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Vaccines such as bacille Calmette-Guérin (BCG) are known for their heterologous effects mediated through a number of mechanisms, including trained immunity constituted by monocyte-macrophage based innate immunity. Other events such as direct hematogenous spread and induction of autoimmunity are also described. There has been a resurgent interest in harnessing some of the benefits of trained immunity in the management of COVID-19, even as several specific vaccines have been approved. We summarize the current knowledge of ocular effects of BCG. Potential effect of granulomatous inflammation on angiotensin converting enzyme activity and accentuation of cytokine storm that may result in undesirable ocular and systemic effects are also discussed.

BackgroundOcular toxoplasmosis is common across all regions of the world. Understanding of the epidemiology and approach to diagnosis and treatment have evolved recently. In November 2020, an international group of uveitis-specialised ophthalmologists formed the International Ocular Toxoplasmosis Study Group to define current practice.Methods192 Study Group members from 48 countries completed a 36-item survey on clinical features, use of investigations, indications for treatment, systemic and intravitreal treatment with antiparasitic drugs and corticosteroids, and approach to follow-up and preventive therapy.ResultsFor 77.1% of members, unilateral retinochoroiditis adjacent to a pigmented scar accounted for over 60% of presentations, but diverse atypical presentations were also reported. Common complications included persistent vitreous opacities, epiretinal membrane, cataract, and ocular hypertension or glaucoma. Most members used clinical examination with (56.8%) or without (35.9%) serology to diagnose typical disease but relied on intraocular fluid testing—usually PCR—in atypical cases (68.8%). 66.1% of members treated all non-pregnant patients, while 33.9% treated selected patients. Oral trimethoprim–sulfamethoxazole was first-line therapy for 66.7% of members, and 60.9% had experience using intravitreal clindamycin. Corticosteroid drugs were administered systemically by 97.4%; 24.7% also injected corticosteroid intravitreally, almost always in combination with an antimicrobial drug (72.3%). The majority of members followed up all (60.4%) or selected (35.9%) patients after resolution of acute disease, and prophylaxis against recurrence with trimethoprim–sulfamethoxazole was prescribed to selected patients by 69.8%.ConclusionOur report presents a current management approach for ocular toxoplasmosis, as practised by a large international group of uveitis-specialised ophthalmologists.

To describe the demographics, clinical presentation, proportion of co-infection with human immunodeficiency virus (HIV), and treatment of patients with ocular syphilis seen at the ophthalmology department of 2 tertiary centres in Montreal, Canada.Retrospective case series.A total of 169 eyes of 115 patients, seen between 2000 and 2015, with a positive syphilis treponemal serology and a likely syphilis-related ophthalmologic diagnosis. Subgroup analysis was performed between HIV-infected and HIV-uninfected patients.Mean age of onset was 55 years, and 79% were male. Mean presenting logMAR visual acuity was 0.7. HIV status was available for 66%, of whom 49% were HIV-infected. The anatomical ocular diagnoses included isolated anterior uveitis (18%) and posterior segment involvement (42%). Both eyes were affected in 47%. Lumbar puncture (LP) was performed in 55%, of whom 22% had a positive cerebrospinal fluid (CSF) Venereal Disease Research Laboratory (VDRL) test. Antibiotherapy, consisting of intravenous penicillin alone or in addition to intramuscular benzathine penicillin, was administered in 65 patients (69%). Treatment allowed a visual improvement of -0.23 logMAR. HIV-infected patients were younger men (p0.01) and had more abnormal CSF analysis (p = 0.02), but there were no statistically significant differences in the anatomical location of ocular inflammation or visual function improvement.Given its varied presentations, syphilis must always be part of the differential diagnosis of intraocular inflammation. HIV testing and an LP are required in the evaluation of ocular syphilis, which should be treated as neurosyphilis with the appropriate regimen.

To report the use of the dexamethasone (Ozurdex, Allergan Inc) intravitreal implant in the management of acute zonal occult outer retinopathy.Observational case report.A 63-year-old woman presented with a 10-year history of progressing bilateral, although asymmetric, visual impairment and scotomata with clinical and imaging findings compatible with acute zonal occult outer retinopathy. The right eye had recently progressed rapidly until macular involvement occurred with loss of visual acuity. Under our observation, progression toward the fovea in the left eye occurred, Ozurdex intravitreal implant treatment was offered and administered. Autofluorescence imaging documented resolution of the hyperautofluorescent borders and slight regression of the involved retina. An injection was repeated every 6 months for 3 injections, and after a follow-up period, 20 months after the first and 8 months after the last injection, no further signs of progression were observed in her left eye.The dexamethasone implant effectively achieved regression of active disease in a patient with longstanding, progressive acute zonal occult outer retinopathy.

Ocular inflammation is a leading cause of vision loss around the world. The presentation can be variable and ophthalmologists have developed a standardized nomenclature to help categorize the numer...

Introduction: Multiple sclerosis (MS)-associated uveitis is an uncommon ocular manifestation of the systemic neurological disease. A wide range of ocular findings has been described including uveit...

Intravesical Bacillus Calmette-Guérin (BCG) instillation has become one of the mainstays of adjunctive therapy in the treatment of superficial bladder cancer. Ophthalmologic complications are rare, but few cases are reported in the literature.Retrospective observational case report.The authors report a case of unilateral Mycobacterium bovis BCG endophthalmitis after intravesical BCG instillations. Despite appropriate systemic antituberculous and corticosteroid therapy, the patient almost completely lost sight in the affected eye. This is the fourth case in the literature of proven M. bovis endophthalmitis suggesting a direct choroidal mycobacterial infection and not only a hypersensitivity immunologic reaction as previously suggested.This case highlights the direct choroidal mycobacterial infection of the disease after BCG instillations for bladder cancer and failure of treatment despite culture-proven drug sensitivity, thus suggesting the need to revaluate adequate treatment to avoid loss of vision.

Background In the past 15 years, a recrudescence of syphilis was observed in Canada, along with a surge in ocular syphilis cases. Without treatment, ocular syphilis can have serious consequences potentially leading to blindness. Our goal was to describe the demographics, clinical presentations, proportion of co-infection with HIV, treatments and visual outcomes of ocular syphilis cases. Methods Patients with a confirmed positive syphilis serology between 2000 and 2015 were identified through the reference laboratory database. A retrospective chart review was performed for those who visited the ophthalmology clinic of Hôpital Maisonneuve-Rosemont or Hôpital Notre-Dame to identify ocular syphilis cases. Results Among the 119 patients (174 eyes) identified (2.5% of the population screened), 80% were male; of which 63% were MSM. Mean presenting logMAR visual acuity was 0.70 (20/100 Snellen) and unilateral ocular involvement occurred in 54%. Ocular manifestations included interstitial keratitis (24 eyes), anterior uveitis (37 eyes), intermediate uveitis (17 eyes), posterior uveitis (31 eyes), panuveitis (27 eyes), isolated optic nerve involvement (25 eyes), and others (12 eyes) including VI nerve palsy, scleritis, and episcleritis. Cerebrospinal fluid (CSF) examination was done in 65 (55%) patients. Of those, VDRL was positive in 14 (22%) patients; white blood cells and proteins were elevated in, respectively, 28 (43%) and 39 (60%) of patients. HIV status was unknown in 39 (33%) patients; among those whose serology were performed (or previous status was known), 38 (48%) were HIV infected. Intravenous aqueous penicillin G was administered in 69 (58%), intramuscular benzathine penicillin in 25 (21%) and other antibiotics, mainly due to allergy, in three (3%) patients. Treatment allowed a visual improvement of –0.22 logMAR (gain of five lines on Snellen chart) after a mean follow-up period of 19 months. Conclusion Syphilis can manifest with a widely diversified array of ocular presentations, especially uveitis and optic nerve involvement. Therefore it is primordial to keep this diagnosis in mind when facing high-risk patients with ocular symptoms. It is of utmost importance that clinicians improve rates of lumbar puncture, HIV screening and intraveinous penicillin treatment when managing ocular syphilis. Disclosures All authors: No reported disclosures.