Vitreous Noise on Optical Coherence Tomography as an Early Finding of Brolucizumab-Related Intraocular Inflammation

We describe a case of brolucizumab-related intraocular inflammation (IOI) detected using vitreous haze on optical coherence tomography (OCT) at an early stage before the patient was aware of any symptom. A 69-year-old female presented with decreased right vision. The patient was diagnosed with pachychoroidal neovasculopathy and started intravitreal aflibercept (IVA) with a 3+ treat-and-extend strategy (TAE). Although the serous retinal detachment (SRD) disappeared after IVA treatment, the patient was managed with treatment every 4 weeks without extending the treatment interval To shorten the treatment interval, intravitreal brolucizumab (IVBr) was started 44 weeks after starting IVA treatment. After initiating IVBr treatment, the SRD completely disappeared. However, 16 weeks after starting IVBr, OCT showed noise in the vitreous cavity, which had not been seen before, and infrared images showed a black smoke-like shadow over the macula. Despite these findings, the patient had no subjective symptoms, and so IVBr was re-administered with an 8-week TAE interval. Five days after IVBr treatment, vitreous inflammatory cells were observed, and the noise in the vitreous cavity and the smoke-like shadow in the infrared image were further enhanced. We diagnosed the patient with brolucizumab-related IOI, and anti-inflammatory treatment was initiated. After extensive treatment, the vitreous opacity gradually disappeared, and the vitreous noise on OCT and the black smoke-like shadow on infrared images disappeared. IOI may have already been present 16 weeks after starting IVBr treatment, when we judged that there was no inflammation and IVBr was re-administered. When following patients receiving IVBr, IOI may be detected by OCT at an earlier stage by evaluating vitreous haze.

A case of endophthalmitis following needling procedure after PRESERFLO® Micro Shunt implantation

Purpose: To report a case of endophthalmitis following bleb needling in a patient previously implanted with a PRESERFLO® MicroShunt. Methods: Case report. Results: A 40-year-old woman with bilateral malformative glaucoma repeatedly operated on in childhood underwent PRESERFLO® MicroShunt implantation in her right eye and six needling revisions (NRs) and a surgical revision due to unsatisfactory intraocular pressure (IOP) control due to bleb encapsulation. About 3 months after the surgical revision the bleb encapsulation relapsed and she underwent a further NR with betamethasone. About 4 days after the last NR, she experienced visual acuity reduction and was therefore advised to come immediately to the hospital for an unscheduled visit, showing up with hypopyon and diffuse vitreous haze. A clinical diagnosis of endophthalmitis (later confirmed by bacteria culture tests) was made and she was treated with pars-plana vitrectomy with silicone oil and intravitreal antibiotics. Preoperative visual function was luckily completely restored. Conclusions: Endophthalmitis can occur after NR in an eye with PRESERFLO® MicroShunt implant which therefore does not prevent reflux of bacteria from a filtering bleb to the anterior chamber.

Primary Vitreoretinal Lymphoma Therapy Monitoring: Significant Vitreous Haze Reduction After Intravitreal Rituximab

BACKGROUND/AIMS: Intravitreal rituximab is an off-label treatment option for primary vitreoretinal lymphoma (PVRL). The objective of this study was to monitor the therapeutic response and safety profile of intravitreal rituximab in a cohort of PVRL patients. METHODS: In this retrospective, uncontrolled, open label, multicentre study, 20 eyes from 15 consecutive patients diagnosed with PRVL received at least one intravitreal injection of 1mg in 0.1ml rituximab. Biodata of the PVRL patients was recorded as well as visual acuity and vitreous haze score immediately before rituximab intravitreal injection and at follow-up examinations. Intravitreal rituximab safety data was also recorded. Additional rituximab injections were made during control visits on a pro re nata (PRN) regime using increased vitreous haze to indicate recurrence. RESULTS: There was significant vitreous haze reduction (p=0.0002) followed by significant improvement of visual acuity (mean best visual acuity before therapy 0.57 logMAR, after therapy 0.20 logMAR (p=0.0228) during the follow-up time up to 4 years. Only mild ocular side effects were reported. Median follow-up time was 565 days (range, 7-1253 days). CONCLUSION: Intravitreal rituximab therapy shows promising PVRL regression without any severe side effects. Although our clinical data support rituximab as intravitreal therapy in PVRL disease, further study is warranted.

A Study to Analyse the Presentation of Autoimmune and Idiopathic Serpiginous Choroiditis in Indian Population

BACKGROUND Serpiginous choroiditis (SC) is an intraocular inflammatory disorder displaying a geographic pattern of choroiditis, extending from the juxtapapillary choroid and intermittently spreading centrifugally. It involves the overlying retinal pigment epithelium (RPE), the outer retina including the choriocapillaries and the choroid.1,2,3 Infectious diseases like tuberculous (TB) uveitis, herpes simplex virus (HSV) uveitis whose fundus changes mimic SC are termed as serpiginous-like choroidopathy (SLC). On slit lamp examination, anterior segment usually appears quiet, non-granulomatous anterior uveitis with mild vitritis and / or fine pigmented cells within the vitreous can be seen. The pattern of fundus involvement varies between the two groups. Fundus fluorescein angiography and indocyanine green angiography (FFA and ICG) are important modalities of investigation that help in differentiating the pattern of involvement and confirming clinical findings. The duration of follow up, reactivation of lesions and complications vary. Hence, it is important to differentiate between SC and SLC for proper diagnosis and appropriate management. The aim of this study is to highlight important features of serpiginous choroiditis and serpiginous like choroidopathy that will aid in the correct diagnosis of these two entities. METHODS This is a retrospective study of 40 patients. Following variables were analysed - age, gender, laterality, visual acuity, and intraocular inflammation through slit lamp examination, pattern of involvement, choroidal-neovascularization, reactivation, clinical investigations and diagnosis. RESULTS 32 patients had serpiginous choroiditis (SC) and eight patients had serpiginous like choroiditis (SLC). Mean age was 50 and 51 years (SC and SLC respectively). Males were predominantly affected (65.5 % in serpiginous choroiditis and 62.5 % in serpiginous like choroiditis). Bilaterality was 80 % in SC-group and 46 % in the SLC-group. Vitreous haze was lesser than or equal to 1 + in SC group. The juxtapapillary-area was involved in 90 % in SC eyes and 0 % in SLC-group. Midperiphery of fundus was involved in 54 % of SLC-group. Reactivation is more common in SLC group than in SC group in a follow up period of one year. Choroidal-neovascularisation was found in two patients only in SLC-group. CONCLUSIONS In cases where vitreous haze is greater than 1 + with unilateral involvement and disease free peripapillary area is present, an infectious aetiology has to be strongly suspected, as an immunomodulatory therapy could have severe consequences. KEYWORDS Serpiginous Choroiditis, Serpiginous like Choroiditis, Autoimmune

Extralesional microvascular and structural macular abnormalities in cytomegalovirus retinitis

To evaluate extralesional microvascular and structural changes of the macula using optical coherence tomography angiography (OCTA) and structural OCT in cytomegalovirus retinitis (CMVR). An observational study of CMVR patients were performed. Complete ophthalmic examination, serial color fundus photography, structural OCT and OCTA were performed at baseline and follow-up visits for up to 12 months. The structural OCT was analyzed to evaluate macular areas within, bordering and beyond the CMVR lesions. Extralesional retinal capillary plexus of the macula were evaluated by OCT angiography and compared with the unaffected fellow eyes. Thirteen eyes from 13 patients were enrolled. At baseline, macular areas without CMVR lesions showed decreased vessel density (VD) of both the superficial (P = 0.0002) and deep (P < 0.0001) retinal capillary plexus in eyes with CMVR as compared with the corresponding macular areas of the unaffected fellow eyes. The decrease of VD persisted through the follow-up period for up to 12 months after adjusting for degree of vitreous haze. Structural macular OCT characteristics at the borders and beyond the lesions included intraretinal hyperreflective dots, cystoid macular edema, subretinal fluid and selective ellipsoid zone (EZ) loss. The selective EZ loss found in 6 of 12 eyes showed recovery in 4 eyes after receiving anti-viral treatment. In CMVR eyes, there were microvascular and microstructural abnormalities in the macular area without clinically visible CMVR lesions. Our results provided interesting insights into CMV infection of the retina.

Coincidental retinal dysplasia in patients presenting with pseudohypopyon: a series of two cases

Clinical diagnosis is always challenging in cases with atypical presentation. Herein, we present two cases which masqueraded as ocular infection/inflammation on presentation, were clinically suspicious for retinoblastoma, and histopathology revealed the diagnosis of retinal dysplasia. Case 1 had left corneal perforation with anterior chamber exudates on presentation. On ultrasound B-scan, ill-defined mass was noted, raising a suspicion of malignancy. MRI showed dilated ventricles with midline shift. Vitreous cytology was inconclusive. Enucleation was performed as malignancy could not be ruled out. Histopathology revealed detached retina with dysplastic rosettes in addition to inflammation and multinucleate giant cell reaction. Case 2 presented with right eye anterior chamber pseudohypopyon. Fundus examination revealed diffuse vitreous haze and a suspicious mass in the retinal periphery raising suspicion for retinoblastoma. Histopathology revealed the diagnosis of retinal dysplasia.

Aurora borealis and string of pearls in vitreoretinal lymphoma: patterns of vitreous haze

AimsPeculiar retinal signs of vitreoretinal lymphoma (VRL) have been identified. However, limited information on the vitreous features of VRL is available. This study aims to characterise the vitreous involvement in VRL with the help of multimodal imaging.MethodsIn this retrospective, observational study, we reviewed charts and imaging of all patients with biopsy-proven VRL seen from January 2016 to April 2018 at a single referral centre. These included ultrawide-field imaging, ophthalmic ultrasonography and slit-lamp photography. The main outcome measures were patterns of vitreous haze of VRL, as observed by combining clinical and multimodal imaging information.ResultsTwenty-six eyes of 13 patients were included. At presentation, vitreous haze was present in 24 eyes (92%) and was the only sign of VRL in 4 eyes (15%). Three patterns of vitreous haze were identified in VRL. An aurora borealis pattern was present in 12 eyes and showed linear opacities with a myriad of cells aligned along the vitreous fibrils. A string of pearls pattern was present in two eyes at baseline and developed in other four eyes after vitrectomy, showing fine fibrils connecting bunches of inflammatory material. A non-specific pattern was observed in 10 eyes. Ophthalmic ultrasound showed corpuscular material correlating with the grading of vitreous haze.ConclusionVRL shows different patterns of vitreous haze. Multimodal imaging, including ultrawide-field imaging and slit-lamp photography, helps in recognising these patterns, raising suspicion for VRL.