The Role of Corticosteroids and Immunomodulatory Therapy in the Management of Infectious Uveitis.

PURPOSE: The index review aims to provide an update on the role of corticosteroids and steroid-sparing immunomodulatory therapy (IMT) in managing patients with infectious uveitis. METHOD: Narrative literature review. RESULTS: Corticosteroids and immunomodulatory therapy (IMT) focus on the host defense system instead of the pathogen, adjusting exaggerated inflammatory reactions to reduce potential harm to ocular tissues. Systemic or local corticosteroids are primarily selected as adjunctive medication for infectious uveitis. Concomitant corticosteroids have also been used in cases of paradoxical worsening in ocular tuberculosis and immune recovery uveitis in cytomegalovirus (CMV) retinitis. While there is no well-established evidence to support the use of IMT in infectious uveitis, it is occasionally used in clinical settings to treat persistent inflammation following resolution of infection such as cases of ocular tuberculosis and ocular syphilis where an insufficient response is observed with corticosteroids. CONCLUSION: There is no consensus on the position of immunomodulatory therapy in the management of infectious uveitis with different etiologies. The index review provides an overview of available adjunctive corticosteroids and IMT options to assist clinicians in managing such disease entities more efficiently.

Color enhancement and achromatization to increase the visibility of indocyanine green-stained internal limiting membrane during digitally assisted vitreoretinal surgery.

PURPOSE: To investigate the impact of using digital assisted vitrectomy (DAV) for color enhancement in color channel and achromatization in color profile on the visibility of indocyanine green (ICG)-stained internal limiting membrane (ILM). STUDY DESIGN: Retrospective observational study. METHODS: Twenty eyes from 20 patients (7 men, 13 women) who underwent 27-gauge pars plana vitrectomy for epiretinal membrane removal were included. The presettings of five different imaging modes of the NGENUITY® 3D visualization system (Alcon laboratories, Inc.), were adjusted, and intraoperative images of ILM removal were captured under each presetting. The color contrast ratios (CCR) between the ICG-stained ILM area and peeled ILM area were compared across presettings objectively. Subjective visibility of ILM in each patient for different presettings was ranked using a Likert scale and evaluated by five examiners. Data on sex, age, preoperative and postoperative best-corrected visual acuity (BCVA), preoperative and postoperative intraocular pressure (IOP), and postoperative complications were analyzed. RESULTS: Compared to other presettings the best CCR was achieved by adjusting the color channel to enhance red and by modifying the color profile to create a monochrome image (P<0.01). The same presetting resulted in a highest subjective visibility (P<0.01). Mean preoperative BCVA and 6-month postoperative BCVA (logMAR) were 0.11±0.18 and 0.05±0.19, respectively (p=0.24). Mean preoperative IOP and 6-month postoperative IOP were 13.8±2.8 mmHg and 13.3±3.4 mmHg, respectively (p=0.51). No apparent intra- and post-operative complications were observed. CONCLUSION: Color enhancement and achromatization using DAV may offer potential advantages to enhance the visibility of ICG-stained ILM.

Continuous glucose monitoring metrics following sub-Tenon's injection of triamcinolone acetonide for diabetic macular edema.

PURPOSE: This pilot study aims to comprehensively evaluate the effects of sub-Tenon's injection of triamcinolone acetonide (STTA) on glycemic control in patients with diabetic macular edema (DME) using professional continuous glucose monitoring (CGM). METHODS: This retrospective study analyzed changes in glycemic control in 20 patients with type 2 mellitus and DME following single STTA (20 mg/0.5 mL) using The FreeStyle Libre Pro system. Professional CGM provides core CGM metrics such as the percentage of time that glucose levels fall within a target range and include the time in range (TIR) (70-180 mg/dL), time above range (TAR) (> 180 mg/dL), and time below range (TBR) (< 70 mg/dL). Outcome measures were the changes in CGM metrics (TIR, TAR and TBR) and the percentage of patients in whom TAR increased by at least 10 percentage points (ppt) 4 days before to 4 days after STTA administration. RESULTS: The mean CGM metrics (TIR/TAR/TBR) were 75.5%/19.9%/4.4% 4 days before STTA and 73.7%/22.4%/3.5% 4 days after STTA; the metrics 4 days before and 4 days after STTA were not significantly different (P = 0.625 for TIR, P = 0.250 for TAR, and P = 0.375 for TBR). TAR increased by more than 10 ppt in four (20%) patients treated with sulfonylurea and/or insulin. CONCLUSION: Although there were no significant changes in the CGM metrics, four patients developed CGM-measured hyperglycemia after STTA for DME.

Birdshot Chorioretinopathy in Early Adulthood: Review of Current Literature and Case Report.

Purpose: We describe the course of a patient diagnosed with birdshot chorioretinopathy (BSCR) in early adulthood and summarize clinical findings from similar BSCR patients reported in the literature. Observations: A 37-year-old male presented to our tertiary uveitis facility with bilateral ocular discomfort, hazy vision, and floaters. Ocular examination was notable for vitritis, optic disc edema, and ovoid hypopigmented chorioretinal lesions, visible on indocyanine green chorioangiography as multiple hypocyanescent spots in the intermediate phase. Full-field electroretinography and visual evoked potential showed global retinal dysfunction and optic nerve dysfunction. Laboratory evaluations were notable only for human leukocyte antigen (HLA)-A29 positivity. The patient was diagnosed with BSCR and started on oral prednisone and eventually managed with infliximab. Conclusions and Importance: BSCR can affect patients in early adulthood. Proper diagnostic work-up, including assessing HLA-A29 positivity, is needed to manage atypical cases.

Aniseikonia after reduced-fluence photodynamic therapy in patients with central serous chorioretinopathy.

This study investigated aniseikonia after reduced-fluence photodynamic therapy (RFPDT) for central serous chorioretinopathy (CSC). We examined 48 eyes of 48 patients (38 men; mean age, 49.2 ± 9.9 years) with CSC resolved after RFPDT. Horizontal and vertical aniseikonia were measured using the New Aniseikonia Test at baseline, 6 months, and 12 months after RFPDT. The maximum absolute value of the horizontal and vertical measurements indicated the aniseikonia score. The aniseikonia score was 2.2 ± 2.3 at 6 months and 2.2 ± 2.0 at 12 months after RFPDT, both of which improved significantly from the baseline score of 4.1 ± 2.9 (P < 0.05 and P < 0.01, respectively). The 12-month aniseikonia score significantly correlated with the baseline aniseikonia score (P = 0.047), outer nuclear thickness at baseline (P = 0.027) and 12 months after RFPDT (P = 0.014), baseline SRD area (P = 0.005), and ellipsoid zone disruption at 12 months after RFPDT (P = 0.021). In multivariate analysis, baseline serous retinal detachment (SRD) area (P = 0.034) was significantly associated with aniseikonia score at 12 months after RFPDT. Eyes with a larger SRD area might have higher aniseikonia scores even after SRD resolution following RFPDT.

A CASE OF RAPIDLY PROGRESSIVE RETINOPATHY ASSOCIATED WITH PEMBROLIZUMAB IMMUNOTHERAPY FOR METASTATIC UROTHELIAL CARCINOMA.

PURPOSE: To describe a novel case of bilateral rapidly progressive retinopathy after immunotherapy with pembrolizumab for metastatic urothelial carcinoma. METHODS: Case report. RESULTS: A 64-year-old man undergoing pembrolizumab immunotherapy was referred to our hospital because of bilateral acute vision loss. His best-corrected visual acuity was 20/30 in the right eye and 20/320 in the left eye, and a visual field test revealed central and paracentral scotomas in the right eye and central scotoma in the left eye. We suspected immune-related retinopathy based on the progressive photoreceptor damage with abnormal electroretinogram findings, absence of overt intraocular inflammation, and presence of malignancy. Cessation of pembrolizumab and steroid pulse therapy followed by decreasing oral prednisolone improved visual function and photoreceptor damage, although there was recurrence after pembrolizumab was restarted. CONCLUSION: We reported a case of rapidly progressive retinopathy that may have been triggered by pembrolizumab immunotherapy for metastatic urothelial carcinoma. High-dose corticosteroid pulse therapy was effective in reversing photoreceptor damage.

Pars plana vitrectomy with internal limiting membrane flap versus pars plana vitrectomy with conventional internal limiting membrane peeling for large macular hole.

BACKGROUND: Macular hole (MH) is a full-thickness defect in the central portion of the retina that causes loss of central vision. According to the usual definition, a large MH has a diameter greater than 400 µm at the narrowest point. For closure of MH, there is evidence that pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling achieves better anatomical outcomes than standard PPV. PPV with ILM peeling is currently the standard of care for MH management; however, the failure rate of this technique is higher for large MHs than for smaller MHs. Some studies have shown that the inverted ILM flap technique is superior to conventional ILM peeling for the management of large MHs. OBJECTIVES: To evaluate the clinical effectiveness and safety of pars plana vitrectomy with the inverted internal limiting membrane flap technique versus pars plana vitrectomy with conventional internal limiting membrane peeling for treating large macular holes, including idiopathic, traumatic, and myopic macular holes. SEARCH METHODS: The Cochrane Eyes and Vision Information Specialist searched CENTRAL, MEDLINE, Embase, two other databases, and two trials registries on 12 December 2022. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that evaluated PPV with ILM peeling versus PPV with inverted ILM flap for treatment of large MHs (with a basal diameter greater than 400 µm at the narrowest point measured by optical coherence tomography) of any type (idiopathic, traumatic, or myopic). DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane and assessed the certainty of the body of evidence using GRADE. MAIN RESULTS: We included four RCTs (285 eyes of 275 participants; range per study 24 to 91 eyes). Most participants were women (63%), and of older age (range of means 59.4 to 66 years). Three RCTs were single-center trials, and the same surgeon performed all surgeries in two RCTs (the third single-center RCT did not report the number of surgeons). One RCT was a multicenter trial (three sites), and four surgeons performed all surgeries. Two RCTs took place in India, one in Poland, and one in Mexico. Maximum follow-up ranged from three months (2 RCTs) to 12 months (1 RCT). No RCTs reported conflicts of interest or disclosed financial support. All four RCTs enrolled people with large idiopathic MHs and compared conventional PPV with ILM peeling versus PPV with inverted ILM flap techniques. Variations in technique across the four RCTs were minimal. There was some heterogeneity in interventions: in two RCTs, all participants underwent combined cataract-PPV surgery, whereas in one RCT, some participants underwent cataract surgery after PPV (the fourth RCT did not mention cataract surgery). The critical outcomes for this review were mean best-corrected visual acuity (BCVA) and MH closure rates. All four RCTs provided data for meta-analyses of both critical outcomes. We assessed the risk of bias for both outcomes using the Cochrane risk of bias tool (RoB 2); there were some concerns for risk of bias associated with lack of masking of outcome assessors and selective reporting of outcomes in all RCTs. All RCTs reported postoperative BCVA values; only one RCT reported the change in BCVA from baseline. Based on evidence from the four RCTs, it is unclear if the inverted ILM flap technique compared with ILM peeling reduces (improves) postoperative BCVA measured on a logarithm of the minimum angle of resolution (logMAR) chart at one month (mean difference [MD] -0.08 logMAR, 95% confidence interval [CI] -0.20 to 0.05; P = 0.23, I2 = 65%; 4 studies, 254 eyes; very low-certainty evidence), but it may improve BCVA at three months or more (MD -0.17 logMAR, 95% CI -0.23 to -0.10; P < 0.001, I2 = 0%; 4 studies, 276 eyes; low-certainty evidence). PPV with an inverted ILM flap compared to PPV with ILM peeling probably increases the proportion of eyes achieving MH closure (risk ratio [RR] 1.10, 95% CI 1.02 to 1.18; P = 0.01, I2 = 0%; 4 studies, 276 eyes; moderate-certainty evidence) and type 1 MH closure (RR 1.31, 95% CI 1.03 to 1.66; P = 0.03, I² = 69%; 4 studies, 276 eyes; moderate-certainty evidence). One study reported that none of the 38 participants experienced postoperative retinal detachment. AUTHORS' CONCLUSIONS: We found low-certainty evidence from four small RCTs that PPV with the inverted ILM flap technique is superior to PPV with ILM peeling with respect to BCVA gains at three or more months after surgery. We also found moderate-certainty evidence that the inverted ILM flap technique achieves more overall and type 1 MH closures. There is a need for high-quality multicenter RCTs to ascertain whether the inverted ILM flap technique is superior to ILM peeling with regard to anatomical and functional outcomes. Investigators should use the standard logMAR charts when measuring BCVA to facilitate comparison across trials.

Short-Term Outcomes of Faricimab Treatment in Aflibercept-Refractory Eyes with Neovascular Age-Related Macular Degeneration.

To evaluate the functional and anatomical effects of switching to faricimab for patients with neovascular age-related macular degeneration (nAMD) refractory to intravitreal aflibercept, this retrospective study evaluated patients with nAMD who received intravitreal injections of aflibercept (IVA) every <8 weeks and were switched to faricimab. After switching, the patients were treated with a treatment and extended regimen that started with the interval just before switching and received at least three injections. We evaluated changes in the best-corrected visual acuity (BCVA), central retinal thickness (CRT), central choroidal thickness (CCT), treatment interval, and presence of retinal fluid. Overall, 55 eyes from 55 patients were examined. After three injections of faricimab, the BCVA and CCT did not change significantly. However, the CRT decreased significantly (p < 0.05), the injection interval was significantly extended (7.5 ± 2.3 vs. 5.9 ± 1.5 weeks, p < 0.01), and the rates of the presence of intraretinal fluid and subretinal fluid decreased significantly to 16.4% and 40% of eyes, respectively (both p < 0.01). An ocular adverse event (retinal pigment epithelium tear) developed in one eye. Switching to faricimab was effective for anatomic changes. It may be an additional treatment option for some eyes refractory to IVA.

Usefulness of intraoperative optical coherence tomography to minimize the intraocular lens tilt during the intrascleral fixation: a clinical and experimental evaluation.

To report the usefulness of intraoperative real-time adjustment of intraocular lens (IOL) tilt during the intrascleral fixation with intraoperative optical coherence tomography (iOCT) as a clinical evaluation and investigate the factors contributing to IOL tilt using iOCT as an experimental evaluation. Retrospective cohort study and experimental research. As a clinical evaluation, the medical records of 43 eyes of 41 patients who underwent intrascleral IOL fixation combined with real-time iOCT observation were retrospectively reviewed. As an experimental evaluation, in order to investigate the factors contributing to IOL tilt, the four experiments were performed using iOCT. The mean IOL tilt angle (°) at the end of surgery and 3 months after surgery were 1.81 ± 1.15 and 2.10 ± 1.66, respectively (p = 0.46). No apparent intra- or postoperative complications occurred during the follow-up period. The experimental evaluation indicated that the IOL tilt was influenced by the insertion angle of the haptic in the vertical direction. The mean IOL tilt angle (°) was 1.94 ± 0.09, 4.67 ± 0.11, 8.90 ± 0.11, and 15.78 ± 0.85 when the insertion angle of the haptic was 0°, 10°, 27.5°, and 45° in the vertical direction, respectively (p < 0.01). Clinical and experimental IOL tilt assessment using iOCT is interactively useful for better quality surgery and better postoperative outcome.

ASSOCIATION OF ORAL MONTELUKAST WITH REDUCED ODDS OF DEVELOPING EXUDATIVE AGE-RELATED MACULAR DEGENERATION.

PURPOSE: This study was conducted to evaluate the association of oral montelukast, selective antagonism for cysteinyl leukotriene receptor 1, with reduced odds of exudative age-related macular degeneration (exAMD) development. METHODS: This case-control study was conducted using institutional cohort finder tool, and included 1913 patients with exAMD (ICD: H35.32 and 362.52) and 1913 age- and gender-matched control subjects without exAMD. Subanalysis among 1913 exAMD and 324 nonexudative AMD was also conducted. RESULTS: A total of 47 (2.5%) exAMD cases were identified to have a history of oral montelukast use before exAMD diagnosis, compared with 84 (4.4%) controls. Montelukast usage was significantly associated with reduced odds of exAMD in the multivariable analysis (adjusted odds ratio [OR]: 0.50, 95% confidence interval: 0.31-0.80) and nonsteroidal anti-inflammatory drug usage (adjusted OR: 0.69). Caucasian race, history of smoking, and nonexudative macular degeneration in either eye were also found to have a significant relationship with increased odds of exAMD. In the subanalysis, montelukast usage showed significant association with reduced odds of developing exAMD from nonexudative AMD (adjusted OR: 0.53, 95% confidence interval: 0.29-0.97) and the presence of atopic disease (adjusted OR: 0.60). CONCLUSION: The study results suggested that oral montelukast is linked to reduced odds of exAMD development.

Two-year outcome of half-time photodynamic therapy for chronic central serous chorioretinopathy with and without choroidal neovascularization.

PURPOSE: To compare the two-year outcome of half-time photodynamic therapy (htPDT) in chronic central serous chorioretinopathy (cCSC) with and without choroidal neovascularization (CNV). METHODS: In this retrospective study, we included 88 eyes of 88 patients with cCSC who underwent htPDT and were followed up for more than 24 months. Patients were divided into two groups with (21 eyes) or without (67 eyes) CNV before htPDT treatment. The best-corrected visual acuity (BCVA), central retinal thickness (CRT), subfoveal choroidal thickness (SCT), and the presence of subretinal fluid (SRF) were evaluated at baseline and at 1, 3, 6, 12, and 24 months after PDT. RESULTS: A significant intergroup difference was noted in terms of age (P = 0.038). Significant improvements in the BCVA and SCT were found at all time points in eyes without CNV but only at 24 months in eyes with CNV. CRT was significantly reduced in both groups at all time points. No significant intergroup differences were noted in terms of BCVA, SCT and CRT at all time points. There were significant differences in the rate of recurrent and persistent SRF between groups (22.4% (without CNV) vs. 52.4% (with CNV), P = 0.013, and 26.9% (without CNV) vs. 57.1% (with CNV), P = 0.017, respectively). The presence of CNV was significantly associated with the recurrence and persistence of SRF after initial PDT (P = 0.007 and 0.028, respectively). Logistic regression analyses showed that the baseline BCVA, and not the presence of CNV, was significantly associated with BCVA at 24 months after initial PDT (P < 0.01). CONCLUSIONS: A htPDT for cCSC was less effective in eyes with CNV than in those without CNV regarding the recurrence and persistence of SRF. Additional treatment might be required in eyes with CNV during 24-month follow-up periods.

Removal of Sub-Internal Limiting Membrane Hemorrhage Secondary to Retinal Arterial Macroaneurysm Rupture: Internal Limiting Membrane Non-Peeling Technique.

The appropriate surgical technique to improve the closure rate of perioperative full-thickness macular hole (FTMH) secondary to submacular hemorrhage (SMH) with sub-internal limiting membrane (ILM) hemorrhage caused by retinal arterial macroaneurysm (RAM) rupture remains an unsolved clinical problem. Several ILM transplantation techniques have been attempted, but these are challenging. Our new technique can remove sub-ILM hemorrhage with the central fovea ILM intact, without peeling the ILM. The medical records of three eyes from three patients with SMH and sub-ILM hemorrhage secondary to RAM rupture were retrospectively reviewed. During the surgery, a small ILM fissure was made outside the central fovea with ILM forceps, and sub-ILM hemorrhage was washed out through it by manually spraying balanced salt solution. Sub-ILM hemorrhage removal was achieved successfully in all eyes, with no occurrences of FTMH or other complications. Best-corrected decimal visual acuity improved from 0.05 (Snellen equivalent (SE), 20/400), 0.05 (SE, 20/400), and 0.05 (SE, 20/400) preoperatively to 0.3 (SE, 20/63), 0.4 (SE, 20/50), and 0.15 (SE, 20/125) at 3 months postoperatively, respectively. This new technique may help keep the foveal ILM intact and prevent perioperative FTMH formation.

Short-Term Outcomes of Intravitreal Faricimab Injection for Diabetic Macular Edema.

Background and Objectives: Faricimab is a novel bispecific antibody with Fab regions inhibiting both vascular endothelial growth factor-A and angiopoietin-2. Therefore, this study aimed to obtain short-term outcomes of intravitreal injection of faricimab (IVF) for the treatment of diabetic macular edema (DME) in daily clinical practice. Materials and Methods: A retrospective review was carried out on consecutive patients with DME who had been treated with IVF and were followed up for at least 1 month. Outcome measures included changes in logMAR best-corrected visual acuity (logMAR BCVA), central retinal thickness (CRT), number of IVF administrations, and safety. Clinical outcomes were also compared between the treatment-naïve and switch groups. Results: A total of 21 consecutive DME eyes from 19 patients were identified. The mean number of IVFs was 1.6 ± 0.8 during the mean follow-up time of 5.5 months. The overall mean logMAR BCVA following IVF was 0.236, 0.204, 0.190, and 0.224 at baseline, 1, 3, and 6 months, respectively, without a significant change from baseline to 1 month (p = 0.176) or for 6 months (p = 0.923). The overall mean CRT (µm) following IVF was 400.6, 346.6, 342.1, and 327.5 at baseline, 1, 3, and 6 months, respectively. CRT significantly decreased from baseline to 1 month (p = 0.001) but did not reach a significant level over 6 months following IVF (p = 0.070). No significant difference in BCVA or CRT was observed between the treatment-naïve and switch groups. No serious safety concerns were noted. Conclusions: IVF for the treatment of DME may preserve visual acuity and improve macular thickness without serious safety concerns in the short term in a real-world clinical setting.

Clinical features and associated factors of intraocular inflammation following intravitreal brolucizumab as switching therapy for neovascular age-related macular degeneration.

PURPOSE: The aim of this study is to explore the clinical features and associated factors of intraocular inflammation (IOI) following intravitreal brolucizumab (IVBr) administration for neovascular age-related macular degeneration (nAMD). METHODS: This retrospective study included 87 eyes from 87 Japanese patients with nAMD who were followed up for 5 months after the initial administration of IVBr as switching therapy. Clinical pictures of IOI post-IVBr and changes in best corrected visual acuity (BCVA) at 5 months were evaluated between eyes with and without IOI (non-IOI). The association between IOI and baseline factors (age, sex, BCVA, hypertension, and/or arteriosclerotic changes in the fundus, subretinal hyperreflective material [SHRM], and macular atrophy) was evaluated. RESULTS: Of the 87 eyes, 18 (20.6%) developed IOI and 2 (2.3%) developed retinal artery occlusion. There were 9 (50%) cases of posterior or pan-uveitis among eyes with IOI. The mean interval from initial IVBr administration to IOI was 2 months. The mean changes in logMAR BCVA at 5 months were significantly worse in IOI eyes than in non-IOI eyes (0.09 ± 0.22 vs. - 0.01 ± 0.15, P = 0.03). There were 8 (44.4%) and 7 (10.1%) cases of macular atrophy and 11 (61.1%) and 13 (18.8%) cases of SHRM in the IOI and non-IOI groups, respectively. SHRM and macular atrophy were significantly associated with IOI (P = 0.0008 and P = 0.002, respectively). CONCLUSION: In IVBr therapy for nAMD, eyes with SHRM and/or macular atrophy should be observed more meticulously, given the increased risk of developing IOI, which is associated with insufficient BCVA gain.

Characteristics of Cellular Infiltration into Posterior Vitreous in Eyes with Uveitis on the Classification Basis Assessed Using Optical Coherence Tomography.

Purpose: To evaluate the characteristics of posterior vitreous cells in patients with uveitis on the classification basis using spectral domain optical coherence tomography (SD-OCT). Methods: In this retrospective chart review, all eyes were classified into three groups: infectious uveitis (IFU, n=7), noninfectious granulomatous uveitis (NIGU, n=13), and noninfectious nongranulomatous uveitis (NINGU, n=13). We measured the size, number, and density of vitreous hyperreflective particles in the posterior vitreous area that was defined as the space between the vitreous top and the internal limiting membrane on OCT. The correlations between vitreous haze and vitreous particles were also evaluated. Results: Thirty-three eyes from 23 patients with active posterior uveitis were included. IFU had significantly more particles than NIGU and NINGU (P=0.03 and P<0.001, respectively). The vitreous particle density was higher in IFU than in NIGU and NINGU (P=0.03 and P=0.003, respectively). The mean largest particle size was greater in IFU and NIGU than in NINGU (P=0.01 and P=0.03, respectively). The median vitreous haze of 2+ in IFU, 1+ in NIGU and NINGU showed no significant difference among three groups (P=0.21). Conversely, the correlation of the largest particle size with vitreous haze was significant at ρ= 0.44 (P=0.01). Conclusion: SD-OCT may be useful for assessing ocular inflammation based on morphological characteristics of vitreous particles on the uveitis classification basis.

Six-month outcomes of infliximab and tocilizumab therapy in non-infectious retinal vasculitis.

PURPOSE: To evaluate the efficacy of infliximab (IFX, 5-10 mg/kg) (Group 1) and tocilizumab (TCZ, 4-8 mg/kg) (Group 2) infusions in non-infectious retinal vasculitis (RV) using Angiographic Scoring for the Uveitis Working Group fluorescein angiography (FA) scoring system. METHODS: Records of 14 patients (24 eyes) in Group 1 and 8 patients (11 eyes) in Group 2 were retrospectively evaluated to assess visual acuity (VA), anterior chamber cell and flare, vitreous haze, central subfield thickness (CST), and FA scoring at baseline and 6 months of follow-up. The measurements were employed to grade in each group. RESULTS: In Group 1 and 2, respectively, there was no underlying disease in 9 (60%) and 3 (42.9%) patients. Three (42.9%) patients in Group 2 had juvenile idiopathic arthritis (JIA) as the most common identified cause. Mean improvement in VA (log MAR) and CST were 0.04 ± 0.14 and 40.3 ± 78.5 µm in Group 1; 0.04 ± 0.09 and 47.3 ± 82.3 µm in Group 2, respectively. Mean FA scores were significantly reduced from 12.4 ± 5.2 and 11.6 ± 4.4 at baseline to 6.4 ± 5.0 and 5.8 ± 3.9 at 6-month in Group 1 and 2, respectively. In Group 2, 9 eyes of 6 patients (75%) had the history of IFX use prior to TCZ initiation. There was no significant safety concern requiring treatment discontinuation during the follow-up in either group. CONCLUSION: IFX and TCZ infusions showed statistically significant improvement of non-infectious RV as shown by ASUWOG FA Scoring System. TCZ, as well as IFX, appeared to be effective treatment options for non-infectious RV.

Electroretinographic findings in retinal vasculitis.

AIM: To describe and correlate electroretinographic responses with clinical and angiographic findings in retinal vasculitis (RV). METHODS: Medical records of patients with diagnosis of RV at a tertiary eye centre from December 2017 to May 2021 were reviewed. Cases in which fluorescein angiography (FFA) and full field electroretinography (ffERG) were done within 1 month were included. FFAs were graded according to the Angiography Scoring for Uveitis Working Group from 0 to 40, where 0 is normal. A novel ffERG grading system was implemented where individual waves were graded for timing and amplitude and general ffERG score was determined with 6 being a perfect score. RESULTS: 20 patients (34 eyes) were included. Mean age was 43.9±19.8 years; 70% were female. Median best-corrected visual acuity was 0.8 (0.08-1). Mean FFA score was 12.6±6.5. Median general ffERG score was 5 (0-6). 68% and 91% of eyes had responses with general ffERG scores ≥5 and 4, respectively. Flicker timing was most commonly affected.FFA scores weakly correlated with delayed photopic cone b-wave and flicker timing (p=0.03 and 0.016, respectively). Vitreous haze moderately correlated with delayed cone b-wave timing (p<0.001), delayed flicker timing (p=0.002) and weakly correlated with lower flicker amplitude (p=0.03). Underlying systemic disease was associated with poor ffERG responses. CONCLUSION: In this study, RV was not frequently associated with severe global retinal dysfunction Higher FFA scores, and vitreous haze grading were weakly, but significantly, correlated with cone-generated ffERG responses.

Neurosarcoidosis, Coccidioidomycosis, or Both!

Purpose: To report a case of neurosarcoidosis (NS) who was initially diagnosed as Coccidioidomycosis immitis (CI) infection. Observations: A 57-year-old diabetic man presented with sudden painless diminution of vision, metamorphopsia, and color vision deficits in the left eye (OS) for one month. His vision was 20/20 in the right eye (OD) and 20/40 OS. Ophthalmic examination revealed left relative afferent pupillary defect, blurred optic nerve margin, creamy chorioretinal infiltration around the optic disc, and mild macular edema. OD examination was non-revealing. Chest CT scan with contrast showed calcified mediastinal lymph nodes, but biopsy of the lymph nodes was normal. Brain and orbit MRI demonstrated soft tissue abnormality with enhancement in left orbital apex with involvement of the extraocular muscles. CSF culture was negative, but complement fixation had positive titer of 1:2 for CI. The patient was diagnosed with CI meningitis, and antifungal therapy was initiated. Slight visual and symptomatic improvement was observed, which was not completely satisfactory. Biopsy of extraocular orbital muscle five months later revealed non-caseating granulomatous inflammation, leading to initiation of prednisone trial therapy. Nine months later, the patient was referred to a tertiary center owing to persistence of optic disc edema OS. PET CT was consistent with a diagnosis of sarcoidosis. Antifungal treatment was discontinued, and oral prednisone with methotrexate was initiated. Subsequently, methotrexate was replaced by infliximab to further manage ocular inflammation and neurologic symptoms which was effective. Vision was 20/20 OD and 20/30 OS at the most recent visit. Conclusion and Importance: Signs and symptoms of neurosarcoidosis and coccidioidomycosis can be similar and deceiving. The index case underscores importance of considering appropriate differential diagnoses in patients with similar symptoms and signs who may respond to preliminary designated treatment but not to the optimal extent. Considering such possibility could assist clinicians in managing the patients timely and efficiently.

Efficacy and Safety of Tocilizumab in the Management of Non-Infectious Uveitis Failed with Conventional Immunomodulatory and Anti-TNFα Therapies.

PURPOSE: To determine the outcomes of intravenous (IV) tocilizumab (TCZ) in patients with non-infectious uveitis who failed with conventional immunomodulatory and anti-TNFα therapies. METHODS: Records of seven patients with non-infectious uveitis treated with monthly IV TCZ (4-10 mg/kg) or biweekly IV TCZ (8 mg/kg) were reviewed. Outcome measures were changes in visual acuity, anterior chamber cell and flare grade, vitreous haze, central subfield thickness (CST), and fluorescein angiography (FA) score. RESULTS: Ten eyes of seven patients received TCZ therapy. Median age of patients was 14 (range, 7-24) years. Median duration of TCZ therapy was 15 (range, 5-32) months. Mean CST reduced from 373 ± 101.0 µm to 298.2 ± 40.3 µm. Mean FA score reduced from 12.5 ± 4.3 to 3.6 ± 2.6. One patient developed elevated liver transaminases. CONCLUSION: IV TCZ is a potentially effective and safe therapeutic option for the management of refractory non-infectious uveitis.