Seminars in Ophthalmology最新文献

Background: Intraocular biopsy is a diagnostic procedure used to obtain tissue samples to identify intraocular lesions, including tumors, infections, and inflammatory conditions. Inconclusive clinical and imaging findings necessitate intraocular biopsy.

Methods: This retrospective review reviewed the relevant literature, including relevant reviews, original articles, case reports, and case series published up to July 2024.

Results: Depending on the location and suspected nature of the lesion, intraocular biopsy is performed using various techniques, such as fine-needle aspiration biopsy (FNAB), vitreous biopsy, and chorioretinal biopsy. Despite its challenges, such as small sample size and potential complications like retinal detachment and hemorrhage, intraocular biopsy plays a vital role in guiding management decisions, including treatment planning. Recent advancements in molecular pathology and imaging-guided biopsy techniques have enhanced tissue yield and safety, making biopsy an invaluable diagnostic tool. In ocular oncology, prognostic biopsy for uveal melanoma has become the standard of care.

Conclusion: Intraocular biopsy remains a crucial diagnostic tool for treatment decision-making and improving patient outcomes. Technological advancements continue to refine its efficacy and safety, reinforcing its role in modern ophthalmic practice.

Background: A symblepharon is an adhesion between the bulbar and the palpebral conjunctiva and is a manifestation of the loss of conjunctival redundancy. It occurs due to conjunctival scarring, most commonly resulting from trauma or chronic inflammation. Vision can be affected either if the symblepharon is present along with primary keratopathy and limbal stem cell deficiency, or if it is extensive leading to secondary corneal involvement. There is currently no medical treatment for symblepharon, nor can its occurrence be fully prevented. Surgical management is often necessary in cases associated with chronic cicatrizing conjunctivitis.

Purpose: This review aims to summarize the etiology, clinical presentation, and management strategies for ocular symblephara. Methods: A comprehensive literature search was conducted using PubMed database, identifying published studies addressing ocular symblephara and their management. Mechanisms of symblephara formation and emerging treatment modalities for prevention of symblephara were also evaluated.

Conclusion: Surgical approaches to symblephara management involve excision of the fibrotic tissue and placement of mechanical barriers or biological tissue substitutes such as amniotic membranes, conjunctival autografts, and oral mucous membrane grafts. Surgical intervention is recommended for symblepharon in cases where cosmesis is a concern, the visual axis is affected, or in extensive cases before procedures such as cataract surgery, limbal stem cell transplantation, or keratoprosthesis surgery, as well as to facilitate scleral contact lens fitting. Management also involves addressing the underlying disease that led to symblepharon formation. The recurrence rate of symblepharon following surgical treatment is higher in eyes with Stevens-Johnson syndrome or mucous membrane pemphigoid compared to those with ocular chemical burns. Further research is needed to explore preventive strategies such as anti-fibrotic agents and potential medical treatment for symblepharon.

Purpose: The aim of this paper is to describe and analyse the retinal involvement and Optical Coherence Tomography (OCT) findings in Progressive Outer Retinal Necrosis (PORN) and revisiting its terminology.

Methods: Retrospective review of 26 eyes of 15 HIV-positive patients diagnosed with PORN. Cases were confirmed based on history, clinical features, and OCT imaging. Patients with media opacities were excluded. Clinical records, retinal fundus photography images and serial OCT images were reviewed from initial presentation to final follow-up. Retinal changes, extent and layers of retinal involvement and other OCT features of eyes diagnosed as PORN were analysed.

Results: OCT findings revealed that 61.5% of eyes exhibited increased inner retinal thickness, while 69.2% demonstrated hyperreflectivity of the inner retinal layers at initial presentation, both of which resolved over time. The outer retinal layers remained structurally intact initially but showed full-thickness necrosis in advanced cases. OCT findings indicate that inner retinal involvement preceded outer retinal necrosis.

Discussion: As the retinal necrosis originates in the inner retina and progresses towards the outer retina, OCT and histopathological evidence suggest that "Progressive Outer Retinal Necrosis" is a misnomer. The term "Acute Aggressive Posterior Progressive Necrotising Retinitis" is a more accurate term that characterizes the disease pathophysiology.

Methods: A retrospective analysis of 44 TED patients (22 teprotumumab, 2023-2025 at Sheikh Shakhbout Medical City and 22 tocilizumab, 2018-2024 at Sheikh Khalifa Medical City) was conducted. Outcomes included proptosis reduction (Hertel exophthalmometry), clinical activity score (CAS) improvement, diplopia improvement, quality of life (QoL) improvement (TED-QOL), recurrence rates, and adverse events. Mann-Whitney U tests and chi-square/Fisher's exact tests were used (p < .05).

Results: Teprotumumab produced greater mean proptosis reduction (2.55 ± 1.01 mm vs 2.07 ± 1.07 mm, p = .04) and a larger mean CAS improvement (5.18 ± 1.99 vs 4.59 ± 1.82, p = .34). Diplopia improvement occurred in 78.6% vs 75.0% of patients (p = .82), while ≥1-grade improvement by Gorman criteria was achieved in 59.1% of each group (p = .61). Quality-of-life improvement averaged 4.2 ± 1.4 vs 3.4 ± 1.5 points (p = .18). Disease recurrence was lower with teprotumumab (4.5% vs 13.6%, p = .28). Adverse events occurred in 54.5% (teprotumumab) and 43.5% (tocilizumab) patients (p = .47), and were generally mild and reversible.

Conclusion: Teprotumumab and tocilizumab improved TED outcomes, with teprotumumab showing trends toward better proptosis reduction and lower recurrence. Larger studies are needed to confirm these findings.

Purpose: To differentiate the clinical features of fungal keratitis with predominantly deep stromal and endothelial (FSKE) involvement and HSV Endothelial Keratitis (HEK).

Methods: Medical records of patients diagnosed with FSKE or HEK between January 2019 and March 2024 were reviewed. We included cases presenting with predominant posterior stromal infiltrates and endothelial exudates that were later confirmed as fungal etiology by microbiology or confocal imaging. These were compared with confirmed HSV endothelial keratitis, diagnosed clinically and/or by PCR (Polymerase Chain Reaction).

Results: A total of 77 cases were included in the study, of which 45 were of FSKE and 32 of HEK. Hyphate edges, along with satellite lesions and the presence of hypopyon, are more commonly seen in fungal cases (66.6% (FSKE) vs. 3.1%, (HEK) OR = 62.0, p = .0001). Posterior stromal involvement was also significantly higher in fungal cases (46.6% vs. 8.8%, OR = 9.4, p = .001). Exudates over the endothelial surface (Endo-exudates) were defined as fluffy in cases with Fungal keratitis as opposed to HSV, where they were more of multiple dot-like (OR = 4.1, p = .005). An intact epithelium was more frequently noted in HEK (84.3% vs. 60% in FSKE, OR = 3.5, p = .02), with the presence of corneal oedema (46.8% vs. 13.3%, OR = 5.7, p = .001). Sampling of these endo-exudates revealed the presence of fungal filaments in 88.8% of fungal keratitis.

Conclusions: Hyphate edges, satellite lesions, hypopyon, fluffy endothelial exudates, and posterior stromal involvement strongly suggest fungal aetiology, whereas intact epithelium, corneal edema, and dot-like endothelial exudates favour HSV.

Purpose: The benefits of anti-tubercular therapy (ATT) in treating ocular tuberculosis (TB) are well documented. However, the optimal duration of ATT remains uncertain. We assessed the efficacy of 6-month ATT compared to 9-month therapy in preventing recurrent intraocular inflammation.

Design: Multi-center, open-label, non-inferiority, randomized controlled trial across three centers in India, Myanmar, and Thailand.

Methods: Patients aged $\ge$ 18 years with tubercular posterior uveitis (retinal vasculitis, serpiginous-like choroiditis [SLC] or multifocal choroiditis) were randomized to receive either 6- or 9-month ATT. Systemic corticosteroids were mandatory for SLC and, at the treating physician's discretion, for other phenotypes. The primary outcome measure was the non-recurrence of inflammation 1 year after ATT.

Results: Sixty-four patients (64.1% males, median age 38 years [22-70], 43.8% bilateral) were randomized across the three sites during the study period. Thirty patients were assigned to the 6-month arm and 34 to the 9-month arm. Both treatments demonstrated a high non-recurrence rate on intention-to-treat (ITT) analysis (0.94 [0.79-0.99] for 9-month [n = 32] and 0.85 [0.65-0.96] for 6-month treatment [n = 26]). The difference in proportion remained below the non-inferiority margin (0.16) for both the ITT (0.09 [84% CI -0.02 - 0.2]) and per-protocol (0.13 [84% CI 0.01 - 0.25]) analyses. In subgroup analysis, retinal vasculitis appeared to favor 6-month ATT, and SLC 9-months, with the confidence intervals not deviating on bootstrap resampling. No discontinuation due to drug toxicity was reported in either group.

Conclusion: Six-month ATT is non-inferior to 9-month ATT for treating tubercular posterior uveitis, though it may vary between the different clinical phenotypes.