Acute Bilateral Neuroretinitis and Panuveitis in A Patient with Coronavirus Disease 2019: A Case Report.

Purpose: Herein, we report a case of bilateral neuroretinitis and panuveitis in a patient recovered from coronavirus disease 2019 (COVID-19).Case presentation: A 37-year-old male patient with a history of recovered COVID-19, which was confirmed with nasopharyngeal reverse transcriptase polymerase chain reaction (RT-PCR) for Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), about one-month ago was referred with one-week history of bilateral severe vision loss. Visual acuity was counting fingers, and bilateral retinitis and panuveitis were revealed in ocular examination. The result of the vitreous sample using RT-PCR was positive for SARS-CoV-2 and negative for Herpesviridae viruses and mycobacterium tuberculosis. The patient was successfully treated with corticosteroid.Conclusion: We report a case of bilateral neuroretinitis and panuveitisin a recovered COVID-19 patient and positive RT-PCR of the vitreous sample. It is suggested to apply intraocular sampling and evaluation for COVID-19 in patients with the new-onset of uveitis and/or retinitis during the pandemic.

Vascular Damage May Mimic Retinitis and Optic Neuritis in COVID-19.

Ophthalmologic nvolvement in SARS-CoV-infected patients is variegated. One of the ophthalmologic pathologies is optic neuritis. Optic neuritis in SARS-CoV-infected patients may precede the classical pulmonary manifestations of COVID-19 and can be unilateral or bilateral. Optic neuritis has been repeatedly reported in COVID-19 patients and may occur with or without affection of other cranial nerves. Since cerebro-spinal fluid parameters can be abnormal in COVID-19 associated optic neuritis, these patients require a spinal tap. Before diagnosing SARS-CoV-2 associated optic neuritis various differentials need to be excluded. Since SARS-CoV-2 causes endothelial damage complicated by thrombus formation and thromboembolism, ophthalmologic vascular complication due to an infection with SARS-CoV-2 such as anterior ischemic optic neuropathy (AION), central retinal artery occlusion (CRAO), and retinal vein occlusion need to be excluded. CRAO may result from arterial hypertension, myocarditis, heart failure, Takotsubo syndrome, atrial fibrillation, or atrial flutter, frequent cardiac complications of COVID-19. Since CRAO can be accompanied by ischemic stroke, patients with SARS-CoV-2 associated optic neuritis need to undergo a cerebral MRI.

COVID-2019 Associated with Acquired Monocular Blindness.

OBJECTIVE: We documented an older female with Coronavirus(CoV) Disease 2019 (COVID-19) and concomitant acquired monocular blindness. We examined this phenomenon in order to understand COVID-19 better. METHODS: We observed an older female with COVID-19 and concomitant acquired monocular blindness. The following indicators were monitored during the course of the disease: ocular examinations, flash visual evoked potential examination, a blood test for COVID-19 IgM antibodies, as well as nasopharyngeal swab and tear sample tests for COVID-19 nucleic acid. RESULTS: The patient's visual acuity for the left eye was NLP and the intraocular pressure was 51 mmHg. Keratic precipitates similar to mutton-fat were spread over the corneal endothelium of the left eye. The funduscopic examination of the patient's left eye revealed severe retinal arterial ischemia, and the color of the retina was off-white. Compared to the right eye, the flash visual evoked potential examination revealed a moderate decrease in P2 wave amplitude for the left eye. A blood test was positive for COVID-19 IgM antibodies, and a nasopharyngeal swab test taken for COVID-19 nucleic acid was positive on May 4, 2020. A sample of the patient's tears was taken, and the nucleic acid test for COVID-19 was still positive two weeks later. CONCLUSIONS: Our study was the first to find that acute viral retinitis could occur in patients with COVID-19 and severe blindness could be associated with SARS-CoV-2 infection. Therefore, physicians should consider the possibility of coronavirus infection in patients with an abnormal fundus or suddenly vision loss.

Epidemic Retinitis with Macular Edema -Treatment Outcome with and without Steroids.

Purpose: To study treatment outcomes with and without oral corticosteroids in epidemic retinitis (ER).Method: A retrospective, observational study of 35 eyes of 29 patients diagnosed as ER. Days taken for resolution of macular edema and retinitis lesions were compared in patients treated with oral antibiotics (Group 1) and with corticosteroids-antibiotics combination (Group 2).Result: Eighteen eyes of 14 patients and 17 eyes of 15 patients formed Groups 1 and 2, respectively. At the presentation, mean best-corrected visual acuity (BCVA) was 40 and 44 letters and mean central macular thickness was 648 (±243) and 626 (±256) microns in Groups 1 and 2, respectively. Macular edema resolved in 30.83 and 31.94 days; retinitis lesions resolved in 36.71 and 41.41 days in Groups 1 and 2, respectively. BCVA improved to 74 and 77 letters in Groups 1 and 2, respectively.Conclusion: ER with macular edema can be well managed without corticosteroids.

Features of Retinitis-like Lesions in Vitreoretinal Lymphoma.

Purpose: To describe the distinguishing features of retinitis-like lesions seen in vitreoretinal lymphoma (VRL) from viral and toxoplasma retinitis.Methods: In this multicenter, retrospective study, we reviewed charts and imaging of consecutive patients with VRL. The associated features and the characteristics of retinitis-like lesions were assessed and compared with those of viral and toxoplasmic retinochoroiditis. Primary outcome measures were the unique features of VRL retinitis-like lesions.Results: Out of 76 eyes of 38 patients with VRL, retinitis-like lesions were identified in 6 eyes and confirmed on OCT. Distinctive features of VRL retinitis-like lesions were massive retinal thickening, associated sub-retinal pigment epithelium infiltrates and partial restoration of retinal layers after specific therapy.Conclusion: VRL can present with retinitis-like lesions that have distinctive OCT features on presentation as well as healing that can help to differentiate them from other lookalike etiologies and can guide further diagnostic and therapeutic interventions.

[Ocular manifestations of viral diseases]. / Atteintes ophtalmologiques des infections virales.

Viral infections may involve all ocular tissues and may have short and long-term sight-threatening consequences. Among them, ocular infections caused by herpesviruses are the most frequent. HSV-1 keratitis and kerato-uveitis affect approximately are the leading cause of infectious blindness in the Western world, mainly because of corneal opacification caused by recurrences. For this reason, they may warrant long-term antiviral prophylaxis. Herpes zoster ophthalmicus, accounts for 10 to 20% of all shingles locations and can be associated with severe ocular involvement (keratitis, kerato-uveitis) of which a quarter becomes chronic/recurrent. Post herpetic neuralgias in the trigeminal territory can be particularly debilitating. Necrotizing retinitis caused by herpesviruses (HSV, VZV, CMV) are seldom, but must be considered as absolute visual emergencies, requiring urgent intravenous and intravitreal antiviral treatment. Clinical pictures depend on the immune status of the host. Adenovirus are the most frequent cause of infectious conjunctivitis. These most often benign infections are highly contagious and may be complicated by visually disabling corneal lesions that may last over months or years. Some arboviruses may be associated with inflammatory ocular manifestations. Among them, congenital Zika infections may cause macular or optic atrophy. Conjunctivitis is frequent during the acute phase of Ebola virus disease. Up to 15% of survivors present with severe chronic inflammatory ocular conditions caused by viral persistence in uveal tissues. Finally, COVID-19-associated conjunctivitis can precede systemic disease, or even be the unique manifestation of the disease. Utmost caution must be taken because of viral shedding in tears.

Successful Treatment of Necrotizing Retinitis with Epstein-Barr Virus-Positive Ocular Fluid by Intravitreal Methotrexate Injection.

PURPOSE: To present a case of necrotizing retinitis with Epstein-Barr virus (EBV)-positive ocular fluid in a patient with sudden unilateral vision loss, which was successfully treated with intravitreal methotrexate (MTX) injections. METHODS: Retrospective case report. RESULTS: An 83-year-old female who had been on methylprednisolone for 20 years due to interstitial pneumonia developed vitreous opacity and extensive necrotizing retinitis with retinal hemorrhage sparing the posterior pole in the left eye. Multiplex polymerase chain reaction (PCR) for viral DNA using vitreous sample was positive for EBV but negative for herpes simplex virus, varicella-zoster virus, and cytomegalovirus. Real-time PCR detected EBV-DNA in aqueous humor but not in peripheral blood sample. Serologic testing was negative for Toxoplasma gondii, syphilis, and HIV. The patient did not respond to systemic ganciclovir or acyclovir. Subsequent treatment with intravitreal MTX resulted in immediate clinical improvement correlating with a decrease in copy number of EBV-DNA. CONCLUSION: Intravitreal MTX may be an effective treatment option for patients with necrotizing retinitis and EBV-positive ocular fluid not responding to conventional antiviral therapy.

Immune recovery uveitis in a patient with herpes retinitis as a complication of hairy cell leukaemia. / Respuesta similar a la uveítis de recuperación inmune en un paciente con retinitis herpética como complicación de una leucemia de células peludas.

A 51 year-old man with hairy cell leukaemia was treated with pentostatin. While receiving the treatment, he was diagnosed with herpes retinitis in his right eye. After the last cycle of pentostatin the patient developed a mild vitritis and cystoid macular oedema. There were no signs of herpes retinitis reactivation. After excluding other possible causes of intraocular inflammation, a diagnosis of immune recovery uveitis was made. The patient was treated with 2-monthly retro-septal injections of triamcinolone, oral corticosteroids, intravitreal dexamethasone implants and, finally, pars plana vitrectomy. An immune recovery uveitis-like response is possible in HIV negative individuals. The immune reconstitution after the treatment of hairy cell leukaemia may have led to intraocular inflammation. Management of immune recovery uveitis is challenging and difficult. Pars plana vitrectomy may be necessary. Ophthalmologists should be alert to the possibility of immune recovery uveitis in HIV negative patients.

The eye in dengue fever, a rarely appreciated aspect of dengue expanded syndrome: a case report.

BACKGROUND: Dengue fever is a mosquito-borne illness prevalent mainly in the tropics. It is feared for causing the dengue hemorrhagic spectrum of the disease leading to significant morbidity and mortality. Its rarer manifestations are categorized as the expanded dengue syndrome, and though being recognized, they are not fully appreciated and understood. The involvement of the eye in dengue fever is one such phenomenon. CASE PRESENTATION: A 27-year-old South-Asian woman presented on day 2 of dengue fever, without capillary leakage, for further management. Despite developing hepatitis, she had an otherwise uncomplicated progression of the illness because she did not develop capillary leakage. On day 8 of the illness, she had the lowest platelet count and developed bilateral blurred vision. Examination revealed that only gross movements were detected in the left eye, and the right eye had a visual acuity of 6/9. She was diagnosed with foveolitis in the right eye and central serous chorioretinopathy in the left eye, along with hemorrhages in both eyes. These were confirmed by funduscopy, fluorescein angiography, optical coherence tomography, and macular scans. She received systemic and intravitreal steroids and was assessed regularly. After 6 months of observation, her visual acuity was 6/6 in the right eye and 6/9 in the left eye, which remained the same thereafter. DISCUSSION: The exact mechanism of eye involvement in dengue viral infection is poorly understood. Multiple causes have been suspected and include viral factors, immune mediation, capillary leakage, stress, and hemorrhage. Eye involvement is classically seen at the lowest platelet count and when the count begins to rise. Though symptoms are nonpathognomonic, blurring of vision is the commonest complaint, but the range of presentation is extensive and variable. Ophthalmological assessment and funduscopy are very useful in addition to advanced assessments. There is no clear consensus on management; suggestions range from conservative care to aggressive steroid therapy with immune modulation and even ophthalmological intervention. Recovery can be full or partial with a variable time scale. CONCLUSION: The extensive spectrum of possible visual symptoms should prompt the clinician to suspect any visual complaint as potential dengue eye involvement. Guided studies and screening are needed to better understand the true incidence of eye involvement in dengue fever.

[Diagnostic vitrectomy in intraocular inflammations: A retrospective series]. / Vitrectomie diagnostique dans les inflammations intraoculaires : étude d'une série rétrospective.

PURPOSE: To determine the diagnostic and functional yield of vitrectomy in patients with uveitis of unknown origin. METHODS: A single-centered retrospective study was performed on patients who underwent a diagnostic vitrectomy for uveitis in the Department of Ophthalmology of the Nancy University Hospital from January 2011 to December 2016. Vitreous samples were analyzed in the cytology laboratory by cytological and immunohistochemical techniques, and in the microbiological laboratory by culture and bacterial, fungal and viral PCR, depending on clinical findings. Preoperative and one- and six-month postoperative visual acuity were collected and compared. RESULTS: Thirty-four patients (39 vitrectomies) were included. Vitreous testing led to a diagnosis in 14 out of 39 cases (36 %): 10 intraocular lymphoma, 2 amyloidosis, 1 CMV retinitis, and 1 choroidal metastasis of cutaneous melanoma with vitreous dissemination. Vitrectomy was negative in 20 patients. Visual acuity improved from 1.2±0.7 logMAR preoperatively to 0.8±0.7 logMAR at 1 month (p<0.001) and 0.9±0.8 logMAR at 6 months (p=0.054). CONCLUSION: In our study, diagnostic vitrectomy and vitreous fluid analysis were useful to diagnose uveitis of unknown origin, most of which were found to be intraocular lymphomas. Visual acuity improved for the majority of patients. Diagnostic vitrectomy with appropriate vitreous analysis related to clinical examination must be considered in the evaluation of uveitis of unknown origin.

Viral retinitis: diagnosis and management in the era of biologic immunosuppression: A review.

Necrotising retinitis is a rare ocular infection that historically led to high rates of visual morbidity. While acute retinal necrosis occurs in immunocompetent patients, the majority of cases are associated with immunocompromise such as in cytomegalovirus retinitis and progressive outer retinal necrosis. This review summarises the clinical and diagnostic features, management, and outcomes of herpetic retinitis. Iatrogenic immunosuppression is increasingly being utilised for a wide range of indications, and biologic agents especially so due to their targeted nature. While the intended actions are well-studied, the flow-on effects and complex interaction with host immunity are not well understood. Furthermore, biologics are frequently used concomitantly with other immunosuppressive agents, potentiating the immunodepression. This article reviews the literature on biologic immunosuppression and viral retinitis, and presents an approach to the vulnerable or affected patient. Early identification, prompt and aggressive treatment, and a multidisciplinary approach to managing immunodeficiency are the cornerstones of management.

Epidemic Retinitis.

Purpose: To study demography, seasonal variation, clinical presentation, and treatment outcome of "retinitis post febrile illness." (RpFI) Method: Case records of patients diagnosed as RpFI, from July 2009 to May 2017 were studied retrospectively. Patients with complete follow up were evaluated for treatment and visual outcomes. Results: Two hundred and five eyes of 119 patients were studied. The peak incidence of RpFI was from November to March each year. Diagnosis of fever largely remained unknown. Chikungunya IgM, Dengue IgM, and Weil-Felix test was positive in 22.22%, 15.38%, and 39.75%, respectively, in investigated cases. The mean visual acuity at presentation and at resolution was 20/63 and 20/32, respectively, in 122 eyes with complete follow up. Conclusion: We suggest a term "Epidemic Retinitis" for RpFI due to its seasonal variation and to differentiate it from other sporadic forms of retinitis. Although RpFI has aggressive presentation, it resolves over 3-4 months and the overall visual outcome is satisfactory.

Intravitreal aflibercept for the treatment of choroidal neovascularization associated with rubella retinopathy.

PURPOSE: To report a case of choroidal neovascularization (CNV) associated with rubella retinopathy (RR) treated with intravitreal aflibercept. CASE PRESENTATION: A 15-year-old girl presented a complaint of visual decrease in her left eye. She had a history of hearing decrease since she was 1 year old in addition to patent ductus arteriosus. On ocular examination, the best corrected visual acuity (BCVA) was 20/20 in the right eye and 20/400 in the left eye. Dilated fundus examinations revealed a classic salt-and-pepper appearance in both eyes and a whitish subretinal lesion with retinal hemorrhages in the left macula. Fundus fluorescein angiography (FFA) of the left eye illustrated a pattern of diffuse spotty fluorescence with an active subfoveal CNV lesion, that hyperfluoresces in the early phases of the FFA, maintains well-demarcated borders, and leaks. Spectral domain optical coherence tomography (SD-OCT) revealed thickened and elevated retinal layers at the macula due to the subretinal and intraretinal fluid with foveal and extrafoveal protruding hyper-reflective lesion in the left eye. Single dose of intravitreal aflibercept was performed to the left eye and at the first month after the injection, the BCVA improved to 20/100 and the OCT revealed scar formation. At the follow-up visits, the macula was similar to those at the first month post-injection, and the BCVA was preserved. No additional injections were needed. CONCLUSION: Intravitreal aflibercept may be a treatment alternative, which provides satisfactory anatomical and functional results and leads to a better visual acuity in cases with RR complicated by CNV.

Retinitis as the presenting feature of subacute sclerosing panencephalitis in an Indian male: A case report.

Measles virus is a rare but important cause for acute retinitis as it can eventually lead to the fulminant complication of SSPE. We report a case of a young Indian male with acute viral retinitis who subsequently developed SSPE. It is of paramount importance to consider measles virus and SSPE as a cause in an immunocompetent young adult with necrotizing viral retinitis.

Recurrent chikungunya retinitis.

Chikungunya is a systemic viral disease transmitted to humans by infected mosquitoes in endemic areas of Africa, Asia and more recently in the Americas. Chikungunya infection produces a sudden onset of fever, joint pains and erythematous skin eruption. A plethora of ocular manifestations have been described ranging from a non-specific conjunctivitis to exudative retinal detachment. Ocular chikungunya seems to respond well to corticosteroid therapy, and outcomes are usually better if treated early. Our patient acquired this infection on a travel to Mexico jungle. This was confirmed by ReverseTranscriptase-PCR test once she returned to the UK. The peculiarity of the case is the inordinate delay of almost a year in the onset of eye symptoms, from acquiring the viral infection. The ocular inflammation responded to systemic corticosteroid therapy with a favourable visual outcome. She developed a recurrence many months later which again responded well to a course of oral steroids.

Retinitis associated with double infection of Epstein-Barr virus and varicella-zoster virus: A case report.

RATIONALE: Chronic uveitis with immunosuppressive agents could develop chronic herpetic retinitis with varicella-zoster virus (VZV) or herpes simplex virus (HSV). Ocular Epstein-Barr virus (EBV) infection develops uveitis and vitritis, but the clinical feature of EBV retinitis is not typical as a viral retinitis. EBV retinitis is rare, and only a few cases of EBV retinitis have been reported. Herein, we describe a case of retinitis with EBV and VZV which were the primary viruses verified by multiplex polymerase chain reaction (PCR). PATIENT CONCERNS: A 75-year-old woman suffered from sudden visual loss in the left eye. She had been diagnosed with rheumatoid arthritis. At presentation, visual acuity (VA) was 20/400 in the left eye. Slit lamp examination disclosed fine white keratic precipitates with infiltrating cells and dense vitreous opacities in the anterior segment and vitreous. Fundus photographs showed multifocal chorioretinal scars in macula and peripheral retina, and granular lesions surrounding arcade vessels. DIAGNOSES: Ocular toxoplasmosis was primarily suspected. INTERVENTIONS: However, serological test showed negative of toxoplasmosis. Therefore, a diagnostic and therapeutic vitrectomy was performed. Vitreous fluid sample was used for multiplex PCR for detection of human herpesvirus (HHV) -1 to -8, toxoplasmosis and toxocariasis. OUTCOMES: Multiplex PCR detected 5.8 × 10 copies/mL of EBV-deoxyribonucleic acid (DNA), and 3.6 × 10 copies/mL of VZV-DNA in the sample. Therefore, we could diagnose the unidentified panuveitis a retinitis associated with double infection of EBV and VZV. At 85 days after the vitrectomy, VA of the left eye recovered to be 20/16. LESSONS: Elderly patients under immunosuppression may be susceptible to develop retinitis associated with infection of multiple HHVs, and multiplex PCR is an excellent tool to diagnose an unidentified panuveitis resembling this case.