Vitiligo in a Patient Receiving Adalimumab for Idiopathic Uveitis.

In recent years, adalimumab has been increasingly used in the chronic treatment of non-infectious uveitis. This case report aimed to describe a drug-induced adverse event in a 34-year-old man who presented with blurred vision and floaters in the right eye and was being treated for intermediate uveitis. The patient had started topical treatment with a diagnosis of uveitis at another center. Best corrected visual acuity at presentation was 0.8 (decimal) in the right eye and 1.0 in the left eye. On examination, the anterior chamber in the right eye was clear, with anterior vitreous cells and mild haze, and snow banking and vitreous opacities in the inferior periphery. Fluorescein angiography (FA) showed hyperfluorescence in the right disc and leakage in the inferior periphery. As the inflammation did not resolve with local treatment, systemic cyclosporine was administered, after which the patient exhibited vomiting and weakness. Cyclosporine was discontinued and adalimumab treatment was started. On examination 5 months later, bilateral vitreous cells and mild vitreous opacity were noted, and FA showed mild leakage in the inferior periphery bilaterally. In addition, a depigmented patchy vitiligo lesion was observed on the chin. Due to the persistence of intraocular inflammation and on the recommendation of the dermatology clinic, adalimumab treatment was continued and topical tacrolimus was started for the lesion. On examination 3 months later, the inflammatory findings had resolved and there was no progression of the vitiligo lesion. The patient's treatment was continued. Taken together with the previous literature findings, no pathology was found in the patient's systemic examination, suggesting that this lesion was a side effect of the treatment. Ophthalmologists should be alert for this side effect in patients receiving adalimumab.

Evaluation and comparison of microperimetry and optical coherence tomography findings in patients with Behçet uveitis.

PURPOSE: To evaluate and compare the findings of MP and OCT in patients with inactive Behçet's uveitis (BU). METHODS: Sixty-five eyes of 38 patients were included in this retrospective study. Ophthalmologic examination findings and OCT and MP results were recorded. The relationship between best corrected visual acuity (BCVA), duration of uveitis, central macular thickness (CMT), presence of photoreceptor zone (PZ), and/or retinal pigment epithelium (RPE) damage, macular integrity index, mean threshold and fixation stability was analyzed. RESULTS: There was a positive correlation between BCVA and CMT (p < 0.001). The eyes with PZ and/or RPE damage had significantly lower visual acuity (p < 0.001). There was a negative correlation between BCVA and macular integrity index (p = 0.005). BCVA showed positive correlations with mean threshold and fixation stability [(BCVA vs. mean threshold, p < 0.001), (BCVA vs. P1, p < 0.001), and (BCVA vs. P2, p < 0.001)]. While there was no significant correlation between CMT and macular integrity index (p = 0.08), both mean threshold and fixation stability were significantly positively correlated with CMT [(CMT vs. mean threshold, p = 0.01), (CMT vs. P1, p = 0.008), and (CMT vs. P2, p = 0.005)]. Mean threshold and fixation stability (P1 and P2) were significantly lower in the eyes with PZ and/or RPE damage (p = 0.008, p = 0.02, and p = 0.01, respectively). CONCLUSION: MP showed results consistent with visual acuity and morphological findings by OCT in patients with inactive BU. Although MP is promising for patient follow-up, controlled prospective studies are needed.

Are optical coherence tomography and fluorescein angiography comparable for detection of macular edema in Behçet uveitis?

PURPOSE: To investigate the role and agreement of spectral domain optical coherence tomography (SD-OCT) and fluorescein angiography (FA) for macular edema (ME) diagnosis in Behçet uveitis (BU). METHODS: Eyes with ME detected by SD-OCT and/or FA were enrolled. Type of ME by SD-OCT and grade of macular leakage (ML) by FA were investigated. Eyes were divided into three groups according to the agreement of tests. Three groups and factors that could affect the compatibility of tests were statistically analyzed. RESULTS: Sixty-one eyes of 61 patients were included. Both imaging methods detected ME in 42.6% of eyes (group 1). In 47.5% of eyes, ME was revealed by OCT (group 2). The remaining 9.8% of the eyes had ME, detected only by FA (group 3). Grade 2 ML by FA was more common in group 1 (p = 0.01). The grade of ML by FA was similar in groups 2 and 3. In group 2, most of the eyes showed diffuse ME by OCT (p < 0.001). Epiretinal membrane was detected more frequently in group 3 (p = 0.005). Duration and activity of uveitis were similar between groups. CONCLUSION: SD-OCT was able to detect ME in 90% of the eyes with BU. Duration and activity of uveitis were not related to the compatibility of imaging methods.

Short-term changes detected by corneal topography and optical coherence tomography after prophylactic laser iridotomy in primary angle closure suspect.

PURPOSE: To evaluate early changes in anterior segment parameters by Scheimpflug-Placido disc topography system and changes in retinal layers by optical coherence tomography in primary angle-closure suspects after laser peripheral iridotomy. METHODS: One eye of 26 patients with primary angle closure suspect and of 20 healthy subjects were included in this retrospective cross-sectional study. Anterior chamber depth/volume, iridocorneal angle and central corneal thickness were obtained by Scheimpflug-Placido disc topography system. Retinal thickness, retinal nerve fiber layer thickness and ganglion cell-inner plexiform layer thickness were acquired by optical coherence tomography. All the tests were repeated 1 week and 1 month after laser peripheral iridotomy. RESULTS: The mean ages of the patients and healthy controls were 64.8 ± 10.7 years and 64.5 ± 3.9 years, respectively (p = 0.990). Anterior chamber depth/volume and iridocorneal angle value were lower in the PACS group (p < 0.001, for all). Anterior chamber volume and iridocorneal angle increased significantly after laser peripheral iridotomy (p = 0.004, for both). While foveal thickness decreased significantly after laser peripheral iridotomy (p = 0.027), retinal nerve fiber layer thickness increased in superior and temporal quadrants (p = 0.038 and p = 0.016, respectively). CONCLUSION: Our results suggest that LPI in patients with PACS provides improved retinal thickness and RNFL thickness, as well as anterior chamber parameters.

Factors affecting the response to subthreshold micropulse laser therapy used in center-involved diabetic macular edema.

The purpose of this study was to investigate the effect of the status of retinal pigment epithelium (RPE) and HbA1c levels on the efficacy of the subthreshold micropulse laser (SMPL) in the treatment of center-involving diabetic macular edema (DME). A total of 20 eyes of 20 patients (mean age 57.9 ± 9.7 years) who were diagnosed with center-involving DME and treated with SMPL for refusing intravitreal injection and 20 eyes of 20 age- and sex-matched healthy participants were enrolled. All patients were followed up in the 1st and 3rd months after SMPL. For measurement of RPE area central 1000 microns, macular EDI-OCT scans were binarized by using the public domain software ImageJ, with a semi-automated technique. There was a significant increase in BCVA values and a significant decrease in CMT values during follow-up. The area of RPE before SMPL was significantly thinner in the patient group (p: 0.004). When the areas of RPE before and 3 months after SMPL were compared, no significant change was observed (p: 0.437). When the relationship between pre-treatment area of RPE and HbA1c was examined, an inverse correlation was observed (p: 0.018). The patients were evaluated by dividing them into 2 groups as 2nd session SMPL required and not required, and the area of RPE was smaller in the group requiring 2nd session SMPL (p: 0.030). The status of central RPE may be a determining factor on the response to treatment. Additionally, HbA1c levels may have an impact on treatment efficacy.

COVID-19 and the Use of Immunomodulatory Agents in Ophthalmology

Immunomodulatory agents are often used in the systemic treatment of non-infectious uveitis. These drugs consist of corticosteroids, conventional immunosuppressives, and biological agents. As it is known that they suppress the immune system, the most important concern associated with immunomodulatory therapy (IMT) is the increased risk of infection. The World Health Organization declared COVID-19 a pandemic on 11 March 2020. Although severe acute respiratory distress syndrome secondary to SARS-CoV-2 infection may develop in all people, patients who receive IMT may be at higher risk in terms of both the transmission of the infection and more severe disease course. Therefore, guidelines on the management of patients receiving IMT due to uveitis during the pandemic are needed. In this review, we examined the immunomodulatory drugs used in the treatment of uveitis in terms of infectious complications and the data of patients who received IMT during the COVID-19 pandemic and discussed recommendations for the use of these drugs. According to the latest information, patients who receive IMT may continue their treatment as long as there are no disruptions in regular complete blood count (especially white blood cell count >4,000/µL) and liver and kidney function tests. Patients diagnosed with COVID-19 should be managed with a multidisciplinary approach.

Evaluation of the choroidal features in pachychoroid spectrum diseases by optical coherence tomography and optical coherence tomography angiography.

PURPOSE: To evaluate choroidal area, stroma/lumen ratio, choriocapillaris vessel density, and choriocapillaris flow area in eyes with central serous chorioretinopathy, uncomplicated pachychoroid, and pachychoroid pigment epitheliopathy using enhanced depth imaging-optical coherence tomography and optical coherence tomography angiography. MATERIALS AND METHODS: This retrospective study analyzed enhanced depth imaging-optical coherence tomography and optical coherence tomography angiography scans of 142 eyes of 92 patients with central serous chorioretinopathy, uncomplicated pachychoroid, and pachychoroid pigment epitheliopathy. The choroidal area and stroma/lumen ratio were measured by binarization of enhanced depth imaging-optical coherence tomography images. Choriocapillaris vessel density and choriocapillaris flow area were measured at the choriocapillaris level by manual segmentation of optical coherence tomography angiography scans. RESULTS: The mean stroma/lumen ratio results were 0.361, 0.345, and 0.354 in central serous chorioretinopathy, uncomplicated pachychoroid, and pachychoroid pigment epitheliopathy groups, respectively (p > 0.05). The mean whole image choriocapillaris vessel density in uncomplicated pachychoroid group was higher compared with central serous chorioretinopathy and pachychoroid pigment epitheliopathy groups (p < 0.0001). The mean foveal, parafoveal, and perifoveal choriocapillaris vessel densities were lower in central serous chorioretinopathy group than in uncomplicated pachychoroid group (p < 0.0001). The mean choriocapillaris flow area was lower in central serous chorioretinopathy group than in uncomplicated pachychoroid and pachychoroid pigment epitheliopathy groups (p < 0.0001 and p = 0.01, respectively). CONCLUSION: Our findings suggest that both choroidal vessels and stroma are equally involved in central serous chorioretinopathy, uncomplicated pachychoroid, and pachychoroid pigment epitheliopathy. The choriocapillaris segment seems to be more affected in central serous chorioretinopathy compared to uncomplicated pachychoroid and pachychoroid pigment epitheliopathy. However, the reduced optical coherence tomography angiography signal in central serous chorioretinopathy group could be due to shadowing artifact or choriocapillaris hypoperfusion and further studies with higher quality imaging tools are needed.

The Clinical Characteristics of Pediatric Non-Infectious Uveitis in Two Tertiary Referral Centers in Turkey.

Purpose: To report the manifestations, patterns of disease, treatment strategies and outcomes in pediatric patients with noninfectious uveitis.Methods: Demographic information of 76 cases was recorded. Symptoms, anatomic location, laterality, visual acuity (VA), intraocular pressure, associated systemic diseases, therapeutic strategies, side effects, complications were reviewed.Results: Thirty-one patients were diagnosed as uveitis on routine surveillance because of underlying systemic disease. The most common anatomic location was intermediate uveitis (34.2%). Juvenile idiopathic arthritis (JIA) was the most common underlying systemic disease (25%). Glaucoma was the most common complication (7.7%). The patients with refractory uveitis received adalimumab (26.5%), infliximab (4.6%) and tocilizumab (3.1%). The mean first-year VA was between 20/32 and 20/20 in 116/140 eyes.Conclusion: Most pediatric noninfectious uveitis cases have bilateral intermediate uveitis. JIA was the most common systemic association. The first-year VA was good in most eyes which may be due to early use of corticosteroid-sparing agents.

Efficacy of the subthreshold micropulse yellow wavelength laser photostimulation in the treatment of chronic central serous chorioretinopathy.

AIM: To evaluate the efficacy and safety of subthreshold micropulse yellow laser (SMYL) in the treatment of chronic central serous chorioretinopathy (CCSC). METHODS: The medical records of 58 eyes of 58 patients with CCSC were reviewed. A 577-nm SMYL system was used for the treatment. Fundus fluorescein angiography was used as the primary method of identifying CCSC, and resolution of subretinal fluid (SRF) evaluated by optical coherence tomography (OCT) and fundus autofluorescence. Central macular thickness (CMT), central macular volume (CMV), total macular volume (TMV), subfoveal choroidal thickness (SFCT), subretinal fluid height (SRFH), and subfoveal fluid basement diameter values were measured by spectral domain-OCT (SD-OCT) for all eyes. RESULTS: The mean age of the patients was 42.4±9.9 (range: 20-72)y. The mean follow-up was 11.4±8.5 (range: 6-37)mo. Median BCVA at at the final follow up after treatment was statistically significant from the baseline. Complete SRF resolution was 12.1% of the eyes in the 1st month, 67.2% of the eyes in the 3rd month and 67.2% of the eyes in the last follow up. The initial median CMT, CMV, TMV, and SFCT values before treatment was significantly higher than 3rd month visit values (P<0.001). In the multivariate analysis performed, age and disease duration were found to be a risk factor for persistent SRF (P=0.017, P=0.016, respectively). CONCLUSION: SMYL treatment provides a significant anatomical and functional improvement and is effective in eliminating SRF in eyes with CCSC.

Quantitative Evaluation of the Retinal Vascular Parameters With OCTA in Patients With Behçet Disease Without Ocular Involvement.

BACKGROUND AND OBJECTIVE: To evaluate the optical coherence tomography angiography (OCTA) features of patients with Behçet disease (BD) without ocular involvement. PATIENTS AND METHODS: Twenty-three patients with BD without ocular involvement and 29 healthy age/sex-matched control subjects were involved. The authors measured foveal avascular zone (FAZ) area, vessel density in the parafoveal region, and flow area (fovea-centered 3-mm radius area) in the superficial and deep capillary plexuses evaluated by OCTA. RESULTS: FAZ area was significantly larger in eyes with BD in both the superficial and deep capillary plexuses (0.331 vs. 0.240 mm2 [P = .004] and 0.352 vs. 0.257 mm2 [P = .003], respectively). Although mean capillary vessel density in parafoveal region and mean flow area were lower in eyes with BD for both superficial and deep capillary plexuses, these findings were not statistically significant. CONCLUSION: Microvascular changes in macular region can be identified in patients with BD without ocular manifestation. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:31-34.].

Short-term Efficacy of Micropulse Yellow Laser in Non-center-involving Diabetic Macular Edema: Preliminary Results.

OBJECTIVES: The aim of this study was to evaluate the efficacy of micropulse yellow laser (MPL) on best corrected visual acuity (BCVA) and retinal thickness in patients with non-center-involving diabetic macular edema (DME). MATERIALS AND METHODS: We retrospectively reviewed 9 eyes of 8 patients with non-center-involving DME who underwent MPL treatment between January 2015 and December 2016. BCVA (logMAR) and retinal thickness were evaluated before and 3 months after treatment. Maximum retinal thickness was determined manually from simultaneous spectral-domain optical coherence tomography images and recorded. The change in the measurements from before to after treatment was analyzed statistically. RESULTS: Of the 8 patients, 3 were female and 5 were male. The mean age was 52.8 years. Two of the 9 eyes had received previous intravitreal anti-vascular endothelial growth factor injection(s). Median BCVA was improved 3 months after treatment, although the difference was not statistically significant (0.34 logMAR before and 0.29 logMAR after treatment). BCVA was improved in 4 eyes while it showed no change in the remaining 5 eyes. The mean retinal thickness was 470.6 µm at baseline and 416 µm at 3 months after MPL treatment (p=0.01). Retinal thickness decreased in all eyes after treatment. CONCLUSION: In this study, parafoveal retinal thickness showed significant decrease after MPL treatment in patients with DME. The limited increase in BCVA may be due to the inclusion of a low number of patients and only those with non-center-involving macular edema. MPL may be used as an alternative to conventional argon laser in non-center-involving DME.

Role of a mydriasis-free, full-field flicker ERG device in the detection of diabetic retinopathy.

PURPOSE: To determine if the RETeval system can be used for the screening of diabetic retinopathy (DR) to provide early diagnosis. METHODS: The subjects were 42 diabetic patients selectively recruited by examination of their medical records to have varying severities of DR. The severity of DR was classified into four groups according to the International Clinical Diabetic Retinopathy Disease Severity Scale. Full-field electroretinograms (ERG) without mydriasis were obtained by the DR assessment protocol of the RETeval system. Macular retinal nerve fiber layer (RNFL) thickness was measured by optical coherence tomography. We compared the DR assessment protocol results and the macular RNFL thickness among four groups. Moreover, an analysis was conducted on whether there was any correlation among the DR assessment protocol results, duration of diabetes mellitus, and RNFL thickness individually for each group of patients. RESULTS: The mean ages and mean duration of diabetes mellitus of the four groups were similar. The DR assessment protocol results in the moderate-severe nonproliferative DR, and proliferative DR groups were significantly higher than those in the other groups (p < 0.001). The mean macular RNFL thickness was similar in all groups. No significant correlation was found between the DR assessment protocol results and duration of DM and the RNFL thickness. CONCLUSIONS: Our results suggest that the RETeval full-field ERG system can be used as an adjunctive tool for the mass screening of DR, while macular RNFL thickness would not be useful.

Optic Nerve Avulsion and Retinal Detachment After Penetrating Ocular Trauma: Case Report.

Optic nerve avulsion is a rare pathology with poor prognosis usually seen after blunt trauma. The optic nerve is separated from the sclera by indirect forces due to the relatively weak structure of the lamina cribrosa area. Here we describe an 11-year-old boy who experienced optic nerve avulsion and retinal detachment after penetrating ocular trauma.

The Recovery of Microvascular Status Evaluated by Optical Coherence Tomography Angiography in Patients after Successful Macular Hole Surgery.

PURPOSE: The aim of this study was to evaluate the optical coherence tomography angiography (OCTA) features of patients who underwent successful macular hole (MH) surgery. METHODS: Nineteen patients who underwent surgery in a single eye due to MH and 13 healthy subjects as a control group were included in the study. Vascular densities, flow indexes, and the foveal avascular zone (FAZ) area in superficial and deep retinal capillary plexuses were evaluated by OCTA in the right eyes of the control group, and both the surgical and healthy fellow eyes of the patients. RESULTS: The mean vascular densities of the superficial and deep capillary plexuses were significantly lower in the surgical eyes than in the control group (44.1 vs. 49.6%, p = 0.002, and 47.3 vs. 59.1%, p = 0.009, respectively). The mean superficial and deep capillary flow indexes were significantly lower in the surgical eyes than in the control group (0.85 vs. 1.35, p = 0.003, and 0.57 vs. 1.45, p = 0.001, respectively), while the mean superficial and deep FAZ area were significantly greater in the surgical eyes in comparison to the control group (0.55 vs. 0.32, p < 0.001, and 0.64 vs. 0.37, p = 0.001, respectively). There was no difference between the flow indexes of both layers of the healthy fellow eyes and the control group. CONCLUSIONS: These preliminary results may be an explanation for unsatisfactory visual gain after surgery, despite the successful anatomical closure of the MH.