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.

RELATIVE QUIESCENCE OF EXUDATIVE AGE-RELATED MACULAR DEGENERATION AFTER RESOLUTION OF POSTINJECTION ENDOPHTHALMITIS.

PURPOSE: To evaluate alterations in treatment burden and course of exudative age-related macular degeneration in patients who contracted endophthalmitis from intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections. METHODS: Retrospective study at the University of Pittsburgh Medical Center examining frequency of anti-VEGF injections, activity of choroidal neovascularization, and visual acuity before and after endophthalmitis treatment. RESULTS: Twenty-one patients meeting inclusion criteria were identified, of whom 7 (33%) patients did not restart anti-VEGF treatment 12 months after endophthalmitis because of quiescence of exudative age-related macular degeneration without significant visual acuity loss (P > 0.05). Patients who resumed anti-VEGF treatment exhibited 32% and 38% decreases in injection frequency by 12 and 24 months after endophthalmitis, respectively (P < 0.05). On first optical coherence tomography follow-up, 10 patients exhibited quiescence of choroidal neovascularization activity, although there were no measurable changes in macular thickness (P > 0.05). No differences in post-endophthalmitis exudative age-related macular degeneration progression or treatment burden were observed when factoring adjuvant intravitreal steroid therapy, culture results, nor choroidal neovascularization subtypes. CONCLUSION: Endophthalmitis resolution is associated with a decrease in choroidal neovascularization activity and a reduction of anti-VEGF treatment burden in patients with exudative age-related macular degeneration.

SPONTANEOUS CLOSURE OF A LARGE STAGE III MACULAR HOLE AFTER PANRETINAL PHOTOCOAGULATION IN A PATIENT WITH SEVERE PROLIFERATIVE DIABETIC RETINOPATHY.

PURPOSE: To report spontaneous closure of a tractional Stage III macular hole (MH) in a patient with proliferative diabetic retinopathy (PDR) after panretinal photocoagulation (PRP). METHODS: Case report of a 43-year-old man with poorly controlled Type I diabetes and bilateral severe proliferative diabetic retinopathy. RESULTS: On presentation, visual acuity was 20/400 and fundus examination was significant for a Stage III tractional MH in the left eye. Vision in the right eye was light perception from neovascular glaucoma. Fluorescein angiography showed extremely severe macular and peripheral ischemia, disk neovascularization, and macular traction from fibroglial tissue. After 5 panretinal photocoagulation sessions over 3 months, the MH spontaneously closed; however, vision remained 20/400. Fluorescein angiography showed regressed disk neovascularization and mild diffuse macular leakage. After a 13-month loss to follow-up, he presented with 20/300 vision, and, despite extensive macular traction from fibroglial tissue, the MH remained closed. Owing to progressive traction from the fibroglial tissue, macular retinal detachment occurred and vision decreased to hand motions. The patient underwent pars plana vitrectomy, scar tissue removal, silicone oil tamponade, and laser. Postoperatively, visual acuity decreased to no light perception because of neovascular glaucoma complications and lack of proper follow-up. CONCLUSION: Spontaneous closure of a Stage III MH may occur in patients with PDR after PRP; however, it may not result in long-term visual improvement.