SWEPT-SOURCE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN RICKETTSIAL RETINITIS.

PURPOSE: To report optical coherence tomography angiography findings in a patient with rickettsial retinitis. METHODS: A 29-year-old man complaining of acute blurring vision in the right eye associated with Rickettsia conorii infection underwent a comprehensive ocular examination, fluorescein angiography, spectral-domain optical coherence tomography, and swept-source optical coherence tomography angiography. RESULTS: Funduscopy showed two large areas of retinitis in the inferior macula along the distribution of the inferotemporal artery with associated retinal hemorrhages, retinal edema, and serous retinal detachment. Fluorescein angiography showed early hypofluorescence and late staining of white retinal lesions and associated adjacent retinal vascular leakage and optic disc hyperfluorescence. Optical coherence tomography angiography showed hypointense dark areas in the superficial capillary plexus and larger hypointense areas in the deep capillary plexus, outer retina, and choriocapillaris layer. The patient was treated with doxycycline and prednisone. Six weeks after presentation, retinal changes seen at the acute phase had resolved, leading to mild residual retinal pigment epithelial changes. Fluorescein angiography showed retinal capillary nonperfusion within areas of resolved retinitis. Spectral-domain optical coherence tomography findings included inner retinal atrophy, intraretinal cysts, and disruption of ellipsoid zone and interdigitation zone. Swept-source optical coherence tomography angiography showed well-delineated hypointense greyish areas of retinal capillary nonperfusion in both the superficial and deep capillary plexuses. Visual field testing revealed the presence of a corresponding paracentral defect. CONCLUSION: Optical coherence tomography angiography may be a valuable noninvasive imaging technique for detecting and analyzing occlusive complications associated with rickettsial retinitis.

Acute multifocal retinitis: a retrospective review of 35 cases.

BACKGROUND: Acute multifocal retinitis is a rare condition that has been considered to be often idiopathic. The purpose of this study was to analyze clinical features and causes of acute multifocal retinitis. RESULTS: This study is a retrospective review of the charts of 35 patients with acute multifocal retinitis. Patients with three or more retinal lesions in at least one eye, with at least one lesion of less than 500 µm in size were included. All patients had complete ophthalmological examination, fundus photography, and fluorescein angiography. Twelve patients (34.3%) had optical coherence tomography. An extensive work-up was performed including a detailed comprehensive medical history, examination by an internist and an infectious disease specialist, a chest X-ray, Mantoux test, and laboratory tests for syphilis, human immunodeficiency virus, Bartonella, and Rickettsia. Of the 35 patients, 25 (71.4%) had bilateral involvement and 10 (28.6%) had unilateral involvement (total number of eyes: 60). Mean best-corrected visual acuity (BCVA) was 20/25 (range, 20/1000-20/20). Retinal lesions ranged from 3 to more than 20 in number in at least 1 eye, and from 150 to 1500 µm in size. Associated findings included mild anterior chamber inflammation in 5 eyes (8.3%), mild vitritis in 46 eyes (76.7%), optic disc swelling in 9 eyes (15%), macular star in 4 eyes (6.7%), exudative retinal detachment in 6 eyes (10%), and branch retinal artery occlusion in 6 eyes (10%). Acute multifocal retinitis was found to be caused by Rickettsia conorii infection in 20 patients (57.1%), Rickettsia typhi infection in 4 patients (11.4%), cat-scratch disease in 8 patients (22.9%), and syphilis in 1 patient (2.9%). It was idiopathic in two patients (5.7%). Retinal lesions resolved without scarring in 3 to 12 weeks in all but three eyes (5%), in which residual retinal pigment epithelial changes were noted. CONCLUSION: Rickettsial disease was the most common cause of acute multifocal retinitis. Other identified causes included cat-scratch disease and syphilis, and a very small subset of patients was diagnosed with idiopathic multifocal retinitis.

Anterior chamber aqueous flare, pseudoexfoliation syndrome, and glaucoma.

The purpose of this study is to evaluate anterior chamber aqueous flare (ACAF) in Tunisian patients with pseudoexfoliation (PEX) syndrome with or without associated glaucoma. This is a prospective, cross-sectional, comparative study including 53 patients (88 eyes) with PEX syndrome, 48 patients with PEX glaucoma (86 eyes), and 53 healthy sex-and age-matched control subjects (106 eyes). All patients underwent a complete ophthalmic examination and laser flare photometry. Mean ACAF was significantly higher in the PEX syndrome group in comparison with the control group (17.96 ± 10.05 vs 7.06 ± 2.95 ph/ms; p = 10(-4)), in patients with PEX glaucoma compared to PEX syndrome without associated glaucoma (27.99 ± 15.45 vs 17.96 ± 10.05 ph/ms; p = 10(-4)), in the PEX glaucoma group in comparison with control group (27.99 ± 15.45 vs 7.06 ± 2.95 ph/ms; p = 10(-4)), and in patients with unilateral PEX syndrome in comparison with contralateral-unaffected eyes (25.72 ± 14.88 vs 8.58 ± 3.45 ph/ms; p = 0.000). For patients with PEX syndrome, a high ACAF might be a predictor for the development of glaucoma. Further investigations are needed to clarify the role of laser flare photometry in predicting the risk of glaucoma in patients with PEX syndrome.

Clinical and multimodal imaging characteristics of acute Vogt-Koyanagi-Harada disease unassociated with clinically evident exudative retinal detachment.

The purpose of this study was to describe the clinical and multimodal imaging findings in acute Vogt-Koyanagi-Harada (VKH) disease without clinically evident exudative retinal detachment (ERD). We retrospectively reviewed the charts of 18 patients (36 eyes), diagnosed with acute VKH disease without clinically evident ERD. All patients underwent complete ophthalmic examination, fundus photography, optical coherence tomography (OCT), B-scan ultrasonography, fluorescein angiography (FA), and indocyanine green angiography (ICGA). Of 18 patients, twelve (66.7 %) were female and 6 (33.3 %) were male. Mean age was 39 years (range, 23-60). Ten patients had been referred with an erroneous diagnosis of primary optic nerve disorder (8; 44.4 %) or isolated anterior uveitis (2; 11.1 %). Anterior chamber or vitreous inflammatory reaction was noted in 22 eyes (61.1 %), each. Fundus findings included optic disc swelling in 30 eyes (83.3 %), retinal striae in 20 eyes (55.5 %), and yellowish deep lesions in 3 eyes (8.3 %). OCT showed a shallow, localized subclinical ERD in 18 eyes (50 %), and retinal pigment epithelial folds in 23 eyes (63.9 %). B-scan ultrasonography showed diffuse, low- to medium-reflective choroidal thickening in all eyes. FA disclosed delayed choroidal perfusion in at least one eye of all patients (100 %), mild pinpoint leakage in 21 eyes (58.3 %), optic disc hyperfluorescence in 35 eyes (97.2 %) and choroidal folds in 13 eyes (36.1 %). ICGA findings included delayed choroidal perfusion in 24 eyes (66.7 %), decrease in the number of large choroidal vessels in 36 eyes (100 %), fuzzy choroidal vessels in 35 eyes (97.2 %), and hypofluorescent dark dots in 28 eyes (77.8 %). The association of bilateral optic disc edema with retinal striae and intraocular inflammatory reaction highly suggests acute VKH disease. A multimodal imaging approach including fundus photography, OCT, B-scan ultrasonography, FA, and ICGA provides important clues for the definite diagnosis and help differentiate VKH disease from primary optic nerve disorders.

Parinaud's oculoglandular syndrome revealing subclinical Rickettsia conorii infection.

The purpose of this study was to report a case of Parinaud's oculoglandular syndrome associated with subclinical Rickettsia conorii infection. We report a case of a 66-year-old male patient presented with unilateral persistent granulomatous conjunctivitis in the left eye and an ipsilateral preauricular lymphadenopathy without associated systemic features. Laboratory evaluation showed a positive indirect immunofluorescence antibody test for R. conorii. The patient received a 2-week course of oral doxycycline, with subsequent complete resolution of all his symptoms. Rickettsial disease should be considered in the differential diagnosis of oculoglandular syndrome with or without associated systemic symptoms in any patient living in or returning from a specific endemic area.

Orbital infections: review of 28 cases.

BACKGROUND: Orbital infections (OI) are a serious disorder that may results in visual and systemic morbidity. AIM: To study epidemiologic data and outcome of OI in a tertiary eye care center. METHODS: Retrospective study of 28 patients (28 eyes) with OI. All patients underwent detailed ophthalmic examination, otolaryngology examination, and cranio-orbital computed tomography scan. All patients received parenteral probabilistic antibiotic treatment then adapted depending on the sensitivity of antibiogram and clinical evolution, associated or not to corticosteroid treatment. The mean follow-up was 14 months. RESULTS: The mean age of our patients was 35.9 years. Fifteen patients (54%) were male. Of 28 cases, retroseptal cellulitis was the most common, noted in 67.8% of cases. subperiosteal or orbital abscess was recorded in 28.6% of the cases. Sinusitis was the most common etiology, found in 39.3% of cases. Treatment was based on empirical broad spectrum systemic antibiotics in all cases. Surgical management was performed in 39.3% of cases. Bacteriological samples were obtained for 28.5% of patients, with Staphylococcus aureus the most frequently isolated pathogen (5 cases; 62.5%). The evolution was favorable with complete resolution without sequelae in 92.8% of the cases and improvement of visual acuity in 82% of cases. Causes of poor visual outcome were corneal perforation, cataract and retinal detachment. CONCLUSIONS: In our series, OI affects children and young adults. Their prognosis is generally favorable provided rapid and appropriate management.

Infectious optic neuropathies: a clinical update.

Different forms of optic neuropathy causing visual impairment of varying severity have been reported in association with a wide variety of infectious agents. Proper clinical diagnosis of any of these infectious conditions is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular findings. Diagnosis is confirmed by serologic testing and polymerase chain reaction in selected cases. Treatment of infectious optic neuropathies involves the use of specific anti-infectious drugs and corticosteroids to suppress the associated inflammatory reaction. The visual prognosis is generally good, but persistent severe vision loss with optic atrophy can occur. This review presents optic neuropathies caused by specific viral, bacterial, parasitic, and fungal diseases.

Final Diagnosis in Patients Referred with a Diagnosis of Neuroretinitis.

The purpose of this study was to determine final diagnosis of patients referred with a diagnosis of neuroretinitis. A retrospective study of 40 patients with optic disc oedema with macular star (ODOMS) referred with a diagnosis of neuroretinitis was conducted. The final diagnosis was neuroretinitis in 26 patients (65%), with most of these patients (96.1%) having unilateral involvement. Main underlying aetiologies included cat scratch disease (30.8%), rickettsiosis (19.2%), and idiopathic neuroretinitis (23.1%). The remaining 14 patients (35%) had ODOMS that had been mistaken for neuroretinitis. Of these patients, 42.8% were found to have a previously unknown malignant systemic hypertension in association with bilateral ODOMS. Neuroretinitis, usually unilateral, should be differentiated from other causes of unilateral or most often bilateral ODOMS that may masquerade as neuroretinitis, mainly malignant systemic hypertension. This is essential to avoid inappropriate work-up and management and subsequent potential visual or systemic morbidity.

Optic nerve head drusen: a comparative study of 10 MHz and 20 MHz ultrasound probes.

The aim of this study was to evaluate and compare 10-MHz and 20-MHz ultrasonography in the assessment of patients with optic nerve head drusen (ONHD). The design of the study was prospective, comparative and cross-sectional. Ultrasonographic examination with a 10 and 20 MHz probe was performed in 45 eyes with suspected ONHD. The 20 MHz probe showed drusen in 43 eyes (95.5 %), while the 10 MHz probe revealed drusen in only 33 eyes (73.3 %, p = 0.0001). The 10 MHz probe showed surface drusen in 10 eyes (22.2 %), while the 20 MHz probe showed surface drusen in 14 eyes (31.1 %) (sensitivity 71.4 %; 95 % CI [47.6-95.1 %]). The 10 MHz probe showed buried drusen in 23 eyes (23.1 %), while the 20 MHz probe showed buried drusen in 29 eyes (64.4 %) (sensitivity 79.3 %; 95 % CI [56.6-86.2 %]). The sensitivity was 76.7 % with 10 MHz probe compared to a 20 MHz as gold standard. The use of 20 MHz probe increased the sensitivity of buried disc drusen by 1.5 times and surface disc drusen by nearly 2 times. Using the 10 MHz probe alone the false negative error rate was 83.3 %. The 20 MHz probe has shown itself to be an excellent method for the diagnosis of ONHD; it is more sensitive and reliable than 10 MHz probe and should be considered in the management of patients with clinical evidence of ONHD.

Pattern of Acute Retinal Necrosis in a Referral Center in Tunisia, North Africa.

PURPOSE: To describe the pattern of acute retinal necrosis (ARN) syndrome in a referral center in Tunisia. METHODS: Retrospective review of the charts of 12 patients (12 eyes). RESULTS: Necrotizing retinitis involved >50% of the retina in 33.3% of eyes. Polymerase chain reaction on aqueous humor sample identified herpes simplex virus-1 in 4 eyes (33.3%) and varicella zoster virus in 3 eyes (25%), and was negative in 5 eyes (41.7%). All patients received intravenous acyclovir, followed by oral antivirals. Follow-up ranged from 6 to 16 months. Retinal detachment (RD) occurred in 3 eyes (25%), but no patient developed bilateral ARN. Final visual acuity was 20/200 or worse in 7 eyes (58.3%). Delay in diagnosis (p = 0.015), macular involvement (p = 0.045), development of RD (p = 0.018), and 25-50% of retinal involvement (p = 0.045) were associated with a worse visual outcome. CONCLUSION: ARN carries poor visual prognosis in Tunisia.

Ocular involvement and visual outcome of herpes zoster ophthalmicus: review of 45 patients from Tunisia, North Africa.

BACKGROUND: Ocular complications of herpes zoster ophthalmicus (HZO) may lead to substantial visual impairment. The purpose of this study was to characterize and analyze ocular involvement and visual outcome of HZO in patients from Tunisia, North Africa. This study is a retrospective chart review of 51 eyes of 45 patients with HZO. RESULTS: Mean age was 44.5 years. Thirty patients (66.7%) were aged over 50 years. Twenty-four patients (53.3%) were male and 21 patients were female (46.7%). There was no statistically significant difference in gender distribution. Initial mean best corrected visual acuity (BCVA) was 20/50. Ocular manifestations included adnexal involvement (58.8%), keratitis (31.4%), keratouveitis (31.4%), isolated anterior uveitis (AU) (29.4%), intraocular pressure elevation (23.5%), oculomotor nerve palsy (5.8%), and optic neuritis (1.9%). Isolated AU (p < 0.001), isolated keratitis (p = 0.001), and intraocular pressure elevation (p = 0.013) were more likely to be concomitant to HZO active skin disease, while keratouveitis occurred more likely more than 1 month after HZO eruption (p < 0.001). AU and keratouveitis were more likely to be associated with age ≥ 50 years (p = 0.001 and p = 0.02, respectively). Ocular complications included neurotrophic keratopathy (1.9%), corneal opacity (5.9%), secondary glaucoma (7.8%), optic atrophy (1.9%), and postherpetic neuralgia (13.3%). Mean follow-up was 12 months. Mean final BCVA was 20/32; it was ≥ 20/40 in 78.4% of the eyes. CONCLUSIONS: Our study provided epidemiologic and clinical data of HZO in a Tunisian population. AU and keratitis were the most common ocular complications. Neurotrophic keratopathy was scarce. The overall visual outcome is good, with about three quarters of the treated patients maintaining VA of 20/40 or better.

Neuroretinitis: a rare feature of tubulointerstitial nephritis and uveitis syndrome.

A 17-year-old female presented to our hospital with fatigue, arthralgia and fever associated with non-granulomatous anterior uveitis in the left eye. Blood tests revealed renal failure and a renal biopsy showed acute tubulointerstitial nephritis. Findings were consistent with tubulointerstitial nephritis and uveitis (TINU) syndrome. The patient received systemic corticosteroids for 2 months as well as dexamethasone and mydriatic drops. Bilateral non-granulomatous anterior uveitis occurred 10 days after prednisone discontinuation, and was treated with topical steroids; however, uveitis recurred several weeks later. Bilateral anterior chamber inflammation was associated with neuroretinitis in the right eye. Extensive posterior synechiae precluded fundus examination of the left eye. The posterior segment manifestations responded to systemic prednisone, which was slowly tapered. The final visual outcome was favorable. TINU syndrome may rarely manifest with neuroretinitis.

Macular involvement in patients with Behçet's uveitis.

PURPOSE: The purpose of this study is to assess macular involvement in patients with Behçet's uveitis. METHODS: The study included 65 patients (120 eyes) with Behçet's uveitis. All patients underwent detailed ophthalmic examination, including dilated biomicroscopic fundus examination, fundus photography, fluorescein angiography, and optical coherence tomography. Follow-up ranged from 6 to 46 months (mean 20 months). RESULTS: At initial examination, 29 eyes (24.1 %) had macular involvement including macular edema (16 eyes, 13.3 %), serous retinal detachment (SRD; five eyes, 4.1 %), active retinitis (three eyes, 2.5 %), macular hole (three eyes, 2.5 %), macular atrophy (two eyes, 1.6 %), macular ischemia (one eye, 0.8 %), epiretinal membrane (one eye, 0.8 %), branch retinal vein occlusion involving the macula (three eyes, 2.5 %), and branch retinal artery occlusion involving the macula (two eyes, 1.6 %). During follow-up, 22 eyes (18.3 %) developed macular complications including macular edema (ten eyes, 8.3 %), SRD (four eyes, 3.3 %), active retinitis (two eyes, 1.6 %), severe macular atrophy (two eyes, 1.6 %), macular ischemia (three eyes, 2.5 %), macular hole (one eye, 0.8 %), epiretinal membrane (two eyes, 1.6 %), and subretinal fibrosis (one eye, 0.8 %). Branch retinal vein occlusion involving the macula developed in two eyes (1.6 %). Final best corrected visual acuity in patients with macular involvement ranged from 20/400 to 20/25 (mean 20/80). CONCLUSIONS: Macular edema and other vision-threatening macular complications are common in Behçet's uveitis. Macular damage is often irreversible, causing permanent visual impairment. Early and appropriate treatment of Behçet's uveitis is mandatory to reduce the risk of visual impairment due to macular involvement.

Supratarsal injection of triamcinolone acetonide and childhood allergic keratoconjunctivitis.

To evaluate the efficacy and safety of supratarsal injection of triamcinolone acetonide in the treatment of refractory allergic keratoconjunctivitis in childhood. Thirty-five patients (70 eyes) with severe allergic keratoconjunctivitis were included in this study. Fifteen patients (42.8%) had atopic keratoconjunctivitis (AKC) and 20 (57.2%) had vernal keratoconjuncivitis (VKC). All patients underwent a bilateral supratarsal injection of 20 mg triamcinolone acetonide. Mean follow-up was 28 months (range 14-38). All patients showed a significant symptomatic improvement and partial resolution of clinical features of keratoconjunctivitis within the first 2 weeks. Corneal complications related to keratoconjunctivitis disappeared in all patients. One patient with VKC experienced ocular hypertension. No patient with AKC showed side-effects. Severe relapse of the disease was noted in 10% of eyes with VKC and in 6.7% of eyes with AKC after a mean follow-up of 9 and 11 months, respectively. Supratarsal injection of triamcinolone acetonide is effective and safe in patients with severe chronic allergic keratoconjunctivits to relieve severe inflammation associated with this disease.

Clinical characteristics of intermediate uveitis in Tunisian patients.

To analyze the pattern of intermediate uveitis (IU) in a referral center in Tunisia, North Africa. A retrospective, descriptive study of 87 consecutive patients (145 eyes) examined at the Department of Ophthalmology of Monastir (Tunisia) from January 1996 to August 2008. All patients underwent an extensive ocular and systemic history, a complete ophthalmic examination, and fluorescein angiography. Standard diagnostic criteria of IU were employed. The mean follow-up period was 43.2 months (range, 4-65 months). The mean age at diagnosis of IU was 29.1 years (range, 5-54 years). The male-to-female ratio was 1:1.6. Both eyes were affected in 58 patients (66.7%). The best-corrected visual acuity at onset of uveitis ranged from light perception to 20/20 (mean, 20/32). The most frequent ocular findings were vitritis (100%), snowballs (53.8%), and retinal vasculitis (28.3%). Concurrent anterior uveitis was noted in 38.6% of affected eyes. Intermediate uveitis was most commonly idiopathic (86.2%). Systemic associations were found in 13.8%; sarcoidosis (9.2%) and multiple sclerosis (2.3%) were the most common systemic diseases. The ocular complications that developed during the follow-up period included cystoid macular edema (39.3%), cataract (31.7%), inflammatory optic disc involvement (26.2%), and glaucoma or ocular hypertension (9%). One hundred-twelve affected eyes (77.2%) had a final visual acuity more than or equal to 20/40. Factors of poor visual outcome were initial VA less than 20/40 (P = 0.00011), CME (P = 0.0016), and vitritis more than 3+ cells (P = 0.023). In a hospital population in Tunisia, intermediate uveitis started frequently at the 3rd decade. This type of uveitis was most commonly idiopathic. Cystoid macular edema and cataract were the most frequent complications. Visual prognosis appeared to be fairly good.

Pattern of uveitis in Behçet's disease in a referral center in Tunisia, North Africa.

The purpose of this study was to analyze the pattern of uveitis in Behçet's disease in Tunisia, North Africa. We retrospectively reviewed the clinical records of 62 patients (111 eyes) diagnosed with Behçet's uveitis (BU) at the Department of Ophthalmology, Fattouma Bourguiba University Hospital, Monastir, Tunisia, between January 1995 and December 2006. Forty-seven of 62 patients (75.8%) were men and 15 (24.2%) were women. Mean age at onset was 29.3 years. The average follow-up was 75.6 months. The most common extraocular clinical manifestations were recurrent oral ulcer in all patients and pseudofolliculitis in 52 patients (83.9%). Uveitis was bilateral in 79%. Initial best-corrected visual acuity was > or =20/40 in 41 affected eyes (36.9%) and <20/200 in 49 affected eyes (44.2%). Panuveitis (68 eyes, 61.3%) and posterior uveitis (38 eyes, 34.2%) were the most common forms, followed by anterior uveitis (five eyes, 4.5%). Retinal vasculitis was found in 89 eyes (80.2%). Most common complications included posterior synechiae (32.4%), cataract (31.5%), and cystoid macular edema (19.8%). Systemic corticosteroids were administered in 58 patients (93.5%). Immunosuppressive drugs were used in 22 patients (35.5%). Fifty-six affected eyes (50.5%) had final visual acuity > or =20/40 and 34 affected eyes (30.6%) had final visual acuity <20/200. In Tunisia, BU affects predominantly young men. Bilateral panuveitis associated with retinal vasculitis was the most common ocular manifestation. More than 50% of patients maintained a visual acuity of 20/40 or better, and immunosuppressive therapy probably contributed to the improvement of visual prognosis of these patients.

External ophthalmomyiasis manifesting with keratouveitis.

PURPOSE: To report a case of external ophthalmomyiasis manifesting with keratouveitis. CASE REPORT: A 77-year-old man, presented with keratouveitis secondary to external ophthalmomyiasis. Slit-lamp examination of the affected eye disclosed subepithelial linear opacities, stromal keratitis, and anterior uveitis. There were also some moving maggots identified as Oestrus ovis larvae. Following removal of the maggots and instillation of tobramycin, the symptoms completely resolved within 2 days and visual acuity improved. CONCLUSIONS: Although external ophthalmomyiasis usually manifests with ocular surface involvement, this uncommon condition must be considered in the differential diagnosis of keratouveitis, especially in rural areas.