by Stratus(®) optical coherence tomography (OCT) and to detect progression across the spectrum of glaucoma. Adult glaucoma suspects, ocular hypertensives and glaucoma patients who had undergone baseline RNFL thickness measurement on Stratus OCT and reliable automated visual field examination by Humphrey's visual field analyser prior to March 2007 and had 5-year follow-up data were recruited. Progression on OCT was defined by two criteria: decrease in average RNFL thickness from baseline by at least 10 and 20 µ. Visual field progression was defined by the modified Hodapp-Parrish-Anderson criteria. Absolute and percentage change in RNFL thickness from baseline was compared in progressors and non-progressors on visual fields. Concordance between structural and functional progression was analysed. 318 eyes of 162 patients were analysed. 35 eyes (11 %) progressed by visual fields, 8 (2.5 %) progressed using the 20 µ loss criterion, while 30 eyes (9.4 %) progressed using the 10 µ loss criterion. In glaucoma suspects, mean absolute RNFL attenuation was 8.6 µ (12.1 % of baseline) in those who progressed to glaucoma by visual fields. OCT was more useful to detect progression in early glaucoma, but performed poorly in advanced glaucoma. The 10 µ criterion appears to be closer to visual field progression. However, the ability to detect progression varies considerably between functional and structural tools depending upon the severity of the disease.