A New Ray of Hope in the Treatment of Seasonal Hyperacute Panuveitis: Could Intravitreal Triple Combination Therapy of an Antibiotic with Dual Steroids Play a Pivotal Role?

INTRODUCTION: Seasonal Hyperacute Panuveitis (SHAPU) is a blinding disease in Nepal with unknown aetiology. Henceforth, we proposed to study the treatment outcome of a triple intravitreal combination therapy of dual steroids triamcinolone (long-acting steroid) and dexamethasone (short-acting steroid) along with antibiotic moxifloxacin for patients with severe stage of SHAPU. METHODS: A prospective study was conducted among the SHAPU patients presenting in severe stages during the September to December 2023 outbreak. Intravitreal injection of 4-mg preservative-free triamcinolone acetonide (4 mg/0.1 ml) with intravitreal dexamethasone injection (0.4 mg/0.1 ml) and 0.5 mg/0.1 ml of moxifloxacin was given in the operating theatre. Best corrected visual acuity, intraocular pressure measurements, vitreous haze and fundus evaluation, were assessed to determine the treatment outcome on examination on day 7 and day 30 following intravitreal combination therapy. RESULT: A total of 6 patients (2 female and 4 male) were enrolled. At presentation, the mean BCVA was 2.40 ± 0.30 logMAR, mean intraocular pressure was 12.8 mmHg and vitreous haze was 4+ haze in all cases. The evaluation on the 7th day and 30th after injection showed significant improvement in BCVA (p value = 0.039; p value = 0.040, respectively). The change in the IOP at day 7 (p value = 0.85) was insignificant. However, the IOP change was significant at day 30 (p value = 0.5). Similarly, there was a marked reduction in the vitreous haze with better fundus visibility after treatment. CONCLUSION: This study depicted that steroids prevent the dreaded complication of hypotony due to ciliary shutdown by combating severe inflammation, thus adding new hope to the armamentarium of SHAPU management.

Seasonal Hyperacute Panuveitis (SHAPU) in Bhutan.

PURPOSE: To report the first series of Seasonal Hyperacute Pan Uveitis (SHAPU) from Bhutan. METHODS: We retrospectively analyzed the patients with clinically diagnosed SHAPU treated in the referral center in the last 5 years. Data included demographics (age, sex, laterality), region, time of presentation (year, season) and treatment received. RESULTS: The series included 3 males and 2 females. The mean age was 16 years. Three patients had presented in autumn of 2021, and two in autumn of 2019. Four patients presented within 2 weeks of the onset of symptoms. All patients had either exposure or contact with white moths. All patients presented with unilateral sudden painless reduction in vision and low Intraocular pressure. Four patients required vitrectomy. The final visual acuity of 3 patients was >6/36, and one patient was 6/60. CONCLUSIONS AND IMPORTANCE: The time of presentation and early treatment intervention are crucial in achieving good visual prognosis in SHAPU.

Seasonal Hyperacute Panuveitis (SHAPU) Outbreak Amidst COVID-19 Pandemic.

PURPOSE: To document the demographic profile of the SHAPU outbreak amidst the COVID-19 pandemic. METHODS: A multicentric cross-sectional study of the 2021 SHAPU outbreak during the second phase of the COVID-19 outbreak. RESULTS: A total of 135 patients were diagnosed with SHAPU from August to December 2021, 77 (57%) were children <16 years, males 54.8% and 34.8% had direct physical contact with white moths and 41.5% had severe type of SHAPU. Dramatic increment in the moth abundance was noted in these outbreak sites. Few cases presented with atypical ocular findings, unlike past outbreaks. Due to the ongoing COVID-19 pandemic with restrictions on travel and transportation, timely management was difficult and good visual outcome was achieved only in mild-moderate cases with an early presentation. CONCLUSION: The surge in the number of SHAPU patients, its occurrence in areas previously unreported, and some atypical presentation added raised suspicion of a possible link between COVID-19 and SHAPU.

Increase in SHAPU patients, incidence in unreported areas of Nepal, atypical ocular presentations and shift in disease affection from children towards adults population have raised doubt between connections between SHAPU, white moths and COVID pandemic.

Classification of Seasonal Hyperacute Panuveitis (SHAPU).

INTRODUCTION: Classification are essential part of scientific methodology and has important role in medical reporting system. Even after having 46 years long history, Seasonal Hyperacute Panuveitis (SHAPU), the blinding diseases reported mainly from Nepal lacks a standard classification system. Thus, we aim to contribute in the ophthalmic nosology by purposing a classification system for SHAPU. METHODOLOGY: The classification is suggested on the background of prolonged experience of this entity by the group of investigators who have dedicated years of research on this topic. CONCLUSION: We are optimistic that the proposed classification system will help in effective planning and evaluation of this ocular emergency condition and deliver the appropriate and reliable information for timely management and prevention of complications.

Sporadic summer outbreak of SHAPU in even years: Does the pattern match with the usual autumn outbreak?

PURPOSE: Seasonal Hyperacute Panuveitis (SHAPU), is a mysterious blinding disease seen only in Nepal with a higher prevalence among children usually seen in autumn every alternate odd year since 1975. This report highlights the sporadic summer outbreak in the even years with atypical presentation. OBSERVATIONS: Three patients were diagnosed as SHAPU in the summer (May) of 2020. All of them noted the presence of white moths (Gazalina species) in their environment with or without direct physical contact. The clinical patterns were severe in nature including corneal melting. Two out of three patients (66.6%) developed phthisis bulbi and lost their vision. CONCLUSIONS AND IMPORTANCE: White moth has been associated as a risk factor for SHAPU. Despite the known natural history of appearance after monsoon of every odd year, the few unhatched eggs of the moths may hatch under the favorable circumstances in the summer of the even years and may lead to the sporadic outbreak of SHAPU. Though less in numbers, the clinical presentation of such sporadic SHAPU cases may be atypical with less favorable outcome.

The Risk Factors of Seasonal Hyperacute Panuveitis.

BACKGROUND: Seasonal Hyperacute Panuveitis (SHAPU) is an eye disease of unclear aetiology occurring cyclically during the autumn in odd years in Nepal causing blindness within a week. This study is the first of its type to investigate the risk factors of SHAPU. METHODS: A multicentric national level case-control study was performed during the 2017 SHAPU outbreak. Cases were matched to controls in a 1:3 ratio based on age, sex and geographic area.Questionnaire-based personal interview was used and risk factors were categorized as biological and behavioral. For univariate analysis, frequency, median and interquartile range was calculated. Chi-squared test with/without continuity correction and Fisher's exact test were used. Multivariate conditional logistic regressions were used for all the independent variables for p <0.1 in the univariate analyses. RESULTS: We identified 35 cases and 105 controls; 71.4% were children≤16 years (38-day infant to 50-year-old). All were immunocompetent individuals, males were 57.1% and females 42.9%. Potential risks such as visible moths/butterfly activity, contact with livestock, and attending mass gatherings of people were not reported more frequently in cases vs controls in univariate analyses. Differences in possibly protective factors such as self-reported mosquito net use, light off at night while sleeping, and habit of hands/face washing after physical contact/touch with any insects/butterflies/birds were not statistically significant between both groups. In multivariate model, SHAPU cases were significantly more likely than controls to report physical contact with butterflies/white moths (Adjusted OR:6.89; CI:2.79-17.01,p < .001). CONCLUSIONS: Direct physical contact with butterflies/moths was associated with significantly increased odds of SHAPU cases.

Pattern of vitreo-retinal diseases at the national referral hospital in Bhutan: a retrospective, hospital-based study.

BACKGROUND: Knowing the pattern and presentation of the diseases is critical for management strategies. To inform eye-care policy we quantified the pattern of vitreo-retinal (VR) diseases presenting at the national referral hospital in Bhutan. METHODS: We reviewed all new patients over three years from the retinal clinic of the Jigme Dorji Wangchuck National Referral Hospital. Demographic data, presenting complaints and duration, treatment history, associated systemic diseases, diagnostic procedures performed, and final diagnoses were quantified. Comparisons of the expected and observed frequency of gender used Chi-squared tests. We applied a sampling with replacement based bootstrap analysis (10,000 cycles) to estimate the population means and the standard errors of the means and standard error of the 10th, 25th, 50th, 75th and 90th percentiles of the ages of the males and females within 20-year cohorts. We then applied t-tests employing the estimated means and standard errors. The 2913 subjects insured that the bootstrap estimates were statistically conservative. RESULTS: The 2913 new cases were aged 47.2 ± 21.8 years. 1544 (53.0%) were males. Housewives (953, 32.7%) and farmers (648, 22.2%) were the commonest occupations. Poor vision (41.9%), screening for diabetic and hypertensive retinopathy (13.1%), referral (9.7%), sudden vision loss (9.3%), and trauma (8.0%) were the commonest presenting symptoms. Coexistent diabetes and hypertension were the most common associated systemic diseases. Haematological tests (blood sugar, HbA1c and lipid profile, 31.8%), OCT (27.4%), refraction (9.9%), B-scan (8.7%), fundus photography (8.0%) were the most commonly performed diagnostic tests. Hypertensive retinopathy (18.9%) was the commonest VR disease, followed by refractive errors referred for retinal evaluation (16.7%), diabetic retinopathy with macular oedema (15.8%), and AMD (11.0%). Retinal detachment was more prevalent in females (83 vs. 41, p = 0.007). Rare vision-threatening diseases like seasonal hyper-acute pan-uveitis also presented. CONCLUSIONS: The developing VR service in Bhutan is challenged by the spectrum of diseases, limited human resources (e.g. one retinal surgeon during the study), and accessibility to tertiary eye-care services, all amidst difficult terrain. Sustained effort and robust coordination among the eye-care professionals, government and non-governmental organisations are critical for optimising VR services, especially as rates of diseases such as diabetes and hypertension grow.

Youngest reported Seasonal Hyperacute Panuveitis case.

PURPOSE: Seasonal Hyperacute Panuveitis (SHAPU) is a mysterious but rapidly devastating intraocular inflammatory disease reported only from Nepal during odd years after monsoon. Though it predominantly affects children, it has been reported between 9 months and 50 years age. But herein, we report a case of SHAPU in a 38-days-baby during 2017 SHAPU outbreak. OBSERVATIONS: Parents of a 38-days-healthy male baby from Pokhara noticed redness in child's right eye since 5 days (October 2017). They noticed the fall of a white moth from the tubelight over the child's face 1-day prior to symptom onset. On examination, both eyes followed and fixated at light. The right eye was congested with dense anterior chamber reaction and white pupillary reflex obscuring the glow of the retina. Ultrasonography showed hyperechoic vitreous shadows with choroidal thickening. Left eye was normal. The child underwent vitreous tap with core vitrectomy + lensectomy with intravitreal antibiotics and steroid ↓GA. The blood investigations were normal and the vitreous sample yielded no organism growth. Viral PCR analysis was negative. The intraocular inflammation decreased and fundal glow was visible. CONCLUSIONS: AND IMPORTANCE: SHAPU can occur in a child as young as 38 days. Link with moth remains the strongest suspect.

Patterns of Uveitis and Scleritis in Nepal: A Tertiary Referral Center Study.

PURPOSE: To analyze the patterns of uveitis and scleritis at the tertiary referral center in Nepal. METHODS: A retrospective review of uveitis and scleritis cases at Tilganga Institute of Ophthalmology in 2014. RESULTS: A total of 1113 uveitis, 73 scleritis, 35 sclerouveitis cases were reviewed. Anterior uveitis (590, 53%) was most common, followed by panuveitis (20%), intermediate uveitis (14%), then posterior uvietis (12.9%). The most common causes of anterior, pan, and posterior uveitis were herpetic disease (15.1%), SHAPU (15.2%) and toxoplamosis (27.1%) respectively. The most common cause of scleritis & sclerouveitis was Tuberculosis (15.1%, 31.4% respectively). CONCLUSION: Herpetic disease, toxoplasmosis, tuberculosis and SHAPU were common infections.