Long-term Ocular Outcomes in Congenital Toxoplasmosis Treated Perinatally.

BACKGROUND: Congenital toxoplasmosis (CT) can be accompanied by serious organ manifestations, particularly retinochoroiditis, and may occur throughout life. We aimed to monitor long-term ocular prognosis in a large French cohort of patients with CT and its changes over time in the context of mandatory prenatal screening (since 1992) and incidence decrease since 2008. METHODS: Patients with CT diagnosed between 1987 and 2021 were prospectively included and followed for up to 35 years. The effect of the period of conception on the risk of first retinochoroiditis has been tested using a flexible extension of the Cox model. Incidence rates of retinochoroiditis were estimated. RESULTS: A total of 646 infected live born children were followed for a median of 12 years (range, 0.5-35); 187 patients (29%) had at least 1 ocular lesion (first at a median age of 5 years; range, 0-26 years) with peaks at 7 and 12 years. Early maternal infection and the presence of nonocular signs at birth were associated with a higher risk of retinochoroiditis, whereas delayed diagnosis of CT (after birth versus before or at birth) was associated with a lower risk (13% decrease for each additional month after birth; P = .01). A period effect for the risk of developing retinochoroiditis in patients born after 2008 was not detected. CONCLUSIONS: Despite prenatal screening and prolonged perinatal treatment, retinochoroiditis is not a rare event in French patients with CT and can occur well into adulthood, with peak incidences at 7 and 12 years of age. It rarely causes severe damage but warrants regular follow-up into adulthood.

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.

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.

A Case of Neuroretinitis following Inactivated Virion COVID-19 Vaccination.

PURPOSE: We report a rare presentation of neuroretinitis following vaccination with inactivated virion vaccine (COVAXIN). METHODS: Interventional Case Report. OBSERVATION: A 14-year-old female presented with sudden unilateral vision loss 3 days following COVID-19 vaccination. The clinical and radiological evaluation was consistent with classical neuroretinitis; the serological and immunological workup was negative. The patient responded well to the pulse steroid therapy and regained complete vision. CONCLUSION: The COVID-19 vaccine related adverse ocular events are beginning to emerge slowly and thus warrants close monitoring of all such cases. Also, ophthalmologists should be encouraged to seek vaccination status of patients presenting with inflammatory ocular conditions.

Idiopathic Retinal Vasculitis, Aneurysms and Neuroretinitis: Clinical Improvement with Infliximab.

PURPOSE: Idiopathic retinal vasculitis, aneurysms and neuroretinitis is a rare vision-threatening condition. If untreated vision loss occurs due to complications of progressive retinal ischaemia including retinal neovascularisation, neovascular glaucoma and retinal exudation. Despite the proposed underlying inflammatory aetiology this condition demonstrates poor response to corticosteroid treatment. The aim was to describe two paediatric cases of idiopathic retinal vasculitis, aneurysms and neuroretinitis treated with infliximab. METHODS: Two case reports. RESULTS: Infliximab treatment led to resolution of aneurysmal dilatations and retinal vasculitis, and reversal of some retinal capillary non-perfusion. CONCLUSION: Early infliximab treatment should be considered in cases of idiopathic retinal vasculitis, aneurysms and neuroretinitis.

Response to Comments on 'Acute Bilateral Neuroretinitis and Panuveitis in A Patient with Coronavirus Disease 2019: A Case Report'.

PURPOSE: to respond to comments on our case report on COVID associated neuroretititis. METHODS: We gathered up to date statistics about the prevalence and incidence of epidemic retinitis in Iran and specifically our region, north-east of Iran. RESULTS: Our response to Kawal et al comments includes 3 items. First, the PCR result of the vitreous specimen was positive for COVID-19. Secondly, the clinical course of the patient's illness was typically similar to our numerous COVID patients and we were in the middle of the second peak of COVID at the time. Thirdly, although other causes of epidemic retinitis such as west nile river are relatively rare in our region, we had a significant rise in the incidence of epidemic retinitis in the peak of COVID. So, the most probable cause may be COVID-19. CONCLUSION: Although the ocular findings of our patient was similar to epidemic retinitis caused by other well-known organisms, we believe that based on positive vitreous sample PCR for COVID, typical clinical course of systemic illness, being in the peak of COVID pandemic with significant increase of similar patients during this period, our patient had COVID associated neuroretinitis/ epidemic retinitis.

Bilateral Optic Nerve Head Drusen Complicated by Choroidal Neovascularization Misdiagnosed as Papilledema and Neuroretinitis.

We report a case of bilateral optic nerve head drusen complicated by choroidal neovascularization (CNV) in the left eye at presentation. The presence of optic disc and macular edema in addition to exudation led to the misdiagnosis of neuroretinitis at an outside medical center. Swept-source optical coherence tomography (SS-OCT) and SSOCT angiography were critical in establishing the diagnosis and follow-up in a noninvasive manner. Secondary CNV associated with optic nerve head drusen responded well to intravitreal injections of anti-vascular endothelial growth factor in the left eye. Asymptomatic nonexudative CNV that developed in the right eye during follow-up regressed spontaneously without treatment. [Ophthalmic Surg Lasers Imaging Retina 2022;53:518-521.].

Observations on Six Rare Cases of Chorioretinitis Sclopetaria.

INTRODUCTION: Chorioretinitis sclopetaria (CS) is a rare consequence of ocular injury. Its association with open globe injury (OGI) and retinal detachment (RD) is controversial. This study evaluates patterns of chorioretinitis sclopetaria and its association with open globe injury and retinal detachment. CASE: This is an electronic review of records of a tertiary eye care institute of south India with descriptive analysis of six cases. Cases where fundus findings of chorioretinitis sclopetaria were available were included. Information regarding mode of injury, visual outcomes, follow up and causes of poor visual outcomes were obtained. Presence of open globe injury, retinal detachment, vitreous hemorrhage (VH) and orbital foreign body (FB) was also noted. Ultrasound scans of the eyeball were reviewed for presence of signs of chorioretinitis sclopetaria. OBSERVATIONS: All the injured patients were male (age range 23-52 years). Bullet and blast injuries were the modes of injury. The duration since injury to the last follow up ranged from 0.25 to 12 years. The final visual acuity was <20/200 in 3/6 cases. Open globe injury and retinal detachment was noted in one case each, while 3/5 cases had orbital foreign body. Extensive facial and neuro-surgery were required in 2/6 cases. Sonography showed signs of chorioretinitis sclopetaria in 2/3 cases where scans were available for review. CONCLUSIONS: Though manifestations of chorioretinitis sclopetaria evolve with time with visual improvement, final visual acuity is generally poor. Cases of chorioretinitis sclopetaria may have accompanying retinal detachment or open globe injury. Sonography should be evaluated with a high degree of suspicion for chorioretinitis sclopetaria in typical cases.

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.

Indocyanine Green Angiography Features in Acute Syphilitic Posterior Placoid Chorioretinitis.

PURPOSE: Acute syphilitic posterior placoid chorioretinitis (ASPPC) is a rare clinical manifestation of ocular syphilis. The cause of the placoid lesion is still up for debate but could be caused by an impaired choriocapillaris perfusion. However, less attention has been paid to the hypofluorescence of the plaque on late-phase indocyanine green angiography (ICGA). The aim of this study was to comprehensively analyze multimodal imaging findings in patients with ASPPC and to highlight the value of ICGA for the diagnosis of ASPPC. DESIGN: Retrospective observational case study. METHODS: The medical records of patients with uveitis who consulted our tertiary center between 2012 and December 2015 were reviewed. Patients who were diagnosed with uveitis related to syphilis infection with posterior placoid lesions seen on multimodal imaging were included. We compared the aspect of ASPPC on fundus color photography, blue autofluorescence, fluorescein angiography, optical coherence tomography, and early-, mid- and late-phase ICGA. RESULTS: Fifteen eyes of 12 patients were included in the study. Hypofluorescent plaques were seen on late-phase ICGA in all eyes, corresponding to the placoid lesions visible on blue autofluorescence, while the choriocapillaris filling was normal on fluorescein angiography and ICGA. Within the plaques, optical coherence tomography showed ellipsoid zone disruptions, outer retinal disruptions, and retinal pigment epithelium granulations. CONCLUSION: ASPPC could be caused by retinal pigment epithelium dysfunction secondary to an infectious or inflammatory disorder, characterized by a hypofluorescence visible only on late-phase ICGA, and resulting in photoreceptor disruptions. The RPE impairment was reversible after prompt antibiotic treatment.

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.

Is There a True Neuroretinitis in Idiopathic Retinal Vasculitis, Aneurysms, and Neuroretinitis (IRVAN) Syndrome ?

PURPOSE: To clarify whether a true neuroretinitis is part of  idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome. METHODS: Critical literature review. RESULTS: Neuroretinitis has been considered as a prominent feature of IRVAN syndrome. It has been described as late diffuse optic  disc staining on fluorescein angiography. However, patients with IRVAN syndrome usually do not present with visual function alterations consistent with optic neuropathy or neuroretinitis. The typical stellate exudative maculopathy seen in IRVAN syndrome is primarily caused by leakage from retinal arteriolar aneurysms at or near the optic disc, and it could be misinterpreted as a feature of neuroretinitis. CONCLUSION: There is no clinical evidence of true neuroretinitis at any of the disease stages in patients with IRVAN syndrome. The acronym « IRVARE ¼ (Idiopathic Retinal Vasculitis, Aneurysms, and Retinal Exudates) is proposed to better characterize this syndrome.

Incidence of chorioretinitis and endophthalmitis in hospitalized patients with fungemia.

AIM/PURPOSE: Bloodstream candida infections can seed the eye via hematogenous spread and result in chorioretinitis or endophthalmitis. If undetected and untreated, this can result in permanent vision loss. Past studies evaluating incidence of ocular candidiasis among hospitalized patients with positive fungal blood cultures have demonstrated variable rates of occurrence, but recent studies have generally shown a lower incidence than was reported several decades ago. Given low rates of occurrence, the utility of screening patients with dilated fundus exams has been called into question. The primary aim of this investigation is to identify the rate of chorioretinitis and endophthalmitis based on dilated fundoscopy for patients with fungemia at a tertiary care hospital. METHODS: This study was a retrospective chart review of adult patients admitted to the medical centre of the University of Arkansas for Medical Sciences (UAMS) between May 1, 2014 and December 31, 2017, who had positive fungal blood cultures during their hospitalization. RESULTS: There were 324 positive fungal cultures in 290 patients. Of this initial group, there were 161 eye exams. Ocular examination identified 7 of 161 patients (4.3%) with chorioretinitis or endophthalmitis. DISCUSSION: These outcomes along with previous studies support the current guidelines that screening with dilated fundus examination for these patients is appropriate and necessary.

Infectious Uveitis after Local Steroid and/or Methotrexate Injections at A Tertiary Referral Center in New Zealand: A Case Series.

AIM: Infectious uveitis is one of the most visually devastating causes of uveitis worldwide and accounts for 19.6% of all cases of uveitis in New Zealand. With the burgeoning use of intravitreal injections, there has been a commensurate increase in the number of injection-related complications and reports of infectious uveitis following their administration in recent years. We present a case series of four patients with infectious uveitis after local injections. METHOD: We retrospectively reviewed the data of four patients (mean age, 67.25 ± 7.58 years) who presented to the department of ophthalmology at Auckland District Health Board with infectious uveitis which occurred or worsened after local triamcinolone acetonide (TA) and/or methotrexate (MTX) injections. RESULTS: Three patients received local TA and one patient received intravitreal MTX. All patients were immunosuppressed prior to treatment. Two patients had toxoplasma chorioretinitis which worsened with local TA and one patient developed cytomegalovirus (CMV) retinitis after intravitreal TA. The last patient had syphilis retinopathy which worsened with intravitreal MTX. There were atypical presentations, as demonstrated by a case of presumed birdshot chorioretinopathy flare which tested positive for toxoplasma chorioretinitis with polymerase chain reaction (PCR). CONCLUSION: Uveitis due to infectious etiologies needs to be carefully excluded prior to the use of local steroid and/or methotrexate injections. Disease presentations may be atypical in the presence of marked immunosuppression following local therapy. Polymerase chain reaction (PCR) can play an important role in the diagnosis in this setting.

Ocular Toxoplasmosis after Exposure to Wild Game.

PURPOSE: To describe eight patients with toxoplasma retinochoroiditis following exposure to wild game. METHODS: Retrospective, multicenter case series. RESULTS: Eight men, aged 29 to 71 (mean, 56 years), developed toxoplasmic retinochoroiditis after hunting and/or consuming wild game in the United States, including seven deer and one bear. Five patients developed the disease after eating undercooked game meat, while three developed ocular findings after cleaning hunted animals. Seven patients were healthy prior to exposure. LogMAR visual acuity at presentation was 0.697 ± 0.745, improving to 0.256 ± 0.335 by last follow-up. Disease complications developed in five (62.5%) patients, of which recurrence of retinochoroiditis was the most common. CONCLUSIONS: Contact with wild game is a potential source of primary ocular toxoplasmosis in immunocompetent adults. Hunters and consumers of rare game are at risk of serious ocular disease and appropriate contact precautions and cooking may reduce this complication.

Optic Disc Edema in Syphilis.

BACKGROUND: Syphilis is an uncommon cause of optic nerve head edema; however, differentiating syphilis from other etiologies of optic nerve head swelling may be challenging. We describe 4 cases of ocular syphilis presenting with swollen optic nerve head(s) without overt signs of intraocular inflammation to better define the phenotypic presentation of this condition to allow its early recognition and treatment and discuss potential pathophysiological mechanisms of syphilitic optic neuropathy. METHODS: Retrospective case series of patients presenting to a tertiary neuro-ophthalmology practice with a swollen optic nerve head(s) but no overt signs of intraocular inflammation, which was eventually determined to be secondary to syphilis. RESULTS: Four patients were included in the study. The mean age was 43 years, 2 were women and 2 had bilateral involvement. Two patients had a recent history of skin rash, and one patient was investigated for abdominal pain and elevated liver enzymes. Two patients presented with photopsias and preserved visual function, whereas 2 presented with vision loss. Although chorioretinitis was present in all cases, it was very subtle in all and was only appreciated on fundus autofluorescence (FA) in 3 of 4 cases. Three patients demonstrated evidence of optic perineuritis on neuro-imaging. All patients were treated with a course of intravenous penicillin with a variable degree of visual recovery. CONCLUSIONS: Systemic symptoms are common in patients with syphilic optic neuropathy. Optic disc edema as a manifestation of syphilis is usually accompanied by subtle chorioretinitis, which is best appreciated on FA. Optic perineuritis is common in patients with syphilitic optic neuropathy, with its pathophysiology likely similar to meningitis seen in neurosyphilis.

Pars plana vitrectomy and visual stimulation for treatment of vitreomacular traction secondary to toxoplasmosis retinochoroiditis in a 5-year-old child / Vitrectomia via pars plana e estimulação visual para tratamento da tração vitreomacular secundária à retinocoroidite por toxoplasmose em criança de 5 anos

ABSTRACT Objective: A unusual case of ocular toxoplasmosis with significant vitreomacular traction is reported. The patient improved significantly following pars plana vitrectomy combined with visual stimulation and occlusion therapy. Methods: The case of a 5-year-old girl with significant unilateral vision loss associated with vitreous condensation and macular traction is described. Results: Pars plana vitrectomy was carried out for vitreomacular traction release. This was followed by visual stimulation and occlusion therapy. Significant improvement was observed. Conclusion: Despite structural damage, the combination of properly indicated surgery and amblyopia management strategies allowed the achievement of maximum vision goals in this case, suggesting structural damage may be associated with functional amblyopia.

RESUMO Objetivo: Relata-se um caso de apresentação atípica de toxoplasmose ocular, com importante tração vitreomacular. A paciente apresentou melhora significativa após vitrectomia via pars plana, com estimulação visual e oclusão. Métodos: Descreve-se o caso de uma menina de 5 anos, com importante perda de visão unilateral associada à condensação vítrea e à tração macular. Resultados: Foi realizada vitrectomia via pars plana para alívio da tração vitreomacular, seguida de estimulação visual e oclusão. Foi observada melhora significativa. Conclusão: Apesar dos danos estruturais, a combinação de cirurgia bem indicada com estratégias de tratamento da ambliopia permitiu alcançar o máximo do potencial visual nesta paciente, sugerindo que os danos estruturais podem estar associados à ambliopia funcional.

PERSISTENT PLACOID MACULOPATHY IN A PATIENT WITH HIGH MYOPIA.

PURPOSE: To describe a case of persistent placoid maculopathy in a patient with high myopia. METHODS: Interventional case report. RESULTS: A 59-year-old white man with high myopia presented with blurriness in the left eye. Vision was 20/20 bilaterally. Optical coherence tomography showed subretinal thickening and fluid without definitive leakage on fluorescein angiography after which anti-vascular endothelial growth factor (anti-VEGF) therapy was initiated. The patient was diagnosed with persistent placoid maculopathy based on multimodal imaging and clinical response. His disease course was characterized by multiple bilateral recurrences despite active treatment. At final visit (23 months after presentation), the vision was 20/20 in the right eye and 20/25 in the left eye, and the disease remained quiescent on immunomodulating therapy. CONCLUSION: Prompt initiation of anti-VEGF injections and immunosuppression resulted in disease control and preservation of vision in both eyes for almost 2 years.

Triple trouble: A case of retinochoroiditis in a patient with syphilis, tuberculosis, and human immunodeficiency virus infection.

A 31-year-old male patient presented with sudden onset loss of vision in the left eye. Ocular examination revealed significant vitritis with chorioretinitis lesion in the posterior pole. Subsequent investigations revealed positive human immunodeficiency virus (HIV) and syphilis serology; chest imaging revealed active pulmonary tuberculosis. Polymerase chain reaction from aqueous aspirate was positive for Mycobacterium tuberculosis. There was complete resolution of the lesions following antisyphilitic medications, antitubercular therapy along with highly active antiretroviral therapy. Syphilis and tuberculosis coinfection in a previously unknown HIV patient is rare but can occur. It is worthwhile to look for multiple coinfections in HIV patients.