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Objective: To summarize the clinical findings and treatment response in posterior scleritis affecting children and to compare these features with posterior scleritis affecting adults. Design: Retrospective interventional case series. Participants: Twenty eyes of 13 patients aged younger than 18 years who were diagnosed with posterior scleritis in a tertiary referral center. Intervention: Investigations and treatment were according to standard care, following published recommendations for scleritis. Main Outcome Measures: Clinical features, investigation results, treatment received, and visual outcome were studied. Results: Twenty eyes of 13 patients (aged 5–16 years, median 11.53 years; 8 female, 5 male) were included. Scleritis was unilateral in 6 cases and bilateral in 7 cases at presentation. The median presenting vision was 20/30. All eyes had T-sign demonstrable on B-scan ultrasound. Concurrent anterior segment signs included anterior uveitis (80.0%) and anterior scleritis (20.0%). Posterior segment signs included optic disc swelling (95.0%) and retinal striae (85.0%). No underlying connective tissue disorder was diagnosed in any patient. Scleritis resolved with oral nonsteroidal anti-inflammatory agent alone in 1 patient (8%). Twelve patients (92.3%) received oral corticosteroid. Immunosuppressive agents were required in 11 patients (84.6%) because of relapse or intolerance to corticosteroid. The median final vision at 1 year was 20/20. Seven patients (63.6%) remained on immunosuppression at latest follow-up (median 4 years). Conclusions: Common features of posterior scleritis include concurrent anterior uveitis, disc swelling, and retinal striae. B-scan ultrasound demonstrating T-sign was the most useful confirmatory investigation in all cases. Systemic association is uncommon. Aggressive therapy with systemic corticosteroid achieves resolution mostly within the first year. Long-term immunosuppression is often required to prevent recurrence. Visual outcome is favorable. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. [ABSTRACT FROM AUTHOR]

Objective: To report 4 cases of undiagnosed cytomegalovirus (CMV) endotheliitis in patients who underwent Descemet''s stripping automated endothelial keratoplasty (DSAEK). Design: Retrospective interventional case series. Participants: Four eyes of 4 patients diagnosed with active CMV endotheliitis after DSAEK. Methods: Retrospective review of the medical records of 4 patients with DSAEK who had an aqueous tap that was positive for CMV DNA but negative for herpes simplex virus (HSV) and varicella zoster virus. Main Outcome Measure: Clinical features and management. Results: Four immunocompetent Chinese male patients with a mean age of 67 years underwent DSAEK for posterior polymorphous dystrophy (1), Fuchs'' heterochromic cyclitis (1), pseudophakic bullous keratopathy (1), and herpetic keratouveitis (1). Clinical findings seen in all patients were localized corneal edema, increased intraocular pressure, pigmented keratic precipitates (KPs), and no/minimal anterior chamber (AC) activity. An unexplained sudden decrease in endothelial cell count (ECC) in the absence of rejection or significant inflammation was seen in 3 patients, whereas 1 patient also developed concomitant retinitis. CMV DNA was positive in all aqueous specimens and from the vitreous of the patient with retinitis. All patients were treated with oral valganciclovir with resolution of inflammation; 2 patients had recurrences; 1 patient developed recurrent retinitis; and 1 patient developed recurrent CMV endotheliitis and is currently receiving maintenance therapy with oral valganciclovir. Conclusions: CMV endotheliitis with corneal edema masqueraded as a variety of other endothelial conditions, which resulted in DSAEK surgery being performed in these patients who may have responded to antiviral treatment without the need for endothelial transplantation. A heightened awareness is required to exclude CMV endotheliitis as the cause for endothelial decompensation or unexplained, sudden reduction in ECCs post-DSAEK in the absence of other complications, and it should be differentiated from allograft rejection in view of the critical difference in treatment. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. [Copyright &y& Elsevier]

Purpose: To compare the characteristics of cytomegalovirus (CMV)-positive and negative eyes with presumed Posner-Schlossman syndrome (PSS) and Fuchs heterochromic iridocyclitis (FHI). Design: Retrospective interventional case series. Methods: One hundred and three eyes of 102 patients with presumed PSS or FHI, seen at the Singapore National Eye Centre, underwent aqueous analysis for CMV by polymerase chain reaction (PCR). Their records were reviewed for clinical features and human immunodeficiency virus (HIV) status of the CMV-positive patients. The main outcome measures were age, gender, maximum intraocular pressure, endothelial cell count, endothelial changes, PCR results, and presence of uveitic cataract and/or glaucoma. Results: Sixty-seven eyes with presumed PSS were tapped, of which 35 (52.2%) were CMV-positive. There were 36 eyes of 35 patients with presumed FHI, of which 15 (41.7%) were CMV-positive. All the CMV-positive patients were HIV negative. Nodular endothelial lesions were seen in 18 eyes (36.0%) with CMV infection, and reticulate deposits were seen in all the presumed FHI eyes. CMV-positive and CMV-negative PSS eyes were clinically similar. Older age at diagnosis, male gender, and nodular endothelial lesions were significantly associated with CMV infection in presumed FHI eyes (age: odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0 to 1.2; P = .01; male gender: OR, 9.4; 95% CI, 1.0 to 88.6; P = .049; nodular endothelial lesions: OR, 13.9; 95% CI, 1.5 to 132.7; P = .02). Conclusions: There are no clinically detectable differences between CMV-positive and negative presumed PSS eyes. CMV-positive presumed FHI patients are more likely to be male, older at diagnosis or have nodular endothelial lesions. [Copyright &y& Elsevier]

Purpose: To describe the clinical presentation of cytomegalovirus (CMV) anterior uveitis in human immunodeficiency virus (HIV)-negative patients. Design: Retrospective, interventional case series. Methods: HIV-negative patients with anterior uveitis associated with elevated intraocular pressure (hypertensive anterior uveitis) seen at the Singapore National Eye Centre had their aqueous analyzed for viral deoxyribonucleic acid by polymerase chain reaction, and their records were reviewed for demographic data, ocular findings, laboratory results, and treatment. Results: Aqueous was obtained from 105 of 106 eligible eyes. Twenty-four eyes demonstrated positive results for CMV (22.8%). Eighteen eyes had Posner-Schlossman syndrome (PSS; 75%) at presentation, five eyesba had Fuchs heterochromic iridocyclitis (FHI; 20.8%), and one eye had a presumed herpetic anterior uveitis. Twelve of the 24 eyes were treated with ganciclovir. Of the 12 who completed treatment, all responded clinically, and their aqueous demonstrated negative results for CMV on repeat testing. However, nine had recurrences within eight months of stopping treatment and required further courses of ganciclovir. The 81 CMV-negative eyes included 30 with PSS, 11 with FHI, 27 with uveitic glaucomas of unknown cause, and 13 with presumed herpetic anterior uveitis. Conclusions: CMV anterior uveitis is not uncommon in our immunocompetent patients and it may present as a recurrent acute or chronic inflammation, resembling PSS, herpetic anterior uveitis, or FHI. [Copyright &y& Elsevier]

Objective: To describe the clinical presentation of cytomegalovirus (CMV) corneal endotheliitis in human immunodeficiency virus (HIV)–negative patients. Design: Retrospective interventional case series. Participants: Twelve consecutive patients with corneal endotheliitis diagnosed between 2002 and 2005. Methods: Aqueous of eyes with corneal endotheliitis was analyzed for viral DNA by polymerase chain reaction (PCR), and patient records were reviewed for demographic data, medical and ocular history, best-corrected Snellen visual acuity, intraocular pressure (IOP), anterior and posterior segment findings, laboratory workup, diagnosis, and treatment. Main Outcome Measure: Presence of CMV DNA. Results: Corneal endotheliitis was seen in 12 eyes of 10 patients during the study period. There were 8 men and 2 women, and all were Chinese. Their mean age was 49 years (range, 25–61 years). The corneal involvement ranged from small areas of focal endotheliitis to diffuse bullous keratopathy. The keratic precipitates had a variable appearance. There was only mild anterior chamber inflammation with no posterior synechiae. Two thirds of eyes had diffuse iris atrophy. All the eyes had elevated IOP. Eleven of the 12 eyes were positive for CMV DNA. None of the patients were positive for HIV. All patients had received local or systemic immunosuppression, or both, before corneal endotheliitis developed. Ten eyes of 8 patients were treated with systemic antiviral therapy. After treatment, the endotheliitis resolved completely in 7 eyes, and 3 eyes had significant improvement in corneal translucency. The IOP was normal, with no medications in all but 1 eye. Repeat PCR analysis in all the treated eyes was negative for CMV DNA. Conclusions: Cytomegalovirus infection is an important cause of corneal endotheliitis in our patients, and appropriate antiviral therapy may prevent more ocular damage. [Copyright &y& Elsevier]

: ObjectiveTo describe the incidence, risk factors, and clinical outcome of acute endophthalmitis after cataract extraction in a multiethnic Asian population.: DesignProspective case series.: ParticipantsAll patients with cataract extractions performed at the Singapore National Eye Center from 1996 to 2001.: MethodsData on patients with acute endophthalmitis cases presenting within 6 weeks after cataract surgery were prospectively collected in a standardized format.: Main outcome measuresAcute endophthalmitis after cataract surgery.: ResultsDuring the study period, 44 803 cataract operations (25 476 phacoemulsification and 19 327 extracapsular cataract extractions) were performed. There were 34 cases of acute endophthalmitis (average annual incidence of 0.076%), 21 of which were culture positive (average annual incidence of 0.040%). In multivariate analysis, risk of endophthalmitis was associated with phacoemulsification technique (relative risk [RR], 1.9; 95% confidence interval [CI], 0.9, 3.9; P = 0.10 for all endophthalmitis cases; RR, 3.1; 95% CI, 1.1, 9.4; P = 0.04 for culture-positive endophthalmitis cases) and the occurrence of intraoperative posterior capsule rupture (RR, 8.0; 95% CI, 3.1, 20.7; P<0.001 for all endophthalmitis cases; RR, 11.0; 95% CI, 3.7, 23.9; P<0.001 for culture-positive endophthalmitis cases). After a median follow-up of 234 days, half of the eyes achieved a final best-corrected visual acuity of 20/40. Predictors of this visual acuity included baseline acuity of counting fingers or better, culture-negative endophthalmitis, or infection caused by coagulase-negative Staphylococcus.: ConclusionThe incidence of acute endophthalmitis after cataract extraction in Singapore is consistent with rates reported elsewhere. The phacoemulsification technique is associated with a higher risk of acute culture-positive endophthalmitis compared with extracapsular cataract extraction. Intraoperative posterior capsule rupture is associated with an 8- to 11-fold higher risk of acute endophthalmitis, suggesting that these eyes should be closely monitored for signs of infection in the immediate postoperative period. [Copyright &y& Elsevier]

: PurposeTo report five cases of group B Streptococcus endogenous endophthalmitis (GBSEE) and to review the literature.: DesignRetrospective, noncomparative, interventional case series and literature review.: PatientsAll patients with this condition treated at the Singapore National Eye Centre from 1994 through 2001.: InterventionsCore or complete vitrectomy and intravitreal and systemic antibiotics.: MethodsA review of the systemic and ocular characteristics and treatment.: Main outcome measureVisual outcome.: ResultsGroup B Streptococcus endogenous endophthalmitis developed in four patients after the onset of septic arthritis and in one patient with cervical epidural abscess after acupuncture, presenting as a diffuse endophthalmitis. Group B Streptococcus was isolated in the blood, vitreous, and joints. Despite the use of high-dose intravenous antibiotics within 72 hours of ocular presentation, intravitreal antibiotic injection, and vitrectomy (two eyes), all eyes lost light perception and became phthisical. A survey of the literature revealed that GBSEE is rare and that 17 cases have been reported since 1985. For purposes of analysis, four of these cases were excluded because of inadequate details and our five cases were included. Group B Streptococcus endogenous endophthalmitis was found to arise from hematogenous spread from cutaneous sites of infection (16.7%), pharyngitis (11.1%), and pneumonia (11.1%). Septic arthritis (38.9%) and endocarditis (33.3%) were concomitant sites of infection along with endophthalmitis. The septic arthritis typically involved multiple joints. Four patients (22.2%) had diabetes mellitus and three had other underlying predisposing illness. Although most patients received intravenous (83.3%) and intravitreal (55.6%) antibiotics and four eyes underwent therapeutic vitrectomy, useful vision was preserved in only four eyes. Two patients died of sepsis.: ConclusionsGroup B Streptococcus endogenous endophthalmitis is a devastating condition often associated with septic arthritis. The visual prognosis is poor, despite therapy. [Copyright &y& Elsevier]

Purpose: We report the immunopathology of progressive subretinal fibrosis, a variant of sympathetic ophthalmia.Design: Brief case report.Method: Review of medical record and immunopathology of a chorioretinal biopsy of a 40-year-old man who presented with left total retinal detachment (RD) following multiple vitrectomies in the right eye for RD. Small peripherally retinal holes, snow banks, and inflammatory nodules along the ora serrata were observed during left vitrectomy. Both eyes deteriorated rapidly to blindness with progressive subretinal fibrosis and inflammation over 3 months, and the patient was unresponsive to systemic prednisolone and azathioprine.Result: Immunopathology of the chorioretinal biopsy of the right eye revealed aggregates of CD20+ B cells, surrounded by CD3+ T cells. CD68+ macrophages were scattered throughout.Conclusion: The rapid clinical course described in this case may be related to the unique immunopathology of rapidly forming peudogerminal centers in the choroids and retina. [Copyright &y& Elsevier]

Acute retinal necrosis is a progressive intraocular inflammatory syndrome characterized by diffuse necrotizing retinitis that can lead to a poor visual outcome, mainly from retinal detachment. The antiviral treatment approach for acute retinal necrosis varies as there are no established guidelines. We summarize the outcomes of acute retinal necrosis with available antiviral treatments. Electronic searches were conducted in PubMed/MEDLINE, EMBASE, Scopus, and Google Scholar for interventional and observational studies. Meta-analysis was performed to evaluate the pooled proportion of the predefined selected outcomes. This study was registered in PROSPERO (CRD42022320987). Thirty-four studies with a total of 963 participants and 1,090 eyes were included in the final analysis. The estimated varicella-zoster virus and herpes simplex virus polymerase chain reaction-positive cases were 63% (95% CI: 55–71%) and 35% (95% CI: 28–42%), respectively. The 3 main antiviral treatment approaches identified were oral antivirals alone, intravenous antivirals alone, and a combination of systemic (oral or intravenous) and intravitreal antivirals. The overall pooled estimated proportions of visual acuity improvement, recurrence, and retinal detachment were 37% (95% CI: 27–47%), 14% (95% CI: 8–21%), and 43% (95% CI: 38–50%), respectively. Patients treated with systemic and intravitreal antivirals showed a trend towards better visual outcomes than those treated with systemic antivirals (oral or intravenous) alone, even though this analysis was not statistically significant (test for subgroup differences P = 0.83). [ABSTRACT FROM AUTHOR]

Obstructive sleep apnoea (OSA) has been linked to various ocular disorders, including floppy eyelid syndrome (FES). Previous studies have hypothesised the underlying association between the 2 , but results are currently still inconclusive. To investigate the association between OSA and FES. Four databases (Pubmed, Embase, Scopus, and Cochrane Library) were searched from inception until 28 February 2022 for observational studies and randomized controlled trials assessing the association between OSA and FES. Two reviewers selected studies, extracted data, graded the risk of bias using the Newcastle-Ottawa scale and the quality of assessment using the Grading of Recommendations Assessment, Development, and Evaluation system. Random-effects models were used to metaanalyze the associations. Twelve studies were included in the systematic review, of which nine were suitable for metaanalysis, with a combined cohort of 1,109 patients. Risk of bias was low to moderate. The overall analysis showed a significant positive association between OSA and FES (OR = 1.89, 95% CI = 1.27–2.83, I 2 = 44%). Further analysis revealed that the more severe the OSA was, the higher the risk of developing FES. Patients with severe OSA had the nominally highest risk of developing FES (OR = 3.06, 95% CI = 1.62–5.78, I 2 = 0%), followed by moderate OSA (OR = 2.53, 95% CI = 1.29–4.97, I 2 = 0%), and patients with mild OSA had the lowest risk (OR = 1.76, 95% CI = 0.85–3.62, I 2 = 0%). Our metaanalysis reports a positive association between OSA and FES, with increasing severity of OSA correlating with a significantly higher risk of FES. More longitudinal studies with sufficient duration of follow-up are needed to better characterise the relationship between OSA and FES. [ABSTRACT FROM AUTHOR]

Purpose: To describe immune ring (IR) formation as a manifestation of cytomegalovirus (CMV) endotheliitis. Design: Retrospective observational case series. Methods: Review of all consecutive CMV anterior uveitis and endotheliitis patients seen at the Singapore National Eye Centre for the occurrence of an IR. CMV infection was diagnosed by polymerase chain reaction analysis of the aqueous. Results: None of the 72 eyes with CMV anterior uveitis had an IR formation. Four episodes of IR formation were seen in 3 eyes (14.3%) of 21 cases of CMV-positive endotheliitis. All were unilateral and all 3 patients were human immunodeficiency virus negative middle-aged Chinese males. The IR developed 2 to 7 months after occurrence of the endotheliitis and the aqueous was positive for CMV during 2 of the episodes of IR formation. In 2 eyes, the IR occurred at the completion of a course of systemic ganciclovir when the aqueous was negative for CMV. The immune rings resolved with combination therapy of topical prednisolone acetate 0.12% and ganciclovir. Patient 1 had a recurrence of the IR 4 months after stopping treatment but again resolved following treatment with ganciclovir and topical corticosteroids. Conclusion: Corneal immune rings can occur as a result of CMV infection. Hence CMV infection may have to be considered in such cases. [ABSTRACT FROM AUTHOR]

Purpose: To determine outcome of cataract surgery in severely subluxated traumatic cataracts. Design: Noncomparative case series. Methods: Retrospective review of cataract surgery in all consecutive eyes with at least 6 clock hours of zonulysis, for patient demographics, presenting best-corrected visual acuity (BCVA) and postoperative BCVA at various time points, extent of zonulysis, and type and timing of insertion of capsular tension device. Main outcome measures were retention of the capsular bag and BCVA at last visit. Secondary outcome measures included IOL stability and centration, and perioperative complications. Results: There were 41 eyes (41 patients). Mean age at time of surgery was 57 years and the mean duration of follow-up was 21.4 months. The capsular bag was preserved with aid of a Cionni modified capsular tension ring (CTR) in 36 eyes (87.8%) and a combination of a capsular tension segment (CTS) and CTR in 2 eyes. In 3 eyes with total zonulysis, the bag could not be preserved despite the use of a CTS in 2 eyes. Preoperatively only 9 of the 41 eyes (22.0%) had a BCVA of 20/40 or better, as compared to 38 eyes at the last visit (92.7%, P < .001, χ2 test). Posterior capsule rupture occurred in 3 eyes, 2 of which occurred during fixation of the CTR. Conclusions: The capsular bag can be successfully preserved even in severely subluxated traumatic cataracts with the aid of fixated capsular tension devices. [Copyright &y& Elsevier]

Purpose: To determine the prognostic value of fluorescein angiography (FA) and indocyanine green angiography (ICGA) in Vogt-Koyanagi-Harada disease (VKH). Design: Retrospective noninterventional study. Methods: Chart, FA, and ICGA review of VKH patients of Singapore National Eye Centre for age at onset, gender, race, timing of treatment, and angiographic features during the different phases of FA and ICGA. Outcome measure was disease outcome (acute resolved or chronic recurrent). Results: Twenty-one of the 28 patients with pretreatment FA also had ICGA. Median follow-up duration was 3.6 years (range 0.94–13.42 years). Median age was 42.2 years (range 15.7–77.2 years). The majority (18, 64.3%) were Chinese. The most frequently observed FA features included early pinpoint hyperfluorescence in the posterior pole and disc hyperfluorescence. Large choroidal vessel hyperfluorescence (early and intermediate phase), areas of delayed choroidal perfusion (early phase), and persistent dark dots were the 3 most common ICGA features. Pinpoint peripapillary hyperfluorescence was found to be a significant prognostic FA factor on both univariate and multivariate analysis. None of the ICGA features were found to be significant prognostic factors. Conclusion: Early pinpoint peripapillary hyperfluorescence on pretreatment FA is a useful prognostic sign in VKH patients, whereas pretreatment ICGA has limited prognostic value. [ABSTRACT FROM AUTHOR]

Purpose: To compare wound characteristics and integrity of the 2.2-mm and 2.65-mm clear corneal incisions. Design: Prospective, randomized clinical trial. Methods: Patients undergoing phacoemulsification with lens implant were randomized to receive a 2.2-mm or 2.65-mm temporal clear corneal incision. The incisions were evaluated at 2, 24, and 96 hours for gape and wound architecture using anterior segment optical coherence tomography and for integrity using the Seidel test. Squareness of an incision was calculated (ratio of the incision length to the width). Results: There were 30 patients in each group. Both incision sizes were watertight, although a mild internal main wound gape was detected on anterior segment optical coherence tomography in 35 eyes (58.3%) at 2 hours. The smaller wound was more square (0.81; standard deviation [SD], 0.11) than the larger wound (0.62; SD, 0.08; P < .001, t test). The mean squareness of eyes without wound gape at 2 hours (0.66; SD, 0.11) was lower than those with a wound gape (0.75; SD, 0.14; P = .008). A squareness factor of 0.72 or more had a positive predictive value for presence of wound gape at 2 hours of 79.3% and a negative predictive value of 61.3%. One side port incision with squareness of 1.39 had a mild leak at 2 and 24 hours, but no gape was seen on anterior segment optical coherence tomography. Conclusions: Both the 2.2-mm and 2.65-mm clear corneal incisions clinically were competent, but the side port incision may leak. A truly square wound has a greater likelihood of being associated with internal wound gape at 2 hours after surgery, especially if the squareness factor is 0.72 or more. [Copyright &y& Elsevier]

Cytomegalovirus (CMV) anterior uveitis is the most common form of ocular manifestation of CMV in immunocompetent individuals. The difficulty in diagnosing CMV anterior uveitis may delay adequate treatment and affect outcomes. We sought to review systemically the overall clinical characteristics and compare treatment outcomes in CMV anterior uveitis and endotheliitis. A literature search was performed, and studies describing clinical characteristics, treatment regimens, and outcomes that included more than 5 treated eyes were included. In these 23 studies, acute CMV anterior uveitis commonly presented with high intraocular pressure (95.31%, 95% CI 90.45–98.60) and mild anterior chamber inflammation (cells >2+ = 3.18%, 95% CI 0.21–0.54). About two-thirds of CMV endotheliitis cases presented with high intraocular pressure and coin-shaped corneal lesions. Acute CMV anterior uveitis showed good clinical response to topical 0.15% ganciclovir (GCV) gel or oral valganciclovir (VGCV) (90%, 95% CI 74–100% and 95%, 95% CI 88–100%, respectively). For chronic CMV anterior uveitis, both topical GCV and oral VGCV yielded comparable results. Topical 0.5–2% GCV or a combination of topical and oral VGCV for CMV endotheliitis both resulted in good clinical response. Recurrence of inflammation was common after cessation of maintenance therapy. Overall, topical GCV resulted in an optimal outcome for CMV anterior uveitis. Escalated concentration and frequency of usage are needed for chronic CMV anterior uveitis and endotheliitis. Adequate induction and maintenance phases of anti-CMV treatment seem necessary to prevent recurrences. [ABSTRACT FROM AUTHOR]

Purpose: To determine the role of the QuantiFERON-TB Gold In-Tube (QFT) (Cellestis Inc., Carnegie, Australia) assay in the diagnosis of tuberculosis (TB) uveitis. Design: Retrospective cohort study. Participants: The study included 157 patients with suspected TB uveitis seen over an 18-month period (August 1, 2006, to February 31, 2007) at the Singapore National Eye Center (SNEC) uveitis clinic. Methods: We identified all cases of suspected TB uveitis in the above-mentioned time period and reviewed all medical records of the cases. Clinical findings, type of treatment instituted, response to treatment, and results of investigations such as QFT, tuberculin skin test (TST), and chest x-rays were recorded. A novel method of using treatment response to determine the presumed diagnosis of TB was used to estimate the accuracy of QFT and TST. Main Outcome Measures: The positive likelihood ratio (LR+), negative likelihood ratio (LR−), and area under the receiver operator characteristic curve (ROC) of the investigations were estimated. Results: QFT is not superior to the TST in sensitivity as a screening test or first-line study in TB-related uveitis; however, QFT is more specific than the TST in identifying infections by Mycobacterium tuberculosis. Negative QFT tests should be interpreted with caution, because they do not exclude the diagnosis. Conclusions: The new QFT is only slightly superior to the TST in the diagnosis of TB uveitis. Thus, there is an important role for interpreting the QFT together with the TST. This is the first and largest study of its kind to evaluate the use of QFT in the clinical diagnosis of TB uveitis. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. [Copyright &y& Elsevier]

Purpose: To determine whether clinically isolated anterior segment recurrence is associated with concomitant subclinical choroidal inflammation in Vogt-Koyanagi-Harada (VKH) disease. Design: Interventional, retrospective case series. Methods: Nine patients with recurrent VKH disease who satisfied the following criteria: 1) presence of anterior chamber (AC) inflammation of at least 1+ cells after a period of quiescence of three months or more, 2) no posterior segment involvement, and 3) indocyanine green angiography (ICGA) performed during the time of anterior segment recurrence at the Singapore National Eye Centre. ICGA was performed. Therapy was administered based on clinical features. The main outcome measures were the ICGA features. Results: Twelve eyes of nine patients were included in the study. All eyes had mild AC inflammation of 1 to 2+ cells, except for one eye that had 3+ cells. ICGA showed early large vessel hyperfluorescence, becoming fuzzy in character in the intermediate phase in 11 of 12 eyes with AC inflammation. In four eyes, few hypofluorescent dots were seen in the intermediate phase that remained hypofluorescent in the late phases. Late diffuse hyperfluorescence was observed in five eyes. All patients received high-dose oral prednisolone and topical prednisolone acetate. Four patients required additional steroid-sparing immunosuppressants. All patients attained clinical quiescence within two weeks to two months. Repeat ICGA showed absence of active leakage, significant decrease in choroidal vascular leakage, or no change in the number and density of hypofluorescent spots. Conclusions: Isolated anterior segment recurrence in VKH disease may occur concomitantly with subclinical choroidal inflammation and requires systemic therapy. [Copyright &y& Elsevier]

Objective: Dengue fever causes numerous systemic manifestations, including maculopathy, with loss of vision. This study sought to determine the prevalence of dengue maculopathy in patients hospitalized with dengue fever. Design: Cross-sectional observational study in which consecutive patients hospitalized with dengue fever during a dengue epidemic were enrolled over a 3-week period. Participants: Patients hospitalized in 2 general hospitals in Singapore with dengue fever. Testing: Patients completed a standardized questionnaire and underwent tests for near and distance visual acuity (VA), Amsler grid testing, dilated retinal examination, serum complements C3 and C4, and urinary microalbumin. Main Outcome Measures: Dengue maculopathy found on retinal examination. Results: One hundred ninety-seven patients were enrolled, of whom 119 (60.4%) were male and 78 (39.6%) female. The patients ranged between 12 and 67 years old (mean, 32.65). One hundred sixty of 197 patients had positive dengue immunoglobulin M serology. Dengue maculopathy was detected in 27 eyes of 16 of the seropositive patients, giving a prevalence of 10% (95% confidence interval, 6.03%–15.40%). None of the patients who were dengue immunoglobulin M negative had dengue maculopathy. Dengue maculopathy eyes were more likely to have distance acuity worse than logarithm of the minimal angle of resolution 0.15 (Snellen 6/9 or worse) (P = 0.005) and abnormalities on Amsler grid testing (P = 0.001), with a greater proportion of these patients having visual complaints (P = 0.002) and lower mean complement C3 levels (P = 0.008) as compared with patients without maculopathy. Logistic regression analysis showed Amsler grid abnormalities to be the most consistent factor associated with dengue-related maculopathy (P<0.001), with a hazard ratio of 8.669; sensitivity, 29.6%; and specificity, 95.4%. Conclusion: The prevalence of dengue maculopathy among patients hospitalized for dengue fever is 10% in our series. Amsler grid abnormalities, reduced distance VA, and the presence of visual symptoms are associated with dengue maculopathy. Low complement C3 levels in these patients suggest that this is an immune-mediated disease. [Copyright &y& Elsevier]

Topic An international, expert-led consensus initiative to develop systematic, evidence-based recommendations for the treatment of noninfectious uveitis in the era of biologics. Clinical Relevance The availability of biologic agents for the treatment of human eye disease has altered practice patterns for the management of noninfectious uveitis. Current guidelines are insufficient to assure optimal use of noncorticosteroid systemic immunomodulatory agents. Methods An international expert steering committee comprising 9 uveitis specialists (including both ophthalmologists and rheumatologists) identified clinical questions and, together with 6 bibliographic fellows trained in uveitis, conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol systematic review of the literature (English language studies from January 1996 through June 2016; Medline [OVID], the Central Cochrane library, EMBASE, CINAHL, SCOPUS, BIOSIS, and Web of Science). Publications included randomized controlled trials, prospective and retrospective studies with sufficient follow-up, case series with 15 cases or more, peer-reviewed articles, and hand-searched conference abstracts from key conferences. The proposed statements were circulated among 130 international uveitis experts for review. A total of 44 globally representative group members met in late 2016 to refine these guidelines using a modified Delphi technique and assigned Oxford levels of evidence. Results In total, 10 questions were addressed resulting in 21 evidence-based guidance statements covering the following topics: when to start noncorticosteroid immunomodulatory therapy, including both biologic and nonbiologic agents; what data to collect before treatment; when to modify or withdraw treatment; how to select agents based on individual efficacy and safety profiles; and evidence in specific uveitic conditions. Shared decision-making, communication among providers and safety monitoring also were addressed as part of the recommendations. Pharmacoeconomic considerations were not addressed. Conclusions Consensus guidelines were developed based on published literature, expert opinion, and practical experience to bridge the gap between clinical needs and medical evidence to support the treatment of patients with noninfectious uveitis with noncorticosteroid immunomodulatory agents. [ABSTRACT FROM AUTHOR]

Aim To outline recommendations from an expert committee on the assessment and investigation of patients with severe inflammatory eye disease commencing immunosuppressive and/or biologic therapy. Method The approach to assessment is based on the clinical experience of an expert committee and a review of the literature with regard to corticosteroids, immunosuppressive drug and biologic therapy and other adjunct therapy in the management of patients with severe sight-threatening inflammatory eye disease. Conclusion We recommend a careful assessment and consultative approach by ophthalmologists or physicians experienced in the use of immunosuppressive agents for all patients commencing immunosuppressive and/or biologic therapy for sight threatening inflammatory eye disease with the aim of preventing infection, cardiovascular, metabolic and bone disease and reducing iatrogenic side effects. [ABSTRACT FROM AUTHOR]

Purpose: To determine risk factors for poor visual acuity outcomes in patients with endogenous Klebsiella pneumoniae endophthalmitis. Design: Retrospective case-control study. Methods: We reviewed all consecutive patients diagnosed with endogenous Klebsiella pneumoniae endophthalmitis over 20 years. Data collected included patients'' demographics, clinical findings, investigations, and therapeutic intervention. Main outcome measures were visual acuity (VA) at 3 months postinfection and/or evisceration. Poor vision was defined as VA worse than 4/200. Results: Seventy-one eyes of 61 patients were studied. Mean age was 55.7 (standard deviation [SD] ± 13.1) years. Majority were male (49/61, 80.3%), Chinese (51/61, 83.6%), and had hepatobiliary sepsis (47/61, 77.5%). Mean time to ocular symptoms was 4.4 (± 3.0) days. Fifty-four of 71 eyes (80.2%) had poor vision and 19/71 eyes (26.8%) required evisceration. The most significant risk factor was hypopyon (41/71 eyes, 57.7%) on multivariate analysis (odds ratio [OR], 52.6; 95% confidence interval [CI], 1.7–1000; P = .01). Unilateral involvement (OR, 10.4; 95% CI, 1.2–90.2; P = .01) and patients that were managed before year 2000 (before routine screening was implemented) (OR, 5.2; 95% CI, 1.5–17.9; P = .037) were significant risk factors for evisceration on multivariate analysis. Conclusion: Patients presenting with hypopyon and unilateral involvement have a poorer prognosis. [Copyright &y& Elsevier]

Purpose: We sought to characterize the long-term outcomes and complications of subconjunctival triamcinolone acetonide injection (STI) for non-necrotizing, noninfectious anterior scleritis. Design: Retrospective, interventional, noncomparative, multicenter study. Participants: Sixty-eight eyes of 53 patients from 9 participating hospitals in the United States, Singapore, and Australia. Only eyes with 6 or more months of follow-up were included. Intervention: Subconjunctival injection of 2 to 8 mg of triamcinolone acetonide was administered to eyes with non-necrotizing, noninfectious anterior scleritis. Main Outcome Measures: Resolution of signs and symptoms, time to recurrence of scleritis, and side effect profile. Results: Median follow-up was 2.3 years (range, 6 months to 8.3 years). Sixty-six eyes (97.0%) experienced improvement of signs and symptoms after 1 injection. Twenty-four months after a single injection, 67.6% of eyes remained recurrence-free, whereas at 48 months, 50.2% were recurrence-free. Some 55.0% of patients who had adverse effects from systemic medications were off all systemic medications at last follow-up; 55.0% of patients who were taking systemic medications at the time of first triamcinolone acetonide injection were not taking prednisone and immunosuppressants at this time; 76.2% of patients still requiring systemic agents had associated systemic disease. Fourteen eyes (20.6%) had ocular hypertension not requiring intraocular pressure (IOP)-lowering therapy. Two eyes (2.9%) were treated with topical IOP-lowering agents alone, and 2 eyes required surgical intervention for glaucoma. None developed scleral necrosis or melt. Conclusions: This retrospective, international study carried out at 9 hospitals suggests that STI can treat non-necrotizing, noninfectious anterior scleritis with side effects limited to elevated IOP in a few patients. Although no cases of scleral melt or necrosis were observed, we cannot definitively conclude that this may not occur after STI. Intraocular pressure should be closely monitored after STI. Subconjunctival triamcinolone acetonide injection may be useful as adjuvant therapy or to decrease systemic medication burden. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references. [Copyright &y& Elsevier]

Purpose: To evaluate ocular manifestations associated with dengue fever.Design: Retrospective case series and literature review.Methods: Clinical records of patients with dengue fever who subsequently had ocular symptoms and signs develop were reviewed. The clinical presentation and ocular complications were evaluated.Results: Six patients, 5 females and 1 male, were seen with a sudden decrease in vision 6 to 7 days after the initial manifestations of dengue fever were identified. The diagnosis was confirmed by detection of dengue-specific IgM antibodies (IgM enzyme-linked immunoassay). The presenting best-corrected visual acuity ranged from 20/30 to counting fingers, and ocular involvement was bilateral but asymmetric in 5 cases and unilateral in 1 case. Fundus findings included small, intraretinal, whitish lesions, with localized retinal and retinal pigment epithelium (RPE) disturbance, small dot hemorrhages, and vascular sheathing around the macula and the papillomacular bundle. Fluorescein angiography showed arteriolar focal knobby hyperfluorescence at the macula with mild staining of the vascular walls and leakage at the level of the RPE. All 5 cases that had indocyanine green angiography done showed early diffuse choroidal hyperfluorescence with late silhouetting of the larger choroidal vessels. Five patients received steroid therapy: 1 topical, 2 periocular, and 2 oral. Over 2 to 4 months, RPE discoloration was observed over the affected areas. After the acute episode, 3 patients showed partial recovery of vision, and in the remaining patients, the visual acuity remained stable.Conclusions: Ocular complications associated with dengue fever are rare but may result in permanent visual impairment. [Copyright &y& Elsevier]

Purpose: To determine the frequency of occurrence of limited clinical features which distinguish patients with Vogt-Koyanagi-Harada (VKH) disease from those with non-VKH uveitis. Design: Comparative case series. Participants: We included 1147 patients. Methods: All patients with bilateral ocular inflammatory disease presenting to any of 10 uveitis centers in the 3-month period between January 1 and March 31, 2006 (inclusive), were asked to participate. The clinical and historical features of disease were obtained from the participants via direct interview and chart review. Patients were stratified based on whether they were diagnosed with VKH disease or non-VKH uveitis for statistical analysis. Main Outcome Measures: Presence or absence of various clinical features in the 2 populations. Results: Of 1147 patients, 180 were diagnosed with VKH disease and 967 with non-VKH uveitis. Hispanics and Asians were more likely to be diagnosed with VKH than non-VKH disease compared with other ethnicities. In acute disease, the finding of exudative retinal detachment was most likely to be found in VKH disease with a positive predictive value (PPV) of 100 and negative predictive value (NPV) of 88.4, whereas in chronic disease, sunset glow fundus was most likely to be found, with a PPV of 94.5 and NPV of 89.2. Conclusions: Numerous clinical findings have been described in the past as important in the diagnosis of VKH. The current study reveals that of these, 2 are highly specific to this entity in an ethnically and geographically diverse group of patients with nontraumatic bilateral uveitis. These clinical findings are exudative retinal detachment during acute disease and sunset glow fundus during the chronic phase of the disease. Financial Disclosure(s): Proprietary or commercial disclosures may be found after the references. [Copyright &y& Elsevier]