Challenges in posterior uveitis-tips and tricks for the retina specialist.

PURPOSE: Posterior uveitis is a common chorioretinal pathology affecting all ages worldwide and is a frequent reason for referral to the retina clinic. The spectrum of etiologies for uveitis is very broad and includes infectious and auto-immune diseases. Inflammation can be confined to the eye or may be a part of systemic disease. A useful outline is therefore proposed to aid in the correct diagnosis of these challenging entities. The situation is further complicated by the fact that many neoplastic conditions resemble features of posterior uveitis; they are known as "masqueraders of uveitis". Here, we summarize different posterior uveitides that present with rare findings, along with masqueraders that can be difficult to distinguish. These conditions pose a diagnostic dilemma resulting in delay in treatment because of diagnostic uncertainty. METHODS: An extensive literature search was performed on the MEDLINE/PUBMED, EBSCO and Cochrane CENTRAL databases from January 1985 to January 2022 for original studies and reviews of predetermined diagnoses that include posterior uveitic entities, panuveitis and masquerade syndromes. RESULTS: We described conditions that can present as mimickers of posterior uveitis (i.e., immune check-points inhibitors and Vogt-Koyanagi-Harada-like uveitis; leukemia and lymphoma associated posterior uveitis), inflammatory conditions that present as mimickers of retinal diseases (i.e., Purtscher-like retinopathy as a presentation of systemic lupus erythematosus; central serous chorioretinopathy masquerading inflammatory exudative retinal detachment), and uveitic conditions with rare and diagnostically challenging etiologies (i.e., paradoxical inflammatory effects of anti-TNF-α; post vaccination uveitis; ocular inflammation after intravitreal injection of antiangiogenic drugs). CONCLUSION: This review of unique posterior uveitis cases highlights the overlapping features of posterior uveitis (paradoxical inflammatory effects of anti -TNF α and uveitis; Purtscher-like retinopathy as a presentation of systemic lupus erythematosus, …) and the nature of retinal conditions (ischemic ocular syndrome, or central retinal vein occlusion, amyloidosis, inherited conditions like retinitis pigmentosa, autosomal dominant neovascular inflammatory vitreoretinopathy (ADNIV), etc.…) that may mimic them is represented. Careful review of past uveitis history, current medications and recent vaccinations, detailed examination of signs of past or present inflammation, eventually genetic testing and/ or multimodal retinal imaging (like fluorescein angiography, EDI-OCT, OCT-angiography for lupus Purtscher-like retinopathy evaluation, or ICG for central serous retinopathy, or retinal amyloid angiopathy) may aid in correct diagnosis.

Herpes zoster ophthalmicus: frequency and risk factors for developing uncommon ocular manifestations.

OBJECTIVE: To determine the frequency of herpes zoster ophthalmicus (HZO) and assess risk factors for developing uncommon ocular manifestations of laboratory-verified HZO. DESIGN: Retrospective cohort study. METHODS: The frequency of HZO out of all herpes zoster cases was calculated using International Classification of Diseases codes for patients seen at the University of Pittsburgh Medical Center from January 1, 2004 to October 31, 2021. We also collected demographic and clinical data of patients with HZO identified by polymerase chain reaction (PCR) detection of varicella zoster virus from January 1, 2011 to December 31, 2020. RESULTS: The frequency of HZO from 2004 to 2021 in all ages was 4.2% and ranged from 2.7% to 6.7% annually, with a consistent increase of 2.9% from 2012 to 2021. After the live zoster vaccine became available in 2008, the frequency of HZO decreased by 5.1% from 2008 to 2012 in patients aged 60 and older. Among 50 cases of PCR-verified HZO, 62% represented clinically-common ocular manifestations, mostly comprised of 13 cases of keratitis and 10 cases of anterior uveitis. Fifteen cases of acute retinal necrosis (ARN) represented the majority of uncommon HZO manifestations (38%), which were significantly more likely to occur in immunosuppressed patients (unadjusted odds ratio 4.55, 95% confidence interval 1.29-13.83). CONCLUSIONS: The overall frequency of HZO from 2004 to 2021 was 4.2% and has increased annually since 2012. Uncommon ocular manifestations of PCR-verified HZO, mostly comprised of ARN, were more likely to occur in immunosuppressed patients.

Investigation of the Use of Non-Invasive Samples for the Molecular Detection of EHV-1 in Horses with and without Clinical Infection.

The purpose of this study was to explore sampling options for a reliable and logistically more feasible protocol during a large EHV-1 outbreak. Seventeen horses with clinical infection as well as nineteen healthy herdmates, all part of an EHM outbreak, were enrolled in the study. Each horse was sampled two-four times at intervals of 2-6 days during the outbreak. All samples were collected using 6'' rayon-tipped swabs. Nasal secretions were used as the diagnostic sample of choice. Additional samples, including swabs from the muzzle/nares, swabs from the front limbs, rectal swabs, swabs of the feed bin, and swabs of the water troughs were collected as well. All swabs were tested for the presence of EHV-1 by qPCR. With the exception of two EHV-1 qPCR-positive swabs from two different horses, all remaining swabs collected from healthy herdmates tested qPCR-negative for EHV-1. For horses with clinical infection, EHV-1 was detected in 31 nasal swabs, 30 muzzle/nares swabs, 7 front limb swabs, 7 feeders, 6 water troughs and 6 rectal swabs. Not all positive muzzle/nares swabs correlated with a positive nasal swab from the same set, however, and all other positive swabs did correlate with a positive nasal swab in their respective set. The agreement between nasal swabs and muzzle/nares swabs was 74%. The sampling of non-invasive swabs from the muzzle/nares should facilitate the identification of EHV-1 shedders during an outbreak, allowing for prompt isolation and implementation of biosecurity measures.

Prospective Randomized Crossover Trial Comparing Continuous and Cyclic Stimulation in InterStim Therapy.

OBJECTIVES: The aim of this study was to assess a difference in efficacy and patient preference in cyclic versus continuous stimulation with InterStim therapy for urge incontinence or urinary frequency. METHODS: Patients with refractory urge incontinence/urinary frequency and with recent implantation of the InterStim system were randomized to continuous or cyclic InterStim stimulation after institutional review board-approved consent. They completed a 3-day voiding diary after 1 month of stimulation. They were then switched to the alternative setting for 1 month and completed another voiding diary. Subjective responses were evaluated with the Urinary Incontinence Impact Questionnaire and the Urinary Distress Inventory. Patient preference of stimulation setting was assessed. Statistical analysis was performed with paired t tests and repeated-measures analysis of variance. RESULTS: Data were available for 32 patients. Indication for InterStim: urge incontinence = 24, frequency = 8. No differences were noted in the number of urgency or urge incontinence episodes (mild, moderate, severe, or total) with cyclic or continuous stimulation. No differences were noted in the number of number of pads per day or the number of daytime or nighttime voids. The Urinary Incontinence Impact Questionnaire and Urinary Distress Inventory symptoms scores showed no significant differences between cyclic and continuous stimulation. No significant difference was noted in measured parameters based on the order of stimulation. Continuous stimulation was preferred by 17 patients, 9 preferred cyclic stimulation, and 6 had no preference. CONCLUSIONS: No significant differences were noted in voiding diaries and subjective responses between cyclic and continuous stimulation in InterStim therapy for patients with urge incontinence or frequency.

The effect of age and medical comorbidities on in vitro myoblast expansion in women with and without pelvic organ prolapse.

INTRODUCTION: This is an observational study is designed to assess the influence of age, prolapse and medical co-morbidities on myogenic stem cells growth in-vitro. METHODS: A biopsy of the rectus abdominus muscle was obtained during surgery in patients with and without pelvic organ prolapse (POP). Nuclei number and fiber count were correlated with patient's age, presence of POP, and medical comorbidities. Efficiency of expansion of myogenic stem cells in vitro was calculated. The percentage of Pax7-, MyoD-, and desmin-positive cells was correlated with age, POP status, and medical comorbidities. RESULTS: A total of 17 specimens were obtained; 13 specimens were available for histologic analysis. There was no correlation between patient's age, POP status or medical comorbidities and nuclei or fiber count, growth rate, or the percentage of Pax7- and MyoD-positive cells. Patients with 2 to 4 medical comorbidities were noted to have a significantly lower percentage of desmin-positive cells. Specimens with a higher nuclear count had significantly better cellular expansion. Data were analyzed using Kruskal-Wallis or Wilcoxon rank sum statistics. CONCLUSIONS: Multiple medical comorbidities but not patient's age or POP status influenced in vitro myogenic stem cell growth. These data suggest that patients with advancing age or POP may be acceptable autologous donors if treatment of urinary or anal incontinence requires myoblast transplantation.

Comparison of the cough stress test and 24-h pad test in the assessment of stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: The 24-h pad test and cough stress test are commonly used to assess stress urinary incontinence; however, no comparative data are available. The cough stress test is superior to the 24-h pad test. METHODS: Women with predominant stress urinary incontinence symptoms underwent a cough stress test, a 24-h pad test, and urodynamic testing. RESULTS: Complete data were available on 55 women. Agreement between the urodynamic results and the stress test occurred in 89% of women (k = 0.51). Sensitivity, specificity, and positive and negative predictive values were 90%, 80%, 98%, and 44%. Agreement between the urodynamic results and the pad test occurred in 60% of women (k = 0.08). Sensitivity, specificity, and positive and negative predictive values were 60%, 60%, 94%, and 13%. Agreement between the cough stress test and the pad test occurred in 67% (k = 0.26). CONCLUSIONS: The cough stress test is more reliable than the pad test for documentation of stress urinary incontinence.