Nesrine Abroug

Optical Coherence Tomography Angiography In Patients With BehÇet Uveitis

Purpose: To describe optical coherence tomography angiography (OCTA) findings in eyes with Behçet uveitis (BU) and to compare these findings with those of fluorescein angiography (FA). Methods: Prospective, comparative, cross-sectional study. Patients presenting with clinically active BU involving the posterior segment were evaluated using FA, spectral domain optical coherence tomography (SD-OCT), and OCTA. Optical coherence tomography angiograms were reviewed and analyzed. Foveal avascular zone areas and vessel densities were also reported. Results: Twenty-five patients (44 eyes) were included. Perifoveal microvascular changes were more frequently observed on OCTA than on FA (95.5 vs 59.1%; P < 0.001). Disruption of the perifoveal capillary arcade, areas of retinal capillary nonperfusion/hypoperfusion, and perifoveal capillary abnormalities, including rarefied, dilated, or shunting vessels were observed more frequently using OCTA than FA (40.9 vs 25%; P = 0.039, 86.4 vs 34.1%; P < 0.001, and 84.1 vs 36.4%; P < 0.001, respectively). Areas of retinal capillary nonperfusion/hypoperfusion were more frequently observed in the deep than in the superficial capillary plexus (81.8 vs 63.6%; P = 0.039). Capillary abnormalities and disorganization of the normal architecture of the capillary network were more frequent in the deep than in the superficial capillary plexus (P < 0.001). Foveal avascular zone area was not significantly larger in eyes with BU than in control group in both the superficial and the deep capillary plexuses (0.4 vs 0.34 mm2; P = 0.23 and 0.72 vs 0.53 mm2; P = 0.053, respectively). Capillary vessel density was significantly lower in eyes with BU than in control group in the deep capillary plexus (13.7 vs 17.2 mm 21; P = 0.004). Conclusion: OCTA allows better visualization and characterization of perifoveal microvascular changes than FA in eyes with active BU. The deep capillary plexus seemed to be more severely involved than the superficial capillary plexus.

Visual Loss Associated with Rickettsial Disease

Abstract Purpose: To characterize and analyze ocular involvement associated with visual loss in a cohort of patients with rickettsial disease. Methods: Retrospective study of 16 eyes of 14 patients. Results: Mean initial visual acuity (VA) was 20/63 (range, 20/800–20/25). White retinal lesions infiltrating inner retina was the most common finding occurring in 14 eyes (87.5%). It was associated with a serous retinal detachment (SRD), accurately detectable by optical coherence tomography, in 11 eyes (78.6%). Other findings included optic neuropathy in 7 eyes (43.75%), cystoid macular edema in 1 eye (6.25%), branch retinal artery occlusion in 1 eye (6.25%), and choroidal neovascularization in 1 eye (6.25%). Thirteen patients were treated with a 2-week course of oral doxycycline 200 mg/day. Mean final VA was 20/40. Conclusions: Inner retinitis, associated with mild vitritis and SRD, and optic neuropathy are the most common vision-threatening ocular manifestations of rickettsial disease.

Pattern of Acute Retinal Necrosis in a Referral Center in Tunisia, North Africa

Abstract Purpose: To describe the pattern of acute retinal necrosis (ARN) syndrome in a referral center in Tunisia. Methods: Retrospective review of the charts of 12 patients (12 eyes). Results: Necrotizing retinitis involved >50% of the retina in 33.3% of eyes. Polymerase chain reaction on aqueous humor sample identified herpes simplex virus-1 in 4 eyes (33.3%) and varicella zoster virus in 3 eyes (25%), and was negative in 5 eyes (41.7%). All patients received intravenous acyclovir, followed by oral antivirals. Follow-up ranged from 6 to 16 months. Retinal detachment (RD) occurred in 3 eyes (25%), but no patient developed bilateral ARN. Final visual acuity was 20/200 or worse in 7 eyes (58.3%). Delay in diagnosis (p = 0.015), macular involvement (p = 0.045), development of RD (p = 0.018), and 25–50% of retinal involvement (p = 0.045) were associated with a worse visual outcome. Conclusion: ARN carries poor visual prognosis in Tunisia.

Final Diagnosis in Patients Referred with a Diagnosis of Neuroretinitis

Abstract The purpose of this study was to determine final diagnosis of patients referred with a diagnosis of neuroretinitis. A retrospective study of 40 patients with optic disc oedema with macular star (ODOMS) referred with a diagnosis of neuroretinitis was conducted. The final diagnosis was neuroretinitis in 26 patients (65%), with most of these patients (96.1%) having unilateral involvement. Main underlying aetiologies included cat scratch disease (30.8%), rickettsiosis (19.2%), and idiopathic neuroretinitis (23.1%). The remaining 14 patients (35%) had ODOMS that had been mistaken for neuroretinitis. Of these patients, 42.8% were found to have a previously unknown malignant systemic hypertension in association with bilateral ODOMS. Neuroretinitis, usually unilateral, should be differentiated from other causes of unilateral or most often bilateral ODOMS that may masquerade as neuroretinitis, mainly malignant systemic hypertension. This is essential to avoid inappropriate work-up and management and subsequent potential visual or systemic morbidity.

CYP1B1 gene mutations causing primary congenital glaucoma in Tunisia.

Primary congenital glaucoma (PCG) is responsible for a significant proportion of childhood blindness in Tunisia. Early prevention based on genetic diagnosis is therefore required. This study sought to determine the frequency of CYP1B1 (cytochrome P450, family 1, subfamily B, polypeptide 1) mutations in 18 PCG patients, recruited from Central and Southern of Tunisia.

Parinaud’s oculoglandular syndrome revealing subclinical Rickettsia conorii infection

The purpose of this study was to report a case of Parinaud’s oculoglandular syndrome associated with subclinical Rickettsia conorii infection. We report a case of a 66-year-old male patient presented with unilateral persistent granulomatous conjunctivitis in the left eye and an ipsilateral preauricular lymphadenopathy without associated systemic features. Laboratory evaluation showed a positive indirect immunofluorescence antibody test for R. conorii. The patient received a 2-week course of oral doxycycline, with subsequent complete resolution of all his symptoms. Rickettsial disease should be considered in the differential diagnosis of oculoglandular syndrome with or without associated systemic symptoms in any patient living in or returning from a specific endemic area.

Infectious optic neuropathies: a clinical update

Different forms of optic neuropathy causing visual impairment of varying severity have been reported in association with a wide variety of infectious agents. Proper clinical diagnosis of any of these infectious conditions is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular findings. Diagnosis is confirmed by serologic testing and polymerase chain reaction in selected cases. Treatment of infectious optic neuropathies involves the use of specific anti-infectious drugs and corticosteroids to suppress the associated inflammatory reaction. The visual prognosis is generally good, but persistent severe vision loss with optic atrophy can occur. This review presents optic neuropathies caused by specific viral, bacterial, parasitic, and fungal diseases.

Ocular Manifestations of Rickettsial Disease

Rickettsioses are emergent and resurgent arthropod vector borne diseases due to obligate intracellular small gram-negative bacteria. Most of them are transmitted to humans by the bite of contaminated arthropods, such as ticks. Systemic disease typically consists of high fever, headache and skin rash, with or without «tache noire» (dark spot). Ocular involvement is common including conjunctivitis, keratitis, anterior uveitis, panuveitis, retinitis, retinal vascular changes, and optic nerve involvement. Proper clinical diagnosis of this infectious disease is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular involvement. The diagnosis is usually confirmed by detection of specific antibodies in serum. Ocular involvement associated with rickettsial infection usually has a selflimited course, but it can result in persistent visual impairment. Doxycycline is the treatment of choice for rickettsial diseases but prevention is the mainstay of rickettsial infection control.

Response to Ilhan and Yolcu's Letter Regarding "Pattern of acute retinal necrosis in a referral center in Tunisia, North Africa".

We appreciate the interest of Ilhan and Yolcu in our recent article “Pattern of acute retinal necrosis in a referral center in Tunisia, North Africa.” Ilhan and Yolcu raise concerns regarding the accuracy of acute retinal necrosis (ARN) diagnosis in our patients. Diagnosis of ARN syndrome was made in all our patients according to the criteria of the American Uveitis Society. All affected eyes exhibited active peripheral necrotizing retinitis typical of ARN. All of them showed mild to moderate anterior uveitis, with granulomatous keratic precipitates in 10 eyes (83.3%). Mild to severe vitritis was seen in all eyes, and arteritis was noted in 10 eyes (83.3%). All these are distinctive features of ARN, which exclude progressive outer retinal necrosis (PORN). In fact, in contrast to ARN, PORN is characterized by absent or minimal intraocular inflammation, absent retinal vasculitis, and typical multifocal onset in the posterior pole. Varicella zoster virus (VZV), which is usually responsible for PORN, was also found to be the most common cause of ARN. Identification of VZV by polymerase chain reaction on aqueous humor sample cannot allow to differentiate between these two types of necrotizing herpetic retinopathies, and the differential diagnosis remains mainly clinical. Furthermore, ARN typically develops in otherwise healthy patients, or in those with only a mild immune dysfunction, whereas PORN occurs in profoundly immunocompromised individuals. No patient in our series had a history of immunosuppression, and serology results for human immunodeficiency virus were negative in all cases. Four patients (33.3%) had been mistakenly treated with systemic corticosteroids without antivirals for 3–7 days before referral to our department. Further investigation is required to clarify whether misuse of corticosteroid monotherapy before referral, can induce delayed healing of retinal lesions or increase the risk of retinal detachment or bilateral disease in patients with ARN syndrome.

West Nile Virus Infection

West Nile virus (WNV) infection is an emerging and resurgent arthropod vector-borne disease caused by WNV, which belongs to the Flaviviridae family. WNV infection in humans usually manifest as a mild febrile illness, but a severe potentially lethal neurologic involvement may occur in patients who are elderly or debilitated. A bilateral multifocal chorioretinitis with typical linear clustering of lesions is the most common ocular finding in patients with acute WNV infection associated with neurologic illness. Other less common findings may include retinitis, anterior uveitis, retinal vasculitis, and optic neuropathy. Diabetes mellitus and advanced age appear to be a potential risk factor for developing severe neurologic disease and also severe chorioretinitis. Diagnosis is based on epidemiologic data, pattern of ocular and systemic involvement, and is usually confirmed by serologic testing and/or PCR. Treatment of WNV infection is entirely supportive, and prevention is the mainstay of infection control.