Pediatric Posterior Infectious Uveitis.

PURPOSE: To describe the most important cause of infectious posterior uveitis in pediatric patients. METHODS: Review of the literature. RESULTS: The most important causes of infectious uveitis in pediatric patients are: cat-scratch disease, toxocariasis, tuberculosis, viral diseases and toxoplasmosis. Ocular manifestations include retinitis, neuroretinitis, choroidal granulomas, peripheral granulomas and posterior pole granulomas. CONCLUSION: Infectious posterior uveitis is a challenging subject and should be considered in the differential diagnosis of any posterior uveitis in children. Infectious uveitis must be excluded before initiating immunosuppressive therapy.

Practical tips and common mistakes in ocular microbiology sampling and processing.

Ocular microbiology deals with miniscule samples from ocular infections, which are difficult to collect, process, and analyze, necessitating special skills, and the knowledge of troubleshooting errors to reach a specific diagnosis. In this article, we highlight several practical points in ocular microbiology, common mistakes, and various approaches to resolve them. We have covered sample collection from different ocular compartments, processing for smear preparation and culture, transport of samples, staining and reagents issues, artifacts and contaminants, and interpretation of in-vitro antimicrobial susceptibility testing reports. This review aims to help both ophthalmologists and microbiologists in making the practice of ocular microbiology and the interpretation of reports more reliable, hassle-free, and precise.

Practical Guidance for Clinical Microbiology Laboratories: Diagnosis of Ocular Infections.

The variety and complexity of ocular infections have increased significantly in the last decade since the publication of Cumitech 13B, Laboratory Diagnosis of Ocular Infections (L. D. Gray, P. H. Gilligan, and W. C. Fowler, Cumitech 13B, Laboratory Diagnosis of Ocular Infections, 2010). The purpose of this practical guidance document is to review, for individuals working in clinical microbiology laboratories, current tools used in the laboratory diagnosis of ocular infections. This document begins by describing the complex, delicate anatomy of the eye, which often leads to limitations in specimen quantity, requiring a close working bond between laboratorians and ophthalmologists to ensure high-quality diagnostic care. Descriptions are provided of common ocular infections in developed nations and neglected ocular infections seen in developing nations. Subsequently, preanalytic, analytic, and postanalytic aspects of laboratory diagnosis and antimicrobial susceptibility testing are explored in depth.

Comprehensive pathogen detection for ocular infections.

BACKGROUND: Molecular diagnostics such as pathogen-directed PCRs have transformed testing for ocular infections since the late 1990s. Although these assays remain important diagnostic tools for samples with low biomass, the lack of diagnostic range motivates alternative molecular approaches for ocular infections. The aim of this study was to determine the performance of a high-throughput RNA sequencing approach, RNA-seq, to detect infectious agents in ocular samples from patients with presumed ocular infections. METHODS: We compared the performance of RNA-seq to pathogen-directed PCRs using remnant nucleic acids from 41 aqueous or vitreous samples of patients with presumed ocular infections. Pathogen-directed PCRs were performed at the CLIA-certified Stanford Clinical Virology Laboratory. RNA-seq was performed in a masked manner at the Proctor Foundation at the University of California San Francisco. Percent positive and negative agreement between the two testing approaches were calculated. Discordant results were subjected to orthogonal testing. RESULTS: The positive percent agreement between RNA-seq and pathogen-directed PCRs was 100% (95% confidence interval (CI): 78.5%-100%). The negative percent agreement was 92.6% (95% CI: 76.6%-97.9%). RNA-seq identified pathogens not on the differential diagnosis for 9.7% (4/41) of the samples. Two pathogens solely identified with RNA-seq were confirmed with orthogonal testing. CONCLUSIONS: RNA-seq can accurately identify common and rare pathogens in aqueous and vitreous samples of patients with presumed ocular infections. Such an unbiased approach to testing has the potential to improve diagnostics although practical clinical utility warrants additional studies.

Non-infectious and non-hereditary diseases of the corneal epithelium.

The corneal epithelium serves as a physical barrier and a refractive element. Therefore, diseases of the corneal epithelium can increase the risk for infection and causes vision loss. The corneal epithelium can be affected by a multitude of conditions, such as infections, hereditary diseases, depositions, trauma, autoimmune conditions, factitious disorders, and iatrogenic causes. Non-infectious and non-hereditary corneal epithelial diseases represent a collection of conditions with diverse etiologies and clinical presentations but similar patient symptoms. The differing therapeutic interventions for each condition make clinical distinction important. The clinical characteristics, disease course, pathophysiology and current treatments for non-infectious, non-hereditary corneal epithelial diseases are reviewed.

Orbital abscess caused by Exophiala dermatitidis following posterior subtenon injection of triamcinolone acetonide: a case report and a review of literature related to Exophiala eye infections.

BACKGROUND: Subtenon injection of triamcinolone acetonide (STTA) has been widely adopted in the clinical setting of ophthalmology and its infectious complications are rare. However, orbital abscess following STTA has been reported in seven cases. Furthermore, although eye infections due to Exophiala species are uncommon, there have been 19 cases to date. E. jeanselmei, E. phaeomuriformis, E. werneckii, and E. dermatitidis have been reported to cause human eye infections; however, to the best of our knowledge, orbital abscess caused by E. dermatitidis has not yet been reported. We describe the first documented case of fungal orbital abscess caused by E. dermatitidis following STTA. We also review the related literature of orbital abscess following STTA, as well as eye infections caused by the four Exophiala species. CASE PRESENTATION: The patient was a 69-year-old Japanese woman with diabetic mellitus. She had a macular oedema in her right eye, which occurred secondary to branch retinal vein occlusion. An orbital abscess caused by E. dermatitidis occurred 4 months after the second STTA for the macular oedema, which was successfully treated by a surgical debridement and systemic administration of voriconazole. CONCLUSIONS: Our findings in the patient and from our literature survey caution ophthalmologists to the fact that STTA can cause fungal orbital infections, especially in diabetic patients. Furthermore, surgical treatment is one of the most important risk factors.

[Ocular foreign bodies: Epidemiological, clinical and therapeutic aspects in Lubumbashi: About 98 cases]. / Corps étrangers oculaires : aspects épidémiologiques, clinique et thérapeutique à Lubumbashi : à propos de 98 cas.

PURPOSE: The purpose of this study was to determine the epidemiological, clinical and therapeutic features of ocular foreign bodies in our practice setting. METHODS: We conducted a cross-sectional descriptive study with retrospective data collection at the Sainte Ivonne ophthalmology center in Lubumbashi. We studied 98 medical records of patients seen from January through December 2016 for an ocular foreign body. The parameters used for this study were: age, gender, profession, circumstances of the injury, nature of the foreign body, complications, location, entry site, management and prognosis. RESULTS: The frequency of ocular foreign bodies was 2.4%. We saw predominantly young subjects; the mean age was 33.18±17.98 years. Males predominated, with a frequency of 78.57% of the cases, for a gender ratio of 3.7 men to women. The circumstances of the injuries were primarily work-related (36.46% of cases). The type of foreign body was most commonly wood (41.8% of cases). The FB was corneal in 81.7% of cases, conjunctival (bulbar and tarsal) in 13.3% of cases, and limbal in 5% of cases. Treatment consisted of either simple removal (86.61% of cases) or removal with suturing for deeper foreign bodies (13.27% of cases). The functional results obtained were encouraging; 90.82% of patients recovered well with preservation of visual acuity. The majority of the complications consisted of superficial punctate keratopathy in 27.53% of cases and corneal ulcer in 26.53% of cases. The results of our study are consistent with those in the literature in terms of the frequent corneal location of FB's. CONCLUSION: Ocular foreign bodies represent a situation of non-negligable severity and thus require proper early management in order to prevent progression to visual loss or blindness.

Utility of Neonatal Ophthalmologic Examination for Detection of Infectious Etiologies for Symmetric Intrauterine Growth Restriction.

OBJECTIVE: To determine the utility of ophthalmologic examination as part of evaluation for infection in infants with intrauterine growth restriction (IUGR). STUDY DESIGN: This is a single-institution retrospective chart review of neonates diagnosed with symmetric IUGR or small for gestational age (SGA) who underwent complete ophthalmologic consultation to assess for intraocular findings suggestive of congenital infection. Data collected included other factors that may cause IUGR, findings of general and ophthalmologic examinations, and results of investigation for intrauterine infection. Cost minimization analysis was also performed. RESULTS: One hundred neonates met the study's inclusion criteria (IUGR, n = 24; SGA, n = 45; IUGR and SGA, n = 31). The mean gestational age at birth was 34.6 ± 3.0 weeks, and the mean birth weight was 1691 ± 530 g; 74% had an identifiable risk factor for IUGR and 84 patients underwent investigation for intrauterine infection. Two of the 73 patients who had urine culture for cytomegalovirus (CMV) were positive (1 of whom had systemic signs of severe congenital infection without eye involvement, the other who had no clinical signs of congenital CMV); evaluations for infection were negative otherwise. No patients had any ophthalmologic signs of congenital infection. CONCLUSIONS: Current literature suggests that routine evaluation of neonates with isolated IUGR for congenital infection may be low-yield and not cost-effective. Our study found that routine ophthalmologic evaluation in newborns with symmetric IUGR who have no systemic signs of intrauterine infection is of little value.

[Quantitative evaluation of infectious keratitis by anterior segment optical coherence tomography]. / Évaluation quantitative des kératites infectieuses par tomographie en cohérence optique du segment antérieur.

The clinical evaluation of infectious keratitis takes place largely through biomicroscopic examination, which presents limitations in the evaluation of the depth of the infiltrate and the exact thickness of the cornea, whether edematous or thinned. In this study, we aim to quantify the human corneal inflammatory response in treated infectious keratitis by anterior segment optical coherence tomography (AS-OCT). Patients with infectious keratitis were recruited prospectively in the ophthalmology department of the military hospital of Rabat between November 2017 and May 2019. Over the study period, 32 patients were included. A standardized scanning protocol was used. The thickness of the infiltrate, when present, and corneal thickness in any area of thinning and any surrounding edematous areas were measured. The various thicknesses gradually decreased over the course of follow-up, providing objective evidence of therapeutic efficacy in the early stages. Improvement in corneal edema and thinning was faster in the early stage. AS-OCT scanning can be used along with slit lamp examination to quantify and objectively follow infectious keratitis.

Ocular infection by a psychrophile: Pseudomonas fluorescens.

Accurate identification of infectious pathogens is essential for appropriate management of ocular infections. Routine laboratory protocols typically support bacterial growth at 37°C. We report a case, wherein we serendipitously isolated Pseudomonas fluorescens - an organism that prefers lower temperatures for optimal growth (psychrophilic) in the environment - from eviscerated contents of an eye with total corneal melt. This case highlights the need for being vigilant for organisms with different temperature sensitivities in culture media than that found in routine protocols.

Real-Time Multiplex PCR Analysis in Infectious Uveitis.

Introduction: Infectious uveitis is a serious inflammatory condition that often causes grave ocular morbidity including permanent vision loss and damage to the structures of the eye. The most common causes of infectious uveitis include herpesviruses and Toxoplasma gondii. Traditionally, these infections have been identified and differentiated based on characteristic clinical examination findings; however, there is often overlap between these presentations and the unique cause of a given patient's infection is not always clear. Therefore, a reliable and fast method for definitively diagnosing infectious uveitis would be helpful and potentially sight-saving. Several groups have recently found experimental success with real-time multiplex polymerase chain reaction (PCR) techniques. Methods: A comprehensive review of the literature was undertaken to further understand the current state of real-time multiplex PCR and its clinical use. Search terms including "real time multiplex PCR", "infectious uveitis", and "uveitis diagnosis" were used. Appropriate English-language articles were included in this review. Results: Publications from four main groups (two from the United States, one from Japan, and one from India) citing success with real-time multiplex PCR were compared and contrasted. All four groups used the same technique to develop a highly sensitive and specific multiplex PCR analysis and found that their tests maintained high sensitivity and specificity during validation testing. These tests confirmed clinical suspicions in the majority of cases of infectious uveitis, but there were also cases of clinical misdiagnosis that were corrected based on molecular pathogen detection. These patients were then initiated on appropriate antimicrobial therapy with subsequent clinical improvement. Discussion: Real-time multiplex PCR is a highly sensitive and specific laboratory assay that allows for rapid and reliable molecular diagnosis of causative agents in infectious uveitis. This in turn facilitates swift initiation of effective therapy and prevents long-term ocular damage and vision loss.

A Review of Next-Generation Sequencing (NGS): Applications to the Diagnosis of Ocular Infectious Diseases.

Purpose: To review the value of next-generation sequencing (NGS) in identifying the pathogens which cause ocular infections, thereby facilitating prompt initiation of treatment with an optimal anti-microbial regimen. Both contemporary and futuristic approaches to identifying pathogens in ocular infections are covered in this brief overview. Methods: Review of the peer reviewed literature on conventional and advanced methods as applied to the diagnosis of infectious diseases of the eye. Conclusion: NGS is a novel technology for identifying the pathogens responsible for ocular infections with the potential to improve the accuracy and speed of diagnosis and hastening the selection of the best therapy.

Epidemiologia da conjuntivite no departamento de emergência de um hospital de referência em Goiânia / Epidemiology of conjunctivitis in the emergency department of a reference hospital in Goiânia

RESUMO Objetivo: Avaliar as características das urgências oftalmológicas atendidas no Pronto Socorro do Instituto de Olhos de Goiânia, com destaque à conjuntivite infecciosa, morbidade de maior incidência neste Serviço. Visa ainda delinear as principais etiologias encontradas dentre as conjuntivites infecciosas e compará-las às encontradas em diversos outros serviços de referência em Oftalmologia, norteando, assim, futuros diagnósticos e tratamentos das patologias infecciosas oculares. Métodos: Estudo transversal e retrospectivo, com 783 pacientes atendidos na emergência oftalmológica do Instituto de Olhos de Goiânia, no período de primeiro de maio a 03 de setembro de 2017. Os dados foram coletados por meio de protocolos baseados nos prontuários físicos da emergência oftalmológica do hospital. Resultados: Observou-se que, quanto às causas diagnósticas, a principal foi a conjuntivite aguda, seguida, em ordem decrescente de incidência, por hordéolo e corpo estranho em superfície ocular, com porcentagens, respectivamente, de 10,98% e 9,96%. Dentre os 783 pacientes admitidos na emergência neste período, 302 foram diagnosticados com conjuntivite, representando uma porcentagem de 38,56% da totalidade dos atendimentos. Dentre essas, 226 foram diagnosticados como sendo de etiologia bacteriana e 38 de etiologia viral. Os números absolutos nos levam a uma porcentagem de 74,8% de conjuntivite bacteriana. Conclusão: A conjuntivite infecciosa representa uma porcentagem substancial dentre as patologias admitidas nos serviços de urgência oftalmológica em todo o mundo. No presente estudo houve ainda prevalência da conjuntivite bacteriana, bem como uma tendência irrefutável à instituição precoce de antibioticoterapia tópica. A alta prevalência desta comorbidade e a dificuldade no diagnóstico clínico da etiologia da infecção reitera a necessidade de realização de maiores estudos na área, a fim de otimizar o diagnóstico e a terapêutica da conjuntivite infecciosa.

ABSTRACT Objective: Evaluate the epidemiology of ocular emergencies in a Reference Ophthalmological Hospital in Goiânia, with emphasis on acute infectious conjunctivitis, morbidity with a higher incidence in this Service. It aims to delineate the main etiologies found among infectious conjunctivitis and to compare them with those found in several others Ophthalmology reference services, thus guiding future diagnoses and treatments of ocular infectious diseases. Methods: A cross-sectional and retrospective study was conducted with 783 patients seen at the ophtalmological emergency of the Goiânia Institute of Eyes from May 1 to September 3, 2017. Data were collected through protocols based on physical charts of the ophthalmologic emergency of the hospital. Results: The most common ocular emergencies were acute conjunctivitis, followed in decreasing order of incidence by hordeolum and foreign body on ocular surface, with percentages, respectively, of 10.98% and 9.96%, respectively. Among the 783 patients admitted to the emergency room in this period, 302 were diagnosed with conjunctivitis, representing a percentage of 38.56% of the total number of visits. Of these, 226 were diagnosed as having bacterial etiology (74.8%) and 38 (25.2%) as viral etiology. Conclusion: Infectious conjunctivitis represents a substantial percentage of the pathologies admitted to ophthalmological emergency services worldwide. In the present study there was also a prevalence of bacterial conjunctivitis, as well as an irrefutable tendency to the early institution of topical antibiotic therapy. The high prevalence of this comorbidity and the difficulty in the clinical diagnosis of the etiology of the infection reiterates the need for further studies in the area in order to optimize the diagnosis and treatment of infectious conjunctivitis.

[Panorama of limbal alterations (French translation of the article)]. / Panorama des altérations limbiques cornéennes.

The corneal limbus is a privileged region on the border between two quite different microenvironments, where corneal epithelial stem cells, numerous melanocytes, and antigen-presenting cells are all concentrated within a richly vascularized and innervated stroma. This situation within the ocular surface confers on it the key functions of barrier, epithelial renewal and defense of the cornea. As an immunological crossroads and since the corneoscleral limbus is directly exposed to external insults such as caustic agents, ultraviolet radiation, microbial agents, and allergens, it is the potential site of many tumoral, degenerative or inflammatory pathologies and may progress under certain conditions to limbal stem cell deficiency.

[Efforts to improve the level of clinical diagnosis and treatment of infectious fundus diseases].

In recent years, the incidence of tuberculosis, HIV, syphilis and other infectious diseases has a "rising" trend. The incidence of infectious fundus diseases is also increasing, and missed diagnosis and misdiagnosis are becoming more common. How to diagnose infectious fundus diseases accurately, avoid missed diagnosis and misdiagnosis, carry out standardized treatment in time, carry out research on infectious fundus diseases related to systemic infectious diseases, and save the visual function of patients are the problems we are facing. This article discusses the related issues. (Chin J Ophthalmol, 2019, 55: 241-245).

Association Between Noninfectious Uveitis and Psychological Stress.

Importance: Uveitis involves dysregulation of the ocular immune system. Stress has been shown to affect immune function, but it is unclear whether there is an association between stress and uveitis. Objective: To determine whether having uveitis is associated with psychological stress. Design, Setting, and Participants: A cross-sectional, case-control study including a self-administered survey, medical records review, and diurnal salivary cortisol test was conducted at a university-based uveitis clinic and comprehensive eye clinic. Participants included 146 consecutive adults with noninfectious uveitis and age-matched controls with no eye disease. The study was conducted from December 1, 2017, to March 14, 2018. Main Outcomes and Measures: Participants completed the self-administered, Cohen 10-item Perceived Stress Scale (PSS-10), a demographics questionnaire. Responses to each question were categorized on a 5-point Likert scale, with total scores ranging from 0 (no stress) to 40 (high stress). In addition, participants submitted 3 salivary cortisol samples. Those with uveitis were classified as having recently active or controlled disease through medical records review. The prespecified primary analysis was a linear regression of PSS-10 score and uveitis correcting for age, sex, educational level, employment, and median income. Secondary analyses included comparing PSS-10 scores in patients with recently active and controlled uveitis, determining predictors of stress, and comparing diurnal salivary cortisol between uveitis and control groups. Results: Of 146 eligible patients, 17 declined participation and 9 consented but were excluded because they did not complete both questionnaires, resulting in 120 patients (80 uveitis; 40 controls) in the final analysis. Eighty participants (66.7%) were women, and 70 (58.3%) were white. Median age was 40 years (interquartile range, 29-59 years). Having uveitis was associated with a 4.3-point increase in PSS-10 score (95% CI, 1.8 to 6.9; P = .002). There was no significant difference in PSS-10 scores between patients with recently active and controlled uveitis (1.0 point greater for patients with active uveitis; 95% CI, -2.0 to 3.9; P = .52). Factors associated with increased PSS-10 score in patients with uveitis included female sex (coefficient, 4.0; 95% CI, 1.6 to 6.5; P = .002), current immunomodulatory therapy (coefficient, 2.5; 95% CI, -0.3 to 5.2; P = .08), history of depression (coefficient, 3.8; 95% CI, 0.8 to 6.8; P = .02), and having posterior or panuveitis (coefficient, 2.6; 95% CI, 0.8 to 4.4; P = .006). Of the 70 participants (58.3%) who had testable samples for cortisol analysis, diurnal salivary cortisol levels did not significantly differ between uveitis and nonuveitis groups. Conclusions and Relevance: These findings suggest that patients with uveitis have higher levels of psychological stress compared with controls, yet no significant difference was identified in the stress of patients with active vs controlled uveitis. Consequently, comprehensive treatment for noninfectious uveitis may be able to address the psychological results of this disease.

Infectious uveitis: an Asian perspective.

Several intraocular infections can present with protean manifestations posing major diagnostic and management challenges. Infections such as tuberculosis, dengue and chikungunya fever have continued to remain major endemic diseases that are associated with uveitis in the Asia Pacific region. These entities often require a high index of clinical suspicion and laboratory analysis including assays of ocular fluids and/or tissues for confirmation of the diagnosis. Infectious uveitis caused by tuberculosis, dengue and chikungunya can present with characteristic clinical features and imaging findings on ancillary investigations; that may provide clue to the early diagnosis. Use of modern imaging modalities such as enhanced-depth imaging optical coherence tomography, optical coherence tomography angiography and ultra-wide field fundus photography greatly aid in the evaluation of these conditions. In the current review, we have discussed the epidemiology, clinical phenotypes, imaging characteristics, diagnosis and management of uveitis caused by tuberculosis, dengue and chikungunya.