91-month follow-up of solitary punctate chorioretinitis in a Chinese patient.

BACKGROUND: Solitary Punctate Chorioretinitis (SPC) is a recently identified form of punctate inner choroidopathy (PIC) characterized by a single lesion in the fovea of the macula. Previous studies with a maximum follow-up of 48 months were insufficient. Our review uncovered a case sustained for 91 months. CASE PRESENTATION: A 28-year-old young woman experienced with sudden visual loss in her right eye. Comprehensive examinations, including assessment of best-corrected visual acuity (BCVA), slit-lamp biomicroscopy, noncontact tonometry, fundus fluorescein angiography (FFA), fundus autofluorescence (FAF), optical coherence tomography angiography (OCTA), perimetry, and microperimetry, were conducted. Over 91 months, the lesion slightly enlarged, remained yellow-white and punctate, and stayed in the central macula of the posterior pole. OCT images depicted subsidence in the inner nuclear layer (INL), the outer plexiform layer (OPL), photoreceptor layer, and disruption of the external limiting membrane (ELM), ellipsoid zone, and retinal pigment epithelium (RPE)/Bruch's membrane complex. Retinal herniation, focal choroidal excavation (FCE), and abnormal vessels in the choriocapillaris were noted. At the slab of the choriocapillaris, OCTA demonstrated that the lesion resembled a linear vascular structure, distinct from the structure of normal choriocapillaris. This confirmed the lesion as an abnormal vascular formation. FAF revealed a punctate hypo-autofluorescence lesion and abnormal hyper-autofluorescence near the optic disc and macula. FFA demonstrated a punctate hyper-fluorescent lesion inferotemporal to the fovea. The vascular structure remained stable without fluid exudation on OCT images, hence anti-vascular endothelial growth factor (anti-VEGF) treatment was not administered. Visual acuity improved from counting fingers to 0.07 in 52 days, reached 0.6 after 15 months, remained at 0.6 from 56 to 80 months, and returned to 0.8 after 91 months, although accompanied by local scotomas. The lesion pattern slightly enlarged without scarring. CONCLUSIONS: Throughout long-term follow-up, we had long suspected the presence of choroidal neovascularization (CNV) and found the FCE in the last visit. Eventually, we concluded that SPC could potentially constitute a distinct subtype of PIC. The patient received no treatment, and vision recovered to 0.8. If CNV is suspected in SPC, anti-VEGF treatment may not be necessary without activity on OCT, but close monitoring is essential.

Bilateral multifocal chorioretinitis as the only presentation of acute West Nile virus infection: a case report.

BACKGROUND: To describe a case of bilateral multifocal chorioretinitis as the only presentation of acute West Nile virus (WNV) infection in the absence of neurological involvement. CASE PRESENTATION: A 78-year-old Italian woman was admitted to our emergency department because she noticed blurry vision in both eyes. She did not report fever, fatigue, or neurological symptoms in the last few days. Multimodal imaging showed the presence of bilateral hyperfluorescent lesions with a linear distribution, that corresponded to hypocyanescent spots on indocyanine green angiography. Antibody serology showed the presence of IgM antibodies, IgG antibodies, and ribonucleic acid (RNA) for WNV. Magnetic resonance imaging (MRI) of the brain ruled out central nervous system involvement. Three months later, the patient reported spontaneous resolution of her symptoms and remission of the chorioretinal infiltrates. CONCLUSIONS: In endemic areas, it is important to think of acute WNV infection as an explanatory etiology in cases of multifocal chorioretinitis, even without neurological involvement.

Retinochoroiditis secondary to Rickettsia typhi infection: a case report.

BACKGROUND: To report a case of unusual presentation of retinochoroiditis caused by Rickettsia typhi in a patient without prior uveitis. CASE PRESENTATION: In this case, we describe a 24-year-old male soldier with no previous eye disease, who was referred to our ophthalmology department due to bilateral retinochoroiditis and vitritis. The patient initially presented with a paracentral scotoma in his right eye persisting for 7 days and scattered dark spots in his left eye for 2 days in June 2023. Preceding these ocular symptoms, he experienced a two-week episode of fever, headaches, night sweats, and rapid weight loss of 10 kg. A transient rash covered his body briefly. His mother had a history of recurrent eye inflammation. Physical examination revealed bilateral keratic precipitates on the lower corneal periphery, 1 + anterior vitreous cells, small retinal lesions and mild optic discs elevation. Fluorescein angiography indicated mild discs hyperfluorescence, and the clinically visible round punctate lesions on OCT showed inner retinal hyper-reflective lesion with a depth till outer plexiform layer possibly suggestive of a retinitis lesion. Laboratory tests were normal except thrombocytosis, elevated ESR, liver enzymes and ACE levels, with positive Rickettsia typhi serology tests. Rheumatology and infectious disease consultations ruled out autoimmune diseases, confirming Rickettsia typhi infection. Treatment included systemic doxycycline and prednisone, with improvement of visual acuity, ocular symptoms, OCT abnormalities and resolution of inflammation. Prednisone was discontinued, and after two months, additional improvement was seen clinically, with preserved retinal structures on OCT. CONCLUSION: This study explores retinochoroiditis as a rare ocular presentation of Rickettsia typhi, an unusual infection in the Middle East. Previously reported ocular manifestations include conjunctivitis, vitritis, post infectious optic neuropathy and a few cases of uveitis. Ocular symptoms followed systemic illness, highlighting the need for awareness among clinicians. Diagnosis relies on seroconversion, with fluorescein angiography and OCT aiding in assessment. Empiric doxycycline and systemic corticosteroid therapy is recommended. Ocular symptoms resolved in two months. Awareness of these ocular manifestations is essential for timely diagnosis and management. Further research is needed to fully understand this aspect of murine typhus.

Case series of neuroretinitis in Korea.

BACKGROUND: To present the clinical characteristics of neuroretinitis in Korea. METHODS: Twelve patients with neuroretinitis between January 2009 and September 2020 were retrospectively reviewed. Neuroretinitis was diagnosed based on fundus findings, optical coherence tomography, and fluorescein angiography. The serological findings of each patient were reviewed. RESULTS: Fifteen eyes of 12 patients (9 male and 3 female), with a mean age of 46.0 ± 10.7 years were included. Of the nine patients who underwent serological testing for Toxocara antibodies, six (66.6%) were positive. One patient had high titers of Toxoplasma immunoglobulins M and G. One patient diagnosed with dengue fever was suspected to have neuroretinitis in both eyes. There were no related abnormalities in the serological findings in four patients (33.3%) out of 12 patients. There were no suspected cases of cat-scratch disease. The six patients who were positive for Toxocara antibodies were older (mean age: 54.5 ± 9.1 years) than the others (mean age: 37.5 ± 4.4 years, p = 0.004). The four patients without any abnormal serological findings were relatively younger (mean age: 35.7 ± 3.0 years) than the other 8 patients (mean age: 51.1 ± 10.1 years, p = 0.008). CONCLUSIONS: Two-thirds of neuroretinitis patients were seropositive for Toxocara in the current cohort from Koreans. Causative factors in cases of neuroretinitis may vary according to age and region.

Retina-arrestin specific CD8+ T cells are not implicated in HLA-A29-positive birdshot chorioretinitis.

BACKGROUND: HLA-A29-positive birdshot chorioretinitis (BCR) is an inflammatory eye disorder that is generally assumed to be caused by an autoimmune response to HLA-A29-presented peptides from retinal arrestin (SAG), yet the epitopes recognized by CD8+ T cells from patients remain to be identified. OBJECTIVES: The identification of natural ligands of SAG presented by HLA-A29. To quantify CD8+ T cells reactive to antigenic SAG peptides presented by HLA-A29 in patients and controls. METHODS: We performed mass-spectrometry based immunopeptidomics of HLA-A29 of antigen-presenting cell lines from patients engineered to express SAG. MHC-I Dextramer technology was utilised to determine expansion of antigen-specific CD8+ T cells reactive to SAG peptides in complex with HLA-A29 in a cohort of BCR patients, HLA-A29-positive controls, and HLA-A29-negative controls. RESULTS: We report on the naturally presented antigenic SAG peptides identified by sequencing the HLA-A29 immunopeptidome of antigen-presenting cells of patients. We show that the N-terminally extended SAG peptide precursors can be trimmed in vitro by the antigen-processing aminopeptidases ERAP1 and ERAP2. Unexpectedly, no enhanced antigen engagement by CD8+ T cells upon stimulation with SAG peptides was observed in patients or HLA-A29-positive controls. Multiplexed HLA-A29-peptide dextramer profiling of a case-control cohort revealed that CD8+ T cells specific for these SAG peptides were neither detectable in peripheral blood nor in eye biopsies of patients. CONCLUSIONS: Collectively, these findings demonstrate that SAG is not a CD8+ T cell autoantigen and sharply contrast the paradigm in the pathogenesis of BCR. Therefore, the mechanism by which HLA-A29 is associated with BCR does not involve SAG.

Routine ophthalmologic examination in Klebsiella pneumoniae bacteremia is not necessary: incidence of and risk factors for ocular involvement.

Klebsiella pneumoniae bacteremia is known to present a virulent clinical course, including multiple metastatic infections, which is not uncommon in Asia. However, there are limited data on the incidence and risk factors for ocular involvement in K. pneumoniae bacteremia. We retrospectively reviewed the medical records of all patients with K. pneumoniae bacteremia who underwent ophthalmologic examination in a tertiary center in Seoul, Korea, from February 2012 to December 2020. Two retinal specialists reviewed the findings of the ophthalmologic examinations and classified them as endophthalmitis, chorioretinitis, and no ocular involvement. Of 689 patients, 56 [8.1%; 95% confidence interval (CI) 6.2-10.4] had ocular involvement, and 9 (1.3%; 95% CI 0.6-2.5) were diagnosed with endophthalmitis. Of 47 patients with chorioretinitis, 45 (95.7%) improved with systemic antibiotic therapy alone. Community-onset bacteremia (100% vs 62.1% vs 57.4%, P = 0.04), cryptogenic liver abscess (55.6% vs 11.8% vs 8.5%, P = 0.003), and metastatic infection (66.7% vs 5.8% vs 10.6%, P < 0.001) were more common in endophthalmitis than in no ocular involvement or chorioretinitis. In the multivariable analysis, cryptogenic liver abscess [adjusted odds ratio (aOR), 6.63; 95% CI 1.44-35.20] and metastatic infection (aOR, 17.52; 95% CI 3.69-96.93) were independent risk factors for endophthalmitis. Endophthalmitis was not associated with 30-day mortality. Endophthalmitis is rare in Asian patients with K. pneumoniae bacteremia. Targeted ophthalmologic examination in those with cryptogenic liver abscess, metastatic infection, or ocular symptoms may be more appropriate than routine examination of all patients.

Acquired Ocular Toxoplasmosis: a Case Report and Review of the Literature.

BACKGROUND: Toxoplasmosis is a zoonotic illness caused by Toxoplasma gondii. Ocular infection frequently manifests as acute necrotizing retinal chorioretinitis. In this paper, we describe a case of retinal chorioretinitis caused by Toxoplasma gondii infection, as well as the most recent diagnostic and treatment techniques. METHODS: Serum and vitreous fluid were collected and analyzed, and PCR for Toxoplasma gondii DNA, ELISA for Toxoplasma gondii IgG and Goldmann-Witmer coefficient, fundus fluorescein angiography (FFA), indocyanine green angiography (ICGA), and fundus autofluorescence were done (FAF). RESULTS: Toxoplasma gondii DNA (-), serum and vitreous IgG from Toxoplasma gondii (+) cells, and the Goldmann-Witmer coefficient of Toxoplasma gondii were all considerably enhanced, indicating Toxoplasma gondii infection. Antiparasitic infection in combination with an anti-inflammatory glucocorticoid were given, laser treatment of the fundus was provided, and the patient's condition has been stable with no indication of recurrence to date following conclusion of therapy. CONCLUSIONS: Toxoplasma gondii can infect the whole retina, causing variable degrees of visual impairment; thus, rapid diagnosis and tailored therapy are necessary to enhance prognosis and reduce disease recurrence.

SOLITARY PUNCTATE CHORIORETINITIS: A Unique Subtype of Punctate Inner Choroidopathy.

PURPOSE: To describe a case series of a special subtype of punctate inner choroidopathy with solitary lesions in the macular area and named solitary punctate chorioretinitis. METHODS: This retrospective observational study clinically evaluated 12 eyes from 12 patients diagnosed as punctate inner choroidopathy with solitary lesions. Demographic data and multimodal imaging features were analyzed for the included patients. RESULTS: All the included patients were Chinese and of Han ethnicity. The median age of the included patients was 29.5 years (range: 25-40 years). Most patients (11/12, 91.67%) were myopic, with median refraction errors of -4.4 diopters (D) (range: -8.5 to 0 D). Solitary chorioretinitis lesions were yellow‒white and appeared hyperfluorescent during the entire phase of fundus fluorescein angiography without leakage (9/12, 75%) and hypofluorescent on indocyanine green angiography (11/11, 100%). On spectral domain optical coherence tomography, active inflammatory lesions appeared as isolated, heterogeneous, moderately reflective material at the outer retina (10/12, 83.33%) in the fovea or parafoveal region with disruption of the outer retinal layers. When the inflammatory lesions regressed, the moderately reflective materials in the outer retina were absorbed or regressed with outer retinal tissue loss. Additional sequelae of lesion regression included focal choroidal excavation and intraretinal cystoid space. Secondary choroidal neovascularization was noticed in 2 eyes (2/12, 16.67%). CONCLUSION: Solitary punctate chorioretinitis is a rare and unique subtype of punctate inner choroidopathy. Solitary punctate chorioretinitis may also be an unrecognized etiology of some forms of focal choroidal excavation and idiopathic choroidal neovascularization.

HISTOPATHOLOGIC CONFIRMATION OF LYMPHOCYTIC INFILTRATION OF THE OPTIC NERVE AND INNER RETINA IN BIRDSHOT CHORIORETINOPATHY.

PURPOSE: To describe new histological findings involving the inner retina in birdshot chorioretinopathy. METHODS: Evaluation of the inner retinal pathology of the eye of a patient with bilateral birdshot chorioretinopathy who underwent enucleation for a unilateral ciliochoroidal melanoma. RESULTS: Histopathological sections showed focal perivascular lymphocytic infiltration at the optic nerve head that extended into the adjacent inner retina, mainly involving the ganglion and nerve fiber layers. CONCLUSION: We have previously shown that birdshot chorioretinopathy has multiple foci of lymphocytes in the choroid. This is the first report that demonstrates lymphocytic infiltration of the inner retinal layers. This may lead to the bipolar and Müller cell dysfunction that ultimately results in an electronegative electroretinogram.

PERIPHERAL EXUDATIVE HEMORRHAGIC CHORIORETINOPATHY IN ASIAN POPULATIONS.

PURPOSE: Peripheral exudative hemorrhagic chorioretinopathy (PEHCR) is a rare degenerative disease that affects the peripheral retina. Reports of PEHCR in Asian patients are rare. Thus, the aim of this study was to investigate the clinical characteristics and outcomes of PEHCR in Asian patients. METHODS: A retrospective chart review of 33 eyes of 29 Asian patients with PEHCR. RESULTS: The mean age of the patients was 70 years, and 75.9% of them were women. Vitreous hemorrhage occurred in 51.5% of eyes during a mean follow-up of 43.1 months. The occurrence of vitreous hemorrhage was associated with a thicker baseline subfoveal choroid ( P = 0.001) and the male sex ( P = 0.005). Final visual acuity was less than 20/200 in 29.2% of eyes. The predictive factors for a final visual acuity worse than 20/200 included poor initial visual acuity ( P = 0.002), initial lesion involvement of more than 180° of the peripheral retina ( P = 0.03), an extension of subretinal hemorrhage to the macula ( P = 0.040), and absence of complete tumor regression ( P = 0.02). CONCLUSION: Asian PEHCR patients seem to be more frequently associated with vitreous hemorrhages, especially in male patients with thicker choroids. Although PEHCR was largely self-limiting, approximately one-third of the eyes ended up with a visual acuity of less than 20/200 with extensive lesion involvement.

Cat-scratch disease manifesting as uveitis and binocular fundus nodular lesions: a case report.

BACKGROUND: Cat-scratch disease typically presents with various ocular manifestations such as uveitis, vitritis, retinitis, retinochoroiditis, and optic neuritis. However, fundus nodular lesions was rarely reported. In our study, we reported a case of Cat-Scratch disease with binocular fundus nodular lesions. CASE PRESENTATION: An 11-year old male presented with uveitis in the right eye and bilateral fundus nodular lesions after indirect contact with unvaccinated cats. Comprehensive ancillary examinations including wide-angle fundus photography, ultrasonography, fluorescein fundus angiography, optical coherence tomography, and orbital magnetic resonance imaging were performed to elucidate the multidimensional features of the binocular lesions. Metagenomics next-generation sequencing was utilized to confirm the diagnosis of Cat-scratch disease. The patient's condition showed improvement after a 6-month combination treatment regimen involving systemic administration of doxycycline hyclate and methylprednisolone tablets, as well as local application of mydriatic and corticosteroid eye drops. CONCLUSIONS: We firstly reported a case of Cat-scratch disease presenting simultaneously with uveitis and fundus nodular lesions caused by Bartonella henselae infection in a child. Timely diagnosis and treatment with antibiotics and corticosteroids showed promising outcomes for the prognosis of these ocular disorders.

Incidental multiple myeloma in a patient with neuroretinitis: a case report.

BACKGROUND: Neuroretinitis is classically defined as a clinical triad of unilateral, painless vision loss, accompanied by optic disc edema and characteristic macular star formation. The causes of neuroretinitis can be categorized as infectious, non-infectious, and idiopathic, therefore differential diagnosis and careful evaluation are required, owing to the various etiologies and masqueraders. CASE PRESENTATION: A 54-year-old woman presented to the clinic with blurred vision in both eyes. A complete ophthalmic examination revealed optic disc edema with blurred margins and macular exudates, intraretinal edema in the temporal peripapillary area, and subretinal fluid with neurosensory retinal detachment in the macular area. Systemic laboratory investigations showed no signs of infection or inflammation. However, bone marrow suppression was suspected based on the results of the complete blood count test, and the patient was diagnosed with multiple myeloma. CONCLUSION: Although neuroretinitis is rarely accompanied by hematological malignancy, it is important to be mindful of the latter because ophthalmic manifestations are a common feature of hematological malignancies and lesions occur in nearly every ocular structure.

Case Report: Multimode Imaging of Chronic Syphilitic Chorioretinitis.

SIGNIFICANCE: The clinical manifestations of ocular syphilis may mimic those of other diseases, which may result in a missed diagnosis and delayed treatment. PURPOSE: We describe multimodal imaging findings and treatment outcomes of a patient with chronic syphilitic chorioretinitis. CASE REPORT: A 40-year-old male patient complained of progressive decreased visual acuity of his left eye for more than 1 year. The best-corrected visual acuity was 20/20 in the right eye and 3/50 in the left eye. Relative afferent pupillary defect and 1+ vitreous cells were detected in the left eye. The authors performed fundus examination, fluorescence angiography, ultrawide-field fundus autofluorescence, structure optical coherence tomography, wide-field montage optical coherence tomography angiography, and visual field. Laboratory tests including a toluidine red unheated serum test (1:32) and the Treponema pallidum antibody (9.01S/CO) showed positive results. Chronic syphilitic chorioretinitis was diagnosed in both eyes. The patient was admitted for administration of intravenous penicillin G for 14 days, followed by intramuscular benzathine penicillin G weekly for three doses. Six months after treatment, the toluidine red unheated serum test ratio had decreased to 1:2 (positive). The best-corrected visual acuity was 20/20 in the right eye and 6/20 in the left eye. The reexamination results showed that the ocular structure and capillaris flow partially recovered. CONCLUSIONS: Chronic syphilitic chorioretinitis profoundly affects the structure of the retina and choroid; however, eyes may partially recover after an effective treatment. Ultrawide-field imaging technology has several advantages, such as broader imaging field and more details provided, in determining syphilis-induced ocular disorders.

Spectral-domain optical coherence tomography biomarkers in vitreoretinal lymphoma.

BACKGROUND: Although early detection is critical, diagnosing vitreoretinal lymphoma (VRL) remains difficult. We sought to assess the potential diagnostic value of spectral-domain optical coherence tomography (SD-OCT) in VRL. METHODS: We reviewed the clinical records and pre-treatment SD-OCT images of biopsy-confirmed VRL and uveitis patients, with primary involvement of the sub-retinal pigment epithelium (RPE) and the outer retina, including acute syphilitic posterior placoid chorioretinitis (ASPPC), chronic stage sympathetic ophthalmitis (SO), and idiopathic multifocal choroiditis (MFC). RESULTS: We included 45 eyes of 45 VRL patients and 40 eyes of 40 uveitis patients (17 ASPPC eyes, eight chronic SO eyes, and 15 MFC eyes). On SD-OCT, lymphoma cell infiltration was observed in various retinal layers, most commonly in the sub-RPE (80%) and sub-retinal space (62%). Highly sensitive features for VRL as compared to uveitis included vitreous cells (93%), focal hyper-reflective sub-retinal infiltration (51%), and diffuse RPE elevations (56%). The features strongly specific for VRL included preretinal deposits (92.5%), intra-retinal infiltration (except the incomplete vertical hyper-reflective type, 100%), banded hyper-reflective sub-retinal infiltration (90%), and confluent RPE detachments (100%). We identified an approach to VRL diagnosis based on these SD-OCT findings: (1) two highly sensitive features plus one strongly specific feature; or (2) one highly sensitive feature plus two strongly specific features, demonstrated a sensitivity of 80% and specificity of 95% for VRL. CONCLUSIONS: The SD-OCT may enable the detection of detailed lymphoma infiltration characteristics and provide significant supplemental value for VRL diagnosis, particularly when combining highly sensitive and specific VRL-associated SD-OCT features.

Ocular syphilis on the rise: a 10-year analysis from 2010 to 2020.

PURPOSE: The purpose of the study was to evaluate the incidence of ocular syphilis as well as diagnostic parameters, comorbidities, and visual outcomes over a 10-year time period in West Virginia. METHODS: A retrospective chart review included 25 eyes of 17 patients with ocular syphilis between 2010 and 2020. RESULTS: The incidence of systemic syphilis at a large tertiary referral center has increased from 27 cases in 2010 to 105 cases in 2020. Seventeen patients were identified with ocular syphilis. Bilaterality was present in 47.1% of cases. In this study, 70.6% of patients were male and 29.4% were female. The median age of presentation was 40.2 years (range 21-63). Panuveitis was the most common (60.0%) followed by isolated anterior uveitis (16.0%), chorioretinitis (12.0%), inner retinitis (4.0%), and papillitis (8.0%). Forty percent of patients had visual acuity worse than 20/400 on presentation. Post-treatment visual acuity improved in all patients. Rapid plasma reagin (RPR) and Treponema pallidum particle agglutination (TP-PA) tests were positive in 84.6% and 100% of cases, respectively. CSF venereal disease research laboratory (VDRL) was positive in 36.4%, CSF pleocytosis was present in 72.7%, and elevated CSF protein was observed in 81.8%. Human immunodeficiency virus (HIV) co-infection was present in 31.3%. A majority of patients experienced maculopapular rash and/or history of genital chancre. The anatomic classification of presenting uveitis (anterior, intermediate, posterior, and panuveitis) did not correlate with clinical variables including age, gender, HIV status, serologic test, presence of rash, or year of diagnosis (p > 0.05). CONCLUSION: Ocular syphilis is becoming increasingly prevalent and can present with a variety of ocular findings; therefore, it should be considered in the differential diagnosis for patients with ocular inflammation. Visual prognosis is excellent with timely diagnosis and treatment.

BILATERAL SERPIGINOUS-LIKE CHORIORETINITIS ASSOCIATED WITH CILIOCHOROIDAL MELANOMA: A Clinicopathologic Correlation.

PURPOSE: To report the clinicopathologic correlation of a case of bilateral serpiginous-like chorioretinitis (SLC) associated with unilateral ciliochoroidal melanoma. METHODS: A 71-year-old white woman was diagnosed with progressive SLC in both eyes associated with ciliochoroidal melanoma in the right eye. Clinical findings and imaging before and after enucleation in the right eye were correlated to histologic and immunohistochemistry sections. RESULTS: Examination and imaging identified a peripheral bilobed amelanotic lesion with low reflectivity on B-scan ultrasound with an associated exudative detachment in the right eye. Additionally, multiple areas of new SLC lesions in the macula and peripapillary region in the right eye and along the inferior arcade in the left eye were observed. Oncologic evaluation confirmed a Class 2, ciliochoroidal melanoma, and the eye was enucleated. Autoimmune and infectious laboratory evaluations for the etiology of the SLC lesions were negative. Histopathology of the enucleated eye confirmed the diagnosis of uveal melanoma with lymphocytic inflammation at the edges of the tumor itself and in the areas of discrete SLC lesions. Immunohistochemistry identified similar predominantly CD3 and CD8 T cells and fewer CD20 B cells in both regions. CONCLUSION: Serpiginous-like chorioretinitis may present as a paraneoplastic, predominantly T-lymphocyte inflammation associated with intraocular tumor such as uveal melanoma.

Mycobacterium chimaera chorioretinitis preceding central nervous system lesions: a case report and review of the literature.

BACKGROUND: Mycobacterium chimaera ocular infection is a rare disease that is linked to bypass devices used during cardiothoracic surgeries. Reported cases in the literature of ocular involvement preceding CNS involvement are based on clinical exam with no neuroimaging. Here we present a case of M. chimaera ocular infection with no CNS M. chimaera lesions on brain magnetic resonance imaging (MRI). CASE PRESENTATION: A 59-year-old female presented with altered mental status and blurred vision in February 2021. Her past medical history was significant for aortic valve replacement and ascending aortic aneurysm repair in 2017 complicated by known M. chimaera infection. She had been receiving azithromycin, ethambutol, rifampin, and amikacin as systemic anti-mycobacterium treatment. Her dilated fundus exam showed numerous yellow placoid circular lesions scattered throughout the macula and peripheral retina in both eyes with associated vitritis. Systemic workup, including brain MRI showed no acute infectious lesions. Her infections workup was unremarkable except for a positive toxoplasma IgM, for which she was treated with sulfamethoxazole/trimethoprim. One month later, a head computed tomography showed new numerous scattered round foci of hyperdensity throughout the cerebrum and brainstem thought to be foci of M. chimaera infection. Clofazimine was added per culture and sensitivity. MRI brain 1 month later showed mild decrease in conspicuity and number of these intensities while on anti-mycobacterium treatment. Her cognition had improved at that time as well. She was seen in retina clinic 2 months later where her exam showed similar retinal lesions with no associated vitritis or anterior chamber cell in bilateral eyes, suggesting a lack of active infection. Optical coherence tomography macula showed parafoveal cystoid macular edema bilaterally. She was started on steroidal and non-steroidal anti-inflammatory eye drops. CONCLUSIONS: To the best of our knowledge, this is the first case in the literature to report M. chimaera chorioretinitis with concomitant negative neuroimaging. Chorioretinal M. chimaera lesions should motivate high suspicion of CNS involvement prompting early neurological work up.

A case report of isolated primary herpes-simplex virus neuroretinitis in an immunocompetent adult.

BACKGROUND: Herpes simplex virus (specifically HSV-1 and HSV-2) are greatly prevalent viruses that can cause conjunctivitis, keratitis and other rarer ocular disorders such as acute retinal necrosis syndrome or neuroretinitis. We report a case of an isolated unilateral neuroretinitis with primary HSV infection in an immunocompetent adult without other related clinical features. CASE PRESENTATION: A 60-year-old immunocompetent woman presented with sudden painless central vision loss in her left eye (best corrected visual acuity was 20/200) showing optic disc edema, submacular fluid and a delayed development of a macular star. The macular optical coherence tomography (OCT) showed a serous retinal detachment. Arterial hypertension or exposure to ionizing radiation were ruled out and the microbiological blood test battery was only positive for immunoglobulin M (IgM) for HSV-1 which allowed etiological treatment with oral valacyclovir. Complete resolution and good visual results were found within 3 months. CONCLUSIONS: The present case of isolated neuroretinitis as a primary HSV infection in an immunocompetent patient was resolved with good functional results after valacyclovir treatment. Presence of HSV IgM in absence of other laboratory results could be enough evidence to start HSV treatment in immunocompetent patients with a macular star, as an isolated lesion, after ruling out other non-infectious causes, such as arterial hypertension or exposure to ionizing radiation. Rare infectious agents in immunocompetent patients must be considered in the differential diagnosis of neuroretinitis, even if there are no other typical symptoms or signs that could suggest the disease.

Case Report: Choriocapillaris Flow Voids in Acute Syphilitic Posterior Placoid Chorioretinitis.

SIGNIFICANCE: Acute syphilitic posterior placoid chorioretinitis (ASPPC) is a rare clinical presentation of ocular syphilis. The worldwide incidence of syphilis has recently increased. Clinicians should be familiar with the distinct appearance and imaging findings of ASPPC and promptly initiate antibiotic treatment to limit functional vision loss and systemic complications of neurosyphilis. PURPOSE: This case demonstrates the utility of optical coherence tomography angiography (OCT-A) imaging to further understand the pathophysiology and visual prognosis of ASPPC. CASE REPORT: A 75-year-old man presented with 7 days of decreased vision in his left eye. His visual acuity was 20/20 in the right eye and 20/200 in the left eye. Fundus examination revealed placoid lesions in the superior and inferotemporal aspects of the posterior pole in the right eye and a large placoid macular lesion in the left eye. Optical coherence tomography imaging revealed disruption and loss of the ellipsoid zone and external limiting membrane, nodular elevations on the retinal pigment epithelium, and choroidal hyperreflective punctate lesions in the left eye. Optical coherence tomography angiography displayed choriocapillaris perfusion flow voids greater in the left eye than in the right eye. Two months after penicillin treatment, the placoid lesions resolved in both eyes with an improvement in outer retinal structural abnormalities on optical coherence tomography imaging and visual acuity to 20/25 in the left eye. Eleven months after presentation, the OCT-A choriocapillaris flow voids had improved without complete restoration. CONCLUSIONS: The flow voids seen on OCT-A imaging in this case of ASPPC suggest a possible inflammatory process with a primary location in the choriocapillaris.

Case Report: Treatment of Severe Neuroretinitis and other Sequelae Associated with Cat Scratch Disease.

SIGNIFICANCE: Severe vision loss from Bartonella neuroretinitis can be best treated to improve visual outcomes with a combination of systemic corticosteroids and antibiotics. Topical ketorolac 0.5% and difluprednate 0.05% are presented as a new adjunct therapy to potentially improve visual outcomes. PURPOSE: This case illustrates severe posterior pole complications that can occur with cat scratch disease disseminated to the eye. Combination therapy with antibiotics and corticosteroids results in better visual outcomes. Topical treatment might further enhance visual outcome by preventing inflammatory damage without significant immunosuppression. CASE REPORT: A 17-year-old male teenager presented with right eye vision loss. He had been hospitalized 2 weeks prior for optic neuritis and treated with intravenous methylprednisolone. After 3 days, vision had improved from 20/200 to 20/40. After positive serology for Bartonella henselae was obtained, he was released and treated with oral rifampin, doxycycline, and prednisone. Sixteen days later, he regressed to 20/200, and many more ophthalmic complications were observed. After discontinuation of rifampin, oral prednisone was continued for an additional 2 weeks, and doxycycline was continued for approximately 3 weeks. Topical drops ketorolac 0.5% twice a day and difluprednate 0.05% four times a day were used for more than 6 weeks before tapering after vision returned to normal. CONCLUSIONS: Bartonella neuroretinitis associated with pre-retinal hemorrhage, vitritis, and subretinal hemorrhage can be successfully treated with a combination of systemic medications and topical drops. Monotherapy with doxycycline is effective and well tolerated. Rifampin can cause rapid metabolization and reduction in plasma levels of both prednisone and doxycycline and should be avoided with combined therapy. Oral prednisone and topical difluprednate are recommended to quell initial inflammation during the first few weeks. The anti-inflammatory effects of doxycycline and topical ketorolac used for longer duration may be beneficial in preventing tissue damage without systemic immunosuppression and result in better visual outcomes.