An Update on Noninfectious Retinal Vasculitis.

BACKGROUND: Retinal vasculitis (RV) signifies the inflammation of various retinal vessels. Noninfectious RV differs from infectious RV with regard to its pathogenesis and treatment. It can have varied clinical presentations and may be associated with systemic vasculitic diseases. SUMMARY: Noninfectious RV can be caused due to type-III hypersensitivity reactions, increased expression of intracellular adhesion molecules, and genetic susceptibility. Noninfectious RV is primarily classified on the basis of the type of retinal vessels involved. It can be further classified as an occlusive or nonocclusive. RV can be a major association of systemic diseases like Behcet's disease, sarcoidosis and systemic lupus erythematosus. Newer modalities, like ultra-widefield fundus fluorescein angiography, can help in the management of RV. Effective treatment of noninfectious RV requires anti-inflammatory and immunosuppressive therapy. The patients may require treatment with high-dose corticosteroids and biological agents. Anti-vascular endothelial growth factor injections and laser photocoagulation may be indicated to treat the occlusive disease. Prompt treatment may prevent complications like vitreous hemorrhage, neovascular glaucoma, and tractional retinal detachment. The treatment more often requires a multidisciplinary approach. KEY MESSAGES: This review provides a comprehensive update on the various causes of noninfectious RV, including both systemic and isolated ocular conditions. It also details various complications and management strategies for this condition.

Diagnostic work-up of retinal vasculitis: An algorithmic approach.

Retinal vasculitis has heterogenous etiologies encompassing infections, autoimmune, masquerades and idiopathic. The heterogeneity in the underlying clinical features and aetiologies of retinal vasculitis makes its diagnosis challenging for clinicians and the work up thus becomes quite extensive and many a times several unwarranted investigations are done to look for a possible etiology. Timely and accurate diagnosis is crucial for effective management and vision preservation. The algorithmic approach needs understanding of the phenotype, clinical as well as imaging biomarkers so that only customized investigations are done in order to make the timely diagnosis and initiate specific therapy wherever required. In this review article, we shall present an algorithmic approach that combines clinical assessment, ophthalmic imaging, laboratory investigations, and targeted ancillary tests.

Use of Color Channel Optimization in 3D Heads-Up Vitrectomy vs Standard Operating Microscope for Macular Surgeries.

Purpose: To compare the efficacy and safety of color channel optimization with 3-dimensional (3D) heads-up vitrectomy (3D HUD group) vs standard operating microscope vitrectomy (control group) for macular surgery. Methods: This retrospective multicenter comparative study comprised patients having 25-gauge pars plana vitrectomy for macular hole, epiretinal membrane (ERM), or vitreomacular traction. The minimum follow-up was 6 months. Surgeons completed a subjective questionnaire after each case. The main outcome measures were safety related (dye reinjection rate, macular ERM or internal limiting membrane [ILM] peeling time, endoillumination intensity). Other outcome measures included total surgical time, surgical outcomes, and subjective surgeon-related parameters. Results: The study included 74 eyes (36 in 3D HUD group; 38 in control group). There were no statistical differences in baseline parameters between groups. Significantly more eyes in the control group than in the 3D HUD group required dye reinjection (23.7% vs 5.6%; P = .03). Less time was required for ERM and ILM peeling in the 3D HUD group (both P < .01); however, the total surgical time was the same between groups. Eyes in the 3D HUD group required lower endoillumination (P < .001). There were no between-group differences in the rates of complications. Surgeons said depth perception was better in the control group (P < .001), with no differences in comfort or visibility. Conclusions: 3D heads-up-based color channel optimization for macular surgeries is safe and effective. Although it may have safety advantages, it did not affect the visual or anatomic outcomes or total surgical time and did not improve surgeon comfort or visibility.

Outcomes after giant peripheral retinotomy and anterior flap retinectomy for rhegmatogenous retinal detachments with advanced proliferative vitreoretinopathy using small gauge vitrectomy.

PURPOSE: To analyze the visual and anatomical outcomes for eyes with rhegmatogenous retinal detachment (RRD) and advanced proliferative vitreoretinopathy (PVR) undergoing giant peripheral retinotomy (GPR) using 25-gauge pars plana vitrectomy (PPV). METHODS: In this retrospective multi-center study, patients with RRD with either anteroposterior or circumferential retinal shortening and advanced PVR requiring more than 90-degree GPR with/without relaxing retinotomy were included. Subjects of either gender, any age group, and with complete surgical notes were included. Outcome measures of the study included anatomical success (i.e. complete retinal re-attachment) at 6 months using survival analysis, visual outcomes, and post-operative complications. RESULTS: Forty-one eyes of 41 patients (33 males) with a mean age of 44.9 ± 21.4 years were included. At 6 months follow-up, anatomical success was seen in 29 eyes (70.7%) with a cumulative re-attachment rate of 66% (95% confidence interval = 48 = 79%). All re-detachments occurred at ≤6 months with a peak at 4-6 months (n = 9). Twenty-three eyes (56%) achieved ambulatory vision (5/200) or better. Direct perfluorocarbon liquid-silicone oil exchange was performed in 20 eyes. Intra-operative complications included persistent retinal folds (2 eyes), subretinal air (1 eye), and subretinal bleed (1 eye). Eleven eyes (26.8%) developed secondary glaucoma (2 eyes required a drainage device), and hypotony of ≤6 mmHg was noted in 3 eyes (7.3%). Corneal decompensation was noted in 8 eyes (19.5%), and 3 eyes (7.3%) underwent re-surgery for re-RRD. CONCLUSION: After GPR using small gauge PPV, two-thirds achieve anatomical success, and over half have ambulatory vision, but overall post-operative complications can occur in more than half of the eyes.

Intravitreal immunotherapy in non-infectious uveitis: an update.

INTRODUCTION: In the past several years, there have been numerous advances in pharmacotherapeutics for the management of uveitis and other ocular inflammatory diseases, including newer therapeutic agents and ocular drug delivery systems. One of the most attractive modes of drug delivery is the intravitreal route since it has proven to be safe and efficacious and prevents unwanted systemic adverse events related to the agent. AREAS COVERED: In this review, intravitreal delivery of various pharmacotherapeutic agents for noninfectious uveitis has been described. An extensive review of the literature was performed using specific keywords on the PubMed database to identify clinical studies employing various pharmacotherapeutic agents with intravitreal drug delivery for noninfectious uveitis. The mode of action, safety, efficacy, and tolerability of these drugs have also been elucidated. EXPERT OPINION: Several agents, including biologic response modifier agents, have been found to be safe and efficacious for various indications of uveitis, such as cystoid macular edema, active uveitis, and other conditions such as retinal vasculitis and vitreous haze. The use of intravitreal biological therapies, especially infliximab, has been fraught with potential safety signals such as photoreceptor toxicity. However, pharmacotherapeutic agents such as corticosteroids and anti-vascular endothelial growth factor agents are now widely used in the clinical management of uveitis and its complications.

Update on coronavirus disease 2019: Ophthalmic Manifestations and Adverse Reactions to Vaccination.

The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 was one of the most devastating public health issues in recent decades. The ophthalmology community is as concerned about the COVID-19 pandemic as the global public health community is, as COVID-19 was recognized to affect multiple organs in the human body, including the eyes, early in the course of the outbreak. Ophthalmic manifestations of COVID-19 are highly variable and could range from mild ocular surface abnormalities to potentially sight and life-threatening orbital and neuro-ophthalmic diseases. Furthermore, ophthalmic manifestations may also be the presenting or the only findings in COVID-19 infections. Meanwhile, global vaccination campaigns to attain herd immunity in different populations are the major strategy to mitigate the pandemic. As novel vaccinations against COVID-19 emerged, so were reports on adverse ophthalmic reactions potentially related to such. As the world enters a post-pandemic state where COVID-19 continues to exist and evolve as an endemic globally, the ophthalmology community ought to be aware of and keep abreast of the latest knowledge of ophthalmic associations with COVID-19 and its vaccinations. This review is a summary of the latest literature on the ophthalmic manifestations of COVID-19 and the adverse ophthalmic reactions related to its vaccinations.

Blau syndrome: Lessons learned in a tertiary care centre at Chandigarh, North India.

Objectives: Blau syndrome (BS) is a rare autoinflammatory disease characterized by arthritis, dermatitis, and granulomatous uveitis in early childhood. The study presents the clinical experience of patients with BS at a tertiary care centre in Chandigarh, North India. Methods: Analysis of the clinical profile of patients of BS with NOD2 gene mutations under follow-up was carried out. Results: Diagnosis of BS was genetically confirmed in 11 patients (10 children and one adult; six male and five female patients) from 10 families. The median age of onset of symptoms was 12 months (range, 4 months-4 years), while the age at diagnosis ranged from 2.3 to 26 years. The classic triad of arthritis, dermatitis, and uveitis was present in 6/11 (54.5%) patients. The frequency of arthritis, dermatitis, and uveitis was 100%, 81.8%, and 72.7%, respectively. The median age at diagnosis of ocular symptoms was 4 years (range, 2-26 years). Family history was noted in six families. Renal involvement was observed in two children. All patients in our cohort had the R334W variant in NOD2 gene. An asymptomatic carrier sibling with R334W mutation was identified in one family. Methotrexate was used as a first-line agent in all children. Adalimumab, which was commenced in five patients with uveitis, resulted in significant improvement in four patients. The total follow-up duration of the present cohort is 1,063.8 patient-months. Conclusions: The possibility of BS should always be considered in patients with arthritis and early ocular involvement. Uveitis is often progressive and refractory to currently available therapies. Systemic involvement appears to remain a significant cause of morbidity and mortality.

Familial Nanophthalmos Presenting with Spontaneous Uveal Effusion Syndrome.

Purpose: To report two unique cases of spontaneous uveal effusion syndrome (UES) from the same family.Methods: The patients included father (54 years old) and a daughter (23 years old). The father presented 7 years ago with bilateral exudative retinal detachment, nanophthalmic eyes (axial length 16.11 mm and 16.43 mm in right and left eyes, respectively) with hypermetropia, and a thickened sclera on MRI. The daughter presented with left eye peripheral exudative annular retinal detachment with bilateral nanophthalmos (axial length 20.7 mm and 20.33 mm, in right and left eyes, respectively), with MRI showing ciliochoroidal detachment, suprachoroidal effusion and mild thickening of the sclera in left eye.Results: The father underwent subscleral sclerectomy in the left eye that led to resolution of submacular fluid. Scleral biopsy confirmed the deposition of glycosaminoglycans on Alcian blue stain. The daughter was kept under observation, because of absence of any macular subretinal fluid, and counselled about the familial nature of the disease and possible need for future intervention.Conclusion: This is the first report of familial nanophthalmos presenting with spontaneous UES.

Optic Disc Neovascularization in Tubercular Serpiginous-Like Choroiditis.

Optic disc neovascularization in uveitis is uncommon, and has been associated with chronic inflammations like Behcet's disease, Vogt-Koyanagi-Harada disease, sarcoidosis, etc. To our knowledge, optic disc neovascularization has not been reported in tubercular serpiginous-like choroiditis. We report three such cases.

Pattern of Uveitic Hypotony in a Tertiary Eye Hospital in India.

PURPOSE: To report pattern of uveitic patients with hypotony in Indian population. METHODS: Retrospective medical record review of 30 eyes of 21 consecutive patients with uveitic hypotony. Patient demographics, ocular findings and systemic association were recorded. RESULTS: Mean age of the patients was 29.5 years (range 7-71 years) and 80.9%(17 patients) were below the age of 40 years. Most common complaint associated with the development of hypotony was diminution of vision (26 eyes; 86.6%), and cells in anterior vitreous (25 eyes, 83.3%) were the most common slit-lamp finding. Most common type of ocular inflammation causing hypotony was panuveitis (14, 46.6%), and ocular tuberculosis (5; 23.8%) was the most common cause of uveitis in these patients. CONCLUSION: Ocular hypotony is a rare but dreaded complication of uveitis. The etiology of uveitic hypotony is not uniform across the world, and tuberculosis remains an important cause of uveitic hypotony in tuberculosis endemic country like India.