Emerging Disease of the Desert: Rise of West Nile Virus Chorioretinitis in Arizona.

Purpose: To present 7 cases of West Nile virus (WNV)-related chorioretinitis in Arizona. Methods: Retina clinic charts with the terms "chorioretinitis" and "West Nile" were selected from April 1, 2012, to February 1, 2023. Results: Seven patients with initial visits between August 2019 and February 2023 were included. The majority of WNV chorioretinitis cases were seen in the last 4 years of the selected dates. Only 1 patient presented before this time but was excluded for inadequate baseline testing. All 7 patients had hospitalization for neuroinvasive disease before clinical presentation. All patients achieved a final visual acuity of 20/25 to 20/70. Conclusions: In the last 4 years of the study period, an uptrend in WNV chorioretinitis was found in our retina clinics in Arizona, reflecting the overall rise in WNV outbreaks across the state. As WNV continues to rise, the eye specialist should have high suspicion for WNV ocular disease, even in states where WNV had been an uncommon entity.

Challenges in posterior uveitis-tips and tricks for the retina specialist.

PURPOSE: Posterior uveitis is a common chorioretinal pathology affecting all ages worldwide and is a frequent reason for referral to the retina clinic. The spectrum of etiologies for uveitis is very broad and includes infectious and auto-immune diseases. Inflammation can be confined to the eye or may be a part of systemic disease. A useful outline is therefore proposed to aid in the correct diagnosis of these challenging entities. The situation is further complicated by the fact that many neoplastic conditions resemble features of posterior uveitis; they are known as "masqueraders of uveitis". Here, we summarize different posterior uveitides that present with rare findings, along with masqueraders that can be difficult to distinguish. These conditions pose a diagnostic dilemma resulting in delay in treatment because of diagnostic uncertainty. METHODS: An extensive literature search was performed on the MEDLINE/PUBMED, EBSCO and Cochrane CENTRAL databases from January 1985 to January 2022 for original studies and reviews of predetermined diagnoses that include posterior uveitic entities, panuveitis and masquerade syndromes. RESULTS: We described conditions that can present as mimickers of posterior uveitis (i.e., immune check-points inhibitors and Vogt-Koyanagi-Harada-like uveitis; leukemia and lymphoma associated posterior uveitis), inflammatory conditions that present as mimickers of retinal diseases (i.e., Purtscher-like retinopathy as a presentation of systemic lupus erythematosus; central serous chorioretinopathy masquerading inflammatory exudative retinal detachment), and uveitic conditions with rare and diagnostically challenging etiologies (i.e., paradoxical inflammatory effects of anti-TNF-α; post vaccination uveitis; ocular inflammation after intravitreal injection of antiangiogenic drugs). CONCLUSION: This review of unique posterior uveitis cases highlights the overlapping features of posterior uveitis (paradoxical inflammatory effects of anti -TNF α and uveitis; Purtscher-like retinopathy as a presentation of systemic lupus erythematosus, …) and the nature of retinal conditions (ischemic ocular syndrome, or central retinal vein occlusion, amyloidosis, inherited conditions like retinitis pigmentosa, autosomal dominant neovascular inflammatory vitreoretinopathy (ADNIV), etc.…) that may mimic them is represented. Careful review of past uveitis history, current medications and recent vaccinations, detailed examination of signs of past or present inflammation, eventually genetic testing and/ or multimodal retinal imaging (like fluorescein angiography, EDI-OCT, OCT-angiography for lupus Purtscher-like retinopathy evaluation, or ICG for central serous retinopathy, or retinal amyloid angiopathy) may aid in correct diagnosis.

Herpes zoster ophthalmicus: frequency and risk factors for developing uncommon ocular manifestations.

OBJECTIVE: To determine the frequency of herpes zoster ophthalmicus (HZO) and assess risk factors for developing uncommon ocular manifestations of laboratory-verified HZO. DESIGN: Retrospective cohort study. METHODS: The frequency of HZO out of all herpes zoster cases was calculated using International Classification of Diseases codes for patients seen at the University of Pittsburgh Medical Center from January 1, 2004 to October 31, 2021. We also collected demographic and clinical data of patients with HZO identified by polymerase chain reaction (PCR) detection of varicella zoster virus from January 1, 2011 to December 31, 2020. RESULTS: The frequency of HZO from 2004 to 2021 in all ages was 4.2% and ranged from 2.7% to 6.7% annually, with a consistent increase of 2.9% from 2012 to 2021. After the live zoster vaccine became available in 2008, the frequency of HZO decreased by 5.1% from 2008 to 2012 in patients aged 60 and older. Among 50 cases of PCR-verified HZO, 62% represented clinically-common ocular manifestations, mostly comprised of 13 cases of keratitis and 10 cases of anterior uveitis. Fifteen cases of acute retinal necrosis (ARN) represented the majority of uncommon HZO manifestations (38%), which were significantly more likely to occur in immunosuppressed patients (unadjusted odds ratio 4.55, 95% confidence interval 1.29-13.83). CONCLUSIONS: The overall frequency of HZO from 2004 to 2021 was 4.2% and has increased annually since 2012. Uncommon ocular manifestations of PCR-verified HZO, mostly comprised of ARN, were more likely to occur in immunosuppressed patients.

Relentless placoid chorioretinitis: A review of four cases in pediatric and young adult patients with a discussion of therapeutic strategies.

Introduction: Relentless placoid chorioretinitis (RPC) is a rare, bilateral disease of the retinal pigment epithelium. The clinical course is prolonged and relapsing. No standard treatment has been established to date. The purpose of this case series is to report four cases of RPC in pediatric and young adult patients in which varying treatments were used, comparing them to previously published cases. Methods: A literature review was conducted to investigate currently published presentations and treatment options for RPC. A multicenter retrospective chart review was also performed on four consecutive patients. These patients were diagnosed with RPC because of new chorioretinitis lesions continuing to appear without or despite therapy for 5-36 months (2 patients), with a clinical course prolonged and relapsing, or because of the atypical location of the multiple lesions (>50) extending from the posterior pole to the equator and mid-peripheral retina (all four patients), which were not consistent with other entities like acute posterior multifocal placoid pigment epitheliopathy and serpiginous choroiditis. Results: All four cases of RPC received oral or IV steroids acutely, and three of these patients were transitioned to a steroid-sparing agent and biologic therapy: anti-TNF alpha or anti-IL-6. Quiescence of the chorioretinitis lesions was obtained after 7 months, 1 month, and 36 months; however, the latter had issues with treatment adherence. Mycophenolate mofetil was insufficient to control the disease in one patient, but tocilizumab and infliximab thereafter were effective after cessation of adalimumab due to side effects. Adalimumab when started the first month after the presentation was effective in controlling the disease in one patient. After the failure of interferon-alpha-2a, one patient displayed long-term control with infliximab. One patient did not require a steroid-sparing agent after oral prednisone taper as there was no evidence of progression or recurrence. Conclusion: This case series adds to the current knowledge regarding potential treatments for RPC, specifically the use of anti-TNF-alpha treatment and anti-IL-6 tocilizumab. In this case study, relapses of RPC were found among patients on mycophenolate mofetil and interferon-alpha-2a, and one case did not relapse on oral steroids without a steroid-sparing agent. Our findings suggest that adalimumab, infliximab, and tocilizumab may be useful medications to obtain quiescence of RPC.

Lidocaine Gel Interferes With the Antibacterial Activity of Povidone-Iodine.

BACKGROUND AND OBJECTIVE: Retina specialists use lidocaine gel as a topical anesthetic. We determined the antibacterial interaction between povidone-iodine (PI) and lidocaine gel using corneoscleral tissue as a solid phase medium. MATERIALS AND METHODS: Five pieces of corneoscleral tissue in five trials were inoculated with 1.000 colony-forming units of bacteria isolated from endophthalmitis. Inoculated corneal tissue were overlaid with nothing (control), lidocaine gel, 5% PI, lidocaine gel over 5% PI, and 5% PI over lidocaine gel for 5 minutes prior to placement in growth liquid medium at 37°C. Growth was monitored for 48 hours. RESULTS: Application of lidocaine gel prior to 5% PI application provided for the growth of the five bacterial isolates, whereas 5% PI prior to lidocaine gel prevented growth. CONCLUSION: Using corneoscleral tissue, PI and lidocaine gel appear to have an antagonistic interaction when lidocaine gel is applied initially prior to 5% PI, preventing bactericidal activity of PI. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:S13-S16.].

Use of Integrated Intraoperative Ocular Coherence Tomography in Pediatric Cataract Surgery: Thinking outside the Box.

The advent of integrated intraoperative optical coherence tomography (i2OCT) has opened the door for safer and more complex surgeries in the retina and cornea. However, to limit its use to just two subspecialties within ophthalmology is an opportunity lost for many other subspecialties. Here, we describe the use of i2OCT in pediatric cataract surgery in circumstances that are not traditionally considered for i2OCT use. The specific circumstances include: evaluation and treatment of a child following cataract extraction with lens implantation who has failed two attempts at YAG capsulotomy; lysis of post-trauma keratolenticular adhesion in an opaque cornea; surgical removal of secondary lens epithelial cell proliferation after pediatric cataract extraction with lens implantation, and identification of posterior capsular openings and defects. In each case the use of i2OCT allowed the procedure to be completed safely and successfully or informed the surgeon, allowing modification of the surgical decision tree.

Assessing Functional Disability in Glaucoma: The Relative Importance of Central Versus Far Peripheral Visual Fields.

Purpose: To evaluate the importance of central versus far peripheral visual field (VF) loss in assessing disability in glaucoma. Methods: In total, 231 patients with glaucoma or suspected glaucoma completed 24-2 VF testing and automated peripheral VFs using the suprathreshold 30- to 60-degree pattern. Questionnaires assessed fear of falling (FoF), quality of life (QOL), instrumental activities of daily living (IADLs), and driving habits; nonsedentary time, reading speed, and gait were objectively measured. Multivariable regression models analyzed the effect of central VF and/or peripheral VF damage on each outcome. Results: In models including both central and peripheral VF damage (independent effects), greater central, but not peripheral, VF damage was associated with greater FoF, worse QOL, fewer daily steps, and difficulty with IADLs (P < 0.02 for central; P > 0.5 for peripheral). For gait measures, greater peripheral, but not central, damage was associated with shorter steps and shorter strides, as well as greater variability in step length (P < 0.03 for peripheral; P > 0.14 for central). Model R2 values were not substantially higher (less than 5% additional explained variability) for models including both central and peripheral VF damage as compared to the best models incorporating only one region of VF damage (i.e., central or peripheral). Conclusions: The relative importance of central 24 degrees versus more peripheral VF damage differs across functional domains in patients with glaucoma. Central damage is more strongly associated with most disability outcomes, although peripheral damage is more associated with specific gait measures. Studies examining the relative importance of various VF regions should assess functional domain separately and eschew integrated measures of quality of life/activity limitation.

Telemedicine in long-term care of glaucoma patients.

Introduction: This manuscript describes data from an original study, simulating a tele-glaucoma programme in an established clinic practice with an interdisciplinary team. This is a 'real life' trial of a telemedicine approach to see a follow-up patient. The goal is to evaluate the accuracy of such a programme to detect worsening and/or unstable disease. Such a programme is attractive since in-clinic time could be reduced for both the patient and provider. This study evaluates agreement between in-person and remote assessment of glaucoma progression. Methods: A total of 200 adult glaucoma patients were enrolled at a single institution. The in-person assessment by an optometrist or glaucoma specialist at time of enrolment was used as the gold standard for defining progression. Collated clinical data were then reviewed by four masked providers who classified glaucoma as progression or non-progression in each eye by comparing data from enrolment visit to data from the visit immediately prior to enrolment. Agreement of glaucoma progression between the masked observer and the in-person assessment was determined using Kappa statistics. Intra-observer agreement was calculated using Kappa to compare in-person to remote assessment when both assessments were performed by the same provider (n = 279 eyes). Results: A total of 399 eyes in 200 subjects were analysed. Agreement between in-person versus remote assessment for the determination of glaucoma progression was 63%, 62%, 69% and 68% for each reader 1­4 (kappa values = 0.19, 0.20, 0.35 and 0.33, respectively). For intra-observer agreement, reader 1 agreed with their own in-person assessment for 65% of visits (kappa = 0.18). Discussion: Intra-observer agreement was similar to the agreement for each provider who did not see the patient in person. This similarity suggests that telemedicine may be equally effective at identifying glaucomatous disease progression, regardless of whether the same provider performed both in-clinic and remote assessments. However, fair agreement levels highlight a limitation of using only telemedicine data to determine progression compared with clinical detail available during in-patient assessment.

Provider Agreement in the Assessment of Glaucoma Progression Within a Team Model.

PURPOSE: Glaucoma specialists and optometrists who work in a team model at a single institution utilize a common definition of glaucoma progression and treatment algorithm. The purpose of this study was to assess the consistency of agreement in identifying glaucoma progression among glaucoma specialists and optometrists of 1 team. METHODS: In total, 399 eyes of 200 patients age 18 or older with glaucoma were enrolled over 2 years. Clinical data, disc photographs, optical coherence tomography (OCT), and visual fields were independently reviewed by 2 masked optometrists and 2 masked fellowship-trained glaucoma specialists. Each eye was judged as progression or no progression of glaucomatous disease. The following were assessed: (1) agreement among optometrists; (2) agreement among glaucoma specialists; and (3) agreement among optometrists and glaucoma specialists. The frequency of use of testing modality to determine progression was also studied. κ statistics were used to evaluate agreements. RESULTS: Optometrists agreed with each other for 74.2% of the eyes assessed (κ=0.42), whereas glaucoma specialists agreed with each other for 78.7% of eyes (κ=0.39). All 4 providers agreed with each other for 54.4% of the eyes evaluated (κ=0.37). Providers had the highest agreement when the progression decision was based on disc hemorrhage (92%) and the lowest agreement when based on OCT progression analysis (36%). Compared with optometrists, glaucoma specialists used OCT (P≤0.01) more frequently to determine disease progression. CONCLUSIONS: Fair to moderate agreement levels were found among providers in their assessment of glaucoma progression, suggesting that a team approach to glaucoma management may be effective. Further work is needed to investigate ways to optimize consistency within the glaucoma team.

Evaluation of Central and Peripheral Visual Field Concordance in Glaucoma.

PURPOSE: The purpose of this study was to characterize the extent to which central visual field (VF) loss reflects peripheral VF loss in patients with varying degrees of glaucoma severity. METHODS: A total of 232 patients with glaucoma or suspect glaucoma completed static central VF testing using the 24-2 pattern and peripheral VF testing using the suprathreshold 30-60 pattern. Points from 24-2 tests were reclassified as normal/abnormal based on pattern deviation values. RESULTS: Strong positive correlations (r ≥ 0.7) were observed between the proportion of abnormal central and peripheral points for the full VF, superior hemifield, and inferior hemifield, although the percentage of total central and peripheral abnormal points differed by ≥10% in 45% of eyes. In eyes with an average of 10%-40% abnormal points in the central and peripheral VFs, 12.0% more abnormal peripheral points were noted compared with the percentage of abnormal central points (P < 0.001; SD, 16.7%; range, 61% more to 37% less). In eyes with an average of 60%-90% abnormal points in the central and peripheral VFs, 16.4% fewer abnormal peripheral points were noted compared with the percentage of abnormal central points (P = 0.04; SD, 20.9%; range, 19% more to 49% less). CONCLUSIONS: Central 24-2 testing generally reflects the extent of damage to the more peripheral VF in glaucoma, although significant disagreement exists for individual eyes. Further work is needed to determine whether integration of peripheral test points can improve detection of true VF loss in early glaucoma or be useful in monitoring progressive glaucomatous damage to areas of preserved VF in advanced glaucoma.