Driving in Fog without Headlight: Management of a Challenging Case of Presumed Ocular Toxoplasmosis.

Purpose: To describe a case of presumed ocular toxoplasmosis.Method: A retrospective chart review.Result: This case report describes a 35-year-old male who presented hypopyon anterior uveitis in his left eye. Fundus examination revealed severe vitritis which precluded the view of retina. His serum anti-toxoplasma immunoglobulin (Ig)G was significantly raised, with a normal anti-toxoplasma IgM level and PCR from nested primers targeting B1 gene of Toxoplasma gondii was positive. He was started on empirical anti-toxoplasma therapy. Undiluted vitreous specimen collected during lensectomy and diagnostic vitrectomy in left eye was also positive for nested primers targeting B1 gene of T. gondii.Conclusion: Ocular toxoplasmosis without retinochoroiditis, though extremely rare, can occur.

Multiplex Solid-Phase Real-Time Polymerase Chain Reaction without DNA Extraction: A Rapid Intraoperative Diagnosis Using Microvolumes.

PURPOSE: Current polymerase chain reaction (PCR) methods for the diagnosis of infections are time consuming and require large sample volume and skilled technicians. We developed a novel, easy-to-use, and rapid (processing time, 1 minute; total time, 33 minutes) multiplex real-time PCR test (Direct Strip PCR) that did not require DNA extraction to detect 9 pathogens that could cause uveitis in 20-µl samples. DESIGN: Multicenter prospective evaluation of a diagnostic PCR test. PARTICIPANTS: A total of 511 participants (patients with infectious uveitis and controls) were examined at 18 institutes worldwide. METHODS: After validation, intraocular fluid samples were subjected to etiologic or exclusive diagnosis, including intraoperative rapid diagnosis. MAIN OUTCOME MEASURES: The concordance and correlations between Direct Strip PCR and quantitative PCR (qPCR) results. RESULTS: Direct Strip PCR exhibited rapid detection, good repeatability and specificity, long storage stability, and detection ability equal to that of qPCR. It also showed low interinstitutional variability compared with qPCR, even when PCR beginners used various real-time PCR machines. The Direct Strip PCR for 9 pathogens exhibited high concordance against the qPCR (positive concordance rate, 98.8%-100%; negative concordance rate, 99.8%-100%; κ coefficient, 0.969-1.000; P < 0.001-0.031). Additionally, results obtained using Direct Strip PCR and qPCR were highly correlated (ρ = 0.748; P < 0.001). This assay was used for rapid intraoperative diagnosis. CONCLUSIONS: The Direct Strip PCR test may improve the prognosis of various infectious diseases because it facilitates rapid etiologic evaluation at the first hospital visit and can be used for intraoperative diagnosis.

Extensive Chorio-retinal Damage Due to Dirofilaria Repens- Report of a Case.

Purpose: To report a case of ocular dirofilariasis causing extensive chorio-retinal damage.Method: Surgical removal of the worm and identification of the same by microscopic examinationand polymerase chain reaction.Results: The worm was identified as Dirofilaria repens.Conclusion: Ocular dirofilariasis is an arthropod borne parasitic infestation affecting the subconjunctival tissue and anterior chamber. Vitreous involvement in Dirofilaria is very rare. Dirofilaria repens can cause extensive chorio-retinal damage resembling diffuse unilateralsubacute neuroretinitis.

Usefulness of aqueous and vitreous humor analysis in infectious uveitis.

OBJECTIVE: To evaluate the role of intraocular fluid analysis as a diagnostic aid for uveitis. METHODS: Twenty-eight samples (27 patients including 3 HIV-infected patients) with active (n=24) or non-active (n=4) uveitis were submitted to aqueous (AH; n=12) or vitreous humor (VH) analysis (n=16). All samples were analyzed by quantitative PCR for herpes simplex virus (HSV), varicella zoster virus (VZV), cytomegalovirus (CMV), Epstein-Barr virus (EBV) and Toxoplasma gondii. RESULTS: The positivity of the PCR in AH was 41.7% (5/12), with 50% (2/4) in immunocompetent and 67% (2/3) in HIV+ patients. The positivity of the PCR in VH was 31.2% (5/16), with 13% (1/8) in immunocompetent and 50% (4/8) in immunosuppressed HIV negative patients. The analysis was a determinant in the diagnostic definition in 58% of HA and 50% of VH. CONCLUSION: Even in posterior uveitis, initial AH analysis may be helpful. A careful formulation of possible clinical diagnosis seems to increase the chance of intraocular sample analysis being meaningful.

Clinical and Histopathological Evaluation of a Rabbit Model for Pythium insidiosum Keratitis.

Purpose: To describe the clinical characteristics and histopathological features in a rabbit model of Pythium insidiosum keratitis.Methods: Zoospores of P. insidiosum isolated from a patient with microbial keratitis were used for inoculation of the right eye of 48 New Zealand White rabbits in either low (LD) or high dose (HD). Apart from variable dosage the rabbits were grouped (6 rabbits per group) based on route of inoculation (topical on abraded cornea or intracorneal) and immunosuppression (subconjunctival steroid or no steroid). Left eye received phosphate buffered saline via route similar to the right eye. Daily clinical examination of the eye was done, the corneas were harvested on day 3, 7 and 9 and part of the cornea was preserved in 10% neutral buffered formalin for histopathological examination.Results: Left eye of all rabbits were clinically normal. Eyes with intracorneal injection of zoospores developed infection irrespective of dose of inoculation and administration of steroids. One of the consistent early signs of infection was ring like infiltrate in the peripheral cornea. On day 2, rabbits receiving HD developed significantly greater inflammation compared to LD [median clinical score in HD- 11 (IQR = 10-12), versus 9 (IQR = 8-9) in LD (p = 0.004)]. The density of inflammation showed temporal correlation (increase with time) when the inoculum was low. Of the rabbits that received topical inoculation one rabbit cornea showed mild infiltrate in steroid group while no eye was infected in the group without steroid. Sparsely septate to aseptate branching filaments were noted in the stroma of all infected corneas.Conclusions: We describe the first animal model of Pythium keratitis that holds promise for future studies. While topical inoculation of zoospores was unsuccessful in causing infection intracorneal inoculation without immunosuppression was sufficient to develop clinically severe keratitis in rabbits.

Usefulness of aqueous and vitreous humor analysis in infectious uveitis

OBJECTIVE: To evaluate the role of intraocular fluid analysis as a diagnostic aid for uveitis. METHODS: Twenty-eight samples (27 patients including 3 HIV-infected patients) with active (n=24) or non-active (n=4) uveitis were submitted to aqueous (AH; n=12) or vitreous humor (VH) analysis (n=16). All samples were analyzed by quantitative PCR for herpes simplex virus (HSV), varicella zoster virus (VZV), cytomegalovirus (CMV), Epstein-Barr virus (EBV) and Toxoplasma gondii. RESULTS: The positivity of the PCR in AH was 41.7% (5/12), with 50% (2/4) in immunocompetent and 67% (2/3) in HIV+ patients. The positivity of the PCR in VH was 31.2% (5/16), with 13% (1/8) in immunocompetent and 50% (4/8) in immunosuppressed HIV negative patients. The analysis was a determinant in the diagnostic definition in 58% of HA and 50% of VH. CONCLUSION: Even in posterior uveitis, initial AH analysis may be helpful. A careful formulation of possible clinical diagnosis seems to increase the chance of intraocular sample analysis being meaningful.

Rare cause of floaters: A motile live worm in vitreous cavity.

Ocular filariasis commonly presents as subconjunctival or eyelid nodules. We report a rare case of a live, motile worm causing floaters. The worm was isolated from the vitreous cavity and revealed to be Dirofilaria repens. Correct recognition of the worm is necessary as human dirofilariasis does not present as microfilaremia and does not require systemic therapy; in contrast to other causes of ocular filariasis, which require systemic therapy. As ophthalmologist may be the first physician to encounter such patients, a high index of suspicion is required for timely and adequate management.

Assessing the Taxonomic Validity of Austrodiplostomum SPP. (Digenea: Diplostomidae) Through Nuclear and Mitochondrial Data.

Adults of the genus Austrodiplostomum are parasites in cormorants of the New World, whereas metacercariae are parasites from eye globe and brain of freshwater and brackish water fishes. In this study, specimens of Austrodiplostomum mordax from South America (type-species) were analyzed together with other specimens of Austrodiplostomum spp. collected from several locations across Middle America and North America. Partial DNA sequences of the mitochondrial gene cytochrome c oxidase subunit I ( COI), the internal transcribed spacers ( ITS1, ITS2, and 5.8S gene), and the D2-D3, domains of the large subunit ( LSU) of nuclear ribosomal DNA, were generated for both developmental stages and compared with available sequences of Austrodiplostomum spp. Phylogenetic analyses inferred with each molecular marker using maximum likelihood and Bayesian inference revealed the existence of 4 lineages representing 2 described species, A. mordax and Austrodiplostomum compactum (syn. Austrodiplostomum ostrowskiae) and 2 undescribed species of Austrodiplostomum recognized in previous studies. The COI haplotype network inferred with 172 sequences detected 28 haplotypes divided into 4 clusters, separating each other by 33 and 40 substitutions and with a genetic divergence ranging from 9 to 12%. The largest group included specimens identified as A. compactum plus those identified as A. ostrowskiae, supporting the synonymy of both species. As a result, we conclude that A. compactum is widely distributed across the Americas, in locations of the United States, Mexico, El Salvador, Honduras, Costa Rica, Venezuela, Peru, and Brazil. The other 2 undescribed species of the genus Austrodiplostomum were previously recorded in the United States and now are reported in Mexico. These 2 species cannot be described because adult forms have not been found in their definitive hosts. Finally, the species A. mordax has been found only in some lakes from Argentina, and it was validated in this study through molecular analyses.

Intravitreal Angiostrongylus cantonensis: first case report in South America.

This study reports the first case of intravitreal angiostrongyliasis in South America treated with posterior worm removal via pars plana vitrectomy. This was a retrospective, observational case study. Data from medical charts, wide-field digital imaging, ocular ultrasound, and visual evoked potential studies were reviewed. A 20-month-old boy presented with eosinophilic meningitis and right eye exotropia. Polymerase chain reaction analysis of the cerebrospinal fluid showed a positive result for Angiostrongylus cantonensis. Fundus examination revealed a pale optic disc, subretinal tracks, vitreous opacities, peripheral tractional retinal detachment, and a dead worm in the vitreous cavity. The patient underwent pars plana vitrectomy with worm removal. This case report illustrates the first case of intravitreal angiostrongyliasis in South America, possibly related to the uncontrolled spread of an exotic invasive species of snail.

Analysis of Clinical Profile, Investigation, and Management of Ocular Cysticercosis Seen at a Tertiary Referral Centre.

AIM: To analyze the demographic profile, clinical presentation, diagnosis, management, and outcome of ocular cysticercosis (OC) seen at a tertiary referral center. DESIGN: Retrospective case series. MATERIAL AND METHODS: Records of patients with diagnosis of OC from January 2000 to September 2015 were retrieved and the data was analyzed. RESULTS: 102 eyes of OC were seen. 72(71%) eyes had extraocular cysticercosis (EC) and 30(29%) eyes had intraocular cysticercosis (IC). EC was located in the orbit in 69/72 (96%) eyes. Symptoms of extraocular cysticercosis were restriction of ocular movement in 33 eyes (46%). IC was located in vitreous 17 eyes (57%). Symptom of IC was drop in vision in 26/30 eyes (87%). EC was managed medically with albendazole and steroid. Surgical excision was done for IC. CONCLUSION: EC was more common than IC. Prompt and appropriate management of OC results in good visual outcome.

Intravitreal Angiostrongylus cantonensis: first case report in South America / Angiostrongylus cantonensis intravítreo: primeiro relato de caso na América do Sul

ABSTRACT This study reports the first case of intravitreal angiostrongyliasis in South America treated with posterior worm removal via pars plana vitrectomy. This was a retrospective, observational case study. Data from medical charts, wide-field digital imaging, ocular ultrasound, and visual evoked potential studies were reviewed. A 20-month-old boy presented with eosinophilic meningitis and right eye exotropia. Polymerase chain reaction analysis of the cerebrospinal fluid showed a positive result for Angiostrongylus cantonensis. Fundus examination revealed a pale optic disc, subretinal tracks, vitreous opacities, peripheral tractional retinal detachment, and a dead worm in the vitreous cavity. The patient underwent pars plana vitrectomy with worm removal. This case report illustrates the first case of intravitreal angiostrongyliasis in South America, possibly related to the uncontrolled spread of an exotic invasive species of snail.

RESUMO O objetivo deste estudo foi relatar o primeiro caso na América do Sul de angiostrongilíase intravítrea tratada com vitrectomia posterior via pars plana e remoção do verme. Este foi um relato de caso observacional. O prontuário médico, sistema de imagem digital de campo amplo, ultrassonografia ocular, e potenciais evocados visuais foram revistos. Um menino de 1 ano e 8 meses de idade manifestou meningite eosinofílica e exotropia olho direito. A análise de PCR do liquor foi positiva para Angiostrongylus cantonensis. O exame de fundo de olho revelou disco óptico pálido, faixas sub-retinianas, opacidades vítreas, descolamento de retina tracional periférico e um verme morto no vítreo. O paciente foi submetido a vitrectomia posterior via pars plana com a remoção do verme. Concluindo, este é o primeiro relato de caso de angiostrongilíase intravítrea na América do Sul, possivelmente relacionado com a disseminação de uma espécie de lesma exótica neste continente.

False Negative Toxoplasma Serology in an Immunocompromised Patient with PCR Positive Ocular Toxoplasmosis.

PURPOSE: The authors report a case of a 60-year-old Caucasian male with a background of treated Chronic Lymphocytic Leukaemia (CLL) with secondary hypogammaglobulinaemia present with toxoplasma chorioretinitis and negative serum toxoplasma serology on presentation and on subsequent reactivation. METHODS: Retrospective case notes review with fundal photographs. RESULTS: In this case, on initial presentation and on recurrence, the patient's serum anti-Toxoplasma IgG remained negative. The diagnosis was made on quantitative PCR of vitreous initially and aqueous humor on reactivation. CONCLUSIONS: Despite negative serology, one must still consider ocular toxoplasmosis especially in CLL patients where the clinical picture could be compatible. Hypogammaglobulinaemia, the inability to produce IgG antibodies, is a well-recognized complication of CLL. Intraocular fluid sampling is essential in these cases where the sensitivity of PCR on either aqueous or vitreous humor has been shown to be higher in immunocompromised patients.

Morphological and molecular analyses of Tylodelphys spp. metacercaria (Trematoda: Diplostomidae) from the vitreous humour of two freshwater fish species, Channa gachua (Ham.) and Puntius sophore (Ham.).

Trematodes of family Diplostomatidae consists of a large and diverse group of parasites which have larval stages that are very important pathogens of wild and cultured freshwater fishes worldwide, can cause serious impacts. Our understanding of the diplostomids diversity, though, remains deficient and limited especially in India. In the present study, the morphology and molecular characterization of Tylodelphys spp. from the vitreous humour of eye, collected from two economically important food fish, dwarf snakehead Channa gachua (Perciformes: Channidae) and pool barb Puntius sophore (Cypriniformes: Cyprinidae) were described from Bijnor and Meerut, Uttar Pradesh (U.P.), India respectively. Tylodelphys spp. were characterized morphologically by light microscopy and SEM observations. Partial sequences of the ribosomal ITS1-5.8S-ITS2 gene cluster were also used for molecular identification of the species. Combined morphological and molecular analyses revealed the presence of three species of Tylodelphys: Tylodelphys sp. CG from C. gachua and Tylodelphys sp. PS 1, Tylodelphys sp. PS 2 from P. sophore respectively. This study demonstrated that molecular diversity of Tylodelphys spp. in Meerut, UP, India that may contribute to our knowledge of the diagnosis and taxonomy of diplostomids in fish.

Morphological and Molecular Characterization of Metacercaria of Tylodelphys (Digenea: Diplostomidae) from the Piscine Host, Mystus tengara from India.

The diversity and taxonomy of diplostomids infecting freshwater fishes of the Indian region are predominantly poorly known. Yet compared to other trematodes, identification and discrimination of diplostomid metacercaria are difficult using morphology and site of infection. The present study provides the first molecular study of a Tylodelphys sp. from India. Specimens of Tylodelphys were collected from the vitreous humor of the eyes and from the brains of siluriform fish, Mystus tengara (Siluriformes: Bagridae) from Hastinapur, Meerut (U.P.), India. Taxonomic studies were performed on the basis of morphological, morphometrical, and molecular analysis. The dissimilarities in morphological and sites of infection between 2 forms of Tylodelphys, designated as Tylodelphys sp. 1 and Tylodelphys sp. 2, suggested that the forms were different species but, after performing molecular analysis, we conclude that despite morphological differences both morphotypes are conspecific.

Ultrasound biomicroscopic imaging in paediatric ocular toxocariasis.

PURPOSE: To determine the potential and usefulness of ultrasound biomicroscopy (UBM) as a diagnostic procedure on a larger cohort of paediatric patients with ocular toxocariasis. METHODS: UBM was performed on 41 eyes of 41 patients with ocular toxocariasis in order to determine configuration of peripheral retina, pars plana and vitreous. Location and range of peripheral pathology using ophthalmoscopy with scleral indentation, UBM and intraoperative confirmation were recorded and compared. RESULTS: Pathological structures such as vitreous condensations or membranes of various configuration and extent were identified by UBM. UBM revealed peripheral granuloma and pseudocystic changes in the peripheral vitreous in 15 of 41 eyes. Compared with indirect ophthalmoscope, statistical analysis showed significant differences in the number of clock-hours of peripheral pathology detected by UBM (p=0.015), while statistical differences were not found between UBM and intraoperative peripheral examinations using scleral indentation (p=0.432). CONCLUSIONS: UBM seems to be a valuable and reliable diagnostic technique for the evaluation of patients with ocular toxocariasis. Longitudinal studies will have to determine the relevance of UBM findings for the individual clinical course and their influence on therapeutic decisions.

Vitreoretinal traction and lamellar macular holes associated with cicatricial toxoplasmic retinochoroiditis: case series report.

PURPOSE: Inflammation due to retinal neuroepithelial necrotic granulomas of toxoplasmosis can extend to neighbor areas and may develop focal adhesions of the posterior hyaloid, to the surface vessels, and the margins or adjoining areas of retinochoroiditis plaques. These adhesions may develop vitreoretinal traction and retinal tears. Vitreoretinal traction may be macular (VMT) or extramacular depending on the location of the toxoplasmic plaques. Vitreomacular traction may follow anomalous posterior vitreous detachment. We report 7 cases of vitreoretinal traction (macular or peripheral) and the development of 4 lamellar macular holes in cicatricial toxoplasmic retinochoroiditis. METHODS: This is a retrospective and observational study by revision of clinical records in a retinologist office, using diagnostic techniques, especially optical coherence tomography (OCT), current management, and an extended follow-up. The OCT observations on toxoplasmic extramacular plaques are more difficult. RESULTS: Seven cases in 5 patients, 2 of them bilateral, 3 male (66.6%) and 2 female, median age 46 years, were included. Anteroposterior VMT was found in 6 cases and another case was superotemporal midperipheral; 4 developed lamellar macular holes and 3 chronic macular epiretinal membranes. Best-corrected visual acuity was equal to or better than 20/30 in 3 cases, between 20/50 and 20/80 in 2 cases, and 20/160 to 20/200 in 2 cases. One small lamellar macular hole closed spontaneously during follow-up. CONCLUSIONS: Inflammatory retinal granulomas of toxoplasmosis in cicatricial stages may present macular or peripheral focal vitreoretinal adhesions that can eventually lead to VMT and subsequent lamellar macular holes or peripheral retinal tears.