Swept-source Optical Coherence Tomography Angiography in Active and Scarred Toxoplasmic Retinochoroiditis.

PURPOSE: To describe optical coherence tomography angiography (OCTA) findings in eyes with active and scarred toxoplasmic retinochoroiditis. METHODS: OCTA scans in active (25 eyes) and scarred (17 eyes) retinochoroiditis were retrospectively reviewed. RESULTS: In active lesions, OCTA findings included a non-detectable flow signal area in retinal vascular plexuses and choriocapillaris in all 25 eyes (100%), an abnormal intraretinal vascular process in 2 eyes (8%), and an associated area of retinal flow deficit secondary to branch retinal artery occlusion in one eye (4%). In scarred lesions, OCTA findings included a flow deficit area in retinal vascular plexuses and choriocapillaris in all 17 eyes (100%), a visibility of larger deeper choroidal vessels at the level of choriocapillaris in 9 eyes (53%), and a well-defined intraretinal vascular network in one eye (5.9%). Peripapillary scars were associated on OCTA with wedge-shaped loss of radial peripapillary capillaries with corresponding localized retinal nerve fiber layer defect and visual field loss. CONCLUSION: OCTA allows to non-invasively detect retinal and choroidal vascular changes in active and scarred toxoplasmic retinochoroiditis.

Expanded Spectrum of Optical Coherence Tomography Findings in Patients with Ocular Toxoplasmosis.

PURPOSE: To describe the optical coherence tomography (OCT) findings of toxoplasmic retinochoroiditis at different stages of activity. METHODS: Observational case series. RESULTS: A total of 32 eyes of 31 patients were included; 43 sets of OCT were reviewed. A total of 14 lesions were classified as active, 13 as partially active, and 16 as inactive. All active lesions demonstrated increased retinal thickness and reflectivity with blurring of details of retinal layers. Choroidal granuloma was detected in eight (61.5%) and serous retinal detachment in nine (64%). In partially active lesions, sustained thickening and/or attachment of posterior hyaloid face with fine epiretinal membrane was the hallmark. Scarified lesions showed decreased retinal and choroidal thickness starting from the periphery. Characteristic signs for decreased activity of a lesion seen in majority of both partially active and inactive lesions were RPE changes and retina-RPE approximation. We called this unique feature 'hourglass configuration'. CONCLUSION: Features in OCT are helpful to specify and monitor the activity of toxoplasmic retinochoroiditis.

Acute Posterior Ocular Toxoplasmosis: An Optical Coherence Tomography Angiography and Dye Angiography Study.

PURPOSE: To compare Indocyanine Green (ICGA) and fundus fluorescein angiography (FFA) with Optical Coherence Tomography Angiography (OCTA) findings in toxoplasmic chorioretinitis (TCR). METHODS: Patients affected by active TCR were included. FFA, ICGA, and OCTA images were analyzed and lesions were compared between different modalities. Satellite dark dots (SDD) were compared between modalities. RESULTS: Fifteen patients were enrolled. The mean lesion area was similar between fundus photography (FP), FFA, and OCTA-Retina. The mean lesion area was similar between ICGA and OCTA-Choroid slab. ICGA and OCTA-Choroid showed a larger extension of the lesion compared to FP, FFA, and OCTA-Retina (p = .01, 0.0001, and 0.0002 for ICG angiography and p = .03, 0.008, and 0.0002 for OCTA-Choroid, respectively). On OCTA B-scans, the retinal flow defects were smaller than the underlying choroidal non-perfusion. The number of SDD was similar between ICGA and OCTA. CONCLUSIONS: OCTA is a reliable method to assess retinal and choroidal involvement in TCR. OCTA confirmed a wider involvement of the choroid than the retina.

Punctate Inner Retinal Toxoplasmosis: Case Series and Review of Literature.

PURPOSE: To describe clinical and multimodal imaging characteristics of punctate inner retinal toxoplasmosis (PIRT) as an atypical presentation of ocular toxoplasmosis (OT). METHODS: Retrospective review of OT cases with PIRT lesions and review of the literature. We describe five cases (6 eyes). RESULTS: PIRT lesions were seen adjacent to active/healed toxoplasma retinochoroiditis. The appearance of PIRT was creamy yellowish-white, inner retinal, punctate, and sub-centimetric lesions. The depth of these lesions on optical coherence tomography was till the outer plexiform layer. Co-existing punctate outer retinal toxoplasmosis (PORT) was found in three eyes and recurrent retinochoroiditis in three. The fate of PIRT was resolution with minimal retinal thinning or progression to a full-thickness retinochoroiditis. CONCLUSION: PIRT was noted in association with typical toxoplasma retinochoroiditis and PORT lesions, and had equal chances of resolution or progression to full-thickness lesions.

Bilateral ocular toxoplasmosis in a returning traveller: age and route of infection as potential risk factors.

We report the case of a 69-year-old man, who presented in the UK with a short history of deteriorating vision and clinical features of bilateral atypical retinochoroiditis, after travelling to South America. Vitreous samples demonstrated Toxoplasma gondii DNA by PCR. Serology tests demonstrated recent acquired Toxoplasma gondii infection with IgM antibodies. He responded well to treatment with trimethoprim-sulfamethoxazole, azithromycin and oral steroids.This case is a reminder of the global importance of Toxoplasma related eye disease, and its uncommon bilateral severe presentation in a returning traveller, where the risk factors were age and the route of infection likely to be a virulent parasite oocyst from vegetables or water rather than undercooked meat or direct contact with cats.

Optical Coherence Tomography Angiography Analysis of Retinal and Choroidal Vascular Networks during Acute, Relapsing, and Quiescent Stages of Macular Toxoplasma Retinochoroiditis.

PURPOSE: To highlight the advantages of optical coherence tomography angiography (OCTA) in delineating the morphological features of the retinal and choroidal vascular network during acute, relapsing, and quiescent stages of macular toxoplasma retinochoroiditis. METHODS: This prospective study included patients presenting with both active and quiescent ocular toxoplasmoses. OCTA was obtained to diagnose and follow the subsequent vascular network changes at diagnosis and six months after acute presentation. RESULTS: Twenty-three eyes of 23 patients were included. In active lesions, OCTA showed extensive, well-delineated areas of intense hyposignal and perifoveal capillary arcade disruption in the parafoveal superficial capillary plexus (pSCP) and less extensive hyposignal in the parafoveal deep capillary plexus (pDCP). Signals of decreased deep capillary density and disorganization were also seen in the choroid. In nonactive lesions, OCTA demonstrated a homogenous and equally attenuated grayish hyposignal of the pSCP and pDCP and a partial restoration of the nonperfused choroidal areas. CONCLUSION: OCTA is a useful technique for vascular network analysis in toxoplasma retinochoroiditis. It allows the visualization of the different network changes and behaviors during the different stages of the infection.

Morphological characteristics of ocular toxoplasmosis and its regression pattern on swept-source optical coherence tomography angiography: a case report.

BACKGROUND: To report the successful treatment of ocular toxoplasmosis and present the use of multimodal imaging to describe the changes in ocular toxoplasmic lesions subsequent to treatment. CASE PRESENTATION: A 73-year-old female visited the clinic with decreased visual acuity in the left eye. Fundus examination showed severe vitreous haze with yellow-white infiltrates near the foveal center. Spectral-domain optical coherence tomography (SD-OCT) revealed disorganization of the retinal structure with markedly thickened choroid beneath the active lesion. Highly elevated serum titers of IgG antibodies against Toxoplasma gondii were observed. Topical and systemic steroids with oral Bactrim were administered after a diagnosis of ocular toxoplasmosis was made. After improvement in the severity of vitritis, structural en face swept-source optical coherence tomography (SS-OCT) imaging demonstrated diffuse choroidal dilation with many collateral vascular branches surrounding the active lesion. Eight intravitreal injections of clindamycin (1 mg/0.1 ml) were administered at 1- to 2-week intervals along with systemic antibiotics and steroids. After the treatment, the toxoplasmic lesion resolved to an atrophic chorioretinal scar. Dilated choroidal vessel size was normalized and collateral vascular branches were markedly constricted on structural en face SS-OCT images. CONCLUSIONS: This is the first detailed report on the morphological changes in the choroidal vasculature surrounding ocular toxoplasmic lesions that were characterized using SS-OCT-A imaging. Multimodal imaging with SS-OCT-A can be valuable in clinical diagnosis as well as in clarifying the mechanism of choroidal structural changes in ocular toxoplasmosis.

Optic nerve involvement in ocular toxoplasmosis: 12 year data from a tertiary referral center in Turkey / Acometimento de nervo óptico na toxoplasmose ocular: um relato de 12 anos de um centro de referência terciário na Turquia

ABSTRACT Purpose: To evaluate the prevalence, clinical characteristics, and types of optic nerve involvement in patients with ocular toxoplasmosis. Methods: For this retrospective cross-sectional study, we examined all patients with active ocular toxoplasmosis referred to our Uveitis Section during the last 12 years, and we included patients with optic nerve involvement in the study. The primary outcome was the prevalence of optic nerve involvement, and secondary outcomes included the types of optic nerve involvement and the final best-corrected visual acuity after treatment. Results: The prevalence of optic nerve involvement was 14.4%, with the leading cause being the activation of a juxtapapillary lesion (70.5%). We found papillitis in two eyes and neuroretinitis in two eyes (11.7% for each). We only detected one optic nerve involvement secondary to a distant active lesion (5.8%). Sixteen patients (94.1%) had unilateral ocular toxoplasmosis. The overall final best-corrected visual acuity after treatment was 10/10 (LogMAR = 0.0) excluding the three patients with a juxtapapillary scar involving the macula. Conclusions: Optic nerve involvement was common in patients with ocular toxoplasmosis. The main type of optic nerve involvement was caused by activation of an old juxtapapillary lesion. Treatment was quickly effective, but the best-corrected visual acuity was dependent on the presence of a scar in the papillomacular bundle.

RESUMO Objetivos: Avaliar a prevalência, características clínicas e tipos de acometimento do nervo óptico em pacientes com toxoplasmose ocular. Métodos: Para este estudo retrospectivo transversal, examinamos todos os pacientes com toxoplasmose ocular ativa encaminhados ao nosso Setor de Uveíte nos últimos 12 anos, e incluímos pacientes com comprometimento do nervo óptico no estudo. O resultado primário foi a prevalência do envolvimento do nervo óptico, e os resultados secundários incluíram os tipos de envolvimento do nervo óptico e a acuidade visual final melhor corrigida após o tratamento. Resultados: A prevalência de acometimento do nervo óptico foi 14,4%, sendo a principal causa a ativação de uma lesão justapapilar (70,5%). Encontramos papilite em dois olhos e neuroretinite em dois olhos (11,7% para cada um). Apenas detectamos um comprometimento do nervo óptico secundário a uma lesão ativa distante (5,8%). Dezesseis pacientes (94,1%) apresentavam toxoplasmose ocular unilateral. A acuidade visual final com melhor correção após o tratamento foi 10/10 (LogMAR= 0,0) excluindo os três pacientes com uma cicatriz justapapilar envolvendo a mácula. Conclusões: O comprometimento do nervo óptico foi comum em pacientes com toxoplasmose ocular. O principal tipo de comprometimento do nervo óptico foi causado pela ativação de uma lesão justapapilar antiga. O tratamento foi rapidamente eficaz, mas a acuidade visual final com melhor correção foi dependente da presença de uma cicatriz no feixe papilomacular.

Ultrasonographic characteristics of active ocular toxoplasmosis / Achados ultrassonográficos em toxoplasmose ocular ativa

ABSTRACT Purpose: To evaluate ophthalmic ultrasonographic findings associated with active ocular toxoplasmosis. Methods: Forty-seven eyes with active ocular toxoplasmosis in 47 patients were subjected to ocular ultrasonography using the transpalpebral technique (10-MHz transducer) and fundus photography. Patient medical records were retrospectively reviewed. Results: Ocular ultrasonography revealed vitritis, posterior vitreous detachment, retinal wall thickening, and non-rhegmatogenous retinal detachment in 47 (100%), 36 [76.6%; partial in 12 (25.5%) and total in 23 (48.9%)], 12 (25.5%), and 5 eyes (10.6%). Thirty-five of the 36 eyes with posterior vitreous detachment (97.2%) exhibited posterior hyaloid thickening; moreover, adhesion to the exudative lesion and vitreoschisis were observed in 4 (11.1%) and 12 eyes (25.5%), respectively. Ultrasonography detected the location of the exudative focus in 12 eyes (25.5%). Conclusion: Ultrasonography is helpful for detecting important intraocular findings of acute ocular toxoplasmosis that can be hindered by medial opacity or posterior synechiae.

RESUMO Objetivo: Avaliar os achados da ultrassonografia na toxoplasmose ocular ativa. Métodos: Quarenta e sete olhos com toxoplasmose ocular ativa em 47 pacientes foram submetidos à ultrassonografia ocular pela técnica transpalpebral (transdutor de 10 MHz) e fundo de olho. Os prontuários médicos foram revistos retrospectivamente. Resultados: A ultrassonografia ocular revelou vitreíte, descolamento vítreo posterior, espessamento da parede da retina e descolamento de retina não regmatogênico em 47 (100%), 36 [76,6%; parcial em 12 (25,5%) e total em 23 (48,9%)], 12 (25,5%) e 5 olhos (10,6%). Trinta e cinco dos 36 olhos com descolamento vítreo posterior (97,2%) exibiram espessamento hialoide posterior; além disso, a adesão à lesão exsudativa e vitreosquise foi observada em 4 (11,1%) e 12 (25,5%), respectivamente. A ultrassonografia detectou a localização do foco exsudativo em 12 olhos (25,5%). Conclusão: A ultrassonografia é útil na detecção de importantes achados intra-oculares de toxoplasmose ocular aguda que podem ser prejudicados pela opacidade medial ou sinéquia posterior.

Ultrasonographic characteristics of active ocular toxoplasmosis.

PURPOSE: To evaluate ophthalmic ultrasonographic findings associated with active ocular toxoplasmosis. METHODS: Forty-seven eyes with active ocular toxoplasmosis in 47 patients were subjected to ocular ultrasonography using the transpalpebral technique (10-MHz transducer) and fundus photography. Patient medical records were retrospectively reviewed. RESULTS: Ocular ultrasonography revealed vitritis, posterior vitreous detachment, retinal wall thickening, and non-rhegmatogenous retinal detachment in 47 (100%), 36 [76.6%; partial in 12 (25.5%) and total in 23 (48.9%)], 12 (25.5%), and 5 eyes (10.6%). Thirty-five of the 36 eyes with posterior vitreous detachment (97.2%) exhibited posterior hyaloid thickening; moreover, adhesion to the exudative lesion and vitreoschisis were observed in 4 (11.1%) and 12 eyes (25.5%), respectively. Ultrasonography detected the location of the exudative focus in 12 eyes (25.5%). CONCLUSION: Ultrasonography is helpful for detecting important intraocular findings of acute ocular toxoplasmosis that can be hindered by medial opacity or posterior synechiae.

Optic nerve involvement in ocular toxoplasmosis: 12 year data from a tertiary referral center in Turkey.

PURPOSE: To evaluate the prevalence, clinical characteristics, and types of optic nerve involvement in patients with ocular toxoplasmosis. METHODS: For this retrospective cross-sectional study, we examined all patients with active ocular toxoplasmosis referred to our Uveitis Section during the last 12 years, and we included patients with optic nerve involvement in the study. The primary outcome was the prevalence of optic nerve involvement, and secondary outcomes included the types of optic nerve involvement and the final best-corrected visual acuity after treatment. RESULTS: The prevalence of optic nerve involvement was 14.4%, with the leading cause being the activation of a juxtapapillary lesion (70.5%). We found papillitis in two eyes and neuroretinitis in two eyes (11.7% for each). We only detected one optic nerve involvement secondary to a distant active lesion (5.8%). Sixteen patients (94.1%) had unilateral ocular toxoplasmosis. The overall final best-corrected visual acuity after treatment was 10/10 (LogMAR = 0.0) excluding the three patients with a juxtapapillary scar involving the macula. CONCLUSIONS: Optic nerve involvement was common in patients with ocular toxoplasmosis. The main type of optic nerve involvement was caused by activation of an old juxtapapillary lesion. Treatment was quickly effective, but the best-corrected visual acuity was dependent on the presence of a scar in the papillomacular bundle.

Regional Differences in the Clinical Manifestation of Ocular Toxoplasmosis Between the Center and Northeast of Argentina.

Purpose: To compare the clinical characteristics of patients with active episodes of ocular toxoplasmosis from three provinces, Misiones, Santa Fe, and Buenos Aires, Argentina. Methods: Patients with a diagnosis of ocular toxoplasmosis from three databases of four tertiary referral uveitis centers were reviewed. Collected data included presentation of the retinochoroiditis, location of the active lesions, associated inflammatory ocular signs and complications. Results: Three hundred thirty-four patients were included in this study. Bilateral involvement of the ocular disease occurred in 26 patients in Misiones (35.14%), 21 patients (12.8%) in Santa Fe, and 9 patients in Buenos Aires (9.4%) (p < 0.001). Extensive retinitis was observed in 49 patients (66.2%) in Misiones, 39 patients (23.8%) in Santa Fe, and 12 patients (12.5%) in Buenos Aires (p < 0.001). Conclusion: The results indicate that there are differences in the clinical characteristics of ocular toxoplasmosis in patients from Misiones, Santa Fe, and Buenos Aires.

Can the route of Toxoplasma gondii infection affect the ophthalmic outcomes?

Ocular toxoplasmosis is the most common cause of retinochoroiditis worldwide in humans. Some studies highlighted the idea that ocular lesions differ according to the route of infection but none of them mimicked the natural route. The current study aimed to investigate the ophthalmic outcomes in congenital and oral routes of infection with Toxoplasma in experimental animals. Mice were divided into three groups; group I: congenital infection, group II: acquired oral infection and group III: non-infected. We used Me49 chronic low-virulence T. gondii strain. We found that retina is the most affected part in both modes of infections. However, the retinal changes are different and more pronounced in case of congenital infection. The congenitally infected mice showed retinal lesions e.g. total detachment of retinal pigment epithelium from the photoreceptor layer and irregular arrangement of retinal layers. More severe damage was observed in mice infected early in pregnancy. While the postnatal orally infected mice showed fewer changes. In conclusion, the routes of Toxoplasma infection affect the ophthalmic outcomes and this may be the case in human disease. Although both are vision threatening, it seems that the prognosis of postnatal acquired ocular toxoplasmosis is better than that of congenital disease.

Increased IL-27/IL-27R expression in association with the immunopathology of murine ocular toxoplasmosis.

Interleukin 27 (IL-27) is a member of the IL-6/IL-12 family, and IL-27 receptor (IL-27R) consists of WSX-1 (the IL-27Rα subunit) and the signal-transducing subunit gp130. Human and mouse mast cells (MCs) express the IL-27R. To explore the expressions of IL-27/IL-27R subunits (WSX-1 and gp130) during acute ocular toxoplasmosis (OT), we established mouse model by intraocular injection of 500 Toxoplasma gondii RH strain tachyzoites. Histopathological changes were analyzed, MCs were counted by toluidine blue staining, and tryptase+/IL-27+ MCs were examined by immunofluorescence double-staining in the eyes and cervical lymph nodes (CLNs) of T. gondii-infected mice. The mRNA expressions of IL-27p28, WSX-1, gp130, and tachyzoite specific surface antigen 1 (SAG1) in the eyes and CLNs of T. gondii-infected mice, and the expressions of WSX-1 and gp130 in the murine mastocytoma cell line P815 infected with T. gondii tachyzoites in vitro were examined by using quantitative real-time reverse transcription-polymerase chain reaction. Our results showed that, after T. gondii infection, severe histopathological changes, increased numbers of total MCs and degranulated MCs, elevated expressions of IL-27p28, WSX-1, and gp130 were found in the eyes and CLNs, and significant correlations between the levels of IL-27 and SAG1 existed in the eyes and CLNs of T. gondii-infected mice. In addition, increased levels of WSX-1 and gp130 were examined in T. gondii-infected P815 cells. Our data suggested that IL-27/IL-27R expression induced by T. gondii infection may regulate MC-mediated immune response during acute OT in mouse model.

Assessment of ocular toxoplasmosis patients reported at a tertiary center in the northeast of Iran.

PURPOSE: Ocular toxoplasmosis, which is caused by the single-cell parasite Toxoplasma gondii, is currently the most significant cause of posterior uveitis in the world. No previous studies have described the prevalence and clinical features of ocular toxoplasmosis in the northeast of Iran. The purpose of the current study was to address this gap. METHODS: In this retrospective study, the medical records of 488 uveitis patients who presented to the Khatam-al-Anbia Eye Hospital of Mashhad University of Medical Sciences, a tertiary ophthalmology center in the northeast of Iran, between January 2013 and December 2015 were evaluated. The clinical features and risk factors of 99 (20%) consecutive patients with ocular toxoplasmosis were extracted. RESULTS: Ninety-nine including 53 (53.5%) female and 46 (46.5%) male patients with ocular toxoplasmosis were included in the analysis. Reduced vision (77%) and floaters (15.2%) were the most common presenting symptoms. The age category that was most affected by ocular toxoplasmosis was 20-40 years (range: 11-65 years) with a mean age of 27.2. All patients had retinochoroiditis, but just two had anterior uveitis. All of the extracted patients, with the exception of three patients, had unilateral involvement. None of the patients had any other medical disorders with the exception of one woman, who had diabetes. Only four recurring ocular toxoplasmosis patients were referred to the education hospital during the study. Serology data were available for just 32 patients, of which 31 (96.8%) were IgG positive, and 1 (3.2%) was IgM positive. CONCLUSION: Toxoplasma gondii was responsible for 20% of the patients of uveitis that presented to the largest ophthalmology center in the northeast of Iran. There is a high incidence of patients of ocular toxoplasmosis in the northeast of Iran, and it is a significant cause of uveitis and visual impairment in this area.

Causes of visual impairment in patients with ocular toxoplasmosis.

INTRODUCTION: The aim of this study was to report the causes of visual impairment in patients with the classic clinical presentation of ocular toxoplasmosis (OT). METHODOLOGY: Eight patients with OT underwent standardized ophthalmologic examination and fundus imaging. Macula and the lesions that could be visualized were evaluated by spectral domain optical coherence tomography (SOCT) at presentation. The scan acquisition protocols for SOCT included a radial line scan through the retinochoroiditis lesion, radial line macular scan, and horizontal volume scans at the macula. RESULTS: The mean age of the five (62.5%) women and three (37.5%) men was 25.7±7.6 years. The mean logMAR ETDRS best-corrected visual acuity was 0.45 (Snellen equivalent, 20/50). SOCT findings of macula were normal in seven patients, and one patient had decreased retinal thickness from a healed chorioretinitis at the fovea. Of eight patients, two had 3+ vitreous haze, four had 2+ vitreous haze, and two had 1+ vitreous haze at presentation. OCT scans revealed vitreous hyperreflective dots in all patients with different densities in different radial scans. Hyperreflective dots were denser in macular scans of eyes in which the active lesion was closer to the fovea. CONCLUSIONS: In this study, visual impairment in majority of the patients was found to be related to vitreous cells and flare. Dense vitritis on macula scans and visual impairment were seen in the patients who had an active lesion closer to the fovea. SOCT may provide objective data of the cellular load of the eyes with posterior segment inflammation.

Early serum biomarker networks in infants with distinct retinochoroidal lesion status of congenital toxoplasmosis.

The present study characterized the early changes in the serum chemokines/cytokine signatures and networks in infants with congenital-toxoplasmosis/(TOXO) as compared to non-infected-controls/(NI). TOXO were subgrouped according to the retinochoroidal lesion status as no-lesion/(NL), active-lesion/(ARL), active/cicatricial-lesion/(ACRL) and cicatricial-lesion/(CRL). The results showed that TOXO display prominent chemokine production mediated by IL-8/CXCL8, MIG/CXCL9, IP-10/CXCL10 and RANTES/CCL5. Additionally, TOXO is accompanied by mixed proinflammatory/regulatory cytokine pattern mediated by IL-6, IFN-γ, IL-4, IL-5 and IL-10. While TNF appears as a putative biomarker for NL and IFN-γ/IL-5 as immunological features for ARL, IL-10 emerges as a relevant mediator in ACRL/CRL. IL-8/CXCL8 and IP-10/CXCL10 are broad-spectrum indicators of ocular disease, whereas TNF is a NL biomarker, IFN-γ and MIG/CXCL9 point out to ARL; and IL-10 is highlighted as a genuine serum biomarker of ACRL/CRL. The network analysis demonstrated a broad chemokine/cytokine crosstalk with divergences in the molecular signatures in patients with different ocular lesions during congenital toxoplasmosis.