Purpose:Birdshot Retinochoroiditis (BRC) is an uncommon but distinct form of bilateral posterior uveitis. It is generally of indolent onset, making early natural history difficult to study. Our report seeks to expand knowledge on the natural history of the onset of BRC.Observations:Our patient presented with clinical features that were consistent with unilateral BRC, despite it being defined as a bilateral condition. Over the course of one year he developed retinal vasculitis, vitritis and fundus features of BRC in the second eye.Conclusions and Importance:Although BRC is a bilateral disease, our case demonstrates that the onset may sometimes be sequential instead of simultaneous. Unilateral disease that is characteristic of BRC should be monitored for second-eye involvement with multi-modal imaging including fundus photography, angiography, perimetry, electroretinography, and optical coherence tomography of the macula with emphasis on the choroidal thickness.

Purpose: To evaluate features and outcomes of eyes with retinal vasculitis and intraocular inflammation (IOI) after intravitreal injection (IVI) of brolucizumab 6 mg/0.05 ml for treatment of neovascular age-related macular degeneration. Design: Retrospective case series. Participants: Fifteen eyes from 12 patients identified from 10 United States centers. Methods: Review of patient demographics, ophthalmologic examination results, and retinal imaging findings. Main Outcome Measures: Baseline and follow-up visual acuity (VA), prior anti-vascular endothelial growth factor (VEGF) injections, clinical presentation, retinal findings, fluorescein angiography results, and treatment strategies. Results: The number of previous anti-VEGF IVIs ranged between 2 and 80 in the affected eye before switching to brolucizumab. Retinal vasculitis and 101 were diagnosed at a mean of 30 days after brolucizumab IVI. Mean VA before brolucizumab IVI was 0.426 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, 20/53) and VA at diagnosis of retinal vasculitis was 0.981 logMAR (Snellen equivalent, 20/191; range, 20/25-20/1600; P = 0 .008) . All affected eyes showed 101 with variable combinations of focal or elongated segmental sheathing and discontinuity of small and large retinal arteries, sclerotic arteries, regions of vascular nonperfusion, cotton-wool spots, Kyrieleis plaques, irregular venous caliber with dilated and sclerotic segments, perivenular hemorrhages, and foci of phlebitis. Fluorescein angiography revealed delayed retinal arterial filling, retinal vascular nonperfusion, and variable dye leakage from affected vessels and the optic nerve. Systemic evaluation for embolic causes was unrevealing in 2 patients, and 3 patients showed negative laboratory assessment for uveitis. Treatment consisted of various combinations of corticosteroids (systemic, intravitreal, and topical), and 2 eyes underwent vitrectomy without improvement in vision. After a mean follow-up of 25 days, mean VA was 0.833 logMAR (Snellen equivalent, 20/136), which was reduced compared with baseline (P = 0.033). Conclusions: Retinal vasculitis and IOI after brolucizumab IVI are characterized by variable occlusion of large or small retinal arteries, or both, and perivenular abnormalities. It may span from peripheral vasculitis to occlusion of large retinal arteries around the optic nerve or macula with severe vision loss. A high index of suspicion is required because vitreous cells may obscure visualization of retinal details. (C) 2020 by the American Academy of Ophthalmology

BACKGROUND:Idiopathic macular aneurysmal telangiectasia or so-called Coats' disease is usually a unilateral retinal vascular abnormality in males. It has been rarely reported to occur bilaterally with and without associated abnormalities, and its occurrence in a familial setting is even rarer.PURPOSE:This is a report of a familial occurrence of bilateral macular aneurysmal telangiectasia or Coats' disease in a father and daughter.RESULTS:A 44-year-old woman and her father had bilateral macular angiopathy with macular telangiectasia, aneurysms, ischemia, and leakage, including lipid deposition. The clinical findings were confirmed with fluorescein angiography and optical coherence tomography. There was no history of systemic disease associated with a retinal vascular abnormality.CONCLUSION:To our knowledge, this is the first report of a familial occurrence of bilateral macular aneurysmal telangiectasia or Coats' disease in a daughter and father without associated systemic disease.

We report a case of multifocal choroidal melanoma arising in an eye with ocular melanocytosis and review the pertinent literature. A 63-year-old Caucasian male with ocular melanocytosis in the left eye was found to have two discrete choroidal melanomas in the same eye. Histopathology of the enucleated eye confirmed the diagnosis of two discrete choroidal melanomas of mixed cell type within a region of choroidal melanocytosis. It is estimated that 1 in 160,000 patients with unilateral ocular melanocytosis may develop two uveal melanomas, based on the reported data. On the basis of random chance, patients with two melanomas in the same eye would be expected to have approximately 1000-fold greater likelihood of underlying ocular melanocytosis than the general Caucasian population. In conclusion, multifocal choroidal melanoma is rare and may be related to underlying ocular melanocytosis.

BACKGROUND AND OBJECTIVE:To assess a two-drug combination of antiviral therapy for the progressive outer retinal necrosis syndrome (PORN), given the current poor outcome with acyclovir alone.PATIENTS AND METHODS:A retrospective review was performed on six consecutive patients who were diagnosed with PORN and were treated with various combinations of intravenous or oral plus intravenous antiviral therapy. The relative efficacies of these modalities were compared.RESULTS:Six eyes of six patients showed active retinitis at the time of presentation. Three patients had unilateral retinitis, and the remaining patients had necrotic, end-stage disease in their fellow eye. All the patients were treated with combination therapy, consisting of either ganciclovir and acyclovir (three patients), foscarnet and ganciclovir (two patients), or foscarnet and acyclovir (one patient). Standard induction doses were employed. During the combination therapy, all six eyes showed resolution of the retinitis, manifested by complete fading of the original retinal lesions and an absence of new lesion formation. At the final follow-up, the areas of prior active retinitis had resolved and remained quiescent. A mild recurrence developed in one eye when ganciclovir and foscarnet were both tapered to a single daily dose. This recurrence promptly resolved with reinduction (twice daily) dosing. Two patients maintained a visual acuity of 20/50 or better in their involved eye for the duration of follow-up (38 and 27 weeks, respectively). One patient maintained a visual acuity of 20/40 for 14 weeks. The remaining three patients had macula-off retinal detachments despite resolution of active retinitis. In addition, for the duration of follow-up, one of the three patients with unilateral disease had retinitis in the uninvolved eye; all three uninvolved fellow eyes maintained a visual acuity of 20/20. One patient had progressive optic atrophy.CONCLUSIONS:Prolonged combination antiviral therapy for PORN may successfully arrest the progression of retinitis, maintain remission, and prevent involvement of the fellow eye. Furthermore, if aggressive therapy is begun early, good vision may be preserved.

Four years following publication of the popularWills Eye Hospital Office and Emergency Room Diagnosis and Treatment of Eye Disease, the Wills residents have produced a second edition. This text combines the practical approach of ophthalmology residents with the vast expertise of the Wills Eye Hospital faculty to provide a compact yet remarkably comprehensive guide to the treatment of acute eye disease. As stated by the authors, the primary goal has been to "provide a quick reference containing crisp and concise answers to the diagnostic and therapeutic problems which span most of ophthalmology." Although the title has been modified, the format of the text remains nearly identical to the first edition. The first two chapters launch into differential diagnoses for various ocular symptoms and signs. Of all the chapters in the book, these two are the least comprehensive and user-friendly. While very useful for the nonophthalmologist and beginning resident, experienced

Purpose: Although optic pits were described more than a century ago, the pathogenesis and pathologic nature of the associated macular lesions remain controversial. The authors used the technique of optical coherence tomography (OCT) to further define the anatomic relation that exists between optic pits, macular schisis-like spaces, and macular detachments.Methods: Four eyes of three consecutive patients with optic pit-related macular pathology were evaluated. Cross-sectional OCT images were correlated with findings from slit-lamp biomicroscopy and stereo fundus photography. All eyes previously had undergone unsuccessful photocoagulation to the temporal juxtapapillary retina. One eye had undergone vitrectomy and intraocular gas tamponade, resulting in partial resorption and displacement of the submacular fluid.Results: Retinal edema and cystic degeneration were present, overlying macular neurosensory detachments in all four eyes. The most prominent edema was present in the outer retina at the level of the outer plexiform layer. This mimicked a true retinoschisis cavity, although bridging retinal elements were identifiable. A lesser degree of edema was present in the inner retina, predominantly located between the disc and fovea. In one eye, a lamellar hole was shown to be a defect in the outer neurosensory retina. In another eye, a macular detachment developed under a pre-existing schisis-like cavity. The schisis-like cavity or edematous retina communicated with the optic disc in all eyes, whereas none of the eyes demonstrated a direct connection between the macular detachment and optic pit.Conclusion: These findings support the concept of a bilaminar structure in which a macular detachment develops secondarily to a pre-existing schisis-like lesion consisting of severe outer retinal edema. Fluid may enter from the optic pit into the retinal stroma and not directly into the subretinal space, explaining the prolonged recovery and frequency of treatment failure after photocoagulation to the juxtapapillary retina.

OBJECTIVE:The chronic histopathologic effects of focal and grid argon laser photocoagulation were examined in eyes obtained at autopsy that had previously been treated for diabetic macular edema. The focus was on further characterizing fibrous sub-pigment epithelial membranes that previously had been shown to extend beyond burn edges.DESIGN:A total of 131 argon laser burns were evaluated in five eyes. Tissue was embedded in paraffin or glycol methacrylate, serially sectioned, and examined by light microscopy.MAIN OUTCOME MEASURE:Outer and inner nuclear layer defects were measured, and the frequency and extent of sub-pigment epithelial membranes was estimated. The presence of Müller cell processes among membranes was evaluated by immunostaining for glial fibrillary acidic protein and enzyme histochemical staining for carbonic anhydrase.RESULTS:Burns consistently produced defects in the outer nuclear layer that were larger than the spot size of the laser beam. Inner nuclear layer defects were present in only seven of 131 burns. Glycol methacrylate--embedded tissue sections from 73 burns showed sub-pigment epithelial membranes in all five eyes. In one eye, membranes were confluent between burns. In the remaining four eyes, 37 individual membranes were found among 53 burns, and 47% of membranes contained Müller cell processes. The membranes in paraffin-embedded tissue could not be adequately evaluated.CONCLUSIONS:After focal laser treatment for diabetic macular edema, the inner retina was usually spared. Fibrous sub-pigment epithelial membranes were frequent among burns in all five eyes, and they showed a conspicuous contribution by Müller cell processes. We speculate that by impairing the overlying pigment epithelium, these membranes may contribute to a progressive enlargement of laser scars.

Glucocorticoids block the localized accumulation of leukocytes as sites of inflammation by preventing their adherence to vascular endothelium. This implies that glucocorticoids are acting either on the leukocytes, endothelium, or cells which produce adherence-promoting factors (such as interleukin 1 (IL-1)). Previous studies have shown that dexamethasone (DEX) treatment of either polymorphonuclear leukocytes (PMN) or human umbilical vein vascular endothelial cells (VEC) or both in vitro does not prevent adherence induced by thrombin or formylmethionyl-leucyl-phenylalanine (f-met peptide). We now show that pretreatment of PMN and/or VEC for 24 hr with 0.1 microM DEX had no effect on adherence of PMN to VEC activated with IL-1 (2 U/ml), lipopolysaccharide (1 microgram/ml), or 12-O-tetradecanoylphorbol-13-acetate (30 ng/ml) suggesting that glucocorticoids may inhibit adherence in vivo by blocking formation of IL-1 and other adherence-inducing stimuli. We have recently established that cultured human lung fragments produce IL-1 in vitro. To investigate whether glucocorticoids could inhibit the production of adherence-inducing factors, we examined the effect of glucocorticoids on IL-1 production from human lung tissue. Treatment of human lung fragments in vitro for 18 hr with glucocorticoids such as DEX and hydrocortisone resulted in dose dependent inhibition of IL-1 production; these and other glucocorticoids, at concentrations ranging between 0.1 and 1 microM, produced greater than 50% inhibition of IL-1 release. Nonglucocorticoid steroids including testosterone and beta-estradiol (1 microM) had no effect. Inhibition of IL-1 production occurred after a lag period 5 of 16 hr, and the relative glucocorticoid potencies agreed with their known anti-inflammatory potencies in vivo (beta-methasone approximately triamcinolone acetonide greater than DEX greater than fludrocortisone greater than prednisolone greater than hydrocortisone). Inhibition of IL-1 production in vivo may, in part, explain the remarkable ability of glucocorticoids to prevent the adherence of leukocytes to endothelium and their accumulation at an inflammatory site.

Cultured human vascular endothelial cells obtained from umbilical cord veins were observed to acquire adhesive properties for purified neutrophils after exposure to IL 1, endotoxin, and tumor-promoting phorbol diesters. Adhesiveness induced by IL1 and endotoxin had similar kinetics of onset, producing no change after 30 min incubation and reaching optimal change by 4 hr of incubation. The phorbol diester TPA induced changes in adhesiveness more rapidly, with half maximal increase induced by a 15- to 30-min exposure. TPA, but not IL 1 or LPS, induced significant morphologic changes in the endothelial cell monolayer. None of the stimuli decreased endothelial cell viability. All stimuli induced increased adhesiveness at relevant concentrations, i.e., endotoxin, 0.01 to 1 microgram/ml; IL 1, 0.5 to 2 U/ml; and TPA, 1 to 30 ng/ml. Structure activity relationships among phorbol diesters indicate that the response occurs through a typical phorbol diester "receptor." A protein synthesis inhibitor (cycloheximide) and an RNA synthesis inhibitor (actinomycin D) prevented the acquisition of adhesiveness stimulated by IL 1 and endotoxin but not by TPA. In addition, TPA showed a differential temperature sensitivity in inducing adhesiveness in endothelial cells. IL 1 and endotoxin did not produce the effect with a 4-hr incubation at 22 degrees or 4 degrees C, whereas TPA was effective at these lower temperatures. Purified human IL 2 and recombinant-derived interferon-gamma failed to induce adhesiveness in vascular endothelial cells, indicating that this is not a general property of lymphokines. We conclude that endothelium may, under some circumstances, play an active role in producing a leukocyte infiltrate at a local tissue site by acquiring adhesive properties. The production of IL 1 by tissue macrophages, etc., may serve as an important initiator of an inflammatory cell infiltrate. Finally, an action of tumor-promoting phorbol diesters in increasing endothelial cell adhesiveness, combined with their known effects in activating leukocytes, may help explain the extraordinary inflammatory potency of these compounds.