Sanjay Kedhar

Lack of Consensus in the Diagnosis and Treatment for Ocular Tuberculosis among Uveitis Specialists

Abstract Purpose: To assess the approach of specialists to ocular tuberculosis (TB). Methods: The American Uveitis Society (AUS) Listserv was surveyed using two clinical cases and general questions. Results: Of 196 members, 87 responded (44.4%), of whom 64 were affiliated with practices in North America, while 23 were outside of North America. The survey provided normative data on how physicians evaluate patients with uveitis as well as opinions about ocular TB. Responses varied widely on such issues as (1) the pretest probability that a patient with granulomatous panuveitis had TB uveitis (range 1–75%) or that a patient with a risk factor for TB had ocular TB (range 0–90%); (2) the optimal duration of anti-TB therapy; and (3) whether therapy should be discontinued after 2 months in nonresponders. Conclusions: Consensus is lacking among uveitis specialists for the diagnosis or management of ocular TB.

Choroidal metastasis from adenoid cystic carcinoma of the lung

PURPOSEnWe report a case of a choroidal metastasis from an adenoid cystic carcinoma of the lung. Interventional case report.nnnDESIGNnA 40-year old man, 9 months status postresection of a bronchial adenoid cystic carcinoma, was diagnosed by clinical evaluation and fine-needle aspiration biopsy and treated with palladium-103 ophthalmic plaque brachytherapy.nnnRESULTSnThis unusual patient with uveal metastasis from adenoid cystic carcinoma presented with decreased vision in the right eye and a diaphanous amelanotic choroidal tumor in the superotemporal macula. Ultrasound revealed a dome-shaped tumor that measured 4.0 mm in apical height and 11 x 10 mm in basal diameter. Fluorescein angiography revealed a double circulation and late intense subretinal fluorescence. Plaque brachytherapy provided local control and preservation of the eye.nnnCONCLUSIONnBronchogenic adenoid cystic carcinoma can metastasize to the choroid.

CHIKUNGUNYA-ASSOCIATED UVEITIS AND EXUDATIVE RETINAL DETACHMENT: A CASE REPORT.

PURPOSEnTo report the first known case of bilateral granulomatous panuveitis secondary to chikungunya fever in the United States, acquired by a U.S. citizen traveling from an endemic region.nnnMETHODSnCase report.nnnRESULTSnA 47-year-old woman presented with 10 days of bilateral decreased vision and photophobia concurrent with a febrile illness contracted while visiting the Dominican Republic. She presented with bilateral granulomatous panuveitis and exudative retinal detachments. Extensive workup was negative with the exception of positive chikungunya virus immunoglobulin G and immunoglobulin M titers. Initially, she responded to corticosteroid treatment but developed recurrent inflammation 3 months after completing the initial treatment. Immunomodulatory therapy was initiated at the time of recurrence, and with immunomodulatory therapy alone her inflammation has been controlled for 6 months.nnnCONCLUSIONnThe prevalence of chikungunya fever-related uveitis is increasing with the recent epidemics throughout the Americas. Inflammation can occur during the febrile illness or months later and can manifest in a variety of ways. Posterior segment inflammation is more commonly a delayed presentation. Previous reports suggest that chikungunya fever-related uveitis responds well to corticosteroid therapy. This is the first reported case of recurrent inflammation. Given the wide variety of presentations, chikungunya fever-related uveitis should be included in the differential diagnosis of all at-risk patients presenting with acute ocular inflammation, particularly those traveling from endemic regions.

Fundus image diagnostic agreement in uveitis utilizing free and open source software

OBJECTIVEnTo assess the adequacy of image agreement regarding uveitis based on color fundus and fluorescein angiography images alone, and to use free and open source applications to conduct an image agreement study.nnnDESIGNnCross-sectional agreement study.nnnPARTICIPANTSnBaseline fundus and fluorescein images of patients with panuveitis, posterior, or intermediate uveitis enrolled in the Multi-center Uveitis Steroid Treatment (MUST) trial.nnnMETHODSnThree fellowship-trained specialists in uveitis independently reviewed patient images using ClearCanvas™ and responded using Epi Info™. The diagnoses of the 3 reviewers were compared with the MUST clinician as a gold standard. A rank transformation adjusted for the possible variation in number of responses per patient. Chance-corrected interobserver agreement among the 3 reviewers was estimated with the ι coefficient. Confidence interval (CI) and SE were bootstrapped.nnnRESULTSnAgreement between the diagnoses of the respondents and the baseline MUST clinicians diagnosis was poor across all diagnostic categories, ι = 0.09 (95% CI, 0.07-0.11). The agreement among respondents alone also was poor, ι = 0.11 ± 0.02 (95% CI, 0.08-0.13). The specialists requested more patient historical and clinical information to make a diagnosis on all patients.nnnCONCLUSIONSnThe role in distinguishing the multiple conditions in uveitis appears to be limited when based on fundus imaging alone. Future studies should investigate different categories of clinical data to supplement image data. Freely available applications have excellent utility in ophthalmic imaging agreement studies.

Granulomatous Uveitis and Conjunctivitis Due to Common Variable Immune Deficiency: A Case Report

ABSTRACT Purpose: To describe a case of granulomatous anterior uveitis and histologically confirmed chronic granulomatous conjunctivitis in the presence of common variable immune deficiency (CVID). Methods: Interventional case report. Results: A 72-year-old female with a history of CVID treated with regular intravenous immunoglobulin (IVIG) infusions developed chronic conjunctivitis and granulomatous anterior uveitis. She responded to topical steroids, but there was recurrence upon cessation of steroid therapy. Conjunctival biopsy demonstrated micro-granulomas in the stroma and epithelium. Treatment with IVIG was maintained throughout. Conclusion: Although rare, a diagnosis of CVID should be considered in patients with recurrent conjunctivitis and uveitis of unknown etiology, especially if there is a clinical history suggestive of defective immunity. They tend to respond well to continued steroid therapy, and IVIG therapy should not be stopped.