Unusual presentation of cornea verticillata with intravitreal methotrexate in a case of primary intraocular lymphoma

A 56-year-old woman presented with floaters and diminution of vision in the right eye for 1 week. On examination, visual acuity was 20/400 in the right eye and 20/60 in the left eye. Indirect ophthalmoscopy revealed vitritis in the right eye and subretinal deposits in both eyes. Vitreous biopsy of the right eye revealed large B-cell-type primary intraocular lymphoma and the patient underwent multiple intravitreal methotrexate injections (400 μg/0.1 mL) in the right eye and systemic chemotherapy for bilateral disease. Following biweekly injections of methotrexate, her visual acuity improved considerably from 20/400 to 20/60 with resolution of vitritis. However, following eighth dose of intravitreal methotrexate, she experienced visual decline to 20/120 along with photophobia, redness and watering. Whorl-shaped opacities, limbitis and corneal haze were noted on slit-lamp examination. Intravitreal methotrexate was stopped, and the patient was started on frequent topical lubricants, loteprednol, topical folinic acid and oral folic acid. Complete resolution of corneal toxicity was observed at 3 weeks and the injections were suspended as there was no recurrence at 6 months follow-up.

Diagnostic sensitivity of vitrectomy and vitreous biopsy for vitritis

Purpose: To investigate sensitivity of diagnostic vitrectomy and vitreous biopsy for patients with vitritis of unknown aetiology. Methods: Retrospective analysis of all vitrectomies and vitreous biopsies, performed at St Thomas’ Hospital, London, UK, for vitritis between February 2001 and February 2019. Patients were identified using the VITREOR database and records were reviewed. Patients were categorised as infectious, non-infectious or masquerade based on final diagnosis. Sensitivity of both diagnostic pars plana vitrectomy (PPV) and vitreous cutter biopsy in each category was investigated. Furthermore, data on gender, age, and method of anaesthesia were also collected. Results: In our cohort, 64 patients underwent PPV with a diagnostic sensitivity of 67% (43/64) overall and 60% (18/30), 56% (9/16) and 89% (16/18) for those with infectious, masquerade and non-infectious aetiologies, respectively. In comparison, 96 patients underwent a vitreous cutter biopsy with diagnostic sensitivity of 74% (71/96) overall and 71% (55/77), 67% (4/6) and 92% (12/13) for those with infectious, masquerade and non-infectious aetiologies, respectively. No statistically significant difference in sensitivity was identified between the vitrectomy and vitreous biopsy groups for either aetiology. Patients undergoing vitrectomy were noted to be older ( p = 0.02) and more likely to undergo a general anaesthetic ( p < 0.01). Conclusions: Herein we demonstrate similar diagnostic sensitivity of PPV and vitreous cutter biopsy in patients with vitritis of unknown aetiology.

Recurrence of Primary Breast Lymphoma Presenting as Bilateral Vitreoretinal Lymphoma

<b><i>Purpose:</i></b> This report describes a case of relapsed primary breast lymphoma (PBL) presenting as vitreoretinal lymphoma (VRL). <b><i>Methods:</i></b> We describe the clinical and hematopathologic findings in a patient with relapsed PBL involving the vitreous of both eyes. <b><i>Results:</i></b> A 59-year-old woman was treated for PBL with systemic and intrathecal chemotherapy 5 years prior to presentation. Three years later, she presented to an outside clinic with blurred vision in both eyes and bilateral vitritis. She was referred to our clinic with concern for ocular lymphoma. On presentation, the patient’s best-corrected visual acuity was 20/40 in the right eye and 20/25 in the left eye with 3+ vitreous cells in the right eye and 2+ vitreous cells in the left eye. Vitreous biopsy of the right eye revealed CD5-negative/CD10-negative B-cell lymphoma cells on flow cytometry. She had no evidence of disease on brain MRI, lumbar puncture, bone marrow biopsy, or full-body CT scans. She was treated with a regimen of rituximab, methotrexate, procarbazine, and vincristine for central nervous system penetration as well as multiple intraocular injections of methotrexate and rituximab with improvement in vision and ocular inflammation bilaterally. <b><i>Conclusion:</i></b> Relapsed PBL can present as bilateral VRL.

Metastatic endophthalmitis presenting as subretinal abscess following a forearm furuncle

Metastatic endophthalmitis (ME) is rare form of secondary uveitis commonly prevalent in immunocompromised patients. A 55-year-old immunocompetent woman presented with painful decrease in left eye vision (referred to us as cytomegalovirus retinochoroiditis). Ocular examination revealed diffuse yellowish-white retinitis lesion (diagnosed as subretinal abscess on macular optical coherence tomography). Vitreous tap was unremarkable, but vitreous biopsy from the posterior vitreous overlying the subretinal abscess confirmed the growth of methicillin-sensitive Staphylococcus aureus (MSSA). Detailed systemic examination revealed a forearm furuncle, which yielded MSSA on culture. The infection followed relentless course despite aggressive treatment with pars plana vitrectomy and antibiotics (topical, systemic and intravitreal). This case is presented due to rarity of presentation of ME as subretinal abscess following skin infection, which became a management challenge. Due to its rapid progression and irreversible damage to ocular tissue, high index of suspicion and aggressive management is needed in such cases. The disease course, management and prognosis of such cases are dismal in majority of the patients.

Cytomegalovirus retinitis in a patient of granulomatosis with polyangiitis on long-term immunosuppressants

A 69-year-old male patient presented to the retina clinic with a sudden decrease in vision in his right eye since 1 day. He was a known case of granulomatosis with polyangiitis and was on systemic immunosuppression for the past 3 years. The best-corrected visual acuity (BCVA) in his right eye was 20/60 and he has no perception of light in the left eye. Fundus examination revealed the presence of retinitis lesions in the right eye and total optic atrophy in the left eye. A vitreous biopsy was done and the PCR was found to be positive for cytomegalovirus (CMV). He was treated with intravitreal ganciclovir injections. Subsequently, the retinitis lesions regressed and BCVA in the right eye improved to 20/40.This case report elaborates on the risks of the development of opportunistic ocular infections in patients receiving long-term systemic immunosuppressants and the need for regular ocular examinations in such cases.

Immunotherapy-Resistant Vitreoretinal Metastatic Melanoma

<b><i>Purpose:</i></b> To describe 2 cases of vitreoretinal metastases in patients treated with immunotherapy for metastatic melanoma. <b><i>Methods:</i></b> Retrospective case series. <b><i>Results:</i></b> We pre­sent 2 patients with metastatic melanoma treated with systemic immunotherapy with subsequent development of ocular vitreoretinal metastasis. The first patient was a male with metastatic melanoma from a site of unknown origin that was in complete remission following a course of ipilimumab and nivolumab therapy. He presented to an outside provider for evaluation of vitritis and a pigmented lesion in the right eye that was presumed secondary to toxoplasmosis. After failing initial management with oral antibiotics, he underwent diagnostic pars plana vitrectomy, and vitreous biopsy was consistent with metastatic melanoma to the vitreous. He was additionally found to have an elevated pigmented retinal mass consistent with a retinal metastasis from melanoma that initially failed treatment with plaque brachytherapy and ultimately required enucleation. The second case was a monocular male with metastatic melanoma from cutaneous melanoma with decreased vision 3 months after the initiation of nivolumab therapy. He presented with dense vitreous debris in his seeing eye and was thought to have nivolumab-associated inflammation. He was initially treated with difluprednate with improved vision and decrease in vitreous debris, but developed dense pigment deposition in the affected eye later in the treatment course. Diagnostic pars plana vitrectomy was performed, and vitreous biopsy was positive for malignant melanoma cells. His systemic disease was in remission at the time of diagnosis of ocular metastasis. External beam radiation was recommended given his monocular status. <b><i>Conclusion:</i></b> Vitreoretinal metastasis can develop despite favorable systemic response to immunotherapy in patients with metastatic cutaneous melanoma. Lack of ocular penetration and extension of life span with immunotherapeutic agents may be the underlying mechanism for vitreoretinal metastasis.

Apolipoprotein AI-Derived Vitreous Amyloidosis: An Elusive Diagnosis

A 56-year-old female presented with vitreous opacity with gradual visual disturbance in her right eye of 1-year duration. A Non-Hodgkin’s lymphoma had been treated 15 years before. Presenting best-corrected visual acuity (BCVA) was 20/200 in her right eye and 20/25 in her left eye. Intraocular pressure was 18 mm Hg bilaterally. Slit-lamp examination revealed no abnormal findings in the anterior segment of both eyes, including the absence of cells and flare. Fundoscopic examination indicated hazy media with the typical glass-wool-like appearance in her right eye. B-scan ultrasound demonstrated that the vitreous was full of middle-echo spots, vitreous opacities, and posterior vitreous detachment occurred. The patient underwent vitreous biopsy and a standard 25-gauge pars plana vitrectomy (diagnostic and therapeutic). Intraoperatively, the eye was noted to have severe diffuse debris and very strong vitreoretinal adhesions. Cytospin smears prepared from the vitreous aspirate indicated amorphous acellular material that stained positively with Congo Red and showed apple green birefringence on polarized microscopy, consistent with the diagnosis of amyloidosis. A genetic evaluation of tongue tissue demonstrated apolipoprotein AI-derived amyloidosis. The BCVA was 20/25 OU at 3 months postoperatively.

Bleb-related tuberculous endophthalmitis following combined phacoemulsification and trabeculectomy with mitomycin C

A one-eyed 67-year-old man with 20/400 vision, dense cataract, previously failed trabeculectomy and medically uncontrolled advanced glaucoma underwent a single-site phacoemulsification with repeat trabeculectomy and mitomycin C. One-week postoperatively, vision in the right eye improved to 20/120, good bleb and intraocular pressure (IOP) of 14 mm Hg. By third postoperative week, patient presented to the emergency with diminished vision, pain and redness in right eye of 2 days duration and was diagnosed to have bleb-related endophthalmitis (BRE). Vitreous biopsy, smear from the bleb were taken and underwent pars plana vitrectomy with intraocular antibiotic injection. Smears and cultures were negative however, aqueous DNA-PCR was positive for Mycobacterium tuberculosis. Revisited history revealed treated pulmonary tuberculosis 3 years ago with a positive Mantoux test (17 mm) and hilar prominence on chest X-ray. One month after starting anti-tubercular therapy (ATT), the BRE resolved and vision improved to 20/60 with IOP of 14 mm Hg and the ATT was continued.

Branch Retinal Artery Occlusion Following Intravitreal Injection of Methotrexate for the Treatment of Primary Vitreoretinal Lymphoma

Purpose: This paper reports a case of an older white woman presenting with recalcitrant bilateral vitreoretinal inflammation that was ultimately proven to be primary vitreoretinal lymphoma by vitreous biopsy who subsequently developed a branch retinal artery occlusion (BRAO) following an intravitreal injection of methotrexate. Methods: Case summary. Results: The patient was treated with serial intravitreal methotrexate injections and subsequently developed a BRAO immediately following her seventh injection. Conclusions: A full systemic evaluation to rule out other causes of the BRAO was negative and given the timing of her symptoms after the injection it was determined that the BRAO was most likely realted to the intravitreal methotrexate injection.

Variables Associated With Culture-Positive Endophthalmitis After Intravitreal Injection of Vascular Endothelial Growth Factor Inhibitors

Purpose: This work identifies predictive variables associated with culture-positive cases of acute endophthalmitis after vascular endothelial growth factor (VEGF) inhibitor injection. Methods: A retrospective review of cases of endophthalmitis following intravitreal anti-VEGF injection was performed. All patients received a vitreous biopsy or anterior chamber aqueous biopsy (if vitreous biopsy was not successful) that was sent for microbial cultures before initiation of treatment. Results: During a 10-year period, 258 357 anti-VEGF agent injections were performed, of which 40 patients (0.016%) developed presumed endophthalmitis. Sixty percent (n = 24) of the presumed endophthalmitis patients had a positive culture. In multivariable logistic analysis, patients who had a best-corrected visual acuity (BCVA) worse than 20/400 were 35.3 times (adjusted odds ratio [AOR], 95% CI, 2.2-576.1, P = .012) more likely to have a positive culture compared with those who had a BCVA of 20/400 or better. Patients who had pain at initial presentation were 27.0 times (AOR, 95% CI, 1.4-523.9, P = .029) more likely to have a positive culture compared with those who did not have pain at initial presentation. Age, sex, clinical diagnosis, smoking status, anti-VEGF agent injected, duration between last anti-VEGF injection and symptoms of endophthalmitis, duration between endophthalmitis symptoms and initial treatment, intraocular pressure at initial presentation, and presence of hypopyon were not associated with a difference in positive-culture yield. Conclusions: Visual acuity worse than 20/400 and pain at time of initial presentation secondary to endophthalmitis following anti-VEGF injection were strongly associated with a positive culture. Our data support consideration of vitrectomy in cases in which microbe identification is paramount.