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To describe the experience of managing chronic childhood uveitis from a tertiary care center in India. All children diagnosed as chronic uveitis between January 2005 and December 2012 and on follow-up in Pediatric Rheumatology Clinic and Uveitis Clinic, were eligible for enrollment. Information regarding demographics, type of uveitis, treatment, complications, and surgical procedures was obtained from clinic records. All the enrolled patients were assessed for outcome prospectively and underwent a detailed ophthalmological examination to document visual acuity, refraction, intraocular pressure (IOP), slit lamp examination, fundus examination, and vitreous haze findings. Sixty-seven children with chronic uveitis were enrolled in the study. Anterior uveitis was the commonest type seen in 45 children. Juvenile idiopathic arthritis (JIA) was the commonest known etiology and diagnosis of uveitis was made during routine screening in a majority of the JIA patients. No cause could be identified in 43% patients. After a mean follow-up period of 3.95 ± 1.99 y, only 16% eyes were in remission and off therapy. Prolonged oral glucocorticoids were required, besides other immunosuppressants, to control inflammation in 50% patients. Ocular complications were seen in 87% cases with posterior synechiae, band-shaped keratopathy and cataracts being the commonest complications. Among patients with chronic uveitis, 43% had no identifiable cause. JIA was the commonest known cause. Significant ocular complications were common. Even after a mean follow-up of 3.95 ± 1.99 y, a vast majority continued to need immunosuppression for control of disease activity.

AIM To analyze the structural features and therapeutic response in clinical and subclinical inflammatory choroidal neovascularization (i-CNV) detected inside subretinal hyperreflective material (SHRM) using swept-source optical coherence tomography (SS-OCT) and SS-OCT angiography (SS-OCTA). METHODS In this prospective interventional study, subjects with quiescent posterior uveitis presenting with SHRM on SS-OCT and CNV network on SS-OCTA were included. Subjects with intraretinal fluid/subretinal fluid (IRF/SRF) received intravitreal antivascular endothelial growth factor (anti-VEGF) injections, while those with no IRF/SRF either received treatment or observation for 6 months until they developed IRF/SRF or decrease in best-corrected visual acuity (BCVA)/metamorphopsia. Serial comparisons included SHRM width and height and intrinsic flow signal on OCTA. RESULTS 28 eyes of 22 subjects (12 males; mean age: 29.52 ± 12.56 years) were evaluated. Subjects with IRF/SRF at baseline (n = 6 eyes; termed as exudative iCNVs) receiving treatment showed significant improvement in BCVA (p = .017), SHRM width/height and flow signal (p

Purpose: Cataract and diabetes, both being a major health care problem, an intervention evaluated for the combination of the two attains paramount importance. The purpose of the study was to determine the role of intraoperative intravitreal dexamethasone implant in patients with diabetic retinopathy with/without macula edema undergoing phacoemulsification. Methods: The study was a two-arm, single-center, randomized, assessor-blinded trial of 151 patients with type-2 diabetes mellitus and cataract. It had two groups: dexamethasone group (DEX) versus standard of care (SOC) group, i.e. phacoemulsification and intraocular lens (IOL) implantation without injection of dexamethasone drug delivery system (DDS). The number of rescue interventions required, central macular thickness by optical coherence tomography (OCT), Early Treatment Diabetic Retinopathy Study (ETDRS) score, laser flare meter (LFM) values, intraocular pressure (IOP), and grade of diabetic retinopathy (DR) were recorded until three months follow up. Macular thickness and number of rescue medications between the treatment groups were the co-primary outcomes. Results: A statistically significant interaction was present between treatment and time on OCT score (P < 0.001). The requirement of rescue interventions in the dexamethasone DDS group [40.2% (33/82)] was lesser as compared to the SOC group [49.3% (34/69)] at the end of 12 weeks [odds ratio (OR), 0.70 (0.36–1.33)] follow up although not statistically significant (P = 0.343). A statistically significant interaction was present between treatment and time on LFM score (P = 0.003). No statistically significant interaction was present between the treatment and time on visual acuity score (P = 0.08) and IOP score (P = 0.375). Conclusion: Dexamethasone implant may have potential as a valuable therapy for patients undergoing cataract surgery with DR with/without macular edema with effects lasting for at least three months.

Purpose: To quantify retinochoroidal vascular parameters using swept-source optical coherence tomography (SS-OCTA) in quiescent posterior and panuveitis. Methods: In this cross-sectional study, subjects with quiescent posterior and panuveitis underwent fundus imaging using SS-OCTA (DRI Triton®, Topcon, Japan). The metrics calculated were fractal dimension (FD), foveal avascular zone (FAZ) area, retinal vascularity index (capillary density index-CDI), and choroidal vascularity index (CVI). Results: We included 38 eyes of 20 patients, 9 males aged 34.7 ± 10.5 years, 30 eyes of 30 age- and gender-matched healthy controls, 10 females aged 33.6 ± 8.5 years. Comparing patients with controls, we found a lower FD (p .001), lower CDI in the superficial plexus (p = .019), and lower CVI (p

PURPOSE To compare the differences between clinical, demographic, and multimodal imaging features of choroidal granulomas associated with tuberculosis and sarcoidosis. DESIGN Retrospective comparative case series. METHODS Clinical features and fundus imaging including fluorescein and indocyanine green angiography, and optical coherence tomography of patients with tuberculomas and sarcoid choroidal granulomas seen at three tertiary care centers were reviewed. The differences between clinical appearance including morphology of the lesions (size, shape, extent), vascularity, and multimodal imaging features were compared. Repeated measures logistic regression with a multi-level random effects model was used to assess characteristics of individual granulomas that could predict the underlying etiology. RESULTS The study included 47 eyes of 38 patients (22 with tuberculomas and 16 with sarcoid granulomas; total of 138 granulomas). Patients with tuberculoma were significantly younger (33.8±10.1 versus 48.6±14.3 years; p=0.002), but no gender differences were observed. In comparison with sarcoid granulomas, tuberculomas were solitary (p

Topic An international, expert-led consensus initiative organized by the Collaborative Ocular Tuberculosis Study (COTS), along with the International Ocular Inflammation Society and the International Uveitis Study Group, systematically developed evidence- and experience-based recommendations for the treatment of tubercular choroiditis. Clinical relevance The diagnosis and management of tubercular uveitis (TBU) pose a significant challenge. Current guidelines and literature are insufficient to guide physicians regarding the initiation of antitubercular therapy (ATT) in patients with TBU. Methods An international expert steering subcommittee of the COTS group identified clinical questions and conducted a systematic review of the published literature on the use of ATT for tubercular choroiditis. Using an interactive online questionnaire, guided by background knowledge from published literature, 81 global experts (including ophthalmologists, pulmonologists, and infectious disease physicians) generated preliminary consensus statements for initiating ATT in tubercular choroiditis, using Oxford levels of medical evidence. In total, 162 statements were identified regarding when to initiate ATT in patients with tubercular serpiginous-like choroiditis, tuberculoma, and tubercular focal or multifocal choroiditis. The COTS group members met in November 2018 to refine these statements by a 2-step modified Delphi process. Results Seventy consensus statements addressed the initiation of ATT in the 3 subtypes of tubercular choroiditis, and in addition, 10 consensus statements were developed regarding the use of adjunctive therapy in tubercular choroiditis. Experts agreed on initiating ATT in tubercular choroiditis in the presence of positive results for any 1 of the positive immunologic tests along with radiologic features suggestive of tuberculosis. For tubercular serpiginous-like choroiditis and tuberculoma, positive results from even 1 positive immunologic test were considered sufficient to recommend ATT, even if there were no radiologic features suggestive of tuberculosis. Discussion Consensus guidelines were developed to guide the initiation of ATT in patients with tubercular choroiditis, based on the published literature, expert opinion, and practical experience, to bridge the gap between clinical need and available medical evidence.

Topic The Collaborative Ocular Tuberculosis Study (COTS), supported by the International Ocular Inflammation Society, International Uveitis Study Group, and Foster Ocular Immunological Society, set up an international, expert-led consensus project to develop evidence- and experience-based guidelines for the management of tubercular uveitis (TBU). Clinical Relevance The absence of international agreement on the use of antitubercular therapy (ATT) in patients with TBU contributes to a significant heterogeneity in the approach to the management of this condition. Methods Consensus statements for the initiation of ATT in TBU were generated using a 2-step modified Delphi technique. In Delphi step 1, a smart web-based survey based on background evidence from published literature was prepared to collect the opinion of 81 international experts on the use of ATT in different clinical scenarios. The survey included 324 questions related to tubercular anterior uveitis (TAU), tubercular intermediate uveitis (TIU), tubercular panuveitis (TPU), and tubercular retinal vasculitis (TRV) administered by the experts, after which the COTS group met in November 2019 for a systematic and critical discussion of the statements in accordance with the second round of the modified Delphi process. Results Forty-four consensus statements on the initiation of ATT in TAU, TIU, TPU, and TRV were obtained, based on ocular phenotypes suggestive of TBU and corroborative evidence of tuberculosis, provided by several combinations of immunologic and radiologic test results. Experts agreed on initiating ATT in recurrent TAU, TIU, TPU, and active TRV depending on the TB endemicity. In the presence of positive results for any 1 of the immunologic tests along with radiologic features suggestive of past evidence of tuberculosis infection. In patients with a first episode of TAU, consensus to initiate ATT was reached only if both immunologic and radiologic test results were positive. Discussion The COTS consensus guidelines were generated based on the evidence from published literature, specialists’ opinions, and logic construction to address the initiation of ATT in TBU. The guidelines also should inform public policy by adding specific types of TBU to the list of conditions that should be treated as tuberculosis.

PURPOSE To report the frequency, optical coherence tomography (OCT) findings, and visual and anatomic outcomes of patients with acute Vogt-Koyanagi-Harada disease presenting with the bacillary layer detachment (BLD) (intraretinal split at the photoreceptor inner segment myoid). METHODS This was a retrospective analysis of a consecutive series of patients with Vogt-Koyanagi-Harada disease having a minimum follow-up of 6 months. All patients had swept-source OCT, fluorescein angiography, and indocyanine green angiography performed at baseline. The characteristics of serial swept-source OCT were recorded and analyzed. RESULTS Sixty-two subjects (42 women; age: 34.2 ± 12 years) with Vogt-Koyanagi-Harada disease were included. 118 eyes (95.2%) had serous retinal detachment at presentation. 112 eyes (94.9%) showed the BLD at baseline. In 8 of 112 (7.1%) eyes with the BLD, the external limiting membrane at the anterior aspect of the BLD showed focal discontinuity. The interdigitation zone at the base of the BLD showed discontinuity in 53 of 112 (47.3%) eyes with the BLD. The ellipsoid zone could not be identified as a separate hyperreflective line at the base of the BLD in 102 of 112 eyes (91.1%). Bacillary layer detachments resolved within 3.4 ± 1.3 days after intravenous methylprednisolone therapy with improvement in the best-corrected visual acuity from 0.96 to 0.4 logarithm of the minimum angle of resolution (20/184 Snellen's equivalent) (P < 0.001). Resolution of serous retinal detachment was observed after 5.9 ± 2.6 days. CONCLUSION In eyes with acute Vogt-Koyanagi-Harada disease, the BLD is a common finding and represents a split in the photoreceptor layer at the inner segment myoid and can be differentiated from serous retinal detachment using swept-source OCT. In addition, resolution of the BLD and photoreceptor recovery can be evaluated using serial swept-source OCT.

Purpose To analyze and describe serial follow-up of choriocapillaris alterations in tubercular serpiginouslike choroiditis (SLC) using optical coherence tomography angiography (OCTA) and to compare it with multimodal imaging. Methods In this prospective cohort study, patients with active tubercular SLC underwent OCTA using Optovue RTVue XR Avanti and other imaging techniques including enhanced-depth imaging OCT (EDI-OCT) (Heidelberg Spectralis; Heidelberg Engineering, Heidelberg, Germany), fundus autofluorescence, fluorescein angiography, and indocyanine green angiography. Serial imaging was performed for a total follow-up of 3 months. Choriocapillaris alterations at the site of lesions were analyzed on OCTA imaging, and their mean lesion areas were calculated. Results Twenty-six eyes (26 patients; 20 males; mean age: 32.68 ± 10.56 years) were included. Fourteen eyes had active multifocal lesions (n = 39), whereas 12 eyes had active placoid lesions (n = 12). At baseline, OCTA showed hyporeflective flow deficit lesions corresponding to the hypofluorescent lesions on indocyanine green angiography in all eyes. In the multifocal type of SLC, the mean lesion area decreased in all eyes compared with baseline, and lesions with a lesion area less than 0.1 mm2 on OCTA showed near-complete resolution with minimal choriocapillaris atrophy. In comparison, all eyes with a placoid type of SLC showed no significant reduction in the lesion area and showed extensive choriocapillaris atrophy. Conclusion Optical coherence tomography angiography has the unique ability to demonstrate pathological flow impairment at the level of choriocapillaris in active tubercular SLC. Serial OCTA analysis reveals that large tubercular SLC lesions result in choriocapillaris atrophy as the lesions heal, whereas smaller multifocal lesions show resolution of choriocapillaris hypoperfusion with minimal atrophy.

We aim to look at the complications encountered by a cohort of pediatric uveitis patients from north India. Retrospectively, complications seen in patients younger than 16 years diagnosed with uvei...

To report the clinical findings, anatomical features, and treatment outcomes in subjects with ocular tuberculosis (OTB) at 24 months in the Collaborative Ocular Tuberculosis Study (COTS)-1. Of the ...

Purpose : To screen for obstructive sleep apnea (OSA) in patients presenting to diabetic retinopathy (DR) clinic and to correlate its presence with the severity of DR. Methods : A prospective, cross-sectional study of diabetes mellitus patients in retina clinic of a tertiary care referral center, North India (January 2019-March 2020). All were subjected to STOP-Bang Questionnaire and Epworth Sleepiness Scale (ESS) score. Patients at high OSA risk (STOP-Bang score ≥5 and ESS score ≥10) were referred to Department of Otorhinolaryngology (sleep clinic) for polysomnography. Based on Apnea Hypopnea Index (AHI), OSA was graded as mild (AHI = 5-14/h), moderate (AHI = 15-30/h), and severe (AHI >30/h). Statistical analysis was done using three models of outcome measures: (1) "No DR" versus "any DR," (2) "Less severe DR" versus "More severe DR," and (3) "No diabetic macular edema (DME)" versus "DME." Results : Of 362 patients screened, 18 (4.97%) had OSA (11 mild, 5 moderate, and 2 severe). Though OSA did not show a significant association with various outcome measures, patients with moderate-severe OSA had higher odds in developing "any DR" (OR = 7.408; 95% CI = 0.533-102.898), "more severe DR" (OR = 1.961; 95% CI = 0.153-25.215), and "DME" (OR = 2.263; 95% CI = 0.357-14.355), on multiple logistic regression. Conclusion : Ours is the first screening study of OSA in DR patients in India, the diabetes capital of the world. We detected OSA in 4.97% of patients in a DR clinic, with an increased risk of "any DR," "more severe DR," and "DME" in the presence of moderate-severe OSA.

Patients with primary antibody deficiency (PAD) are predisposed to develop meningoencephalitis that is often considered to be enteroviral. However, there is a paucity of literature on this subject, and there are no studies from developing countries. We analyzed our cohort of children with PAD who developed meningoencephalitis. This complication was observed in 11/135 (8.1%) patients with PAD - 4 patients had X-linked agammaglobulinemia (XLA), and 7 had common variable immunodeficiency (CVID). The mean age at onset of neurological illness was 8.6 years (range: 2-28 years). Presenting features included seizures (n=7), neurodevelopmental delay (n=2), regression of milestones (n=1), and acute flaccid paralysis (n=1). Trough IgG levels were found to be low in 9 (81.8%) patients at the time of development of neurological symptoms. Herpes simplex virus (HSV), cytomegalovirus (CMV), and Streptococcus pneumoniae were isolated in 1 patient each. No etiological agent was identified in cerebrospinal fluid of 8 patients. Eight (72.7%) patients had altered signal hyperintensities in gray matter and deep white matter on magnetic resonance imaging (MRI), while 3 patients showed global cerebral atrophy. All patients were treated with high-dose intravenous immunoglobulin (IVIg). Fluoxetine was given to 2 patients. Eight (72.7%) patients in the present series have succumbed, while three have recovered with varying degrees of neurological sequelae. To conclude, meningoencephalitis is an uncommon complication in patients with PAD and is associated with high morbidity and mortality in our setting. Early diagnosis of immune deficiency and initiation of replacement immunoglobulin therapy may prevent the development of neurological complications.

Purpose Retinal detachments (RD) secondary to retinal vasculitis are highly complex. We report the clinical profile and outcome of vitrectomy in RDs secondary to retinal vasculitis in terms of intraoperative findings, final anatomical, and functional outcome. Methods In a retrospective review of 68 patients (6 with bilateral RD; 74 eyes) undergoing pars plana vitrectomy (PPV) between 2000 and 2015 for vasculitic RD, tractional RD was present in 50 (67.57%) eyes and combined RD in 24 (32.43%) eyes. Results The mean age was 31.54 ± 9.95 years (62 males, 6 females). Fibrovascular proliferations (FVPs) involved major vascular arcades (22.98%), optic disc (10.81%), both arcades and disc (20.27%), peripheral retina (32.43%), and arcades with peripheral retina (13.51%). A total of 14 (18.92%) eyes had retinal folds, of which 9 had macular drag. Of 24 eyes with combined RD, 3 (12.5%) eyes had macular hole, 15 (62.5%) eyes had the primary retinal break anterior to equator, and 6 (25%) eyes had the primary break posterior to equator. Twenty-one (28.38%) eyes had iatrogenic retinal breaks. Thirty-eight (51.35%) eyes required an internal tamponade [gas in 31 (81.57%) eyes and silicon oil in seven (18.42%) eyes]. A scleral buckle was additionally required in 26 (35.14%) eyes. Postoperative complications included vitreous hemorrhage (27.03%), re-RD (12.16%), and iris neovascularization (9.46%). The median follow-up was 18 months (range 6-122 months). Sixty-eight (91.9%) eyes achieved final anatomical success. Fifty-two (70.27%) eyes had ≥2 lines visual improvement. Conclusion Vasculitic RDs are complicated by tractional/combined RDs, peripherally located FVPs, retinal folds and iatrogenic retinal breaks, and carry a moderate prognosis.

Pars plana vitrectomy (PPV) in uveitis is indicated for various diagnostic and therapeutic indications. With the advent of microincision vitreous surgery (MIVS), the use of PPV in uveitis has increased with a wider spectrum of indications due to shorter surgical time, less patient discomfort, less conjunctival scarring, and a decreased rate of complications as compared to standard 20G vitrectomy. Because of faster post-operative recovery in terms of visual improvement and reduction of inflammation, and reduced duration of systemic corticosteroids, MIVS has gained popularity in uveitis as an adjunctive therapy to the standard of care medical therapy. The safety and efficacy of MIVS is related to the emerging vitrectomy techniques with better and newer cutters, illuminating probes, and accessory instruments. Because of the instrumentation and fluidics of MIVS, PPV is emerging as a safe and useful alternative for diagnostic challenges in uveitis, aiding in earlier diagnosis and better outcome of inflammatory disease, even in the presence of severe and active inflammation, which was once considered a relative contraindication for performing vitreous surgery. However, for surgical interventions for therapeutic indications and complications of uveitis, it is advisable to achieve an optimum control of inflammation for best results. The increasing reports of the use of MIVS in uveitis have led to its wider acceptance among clinicians practicing uveitis.

Objective: To detect retinal involvement in coronavirus disease 2019 (COVID-19) patients in acute and convalescent phase by their fundus screening.Methods: In a prospective, cross-sectional, observational study (July–November 2020), 235 patients (142 acute and 93 convalescent phase) underwent fundus screening in a tertiary care center in North India. For convalescent phase, “hospitalized” patients (73) were screened at least 2 weeks after hospital discharge, and “home-isolated” patients (20) were screened 17 days after symptom onset/COVID-19 testing.Results: None in acute phase showed any retinal lesion that could be attributed exclusively to COVID-19. Five patients (5.38%) in convalescent phase had cotton wool spots (CWSs) with/without retinal hemorrhage, with no other retinal finding, and no visual symptoms, seen at a median of 30 days from COVID-19 diagnosis.Conclusions: CWSs (and retinal hemorrhages) were an incidental finding in COVID-19, detected only in the convalescent phase. These patients were much older (median age = 69 years) than the average age of our sample and had systemic comorbidities (diabetes mellitus, hypertension, etc.). We propose the term “COVID-19 retinopathy” to denote the presence of CWSs at the posterior pole, occasionally associated with intraretinal hemorrhages, in the absence of ocular inflammation in patients with a history of COVID-19 disease.

To examine disease profile of tubercular uveitis (TBU) in Paediatric population. Among 945 patients of the retrospective multinational study by the Collaborative Ocular Tuberculosis Study (COTS)-1,...

PurposeTo evaluate the change in the ongoing immunomodulatory (IMT) and biological therapies among patients with non-infectious uveitis (NIU), and determine the number of uveitis relapses during the COVID-19 pandemic.MethodsIn this national multicentric prospective case series, data of subjects with NIU receiving corticosteroids, systemic IMT and/or biological agents were analysed. The data collection was performed from 1 March 2020 to 25 June 2020. Main outcome measures included change in the ongoing treatments with corticosteroids, IMT and biological agents, use of alternate therapies and rates of uveitis relapse.ResultsIn this study, 176 patients (284 eyes) with NIU (mean age: 33±17.1 years; males: 68) were included. A total of 121 eyes (90 patients) were deemed to have active NIU. Of these, seven subjects (7.8%) did not receive intravenous methylprednisolone despite need felt by the treating uveitis experts. In addition, 35 subjects (57.4%) received a rapid tapering dosage of oral corticosteroids despite active disease. A total of 161 (91.5%) subjects were receiving systemic IMT and 25 (14.2%) were on biological therapies. Overall, IMT was altered in 29/161 (18.0%) subjects. Twenty-two eyes were treated with intravitreal therapies in the study period. Fifty-three eyes (32.5%, 29 subjects) developed relapse of NIU, of which 25 subjects (86.2%) were deemed to have reactivation related to altered systemic IMT. No patient developed COVID-19 during follow-up.ConclusionsDuring the ongoing COVID-19 pandemic, uveitis specialists may tend to reduce the ongoing systemic IMT, or prefer less aggressive treatment strategies for NIU. These subjects may be at high risk of relapse of uveitis.

To analyze baseline clinical and imaging risk factors associated with poor outcome in patients with tubercular serpiginous-like choroiditis (TB SLC).Retrospective clinical study.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.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).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.

PurposeTo study features, management and outcomes of cluster endophthalmitis following intravitreal bevacizumab (BCZ) injection in North India.MethodsIn this retrospective study, 28 patients (23 men) (mean age of 59.07±13 years) who received intravitreal injection of BCZ were included. Demographic details, best corrected visual acuity (BCVA), clinical features, microbiological findings and management of patients who developed endophthalmitis after injection of contaminated BCZ injections were reviewed. The organism isolated was Stenotrophomonas maltophilia.ResultsAll patients suffered from painful diminution of vision within 24–48 hours. Of the 28 eyes, 12 had lid and corneal oedema, raised intraocular pressure (IOP) (difference between mean preinjection and postinjection IOP: 4.42 mm Hg; p=0.005) and toxic anterior segment syndrome-like picture. 16 eyes presented with clear cornea, severe vitritis and poor media clarity. Among these, three eyes showed posterior hypopyon. Seventeen eyes underwent primary pars plana vitrectomy (PPV) and intravitreal vancomycin+ceftazidime based on severity of inflammation. Eleven eyes underwent primary tap and inject. Among these, four eyes required PPV due to persistent inflammation. Eleven eyes showed positive staining for Gram-negative bacilli. Seven eyes were culture positive for S. maltophilia. Mean preinjection BCVA was 0.77±0.48. The first recorded postinjection BCVA was 2.52±0.82. BCVA (at 1 month) improved to 0.88±0.66.ConclusionsS. maltophilia can be found contaminating hospital surfaces and water supply. Early PPV, prompt intravitreal antibiotics and close communication with microbiologists greatly aided in salvaging all eyes from our cohort. Majority of the patients recovered their preinjection BCVA and IOP and achieved quiescence of inflammation.

PURPOSE: To analyze the serum cytokines profile in patients with tubercular multifocal serpiginoid choroiditis (TB MSC) receiving anti-tubercular therapy (ATT) and oral corticosteroids. METHODS: In this prospective longitudinal study, patients with active TB MSC were included. Serum levels of interferon (IFN)-γ, interleukin (IL)-10, and tumor necrosis factor (TNF)-α were analyzed using bead-based immunoassay. The levels of transforming growth factor (TGF)-β were measured using cytokine bead array. Serial measurement was performed at baseline, 1, 3, and 6 weeks after initiation of therapy. Patients developing paradoxical worsening (PW) of TB MSC were identified and their serum levels of cytokines were compared with those patients who showed healing of lesions. Comparison of cytokine levels with baseline values was also performed. RESULTS: Twelve patients (three females) were included in the study. Four patients showed paradoxical worsening of TB MSC at 3.2 ± 1 weeks after initiation of therapy. Compared to patients who showed healing of lesions, patients with PW showed higher baseline IL-10 (not significant; p = 0.28). Among patients developing PW, levels of IFN-γ peaked at 1 week ((p = 0.01) and levels of TNF-α peaked at 3 weeks (p = 0.02) (coinciding with PW) compared to patients who showed healing. There was no significant difference in TGF-β levels at any time point in either group (p > 0.47). CONCLUSIONS: Baseline and serial levels of inflammatory serum cytokines may help in predicting the response to ATT and corticosteroids in TB MSC. Patients with paradoxical worsening may show rise in pro-inflammatory cytokines after initiation of ATT indicating higher bacillary load.

Purpose: To report a unique case of choroidal detachment following an intravitreal injection in a patient with Vogt-Koyanagi-Harada (VKH) disease.Methods: A 33-year-old male, a known case of chroni...

Optic disc neovascularization in uveitis is uncommon, and has been associated with chronic inflammations like Behcet's disease, Vogt-Koyanagi-Harada disease, sarcoidosis, etc. To our knowledge, optic disc neovascularization has not been reported in tubercular serpiginous-like choroiditis. We report three such cases.

Despite the potential of Idiopathic Intracranial Hypertension (IIH) to cause visual morbidity, limited literature is available focussing on predictors of visual outcome in IIH. This study was planned to assess visual morbidity in patients of IIH in terms of clinical and neuro-ophthalmo- logical parameters. In this prospective study of 40 patients of IIH, neuro-ophthalmological parameters were noted in the form of visual acuity, visual field, contrast sensitivity, Retinal Nerve Fibre Layer thickness, and visual evoked potential. Visual outcome was defined in using specific criteria. Final visual outcome of patients was compared with clinical and neuro-ophthalmologic para- meters to determine any correlation. The most common presenting clinical symptoms were headache (85%) and Transient visual obscurations (TVOs) (52.5%). In univariate analysis severity of visual loss, Cerebro Spinal Fluid (CSF) pressures and abnormal Visual evoked potential (VEP) were associated with worse visual outcome or need of aggressive management. When adjusted for severity of visual loss no independent clinical/neuroophthalmic predictor could be established. High CSF opening pressure, worsening vision/papilledema, greater Retinal Nerve Fiber Layer (RNFL) thickness and abnormal VEPs may be some of the alarming signs for physicians, but none of these parameters can be used as an independent predictor for visual outcome in isolation. Visual loss at presentation is probably the most important predictor of the final visual outcome in these patients. This may also suggest that patients presenting in an advanced disease course (with worse visual status) fair badly despite best medical/surgical management. Early diagnosis and prompt management is the cornerstone of management.

PURPOSE: To analyze the role of polymerase chain reaction (PCR) of ocular fluids in management of tubercular (TB) anterior, intermediate, posterior, and panuveitis. METHODS: In Collaborative Ocular Tuberculosis Study (COTS)-1 (25 centers, n = 962), patients with TB-related uveitis were included. 59 patients undergoing PCR of intraocular fluids (18 females; 53 Asian Indians) were included. RESULTS: 59 (6.13%) of COTS-1 underwent PCR analysis. PCR was positive for Mycobacterium TB in 33 patients (23 males; all Asian Indians). 26 patients were PCR negative (18 males). Eight patients with negative PCR had systemic TB. Anti-TB therapy was given in 18 negative and 31 PCR cases. At 1-year follow-up, five patients with positive PCR (15.15%) and three with negative PCR (11.54%) had persistence/worsening of inflammation. CONCLUSIONS: Data from COTS-1 suggest that PCR is not commonly done for diagnosing intraocular TB and positive/negative results may not influence management or treatment outcomes in the real world scenario.

To analyze the clinical features, course, management, and outcomes of tubercular (TB) uveitis in the pediatric population and assess the response to anti-tubercular therapy (ATT).Hospital records of children (≤16 years) from a large tertiary-care institute between January 2001 and December 2015 were reviewed.A total of 32 children (mean age: 10.7 ± 4.27 years; range 2-16) were diagnosed with TB-associated uveitis. The most common presentation was posterior uveitis (n = 14, 43.75%) and panuveitis (n = 14, 43.75%), followed by intermediate uveitis (n = 2, 6.25%) and anterior uveitis (n = 2, 6.25%); 14 children had probable intraocular tuberculosis (IOTB) (43.75%) and 17 (53.13%) had possible IOTB. Despite ATT and corticosteroids, 29.63% patients showed suboptimal response or worsening of disease requiring additional immunosuppression.TB is an important cause of pediatric uveitis in endemic countries. The manifestations of the disease resemble adult TB-related uveitis. However, higher inflammatory response in children may require more aggressive therapy with corticosteroids/immunosuppression.

A young male with acute blurring of vision (6/9) complained of an inferior altitudinal field defect in right eye. Clinical ophthalmological examination was normal. Magnetic resonance imaging (MRI) of the brain revealed the expansion and mucosal thickening of right posterior ethmoid and sphenoid sinuses and opacified right maxillary sinus. Surgical intervention (transethmoidal sphenoidotomy) and histopathological examination revealed chronic invasive granulomatous fungal sinusitis. Anti-fungal therapy led to resolution of visual complaints and restoration of visual field defects.

Aim of the study was to examine extent, natural history, and clinical features associated with visual impairment (VI) in patients diagnosed with ocular tuberculosis (OTB) by the Collaborative Ocula...

The Collaborative Ocular Tuberculosis Study (COTS) Group sought to address the diagnostic uncertainty through retrospective cohort analysis of treatment regimens and therapeutic outcomes for patien...

An international, expert led consensus initiative was set up by the Collaborative Ocular Tuberculosis Study (COTS) group to develop systematic, evidence, and experience-based recommendations for the treatment of ocular TB using a modified Delphi technique process. In the first round of Delphi, the group identified clinical scenarios pertinent to ocular TB based on five clinical phenotypes (anterior uveitis, intermediate uveitis, choroiditis, retinal vasculitis, and panuveitis). Using an interactive online questionnaires, guided by background knowledge from published literature, 486 consensus statements for initiating ATT were generated and deliberated amongst 81 global uveitis experts. The median score of five was considered reaching consensus for initiating ATT. The median score of four was tabled for deliberation through Delphi round 2 in a face-to-face meeting. This report describes the methodology adopted and followed through the consensus process, which help elucidate the guidelines for initiating ATT in patients with choroidal TB.

Purpose: Tubercular intermediate uveitis (TIU) and panuveitis (TBP) are difficult to manage because of limitations in diagnostic tools and lack of evidence-based treatment guidelines. The Collabora...

Purpose: To report two unique cases of spontaneous uveal effusion syndrome (UES) from the same family.Methods: The patients included father (54 years old) and a daughter (23 years old). The...

Background Mycobacterium tuberculosis (MTB) in latent infection has been demonstrated in pulmonary/extra-pulmonary locations (lung, spleen, liver, kidney, adipose tissue) in autopsy studies, but its presence in ocular tissues in the latent state is not known. Methods We conducted molecular and histopathological study of 100 cadaver eyes (50 humans) who died from causes other than tuberculosis (TB) (and were potential candidates for corneal transplantation) to detect MTB in ocular tissues in an endemic setting. After removal of the corneal button, an 8 to 10 mm block of tissue (choroid, retina and part of the vitreous) was excised from the remaining globe for DNA isolation. Gel-based IS6110 and devR3 polymerase chain reaction (PCR) assays were done, followed by real-time PCR using beta actin gene as an internal control. Sixteen randomly selected DNA samples were double checked using a commercial kit for MTB and non-tuberculous mycobacteria (NTM) DNA. The remaining larger part of the globe was subjected to histopathology. Results The mean age was 65.14 ± 18 years. All 100 samples were negative for both IS6110 and devR, and all 16 samples were negative with NTM MTB commercial kit. All samples were negative with Ziehl-Neelsen stain for acid fast bacilli and none showed any inflammation or granulomatous pathology. Conclusions MTB could not be detected in human ocular tissues in latent state in India, a TB-endemic country. This may suggest the inability of MTB to seed ocular tissues in the latent state, unlike other organs which serve as reservoirs for the bacilli in the absence of manifest disease.

Intraocular tuberculosis (TB) can have several clinical presentations, affecting nearly every tissue of the eye. These clinical signs have specific imaging characteristics which help in associating them with tuberculous etiology. This review enumerates the conventional and emerging imaging techniques for intraocular TB and highlights their clinical application for diagnosis and management of specific clinical presentations.

Purpose: To report epidemiology of uveitis in a tertiary-care referral institute in North India.Methods: Hospital records of patients with uveitis between June 2011 and September 2014 were retrospectively analyzed.Results: Of the 1912 patients, 56.64% were males. Anterior uveitis (43.04%) was the most common manifestation followed by posterior uveitis (24.58%), panuveitis (16.21%), and intermediate uveitis (10.66%). Specific etiologies could be ascertained in 60.56%. Tuberculosis (22.9%) was the most common infectious and HLA-B27-associated uveitis (9.46%) among non-infectious causes.Conclusions: There is a trend towards a decrease in idiopathic etiologies of uveitis. Tuberculosis remains the most common infectious etiology in North India.

Purpose: To report the pattern of pediatric uveitis in a tertiary care referral center in North India.Methods: In a retrospective study, records of pediatric uveitis cases presenting at our center between 1996 and 2015 were reviewed for demographic data, anatomic distribution, and diagnosis.Results: Out of 9600 patients with uveitis, 369 children (3.84%; age ≤16 years; males: 54.20%) were included in the study. Anterior uveitis was the commonest presentation (n = 158; 42.81%), followed by posterior uveitis (n = 102; 27.64%). Uveitis was bilateral in 57.18% (n = 211). Infective etiology was seen in 99 children, of which tuberculosis was the commonest cause (n = 55; 14.91%). Among non-infectious etiologies, juvenile idiopathic arthritis (JIA) was the commonest cause (n = 59; 15.99%).Conclusions: While anterior uveitis is the commonest uveitis in children, our cohort reported a high number of posterior uveitis cases compared to previous studies. Tuberculosis and JIA were the commonest causes of pedia...

To describe optical coherence tomography angiography (OCTA) features of lesions of tubercular multifocal serpiginoid choroiditis (TB MSC) that developed paradoxical worsening (PW).In this prospective study, subjects with TB MSC who developed PW upon initiation of anti-tubercular therapy were included. Multimodal imaging was performed using OCTA, enhanced-depth imaging OCT, fluorescein angiography (FA), and indocyanine green angiography (ICGA). Morphologic changes in the retinochoroidal vasculature during progression of TB MSC were assessed on OCTA.Five subjects (4 males, 1 female) were included in the study. PW of the lesions was associated with increased areas of choriocapillaris flow void on en face OCTA in all eyes. The lesions showed partial healing in the center and continuous progression at the active edges. Two eyes showed development of vascular tufts on OCTA as the lesions progressed.OCTA provides high-resolution imaging of progressive choriocapillaris hypoperfusion among TB MSC patients developing PW of the disease.

To describe the clinical presentations of inflammatory choroidal neovascular membranes (CNVMs) and factors leading to their delayed diagnosis.Retrospective analysis of chart records and digital images of 60 patients (73 eyes) with inflammatory CNVM (January 1998 to December 2013) to obtain demographic and clinical details, particularly the time of the first documentation of inflammatory CNVM by the uveitis specialist, time of its actual appearance on digital images, and the earliest clinical indicators of a CNVM.In total, 14 (19.2%) eyes had a delayed diagnosis of inflammatory CNVMs, of which five developed significant visual loss. The earliest clinical indicators of CNVM that were overlooked initially due to their subtle appearance, included a tiny subretinal hemorrhage (five eyes), peripapillary halo/fluid/scar (eight eyes), and a subfoveal scar (one eye). The causes of uveitis in these eyes included Vogt-Koyanagi-Harada disease (five eyes, 35.7%), tubercular uveitis (five eyes, 35.7%), idiopathic (three eyes, 21.4%), and sympathetic ophthalmia (one eye, 7.1%). Presence of significant background fundus scarring, sunset glow fundus, visually significant cataract, poorly dilating pupil, media haze due to vitritis, cystoid macular edema, and multiple chorioretinal scars in these eyes probably predisposed to delayed detection of an underlying CNVM.A high index of suspicion and comparison of serial fundus photographs to identify the earliest clues of inflammatory CNVMs are important to prevent diagnostic delays and poorer outcomes.

Fungal endogenous endophthalmitis (EE) secondary to contaminated intravenous fluid infusion is frequently seen in developing countries. Molds and yeasts are commonly implicated as the causative agents. Dematiaceous fungi such as Lecythophora have been linked to exogenous endophthalmitis but have never been reported to cause EE. We report a case of Lecythophora EE that was successfully managed with pars plana vitrectomy along with intravitreal and systemic voriconazole. Endogenous endophthalmitis (EE) is a potentially devastating intraocular infection caused by intraocular spread of pathogens through blood stream. It generally accounts for 2%-16% of all reported endophthalmitis cases.[1] Predisposing risk factors include diabetes mellitus, malignancies, intravenous drug use, organ abscess, immunosuppressive therapy, indwelling catheters, urinary tract infection, organ transplant, end-stage renal or liver disease, and endocarditis.[2] It may occur in patients with no overt signs of systemic infection, particularly in the setting of contaminated intravenous fluid infusion in a rural setting.[3] Among the three broad categories of pathogens responsible for EE-bacteria, yeast, and molds, cases caused by molds are most infrequent and have the worst outcomes.[4] While Candida and Aspergillus are the most common species among fungal causes of EE, Lecythophora has been rarely reported as a cause of endophthalmitis due to exogenous causes.[5],[6],[7],[8] We, herein, report a case of EE caused by Lecythophora species.

Purpose The aim of this work was to study various retinochoroidal parameters in patients with obstructive sleep apnea syndrome (OSAS) and the effect of interventions on these parameters at 6 months follow-up. Methods A total of 36 patients were recruited prospectively from the otorhinolaryngology clinics of a large tertiary center between September 2018 to March 2020. The subjects were divided into three groups depending upon intervention chosen for OSAS: Group A (surgery, i.e., uvulopalatopharyngoplasty), group B (medical therapy, i.e., continuous positive air pressure) and group C (no intervention). Various retinochoroidal parameters which were studied included retinal thickness (RT), choroidal thickness (CT), choroidal vascularity index (CVI), arteriovenous ratio (AVR), capillary density index (CDI) in superficial and deep retina, at baseline and 6 months of follow-up after the intervention. Results In group A, CT increased significantly at 6 months (332.76 ± 86.41 um) compared to baseline (306.28 ± 78.19) (P = 0.0004). Similarly, CDI at both superficial and deep capillary plexus increased significantly at 6 months (superficial CDI: 0.65 ± 0.04, deep CDI: 0.38 ± 0.01) compared to baseline (superficial CDI: 0.62 ± 0.03, deep CDI: 0.36 ± 0.02) (P = 0.004 and 0.002 respectively). In group B, CT increased significantly at 6 months (361.38 ± 78.63 um) compared to baseline (324.21 ± 76.97 um) (P = 0.008). Also, CVI showed a significant decrease at 6 months (65.74 ± 1.84%) compared to baseline (67.36 ± 1.57%) (P = 0.019). In group C, all except CDI in deep capillary plexus showed a significant decrease at 6 months (0.35 ± 0.01) compared to baseline (0.36 ± 0.02) (P = 0.003). Conclusion OSAS alters various retinochoroidal parameters and timely intervention in patients with OSAS can prevent these alterations. Also, these retinochoroidal parameters could serve as one of the markers to monitor the disease progression.

Purpose: To assess postoperative inflammation using laser flare photometer, following phacoemulsification with or without single intraoperative intravitreal dexamethasone implant in addition to standard of care, in patients of uveitis with cataract.Methods: Prospectively, 30 eyes with uveitic cataract were randomized into 2 groups (i) standard of care (SOC group) (ii) Dexamethasone implant (DEXA group). Both the groups underwent phacoemulsification with intraocular lens implantation and standard of care treatment for uveitis, but DEXA group additionally received intraoperative intravitreal dexamethasone implant. Patients were followed at least till 6 months.Results: DEXA group had significantly less postoperative flare (LFP values) (P

Purpose: To contribute a global description of the spectrum of choroidal involvement in tubercular uveitis (TBU).Methods: Retrospective cohort study of TBU patients with choroidal involvement from ...

Purpose: To analyze the outcomes of surgical procedures on inciting eye of patients with Sympathetic ophthalmia (SO). Methods: Retrospective study of patients with SO who underwent surgical procedures on inciting eyes between January 2000 and December 2015. Outcome measures included flare up of inflammation in either eye and change in visual acuity in the inciting eye. Results: Four SO patients underwent surgeries in their inciting eyes after adequate control of inflammation. Surgical procedures included penetrating keratoplasty, glaucoma drainage device implantation, pars plana vitrectomy, and silicon oil removal. Keratoplasty, glaucoma surgery, and silicon oil removal were well tolerated, with no flare up of disease. The patient who underwent pars plana vitrectomy, however, had a poor outcome. Conclusions: Surgical intervention in inciting eyes of patients with SO, after being adequately treated with oral steroids and immunosuppression, is a viable option for improving anatomic and functional outcomes in these eyes.

PURPOSE Patients with macula-off rhegmatogenous retinal detachments (RRDs) may have suboptimal visual recovery, despite successful reattachment due to various reasons. This study was performed to evaluate the retinal microvasculature in subjects undergoing surgery for RRD using optical coherence tomography angiography. METHODS In this case-control study, the analysis of optical coherence tomography angiography findings of 19 eyes of 19 patients (15 men) who underwent RRD surgery at a tertiary institute were compared with 19 eyes of 19 age- and sex-matched healthy subjects with no known ocular disease. 3 × 3-mm optical coherence tomography angiography scans were obtained at 3 months postoperatively and analyzed. Optical coherence tomography angiography images of patients with RRD and control subjects were analyzed for capillary density index and fractal dimensions. RESULTS Mean age of the patients was 40.21 years, and the mean age of controls was 43.73 years. Eight eyes underwent scleral buckling alone, and 11 eyes underwent primary vitrectomy with gas tamponade (C3F8 gas) for macula-off RRD. None of the eyes had redetachment during the follow-up at 3 months. Mean capillary density index among patients was 33.28% ± 0.99% and 34.06% ± 2.22% in the superficial and deep retinal plexuses, respectively, compared with 36.11% ± 1.29% and 37.52% ± 1.24% among controls (P < 0.001). The mean fractal dimension was lower among subjects compared with controls (1.46 vs. 1.61 in the superficial plexus, P < 0.001; 1.58 vs. 1.64 in the deep plexus, P < 0.001). CONCLUSION Optical coherence tomography angiography demonstrates significant reduction in mean capillary density index and fractal dimension in patients after surgery for RRD in our patients. Thus, reduction in vascular perfusion and branching pattern identified using novel analysis techniques on optical coherence tomography angiography images may provide an insight into the reasons for suboptimal visual gain after RRD surgery.

Purpose Dengue maculopathy can present with a unique constellation of features resulting in significant central visual morbidity. We aim to describe various findings of dengue-induced inflammatory, ischemic foveolitis, and outer maculopathy (DIII-FOM) and assess the serial changes in vitreous inflammation, retinal structure, and vascularity using swept-source OCT (SS-OCT) and OCT angiography (OCTA). Design Retrospective case series. Participants A total of 32 eyes (16 patients; 7 male) with dengue fever (positive serology for NS1 antigen) were enrolled in the study. Methods In this study, serial assessments of ocular findings and imaging using fundus photography, SS-OCT, and SS-OCTA were performed. All the patients received 0.5 to 1 mg/kg/day oral prednisolone that was tapered over 4 to 6 weeks. Main Outcome Measures Outcome measures included functional change, that is, improvement in best-corrected visual acuity (BCVA), structural changes in the vitreous and retinal layers on SS-OCT, and retinal perfusion on OCTA. Results The mean age of the patients was 29.17±10.91 years. Swept-source OCT showed vitreous cells (32 eyes; 100%), disruption of outer retinal layers (foveolitis) (24 eyes; 75%), and conical foveal elevation (22 eyes; 68.75%). After initiation of systemic corticosteroids, all the eyes showed resolution of vitreous cells and improvement in the integrity of retinal layers. Mean BCVA improved from an initial 0.80±0.33 logarithm of the minimum angle of resolution (logMAR) to 0.23±0.36 logMAR. Retinal plexus flow deficit (superficial plexus: 0.10±0.12 mm2; deep plexus: 0.29±0.13 mm2) persisted in all eyes and correlated well with initial BCVA (P Conclusions The pathophysiology of dengue maculopathy involves both ischemic and inflammatory components. Early institution of corticosteroid therapy may help in resolution of the inflammation-driven vitreoretinal alterations, but ischemia of the deep retinal plexuses may persist and may be the cause of permanent structural and functional changes.

PURPOSE To evaluate the outcome of endovascular procedures on ocular findings in patients with Takayasu arteritis. METHODS Retrospective study of patients who underwent percutaneous endovascular stenting of aortic arch arteries for Takayasu arteritis (TA) and who had documented retinopathy findings before and after the procedure. Change in visual acuity, regression of retinopathy, and development of complications after endovascular procedure were studied over a follow-up of 6 months. RESULTS Ten eyes of five patients were included. Eyes which had Stage II or less of retinopathy before the endovascular procedure had favorable outcome; however, those with advanced stage of retinopathy at presentation had poor outcomes. Patients who underwent revascularization of both-sided arteries within 1 month had better anatomical and functional outcomes as compared with those who underwent sequential endovascular procedures on their arteries after a gap of 3 months or more. CONCLUSION Percutaneous endovascular stenting of aortic arch arteries, affected in TA, can lead to reversal of retinopathy changes and restoration of vision if done before neovascular complications set in.

Purpose: To report the role of CT chest and cytology in suspected tubercular and sarcoid uveitis.Methods: This is a retrospective, interventional case series of 376 uveitis patients with su...

Purpose: To study outcome of secondary glaucoma in pediatric uveitis patients. Methods: Retrospective analysis of records of uveitis patients ≤16 years. Results: Of 182 pediatric uveitis patients, secondary glaucoma was seen in 48 patients (75 eyes, 26.23%) with female preponderance (F:M-29:19) . JIA was the most common etiology (35.71%). BCVA of ≥20/40 was seen in 22 eyes at presentation and in 38 eyes at final follow up (p