MACULAR HOLE ASSOCIATED WITH TOXOPLASMOSIS: A SURGICAL CASE SERIES.

PURPOSE: There are currently limited data addressing the surgical outcomes of pars plana vitrectomy (PPV) in toxoplasmosis-related macular hole (tMH). We aim to report and discuss safety and efficacy of PPV for tMH. METHODS: Surgical case series (n = 11), with minimum postoperative follow-up time of 6 months. Consecutive patients who underwent PPV for tMH from 2013 to 2016 were included. Indications for surgery were: visual acuity ≥ 0.6 logarithm of the minimum angle of resolution (Snellen 20/80 or less), no intraocular inflammation for more than 6 months, extrafoveal toxoplasmosis scar, elevated tMH borders on optical coherence tomography, and patient agreement with surgery. Surgery was performed-PPV with epiretinal (if present) and internal limiting membrane peeling. Safety and efficacy of PPV for tMH were addressed by evaluating: 1) surgery-related complications and 2) visual acuity improvement. RESULTS: A total of 11 patients (6 male), with a mean age of 33.2 ± 11.0 years were studied. Mean preoperative best-corrected visual acuity significantly improved from 1.10 ± 0.24 (Snellen 20/252) to 0.43 ± 0.18 logarithm of the minimum angle of resolution (Snellen 20/54) at last follow-up visit (P < 0.01). The rate of visual acuity improvement (i.e., a gain of at least three lines) and tMH closure was 100% for both. The only reported surgery-related complication was cataract in one case. CONCLUSION: Our results suggest that PPV is a safe and effective option in tMH cases. A controlled, longitudinal study would contribute to confirm these findings.

OUTCOMES AFTER PARS PLANA VITRECTOMY FOR EPIRETINAL MEMBRANES ASSOCIATED WITH TOXOPLASMOSIS.

PURPOSE: To evaluate outcomes and complications of pars plana vitrectomy in patients with epiretinal membrane secondary to toxoplasmic retinochoroiditis. METHODS: Retrospective evaluation of the records of 14 patients who underwent pars plana vitrectomy for epiretinal membrane secondary to toxoplasmic retinochoroiditis. The best-corrected visual acuity, intraoperative and postoperative complications, and macular optical coherence tomography were analysed. All patients received postoperative prophylactic treatment with trimethoprim/sulfamethoxazole. RESULTS: Fourteen patients, 5 men and 9 women, were included. Mean follow-up period after surgery was 6.07 ± 2.64 months. Preoperative mean best-corrected visual acuity was 20/200, and postoperative mean best-corrected visual acuity was 20/60. There were no intraoperative complications. Three patients developed posterior capsule opacification, and one patient developed cataract. CONCLUSION: Pars plana vitrectomy is a safe and effective procedure in patients with epiretinal membrane secondary to toxoplasmic retinochoroiditis, improving both visual acuity and anatomical result on macular optical coherence tomography. The most frequent postoperative complications were posterior capsule opacification and cataract. No recurrences of the disease were recorded.

Peripheral retinal neovascularization in recurrent cicatricial toxoplasmic retinochoroiditis: case series report.

PURPOSE: To report cases of retinal neovascularization in association with cicatricial plaques of congenital recurrent toxoplasmic retinochoroiditis. METHODS: This was a retrospective review of retinologist records. Four cases found were documented with diagnostic techniques, mainly fluorescein angiography, optical coherence tomography and laboratory confirmation. Management included focal laser photocoagulation and pars plana vitrectomy. RESULTS: In 4 cases, one presented spontaneous involution of neovascularization and vitreous hemorrhage. Three cases of neovascularization responded to laser photocoagulation and 2 cases to pars plana vitrectomy. Three cases regained 20/25 vision. CONCLUSIONS: Peripheral neovascularization associated with plaques of cicatricial toxoplasmic retinochoroiditis has been rarely reported. Therefore, a routine careful examination of fundus periphery is recommended.

[Toxoplasma uveitis in a patient with ankylosing spondylitis]. / Ankilozan Spondilitli Olguda Toxoplasma Üveiti.

In this paper, a posterior uveitis case was reported in a patient who was being followed and under treatment for Ankylosing Spondylitis. Toxoplasma antibodies were investigated and anti-toxoplasma IgG was positive. Systematic treatment (Sulfamethoxazole/Trimethoprim and Clindamycin) was started. Despite medical treatment, reduction in visual acuity and development of dense membranous condensation in vitreous occurred. Surgical vitrectomy was performed. When posterior uveitis develops in patients who undergo immunosuppressive treatment, toxoplasma is among the first infectious agents that we should consider. A delay in diagnosis and treatment may result in failure in obtaining the desired outcome from medical treatment and a shift to surgical treatment.

Intraocular cysts of toxoplasma gondii in patients with necrotizing retinitis following periocular/intraocular triamcinolone injection.

PURPOSE: To report the detection of Toxoplasma gondii cysts in intraocular aspirates of patients with necrotizing retinitis following periocular/intraocular corticosteroid injection. DESIGN: Case report. METHODS: Two patients (2 eyes) with widespread necrotizing retinitis in a steroid-exposed eye posed a diagnostic challenge and underwent pars plana vitrectomy (PPV). Intraocular samples (vitreous fluid, retinal tissue, and subretinal aspirate in case 1, and vitreous fluid in case 2) were subjected to cytological examination. RESULTS: The subretinal aspirate (case 1) revealed encysted bradyzoites of Toxoplasma gondii. Vitreous fluid (case 2) tested positive for anti-toxoplasma antibodies and the smear showed encysted forms of Toxoplasma gondii on cytology. CONCLUSION. Toxoplasma gondii cysts were detected in eyes with necrotizing retinitis that developed secondary to injudicious use of corticosteroids.

Interventions for toxoplasma retinochoroiditis: a report by the American Academy of Ophthalmology.

OBJECTIVE: To evaluate the available evidence in peer-reviewed publications about the outcomes and safety of interventions for toxoplasma retinochoroiditis (TRC). METHODS: Literature searches of the PubMed and the Cochrane Library databases were conducted last on July 20, 2011, with no date restrictions. The searches retrieved 275 unique citations, and 36 articles of possible clinical relevance were selected for full text review. Of these 36 articles, 11 were deemed sufficiently relevant or of interest, and they were rated according to strength of evidence. RESULTS: Eight of the 11 studies reviewed were randomized controlled studies, and none of them demonstrated that routine antibiotic or corticosteroid treatment of TRC favorably affects visual outcomes or reduces lesion size. There is level II evidence from 1 study suggesting that long-term treatment with combined trimethoprim and sulfamethoxazole prevented recurrent disease in patients with chronic relapsing TRC. Adverse effects of antibiotic treatment were reported in as many as 25% of patients. There was no evidence supporting the efficacy of other nonmedical treatments such as laser photocoagulation. CONCLUSIONS: There is a lack of level I evidence to support the efficacy of routine antibiotic or corticosteroid treatment for acute TRC in immunocompetent patients. There is level II evidence suggesting that long-term prophylactic treatment may reduce recurrences in chronic relapsing TRC. Adverse effects of certain antibiotic regimens are frequent, and patients require regular monitoring and timely discontinuation of the antibiotic in some cases.

Pars plana vitrectomy in the treatment of severe complicated toxoplasmic retinochoroiditis.

PURPOSE: To present the anatomic and functional results of pars plana vitrectomy performed in severe complicated toxoplasmic retinochoroiditis. METHODS: Three patients, 2 women and 1 man aged 57, 22, and 57 years, are presented. The first patient was under immunosuppressive therapy for dermatomyositis and underwent diagnostic/therapeutic vitrectomy for severe toxoplasmic panuveitis with dense vitritis. The other 2 patients underwent vitrectomy for macula-off rhegmatogenous retinal detachment that developed after severe toxoplasmic panuveitis. RESULT: Preoperative visual acuity was hand movement for the first 2 patients and 20/400 for the third. All patients received pars plana vitrectomy with epiretinal membrane peeling, laser photocoagulation, and SF6 gas tamponade. The second and third patients needed 5 and 3 additional operations, respectively, including extensive retinotomies and silicone-oil tamponade, for recurrent retinal detachment due to proliferative vitreoretinopathy. At the end of the follow-up period (11, 5, and 1 year, respectively), the retina was attached and visual acuity was 20/30 for the first patient but counting fingers for the other 2 patients. CONCLUSIONS: Severe panuveitis and/or recurrent retinal detachment may develop in some cases of ocular toxoplasmosis, compromising the visual prognosis. Retinal detachment due to toxoplasmosis is generally complex, and long-acting tamponade with silicone oil should be contemplated for anatomic retinal reattachment.

Pars plana vitrectomy for vitreoretinal complications of ocular toxoplasmosis.

PURPOSE: Ocular toxoplasmosis is associated with vitreoretinal complications that can potentially cause severe visual loss. The aim of this study is to report the preoperative, intraoperative, and postoperative outcomes of vitreous surgery in eyes with vitreoretinal complications secondary to ocular toxoplasmosis. METHODS: This retrospective study included 15 eyes of 15 patients (8 men, 7 women; mean age at surgery, 37.2 years, range 18-57 years) who had undergone vitreoretinal surgery for vitreoretinal complications secondary to ocular toxoplasmosis. Visual acuity was compared between the last preoperative visit and the most recent follow-up visit. Intraoperative and postoperative complications were also analyzed. RESULTS: Indications for surgery were retinal detachment in 8 eyes (53.3%), epiretinal membrane in 2 eyes (13.3%), persistent vitreous opacities in 2 eyes (13.3%), choroidal neovascularization in 1 eye (6.6%), vitreous hemorrhage secondary to vasoproliferative retinal tumor in 1 eye (6.6%), and hemorrhagic vasculitis with premacular hemorrhage in 1 eye (6.6%). At last examination, visual acuity improved in 11 eyes (73.3%) by 2 lines or more. Postoperative events that might be related to the surgery included 1 localized retinal detachment, 2 cataracts, and 1 glaucoma. CONCLUSIONS: Pars plana vitrectomy for treatment of vitreoretinal complications secondary to ocular toxoplasmosis can be safely performed and may result in improved visual acuity.

[Toxoplasmic chorioretinitis complicated by retinal detachment]. / Choriorétinites toxoplasmiques compliquées de décollement de rétine.

PURPOSE: To describe and analyse relationship between chorioretinal toxoplasmosis and retinal detachment. PATIENTS AND METHODS: Seven immunocompetent patients examined and treated between November 1992 and March 1996, with ocular toxoplasmic retinochoroiditis and retinal detachment. RESULTS: Of the 7 patients examined, 5 had active retinochoroiditis and 2 had typical inactive scars. Of the patients with active focus 3 had giant retinal tears, one had a posterior retinal tear and one had a retinal tear located at the edge of an atrophic scar. Of the patients with inactive lesions, one had tractional retinal detachment and the other presented with a complete retinal detachment, multiples tears and PVR. Five patients were treated by corticosteroid without antitoxoplasmic drug before they were referred. The seven patients underwent endo-ocular surgery with silicon oil or long actic gas tamponade. Three patients developed PVR and redetachment of the retina and two patients underwent further surgery. Good anatomical result was obtained in 6 patients. CONCLUSION: Retinal detachment associated with toxoplasmic retinochoroiditis is rare. However it represents a serious complication. Steroid administrated to salvage vision may then worsen the clinical course, these may be justified to reduce hypersensitivity to toxoplasma antigen, but they should be combined with an antimicrobial agent.

Laser photocoagulation around the foci of toxoplasma retinochoroiditis: a descriptive statistical analysis of 35 patients with long-term follow-up.

Thirty-five patients with toxoplasma retinochoroiditis, receiving medical treatment and then treated with laser photocoagulation around the foci, were retrospectively evaluated for the risk of recurrence of the retinochoroiditis with a Kaplan-Meier representation. The recurrence rates with 95% symmetric confidence intervals were: at 1 year, 12.7 + or - 13%, at 2 years, 19.8 + or - 15%; at 3 years, 24.0 + or - 16%; at 4 years, 33.3 + or - 19%; at 5,6 and 7 years, 53.5 + or - 21%; at 8 and 9 years 66. 8 + or - 22%. With the data provided by our series, it is not possible to show the efficacy of laser photocoagulation as a prevention of recurrence in toxoplasma retinochoroiditis. Moreover, because of their heterogeneity, the recurrence rates from the literature cannot provide precise data for a comparison. Concerning the laser-induced thermal damage, the potential therapeutic mechanism of the laser procedure is discussed.

[Hypertensive anterior uveitis of toxoplasmic origin after vitrectomy]. / Uvéites antérieures hypertensives d'origine toxoplasmique après vitrectomie.

Two cases of vitrectomized congenital chorioretinal toxoplasmosis are presented. During a recurrence, an anterior segment inflammation with hypertony complicated both cases. Hypertony was efficiently controled by a specific antitoxoplasmosis therapy. The role of the vitreous barrier is suggested.

[Pars plana vitrectomy in uveitis]. / Vitrectomie par la pars plana au cours des uveites.

A vitrectomy was performed in 30 eyes suffering from different forms of uveitis. An improvement of visual acuity was obtained in 29 cases and was explained by removal of vitreous haze and/or of the cataract, but not by the improvement of the inflammatory process.

[Laser therapy of ocular toxoplasmosis]. / Laseroterapia w toksoplazmozie ocznej.

The authors present the results of treatment by laser coagulation of inflammatory retino-choroidal foci in 32 persons with ocular toxoplasmosis. The diagnosis of Toxoplasma etiology was set on a basis of positive immunological reaction for Toxoplasma gondii antigen and after exclusion of other etiological factors. Among 42 eyes stabilization of the process after 1 intervention was observed in 34, i.e. in 89 p.c. (period of observation--up to 4 years). In the following 8 eyes arised the necessity to perform additional coagulations because of formation of fresh foci which appeared in 5 eyes after 6 months, in 2 eyes after 1 year and in 1 eye after 2 years since onset. The authors consider the application of laser coagulation in ocular toxoplasmosis as a favourable method together--or independently--with pharmacological treatment.

Current practices in the management of ocular toxoplasmosis.

To determine current practices in the management of ocular toxoplasmosis, 72 of 85 uveitis specialists (85%) in the American Uveitis Society completed a detailed questionnaire. Questions involved the indications for beginning treatment, choice of antiparasitic/antimicrobial agents, and experience with treatment of ocular toxoplasmosis in special situations including pregnancy, neonatal infections, and immunocompromised patients. Most of the respondents treat patients whose visual acuity had decreased to worse than 20/200, lesions located in the peripapillary, perifoveal, or maculopapillary bundle regions, and lesions associated with severe vitreous inflammation. Most would not treat patients who retained visual acuity of 20/20, lesions located in the far peripheral retina, or lesions associated with only trace to mild vitreous inflammation. Treatment of other combinations of factors remains controversial. Eight different antimicrobial drugs are used in various combinations for lesions threatening the macula or optic nerve head. Systemic corticosteroids are used by 59 of 62 respondents (95%) as part of their initial treatment regimen. The most commonly used regimens are pyrimethamine/sulfadiazine/corticosteroids (20 of 62 [32%]) and pyrimethamine/sulfadiazine/clindamycin/corticosteroids (17 of 62 [27%]). Adjunctive therapies (photocoagulation, cryotherapy, or vitrectomy) have been used by 20 of 60 respondents (33%). Most alter treatment during pregnancy, in newborn patients, and in patients with the acquired immunodeficiency syndrome.