Corticosteroids as adjuvant therapy for ocular toxoplasmosis.

BACKGROUND: Ocular infection caused by Toxoplasma gondii, a parasite, may result in inflammation in the retina, choroid, and uvea, and consequently lead to complications such as glaucoma, cataract, and posterior synechiae. OBJECTIVES: The objective of this systematic review was to assess the effects of adjunctive use of corticosteroids to anti-parasitic therapy versus anti-parasitic therapy alone for ocular toxoplasmosis. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register (2016; Issue 11)), MEDLINE Ovid, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, MEDLINE Ovid Daily (January 1946 to December 2016), Embase (January 1980 to December 2016), Latin American and Caribbean Literature on Health Sciences (LILACS (January 1982 to December 2016)), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP; www.who.int/ictrp/search/en). We used no date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 7 December 2016. SELECTION CRITERIA: We had planned to include randomized and quasi-randomized controlled trials. Eligible trials would have enrolled participants of any age who were immunocompetent and were diagnosed with acute ocular toxoplasmosis. Included trials would have compared anti-parasitic therapy plus corticosteroids versus anti-parasitic therapy alone, different doses or times of initiation of corticosteroids. DATA COLLECTION AND ANALYSIS: Two authors independently screened titles and abstracts retrieved through the electronic searches. We retrieved full-text reports of studies categorized as 'unsure' or 'include' after we reviewed the abstracts. Two authors independently reviewed each full-text report for eligibility. Discrepancies were resolved through discussion. MAIN RESULTS: We identified no completed or ongoing trial that was eligible for this Cochrane review. AUTHORS' CONCLUSIONS: Although research has identified a wide variation in practice regarding the use of corticosteroids, our review did not identify any evidence from randomized controlled trials for or against the role of corticosteroids in the management of ocular toxoplasmosis. Several questions remain unanswered by well-conducted randomized trials in this context, including whether the use of corticosteroids as an adjunctive agent is more effective than the use of anti-parasitic therapy alone; if so, when corticosteroids should be initiated in the treatment regimen (early versus late course of treatment), and what would be the best dose and duration of steroid use.

Corticosteroids as adjuvant therapy for ocular toxoplasmosis.

BACKGROUND: Ocular infestation with Toxoplasma gondii, a parasite, may result in inflammation in the retina, choroid, and uvea and consequently lead to complications such as glaucoma, cataract, and posterior synechiae. OBJECTIVES: The objective of this systematic review was to assess the effects of adjunctive use of corticosteroids for ocular toxoplasmosis. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 9), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to October 2012), EMBASE (January 1980 to October 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to October 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We searched the reference lists of included studies for any additional studies not identified by the electronic searches. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 11 October 2012. SELECTION CRITERIA: We planned to include randomized and quasi-randomized controlled trials. Eligible trials would have enrolled participants of any age who were immunocompetent and were diagnosed with active ocular toxoplasmosis. Included trials would have compared anti-parasitic therapy plus corticosteroids versus anti-parasitic therapy alone, or different doses or times of initiation of corticosteroids. DATA COLLECTION AND ANALYSIS: Two authors independently screened titles and abstracts retrieved from the electronic searches. We retrieved full-text articles of studies categorized as 'unsure' or 'include' after review of the abstracts. Two authors independently reviewed each full-text article. Discrepancies were resolved through discussion. MAIN RESULTS: The electronic searches retrieved 368 titles and abstracts. We reviewed 20 full-text articles. We identified no trials eligible for inclusion in this systematic review. AUTHORS' CONCLUSIONS: Although research has identified wide variation in practices regarding use of corticosteroids, our systematic review did not identify evidence from randomized controlled trials for the role of corticosteroids in the management of ocular toxoplasmosis. Several questions remain unanswered by well-conducted randomized trials in this context, including whether use of corticosteroids is more effective than use of anti-parasitic therapy alone, when corticosteroids should be initiated in the treatment regimen (early versus late course of treatment), and which dosage and duration of steroid use is best. These questions are easily amenable to research using a randomized controlled design and they are ethical due to the absence of evidence to support or discourage use of corticosteroids for this condition. The question of foremost importance, however, is whether they should be used as adjunct therapy (that is, additional) to anti-parasitic agents.

Role of Psychological Stress and Choroidal Thickness in Central Serous Chorioretinopathy.

INTRODUCTION: Central serous chorioretinopathy (CSCR) is a disease with a multifactorial aetiology. OBJECTIVES: To evaluate the role of psychological stress and choroidal thickness in patients with CSCR. MATERIALS AND METHODS: This was a hospital-based, analytical cross-sectional study, conducted at Christian Medical College, Vellore, India, from 2018 February to 2019 September, after the approval of the Institutional Review Board and Ethics Committee. Patients who satisfied the eligibility criteria of the study, were selected from the outpatient clinics of the Department of Ophthalmology. Twenty-five patients with unilateral CSCR (Group 1 - cases), and 50 age and gender-matched patients without CSCR (Group 2 - controls), randomly selected in a 1:2 ratio, were enrolled after obtaining informed consent. Psychological stress was assessed using Cohen Perceived Stress Scale (PSS-10). All patients had a Swept Source optical coherence tomography scan of the macula. Subfoveal choroidal thickness (SFCT) of both eyes of all participants was measured using a standard protocol. The data were collated and analysed, using Independent samples t-test and Chi-square/ Fisher's exact test, as appropriate, with IBM SPSS Statistics for Windows, version 21 (IBM Corp., Armonk, N.Y., USA). RESULTS: There was a significant difference between the two groups in mean stress scores (p <0.01), as well as stress categories (p <0.01). Although there was no significant difference in the prevalence of hypertension between the two groups (p = 0.33), there was a significant difference both in the mean systolic (p <0.01) and diastolic (p <0.01) blood pressure between the two groups. We found a significant difference between mean SFCT of CSCR eyes (421+/- 78.34 µm) and control eyes (314.24 +/- 52.48 µm, p <0.01), as well as between fellow eyes (396.20 +/- 68.79 µm) and control eyes (314.24 +/- 52.48 µm, p <0.01). However, there was no significant difference in the mean SFCT of CSCR eyes and fellow eyes (p =0.24). CONCLUSION: The findings reiterate the concept that the underlying pathophysiological changes leading to CSCR involve both the eyes of the patient. Psychological stress and hypertension may be factors that play an important role in the etiopathogenesis of the pachychoroid-related changes leading to CSCR. Stress relief measures, with a holistic approach to management, should be an integral part of the therapeutic strategies for CSCR.

Comparative evaluation of diabetic retinopathy screening programs in regular ophthalmology clinics versus integrated diabetic clinics within rural health-care services.

BACKGROUND: Robust integration of diabetic retinopathy (DR) screening within health systems is essential to prevent DR-related blindness. This, however, remains a challenge in the developing world. The aim of this study was to evaluate two models of DR screening programs within rural general health-care services. MATERIALS AND METHODS: This was a retrospective observational study from two rural health centers. Demographic and clinical data of patients completing DR screening were analyzed. Patients were screened in regular ophthalmology clinics (ROC) or integrated diabetic clinics (IDC). Referral and treatment completion data were retrieved from the clinical charts at the base hospital. RESULTS: A total of 2535 DR screenings were conducted for 2296 patients. The total population prevalence for any DR was 14.2% (95% confidence interval [CI]: 12.8%-15.6%) and vision-threatening DR (VTDR) was 4.7% (95% CI: 3.8%-5.6%). In the ROC and IDC groups, respectively, the prevalence of any DR was 20.4% and 8.2%, VTDR, 7.8% and 1.7%, and blindness, 1.4% and 0.4% (all P < 0.001). Referral completion rates were higher in the ROC group (44.8% vs. 25.2%, P < 0.001), while treatment completion in both was similar (69.6% vs. 70.6%). Referral and treatment completion rates for referable DR were 61.2% and 48.2%, and for VTDR, 62% and 38.8%, respectively. Only 11.45% of patients completed the repeat screening follow-up. CONCLUSIONS: Patients attending IDCs had a significantly lower prevalence of any DR, VTDR, and blindness demonstrating the advantages of integrated diabetic care in a rural setting. However, referral uptake and DR treatment completion need strengthening.

Predictive value of retinal nerve fibre layer thickness for postoperative visual improvement in patients with pituitary macroadenoma.

OBJECTIVE: To determine the usefulness of retinal nerve fibre layer (RNFL) thickness and a reliable cut-off value that can predict postoperative visual function improvement in patients with pituitary macroadenoma. METHODS AND ANALYSIS: This was a prospective observational study. Preoperative optical coherence tomography of the RNFL was performed in patients with pituitary macroadenoma. Postoperative visual function changes (acuity and visual fields) were identified using predefined criteria. Receiver operating characteristic curves were constructed for RNFL values to define the ideal cut-off value that predicted improvement. Other variables including preoperative visual acuity, mean deviation, visual field index and tumour volume were also analysed. RESULTS: Twenty-nine eligible subjects (58 eyes) were recruited. The mean (±SD) age was 43.9 (±12.85) years and 65.5% were male. The mean (±SE) follow-up duration was 20.8 (±6.42) months. RNFL thickness was significantly thinner in eyes with visual dysfunction and optic disc pallor. Better preoperative logarithmic minimum angle of resolution (logMAR) visual acuity, higher RNFL thickness and smaller tumour volume were associated with postoperative visual field improvement on univariate analysis; however, only mean RNFL thickness had significant association on multivariate analysis. None of the preoperative variables showed significant association with improvement in visual acuity. The best cut-off of mean RNFL thickness for visual field improvement was estimated at 81 µm with 73.1% sensitivity and 62.5% specificity. CONCLUSION: Preoperative RNFL thickness can be an objective predictor of visual field outcomes in patients undergoing surgery for pituitary macroadenomas, with moderate sensitivity and specificity. It is, however, not a good predictor of visual acuity outcome.

Ocular manifestations of Takayasu arteritis: a cross-sectional study.

PURPOSE: To detail the spectrum of eye manifestations in Takayasu arteritis and factors predisposing to its development. METHODS: In this cross-sectional study, 61 patients with proven Takayasu arteritis who were identified during a 16-month period were evaluated for disease- and treatment-related eye manifestations. A fundus fluorescein angiography examination was performed where indicated and with the patients consent. RESULTS: The mean (±standard deviation) duration of illness before ophthalmic evaluation was 55 ± 69 months. Decreased vision was the most common ocular symptom (30%). Thirty-five patients underwent fundus fluorescein angiography examination. Takayasu retinopathy was seen in 9 (15%), ocular ischemic syndrome in 4 (7%), and hypertensive retinopathy in 10 (16%) patients. The most common treatment-related ocular complication was steroid-induced cataract (23%). Other manifestations included iris neovascularization (n = 3), anterior ischemic optic neuropathy (n = 2), steroid-induced glaucoma (n = 1), neovascular glaucoma (n = 1), and uveitis (n = 1). Those manifesting Takayasu retinopathy and ocular ischemic syndrome had significantly (P < 0.05) lower blood pressure in both upper limbs compared with patients not manifesting ischemic retinopathy. A significant (P < 0.03) proportion of patients with Takayasu retinopathy and ocular ischemic syndrome had a nonrecordable right upper limb blood pressure. CONCLUSION: Disease- and treatment-related ocular complications are not infrequent in Takayasu arteritis. Arteritis involving the aortic arch and its branches favors the development of ischemic ocular complications.

Prescription of near addition and its relation to accommodative reserve in presbyopia - The dichotomy between theory and practice.

PURPOSE: To study the relationship between the amplitude of accommodation (AA) measured by the Royal Air Force (RAF) rule and near addition (NA) prescribed in presbyopic patients to assess how far practice is different from theoretical recommendations. METHODS: Patients, aged 40 to 60 years with best corrected vision of 6/6 N5 were included in this cross sectional observational study. AA was measured using the RAF rule. Refined with near Duochrome chart, the NA was given with the chart at 40 cm. Accommodative reserve was calculated from the measured AA, NA required and the calculated additional accommodation expended by the patient for reading. The percentage of reserve was calculated with and without the correction for depth-of-field. RESULTS: A total of 130 patients were studied. In the patients above 50 years of age, the negative correlation of AA with age was -0.298 (P = 0.065) and AA and NA was -0.365 (P = 0.002) was weak. Among the patients aged between 40 and 50 years, the negative correlation of AA with Age and NA were strong; -0.853 (P < 0.0001) and -0.823 (P < 0.0001) respectively. When prescribing glasses, 62.01% (CI 58.78 to 65.23) and 90.93% (CI 62.50 to 119.37) of the AA was found to be kept in reserve for patients below and above 50 years of age respectively. CONCLUSION: Accommodative reserve kept in our study patients when prescribing NA was two to three times the theoretical recommendation. High percentage of accommodation kept in reserve suggest that the measured AA is not activated normally and require higher NA and one should not rely on patient's ability to generate accommodative power especially in patients over 50 years.

Primary ocular presentation of tuberous sclerosis - A case report.

A 25-year-old man presented with decreased vision in the left eye with hypopigmented elevated subretinal lesion over the optic disk with abnormal vasculature, subretinal and retinal hemorrhages, and fluid in the macula. An area of high spike over the disk with corresponding orbital shadowing was seen on B scan ultrasonography. Fundus fluorescein angiography revealed abnormal vasculature. Systemic examination revealed facial angiofibroma, ashleaf spot, and dental pits with multiple cortical tubers on CT brain. Intravitreal injection of bevacizumab led to visual and tomographic improvement. Abnormal retinal vascularization and exudation in young individuals may be a presenting feature in tuberous sclerosis.

Bilateral choroidal metastasis from carcinoma of the submandibular gland.

Metastatic tumor is the most common uveal malignancy. However, choroidal metastasis from a salivary gland neoplasm is extremely rare. We report a case of bilateral, multifocal choroidal metastasis from carcinoma of the submandibular gland.

PRIMARY LASER PHOTOCOAGULATION FOR THE TREATMENT OF GIANT RETINAL TEARS.

PURPOSE: Laser photocoagulation has typically been used as an adjunctive treatment to pars planar vitrectomy in achieving retinopexy in the treatment of giant retinal tears. We describe three cases where the giant retinal tear was treated with laser photocoagulation alone. METHODS: A retrospective case report of three patients with giant retinal tears who underwent primary laser photocoagulation. RESULTS: Fundus examination up to 18 months after primary laser photocoagulation of all 3 patients revealed a flat attached retina and no significant complications. CONCLUSION: Laser photocoagulation alone is a viable alternative treatment for giant retinal tears in the absence of significant subretinal fluid.

Incontinentia pigmenti, an x-linked dominant disorder, in a 2-year-old boy with Klinefelter syndrome.

Incontinentia pigmenti (IP) is a rare X-linked dominant disorder, in which skin lesions distributed along Blaschko's lines appear shortly after birth. Early lesions which are erythematous/bullous evolve over time into warty lesions, hyperpigmented swirls/macules, and atrophic hypopigmented streaks. Clinical features are heterogeneous. Abnormalities of the teeth, nails, hair, eyes, central nervous system, and breast may also be present. While intelligence is generally normal, varied degrees of intellectual disability/developmental delay have been reported. Lifespan is normal. IP is associated with mutations of the inhibitor of kappa light polypeptide gene enhancer in B cell, kinase gamma (IKBKG) gene on chromosome Xq28. This gene is involved in the activation of nuclear factor kappa B which protects cells against apoptosis; therefore, cells with IKBKG mutations are extremely susceptible to apoptosis. X-linked dominant disorders are lethal to male fetuses. Males who survive with IP either have mosaicism or an additional X chromosome (Klinefelter syndrome). We present a 22-month-old boy with IP and Klinefelter syndrome.

Recurrent posterior scleritis--report of a case.

Posterior scleritis is a serious ocular inflammatory and potentially blinding disorder. It is uncommon and often under-recognized due to its varied presentations, and general ophthalmologists are not familiar with it. Posterior scleritis may be idiopathic or associated with systemic diseases. Visual disturbances such as blurring or distortion are the commonest symptoms. There may be pain, tenderness, and deep-seated discomfort in and around the orbit. One study reported a 49% recurrence rate of posterior scleritis. Posterior scleritis responds well to systemic nonsteroidal anti-inflammatory agents, systemic steroids, and immunosuppressive agents. Recurrences are known to occur despite therapy. However, multiple recurrences in posterior scleritis are uncommon. We report a patient with posterior scleritis who had one episode in the right eye and four episodes in the left eye over a 35-month period.

Orbital Metastasis of Cervical Carcinoma - Case Report and Review of Literature.

The orbit is a frequent site of metastasis, particularly from the breast, prostate gland and the lung. Carcinoma of the cervix metastasizing to the orbit is rare. We report a 27-year-old woman with Stage II B cervical cancer who presented with progressive painless protrusion of the left eye of one month duration associated with diplopia. Histology of the orbital mass was similar to that of the cervical cancer and reported as squamous cell carcinoma. She received palliative radiation to the left orbit 30 Gy in 10 fractions along with chemotherapy (Paclitaxel and Carboplatin). This resulted in regression of the proptosis. We review published literature of cases of carcinoma of the uterine cervix with metastasis to the orbit.

Hypoperfusive and hypertensive ocular manifestations in Takayasu arteritis.

Takayasu arteritis is a relatively rare inflammatory arteritis that can be associated with ocular manifestations. We report four patients with proven Takayasu arteritis; two patients manifested hypoperfusive ocular manifestations of ocular ischemic syndrome and anterior ischemic optic neuropathy whilst two others had exudative retinal detachment and papilledema as a result of severe hypertension. The ischemic ocular manifestations were a result of hypoperfusion of the ocular structures due to occlusive arteritis of the aortic arch and its branches. The exudative retinal detachment and papilledema were manifestations of severe hypertension due to renal arterial involvement. Patients with Takayasu arteritis should be referred for ophthalmic assessment and screening for hypoperfusive and hypertensive manifestations.