Primary Sjögren's syndrome-related Choroiditis in a Newly Diagnosed Older Adult.

PURPOSE: To report a case of secondary bilateral choroiditis in a patient with primary Sjögren's syndrome(pSS). STUDY DESIGN: Case report. RESULTS: A 69-year-old woman visited our hospital for consultation due to decreased visual acuity in both eyes for 1 month. At the first visit, best corrected visual acuity (BCVA) was 0.2 and 0.3 in her right and left eyes, respectively. Intraocular pressure values were 15 mmHg and 16 mmHg in her right and left eyes, respectively. Examination revealed edema of the eyelids and conjunctiva,and corneal fluorescence staining was positive. No inflammation in the anterior chamber or vitreous opacities were observed. Bilateral multiple retinal detachments were observed on the posterior fundus, and optical coherence tomography revealed bilateral multiple areas of retinal neuroepithelial detachment, choroidal thickening, and choroidal folds. No abnormal fluorescence leakage was observed on fundus fluorescein angiography or indocyanine green angiography. In addition, systematic manifestations included recurrent bilateral parotid gland enlargement. Labial gland biopsy revealed dilated glandular ducts, scattered interstitial glands, and lymphocytic foci. Salivary gland scintigraphy revealed severe impairment of glandular excretory function. Moreover, blood tests for anti-Ro/SSA and anti-La/SSBantibodies were positive. The patient was diagnosed with primary Sjögren's syndrome. After 2 months treatment with oral prednisolone acetate combined with hydroxychloroquine, her BCVAimproved to 0.8 and 1.0 in the right and left eyes, respectively. The fundus also recovered to normal, and no recurrence was observed during the 1-year follow-up period. CONCLUSIONS: The current case highlights that pSS, which usually manifests with dry eye and keratoconjunctivitis, may manifest with chronic choroiditis in both eyes as well. Based on our experience with this case, patients with clinically suspected bilateral choroiditis should be evaluated for pSS.

[Serpiginous-Like Choroiditis: literature Review] / Coroiditis Serpiginosa-Like: revisión de Literatura

Objective: To provide a complete picture and to improve understanding of the serpiginous-like choroiditis caused by Mycobacterium Tuberculosis. Materials and methods: Literature review of serpiginous-like choroiditis. A number of scientific search engines were searched including Medline (PubMed), Scielo, and Cochrane Library. Using MeSH and DeCS terms. Results: 107 articles were obtained, of which 44 met inclusion criteria. Discussion: serpiginous-like choroiditis is described as its etiology, pathogenesis, ocular findings, diagnosis, differential diagnosis and treatment. Conclusions: Modern studies are needed to understand the pathophysiology, new diagnostic strategies, and future treatments of serpiginous-like choroiditis

Objetivo: Proporcionar una imagen completa y mejorar entendimiento de la coroiditis serpiginosa- like causada por Mycobacterium Tuberculosis Materiales y métodos: Revisión de literatura de coroiditis serpiginosa-like. Se realizó búsqueda en varios motores de búsqueda científica incluidos Medline (PubMed), Scielo y Cochrane Library. Usando términos MeSH y DeCS. Resultados: Se obtuvieron 107 artículos, de los cuales 44 cumplieron criterios de inclusión. Discusión: Se describe la coroiditis serpiginosa-like su etiología, patogénesis, hallazgos oculares, diagnostico, diagnóstico diferencial y tratamiento. Conclusiones: Son necesarios estudios modernos para entender más la fisiopatología, nuevas estrategias diagnósticas y futuros tratamientos de la coroiditis serpiginosa-like.

Serpiginous choroiditis presenting after SARS-CoV-2 infection: A new immunological trigger?

INTRODUCTION: To report the first case of a serpiginous choroiditis presenting after SARS-CoV-2 infection in a previously healthy young woman. CASE DESCRIPTION: A 41-year-old woman reported blurry vision OS 1 month after a mild SARS-CoV-2 infection. Left eye fundus examination revealed multiple peripapillary atrophic lesions, adjacent to a larger diffuse, ill-defined, yellow-whitish deep amoeboid-like patch, involving the peripapillary region and extending temporally to the fovea. Multimodal imaging including fluorescein angiography, indocyanine-green angiography, fundus autofluorescence and optical coherence tomography was consistent with serpiginous choroiditis. A complete systemic work-up was performed to exclude potential infectious or inflammatory etiologies. The active choroidal lesions responded to high dose corticosteroids, with functional improvement. Immunomodulatory therapy with methotrexate was initiated for long-term management. CONCLUSION: Serpiginous choroiditis is a rare but important sight-threatening condition that has been previously associated to viral infections, which seem to have a role in the induction and/or perpetuation of choroidal inflammation. SARS-CoV-2 infection appears to have played a role as a possible trigger for intraocular inflammation in this case. Therefore, COVID-19 patients reporting visual symptoms should be carefully evaluated in order to obtain adequate ophthalmological management to avoid irreversible visual damage.

Prognosis of Ocular Tuberculosis Following Long-Term Antitubercular Therapy.

Purpose: This study presents clinical features and prognosis after long-term (12-18 months) antitubercular therapy (ATT) in patients with ocular tuberculosis (OTB) in East China, an endemic area of tuberculosis. Methods: This retrospective study reviewed data from OTB patients treated at the Eye and ENT Hospital of Fudan University from 2008 to 2018. All the patients completed a minimum follow-up of 6 months after the cessation of ATT. Results: Sixty-six patients with OTB were studied. The ocular manifestations included retinal vasculitis (51.6%), choroiditis (24.2%), panuveitis (23.2%), intermediate uveitis (7.4%), scleritis (5.3%), anterior uveitis (2.1%), and optic neuropathy (1%). Except for two patients (ATT for 6 months), all other patients (64/66, 96.97%) received ATT for at least 12 months (6 patients for 12 months, 30 patients for 15 months, and 28 patients for 18 months). Treatment in conjunction with oral corticosteroids was used in 48 patients (72.7%). The average initial best-corrected visual acuity (BCVA) was 0.8 ± 0.64 (LogMAR), which improved to 0.31 ± 0.35 (LogMAR) at the last follow-up (P < 0.05). The final BCVA was significantly associated with the initial BCVA and the duration of clinical symptoms. A complete remission of uveitis was achieved in 97% of the patients. Conclusions: This study observed a favorable prognosis with long-term ATT regimens. Patients with better baseline visual acuity and a shorter duration of clinical symptoms before diagnosis had a better prognosis.

The Use of Optical Coherence Tomography Angiography in the Diagnosis of Inflammatory Type 1 Choroidal Neovascularization Secondary to Tuberculosis: A Case Report.

Purpose: To report a case of choroidal neovascularization (CNV), which was not obvious with dye angiography but was detected with optical coherence tomography angiography (OCTA).Methods: A 50-year-old female presented with decreased vision in her right eye. Funduscopic examination revealed a swollen hyperemic disc, peripapillary exudation, and choroidal infiltration.Results: Optical coherence tomography revealed intraretinal cysts, subretinal fluid in the macular region, and subretinal hyperreflective material in the papillomacular area. Fluorescein angiography revealed early hypofluorescence in the areas of choroidal infiltrations, and indocyanine green angiography (ICGA) also showed hypocyanescence corresponding to these infiltrations and revealed a faint hypocyanescence in the papillomacular region, further corresponding to the subretinal hyperreflective material on OCT scan. Two weeks after the initiation of systemic therapy with the diagnosis of tuberculosis, OCTA scans detected Type 1 CNV in the peripapillary area.Conclusion: OCTA may be superior to ICGA in the detection of CNV secondary to inflammatory situations.

CHOROIDAL INFLAMMATION AND CHORIOCAPILLARIS ISCHEMIA IN FOCAL CHOROIDAL EXCAVATION IN COMPARISON TO PACHYCHOROID NEOVASCULOPATHY.

PURPOSE: To investigate the choriocapillaris and choroidal characteristics of focal choroidal excavation (FCE) to establish pathomechanisms of the disease. METHODS: Thirty eyes with FCE, 26 eyes with pachychoroid neovasculopathy (PNV), and 25 participants without any conditions (control group) were analyzed retrospectively. The thickness of both choriocapillaris equivalent and whole choroid was measured at three different points: under the lesion (excavation or neovascularization), in the normal retina, and in the fovea of fellow eye. Indocyanine green angiographic images were collected to confirm choriocapillaris ischemia and the presence of choroidal inflammation. RESULTS: In both FCE and PNV, choriocapillaris-equivalent attenuation was observed under the lesion compared with other region of the retina (28.1 ± 11.3 µm vs. 69.4 ± 20.0 µm in FCE; 23.5 ± 9.7 µm vs. 62.3 ± 14.7 µm in PNV; both P < 0.001). We also observed focal thinning of the whole choroid under the lesion (149.7 ± 88.7 µm vs. 296.6 ± 83.2 µm; P < 0.001) in FCE but not in PNV. Pachyvessels distribution on optical coherence tomography and numerous dark areas on indocyanine green angiography implied that choroidal inflammation was related to the FCE occurrence. CONCLUSION: Choriocapillaris ischemia was related to both FCE and PNV. The choroidal thinning under the excavation and adjacent pachyvessels observed in FCE suggested that focal inflammation and scarring may contribute to choriocapillaris ischemia and eventual retinal pigment epithelium retraction with dysfunction in the pathomechanism.

Clinical and Imaging Factors Associated With the Outcomes of Tubercular Serpiginous-like Choroiditis.

PURPOSE: To analyze baseline clinical and imaging risk factors associated with poor outcome in patients with tubercular serpiginous-like choroiditis (TB SLC). DESIGN: Retrospective clinical study. METHODS: Charts and fundus photographs of consecutive patients with active TB SLC seen at a single tertiary referral center with 6 months follow-up after initiation of treatment were reviewed. Logistic mixed models were performed to determine the clinical and imaging factors associated with the response to therapy, including the opacity of choroiditis graded according to a 3-point scale. RESULTS: This study included 203 eyes of 183 patients with active TB SLC. Poor initial best-corrected visual acuity (BCVA) and foveal and optic disc involvement were associated with poor response to therapy at 6 months (odds ratio [OR] 4.489, 95% confidence interval [CI]: 1.92-10.47; P = .001; OR 2.892, 95% CI: 1.23-6.81; P = .015; OR 11.633, 95% CI: 3.17-42.71; P < .001, respectively). The high opacity grades (2 and 3) were also associated with poor outcomes OR 9.541; 95% CI: 2.94-30.91; P = .001). Poor baseline BCVA and high grade of opacity of the lesions were the composite risk factors for paradoxical worsening of TB SLC (OR 7.555, 95% CI: 1.78-32.02; P = 0.006; OR 7.434, 95% CI: 1.34-41.18; P =0.021, respectively). CONCLUSIONS: TB SLC with higher grades of lesion opacity at baseline may be associated with greater risk of poor therapeutic response and paradoxical worsening. Grading of baseline lesion opacity may be used in future prospective studies to predict the biological behavior of the lesions and may serve as a guide to therapeutic interventions.

Masquerade syndrome: An eye problem as a manifestation of a more sinister disease. / Síndrome de mascarada: un problema ocular como manifestación de un mal mayor.

A middle-aged man with cardiovascular risk factors, who suffered from a slight loss of unilateral vision for 6 months. After obtaining a diagnosis of diffuse choroiditis+papillitis within a probable masquerade syndrome, the patient was referred to outpatient Internal Medicine where this diagnosis was confirmed as an extended neoplastic disease.

Assessment of measurement methods of posterior inflammation in stromal choroiditis: the value of quantitative outcome measures versus the presently qualitatively based paradigm.

PURPOSE: To assess posterior inflammation using a fluorescein (FA)/indocyanine-green angiography (ICGA) scoring system, and compare them to the presently recommended outcome measure, the standardization of uveitis nomenclature vitreous haze score (SUN-VH) in stromal choroiditis. METHODS: This was a retrospective study on patients with a diagnosis of ocular sarcoidosis(OS), ocular tuberculosis(OT), Birdshot retinochoroiditis(BRC) and Vogt-Koyanagi-Harada disease(VKH) seen in the Centre for Ophthalmic Specialized Care, Lausanne, Switzerland. Angiography signs were quantified according to an established FA/ICGA scoring system. Vitritis was assessed using SUN-VH. Results were compared. RESULTS: 65 newly diagnosed patients (128 eyes) with stromal choroiditis were included. Angiographic scoring showed variable degrees of choroidal versus retinal involvement (87% for OS, 72% for OT, 62.5% for BRC and 100% for VKH). On the other hand, a mere 22 of 128 eyes (17%) showed a SUN-VH score ≥ 2 necessary for inclusion in clinical trials. Moreover, FA/ICGA values followed a normal distribution curve and presented inter-examiner variations greater than 1-SD in only 8.4% of cases. SUN-VH values' distribution was non-normal and showed inter-examiner discrepancies greater than 1-SD in 51.7% of cases. CONCLUSION: This study highlights the precise measurement of global posterior inflammation achieved by a dual FA/ICGA scoring system in stromal choroiditis. In contrast, SUN-VH scale appears imprecise and inadequate, as only a minute percentage of the studied eyes could have been included in a clinical trial based on this criterion. To evaluate posterior intraocular inflammation meaningfully in stromal choroiditis, the use of dual FA/ICGA is strongly advised and should replace the presently recommended SUN-VH system.

Toxoplasmic retinochoroiditis caused by Toxoplasma gondii strain ToxoDB#65.

Ocular toxoplasmosis, caused by Toxoplasma gondii, is the most common cause of inflammation in the back of the eye. Analysis of the infecting strain may provide information regarding disease behavior and recurrence. Here, we describe clinical and epidemiological data for toxoplasmic retinochoroiditis in two Brazilian women infected by T. gondii strain ToxoDB#65, living in an urban region of São Paulo State, Brazil.

Quantitative polymerase chain reaction analysis of serpiginous choroiditis with biopsy-proven testicular tuberculosis.

We report a case of a 47-year-old male patient presenting with diminution of vision in the left eye. The left eye fundus showed yellowish lesions with indistinct geographical margin extending over the posterior pole just abutting the macula, suggestive of diffuse choroiditis. The patient gave a history of testicular swelling for the past 2 years. Aqueous tap for polymerase chain reaction analysis was positive for IS6110 mycobacterial tuberculosis (TB) genome, and a biopsy of testicular sac was suggestive of tubercular epididymitis. A diagnosis of TB-multifocal serpiginoid choroiditis was established and was managed with anti-tubercular therapy and systemic steroids.

Clinical Outcomes of Adjunctive Sustained-Release Intravitreal Dexamethasone Implants in Tuberculosis-Associated Multifocal Serpigenoid Choroiditis.

PURPOSE: To analyze the safety and efficacy of sustained-release intravitreal dexamethasone implant (Ozurdex) in management of TB-associated multifocal serpiginoid choroiditis (MSC). METHODS: Retrospective review of TB-associated MSC patients, treated with anti-TB therapy (ATT) and adjunctive intravitreal Ozurdex. RESULTS: Nine eyes of six patients were included. Four patients required Ozurdex implant for progressive or new lesions following ATT and two for additional systemic contraindications to corticosteroids - hyperglycemia and uncontrolled hypertension, respectively. The mean time to resolution was 9.17 ± 7.71 weeks. The mean follow-up post-injection was 13.11 ± 6.05 months (median 12 months [range 6-24.5 months]). Only one of nine eyes developed recurrent MSC lesions and this was attributed to possible autoimmune etiology. Two eyes (22.2%) developed steroid-induced glaucoma - one required implant removal. CONCLUSIONS: Sustained-release intravitreal dexamethasone is a safe and efficacious adjunctive anti-inflammatory therapy for TB-associated MSC patients with contraindication for systemic corticosteroids or requiring supplemental anti-inflammatory therapy.

Choroidal Structural Changes in Tubercular Multifocal Serpiginoid Choroiditis.

PURPOSE: To assess choroidal vascular changes among patients with tubercular multifocal serpiginoid choroiditis (TB MSC) using previously validated techniques. METHODS: Patients with TB MSC (n = 18) and healthy controls (n = 30) underwent enhanced-depth imaging optical coherence tomography (EDI-OCT) imaging. Using previously validated algorithm of image binarization, EDI-OCT scans were segmented to derive total choroidal area, luminal area, stromal area, and choroidal vascularity index (CVI). RESULTS: There was a statistically significant difference in the CVI between controls (66.90 ± 1.77%) and TB MSC patients (65.46 ± 2.53%; p < 0.001). There was significant reduction in CVI at follow-up (3 months) (63.77 ± 3.91%; p = 0.05). The choroidal thickness was higher in TB MSC compared to controls (278.90 ± 57.84 µm versus 329.33 ± 27.69 µm; p = 0.001). CONCLUSIONS: CVI provides insight into structural changes in choroid in TB MSC. During the active disease, there is relative decrease in choroidal vascularity. As the lesions heal, choriocapillaris atrophy occurs with remodeling of choroid.

Splenic tuberculosis and multifocal serpiginoid choroiditis.

Serpiginoid multifocal choroiditis is a distinct morphological identity with a reported causal association with Mycobacterium tuberculosis. We report a case of serpiginoid multifocal choroiditis in a 17-year-old boy who was suffering from isolated splenic tuberculosis. He was treated with systemic steroids along with anti-tubercular treatment with good visual recovery. This case was unique as no other organs except spleen and choroid showed tubercular involvement. We hereby emphasize association of extrapulmonary sites with multifocal serpiginoid choroiditis and propose a thorough investigation for primary to be included in routine protocol of choroiditis workup.

Tuberculosis intraocular / Intraocular tuberculosis

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