Intravitreal Administration of Ranibizumab and Bevacizumab for Choroidal Neovascularization Secondary to Ocular Toxocariasis: A Case Report

Purpose: To report a case of a choroidal neovascularization (CNV) secondary to ocular toxocariasis treated with intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents.

Methods: A 66-year-old woman presented with decreased vision (20/40) and metamorphopsia in the right eye. Fundus examination revealed inferotemporal retinal whitish lesion and subretinal hemorrhage in the right eye.

Results: She was diagnosed with ocular toxocariasis based on the clinical features and positive serological anti-toxocara antibody test result. Ophthalmic examination revealed classic CNV formation adjacent to a retinal granuloma. She was treated with intravitreal ranibizumab and bevacizumab injections combined with oral albendazole. Her vision decreased to 20/100 following CNV recurrence. However, after additional bevacizumab treatment, the CNV became inactive and her vision recovered to 20/40.

Conclusions: CNV can be combined with retinal granuloma due to ocular toxocariasis. Repeated intravitreal injections of anti-VEGF agents can be efficacious for regressing toxocariasis-associated CNV and improving vision.     

Prevalence of Childhood Blindness and Ocular Morbidity in a Rural Pediatric Population in Southern India: The Pavagada Pediatric Eye Disease Study-1

Purpose: To determine the prevalence of childhood blindness and ocular morbidity in a rural pediatric population in South India.

Methods: A population-based, cross-sectional survey of children was conducted in three phases in Pavagada and Madhugiri taluks (subdivisions) of Tumkur district in the state of Karnataka, India. In the first phase, trained fieldworkers screened 23,100 children. In the second phase, children with eye diseases were referred to the peripheral hospital to be examined by a general ophthalmologist. In the third phase, children with major eye diseases were examined by a pediatric ophthalmologist.

Results: The prevalence of ocular morbidity was 2.66% (95% confidence interval, CI, 2.46–2.87%). The most commonly observed ocular morbidity was Bitot spots (1%) followed by refractive error (0.6%). In total, 18 children were blind and the prevalence of childhood blindness (best-corrected visual acuity <3/60) was 0.08% (95% CI 0.04–0.11%); 8 (44.44%) had retinal blindness, 5 (27.76%) had lens-related blindness, 2 (11.11%) had bilateral microphthalmos, 1 (5.56%) was blind due to anterior staphyloma in the right eye and anophthalmos in the left eye, 1 (5.56%) had bilateral uveal coloboma and 1 (5.56%) had cortical visual impairment.

Conclusions: Nearly half of the blindness in the population was due to unavoidable causes (retinal). In addition to providing eye care services, an appropriate service delivery model would include the provision of rehabilitative and low vision services and implementation of genetic studies to understand the causes and increase awareness of inherited eye diseases.     

Ocular Manifestations in Patients with Human Immunodeficiency Virus Infection in the Pre-HAART Versus the HAART Era in the North Indian Population

Purpose: To compare changes in the demographic profile and ocular manifestations in patients with HIV in the pre-HAART and HAART era in North India.

Methods: In this single-center cross-sectional study, 100 HIV patients receiving HAART and 96 HIV patients in the pre-HAART era were enrolled. Prevalence of ocular manifestations of HIV was calculated for both cohorts.

Results: The prevalence of ocular manifestations was not statistically different in the two eras (38%, SE: 4.85% in HAART era; 41.67%, SE: 5% in pre-HAART era) (p = 0.60). Mean CD4 counts were lower in the pre-HAART era compared with the HAART era (p < 0.001). In the HAART era, cytomegalovirus (CMV) retinitis and HIV retinopathy continued to remain the most common infectious and non-infectious cause of visual morbidity.

Conclusions: While the introduction of HAART has resulted in a major impact on the overall health of patients with HIV, the spectrum of ocular disease remains largely unchanged in developing countries such as India.     

A Hemophagocytic Lymphohistiocytosis Patient that Presented with Unilateral Panuveitis

Purpose: To describe a case of hemophagocytic lymphohistiocytosis (HLH) with ocular changes prior to the systemic changes.

Methods: A 53-year-old man presented with the chief complaint of decreased vision in his right eye. The patient was examined by ocular examination, slit lamp examination, optical coherence tomography, laboratory examination, abdominal ultrasound, and bone marrow biopsy.

Results: Ocular examination revealed uveitis OD and optical coherence tomography revealed macular edema OD. Laboratory examination demonstrated cytopenia in two cell lines, hypofibrinogenemia, and elevated serum ferritin. Abdominal ultrasound findings indicated hepatosplenomegaly. The bone marrow biopsy specimen demonstrated histiocytes and significant hemophagocytosis, leading to a diagnosis of HLH.

Conclusion: Ophthalmic manifestation can be the first sign of HLH and progress to fatal systemic changes.     

Presence of Vision Impairment and Risk of Hospitalization among Elderly Medicare Beneficiaries

Purpose: To examine the association between vision impairment and all-cause hospitalization among elderly Medicare beneficiaries.

Methods: A population-based study (N = 22,681) of community-dwelling Medicare beneficiaries aged 65 years and older who participated in the Medicare Current Beneficiary Survey for the years 2001–2007. Beneficiaries were classified into self-reported presence of vision impairment versus no vision impairment. Inpatient hospitalizations were identified using Medicare claims data. A multivariable Cox proportional hazard model examined the association between presence of vision impairment and time to first hospitalization within 3 years of survey entry after adjusting for sociodemographics, comorbidities, hearing impairment, and activity limitation stages derived from difficulty performing the activities of daily living.

Results: Medicare beneficiaries who self-reported the presence of vision impairment were significantly more likely to be hospitalized over 3 years compared to beneficiaries without vision impairment even after adjustment for potentially influential covariates (hazard ratio = 1.14 and 95% confidence interval: 1.05–1.23).

Conclusions: Medicare beneficiaries with self-reported vision impairment were at higher risk of hospitalization during a 3-year period. Further research may identify reasons that are amenable to policy interventions.     

Varicella Zoster-related Occlusive Retinal Vasculopathy—A Rare Presentation

Purpose: To report a case of occlusive retinal vasculopathy following varicella zoster infection in an immunocompetent adult.

Design: Observational case report.

Methods: A patient with defective vision following chickenpox was evaluated with fluorescein angiography, spectral domain optical coherence tomography and fundus auto fluorescence.

Results: Fundus showed multiple cotton wool spots and a well-demarcated zone of retinal ischemia in the posterior pole with normal optic disc without any evidence of anterior or posterior uveitis. Fluorescein angiography, spectral domain optical coherence tomography and fundus auto fluorescence findings revealed occlusive vasculopathy as the cause of defective vision.

Conclusions: We report a hitherto undescribed case of purely occlusive vasculopathy following varicella zoster infection without features of vasculitis or anterior and posterior uveitis in an immunocompetent individual.     

Chikungunya Virus Infection Manifesting as Intermediate Uveitis

Purpose: To describe a case of intermediate uveitis caused by chikungunya virus infection in the Western Hemisphere.

Methods: Case report of a patient diagnosed with chikungunya infection presenting with blurry vision and floaters.

Results: Exam revealed a unilateral intermediate uveitis, with an extensive work-up positive for chikungunya virus immunoglobulin M and G titers. The patient responded to oral corticosteroids with signs and symptoms resolving over the course of 3 months’ treatment.

Conclusions: While anterior uveitis and retinitis are the most common ocular manifestations of chikungunya infection, we report here a case of chikungunya infection presenting as an intermediate uveitis, responding well to oral corticosteroids. This case demonstrates the varied presentation of chikungunya-related uveitis and highlights its consideration in the differential diagnoses of those who have had preceding systemic viral symptoms and uveitis.     

The TNF-α-308G/A Polymorphism is Not Associated with Ocular Chlamydia trachomatis Infection in Han Chinese Children

Objective: To investigate the association between the TNF-α-308G/A polymorphism and ocular chlamydia trachomatis (C. Trachomatis) infection among Han Chinese children.

Methods: 248 patients and 162 matched healthy controls were recruited. The diagnosis of ocular C. Trachomatis infection was given after clinical observation and latex immunochromatography tests. The TNF-α-308G/A polymorphism was genotyped by sequencing.

Results: No association was found between the TNF-α-308G/A polymorphism and ocular C. Trachomatis infection.

Conclusions: The TNF-α-308A polymorphism is unlikely to play a major role in the risk for ocular C. Trachomatis in the Chinese population.     

Epidemiology of Ocular Toxoplasmosis in Three Community Surveys in the Central Region of Ghana,West Africa

Purpose: To conduct the first ever population-based survey on ocular toxoplasmosis in the Central Region of Ghana.

Methods: A cross-sectional population-based study was conducted in three randomly selected communities in the Central Region, Ghana. Visual acuity (VA) measurement, dilated fundus examination by indirect ophthalmoscopy and serology testing were performed on all participants. Ocular toxoplasmosis was diagnosed based on characteristic retinal lesions and supported by positive serologic testing using commercial enzyme-linked immunosorbent assay (ELISA) kits.

Results: A total of 390 subjects aged 10–100 years (mean age 47 years) were examined; 118 (30.3%) were male and 272 (69.7%) female. Ten subjects (6 females and 4 males) had toxoplasmic ocular lesions (prevalence 2.6%). Of these, two had bilateral lesions and eight had unilateral lesions. Subjects with toxoplasmic ocular lesions were older than those without lesions (p = 0.028). The development of ocular toxoplasmosis was not associated with rural dwelling, sex, keeping cats, or consumption of meat.

Conclusion: The prevalence of ocular toxoplasmosis in our Ghanaian study population was lower than findings from Southern Brazil, where there is a similar prevalence of infection in the general population.     

Eye Disorders among Adult People Diagnosed with Infantile Autism in Childhood: A Longitudinal Case Control Study

Purpose: The objective of this study was to compare the prevalence and types of eye disorders in a clinical sample of 118 adult people diagnosed with infantile autism (IA) during childhood with 336 sex- and age-matched controls from the general population.

Methods: All participants were screened through the nationwide Danish National Hospital Register. The average observation time of both groups was 37.2 years, and mean age was 49.6 years, by the end of the observation period.

Results: The overall prevalence of any eye disorder was 15.3% (18/118) in cases with IA, compared to 10.1% (34/336) in controls (p = 0.18). Refraction and accommodation disorders were significantly associated with IA: 7.6% (9/118) vs 1.2% (4/336) (p = 0.001). The rate of eye disorder was particularly high (24.5%) in those with a co-occurring profound or severe learning disability (IQ < 50).

Conclusions: Refraction and accommodation disorders were more frequently present in Danish adults with IA, particularly when a profound or severe learning disability was co-present. The increased prevalence of eye disorders in participants with a severe or profound learning disability, and the fact that people with IA do not necessarily realize the presence of a vision deficit, necessitates increased ophthalmological attention.     

Boston Type I Keratoprosthesis Implantation Following Autologous Submandibular Gland Transplantation for End Stage Ocular Surface Disorders

Purpose: To describe the results of Boston keratoprosthesis implantation in a patient with Stevens–Johnson syndrome following autologous submandibular gland transplantation.

Design: Observational case report.

Methods: We report the case of a man diagnosed with Stevens–Johnson syndrome. Autologous submandibular gland transplantation was performed in the right eye in 2008 to ameliorate tear film deficiency. Due to the improvement in the microenvironment of the ocular surface, Boston keratoprosthesis implantation was performed in the right eye in 2011.

Results: He maintained a VA of 20/100 for 12 months. At the last follow-up visit (54 months), his VA had declined to finger count level due to de novo glaucoma, which was treated with glaucoma drainage device implantation, cyclophotocoagulation and topical anti-glaucoma medications.

Conclusions: The procedures described provide patients with end-stage ocular surface disease an option to lessen the severity of keratoconjunctivitis sicca and to regain their VA.     

Intraocular Lymphoma: Descriptive Data of 26 Patients Including Clinico-pathologic Features,Vitreous Findings,and Treatment Outcomes

Purpose: To describe clinical manifestations, diagnostic approaches, therapy, and outcomes of biopsy-proven intraocular lymphoma.

Methods: Review of tertiary referral center records between 2005 and 2015.

Results: A total of 51 eyes of 26 patients were included; mean age of onset was 60.42 years. Common ocular complaints included floaters (42%) and blurred vision (35%); 62% of patients had ocular and central nervous system involvement; 11% had systemic lymphoma; and 27% had only ocular involvement. Vitreous analysis was positive for malignant cells in 77% of patients on initial biopsy, and in 100% of patients on repeat biopsy. In total, 20/26 patients received systemic and topical treatment before IOL diagnosis was made; 25 patients received intravitreal methotrexate and/or rituximab; one patient received intracameral rituximab. All patients achieved remission by their final visit.

Conclusions: Intraocular lymphoma often masquerades as intraocular inflammation, resulting in delayed or misdiagnosis with subsequent inappropriate management. Optimal therapy is a challenge for oncologists and ophthalmologists.     

Magnitude and Determinants of the Ratio between Prevalence of Low Vision and Blindness in Rapid Assessment of Avoidable Blindness Surveys

Purpose: To determine the magnitude and determinants of the ratio between prevalence of low vision and prevalence of blindness in rapid assessment of avoidable blindness (RAAB) surveys globally.

Methods: Standard RAAB reports were downloaded from the repository or requested from principal investigators. Potential predictor variables included prevalence of uncorrected refractive error (URE) as well as gross domestic product (GDP) per capita, health expenditure per capita of the country across World Bank regions. Univariate and multivariate linear regression were used to investigate the correlation between potential predictor variables and the ratio.

Results: The results of 94 surveys from 43 countries showed that the ratio ranged from 1.35 in Mozambique to 11.03 in India with a median value of 3.90 (Interquartile range 3.06;5.38). Univariate regression analysis showed that prevalence of URE (p = 0.04), logarithm of GDP per capita (p = 0.01) and logarithm of health expenditure per capita (p = 0.03) were significantly associated with the higher ratio. However, only prevalence of URE was found to be significant in multivariate regression analysis (p = 0.03).

Conclusion: There is a wide variation in the ratio of the prevalence of low vision to the prevalence of blindness. Eye care service utilization indicators such as the prevalence of URE may explain some of the variation across the regions.     

Ocular findings in a patient with Cockayne syndrome with two mutations in the ERCC6 gene

Background: Cockayne syndrome is a rare, autosomal recessive, multisystem disorder that causes a senile appearance. Ophthalmic abnormalities are frequently present. Here, we report a wide range of ocular findings in a child with Cockayne syndrome.

Materials and methods: The systemic and ocular findings were reviewed. A mutation analysis was performed in the patient and her parents.

Results: The patient underwent a complete ocular examination. Both eyes had low visual acuity, corneal epithelial degeneration, punctate opacities of the lens, and retina disorders. The systemic findings included growth deficiency and a senile appearance. Gene analysis showed mutations in exons 4 and 18 of the ERCC6 gene.

Conclusion: Multiple ocular abnormalities were observed in a patient with Cockayne syndrome. A detailed ophthalmic evaluation of children with Cockayne syndrome is advised.     

Repeat Conjunctival Biopsy after Immunomodulatory Therapy for Ocular Mucous Membrane Pemphigoid

Purpose: To evaluate whether conjunctival biopsy findings in patients with ocular mucous membrane pemphigoid (MMP) persist as positive or revert to negative following treatment with immunomodulatory therapy (IMT).

Methods: Patients with biopsy-proven MMP were treated with IMT for at least 2 years before undergoing repeat conjunctival biopsy for immunofluorescence microscopy. Their records were reviewed and findings evaluated to ascertain which patients’ biopsies showed antibody deposition on the conjunctival basement membrane.

Results: Following 2 years of IMT, conjunctival biopsies showed persistent antibody deposition in two patients, and were negative in four patients.

Conclusions: Conjunctival biopsies in patients with ocular MMP may show reversion to inactive disease following IMT. Post-treatment biopsy might be clinically useful as a means of evaluating the efficacy of therapy in this chronic disease.     

Virus-Induced Anterior Uveitis (VIAU) in Immunocompromised Patients

Purpose: To describe the clinical characteristics, diagnosis, and treatment of VIAU in immunocompromised patients.

Methods: A critical review of literature was performed.

Results: Diagnosis and treatment of VIAU in immunocompromised patients may be a challenge due to atypical clinical-courses, severe presentations, and more frequent recurrences. A conclusive diagnosis can be made by aqueous-humour PCR-analysis. Visual prognosis depends on early diagnosis and prompt treatment. Frequent ocular examinations are recommended in HIV patients with CD-4-counts below 100 in order to rule out opportunistic ocular coinfections. It is essential to bear in mind the potential side-effects of therapeutic interventions and consider the possibility of Immune Recovery Uveitis (IRU) in eyes with treated viral retinitis after the initiation of HAART.

Conclusions: Early diagnosis and treatment of VIAU in immunocompromised patients can be achieved with high suspicion, recognizing clinical features, and obtaining specimens for molecular diagnostic testing in order to avoid usually severe ocular morbidity.     

The Usage of a Conjunctival Flap to Improve Retention of Boston Type 1 Keratoprosthesis in Severe Ocular Surface Disease

Purpose: The Boston keratoprostheses type 1 devices (KPro) are utilized in cases unfavorable to penetrating keratoplasty. The prognosis remains guarded in cases of ocular surface disease due to risk of tissue necrosis. We describe a novel surgical approach using a conjunctival flap with a delayed opening to improve retention.

Methods: In three patients with advanced cicatrizing conjunctivitis, a Type 1 keratoprosthesis was stabilized using a full tarsal conjunctival flap. Three months postoperatively, an opening was created in the flap overlying the optical portion of the device.

Results: All patients had no device related complications over a mean follow-up period of 17.7 months (range 15-21 months) and vision remained excellent at better than 20/200 for all patients.

Conclusions: Utilization of a tarsal flap either primarily as part of a two stage modified technique or secondarily in cases of tissue necrosis and impending device extrusion might maximize retention of the type 1 KPro.     

Validity of Teacher-Based Vision Screening and Factors Associated with the Accuracy of Vision Screening in Vietnamese Children

Purpose: To assess validity of teacher-based vision screening and elicit factors associated with accuracy of vision screening in Vietnam.

Methods: After brief training, teachers independently measured visual acuity (VA) in 555 children aged 12–15 years in Ba Ria – Vung Tau Province. Teacher VA measurements were compared to those of refractionists. Sensitivity, specificity, positive predictive value and negative predictive value were calculated for uncorrected VA (UVA) and presenting VA (PVA) 20/40 or worse in either eye. Chi-square, Fisher’s exact test and multivariate logistic regression were used to assess factors associated with accuracy of vision screening. Level of significance was set at 5%.

Results: Trained teachers in Vietnam demonstrated 86.7% sensitivity, 95.7% specificity, 86.7% positive predictive value and 95.7% negative predictive value in identifying children with visual impairment using the UVA measurement. PVA measurement revealed low accuracy for teachers, which was significantly associated with child’s age, sex, spectacle wear and myopic status, but UVA measurement showed no such associations.

Conclusions: Better accuracy was achieved in measurement of VA and identification of children with visual impairment using UVA measurement compared to PVA. UVA measurement is recommended for teacher-based vision screening programs.     

Ocular Morbidity among Street Children in Kathmandu Valley

Purpose: Prevalence of ocular morbidity among street children is largely unknown. The present study was carried out to determine the prevalence of ocular morbidity among street children in the Kathmandu Valley.

Methods: A cross-sectional study consisting of an eye examination program among 569 street children aged younger than 18 years was conducted from March 2013 to February 2014. Children were included from 11 safe houses of 6 non-governmental organizations and an independent eye camp. Eye examination included visual acuity testing, anterior segment and posterior segment examination, retinoscopy and refraction, cover test, convergence, accommodation and color vision tests. Chi-square test was used to analyze the association of ocular morbidity with age, sex and living conditions.

Results: The majority of children (43.8%) were in the age group of 12–15 years, and the male to female ratio was 3.9:1. Uncorrected and best-corrected visual acuity ≥6/9 in at least one eye was found in 89.8% and 98.4% of children, respectively. Total ocular morbidity was observed at 31.6%. The most common types of ocular morbidity were conjunctivitis (11.0%) and refractive error (11.6%). Ocular morbidity was more common in children over 15 years of age (40.9%; p?<?0.01; odds ratio 1.8).

Conclusions: Ocular infection and refractive error represent the most common ocular morbidities in street children in the Kathmandu Valley.     

Severe Ocular Inflammation Following Ranibizumab or Aflibercept Injections for Age-Related Macular Degeneration: A Retrospective Claims Database Analysis

Purpose: Intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents including ranibizumab and aflibercept are used to treat patients with ocular disorders such as neovascular age-related macular degeneration (nAMD); however, the injections are associated with rare instances of severe ocular inflammation. This study compared severe ocular inflammation rates in patients treated with ranibizumab versus aflibercept.

Methods: United States physician-level claims data covering an 18-month period for each therapy were analyzed. The primary analysis compared severe ocular inflammation event rates per 1000 injections. Sensitivity and subgroup analyses evaluated the impact of factors including intraocular surgery, intravitreal antibiotic administration, and previous intravitreal injections.

Results: The analysis included 432,794 injection claims (ranibizumab n = 253,647, aflibercept n = 179,147); significantly, more unique severe ocular inflammation events occurred in patients receiving aflibercept than ranibizumab (1.06/1000 injections, 95% confidence interval [CI], 0.91–1.21, vs. 0.64/1000 injections, 95% CI 0.54–0.74; p < 0.0001). Comparable results were observed for analyses of patients who had undergone glaucoma or cataract surgeries, had antibiotic-associated endophthalmitis, had non-antibiotic-associated endophthalmitis, and were non-treatment-naive. In contrast, no significant differences in severe ocular inflammation claims were recorded in treatment-naive patients who had no record of anti-VEGF treatment in the 6 months preceding the index claim. No significant change occurred in the rate of severe ocular inflammation claims over time following ranibizumab treatment.

Conclusions: Severe ocular inflammation was more frequent following intravitreal injection with aflibercept than with ranibizumab during routine clinical use in patients with nAMD. This highlights the importance of real-world, post-approval, observational monitoring of novel medicines, and may aid clinical decision-making, including choice of anti-VEGF agent.