Clinical characteristics, visual acuity outcomes, and factors associated with loss of vision among patients with active ocular toxoplasmosis: A retrospective study in a Thai tertiary center.

BACKGROUND: Ocular toxoplasmosis (OT) is the most common cause of infectious uveitis worldwide, including Thailand. This study describes the clinical presentation, visual acuity (VA) outcomes, and factors associated with VA loss in patients with active OT following antiparasitic treatment. METHODOLOGY/PRINCIPAL FINDINGS: A retrospective chart review of patients with active OT treated with antiparasitic drugs between 2010 and 2020 was performed. Outcome measures included clinical characteristics, interval VA, and predictive factors associated with loss of VA ≤ 20/50 at 6 months post-treatment. Ninety-two patients (95 eyes) were enrolled. The median follow-up time was 10.9 months (IQR 4.9-31.8 months). The median age at presentation was 35.9 years, 51% were male, and 92.4% had unilateral OT. Eleven patients (12%) were immunocompromised (HIV infection, eight patients; receiving immunosuppressive agents, three patients). Patients mainly presented with primary retinitis without previous scar (62%), posterior pole lesion (56%), and lesion size of ≤ 2-disc area (75%). Immunocompromised patients showed a significantly larger size of retinitis than immunocompetent patients. Oral trimethoprim/sulfamethoxazole monotherapy was the primary short-term antiparasitic drug prescribed (85%). At the final visit, 21% of all affected eyes suffered VA ≤ 20/200. The cumulative incidence of recurrent OT at three years was 33.9% (95% CI, 19.7%-54.2%). Immunocompromised patients [adjusted odds ratio (aOR) 4.9, p = 0.041], macular lesion (aOR 5.4, p = 0.032), and initial VA ≤ 20/200 (aOR 9.1, p = 0.014) were predictive of having VA ≤ 20/50 at 6 months post-treatment. CONCLUSIONS: Ocular toxoplasmosis mainly presents as unilateral primary retinitis within the posterior pole. Severe VA loss was observed in one-fifth of eyes following treatment with lesion resolution. Immunocompromised patients, eyes with macular lesions, and poor initial VA were associated with poor VA outcomes.

Unilateral Toxoplasma retinochoroiditis with frosted branch angiitis: a multimodal imaging study.

A woman in her late 30s presented with sudden diminution of vision, redness and pain in the right eye (OD) of 10 days' duration. Best corrected visual acuity (BCVA) was 20/160 in OD and 20/20 in the left eye (OS). Anterior segment of OD showed keratic precipitates, flare 3+, cells 2+ and a festooned pupil. Vitreous haze and cells were seen in OD. Frosted branch angiitis (FBA) was seen in all quadrants in OD and old Toxoplasma scar was seen in both eyes. Serum toxoplasma immunoglobulin G (IgG) was positive and IgM negative, and PCR of an aqueous humour sample was negative for Toxoplasma She was diagnosed with toxoplasa retinochoroiditis in OD and treated with intravitreal clindamycin injections, oral anti-Toxoplasma antibiotics and steroids. Three months later, her BCVA in OD was 20/40 with resolving inflammation. She presented 2 months later with a new focus of retinochoroiditis without FBA and an old Toxoplasma scar.

Serous macular detachment in ocular toxoplasmosis: A review.

Ocular toxoplasmosis, a disease of the eye caused by the protozoan parasite Toxoplasma gondii, represents a common cause of posterior uveitis. The Authors review the current Literature regarding the uncommon presentation of ocular toxoplasmosis as macular serous retinal detachment (SRD). It is imperative to keep in mind that inflammatory SRD is a possible presentation of toxoplasmic retinochoroiditis. Underestimation of this clinical scenario and treatment with steroids alone without appropriate antiparasitic drugs, could lead to devastating consequences.

Toxoplasmic maculopathy with bacillary layer detachment in a pediatric patient.

We report the case of a 14-year-old girl with ocular toxoplasmosis presenting with severe panuveitis with anterior segment involvement, moderate vitreous haze, focal retinochoroiditis, extensive retinal periphlebitis, and macular bacillary layer detachment. Toxoplasmosis treatment was complicated by Stevens-Johnson syndrome, which developed 8 days after starting trimethoprim-sulfamethoxazole.

Risk factors for recurrences and visual impairment in patients with ocular toxoplasmosis: A systematic review and meta-analysis.

BACKGROUND: Ocular toxoplasmosis (OT) is caused by the parasite Toxoplasma gondii. OT is the leading cause of posterior uveitis globally; it is a recurrent disease that may result in visual impairment and blindness. This systematic review and meta-analysis aim to summarize and evaluate the risk factors for recurrences, visual impairment, and blindness described in the literature worldwide. METHODS AND FINDINGS: We performed a systematic literature search in PubMed, Embase, VHL, Cochrane Library, Scopus, and DANS EASY Archive. All studies reporting patients with clinically and serologically confirmed OT presenting any clinical or paraclinical factor influencing recurrences, visual impairment, and blindness were included. Studies presenting secondary data, case reports, and case series were excluded. An initial selection was made by title and abstract, and then the studies were reviewed by full text where the eligible studies were selected. Then, the risk of bias was assessed through validated tools. Data were extracted using a validated extraction format. Qualitative synthesis and quantitative analysis were done. This study was registered on PROSPERO (CRD42022327836). RESULTS: Seventy two studies met the inclusion criteria. Fifty-three were summarized in the qualitative synthesis in three sections: clinical and environmental factors, parasite and host factors, and treatment-related factors. Of the 72 articles, 39 were included in the meta-analysis, of which 14 were conducted in South America, 13 in Europe, four in Asia, three multinational, two in North America and Central America, respectively, and only one in Africa. A total of 4,200 patients with OT were analyzed, mean age ranged from 7.3 to 65.1 year of age, with similar distribution by sex. The frequency of recurrences in patients with OT was 49% (95% CI 40%-58%), being more frequent in the South American population than in Europeans. Additionally, visual impairment was presented in 35% (95% CI 25%-48%) and blindness in 20% (95% CI 13%-30%) of eyes, with a similar predominance in South Americans than in Europeans. On the other hand, having lesions near the macula or adjacent to the optic nerve had an OR of 4.83 (95% CI; 2.72-8.59) for blindness, similar to having more than one recurrence that had an OR of 3.18 (95% CI; 1.59-6.38). Finally, the prophylactic therapy with Trimethoprim/Sulfamethoxazole versus the placebo showed a protective factor of 83% during the first year and 87% in the second year after treatment. CONCLUSION: Our Systematic Review showed that clinical factors such as being older than 40 years, patients with de novo OT lesions or with less than one year after the first episode, macular area involvement, lesions greater than 1 disc diameter, congenital toxoplasmosis, and bilateral compromise had more risk of recurrences. Also, environmental and parasite factors such as precipitations, geographical region where the infection is acquired, and more virulent strains confer greater risk of recurrences. Therefore, patients with the above mentioned clinical, environmental, and parasite factors could benefit from using prophylactic therapy.

ATYPICAL FORMS OF EYE TOXOPLASMOSIS IN CHILDHOOD. CASE REPORTS.

AIM: To present an outline of acquired atypical forms of ocular toxoplasmosis (OT) in childhood, with reference to the 100th anniversary of the discovery of this etiology by Professor Janků from Czechoslovakia, who was first to describe the clinical congenital picture of OT characterised by macular scar. MATERIAL AND METHODS: Symptoms of intraocular bilateral neuritis appeared in a 6-year-old girl, with visual acuity (VA) bilaterally 0.1. Toxoplasmic etiology was demonstrated in laboratory tests, and the patient was immunocompetent. Following treatment with macrolide antibiotic and parabulbar application of corticosteroid, the condition was normalised stably at VA 1.0 in both eyes. Bilateral retinal vasculitis was determined in an 8-year-old boy, with VA of 0.25 in the right eye and 0.25 in the left, with a medical history of strabismus detected after suffering from varicella. The examination for toxoplasmosis was negative, but pronounced general hypogammaglobulinaemia classes IgG, IgM and IgA was detected. Immunosuppressive and immunomodulatory therapy did not produce the desired effect, and the condition progressed to retinochoroiditis. Due to blindness and dolorous glaucoma, enucleation of the right eye was performed at the age of 15 years. Histologically toxoplasmic cysts with bradyzoites were detected, a subsequent laboratory test demonstrated toxoplasmic etiology upon a background of persistent regressing hypogammaglobulinaemia. General anti-toxoplasma and subsequent immunosuppressive treatment did not produce the desired effect, and at the age of 22 years the patient lost his sight also in the left eye. CONCLUSION: Atypical form of OT intraocular neuritis in an immunocompetent patient had a favourable course, whereas retinal vasculitis with retinochoroiditis in a temporarily immunocompromised patient ended in bilateral blindness.

[Ocular toxoplasmosis in infants 0 to 12 months of age with congenital toxoplasmosis]. / Toxoplasmosis ocular en lactantes de 0 a 12 meses de edad con toxoplasmosis congénita.

BACKGROUND: Ocular toxoplasmosis (OT) is a retinochoroiditis that evolves with several episodes of inflammation and can occur both in the congenital or acquired form of the disease, Aim: To describe the frequency and clinical characteristics of OT in infants aged 0 to 12 months, children of mothers with positive serology for toxoplasmosis in the perinatal period. METHODS: Cross-sectional descriptive, ambispective study. RESULTS: Infants from 0 to 12 months of age, whose mothers had positive serology for toxoplasmosis in the perinatal period, referred to the pediatric ophthalmology service for evaluation, were admitted. Demographic variables, maternal and infant serology and the results of the ophthalmological examination were collected. Data were analyzed in SPSS v21 Results: 46.4% of 125 infants had OT, of them 67.2% were female, (p = 0.04) the median age was 6 months, 41% had IgG and IgM positive. The lesions were bilateral in 82.8%, central in 86.2%, and inactive in 81%. Retinochoroiditis was accompanied by strabismus in 41%. CONCLUSIONS: The frequency of OT in this population of infants with congenital toxoplasmosis was high. more than 80% of the eye lesions were inactive, centrally located and bilaterally involved.

Rate of recurrence of toxoplasmosis retinochoroiditis at a tertiary eye centre in Auckland.

AIM: Our aim was to examine rate of recurrence of toxoplasmosis retinochoroiditis and risk factors for recurrence. No New Zealand epidemiological data on recurrence rates of toxoplasmosis retinochoroiditis have been previously published. METHODS: Retrospective chart review of all patients with toxoplasmosis retinochoroiditis presented to Auckland District Health Board Department of Ophthalmology between 2006-2019. RESULTS: One hundred and twenty-six eyes of 115 patients were included with a median age at initial diagnosis of 36.7 years (IQR 23.7-53.8). Fifty-nine patients were female (51.3%), and 16 patients (13.9%) were immunosuppressed. Twenty-six of the 86 patients tested (30.2%) were IgM positive at presentation. Mean follow-up was 6.1 years and 73 recurrences occurred during the follow-up period in 36 patients (31.3%). Treatment was initiated in 87.4% of cases, with oral cotrimoxazole or clindamycin the most common options. Recurrence occurred in 14.8% in the first year (95% CI 10.3%-21.0%), and the risk of recurrence was increased 2x for every previously documented recurrence (HR 2.00; p<0.001). There was no statistically significant increased risk of recurrence with age, IgM positivity, immunosuppression or macular involvement. CONCLUSIONS: Toxoplasmosis retinochoroiditis had a 14.8% risk of recurrence in the first year, with each previous recurrence increasing the risk by two-times.

Toxoplasmosis ocular en lactantes de 0 a 12 meses de edad con toxoplasmosis congénita / Ocular toxoplasmosis in infants 0 to 12 months of age with congenital toxoplasmosis

INTRODUCCIÓN: La toxoplasmosis ocular (TO) es una retinocoroiditis que evoluciona con varios episodios de inflamación y puede presentarse, tanto en la forma congénita o adquirida de la enfermedad, OBJETIVO: Describir la frecuencia y características clínicas de la TO en lactantes de 0 a 12 meses, hijos de madres con serología positiva para toxoplasmosis en el periodo perinatal. METODOLOGÍA: Estudio descriptivo transversal, ambispectivo. Ingresaron lactantes de 0 a 12 meses de edad, cuyas madres tenían serología positiva para toxoplasmosis en el periodo perinatal, remitidos al servicio de oftalmología pediátrica para evaluación. Se recogieron variables demográficas, serología materna y de los lactantes, y los resultados del examen oftalmológico. Los datos fueron analizados en SPSS-v21. RESULTADOS: El 46,4% de 125 lactantes tenían TO, de ellos, 67,2% era de sexo femenino (p = 0,04), la mediana de edad fue de 6 meses, el 41% tenía IgG e IgM positiva. Las lesiones fueron bilaterales en 82,8%, central en 86,2%, e inactivas en 81%. La retinocoroiditis se acompañó de estrabismo en 41%. CONCLUSIONES: La frecuencia de TO en esta población de lactantes con toxoplasmosis congénita, fue elevada. Más de 80% de las lesiones oculares eran inactivas, de localización central y compromiso bilateral.

BACKGROUND: Ocular toxoplasmosis (OT) is a retinochoroiditis that evolves with several episodes of inflammation and can occur both in the congenital or acquired form of the disease, AIM: To describe the frequency and clinical characteristics of OT in infants aged 0 to 12 months, children of mothers with positive serology for toxoplasmosis in the perinatal period. METHODS: Cross-sectional descriptive, ambispective study. RESULTS: Infants from 0 to 12 months of age, whose mothers had positive serology for toxoplasmosis in the perinatal period, referred to the pediatric ophthalmology service for evaluation, were admitted. Demographic variables, maternal and infant serology and the results of the ophthalmological examination were collected. Data were analyzed in SPSS v21 RESULTS: 46.4% of 125 infants had OT, of them 67.2% were female, (p = 0.04) the median age was 6 months, 41% had IgG and IgM positive. The lesions were bilateral in 82.8%, central in 86.2%, and inactive in 81%. Retinochoroiditis was accompanied by strabismus in 41%. CONCLUSIONS: The frequency of OT in this population of infants with congenital toxoplasmosis was high. more than 80% of the eye lesions were inactive, centrally located and bilaterally involved.

Congenital ocular toxoplasmosis in consecutive siblings.

Toxoplasma gondii infection can cause ocular manifestations after acquired and congenital disease. We report two cases of symptomatic congenital toxoplasmosis with ocular involvement in non-twin siblings, with a 2-year interval between pregnancies. Vertical transmission of toxoplasmosis in successive pregnancies, which was once considered impossible, is now found to be plausible even in immunocompetent subjects.

Treatment of a full-thickness macular hole and retinal detachment secondary to toxoplasma chorioretinitis that developed shortly after COVID-19: A case report.

Although ocular toxoplasmosis is usually a self-limiting infection, it can lead to severe reduction in visual acuity due to intense vitreous inflammation or involvement of posterior segment structures. Depending on the severity of intraocular inflammation, serious complications, including epiretinal membrane or retinal detachment may develop. In this paper, we aim to present a case that complicated by both a full-thickness macular hole and retinal detachment secondary to toxoplasmosis chorioretinitis that developed shortly after the novel coronavirus disease (COVID-19) and discuss our treatment approach. After the patient was diagnosed based on a routine ophthalmological examination, fundus imaging, and serological examination, functional and anatomical recovery was achieved through systemic antibiotherapy and vitreoretinal surgery. Full-thickness macular hole and retinal detachment are rare complications of ocular toxoplasmosis. However, there are only few publications in the literature concerning these complications and their surgical treatment. In this case report, we demonstrated the success of vitreoretinal surgery combined with antibiotic therapy on the posterior segment complications of ocular toxoplasmosis.

Posterior segment findings by spectral-domain optical coherence tomography and clinical associations in active toxoplasmic retinochoroiditis.

Toxoplasmic retinochoroiditis is a common, potentially blinding parasitic infection. We sought to define the spectrum and frequency of signs of active toxoplasmic retinochoroiditis by spectral domain optical coherence tomography (SD-OCT), and to identify clinical associations. Ninety eyes of 90 individuals presenting consecutively to a tertiary referral uveitis service with active toxoplasmic retinochoroiditis and gradable SD-OCT scans were evaluated prospectively. SD-OCT features were collated, and associations with lesion location, primary versus recurrent episode, serological status, human immunodeficiency virus infection and best-corrected Snellen visual acuity were explored. Active toxoplasmic retinochoroiditis presented with thickened (65%) and hyperreflective (61%) retina, choroidal thickening (55%) and hyporeflectivity (61%), hyperreflective vitreous dots (80%) and deposits (36%), and posterior hyaloid thickening (35%) on SD-OCT. Most signs occurred with similar frequency across clinical groups. Retinal hyporeflectivity (17%) was significantly associated with a visual acuity of 20/200 or worse at resolution. Our observations demonstrate that active toxoplasmic retinochoroiditis has diverse SD-OCT signs and that none are universally present. Retinal hyporeflectivity-suggesting liquefactive necrosis-predicts poor visual outcome.

NEW OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY FINDINGS ON AN INTRARETINAL VASCULAR PROCESS SECONDARY TO TOXOPLASMA RETINOCHOROIDITIS: 2 CASE REPORTS.

BACKGROUND/PURPOSE: To determine which retinal layer is primarily involved in intraretinal vascular processes associated with Toxoplasma retinochoroiditis using multimodal imaging, including optical coherence tomography angiography (OCTA). METHODS: Toxoplasma retinal lesions were analyzed through multimodal imaging, including color fundus photographs, fluorescein angiography, indocyanine green angiography, spectral-domain OCT, and OCTA. RESULTS: Two patients with atypical features of Toxoplasma retinochoroiditis are described in the acute phase. The first patient presented with a primary episode of acute Toxoplasma retinitis associated with an intraretinal abnormal vascular process that was detected at the acute phase by indocyanine green angiography and was better delineated by OCTA. Seven months later, the intraretinal vascular process had fully resolved on OCTA imaging. The second patient presented with a recurrence of active Toxoplasma retinochoroiditis adjacent to a pre-existing pigmented scar. He had a similar abnormal intraretinal vascular process that was identified on both fluorescein angiography at the early phase and indocyanine green angiography, which was also confirmed by OCTA imaging. CONCLUSION: We report a new finding associated with Toxoplasma chorioretinitis: an abnormal intraretinal vascular process that resolved without anti-vascular endothelial growth factor therapy but after toxoplasmosis treatment alone.

Ocular Co-infection with Mycobacterium Tuberculosis and Toxoplasma Gondii in an Immunocompetent Patient - A Case Report.

PURPOSE: To report a case of ocular co-infection with Mycobacterium tuberculosis and Toxoplasma gondii in an immunocompetent woman. METHOD: Retrospective observational case report. RESULT: A 61-year-old woman presented with decreased vision and floaters in the right eye of 1-month duration. Ocular examination revealed panuveitis with a large yellowish-white retinochoroiditis lesion adjacent to a chorioretinal scar. Investigations showed positive Mantoux test, QuantiFERON TB test, and HRCT chest suggestive of active pulmonary tuberculosis. Serology revealed raised IgG anti T. gondii antibody. Vitreous aspirate was positive for M. tuberculosis and T. gondii genome by polymerase chain reaction and showed high IgG and IgM T. gondii antibodies. She was treated with anti toxoplasmic and antitubercular therapy along with oral corticosteroid and therapeutic vitrectomy. CONCLUSION: Ocular tuberculosis and toxoplasmosis can not only mimic each other but also present as co-infection in rare cases.