Eales' Disease Management and Follow-Up by Eye Specialists in Chennai, India

1. Eales' disease DrChinmayiVyas M.S. Dr Jyotirmay Biswas M.S., FAMS, FIC Path,FAICO Director of Uveitis and Ophthalmic pathology SankaraNethralaya, Chennai,India

2. Ocular History • 30 year old lady • February 2012 complaints of left eye blurred vision with floaters. • No h/o similar problems • Systemic history : unremarkable

3. February 2012 : First Presentation

6. February 2012 : First Presentation • ESR:12 mm • Mantoux Test : positive • Serum Angiotensinconvertingenzyme: 8.4 U/L • QuantiFeron TB goldtest : positive • High resolutioncomputedtomographyscanchest : non specificlesion

7. February 2012 • Eale’s disease v/s presumed tuberculous vasculitis • Started on Oral prednisolone 1 mg/kg (60 mg/day) • Reviewed with chest physician: started on 2 drug anti TB Rx for 9 months. • High Intra ocular pressure on first visit: steroid responder ?? Started on anti glaucoma Rx

8. Feb 2012 – June 2012 • Improvement in vision • Right eye 6/6 , N6 ; Left eye 6/9, N6 • Activity reduced as compared to first visit. • Oral steroid tapered, anti glaucoma treatment continued

10. June 2012 • complains of reduced vision in Left eye • Patient was on prednisolone 10 mg/day

12. June 2012 • Fundus fluorescine angiography advised • Oral prednisolone dose hiked up • ? ? other causes Tests done: • C-ACNA: negative • P- ANCA: negative • HLA B51: negative

14. July 2012 • Oral steroid dose increased • Lefteyesectoralpanretinalphotocoagulationdonearoundareaofneovascularization • Anti TB treatmentcontinued

15. August 2012 • Sudden reduction in vision in Left eye

16. August 2012

17. August to September 2012 • August 2012 - right eye : vision maintained; disease stabilized - Left eye: non resolving vitreous haem • September 2012 - Left eye: Pars plana vitrectomy with membrane peeling with Endo laser application done under steroid cover - Vitreous sample taken for Polymerase chain reaction(PCR) for Mycobacterium Tuberculosis

18. Diagnosis after vitrectomy • PCR for M. Tuberculosis : positive • Mantoux Test : positive • QuantiFeron TB goldtest : positive PresumedTuberculousretinal periphlebitis

19. Problems • Eales' disease v/s presumed tuberculous periphlebitis • Negative Mantoux test does not exclude Tuberculosis • QuantiFERON TB gold test : adds to the diagnosis • PCR of vitreous biopsy for MPB 64 diagnostic • Presumed tuberculous periphlebitis most common cause for Eales disease.

20. Follow-up: November 2012 continued on oral steroids tapering dose

21. Follow-up: November 2012

22. Follow-up: March 2013 continued on oral prednisolone 10mg/day: stopped after 2 months

23. Follow-up: March 2013

24. Follow-up: November 2013 FFA done: no active vasculitis Off oral steroids >6 months

25. Follow-up: November 2013

26. Discussion • Eales disease is defined as idiopathic inflammatory Retinal vasculitis with peripheral retinal revascularization primarily affecting the peripheral retina. • It has high male preponderance • Etiopathogenesis of Eales’ disease is still controversial and ill-understood. • Tuberculosis is considered to be the most important cause for eales disease as evidenced by molecular micro biological studies.

27. Conclusion • Treatment with anti tuberculous treatment along with oral steroids treatment is very useful especially in developing countries with high prevalence of tuberculosis • Prompt retinal photocoagulation of the area of neovascularization and capillary non perfusion helps in preventing the complications

28. Conclusion • It is in the nature of the disease to have recurrences • Therefore it is prudent to have regular follow ups for early diagnosis of recurrence of vasculitis and complications like peripheral neovascularization and vitreaous hemorrhage