Mamta Agarwal

Triple agent immunosuppressive therapy in Vogt-Koyanagi-Harada syndrome.

Purpose: To describe the role of triple agent immunosuppression in severe recalcitrant cases of Vogt-Koyanagi-Harada syndrome. Materials and methods: Retrospective chart review of five cases of Vogt-Koyanagi-Harada syndrome. Results: All cases were treated with oral prednisolone, azathioprine, and cyclosporine in combination, and rapid remission was observed in all patients. The synergistic effect of the triple agent immunosuppressives helped in preventing recurrences. Prolonged treatment with steroid sparing immunosuppressives in severe and recalcitrant cases of Vogt-Koyanagi-Harada syndrome maintained disease remission. Conclusion: Severe cases of Vogt-Koyanagi-Harada syndrome can be treated with early use of high-dose triple agent immunosuppressives.

Frosted Branch Angiitis in a Patient with Typhoid Fever

ABSTRACT Frosted branch angiitis (FBA), a rare form of retinal vasculitis presenting as bilateral perivascular sheathing, resembling the appearance of frosted tree branches in winter, was first reported by Ito et al.1 in 1976, in a young immunocompetent boy. FBA predominantly affects healthy young patients, the youngest reported in an 11-month-old infant2 and oldest in a 42-year-old patient.3 Classical symptoms include sudden onset of blurred vision with floaters and photopsiae. Fundus examination shows widespread perivascular translucent sheathing affecting both arterioles and venules, more commonly latter. Fluorescein angiography shows late staining of vessels with no obstruction of blood flow. Electroretinogram shows reduced amplitude and visual fields show generalized constriction. Medline search did not show any case of frosted branch angiitis in a patient with typhoid fever.

The Collaborative Ocular Tuberculosis Study (COTS)-1 Report 3: Polymerase Chain Reaction in the Diagnosis and Management of Tubercular Uveitis: Global Trends

ABSTRACT 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.

Unilateral frosted branch angiitis in a patient with abdominal tuberculosis.

PURPOSE To describe a case of unilateral frosted branch angiitis in a patient with abdominal tuberculosis. METHODS Observational case report. RESULTS A 17-year-old girl with chronic abdominal pain, cough, and amenorrhea for 5 months presented with complaints of sudden diminution of vision in both eyes for 1 day. Fundus examination of the right eye showed disk edema, dilated tortuous vessels with perivascular sheathing (frosted branch angiitis), retinal hemorrhages, and macular edema. The left eye had areas of healed choroiditis. Duodenal biopsy showed features suggestive of tuberculosis. She was treated with antituberculosis therapy along with oral steroids after which the ocular condition responded dramatically. CONCLUSION Frosted branch angiitis can be a rare manifestation of intraocular tuberculosis.

Conjunctival Necrosis Masquerading as Necrotizing Scleritis

Conjunctival necrosis is a rare complication known to occur following use of topical antibiotics, subconjunctival or intravitreal corticosteroid, microbial infections, chemical burns, and cryosurgery. We describe a patient who presented with severe conjunctival necrosis and glaucoma after subconjunctival injection of methylprednisolone acetate suspension (80mg/ml) andwas being treated as necrotizing scleritis.

Clinical profile of pythium keratitis: perioperative measures to reduce risk of recurrence

Purpose To report the clinical profile and role of perioperative adjunctive measures to reduce the risk of recurrence in Pythium insidiosum keratitis. Methods Retrospective analysis of 10 eyes of 10 patients with P. insidiosum keratitis. Diagnosis was confirmed by PCR DNA sequencing. Results 7out of 10 patients were from urban locales, and none had any obvious history of injury with vegetative matter and were being treated for fungal keratitis. 6 eyes presented with central full thickness infiltrates with subepithelial and superficial stromal infiltrates radiating in a reticular pattern. Corneal scraping in all eyes revealed sparsely septate fungal-like filaments on potassium hydroxide/Calcofluor. All eyes underwent the first therapeutic penetrating keratoplasty (TPK) based on worsening or non-responsiveness of clinical features to the antifungal regimen. Recurrence was noted in 7 out of 10 eyes of which 2 eyes underwent evisceration. Of the six eyes that underwent cryotherapy following confirmation of microbiological diagnosis of Pythium (along with primary TPK-1, with re-TPK-5), only one eye had a recurrence and had to be eviscerated. Of the two eyes that did not undergo cryotherapy during re-TPK, following microbiological diagnosis, one eye had a recurrence and had to be eviscerated. In two eyes with adjoining scleritis, the host bed was swabbed using absolute alcohol of which one eye was salvaged. Conclusion This series highlights the need to be aware of this entity in the management of refractory fungal keratitis. It also brings to fore the adjunctive measures that could have a beneficial role in the management of pythium keratitis.

Central retinal vein occlusion in primary antiphospholipid antibody syndrome.

PURPOSE To report a case of a 20-year-old healthy patient with central retinal vein occlusion in his right eye attributable to primary antiphospholipid antibody syndrome. METHODS A 20-year-old man with poor vision in the right eye and diffuse retinal hemorrhages was investigated for infections, autoimmune disease, diabetes, and hypertension. Testing for homocysteine, anticardiolipin antibodies, lupus anticoagulant, and functional assays for protein S and protein C was performed to detect a hypercoagulable state. RESULTS Laboratory investigations revealed elevated levels of IgG and M anticardiolipin antibodies. Long-term oral anticoagulants were given to reduce the risk of future thromboses. CONCLUSION Antiphospholipid antibodies play an important role in occlusive retinal vascular disorders, especially in young patients without any conventional risk factors.

Analysis of 130 Cases of Sympathetic Ophthalmia – A Retrospective Multicenter Case Series

ABSTRACT Objective: To analyze the demographic profile, treatment, and visual outcome of the patients with sympathetic ophthalmia (SO) in a multicenter collaborative retrospective cohort study. Methods: Medical records of the patients with SO from UK, Singapore, India were reviewed for history of ocular trauma or surgery and subsequent development of uveitis consistent with SO, presenting symptoms, treatment, and visual outcomes. Results: A total of 130 patients were diagnosed with SO during the study period. Eighty-one (62.3%) patients were men. The mean age was 48.4 ± 15.5 years. The most common presenting symptom was blurring of vision (89.2%), followed by pain (29.2%) and floaters (23.8%). Ninety-two (70.7%) required additional immunosuppressive therapy. Thirty-six (27.9%) patients underwent enucleation of the inciting eye. Conclusions: SO is a potentially sight-threatening disease with high rates of visual loss. It warrants prompt evaluation and treatment. With the advances and availability in immunotherapy, the visual prognosis is relatively good.

Clinical profile, risk factors and outcome of medical, surgical and adjunct interventions in patients with Pythium insidiosum keratitis

Purpose To report clinical profile and compare management options for Pythium keratitis. Method Retrospective interventional study of 46 patients diagnosed as Pythium keratitis by PCR DNA sequencing from January 2014 to July 2017. Interventions were categorised into medical management (MM) (topical azithromycin and linezolid with oral azithromycin at presentation), surgery (S) (therapeutic penetrating keratoplasty, TPK), surgical adjunct (SA) (cryotherapy±alcohol with TPK) and medical adjunct (MA) (MM after TPK). Results Primary treatment included MM (1 eye), SA (3 eyes) and S (42 eyes). Recurrence occurred in 27/43 eyes (MM+S group). Second surgery (S) was required in 11 eyes (TPK-2), with additional procedures (SA) in 10 eyes and evisceration in five eyes. 8/43 eyes received MA after TPK-1. One eye required TPK-3. Recurrence occured in all eyes that received MA (100%) and in 28 of 54 TPKs (51.8%) (TPK 1+2+3) in 42 eyes. Recurrence was noted in 1/14 (7.1%) that underwent SA. Conclusion The currently available and recommended treatment for Pythium keratitis is surgical by means of a TPK and in worse cases evisceration. In our study, MM/MA measures showed no benefit with recurrence or worsening of infection requiring resurgery. Almost 50% of TPKs had a recurrence requiring resurgery. However, adjunctive procedures during TPK appear to have additional benefit with low risk of recurrence and could be included as routine care.

Corticosteroid in Uveitis

Corticosteroids form the mainstay of therapy for noninfectious uveitis. The anti-inflammatory and immunosuppressive action is mediated by controlling the protein synthesis both at cellular and molecular level. Corticosteroids in uveitis can be administered by topical, periocular, intravitreal, and oral routes. Long-term use of corticosteroids is associated with side effects such as hypertension, osteoporosis, hyperglycemia, Cushing’s syndrome, cataract, glaucoma, and others. Corticosteroid-sparing immunosuppressive agents form the next line of treatment in chronic, recurrent, and nonresponsive uveitis.