Adjunctive Intravitreal Anti-vascular Endothelial Growth Factor and Moxifloxacin Therapy in Management of Intraocular Tubercular Granulomas.

PURPOSE: To report pre and post treatment levels of VEGF-A in the aqueous humour of patients with intraocular tubercular granulomas and study the effect of a combined intravitreal anti-VEGF bevacizumab and moxifloxacin therapy on their regression. METHODS: Aqueous samples of 10 consecutive patients with intraocular tubercular granulomas obtained before and after initiating treatment were subjected to ELISA for analysing intraocular VEGF-A levels. Intravitreal injections of bevacizumab and moxifloxacin were given weekly till complete regression of these granulomas. All patients received the usual four-drug ATT and oral corticosteroids. RESULTS: Mean baseline VEGF-A level was 1004.27±411.40 pg/ml (401.32-1688.95) that reduced significantly to 27.62±46.86 pg/ml (6.9-131.83) at the last injection. Meannumber of intravitreal injections was 3.1 (2-4). We found significant correlation of decreasing levels of aqueous VEGF-A with the clinical regression of these tubercular granulomas. CONCLUSIONS: Intraocular TB granulomas have high levels of VEGF-A. Weekly intravitreal injections of anti-VEGF bevacizumab with moxifloxacin as an adjunct to the standard care may cause prompt regression of tubercular granulomas. ABBREVIATIONS: TB: Tuberculosis; IOTB: Intraocular tuberculosis; VEGF: Vascular endothelial growth factor; RD: Retinal detachment; Mtb: Mycobacterium tuberculosis; ATT: Antitubercular therapy; AMD: Age-related macular degeneration; SRF: Subretinal fluid; ELISA: Enzyme immunosorbent assay; PCR: Polymerase chain reaction; ONH: Optic nerve head; MDR-TB: Multidrug-resistant tuberculosis; pg/ml: picogram/milliliter; ESR: Erythrocyte sedimentation rate; CECT: Contrast enhanced computed tomography; DNA: Deoxyribonucleic acid; RNA: Ribonucleic acid; BSL: Biosafety level; BCVA: Best corrected visual acuity; HM: Hand movements; KP: Keratic precipitates; PSC: Posterior subcapsular cataract; PS: Posterior synechiae; CRA: Chorio-retinal atrophy; IVMP: Intravenous methyl prednisolone; OCT: Optical coherence tomography; RPE: Retinal pigment epithelium; FFA: Fundus fluorescein angiography; ICG: Indocyanine angiography; RAP: Retinal arterial proliferans.

Immunological consequences of compromised ocular immune privilege accelerate retinal degeneration in retinitis pigmentosa.

BACKGROUND: Retinitis pigmentosa (RP) is a hereditary retinal disease which leads to visual impairment. The onset and progression of RP has physiological consequences that affects the ocular environment. Some of the key non-genetic factors which hasten the retinal degeneration in RP include oxidative stress, hypoxia and ocular inflammation. In this study, we investigated the status of the ocular immune privilege during retinal degeneration and the effect of ocular immune changes on the peripheral immune system in RP. We assessed the peripheral blood mononuclear cell stimulation by retinal antigens and their immune response status in RP patients. Subsequently, we examined alterations in ocular immune privilege machineries which may contribute to ocular inflammation and disease progression in rd1 mouse model. RESULTS: In RP patients, we observed a suppressed anti-inflammatory response to self-retinal antigens, thereby indicating a deviated response to self-antigens. The ocular milieu in rd1 mouse model indicated a significant decrease in immune suppressive ligands and cytokine TGF-B1, and higher pro-inflammatory ocular protein levels. Further, blood-retinal-barrier breakdown due to decrease in the expression of tight junction proteins was observed. The retinal breach potentiated pro-inflammatory peripheral immune activation against retinal antigens and caused infiltration of the peripheral immune cells into the ocular tissue. CONCLUSIONS: Our studies with RP patients and rd1 mouse model suggest that immunological consequences in RP is a contributing factor in the progression of retinal degeneration. The ocular inflammation in the RP alters the ocular immune privilege mechanisms and peripheral immune response. These aberrations in turn create an auto-reactive immune environment and accelerate retinal degeneration.

Clinical Presentations and Management Outcomes of Culture-Proven Mixed Bacterial and Fungal Endophthalmitis.

OBJECTIVE: To report the clinical features and management outcomes of mixed fungal and bacterial endophthalmitis. METHODS: Retrospective, consecutive non-comparative case series. Fifteen eyes of 15 patients were included from January 2009 to December 2019 with culture proven mixed fungal and bacterial endophthalmitis. Demography, clinical presentations, interventions received, and final visual and anatomical outcomes were noted. A favorable anatomic outcome was defined as preservation of the globe, absence of hypotony, attached retina, and absence of active inflammation at the last visit. RESULTS: The mean age of patients in this series was 34.2 ± 19.6 years (range: 5-61 years). Male preponderance was found in 14 (93.3%). Eight (53.3%) eyes had open globe injury, 5(33.3%) had postoperative endophthalmitis and one (6.6%) each with endogenous endophthalmitis and post-keratitis. Pars plana vitrectomy was done in eight (53.3%) eyes whereas vitreous tap alone was done in seven (46.7%) eyes. Gram positive cocci (n = 11, 73.3%) were the commonest bacterial isolates (n = 7, 46.6%). Staphylococcus aureus (n = 3, 20%) was the most common bacterial isolate. The commonest fungi were filamentous hyaline fungi (n = 5, 33.3%). An unfavorable visual outcome (VA<20/400) was seen in all the eyes. The mean duration of follow-up was 13 ± 18.3 months. Globe salvage was possible only in five (33.3%) eyes. The bacterial isolates were highly sensitive to all of the tested antibiotics. CONCLUSION: Mixed fungal and bacterial endophthalmitis occur commonly in a setting of open-globe trauma. The presence of fungus concurrently leads to a very poor management outcome even if the bacterial isolate sensitivity is good.

An analysis of an educational method to improve the shade-matching ability of dental students.

STATEMENT OF PROBLEM: The predoctoral dental curriculum includes didactic lectures, demonstrations, and training on shade-matching techniques and protocols. However, a significant percentage of esthetic failures are still observed clinically. An assessment is required to determine whether reevaluation and modification of this training protocol would help future dental practitioners better perceive and communicate the dental shade. PURPOSE: The purpose of this study was to evaluate dental students' knowledge of and skill in shade selection and effective prescription writing before and after educational training with 3 different shade guides. MATERIAL AND METHODS: Thirty predoctoral dental students (interns) who had completed their academic program and were undergoing clinical training were selected. After excluding color vision deficiency, the study participants were first asked to evaluate the shade of the right maxillary central incisor of 5 patient participants by using 3 different shade guides (Vitapan Classical, Vitapan 3D-MASTER, Chromascop) under standardized conditions. They were then asked to write an esthetic prescription, communicating the shade to a dental laboratory technician. A dental faculty member evaluated the baseline control shade for each participant, and a standardized prescription format was written. This was used as a reference by a dental laboratory technician to score the intern's prescription as clear, unclear, poor, or illegible. After the assessment, focused small group learning with lectures, clinical demonstrations, and case-based discussion was provided to the interns on shade assessment over 10 to 15 days. All the interns were reassessed for their visual shade perception and prescription writing after a month's interval. The mean percentage agreement, mean percentage shade match, and mean color difference between the shade selected and the control shade for each of the 5 participants, with all 3 shade guides, were evaluated along with the prescription scoring before and after the educational training. Statistical comparison of before and after values were made by using the paired-sample z-test for percentage agreement versus disagreement among the interns for the shade selected, paired t test for mean percentage agreement, mean percentage shade match, and mean color difference. The repeated measure ANOVA test was used for the prescription scorings (α=.05). RESULTS: A significant difference in prescription scoring (P<.001) was observed. A significant difference in the percentage shade match (P<.01) for all 3 shade guides and mean percentage agreement for Chromascop and Vita 3D-MASTER (P<.05) were observed. A nonsignificant mean color difference between the shade selected by the intern and the baseline shade was observed. CONCLUSIONS: A significant difference in prescription scoring was observed after training, along with a higher percentage shade match and percentage agreement. This indicated a need to reconsider the educational training provided for dental shade assessment and communication and to implement better protocols in the dental curriculum.

Correlation of vascular endothelial growth factor with the clinical regression of tubercular granuloma.

Tubercular granulomas are a common manifestation of intraocular tuberculosis. These are said to be hypoxic granulomas with increased expression of vascular endothelial growth factor (VEGF). Management of these granulomas includes a combination of antitubercular therapy (ATT) and oral corticosteroids. We report a case of tubercular granuloma with exudative retinal detachment which was treated with weekly intravitreal anti-VEGF and antibiotic injections along with ATT and corticosteroids. The VEGF levels measured paralleled with the clinical regression of the granuloma.

Branch Retinal Artery Occlusion as a presenting sign of Acute Retinal Necrosis: a rare association.

BACKGROUND: Acute retinal necrosis (ARN) is a potentially blinding necrotizing viral retinitis. It starts with one or more foci and spreads circumferentially and involves the posterior pole in the later stages. Vascular occlusions such as branch retinal artery occlusion, central retinal artery occlusion, and central retinal vein occlusion may occur secondary to underlying infectious etiology such as ARN. FINDINGS: An elderly male patient with a history of coronary artery disease was diagnosed with branch retinal artery occlusion (BRAO) in the right eye and referred to the treating cardiologist. Few days later, he complained of diminution of vision in the left eye which made him seek another consultation when he was diagnosed to have ARN in the left eye, encroaching the posterior pole. He was investigated and treated for the same leading to minimal improvement of vision in the left eye possibly due to a delay in the starting of the anti-viral therapy. CONCLUSION: We report this case to highlight that occlusive vasculopathy can be a presenting sign of an underlying infectious etiology in any age group. BRAO was a rare presenting sign of ARN in our patient. A thorough peripheral examination is recommended in order to avoid missing infectious pathologies such as ARN which starts from the retinal periphery, progresses fast, and if not managed on time may lead to permanent loss of vision.

Tinea corporis infection manifestating as retinochoroiditis-an unusual presentation.

BACKGROUND: Tinea corporis, a superficial dermatophyte, is a fungal infection of the body. Ocular involvement due to dermatophytes can present as eyelid infestation. Various cases of retinochoroiditis have been reported secondary to infective etiology such as Toxoplasma gondii, Candida albicans, Trichosporon beigelii, and Sporotrichum schenkii. However, retinochoroiditis secondary to fungal infection of the skin caused by T. corporis has not been reported in the past. FINDINGS: A 45-year-old female presented with blurring of vision in the left eye for the last 20 days with a history of very severe itching on the abdomen and back. She had been diagnosed to have T. corporis infection by a dermatologist in the past, however, was non-compliant with the treatment. Anterior segment was within normal limits. Fundus examination of the right eye was normal and left eye showed a diffuse yellowish retinochoroiditis patch with irregular margins at the inferotemporal arcade. Optical coherence tomography (OCT) of the left eye through the macula showed shallow subretinal fluid with hyperreflective dots and passing through the retinochoroitidis patch showed increased retinal thickening with a pigment epithelial detachment and subretinal fluid. Left eye fundus fluorescein angiography (FFA) showed three hyperfluorescent areas along the inferotemporal arcade increasing in size and intensity with blurring of margins in the late phases. She had extensive reddish color erythematous plaque-like skin lesions over the abdomen and back. Treatment with oral itraconazole resulted in complete resolution of retinochoroiditis. Itraconazole is an orally active, triazole anti-fungal agent found to be effective in the management of dermatomycosis. CONCLUSION: We report this case to highlight that one must rule out an infective etiology of retinochoroiditis before starting oral corticosteroids as it may worsen the infection especially fungal as in our patient. A detailed medical history and thorough examination helped us in diagnosing a systemic infective pathology and the possible cause of retinochoroiditis. To the best of our knowledge, this is the first case of infective retinochoroiditis secondary to T. corporis to be reported.

The blinding bug found in the eye.

Tubercular uveitis is a common manifestation of tuberculosis (TB) in TB-endemic countries. Due to lack of gold standard diagnostic tests for confirming intraocular TB, it is often either underdiagnosed or rarely over diagnosed. We report a case of a 28-year-old woman with diminution of vision in the left eye. She was started on antitubercular treatment (ATT) and steroids but she did not comply with the treatment. She developed progressive painful loss of vision consequently and was treated with vitrectomy and silicone oil tamponade. After a complete course of ATT, she recovered, salvaging of eye and restoration of some vision was possible. Mycobacterium tuberculosis is rarely demonstrated in the ocular fluid samples of the suspected cases of TB due to the paucibacillary nature of the disease. A vitreous sample can be obtained from these patients. Surgical intervention in the form of vitrectomy and silicone oil tamponade can help in avoiding enucleation/evisceration.

Surgical and visual outcomes of posterior dislocated lens fragments after cataract surgery during 5-years at a tertiary eye hospital of North India.

OBJECTIVE: To determine the surgical and visual outcomes of posteriorly dislocated lens fragments in the vitreous cavity in patients undergoing cataract surgery. METHODS: A total of 149 eyes of 149 patients from 2013 to 2018 were included in the study. The primary cataract surgery was performed either at the base hospital and its peripheral centres or referred from elsewhere. Pars plana vasectomy and nucleus removal was performed along with implantation of intraocular lens, wherever possible. Success was defined as best corrected visual acuity (BCVA) ≥ 6/12 at 3 months follow up. Poor visual outcome was defined as per WHO guidelines as BCVA ≤ 3/60. RESULTS: Posterior capsular rupture and dislocation into vitreous cavity most frequently occurred during phaco-fragmentation in cases of phacoemulsification and during nucleus delivery in cases of small incision cataract surgery. Early vitrectomy was performed within 3 days in 36.2% of cases and within 14 days in 63.8% of cases. Successful visual outcome was achieved in 85.2% of patients at 3 months follow up after vitrectomy. Iatrogenic retinal break occurred in five patients during vitrectomyand five patients had retinal detachment. Poor visual outcome was observed in 12eyes, out of which glaucomatous optic neuropathy seen in 5 cases, cystoid or diabeticmacular edema in 4 cases and age related macular degeneration in 3 cases. CONCLUSION: Posterior dislocation of lens can be successfully managed in majority of cases with vitreoretinal surgical intervention. The timing of vitrectomy whether performed early or late did not affect the visual outcome. The most important predictorof final visual acuity after PPV for retained lens fragments is a less complicated clinical course without any associated complications such as retinal detachment, cystoidmacula edema and glaucoma. Expertise of the primary cataract surgeon could not be assessed in this study, though surgeon grade with more experience is an important factor in the assessment of complications during the cataract surgery.

Choroidal structural analysis in eyes with diabetic retinopathy and diabetic macular edema-A novel OCT based imaging biomarker.

PURPOSE: To evaluate structural changes in the choroid among patients with diabetic macular edema (DME), with varying grades of diabetic retinopathy (DR), using enhance depth imaging spectral domain optical coherence tomography (EDI SD-OCT) scans. METHODS: A cross-sectional study was conducted on 82 eyes with DR and DME and 86 healthy control eyes. Eyes with DME were classified according to the severity of DR as per the international DR severity scale. Sub foveal choroidal thickness (SFCT)was obtained using EDI SD-OCT scans. These scans were binarized into luminal and stromal areas, to derive the choroidal vascularity index (CVI). CVI and SFCT were analyzed between the study and control group using paired-T test. Tukey's test was used to correlate the differences in CVI and SFCT between different grades of DR. Further analysis was done to look for the effect of DR severity and type of DME on CVI as well as SFCT using correlation coefficient and linear regression analysis. RESULTS: SFCT was significantly increased in eyes with DME as compared to the controls (334.47±51.81µm vs 284.53±56.45µm, p<0.001), and showed an ascending trend with worsening of DR, though this difference was not statistically significant [mild non-proliferative diabetic retinopathy (NPDR) = 304.33±40.39µm, moderate NPDR = 327.81±47.39µm, severe NPDR = 357.72±62.65µm, proliferative DR (PDR) = 334.59±47.4µm, p-0.09]. CVI was significantly decreased in DME with DR eyes as compared to controls (63.89±1.89 vs 67.51±2.86, p<0.001). CVI was also significantly decreased with worsening DR (mild NPDR = 66.38±0.3, moderate NPDR = 65.28±0.37, severe NPDR = 63.50±0.47, PDR = 61.27±0.9, p<0.001). CONCLUSION: SFCT and CVI are dynamic parameters that are affected by DME. Unlike CVI, SFCT is also affected by ocular and systemic factors like edema and hypertension. CVI may be a more accurate surrogate marker for DME and DR and can potentially be used to monitor the progression of DR.