Two cases of uveitis masquerade syndrome caused by bilateral intraocular large B-cell lymphoma

Introduction. Sometimes it is not easy to clinically recognize subtle differences between intraocular lymphoma and noninfectious uveitis. The most common lymphoma subtype involving the eye is B-cell lymphoma. Case report. We presented two patients aged 59 and 58 years with infiltration of the subretinal space with a large B-cell non-Hodgkin intraocular lymphoma. The patients originally had clinically masked syndrome in the form of intermediate uveitis. As it was a corticosteroid-resistant uveitis, we focused on the possible diagnosis of neoplastic causes of this syndrome. During hospitalization, the neurological symptoms emerged and multiple subretinal changes accompanied by yellowish white patches of retinal pigment epithelium with signs of vitritis, which made us suspect the intraocular lymphoma. Endocranial magnetic resonance imaging established tumorous infiltration in the region of the left hemisphere of the cerebellum. The histopathological finding confirmed the diagnosis of large B-cell non-Hodgkin lymphoma of risk moderate degree, immunoblast - centroblast cytological type. The other patient had clinical chronic uveitis accompanied by yellowish shaped white echographic changes of the retina and localized changes in the level of the subretina. The diagnosis of lymphoma was made by brain biopsy. Conclusion. Uveitis masquerade syndrome should be considered in all patients over 40 years with idiopathic steroid-resistant uveitis. Treatment begun on time can affect the course and improve the prognosis of uveitis masquerade syndrome (UMS) and systemic disease

Postnatal ocular toxoplasmosis in immunocompetent patients

Introduction: Ocular toxoplasmosis is the most common cause of infectious posterior uveitis worldwide. It can be prenatal or postnatal in origin. Despite estimations that postnatal ocular toxoplasmosis is more prevalent, only several cases of proven postnatal ocular toxoplasmosis have been reported in non-epidemic settings. Here, the clinical evolution of ocular toxoplasmosis of conclusively proven postnatal origin in immunocompetent patients is reported.Methodology: Postnatal ocular toxoplasmosis was diagnosed based on clinical diagnosis supported by the longitudinal detection of Toxoplasma gondii-specific IgG, IgM and IgA antibodies in the serum as well as by direct detection of the parasite (bioassay) and/or its DNA (real-time PCR) in aqueous humor.Results: Three cases involved adults in whom ocular toxoplasmosis developed during primary T. gondii infection, as part of the clinical presentation in two and as the sole manifestation in one patient. The fourth patient was a case of inactive ocular toxoplasmosis in a 14-year-old boy, where postnatal infection was confirmed by exclusion of maternal infection. The causative parasite strain was genotyped in only one case and it belonged to genotype II, the dominant type in Europe. One patient acquired the infection in Africa, suggesting an atypical strain.Conclusions: The distinction between prenatal and postnatal ocular toxoplasmosis is only possible in particular clinical situations, and requires extensive laboratory investigation. Genotyping of the parasite strain involved may be important, particularly if atypical strains are suspected, requiring tailored treatment approaches

Clinical and immunological features of retinal vasculitis in systemic diseases

Background/Aim. Vasculitis is a clinical, pathologic process characterized by inflammation and necrosis of blood vessel occurring anywhere in the body. The aim of the study was to present some clinical and immunologic features of retinal vasculitis in systemic diseases: systemic lupus erythematosus, multiple sclerosis, sarcoidosis, Behcet's diseases, and others. Methods. A total of 1 254 patients with uveitis were included in the study. The immunochemical diagnostic methods were used to determine the pathogenesis of ocular manifestations. Ocular manifestations were examined using biomicroscope, direct or indirect ophtalmoscopy. Results. Primary retinal vasculitis was diagnosed in 85/1254 (6.8%) of total uveitis. In more than half of the cases of vasculitis (58.8%), both arteries and veins were involved in inflammatory process. Periphlebitis was diagnosed far more commonly (36.5%) than periarteritis (4.7%). Retinal vasculitis associated with systemic lupus erythematosus was characterized by microinfarctions and the consequent foci of inflammatory cells or diseases of large arteries manifesting in vasospasm and occlusions. Cotton wool spots occurred in 38.3% and retinal hemorrhages in 34% of the cases. In this study periphlebitis of the retina was one of the less frequent ocular manifestations of multiple sclerosis. Comparing with the other changes of the retinal blood vessels, venous sheating occurred in 25.1% and occlusion and vein trombosis in 43.75% of the cases. Retinal vasculitis associated with chronic sarcoidosis occured in 37.5% of patients with sarcoidosis. The most frequent manifestation of ocular sarcoidosis was intermediary uveitis (43.75%). Anterior granulomatous uveitis occured in 37.5% of patients with sarcoidoses. Immune complexes occurred in 13/20 (65%) of the patients. Antiretinal anti-S antibody in the serum occurred in 73% of the patients with retinal detachment as a complication of primary disease and in 25% those with vasculitis. Conclusion. Systemic diseases such as Behcet's syndrome, collagen vascular diseases, systemic granulomatous diseases (sarcoidosis and tuberculosis) were the main causes of retinal vasculitis. Knowledge of the symptomatology and pathogenesis of retinal vasculitis is of the major significance for the diagnosis and therapy of the disease

The thickness of the retrobulbar portion of the optic nerve in Graves ophthalmopathy measured by ultrasound

Introduction. The clinical diagnostic of Graves ophthalmopathy is based on the association of ocular signs and the disease of the thyroid gland. The evolution of the disease involves the development of eye globe protrusion, extraocular muscle thickening pressuring the optic nerve, which can result in its thickness. Objective. The aim of the paper is to find whether the retrobulbar optic nerve thickened and if there was a correlation between its possible thickening and the thickness of the muscles in Graves ophthalmopathy. We also wished to test the theory of compressive aetiology of such thickening using a 30-degree test. Methods. We examined 28 patients with Graves ophthalmopathy. The thickness of the retrobulbar optic nerve was measured by ultrasound on a B-scan using the Schraeder's method and by the largest thickness of the internal muscle. Results. The thickness of the retrobulbar portion of the optic nerve in the 52 analyzed eyes with signs of the disease ranged between 3.24 mm to 6.30 mm, with median of 5.13 mm, indicating that the majority of the patients had optic nerve thickening rating at this value. Forty-eight eyes had a marked retrobulbar optic nerve thickening, with the thickening over 4 mm, while in 4 eyes with signs of Graves ophthalmopathy the thickness of the optic nerve was within normal limits. We detected that 92.3% of the patients with muscular thickening also had a directly proportional thickening of the retrobulbar optic nerve. By using the 30-degree test we confirmed the diagnosis of compressive neuropathy. Conclusion. Patients with Graves ophthalmopathy and thickened muscles, also have a thickening of the retrobulbar optic nerve; the rate of the thickness directly depends on the degree of the muscular thickness. The word is of compressive neuropathy, i.e. the thickness of the optic nerve is the result of subarachnoid fluid stasis caused by the compression on the optic nerve

Tolosa-Hunt syndrome - diagnostic problem of painful ophthalmoplegia

Background. Tolosa-Hunt syndrome (THS) is an uncommon disease caused by non-specific inflammation of the cavernous sinus, superior orbital fissure and the apex of the orbit. The disease is characterized by periorbital pain, paresis of the bulbomotor and quick response to steroid treatment. The orbital process may lead to optic nerve atrophy. According to the International Headache Society Classification of 2004, the diagnostic protocol includes magnetic resonance imaging (MRI) and biopsy. Case reports. We presented 46-year old male patient, with THS. The patient had unilateral periorbital pain, inflammatory process in the cavernous sinus, the apex of the orbit and the paranasal sinuses. Inflammatory process had spread into the fascia of the bulbomotor and performed compression to the optic nerve, causing paresis of the bulbomotor, protrusion of the eyeball and atrophy of the optic nerve. Pulse doses of corticosteroids were effective. Regarding the presented patient, diagnostic dilemmas arose from nonspecific sinusitis. The initial ophthalmological diagnosis, based on periorbital pain, drop in visual acuity and the narrow chamber angle was angular glaucoma, which resulted in a delayed diagnosis of THS and the beginning of the treatment. MRI and positive response to the treatment with corticosteroids were relevant for making the diagnosis. Conclusion. According to the International Headache Society Classification of 2004, THS is an entity that occurs rarely, its etiopathogenesis is unknown, it is manifested clinically by unilateral orbital pain associated with simple or multiple oculomotor paralyses, which resolves spontaneously but may recur. MRI orbital phlebography and biopsy are the recommended methods for making diagniosis. In our patient MRI findings and positive response to the corticosteroide treatment were relevant for making the diagnosis

Evaluation of Macular OCT findings in Diagnosis, Follow-up and Treatment of Vitreoretinal Interface Pathology

Vitroretinalna dodirna površina (VRDP)je kompleks sastavljen od struktura koje povezuju vitrealni korteks i bazalne membrane ćelija retine...Vitroretinal interface(VRI) is a complex composed of structures that connect vitreal cortex with retinal basal membrane..

Secondary surgical management of suprachoroidal hemorrhage during pars plana vitrectomy

Introduction. Suprachoroidal hemorrhage (SCH) is one of the most feared and devastating complications of intraocular surgery. Intraoperative SCH is defined as sudden hemorrhagic swelling of the choroid which develops at time of intraocular surgery, and is associated with expulsion of some or all of the intraocular contents. Case report. A 56-year-old man was admitted to our Clinic with bullose retinal detachment in the left eye. Intraoperatively, during the substitution of perfluorocar-bone liquid (PFCL) with silicone oil, which is very rare situation, a sudden loss of red reflex happened and SCH was recognized as the cause. No attempt was made to drain the supra-choroidal blood. After 3 weeks the patient was scheduled for pars plana vitrectomy. Initial drainage of liqufied blood was made through a sclerotomy port during pars plana inferotemporally. Massive epiretinal proliferation with funnel shaped retinal detachment was solved during vitrectomy and internal tamponade with silicone oil was done. Postoperative visual aquity was 2/60 on the third postoperative day. Conclusion. Although suprachoroidal hemorrhage is one of most feared and devastating complications of intraocular surgery, it might have relatively good prognosis with proper preoperative, intraoperative and postoperative management

Retinal detachment in the eye with the choroidal coloboma

Introduction. Choroidal coloboma is a congenital defect caused by an inadequate closure of embryonic fissure. About 40% of the eyes with the choroidal coloboma (CHC) develop the retinal detachment (RD). It is extremely difficult to manage these cases due to the lack of pigmentation at the site of choroidal coloboma. Outline of Cases. This is a case series of five patients with CHC and RD who were successfully operated using one of two different surgical techniques: pars plana vitrectomy (PPV) + silicone oil internal tamponade and/or scleral buckle with encircling band with laser photocoagulation (SB+EB+LPC) around the coloboma. The purpose of this paper is to present how to successfully handle patients with CHC, who have concurrent retinal detachment in the same eye and to compare two different techniques and indications for the predominant use of one of them in a specific case. Conclusion. Both surgical techniques can be applied with equal success in the operation of retinal detachment in eyes with the chorioidal coloboma. Which one will be used depends only of the posterior segment of eye findings. We use scleral buckling in cases with RD accompanied by CHC when the peripheral break is evident and there are no breaks in the coloboma itself. We also perform, 2-3 days after surgery, laser burns around the coloboma, which is our modification of this technique. In all other cases it is indicated to perform PPV+silicon oil internal tamponade

RETINAL VASCULITIS, A COMMON MANIFESTATION OF IDIOPATHIC PEDIATRIC UVEITIS?

Purpose: Pediatric idiopathic uveitis typically shows anterior segment involvement. Whether retinal vasculitis is an important manifestation of this disease remains unknown and was therefore the subject of this study. Methods: This study was performed involving patients with pediatric idiopathic uveitis. Fundus fluorescein angiography was used to assess the presence of retinal vasculitis. Results: A total of 1,867 patients with pediatric uveitis were seen between December 2008 and January 2018, of whom 1,364 had undergone fundus fluorescein angiography examination. Idiopathic uveitis was the most common entity, accounting for 81.2%. Among these patients with idiopathic uveitis, 79.6% had retinal vasculitis in at least one eye. After 1-year treatment with oral prednisone mostly combined with cyclosporine, 76.3% patients in the retinal vasculitis group achieved control of their ocular inflammation, which was significantly lower as compared with 85.1% in those without (P = 0.008). Retinal vasculitis was an independent predictor for a lower probability of inflammation control after 1-year treatment. Visual function (best-corrected visual acuity > 20/25 in the better seeing eye) was worse in the retinal vasculitis group than in the control group after 5 years. Conclusion: Almost 80% of patients with pediatric idiopathic uveitis show manifestations of retinal vasculitis, which is associated with a lower probability of inflammation control resulting in a worse visual prognosis