Sana Khochtali

Ocular involvement and visual outcome of herpes zoster ophthalmicus: review of 45 patients from Tunisia, North Africa

BackgroundOcular complications of herpes zoster ophthalmicus (HZO) may lead to substantial visual impairment. The purpose of this study was to characterize and analyze ocular involvement and visual outcome of HZO in patients from Tunisia, North Africa. This study is a retrospective chart review of 51 eyes of 45 patients with HZO.ResultsMean age was 44.5 years. Thirty patients (66.7%) were aged over 50 years. Twenty-four patients (53.3%) were male and 21 patients were female (46.7%). There was no statistically significant difference in gender distribution. Initial mean best corrected visual acuity (BCVA) was 20/50. Ocular manifestations included adnexal involvement (58.8%), keratitis (31.4%), keratouveitis (31.4%), isolated anterior uveitis (AU) (29.4%), intraocular pressure elevation (23.5%), oculomotor nerve palsy (5.8%), and optic neuritis (1.9%). Isolated AU (p < 0.001), isolated keratitis (p = 0.001), and intraocular pressure elevation (p = 0.013) were more likely to be concomitant to HZO active skin disease, while keratouveitis occurred more likely more than 1 month after HZO eruption (p < 0.001). AU and keratouveitis were more likely to be associated with age ≥ 50 years (p = 0.001 and p = 0.02, respectively). Ocular complications included neurotrophic keratopathy (1.9%), corneal opacity (5.9%), secondary glaucoma (7.8%), optic atrophy (1.9%), and postherpetic neuralgia (13.3%). Mean follow-up was 12 months. Mean final BCVA was 20/32; it was ≥ 20/40 in 78.4% of the eyes.ConclusionsOur study provided epidemiologic and clinical data of HZO in a Tunisian population. AU and keratitis were the most common ocular complications. Neurotrophic keratopathy was scarce. The overall visual outcome is good, with about three quarters of the treated patients maintaining VA of 20/40 or better.

Vogt–Koyanagi–Harada disease

Vogt–Koyanagi–Harada (VKH) disease is usually defined as a bilateral chronic granulomatous panuveitis that may be associated with CNS, auditory and integumentary manifestations. An autoimmune reaction against melanocyte antigens in genetically predisposed patients without history of ocular trauma is presumed to cause the disease. Features of ocular and extraocular involvement vary according to disease phase, and the condition can present with disease features limited to intraocular inflammation without associated systemic manifestations. Exudative retinal detachment is the most specific feature to acute VKH disease. Ancillary tests (mainly fluorescein angiography) may help in establishing the definitive diagnosis. On the other hand, sunset glow fundus is typical to chronic VKH disease. Complications are more likely to occur in the chronic recurrent phase. The mainstay of treatment for acute VKH relies on prompt systemic corticosteroid therapy initiated as a high dose and then tapered gradually. The duration of corticosteroid therapy is recommended to be at least 6 months. Other immunosuppressants may be given as second-line or, in selected cases, as first-line therapy. Early diagnosis with rapid initiation of corticosteroids reduces recurrence and thus improves visual prognosis.

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.

Acute Retinal Necrosis Associated With Central Retinal Artery Occlusion Followed After its Resolution by Keratouveitis

Acute retinal necrosis (ARN) is rare sight-threatening condition, typically affecting immunocompetent individuals. It is defined by the combination of clinical features, including areas of retinal necrosis usually located in peripheral retina with circumferential extension, occlusive vasculopathy, as well as vitritis and/or anterior chamber inflammatory reaction. Varicella zoster virus (VZV) and herpes simplex virus (HSV) are the most frequent causes of ARN. Central retinal artery occlusion (CRAO) has been rarely reported in the setting of ARN, worsening the visual prognosis of the condition. Although fellow eye involvement is quite common, recurrence of ARN in the same eye has been rarely seen. Furthermore, occurrence of anterior uveitis without posterior segment involvement has been described after healed ARN. We describe herein a patient with ARN associated with CRAO who developed after complete recovery of ARN ipsilateral keratouveitis. A 53-year-old female complaining of loss of vision in the right eye for 3 weeks was referred to our institution for panuveitis. The patient had a history of arterial hypertension and atrial fibrillation, which was being treated with amiodarone. No previous episode of eye redness was reported. Visual acuity was hand motions in the right eye (RE) and 20/20 in the left eye (LE). Slit-lamp examination of the RE showed granulomatous anterior uveitis without associated iris atrophy, active keratitis, or corneal scar. There were 2þ vitreous cells and haze in the RE. Dilated fundus examination showed areas of necrotizing retinitis in the posterior pole and temporal periphery over approximately 5 clock hours, and an area of ischemic retinal whitening in the posterior pole along with diffuse narrowing of retinal vessels and segmental fuzzy vascular sheathing in the RE (Figure 1A). Results of examination of the LE were unremarkable. Fluorescein angiography revealed a marked delay of retinal artery filling consistent with CRAO in the RE (Figure 1B, C). A diagnosis of ARN was made. Workup for toxoplasmosis, syphilis, tuberculosis, and human immunodeficiency syndrome was negative. Polymerase chain reaction (PCR) on aqueous humor sample was positive for HSV type 1. The patient was treated with intravenous acyclovir (10 mg/kg, 3 times a day) for only 3 days, because of the increase of serum creatinine levels. Oral valacyclovir (1 g, 3 times a day) was then given for 12 weeks, and was associated with oral prednisolone started with a dose of 1 mg/kg/day and gradually tapered over 6 weeks. Necrotic lesions completely healed within 2 months. Visual acuity was then 20/400 in the RE. A cardiovascular workup was conducted to rule out other possible causes of CRAO. Blood pressure values and serum lipid profile were within normal levels. Electrocardiogram showed a regular sinus rhythm. A transoesophageal echocardiography revealed no atrial thrombi. Carotid ultrasonography found some plaques but no significant stenosis. Five months after the resolution of ARN episode, the patient presented with red and painful RE. Slitlamp examination showed disciform keratitis, mutton-fat keratic precipitates, 2þ cells and 1þ flare in anterior chamber, and sectoral iris atrophy (Figure 1D). Corneal sensitivity was found to be decreased. The intraocular pressure was normal. The vitreous cavity was clear, without any obvious cells. Dilated fundus examination showed optic disc atrophy,

Ocular involvement associated with varicella in adults

BackgroundVaricella is a common infectious disease primarily of childhood that is usually benign and self-limited. It is, however, increasingly seen in adults who are at a higher risk of severe infection. Ocular complications of varicella are relatively uncommon and have been rarely described in adults. We describe herein five adults who developed ocular involvement in association with primary varicella-zoster virus infection.FindingsOcular manifestations included acute anterior uveitis in four eyes, with associated stromal keratitis in one of them, epithelial ulcerative keratitis in the two eyes of one patient, and acute retinal necrosis in one eye. One patient with acute anterior uveitis was treated with topical steroids and cycloplegic agents. The four other patients received topical or systemic antiviral drugs, with subsequent resolution of acute ocular inflammatory disease.ConclusionsThe spectrum of chickenpox-associated ocular complications in adults is wide. Early diagnosis and appropriate management are mandatory to improve visual outcome.

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.

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.

Retinal Pigment Epithelium Detachment in Acute Vogt–Koyanagi–Harada Disease: An Unusual Finding at Presentation

ABSTRACT Purpose: To report the cases of two patients who presented with acute Vogt–Koyanagi–Harada (VKH) disease and associated retinal pigment epithelium detachment (PED). Methods: 2 case reports. Case 1: A 22-year-old male patient complained of acute bilateral decrease in vision. Initial best corrected visual acuity (BCVA) was 20/63, OU. There was 1+ vitreous cells, OU, exudative retinal detachment (ERD) in the right eye (RE), and a macular deep yellow lesion suggestive of PED in the left eye (LE). Case 2: A 40-year-old female patient presented with bilateral vision blurring. BCVA was 20/40 in the RE and 20/32 in the LE. There was 1+ vitreous cells OU, bilateral optic disc swelling and retinal striae. Results: Multimodal imaging showed features of acute VKH disease with associated PED in the two patients. ERD and PED resolved under oral prednisone and cyclosporine in both cases. Conclusion: PED may rarely occur in acute VKH disease at presentation.

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.

Choroidal neovascularization complicating optic disc drusen, mistaken for Bartonella neuroretinitis

In their recent article [1], Latanza L et al. report a child with peripapillary choroidal neovascularization (CNV) that has been attributed to serologically proven Bartonella Henselae neuroretinitis. The patient received a single intravitreal injection of ranibizumab and systemic azithromycin for a 7-month long period, to control persistent bilateral papillitis. At last followup examination, CNV was inactive and visual acuity had improved. The fundus photographs provided show typical features of buried optic disc drusen (ODD) in both eyes including optic disc elevation, blurred optic disc margins without obscuration of peripapillary retinal vessels, and nodular border of the optic disc. There are no obvious features of superimposed inflammatory optic disc oedema in either eye such as hyperaemia, obscuration of retinal vessels, microvascular abnormalities or telangiectasia, retinal vascular sheathing, or retinal infiltrates. The partial macular star, seen in the right eye at presentation, could be easily explained by the sole presence of the peripapillary choroidal neovascular membrane. Fluorescein angiograms confirm the diagnosis of CNV, and also show at presentation and on follow-up examinations features highly suggestive of ODD including nodular staining and late circumferential peripapillary staining. The absence of early or late leakage of dye from the discs could allow optic disc oedema, particularly papillitis, to be confidently ruled out [2]. Other imaging modalities could help to confirm the diagnosis of ODD in this patient including fundus autofluorescence, Bscan ultrasonography, optical coherence tomography, and computed tomography [2]. In this child with clinically and angiographically evident ODD complicated with peripapillary CNV associated with a macular star, a diagnosis of primary or superimposed neuroretinitis could be easily excluded. There was therefore no indication for laboratory testing for cat scratch disease or any other infectious or inflammatory condition. The association of positive anti-Bartonella henselae IgM titer with ODD and CNV appears to be only a coincidence. This case report shows that the differential diagnosis of any optic disc abnormality remains primarily clinical. Failure to differentiate non-inflammatory from inflammatory optic nerve disorder may lead to unnecessary laboratory investigations that may give misleading positive results.