Journal of Ophthalmic Inflammation and Infection

Tuberculous optic neuropathy may follow infection with Mycobacterium tuberculosis or administration of the bacille Calmette–Guerin. However, this condition is not well described in the ophthalmic literature. Ophthalmologists, identified through professional electronic networks or previous publications, collected standardized clinical data relating to 62 eyes of 49 patients who they had managed with tuberculous optic neuropathy. Tuberculous optic neuropathy was most commonly manifested as papillitis (51.6 %), neuroretinitis (14.5 %), and optic nerve tubercle (11.3 %). Uveitis was an additional ocular morbidity in 88.7 % of eyes. In 36.7 % of patients, extraocular tuberculosis was present. The majority of patients (69.4 %) had resided in and/or traveled to an endemic area. Although initial visual acuity was 20/50 or worse in 62.9 % of 62 eyes, 76.7 % of 60 eyes followed for a median of 12 months achieved visual acuities of 20/40 or better. Visual field defects were reported for 46.8 % of eyes, but these defects recovered in 63.2 % of 19 eyes with follow-up. Visual recovery from tuberculous optic neuropathy is common, if the diagnosis is recognized and appropriate treatment is instituted. A tuberculous etiology should be considered when evaluating optic neuropathy in persons from endemic areas.

Tubercular vasculitis is an important manifestation of ocular tuberculosis and this report highlights the mimicking nature of the disease with frosted branch angiitis. A patient presented with a severe form of retinal vasculitis in both eyes and a branch retinal vein occlusion in the left eye. He had a positive tuberculin skin test (TST) and a raised erythrocyte sedimentation rate (ESR) and serum angiotensin-converting enzyme (ACE) levels. Radiological investigations revealed a sub-pleural nodule and mediastinal lymph nodes, which on histopathological evaluation confirmed a granulomatous etiology. Retinal vasculitis secondary to tubercular etiology may mimic a viral vasculitis; however, a clinical suspicion with a timely diagnosis and management helps in preventing loss of vision and the eye.

Herpetic anterior uveitis is a frequent cause of infectious uveitis. A definite diagnosis is obtained by anterior chamber puncture and polymerase chain reaction, an invasive procedure. We hypothesized that patients with herpetic anterior uveitis have a certain pattern of inflammatory cells in their cornea that distinguishes herpetic anterior uveitis from other uveitis types. This study is a prospective, controlled, observational study. Ten patients are with active herpetic anterior uveitis and 14 patients are with Fuchs uveitis syndrome. Patients were imaged with the Heidelberg Retina Tomograph with the Rostock Cornea Module attachment. Three images of the subepithelial area of the cornea were evaluated for dendritiform inflammatory cells. Means were calculated and used for analysis. The contralateral unaffected eyes and numbers published in the literature served as controls. The number of dendritiform inflammatory cells in herpetic anterior uveitis was compared to that in the Fuchs uveitis syndrome. Of the eyes of patients with herpetic anterior uveitis, 80% had an average of 98.0±10.8 cells/mm2 (mean±standard error of the mean (SEM), n=10) in their affected eyes and 60.4±26.4 cells/mm2, (n=6) in 30% of their fellow eyes. Patients with Fuchs uveitis syndrome had moderately elevated dendritiform inflammatory cells (47.0±9.7 cells/mm2, n=14) in 96.4% of their affected eyes and normal numbers (23.0±7.3 cells/mm2, n=13) in 46.4% of their fellow eyes. The difference between the four groups was significant (p=0.0004). Patients with herpetic anterior uveitis had significantly higher levels of dendritiform inflammatory cells in their subepithelial cornea than patients with Fuchs uveitis syndrome, which can be detected by in vivo confocal microscopy. The clinically unaffected eyes of herpetic anterior uveitis patients showed a co-response regarding dendritiform inflammatory cell elevation. We conclude that high numbers of dendritiform inflammatory cells in the cornea of uveitis patients may support the clinical diagnosis of herpetic anterior uveitis.

To describe a puzzling case of endophthalmitis caused by three unusual bacteria after intravitreal injection, its outcome, and underlying questions. A 70-year-old female patient was diagnosed with acute endophthalmitis following intravitreal aflibercept injection for age-related macular degeneration. A standard tap and inject procedure was performed. Microbiological analyses on the anterior chamber and vitreous samples yielded the presence of three non-fermenting Gram-negative rods: Pseudomonas stutzeri, Stenotrophomonas maltophilia, and Ochrobactrum anthropi. The outcome was favorable after intravitreal injections of vancomycin and ceftazidime, with an almost complete recovery of the visual acuity to its baseline level. No potential source of infection was identified. Endophthalmitis following intravitreal injection can be caused by a wide variety of bacteria, including some rare Gram-negative species. They can sometimes co-exist in a single patient, but their virulence may vary greatly. Due to the variable antibiotic susceptibility and frequent multiresistance associated with non-fermenting Gram-negative rods, a prompt microbiological approach is required. Favorable outcome can be achieved with standard management.

A challenge in the management of ‘white dot syndromes’ is the lack of sensitive objective measures of disease activity. Retinal thickness maps from spectral domain optical coherence tomography (SD-OCT) inform treatment decisions in other retinal conditions such as age-related macular degeneration and diabetic maculopathy. In this report, we demonstrate their value in providing quantitative monitoring of a patient with punctate inner choroidopathy (PIC). Retinal thickness maps referenced against a baseline scan reliably detected focal areas of increased macular volume in active PIC lesions during symptomatic episodes, highlighting these as ‘hot spots’ that could be quantified, providing an objective basis for treatment decisions.

The purpose of this study was to describe comorbidities, healthcare costs, and resource utilization among patients with chronic non-infectious uveitis initiating corticosteroid, immunosuppressants, or biologics. In this retrospective cohort study, patients with a non-infectious uveitis diagnosis and continuous insurance coverage during a 6-month baseline were selected from a privately insured claims database with 80.7 million enrollees. Index dates were defined as the first prescription/administration of a corticosteroid, immunosuppressant, or biologic between 2003 and 2009. Comorbidities, healthcare costs, and utilization were analyzed in a per-member-per-month (PMPM) framework to account for varying between-patient treatment periods, defined as continuous medication use within the same class. Wilcoxon rank-sum and chi-square tests were used for comparisons of costs and categorical outcomes. Patients on corticosteroids (N = 4,568), immunosuppressants (N = 5,466), and biologics (N = 1,694) formed the study population. Baseline PMPM inpatient admission rates were 0.029 for patients on corticosteroids, 0.044 for patients on immunosuppressants, and 0.045 for patients on biologics (p < 0.001 immunosuppressants or biologics versus corticosteroids); during treatment, PMPM inpatient admissions increased to 0.044 and 0.048 for patients taking corticosteroids and immunosuppressants, respectively, but decreased to 0.024 for patients taking biologics (p < 0.001 versus corticosteroids and p = 0.003 versus immunosuppressants). Baseline average PMPM costs for patients taking corticosteroids, immunosuppressants, and biologics were US$935, US$1,738, and US$1,439 (p < 0.001 between groups), while on-treatment PMPM costs excluding drug costs increased to US$1,129 for patients taking corticosteroids but lowered to US$1,592 for patients taking immunosuppressants, and US$918 for patients taking biologics (p < 0.001 versus corticosteroids or immunosuppressants). There is significant economic burden associated with existing treatments of uveitis. Corticosteroids may be overused as a treatment for uveitis.

A 21-year-old female patient had chorioretinitis in the left eye which relapsed while being on anti-tubercular treatment and oral corticosteroids leading to blindness and the loss of the left eye. Mycobacterium tuberculosis causing chorioretinitis showed a poor response, and the lung lesions showed a good response to the same anti-tubercular treatment. Mycobacterium tubercle bacilli in the eye may show a poor response to the anti-tubercular drugs due to poor ocular penetration of the drugs secondary to early ocular hypoxia.

The purpose of this study is to report a novel case of a Klebsiella oxytoca-associated infectious crystalline keratopathy This is a case report study. An 80-year-old woman presented with complaint of noticing a white spot in the left eye for 2 to 3 days, as well as mild soreness and discharge. Past ocular history was notable for a failed left corneal transplant for which she was taking prednisolone acetate 1 % twice per day. On slit-lamp examination, there was an extensive stromal ulcer and infiltrate in the inferior half of the transplant. Extending superiorly in the graft were branching, needle-like deep stromal opacities, characteristic of infectious crystalline keratopathy. Diagnostic scrapings revealed Gram-negative bacilli, subsequently identified on culture as K. oxytoca. There was also light growth of Staphylococcus species. The patient was placed on double topical antibiotic therapy with moxifloxacin and fortified tobramycin. After 2 months of treatment there was gradual resolution of the infection. K. oxytoca is a microorganism which can be associated with clinical infectious crystalline keratopathy, presenting as a mixed infection along with Staphylococcus species.