Bilateral Optic Neuroretinitis: Uncommon Complication of COVID-19.

At the end of 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China. On 11 March 2020, the World Health Organization declared COVID-19 a pandemic. This virus affects many organs, including the eye, and can manifest through various clinical manifestations. Multiple neuro-ophthalmological manifestations have been reported in association with COVID-19, including, Optic Neuritis, cranial nerve palsies, eye movement abnormalities, and visual field defects. In this article, we report a case of bilateral neuroretinitis in association with (SARS-CoV-2).

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.

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.

Multimodal Imaging in Idiopathic Neuroretinitis with Localized Choroidal Insufficiency: A Case Report.

Neuroretinitis is a rare clinical entity, characterized by optic nerve edema and star-shape hard exudate around fovea. The clinical features include acute unilateral visual loss, dyschromatopsia, relative afferent pupillary defect and visual field abnormalities. Increased vascular permeability of the optic disc is the main pathophysiology. As it is a not fully known clinical entity, diagnosis is challenging. In this case, we use multimodal imaging to reveal pathophysiology and anatomical change of early mild neuroretinitis. Case presentation: A 28-year-old healthy woman presented to the clinic with mild blurred vision in her left eye. After complete ophthalmic examination, outer retinal thickening of the temporal peripapillary area and optic disc edema were observed. Two days after diagnosis, the retinal edema and visual symptoms were aggravated. A hard exudate, maybe a part of macular star, was observed. Multimodal imaging including optical coherence tomography (OCT), swept-source OCT angiography (SS-OCTA), fluorescein angiography, and indocyanine green angiography visualized choroidal thinning and insufficient circulation beneath the outer retinal edema. Following steroid pulse therapy, the retinal edema and blurred vision were completely resolved. Conclusions: Multimodal imaging suggested that unilateral optic disc edema and early macular star help the diagnosis of neuroretinitis. In SS-OCTA, we found focal choroidal insufficiency. The focal insufficient choroidal circulation might be a contribution factor for idiopathic neuroretinitis. Multimodal imaging including SS-OCTA may be a valuable tool for detecting and monitoring disease progression.

Bartonella neuroretinitis (cat-scratch disease).

We report a patient with cat-scratch disease presenting with meningitis and neuroretinitis. This condition, caused by Bartonella henselae, has a worldwide distribution and is among the most common infective causes of neuroretinitis. Bartonella neuroretinitis is a rare but under-recognised mimic of optic neuritis; it should be suspected in a patient with an infective prodrome whose fundus shows optic disc oedema and a macular star. A low-positive initial serological test for Bartonella henselae does not exclude cat-scratch disease if there is high clinical suspicion, and repeat testing is recommended to look for titre rise.

Final Diagnosis in Patients Referred with a Diagnosis of Neuroretinitis.

The purpose of this study was to determine final diagnosis of patients referred with a diagnosis of neuroretinitis. A retrospective study of 40 patients with optic disc oedema with macular star (ODOMS) referred with a diagnosis of neuroretinitis was conducted. The final diagnosis was neuroretinitis in 26 patients (65%), with most of these patients (96.1%) having unilateral involvement. Main underlying aetiologies included cat scratch disease (30.8%), rickettsiosis (19.2%), and idiopathic neuroretinitis (23.1%). The remaining 14 patients (35%) had ODOMS that had been mistaken for neuroretinitis. Of these patients, 42.8% were found to have a previously unknown malignant systemic hypertension in association with bilateral ODOMS. Neuroretinitis, usually unilateral, should be differentiated from other causes of unilateral or most often bilateral ODOMS that may masquerade as neuroretinitis, mainly malignant systemic hypertension. This is essential to avoid inappropriate work-up and management and subsequent potential visual or systemic morbidity.

Anti-MOG (Myelin Oligodendrocyte Glycoprotein)-Positive Severe Optic Neuritis with Optic Disc Ischaemia and Macular Star.

A 44-year-old man presented with severe right visual loss. The right fundus examination showed marked optic disc oedema associated with partial macular star. Serological blood tests for infectious agents were all negative. Serum aquaporin-4 antibody was negative but anti-MOG (myelin oligodendrocyte glycoprotein) was positive. Magnetic resonance revealed extensive lesion in right optic nerve. There was no visual improvement after intravenous therapy. Patient had no further attacks after follow-up. Optic disc oedema with macular star is found in several infectious and non-inflammatory disorders, but it has not been reported in optic neuritis (ON) associated with autoantibodies to myelin oligodendrocyte glycoprotein (anti-MOG).

Paradoxical Exudative Retinopathy and Macular Star Formation After Treatment Initiation in Coats Disease.

Purpose: This work describes a unique clinical feature in Coats disease. Methods: A retrospective series of 2 cases is reported. Results: Two pediatric patients receiving treatment for Coats disease were included. In both cases, vision worsened secondary to paradoxically increased exudation and macular star formation following standard treatment with intravitreal bevacizumab, sub-Tenon triamcinolone acetonide, and laser photocoagulation. After serial treatments under general anesthesia, the exudates in both cases consolidated. Conclusions: A paradoxical exudative retinopathy can occur in some patients when initiating standard treatment of Coats disease. Longitudinal follow-up with continued intravitreal antivascular endothelial growth factor agents, laser photocoagulation, and corticosteroids might help control persistent exudation in these cases.

Leber's idiopathic stellate neuroretinitis: A clinical case.

Introduction: In 1916, Leber's idiopathic stellate neuroretinitis (LISN) was described by Theodore Leber as a rare disease characterized by optic disc swelling associated with a macular star. This fundus appearance can have multiple causes but the etiology of Leber's idiopathic stellate neuroretinitis remains unknown. Case report: A 40 year-old man consulted for a progressive decline in visual acuity and a blurred vision in his left eye. Corrected Visual acuity of the left eye was hand motion, Funduscopy of the left eye revealed a stellate maculopathy with loss of foveolar depression and a normal optic disc. The angiography confirmed an optic disc oedema. Laboratory investigations were normal. No infectious nor inflammatory etiology was found. Brain imaging was normal. Patient received 3 days of intravenous methylprednisolone at 10mg/kg/D for 3 days in a row and an oral relay was started with a progressive degression over 2 weeks. The evolution after treatment was satisfactory, the visual acuity 3 weeks after the intravenous injection of corticoids increased to 2/10. Discussion: Leber's idiopathic stellate neuroretinitis (LISN) is a disorder characterized by disc oedema, peripapillary and macular hard exudates and, often, the presence of vitreous cells. The changes in the optic nerve are the primary cause of reduced vision in this condition. The more common treatable causes must be excluded wich are cat scratch disease (CSD) and vascular disease. 50% of cases have no identifiable cause and are labeled idiopathic neuroretinitis. There is no consensus regarding optimal treatment. The prognosis of Leber's idiopathic stellate neuroretinitis is good in most cases. Conclusion: The cause of neuroretinitis must be aggressively pursued before a diagnosis of lebre's idiopathic neuroretinis can be retained in order to formulate an appropriate treatment strategy.

Non-arteritic Anterior Ischemic Optic Neuropathy with Macular Star following COVID-19 Vaccination.

PURPOSE: To report a case of non-arteritic anterior ischemic optic neuropathy (NAAION) with macular star after receiving the second dose of SARS-CoV-2 vaccination. METHOD: Case report. OBSERVATION: A 51-year-old male presented with acute visual disturbances one day after the second dose of BNT162b2 mRNA SARS-CoV-2 vaccination. At presentation, best corrected visual acuity (BCVA) was 20/25 right eye (OD) and counting fingers at 3 feet left eye (OS). Anterior segment examination was normal in both eyes. Dilated fundoscopy was unremarkable OD, however, it disclosed optic nerve swelling and subretinal fluid OS. Patient was treated with a gradual tapering dose of oral prednisone over 1 month. At the five-week follow-up visit, optic disc swelling and subretinal fluid resolved with minimal improvement in BCVA to 20/400 OS. CONCLUSION: It is unclear whether COVID-19 vaccination was the triggering agent to the NAAION or just a coincidence, yet ophthalmologists should be aware of such a possible association.

Sudden-Onset Blindness in a Child With Hypertensive Emergency: Unmasking of Chronic Kidney Disease.

A 10-year-old male presented with sudden-onset diminution of vision in both eyes. On systemic examination, he had severe hypertension, no pulse deficit, short stature, and no other focal neurological deficit. Dilated fundoscopy showed bilateral grade 4 hypertensive retinopathy with macular star formation. Detailed laboratory investigations revealed a stage 5 chronic kidney disease (CKD). We present this case to highlight this rare ocular manifestation of CKD in pediatric age group.

Toxoplasmosis Related Neuroretinitis: More than Meets the Eye.

BACKGROUND: The intracellular protozoan Toxoplasma (T. gondii) is a parasitic infection, normally asymptomatic in immunocompetent patients. It often manifests ophthalmically, with focal necrotizing retinitis, and is more rarely associated with vitritis and anterior uveitis. Neuroretinitis, which results in severe, painless visual loss, optic disc edema, and a macular star, is an unusual first presentation of toxoplasmosis which despite being rare, when it does occur tends to affect young, immunosuppressed patients. CASE PRESENTATION: This case report describes a 34-year-old, white, European, immunocompetent female, who developed sudden visual loss and was found to have optic disc edema and stellate macular exudates. She was managed in an ophthalmic unit in the UK, a country with a low prevalence of toxoplasmosis Following extensive investigation, confirming Toxoplasma the standard anti-toxoplasmosis treatment was commenced, resulting in visual improvement over the following 6 months. CONCLUSION: Toxoplasmic neuroretinitis should be considered with no background of systemic illness and in the absence of classical risk factors.

Malignant Hypertension and the Role of Ophthalmologists: A Review Article.

Malignant hypertension (MHT) is a sudden and severe increase in systemic blood pressure (BP) associated with advanced bilateral retinopathy. It comes under a broader term, called hypertensive emergency, where an acute rise in BP results in end-organ damage. The condition usually requires hospital admission and intensive care management. Although there are lots of sophisticated machines and laboratory tests present to diagnose various organ damage, the role of ophthalmologists will still be at the top. A record of the acute rise of BP to a defining level and simple ophthalmoscopy with high clinical suspicion can save a patient's life and preserve target organ function by timely referral. So, every ophthalmologist should be aware of this dangerous condition. In this review, we have tried to compile all the current knowledge regarding malignant hypertension that an ophthalmologist may require in day-to-day practice.

Rickettsial neuroretinitis: A report of 2 cases.

PURPOSE: The authors present two cases of neuroretinitis caused by Rickettsia rickettsii infection. OBSERVATIONS: Case 1 is a 24-year-old male who presented with 2 months of vision loss. Case 2 is a 38-year-old female who presented with 4 weeks of eye pain and vision loss. Examination of both patients revealed neuroretinitis characterized by optic disc swelling with macular exudates, and subsequent serological analysis was positive for Rickettsia rickettsii. Both patients responded favorably to treatment with oral doxycycline and prednisone. CONCLUSIONS AND IMPORTANCE: Given the potential for neuroretinitis to cause permanent vision loss, the presence of acute vision loss, optic disc edema, and macular exudates should prompt an evaluation for Rickettsial disease in endemic areas, even in the absence of systemic symptoms or known history of a tick bite.

[Bartonella henselae neuroretinitis in an adolescent]. / Neurorretinitis por Bartonella henselae en un adolescente.

Neurorretinitis as a manifestation of cat scratch disease occurs in 1-2 % of patients with Bartonella Henselae eye disease. Ocular manifestations tend to follow systemic ones, although they can appear in their absence. The presence of star-shaped macular exudate is characteristic and suggestive of this infection. We report a case of a 14-year-old healthy boy, with 15 days of decreased visual acuity, who was admitted for suspected left optic neuritis with papilledema. Ophthalmological examination revealed the characteristic "macular star" that led to the diagnosis of infection by Bartonella Henselae, later confirmed by positive serology.

La neurorretinitis como manifestación de la enfermedad por arañazo de gato se presenta en el 1-2 % de los pacientes con afecciones oculares por Bartonella henselae. Las manifestaciones oculares suelen suceder a las sistémicas, aunque pueden aparecer en ausencia de estas. La presencia de exudado macular en forma de estrella es característico y sugestivo de dicha infección. Se presenta el caso de un paciente de 14 años de edad, previamente sano, con disminución de la agudeza visual de 15 días de evolución, que ingresó por sospecha de neuritis óptica izquierda con edema de papila. El seguimiento oftalmológico reveló la aparición de la lesión característica en "estrella macular" que permitió arribar al diagnóstico de infección por B. henselae, confirmándose luego con serología positiva.

Bilateral Anterior Ischaemic Optic Neuropathy as First Manifestation of Henoch-Schönlein Purpura (IgA Vasculitis).

A 46-year-old man was referred to our department complaining of a bilateral progressive decrease in his visual acuity. Fundus examination revealed bilateral optic disc oedema, indicative of anterior ischaemic neuropathy (AION), and a macular star in the right eye. Laboratory analysis showed low haematocrit and haemoglobin, elevated creatinine, and increased erythrocyte segmentation rate and C-reactive protein level. Physical examination revealed the presence of purpuric rash on the trunk and the extremities. During the investigation we performed a complete laboratory and imaging examination for autoimmune collagen diseases, vasculitides and infectious diseases, which were all negative. Histologic findings of renal biopsy were compatible with IgA glomerulonephritis and thus Henoch-Schönlein purpura (HSP) diagnosis was established. The patient was treated with methylprednisolone and cyclophosphamide. Six months later, his renal function and his visual acuity had improved, and the rash had subsided. This is a rare case of AION in a patient with HSP.

Treatment Strategies for Neuroretinitis: Current Options and Emerging Therapies.

PURPOSE OF REVIEW: To explore and critically appraise the published data on the current and emerging treatment modalities for neuroretinitis. RECENT FINDINGS: The optimum treatment strategy for neuroretinitis due to Bartonella henselae in immunocompetent individuals is not clear and a matter of debate. The role of systemic corticosteroids in infectious neuroretinitis and the optimum immunosuppressive regimen for use in recurrent idiopathic neuroretinitis also remains ill defined. There is no class 1 evidence to support a specific treatment strategy for neuroretinitis. For uncomplicated B. henselae-associated neuroretinitis in immunocompetent patients, initiation of antibiotic and corticosteroid therapy remains controversial. In patients with severe vision loss and/or moderate to severe systemic symptoms, a 4- to 6-week regimen of doxycycline or azithromycin with rifampin may provide some benefit. The routine use of systemic corticosteroids in infectious neuroretinitis is not recommended. Targeted antimicrobial agents should be instituted in cases of neuroretinitis due to specific infectious etiologies (e.g., syphilis, Lyme disease, tuberculosis). Azathioprine may be beneficial in cases of recurrent idiopathic neuroretinitis. There is a need for collaborative, multicenter prospective studies to provide definitive guidelines regarding the use of antibiotics and corticosteroids and to evaluate future therapies in infectious and recurrent idiopathic neuroretinitis.

Neuroretinitis Secondary to Bartonella Henselae in a Patient with Myelinated Retinal Nerve Fibers: Diagnostic Dilemmas and Treatment.

Purpose: To report an unusual case of Bartonella henselae neuroretinitis (BHNR) in a patient with myelinated retinal nerve fibers (MRNFs). Methods: A 56-year-old male presented for a consultation, because of a decrease in visual acuity from his right eye. Onset was unclear and the patient was not sure if this was a new symptom. Results: Fundoscopy revealed MRNF without any other clinical findings. After 2 weeks, the patient returned complaining of further visual acuity decrease. Fundoscopy disclosed macular star formation. The patient was treated with azithromycin. The visual acuity deteriorated to 20/400 and we added systemic corticosteroids with slight improvement of the visual fields but minimal visual gain to 20/160. Serology test results were positive for BH (IgG titers>1/256). Conclusions: Co-existence of BHNR and MRNF can create diagnostic dilemmas. The presence of myelinated nerve sheath in combination with the expected swelling in neuroretinitis may have caused an irreversible mechanical nerve damage.