Tattoo-Induced Exacerbations of Systemic Disease and Uveitis.

Purpose: To examine an underreported and underdiagnosed phenomenon with implications for the pathophysiological mechanisms of tattoo-induced uveitis. Methods: Two cases highlighting the clinical presentation of tattoo-related uveitis were evaluated. Results: A 28-year-old man with biopsy-proven sarcoidosis and ocular manifestations presented with worsening retinal vasculitis after acquiring a red-ink tattoo. Each subsequent flare followed acquisition of a new tattoo. A 31-year-old woman without systemic sarcoidosis presented with multiple episodes of bilateral intermediate uveitis and macular edema concurrent with inflammatory granulomas to recently acquired black-ink tattoos. A skin biopsy in both patients showed cutaneous noncaseating granulomas. Conclusions: These cases add to those reported in the literature and emphasize the importance of understanding the modifiable factors of inflammatory ocular disease. Future study is necessary to understand the mechanisms of tattoo-related uveitis.

Updates on Functional and Morphologic Features via State-of-the-Art Testing in Some Clinically Evident Ocular Diseases.

Recent research on functional and morphologic features is relevant to the diagnosis of ocular diseases [...].

Can the Future be Bright with Advances in Diabetic Eye Care?

The prevalence of diabetic retinopathy is steadily increasing as the population of patients with diabetes grows. In the past decade, the development of anti-VEGF agents has dramatically changed the treatment landscape for diabetic retinopathy and diabetic macular edema (DME). Newer agents in development aim to reduce the treatment burden of diabetic retinopathy.

Use of Visual Electrophysiology to Monitor Retinal and Optic Nerve Toxicity.

It is important for clinicians to consider exposure to toxic substances and nutritional deficiencies when diagnosing and managing cases of vision loss. In these cases, physiologic damage can alter the function of key components of the visual pathway before morphologic changes can be detected by traditional imaging methods. Electrophysiologic tests can aid in the early detection of such functional changes to visual pathway components, including the retina or optic nerve. This review provides an overview of various electrophysiologic techniques, including multifocal electroretinogram (mfERG), full-field ERG (ffERG), electrooculogram (EOG), pattern electroretinogram (PERG), and visual evoked potential (VEP) in monitoring the retinal and optic nerve toxicities of alcohol, amiodarone, cefuroxime, cisplatin, deferoxamine, digoxin, ethambutol, hydroxychloroquine, isotretinoin, ocular siderosis, pentosane, PDE5 inhibitors, phenothiazines (chlorpromazine and thioridazine), quinine, tamoxifen, topiramate, vigabatrin, and vitamin A deficiency.

Intraocular inflammation secondary to intravitreal brolucizumab treated successfully with Sub-Tenon triamcinolone: A case report.

PURPOSE: To report on a case of successful treatment of intraocular inflammation (IOI) secondary to brolucizumab intravitreal injection that responded to a single sub-Tenon injection of triamcinolone. OBSERVATIONS: An 81-year-old female with a longstanding history of exudative age-related macular degeneration (AMD) was unresponsive to various regimens of anti-VEGF injections. Her AMD was treated with one intravitreal injection of brolucizumab (6mg/0.05ml) into the right eye. On a follow-up visit, she had a new-onset conjunctival injection, with anterior chamber and vitreous inflammation, in the right eye, which was diagnosed as non-granulomatous iridocyclitis. The patient was treated with one posterior sub-Tenon injection of triamcinolone (40mg/ml) into the right eye. Subsequently, there was a durable resolution of inflammation, and her vision improved along with the resolution of her exudation. CONCLUSIONS AND IMPORTANCE: This case suggests that some brolucizumab-related IOI episodes may be treated with posterior sub-Tenon triamcinolone. Further studies may serve to elucidate the role of sub-Tenon triamcinolone in brolucizumab-associated IOI.

Treatment outcomes of macular holes in the setting of uveitis: a scoping review.

OBJECTIVE: We conducted a systematic review to evaluate the outcome of macular hole (MH) treatment in eyes with uveitis. DATA SOURCE: We searched PubMed and Embase databases from inception through August 15, 2021. STUDY SELECTION: We included eyes with MHs secondary to uveitis that were managed medically or underwent pars plana vitrectomy (PPV). We excluded eyes with idiopathic MH and those secondary to causes other than uveitis. RESULTS: Of 27 articles, we identified 86 eyes with MH secondary to uveitis that received either conservative medical treatment alone or PPV with adequate follow-up. The mean (± SD) age of patients included in this review was 46.6 (± 16.8) years; 60.5% were males. The most common etiology of uveitis was Behçet's disease (34.6%) and toxoplasmosis (19.7%). The most common anatomical location of uveitis was posterior (59.3%) followed by panuveitis (35.2%). The mean (± SD) baseline LogMAR vision was 1.1 (± 0.5). Conservative medical treatment was employed in 34.9%, while PPV was performed in 65.1% of eyes. Overall, the mean (SD) LogMAR vision improved from 1.1 (± 0.5) at baseline to 0.7 (± 0.5) after treatment. Inflammation-related MHs were closed in 40% of eyes after conservative therapy and in 87.5% of eyes after PPV. Visual improvement occurred in most eyes (83.9%) that had successful closure of their MH. CONCLUSIONS: Visual improvement occurs in most eyes that had successful closure of their inflammation-related MH. Conservative medical control of uveitis may lead to closure of inflammation-related MHs and is an important step prior to surgery, if required. Surgical intervention for inflammation-related MHs is associated with good functional and anatomical results.

Visual outcomes of primary versus secondary epiretinal membrane following vitrectomy and cataract surgery.

PURPOSE: To compare visual outcomes, incidence of cystoid macular edema (CME), and rate of repeat epiretinal membrane (ERM) surgery following phacovitrectomy for primary and secondary ERM. METHODS: Retrospective review of 178,856 cataract surgeries from 2003 to 2015. Eyes that underwent cataract surgery combined with ERM peel were included (n = 708). Eyes were divided into primary (n = 538) and secondary (n = 170) ERM groups. Patient demographics, visual acuity (VA), and postoperative CME were recorded. RESULTS: Patients with secondary ERM had worse preoperative VA, 0.9 ± 0.6 logMAR (20/160 Snellen equivalent) as compared to patients with primary ERM, 0.6 ± 0.3 (20/80), respectively (p < 0.0001). There was no difference between the secondary and primary ERM groups in postoperative vision (0.5 ± 0.4 logMAR vs. 0.5 ± 0.3; p = 0.9962) or proportion with VA ≥ 20/40 (46.4% vs. 43.1%; p = 0.6744) at 12-24 weeks. Postoperative CME was twice as likely in the secondary ERM group (16.5%) compared to the primary ERM group (7.8%) (p = 0.0018). There was no difference in the rate of repeat ERM surgery between the secondary ERM group (1.8%) and the primary ERM group (1.5%) (p = 0.7308). CONCLUSION: Eyes with secondary ERM had significant postoperative improvement in VA. They had worse preoperative VA and had a twofold increase in postoperative CME than primary ERM.

Reactivation of Acute Retinal Necrosis following SARS-CoV-2 Infection.

PURPOSE: To report on a case of reactivation of acute retinal necrosis following SARS-CoV-2 infection. METHODS: Observational case report. Observations. A 32-year-old female with a distant history of left retinal detachment secondary to necrotizing herpetic retinitis complained of right-eye vision loss, pain, redness, and photophobia. An ophthalmological examination revealed findings consistent with acute retinal necrosis of the right eye. A polymerase chain reaction (PCR) analysis of the right vitreous was positive for herpes simplex virus type 2 (HSV-2). A coronavirus disease 2019 (COVID-19) screening test using reverse transcriptase- (RT-) PCR was positive for SARS-CoV-2 RNA. CONCLUSIONS: Our case suggests that COVID-19 may cause a latent HSV infection to reactivate, causing contralateral involvement in patients with a prior history of HSV-associated acute retinal necrosis.

Survey of the use of laser protective eyewear among international retina specialists: a European vitreoretinal society study.

OBJECTIVE: To report the trends for the use of eye protection methods during retinal laser in clinic and operating room. METHODS AND ANALYSIS: Retrospective analysis of a 14-item survey questionnaire submitted to the European Vitreoretinal Society members. RESULTS: Responses from 630 members were analysed. Most of the respondents practised in Europe (52.7%), followed by North America (21.0%). The majority of respondents had laser filters in the microscope for the operating surgeon (92.1%), or used protective goggles (6.8%). Only 38.9% of respondents indicated that auxiliary staff in the operative room used protective goggles during laser treatment. Three-dimensional retina viewing system was used by only 22.5% of respondents, of those, 34.5% reported use of laser protection goggles by the operating surgeon. Rates of laser protection by auxiliary staff were 62.9% for indirect laser and 60.8% for slit lamp laser. We found a higher rate for use of laser protection by auxiliary staff in North America-based practices for endolaser (p<0.00001), laser indirect ophthalmoscope (p<0.00001) and slit lamp laser (p=0.00033) compared with the rest of the world. CONCLUSION: The use of laser protection methods is routinely adopted by the physicians in the operating room and clinic, but less so by their assisting or auxiliary staff.

Outcome of Intravitreal Dexamethasone Implant Use in Uveitic Eyes Undergoing Pars Plana Vitrectomy Surgery.

Purpose: To report the outcomes in eyes with noninfectious uveitis receiving dexamethasone implant at the time of pars plana vitrectomy (PPV).Methods: Retrospective analysis of visual acuity (VA), intraocular pressure (IOP), vitreous haze score (VHS), and central subfield thickness (CST) at baseline and follow-up visits.Results: Fourteen eyes received dexamethasone implant at the time of PPV. The CST was improved from 469 ± 182 µm at baseline to 320 ± 60 at 6 months (p = .0112) and 295 ± 46 at 12 months (p = .0728). Vitritis only recurred in 2 eyes at 6 months (18.2%) and 1 eye at 12 months (14.3%). The probability of VA improvement of ≥0.3 logMAR was 57% at 6 months and 66% at 12 months. Therapy for IOP rise was initiated in 6 eyes (42.9%).Conclusions: Local delivery of dexamethasone implant with PPV is a feasible method to counteract postoperative inflammation and macular thickening.

Ophthalmic Manifestations of Hodgkin Lymphoma: A Review.

BACKGROUND: Hodgkin lymphoma (HL) is a hematopoietic neoplasm characterized by cancerous Reed-Sternberg cells. In contrast to ophthalmic manifestations by non-HL that are well recognized, there is paucity of the literature as it relates to ophthalmic manifestation by HL. We performed a comprehensive review of published studies (case reports and small case series) to characterize the ophthalmic manifestations of HL. SUMMARY: Thirty patients were identified with ophthalmic manifestation of HL. Thirteen (43%) were male, and 14 (46%) were female (in 3 cases, sex was not specified). The median age at ophthalmic presentation was 27 years. Diagnosis of HL was made after ophthalmic manifestation in 10 (33%) cases, whereas 11 (36%) cases had a prior diagnosis of HL. Ophthalmic manifestations can be classified into 3 main groups; direct infiltration, inflammatory reaction, and paraneoplastic process. Seven cases had infiltration of the optic nerve. Uveal inflammatory reaction was reported in 21 cases. The presence of intraocular Reed-Sternberg cells had been confirmed in 1 case with granulomatous uveitis. Conjunctival and corneal reaction was seen in 3 cases. HL was in stage 2 or higher, with only 1 case with stage 1A (12 cases HL stage not specified). Seven cases (22%) died of HD, all were diagnosed with advanced lymphoma, and none was treated with chemotherapy. KEY MESSAGE: Ocular involvement in HL is extremely rare. A few cases of histopathologically confirmed optic nerve/tract infiltration are within the spectrum of CNS involvement by HL. Inflammatory uveitis is the most common ophthalmic association of HL. In the presence of prior known diagnosis of HL, restaging should be considered to exclude recurrence. Toxicity or adverse reaction to drugs used to treat HL may also contribute to ophthalmic involvement.

Ischemic Proliferative Retinopathy as the Presenting Feature of Systemic Sarcoidosis.

Purpose: This work reports a case of systemic sarcoidosis presenting with ischemic ocular manifestations without uveitis. Methods: This case report describes a 28-year-old White male who presented with pain, redness, and blurry vision of his left eye for 1 month who was found to have proliferative retinopathy and neovascular glaucoma. Results: Normal fasting blood glucose and glycated hemoglobin A1c levels warranted further investigation. Abnormal findings from chest x-ray of hilar lymphadenopathy as well as an elevated angiotensin-converting enzyme level were suggestive of sarcoidosis, and they were further confirmed by histopathology derived through bronchoscopy. Conclusions: Systemic sarcoidosis may present with rapidly progressing ischemic retinopathy without signs of inflammation, which may obscure the diagnosis. Such presentation may be misdiagnosed, which may result in delayed treatment and poor outcome.

Photopigment Bleaching Phenomenon With Scanning Laser Ophthalmoscopy and Fluorescein Angiography.

Photopigment bleaching occurs with saturation of photoreceptor pigment by short-wavelength fundus autofluorescence imaging. This phenomenon is seen as characteristic hyperautofluorescence with subsequent imaging acquisition. Herein, a patient with multiple sclerosis was found to exhibit increased choroidal hyperfluorescence during fluorescein angiography (FA) that corresponded with a circumscribed area of intense blue light exposure during initial scanning laser ophthalmoscopy. To the authors' knowledge, this case is the first description of photobleaching phenomenon during FA and should be recognized as nonpathologic by the clinician. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:590-592.].

SUPRACHOROIDAL INJECTION OF TRIAMCINOLONE ACETONIDE, CLS-TA, FOR MACULAR EDEMA DUE TO NONINFECTIOUS UVEITIS: A Randomized, Phase 2 Study (DOGWOOD).

PURPOSE: Evaluate a single suprachoroidal injection of a proprietary triamcinolone acetonide suspension, CLS-TA, in subjects with macular edema due to noninfectious uveitis. METHODS: Randomized, controlled, masked Phase 2 study. Safety and efficacy of a single suprachoroidal injection of CLS-TA (4.0 and 0.8 mg in a 4:1 ratio) were assessed at 1 and 2 months after injection. The primary efficacy endpoint was change in central subfield thickness from baseline to Month 2, assessed by spectral domain optical coherence tomography. RESULTS: Twenty-two adults were enrolled. The primary endpoint was met in subjects who received suprachoroidal injection of CLS-TA 4.0 mg, mean central subfield thickness significantly decreased from baseline by 135 µm and 164 µm at Month 1 (P = 0.0056) and Month 2 (P = 0.0017), respectively. At Month 2, 69% of subjects who received 4.0 mg experienced ≥20% reduction in central subfield thickness, and 65% had improvement of best-corrected visual acuity of ≥5 Early Treatment Diabetic Retinopathy Study letters, with a mean improvement of 9.2 letters (P = 0.0004). Safety analyses supported acceptable safety/tolerability, with no corticosteroid-related increases in intraocular pressure. CONCLUSION: A single suprachoroidal injection of CLS-TA (4.0 mg; 0.1 mL) in subjects with macular edema due to noninfectious uveitis was well-tolerated, significantly reduced central subfield thickness from baseline at 2 months, and significantly improved visual acuity.

INTRAVITREAL DEXAMETHASONE IMPLANT IN RETINITIS PIGMENTOSA-RELATED CYSTOID MACULAR EDEMA.

PURPOSE: To report the clinical outcome after intravitreal dexamethasone implant in patients with retinitis pigmentosa and cystoid macular edema. METHODS: Multicenter retrospective case series of eyes with retinitis pigmentosa and cystoid macular edema that underwent intravitreal dexamethasone implant. Primary outcome measures were best-corrected visual acuity in LogMAR and central macular thickness. Statistical analyses used two-tailed comparison with Wilcoxon signed-rank test. RESULTS: There were a total of 45 eyes from 34 patients with a mean age of 32.7 years (range 16-57) and mean follow-up of 15.5 ± 13.0 months. At Month 3 after the first injection, mean initial best-corrected visual acuity improved from 0.61 ± 0.38 (20/81) to 0.37 ± 0.16 (20/47) (P = 0.012), whereas mean central macular thickness (µm) decreased from 506 ± 288 µm to 311.7 ± 71.6 µm (P < 0.001) and mean intraocular pressure increased from 15.7 ± 2.3 mmHg to 19.8 ± 11.0 mmHg (P = 0.01). Fourteen eyes had multiple injections (1-7 reinjections) at a mean interval of 6 months. Treatment effect was durable with multiple injections, but with seven eyes developing visually significant cataracts. CONCLUSION: Best-corrected visual acuity improved up to 4 months in around half of the eyes. Eyes that benefited the most were pseudophakic, steroid nonresponsive, with large initial central macular thickness, and profuse fluorescein dye leakage.