Three cases of recalcitrant Paecilomyces keratitis in Southern California within a short period.

BACKGROUND: The aim of this report is to describe the risk factors, clinical course, and characteristics of three cases of Paecilomyces keratitis presenting concurrently within three months in the same location. We used in vivo confocal microscopy and histopathology to corroborate our clinical findings. OBSERVATIONS: Three eyes of three elderly patients with culture-proven Paecilomyces keratitis were included in this series. These patients resided within a 15-mile radius and presented to a tertiary care eye institute in Southern California between February and April 2022. All three eyes experienced a prolonged, recalcitrant course with recurrence of keratitis in donor corneal tissue despite antifungal therapy and multiple therapeutic penetrating keratoplasties. In vivo confocal microscopy, histopathology, and microbiologic findings corroborated the diagnosis of fungal keratitis with Paecilomyces. With surgical intervention and extensive medical therapy, all three cases resolved after the addition of oral Posaconazole. CONCLUSIONS: Paecilomyces is a rare cause of infectious keratitis. Herein we report three similar cases in elderly patients. All had prolonged, recalcitrant infections that required multiple treatment modalities. Our cases, which were supported by in vivo confocal microscopy and histopathology, highlight the importance of timely and aggressive therapy to prevent recurrence.

Genome editing in the treatment of ocular diseases.

Genome-editing technologies have ushered in a new era in gene therapy, providing novel therapeutic strategies for a wide range of diseases, including both genetic and nongenetic ocular diseases. These technologies offer new hope for patients suffering from previously untreatable conditions. The unique anatomical and physiological features of the eye, including its immune-privileged status, size, and compartmentalized structure, provide an optimal environment for the application of these cutting-edge technologies. Moreover, the development of various delivery methods has facilitated the efficient and targeted administration of genome engineering tools designed to correct specific ocular tissues. Additionally, advancements in noninvasive ocular imaging techniques and electroretinography have enabled real-time monitoring of therapeutic efficacy and safety. Herein, we discuss the discovery and development of genome-editing technologies, their application to ocular diseases from the anterior segment to the posterior segment, current limitations encountered in translating these technologies into clinical practice, and ongoing research endeavors aimed at overcoming these challenges.

Cytomegalovirus retinitis after treatment with topical difluprednate in an aphakic eye of an immunocompetent patient.

PURPOSE: To report a case of an immunocompetent 64-year-old man who developed cytomegalovirus (CMV) retinitis after using topical difluprednate. OBSERVATIONS: A 64-year-old man with type 2 diabetes developed hemorrhagic retinitis while using topical difluprednate after penetrating keratoplasty. Polymerase chain reaction of the vitreous was positive for CMV DNA. Complete blood count was within normal limits and 4th generation human immunodeficiency virus assay was negative. The retinitis resolved with oral valgancyclovir and intravitreal foscarnet injections. CONCLUSION AND IMPORTANCE: CMV retinitis may occur after topical difluprednate in an immunocompetent patient.

Research in Uveitis and Ocular Inflammation, 2011 to 2012.

PURPOSE: This study was aimed to provide ophthalmologists with an update of recent research and developments in the areas of ocular immunology and uveitis. DESIGN: This is a literature review. METHODS: A 1-year search (July 1, 2011, to June 30, 2012) of the English language literature on PubMed was conducted using the search terms ocular immunology, ocular inflammation, uveitis, iritis, iridocyclitis, intermediate uveitis, posterior uveitis, panuveitis, pediatric uveitis, scleritis, choroiditis, retinitis, uveitic glaucoma, uveitic cataract, hypotony, immunomodulators, immunosuppressive therapy, corticosteroids, drug-induced uveitis, sarcoidosis, toxoplasmosis, tuberculosis, syphilis, herpes simplex virus, herpes zoster virus, cytomegalovirus, optical coherence tomography, mucous membrane pemphigoid, experimental autoimmune uveitis, and endotoxin-induced uveitis. Approximately 10% of articles studied were included in this article. RESULTS: This review incorporates original articles encompassing new insights and updates to the field of uveitis and ocular immunology. Particular consideration was given to randomized, controlled clinical trials as well as analyses of larger cohorts; however, smaller studies and case reports involving new aspects of treatment/diagnosis or expanding the understanding of disease processes were also included. CONCLUSIONS: Review of the literature reflected an improved understanding of uveitic disease and treatments, especially in the areas of immunomodulatory therapy, uveitic cystoid macular edema, toxoplasmosis, and sarcoidosis. Results from the Systemic Immunosuppressive Therapy for Eye Diseases Study and the Multicenter Uveitis Steroid Treatment trial, especially, yielded useful information in a number of areas. By its nature, this review cannot be all inclusive but is meant to focus on the literature and results most relevant to ophthalmologists in practice.

Baylisascaris Procyonis Induced Diffuse Unilateral Subacute Neuroretinitis in New York City.

Diffuse unilateral subacute neuroretinitis (DUSN) secondary to raccoon roundworm (Baylisascaris procyonis) infection has been reported in rural and suburban areas of North America and Europe with extant raccoon populations. Here, we present a case of Baylisascaris-induced DUSN from the densely populated borough of Brooklyn in New York City and alert urban ophthalmologists to consider this etiology even in areas not typically thought to be associated with endemic risk factors. Infected raccoons also occur in urban settings, and urban patients may be exposed in surrounding areas. Most patients with Baylisascaris ocular larva migrans-DUSN will not have concomitant neurologic disease; this fact and larval neurotropism are both misconceptions regarding this infection.

Incidence of cystoid macular edema after cataract surgery in patients with and without uveitis using optical coherence tomography.

PURPOSE: To determine the incidence of cystoid macular edema (CME) after cataract surgery among eyes with and without uveitis using optical coherence tomography (OCT) and to determine risk factors for postoperative CME among eyes with uveitis. DESIGN: Prospective, comparative cohort study. METHODS: Single-center, academic practice. Forty-one eyes with uveitis and 52 eyes without uveitis underwent clinical examination and OCT testing within 4 weeks before cataract surgery and at 1-month and 3-month postoperative visits. The main outcome measure was incidence of CME at 1 and 3 months after surgery. RESULTS: Both uveitic and control eyes gained approximately 3 lines of vision (P = .6). Incidence of CME at 1 month was 12% (5 eyes) for uveitis and 4% (2 eyes) for controls (P = .2). Incidence of CME at 3 months was 8% (3 eyes) for uveitis and 0% for eyes without uveitis (P = .08). Eyes with uveitis treated with perioperative oral corticosteroids had a 7-fold reduction in postoperative CME (relative risk [RR], 0.14; P = .05). In uveitic eyes, active inflammation within 3 months before surgery increased the risk of CME when compared with eyes without inflammation (RR, 6.19; P = .04). CME was significantly associated with poorer vision (P = .01). CONCLUSIONS: Eyes with well-controlled uveitis may obtain similar outcomes to control eyes after cataract surgery (up to 3 months). Use of perioperative oral corticosteroids and control of uveitis for more than 3 months before surgery seemed to decrease the risk of postoperative CME among uveitic eyes in this study.

A method of reporting macular edema after cataract surgery using optical coherence tomography.

OBJECTIVE: To validate a method of reporting postcataract macular edema (ME) using optical coherence tomography (OCT). METHODS: : Data were analyzed for 130 eyes followed prospectively for ME after uncomplicated cataract surgery. Each eye underwent OCT within 4 weeks before surgery and at 1 month and 3 months after surgery. ME was defined by observation of cystoid changes by OCT. RESULTS: Incidence of ME was 14% (95% confidence interval, 8-20). Average increase in baseline center point thickness (CPT) +/- SD at 1 month for eyes with and without ME was 202 +/- 113 microm and 8 +/- 19 microm, respectively (P < 0.001), which resulted in a 1-letter loss (-0.02 logMAR [logarithm of the minimum angle of resolution]) and a 3-line gain (0.29 logMAR) in vision, respectively (P < 0.001). Percent change in baseline CPT +/- SD for eyes with and without ME was 115 +/- 67% and 6 +/- 11%, respectively (P < 0.001). A > or =40% increase in baseline CPT accurately determined 100% of eyes with ME and 99% of eyes without ME. CONCLUSIONS: A > or =40% increase in baseline CPT, determined by OCT, offers a valid and objective method of reporting clinically relevant postcataract ME. Standardized reporting of postcataract ME would allow objective assessment and comparison of treatment outcomes among clinical studies.

Comparison of antimetabolite drugs as corticosteroid-sparing therapy for noninfectious ocular inflammation.

PURPOSE: To compare the relative effectiveness and side effect profiles of antimetabolite drugs in the treatment of noninfectious ocular inflammation. DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 257 patients with inflammatory eye disease seen in a single-center, academic practice and treated with an antimetabolite as a first-line immunosuppressive agent from 1984 to 2006. METHODS: Data recorded included demographics, antimetabolite and prednisone doses, use of other immunosuppressive drugs, response to therapy, and side effects associated with drug use. MAIN OUTCOME MEASURES: Ability to control ocular inflammation and to taper prednisone to

Smoking as a risk factor for cystoid macular edema complicating intermediate uveitis.

PURPOSE: To describe risk factors for the presence of cystoid macular edema (CME) among patients presenting with intermediate uveitis. DESIGN: Cross-sectional study. SETTINGS: Single-center, academic practice. STUDY POPULATION: Two hundred and eight patients with intermediate uveitis evaluated from July 1, 1984 through September 30, 2006. PROCEDURES: Clinical and demographic data were entered retrospectively into a database and analyzed. OUTCOME MEASURES: Presence of CME at presentation to our clinic; risk factors for presenting with CME. RESULTS: Of the 208 patients, 74% had bilateral intermediate uveitis, yielding 363 affected eyes. Eighty-nine patients (43%) had CME in at least one eye at the time of presentation to our clinic. After controlling for potentially confounding variables including demographics, duration of disease, active intraocular inflammation, history of diabetes mellitus or hypertension, and presence of epiretinal membrane, actively smoking at presentation was associated with a four-fold increased risk of CME at presentation vs never smoking (odds ratio (OR), 3.90; 95% confidence interval (CI), 1.43, 10.66; P = .008). Former smoking also appeared to increase the risk of CME at presentation in the multivariate analysis, but the result was of borderline statistical significance (OR, 1.97; 95% CI, 0.99, 3.94; P = .055). After adjusting for confounding, there was a 4% increased risk of CME at presentation for each cigarette smoked per day (OR, 1.04; 95% CI, 1.01, 1.7; P = .005). CONCLUSIONS: CME was a common structural ocular complication observed in our cohort. Current smoking was associated with a dose-dependent increased risk of having CME at the time of presentation to our clinic.

Loss of visual field among patients with birdshot chorioretinopathy.

PURPOSE: To describe the prevalence and incidence of loss of visual field among patients with birdshot chorioretinopathy (BSCR) and to describe the effect of therapy on such field loss in these patients. DESIGN: Retrospective cohort study. SETTING: Single-center, academic practice. STUDY POPULATION: Fifty-five patients with BSCR evaluated from January 1984 through July 2006. PROCEDURES: Demographic, clinical, and visual field data were collected retrospectively. OUTCOME MEASURES: Visual field loss is defined as an abnormal visual field score on Goldmann perimetry within six months of presentation and during follow-up; rate of visual field loss is defined as the number of degrees lost per year. RESULTS: Forty-eight eyes of 24 patients had Goldmann visual fields performed within six months of presentation and of these eyes, 75% and 56% had abnormal field scores for the I-4 and IV-4 isopters, respectively. Of the 28 eyes of 14 patients that received immunosuppressive drug therapy during the follow-up period, the rate of visual field "loss" prior to treatment was 107 degrees/year (95% confidence interval [CI]: 65, 148 degrees/year) and 56 degrees/year (95% CI: 5, 109 degrees/year) for the I-4 and IV-4 isopters, respectively. The rate of "gain" after institution of immunosuppressive drug therapy was 53 degrees/year (95% CI: 10 degrees lost/year, 98 degrees gained/year) and 30 degrees/year (95% CI: 20 degrees lost/year, 81 degrees gained/year) for each isopter. CONCLUSIONS: Visual field loss was common among our patients with BSCR. Usage of immunosuppressive drug therapy may reverse some of the visual field loss while therapy is employed.

Multifocal choroiditis with panuveitis and punctate inner choroidopathy: comparison of clinical characteristics at presentation.

PURPOSE: To compare the clinical characteristics at presentation of multifocal choroiditis with panuveitis (MFCPU) and punctate inner choroidopathy (PIC). METHODS: A cross-sectional study of 66 patients (122 eyes) with MFCPU and 13 patients (22 eyes) with PIC was carried out. Diagnosis was based solely on retinal morphology. Demographic information, visual acuity at presentation, and presence of intraocular inflammation, choroidal neovascularization (CNV), and structural complications of intraocular inflammation (including cataract, cystoid macular edema [CME], and epiretinal membrane [ERM]) were compared for the two groups. RESULTS: The median ages at presentation of patients with MFCPU and PIC were 45 years and 29 years, respectively (P = 0.007). At presentation, patients with MFCPU had a higher frequency of structural complications, such as cataract (31.6%), CME (13.6%), and ERM (4.6%). Patients with PIC had none of these complications. Although CNV occurred more frequently in patients with PIC (PIC, 76.9%; MFCPU, 27.7%; P = 0.002), those with MFCPU were more likely to have bilateral visual impairment of 20/50 or worse (MFCPU, 20%; PIC, 0; P = 0.03). CONCLUSION: PIC and MFCPU appeared to have different clinical characteristics at presentation. Patients with PIC had a higher frequency of CNV at presentation but lower frequencies of structural complications from intraocular inflammation and a lower frequency of visual impairment at presentation.

Juvenile idiopathic arthritis-associated uveitis: incidence of ocular complications and visual acuity loss.

PURPOSE: To estimate the incidences of ocular complications and vision loss in patients with juvenile idiopathic arthritis (JIA)-associated uveitis, to describe risk factors for vision loss, and to describe the association between therapy and complications and vision loss. DESIGN: Retrospective cohort study. METHODS: setting: Single-center, academic practice. study population: A total of 75 patients with JIA-associated uveitis evaluated between July 1984 and August 2005. procedures: Clinical data on these patients were analyzed. outcome measures: Occurrence of ocular complications and visions of 20/50 or worse and 20/200 or worse. RESULTS: Over a median follow-up of three years, the incidence of any ocular complication was 0.33/eye-year (EY). Rates of vision loss to 20/50 or worse and 20/200 or worse were 0.10/EY and 0.08/EY, respectively. Risk factors at presentation for incident vision loss included presence of posterior synechiae, anterior chamber flare > or = 1+, and abnormal intraocular pressure (IOP). During follow-up, ocular inflammation > or = 0.5+ cells was associated with an increased risk of visual impairment (relative risk [RR] = 2.02, P = .006) and of blindness (RR = 2.99, P = .03). Immunosuppressive drug therapy reduced the risk of hypotony by 74% (P = .002), epiretinal membrane formation by 86% (P = .05), and blindness in the better eye by 60% (P = .04). CONCLUSIONS: Incident vision loss and complications were common. Presence of posterior synechiae, anterior chamber flare > or = 1+, and abnormal IOP at presentation were associated with vision loss during follow-up. Use of immunosuppressive drugs reduced the risk of some ocular complications and of blindness in the better-seeing eye.

Optic neuropathy complicating multifocal choroiditis and panuveitis.

PURPOSE: To describe the clinical characteristics of patients with optic neuropathy complicating multifocal choroiditis and panuveitis (MFCPU). DESIGN: Retrospective case series. METHODS: Eight patients (11 eyes) with MFCPU and optic neuropathy from a single center were reviewed and clinical outcomes described. RESULTS: The median age of patients was 45 years; six patients were women and seven were Caucasian. In the six patients with available follow-up, the optic neuropathy was corticosteroid-responsive, but required corticosteroid treatment to prevent recurrences of optic nerve inflammation and subsequent vision loss. Five patients required immunosuppressive drug therapy during their treatment course. No patients had recurrence of optic neuropathy while receiving immunosuppressive drug therapy. Visual acuity improved or stabilized with treatment in nine of 11 affected eyes. CONCLUSIONS: Optic neuropathy is an uncommon complication of MFCPU that may result in substantial visual morbidity. Immunosuppressive drug therapy may prevent recurrences of optic neuropathy and subsequent vision loss.

Risk factors for ocular complications and poor visual acuity at presentation among patients with uveitis associated with juvenile idiopathic arthritis.

PURPOSE: To describe the frequencies of and risk factors for ocular complications and poor visual acuity at presentation in a cohort of patients with juvenile idiopathic arthritis (JIA)-associated uveitis. DESIGN: Cross-sectional study. METHODS: setting: Single-center, academic practice. study population: Seventy-five patients with JIA-associated uveitis were evaluated between July 1984 and August 2005. observation procedures: Data on patients diagnosed with JIA-associated uveitis were entered retrospectively into a database and analyzed. outcome measures: Visual acuity of 20/50 or worse or 20/200 or worse, and presence of ocular complications (including cataract, posterior synechiae, band keratopathy, elevated intraocular pressure, hypotony, macular edema, and epiretinal membrane) at presentation. RESULTS: At presentation, ocular complications were seen in 67% of eyes affected by JIA-associated uveitis. Presence of > or =1+ anterior chamber flare, a positive antinuclear antibody (ANA), and a shorter duration between the diagnosis of arthritis and uveitis were significantly associated with the presence of ocular complication. The frequencies of 20/50 or worse and of 20/200 or worse visual acuities at presentation in affected eyes were 36% and 24%, respectively. The presence of > or =1+ anterior chamber flare and a history of intraocular surgery before presentation were significantly associated with 20/50 or worse and 20/200 or worse vision. Presence of posterior synechiae also was associated with 20/200 or worse vision at presentation. The main causes of poor vision at presentation for affected eyes and better-seeing eyes were cataract, band keratopathy within the visual axis, and glaucoma. CONCLUSIONS: Ocular complications and poor vision at presentation were common in our patients with JIA-related uveitis.

Cytomegalovirus retinitis in the era of highly active antiretroviral therapy.

Cytomegalovirus (CMV) is a common opportunistic infection in individuals with AIDS. Moreover, CMV retinitis represents a significant portion of end-organ disease in patients with CMV and AIDS. Prior to the advent of highly active antiretroviral therapy (HAART), almost one-third of people with AIDS developed CMV retinitis during their lifetime. Although effective therapies for CMV infection had been developed, treatment was often life-long due to persistent immune deficiency. Despite chronic suppressive maintenance therapy, disease relapse was nearly universal, and development of drug resistance was not uncommon. Widespread use of HAART has reduced the incidence and complications of CMV retinitis. With sustained immune recovery, discontinuation of anti-CMV therapy has been possible in many patients. Still, immune recovery does not guarantee protection from recurrent disease. CMV retinitis and uveitis associated with immune recovery remain causes of vision loss in this population and demand vigilance on the part of physicians.

Multifocal choroiditis with panuveitis incidence of ocular complications and of loss of visual acuity.

PURPOSE: To estimate the incidences of ocular complications and vision loss in patients with multifocal choroiditis with panuveitis (MFCPU) and to describe the association between therapy and the incidences thereof. DESIGN: Retrospective cohort study. PARTICIPANTS: Sixty-six patients (122 eyes) with MFCPU evaluated from January 1984 through June 2005 at a single-center academic practice. METHODS: Demographic and clinical information on patients diagnosed with MFCPU was collected and entered into a computerized database for statistical analyses. MAIN OUTCOME MEASURES: Development of ocular complications, including choroidal neovascularization, epiretinal membrane, and cystoid macular edema (CME), and loss of visual acuity (VA) to 20/50 or worse and to 20/200 or worse. RESULTS: Among affected eyes of patients with MFCPU, frequencies of VAs of 20/50 or worse and of 20/200 or worse at presentation were 55% and 38%, respectively. Choroidal neovascularization was observed in 22% of affected eyes at presentation and was the leading cause of poor VA at presentation. The incidence rates of vision loss to 20/50 or worse and to 20/200 or worse were 0.19/eye-year (EY) and 0.12/EY in affected eyes and 0.07/person-year (PY) and 0.04/PY in better-seeing eyes. Choroidal neovascularization was the most common cause of incident vision loss, with approximately 45% of incident vision loss attributed to new-onset or recurrent choroidal neovascularization. Presence of epiretinal membrane and CME also was associated with the development of vision loss during follow-up. When taken in combination, the incidence of any posterior pole complication was 0.13/EY in affected eyes. Use of immunosuppressive drug therapy (but not low-dose corticosteroid therapy) was associated with an 83% reduction in the risk of posterior pole complications (P = 0.004) and with a 92% reduction in the risk of 20/200 or worse VA in affected eyes (P = 0.05). Of the 6 eyes with recurrent choroidal neovascularization, only one recurrence was observed, in a patient receiving immunosuppressive drug therapy. CONCLUSIONS: Treatment with immunosuppressive drugs may improve VA outcomes among patients with MFCPU by reducing the risk of sight-threatening posterior pole complications, including new-onset choroidal neovascularization and recurrent choroidal neovascularization among eyes with existing choroidal neovascularization.