Ocular toxoplasmosis in pregnancy

Considerations in the management of ocular toxoplasmosis in pregnancy: a review of literature

Ocular toxoplasmosis is the most common cause of infectious posterior uveitis. Available literature is still conflicting regarding the incidence of recurrence during pregnancy as various calculations were employed in the different published studies. Although earlier reports have suggested a difference in presentation and an increase in severity during pregnancy, newer studies appear to show otherwise. Further diagnostic testing, including serologic and intraocular fluid sampling, may be indicated to increase the diagnostic accuracy in this special population of patients. The management of ocular toxoplasmosis during pregnancy is challenging as the foetus is additionally considered in the choice of treatment. Traditionally preferred anti-toxoplasmosis regimens containing antifolate drugs, such as pyrimethamine and trimethoprim-sulfamethoxazole, cannot be used routinely in pregnant patients, especially during the first trimester. This review includes literature on alternative treatments for ocular toxoplasmosis during pregnancy, including spiramycin and intravitreal treatment options.

Pregnancy and the eye: What do we need to watch out for? A review

Pregnancy causes changes in all body systems, including the eye. The eye can undergo physiological and pathological changes in pregnancy. Some changes exacerbate pre-existing eye conditions while other conditions manifest for the first-time during pregnancy. Early recognition and management are essential to prevent sight threatening complications. In addition, some obstetric complications can be associated with ophthalmic signs. Prompt recognition of these eye findings may be life saving for both the mother and the foetus. The aim of this article is to present potential ocular complications in pregnancy and outline the appropriate management to preserve sight and maintain maternal and foetal safety. The safety of the use of common ophthalmological medications will also be discussed.

Ocular toxoplasmosis: a review of the current diagnostic and therapeutic approaches

PURPOSE

This review aims to summarize the current knowledge concerning the clinical features, diagnostic work-up and therapeutic approach of ocular toxoplasmosis focusing mainly on the postnatally acquired form of the disease.

METHODS

A meticulous literature search was performed in the PubMed database. A supplementary search was made in Google Scholar to complete the collected items.

RESULTS

Ocular toxoplasmosis is one of the most frequent infectious etiologies of posterior uveitis. It typically presents with retinochoroiditis. Setting an accurate diagnosis depends to a considerable degree on detecting characteristic clinical characteristics. In addition to the evaluation of clinical features, the diagnosis of toxoplasmosis relies at a large degree on serologic testing. The detection of the parasite DNA in the aqueous or vitreous humor can provide evidence for a definitive diagnosis. The current mainstay for the treatment, if necessary, is the use of oral antibiotic with systemic corticosteroids. Recent evidence suggests other therapeutic approaches, such as intravitreal antibiotics can be used.

CONCLUSION

Recent developments in the diagnostic and therapeutic approach have contributed to preventing or limiting vision loss of patients suffering from ocular toxoplasmosis. Further studies are required to provide a better understanding of epidemiology, pathogenesis, diagnosis, and treatment with a significant impact on the management of this challenging clinical entity.

Treatment of Toxoplasmosis: Historical Perspective, Animal Models, and Current Clinical Practice

Primary Toxoplasma gondii infection is usually subclinical, but cervical lymphadenopathy or ocular disease can be present in some patients. Active infection is characterized by tachyzoites, while tissue cysts characterize latent disease. Infection in the fetus and in immunocompromised patients can cause devastating disease. The combination of pyrimethamine and sulfadiazine (pyr-sulf), targeting the active stage of the infection, is the current gold standard for treating toxoplasmosis, but failure rates remain significant. Although other regimens are available, including pyrimethamine in combination with clindamycin, atovaquone, clarithromycin, or azithromycin or monotherapy with trimethoprim-sulfamethoxazole (TMP-SMX) or atovaquone, none have been found to be superior to pyr-sulf, and no regimen is active against the latent stage of the infection. Furthermore, the efficacy of these regimens against ocular disease remains uncertain. In multiple studies, systematic screening for Toxoplasma infection during gestation, followed by treatment with spiramycin for acute maternal infections and with pyr-sulf for those with established fetal infection, has been shown to be effective at preventing vertical transmission and minimizing the severity of congenital toxoplasmosis (CT). Despite significant progress in treating human disease, there is a strong impetus to develop novel therapeutics for both the acute and latent forms of the infection. Here we present an overview of toxoplasmosis treatment in humans and in animal models. Additional research is needed to identify novel drugs by use of innovative high-throughput screening technologies and to improve experimental models to reflect human disease. Such advances will pave the way for lead candidates to be tested in thoroughly designed clinical trials in defined patient populations.

Ocular Changes During Pregnancy

Pregnancy is needed for the perpetuation of the human species, and it leads to physiological adaptations of the various maternal organs and systems. The eye, although a closed space, also undergoes some modifications, most of which are relatively innocuous, but they may occasionally become pathological. For women, pregnancy is a susceptibility period; however, for many obstetricians, their knowledge of the ocular changes that occur during pregnancy tends to be limited. For this reason, this is a important area of study as is necessary the development of guidelines to approach those changes. Of equal importance are the knowledge of the possible therapies for ophthalmological problems in this period and the evaluation of the mode of delivery in particular conditions. For this article, an extensive review of the literature was performed, and a summary of the findings is presented.

Activation of toxoplasma retinochoroiditis during pregnancy and evaluation of ocular findings in newborns

The purpose of this study was to evaluate patients with activation of toxoplasma retinochoroiditis during pregnancy and ocular findings in newborns. A total of 17 pregnant patients who were clinically and serologically diagnosed with ocular toxoplasmosis were retrospectively reviewed. After birth, ocular findings for all infants were recorded. The mean age of the patients was 29.08 ± 5.71 years. In all cases, activation was present in only one eye. In 13 cases, anterior uveitis was associated with posterior uveitis. Visual acuity in all cases prior to treatment was 0.3 ± 0.21 and increased to 0.55 ± 0.29 after treatment. The mean gestational age of the patients was 19.76 ± 8.71 weeks at the time of hospital admission. No case of toxoplasmic ocular involvement was identified in the infants on postnatal examination. In the case of toxoplasma retinochoroiditis during pregnancy, appropriate treatment and follow-up is very important to protect the newborns and to prevent impaired vision in mothers.

Ocular toxoplasmosis: background and evidence for an antibiotic prophylaxis

PURPOSE OF REVIEW

The purpose of this review was to provide an overview of current data on antibiotic prophylaxis in ocular toxoplasmosis.

RECENT FINDINGS

Studies showing the prophylactic effect of long-term antibiotics are discussed. Prophylaxis seems to be justified in patients with a high risk of recurrence because of antibiotic's potential side-effects. Therefore, predisposing factors leading to a higher risk of recurrence and the time period during which an antibiotic prophylaxis is most appropriate are reviewed. Finally, a patient-individualized treatment recommendation is summarized.

SUMMARY

In the current literature, two prospective, randomized case-control studies exist, which show the protective effect of an antibiotic prophylaxis. Hematologic, gastrointestinal and dermatologic complications are potential side-effects. Especially during the first year after suffering a recurrence, an antibiotic prophylaxis seems to be justified. The risk of a recurrence is inter alia influenced by the duration of the disease, the immune status of the host and the patient's age. Therefore, an antibiotic prophylaxis should be considered for patients who have recently been infected with ocular toxoplasmosis, for middle-aged and elderly patients and patients with a compromised immune system. This should be discussed with each patient individually, especially if the lesion is close to the macula.

Current Therapy of Acquired Ocular Toxoplasmosis: A Review

Caused by the parasite Toxoplasma gondii, ocular toxoplasmosis (OT) is the most common form of posterior infectious uveitis. Combined antiparasitic therapy is the standard treatment for OT, but several other schemes have been proposed. The purpose of the present study was to review the literature on the treatment of OT and provide ophthalmologists with up-to-date information to help reduce OT-related visual morbidity. In conclusion, no ideal treatment scheme was identified; currently prescribed therapeutic schemes yield statistically similar functional outcomes.

Management of toxoplasmic retinochoroiditis during pregnancy, postpartum period and lactation: clinical observations

Background

During pregnancy and labor, the immune response is physiologically impaired and women are more susceptible to infections. Since many drugs may have potentially adverse effects on the fetus and newborn, less aggressive treatment regimens should be considered in pregnant and lactating patients. The aim of our study was to present the management of toxoplasmic retinochoroiditis during pregnancy, postpartum period, and lactation.

Material/Methods

A retrospective study was undertaken of the clinical records of 24 women during pregnancy, postpartum period, and lactation who were referred in the years 1994–2014 to the Department of Zoonoses and Tropical Diseases or the Department of Ophthalmology, Medical University of Warsaw for toxoplasmic retinochoroiditis. The diagnosis was based on the typical ophthalmoscopic picture, confirmed by serological testing using an ELISA method.

Results

A total of 28 attacks of toxoplasmic retinochoroiditis were observed in 24 patients during pregnancy, postpartum period, and lactation. The choice of treatment was guided by the character and location of the inflammatory lesion and the gestational age. Topical (steroidal/nonsteroidal eye drops) and systemic treatments with spiramycin or azithromycin, Fansidar (pyrimethamine 25 mg/sulfadoxine 500 mg), and prednisone were used.

Conclusions

Management of toxoplasmic retinochoroiditis during pregnancy, postpartum period, or lactation must be individualized and guided by the gestational age and location of the active lesion. Women of childbearing age with toxoplasma ocular lesions should be informed by their doctors about possible active recurrences during pregnancy and followed carefully by an ophthalmologist when pregnant.

Do pregnancy, postpartum period and lactation predispose to recurrent toxoplasmic retinochoroiditis?

Backgrund

The aim of the study was a statistical analysis of the possible effects of pregnancy, postpartum period, and lactation on increased risk for reactivation of toxoplasmic retinochoroiditis.

Material/Methods

A retrospective study was undertaken of the clinical records of 661 patients referred with the diagnosis of acute toxoplasmic retinochoroiditis to the Department of Zoonoses and Tropical Diseases, Medical University of Warsaw and to the Department of Ophthalmology, Medical University of Warsaw in the years 1994–2014.

This group of inpatients consisted of 213 women of child-bearing age (18 to 40 years). Reactivation of toxoplasmic retinochoroiditis was observed in 24 women aged 15 to 39 years who were pregnant, in the postpartum period, or lactating.

To compare the rate of the relapses in pregnant/lactating patients vs. non-pregnant/non-lactating patients, the Fisher exact test was used. Calculations were performed with WinPepi software (Abramson JH (2004) WINPEPI (PEPI-for-Windows) for epidemiologists. Epidemiologic Perspectives & Innovations, 2005, 1: 6).

Results

A total of 28 reactivations of toxoplasmic retinochoroiditis were observed (16 episodes in pregnancy, 4 in the postpartum period, and 8 during lactation) in 24 women aged 15 to 39 years. In 3 women, multiple episodes were reported (in early pregnancy and the postpartum period in 2 women, and during 2 pregnancies and lactation in 1 woman). Statistical analysis showed that the risk of an episode of toxoplasmic retinochoroiditis is 7.4-fold higher in pregnancy compared to the non-pregnant/non-lactating women (p<0.0001).

Conclusions

Women of childbearing age with toxoplasma ocular lesions should be informed by their doctors about possible active recurrences during pregnancy and should be followed carefully by an ophthalmologist when pregnant.

Risk of Recurrence of Preexisting Ocular Toxoplasmosis during Pregnancy

PURPOSE

Comparison between the risk of recurrence during pregnancy with nonpregnant periods in patients with ocular toxoplasmosis (OT).

METHODS

Records of 40 women were retrospectively reviewed. The women were subdivided into either a pregnant group or a control group formed by nonpregnant women during follow-up. Comparable cases from the literature were added. Mean number of recurrences per year was compared.

RESULTS

Eleven women with pregnancies could be included. Six cases from the literature were added (total n = 17). Mean number of recurrences per year during versus not during pregnancy was 0.16 (SD 0.39) versus 0.32 (SD 0.30; p = 0.088), respectively. In the control group (n = 29) the mean number of recurrences per year (0.31; SD 0.27) was significantly higher when compared to cases during pregnant periods (p = 0.002).

CONCLUSION

Adding to published series, the presented data do not provide evidence for a relevant impact of pregnancy on recurrence behavior in OT.

Recurrence rates of ocular toxoplasmosis during pregnancy

PURPOSE

To investigate whether recurrence rates of ocular toxoplasmosis are higher during pregnancy in women of childbearing age.

DESIGN

Retrospective longitudinal cohort study.

METHODS

We reviewed medical records of all women seen at a university eye clinic (Utrecht, Netherlands) during episodes of active toxoplasmic retinochoroiditis that occurred while the women were of childbearing age (16-42 years). Each woman was sent a questionnaire requesting information regarding all pregnancies and episodes of ocular toxoplasmosis, whether or not episodes were observed at the eye clinic. Conditional fixed-effects Poisson regression was used to model incidence rate ratios of recurrence during pregnant versus nonpregnant intervals, adjusted for potential confounders, including age at time of active toxoplasmic retinochoroiditis and interval since last episode of active disease, which are known to influence risk for recurrence.

RESULTS

Questionnaires were returned by 50 (58%) of 86 women, 34 of whom had had 69 pregnancies during 584 person-years of study. There were 128 episodes of ocular toxoplasmosis during the study period (6 during pregnancy). First episodes of ocular toxoplasmosis occurred between ages 9.6 and 38.5 years. The youngest age at pregnancy was 16.1 years; the oldest age at childbirth was 40.9 years. The incidence-rate ratios for pregnant versus nonpregnant intervals were in the direction of lower recurrence rates during pregnancy, with point estimates of 0.54 and 0.75 under 2 different approaches, but the ratios were not significantly different from the null value (P values of 0.16 and 0.55).

CONCLUSIONS

Recurrence rates of ocular toxoplasmosis are probably not higher during pregnancy, in contrast to traditional beliefs.

Ocular toxoplasmosis II: clinical features, pathology and management

The term, ocular toxoplasmosis, refers to eye disease related to infection with the parasite, Toxoplasma gondii. Recurrent posterior uveitis is the typical form of this disease, characterized by unilateral, necrotizing retinitis with secondary choroiditis, occurring adjacent to a pigmented retinochoroidal scar and associated with retinal vasculitis and vitritis. Multiple atypical presentations are also described, and severe inflammation is observed in immunocompromised patients. Histopathological correlations demonstrate focal coagulative retinal necrosis, and early in the course of the disease, this inflammation is based in the inner retina. For typical ocular toxoplasmosis, a diagnosis is easily made on clinical examination. In atypical cases, ocular fluid testing to detect parasite DNA by polymerase chain reaction or to determine intraocular production of specific antibody may be extremely helpful for establishing aetiology. Given the high seroprevalence of toxoplasmosis in most communities, serological testing for T. gondii antibodies is generally not useful. Despite a lack of published evidence for effectiveness of current therapies, most ophthalmologists elect to treat patients with ocular toxoplasmosis that reduces or threatens to impact vision. Classic therapy consists of oral pyrimethamine and sulfadiazine, plus systemic corticosteroid. Substantial toxicity of this drug combination has spurred interest in alternative antimicrobials, as well as local forms of drug delivery. At this time, however, no therapeutic approach is curative of ocular toxoplasmosis.

[Management of patients with ocular diseases during pregnancy. Diabetes, glaucoma and uveitis]

Many ocular diseases require treatment even during pregnancy. Some conditions, such as diabetic retinopathy tend to worsen during pregnancy but others, such as uveitis may benefit from the physiological changes occurring during pregnancy. But generally even a favorable development is not sufficient to obtain a steady state without treatment. Each medication applied during pregnancy should only be given after thorough consideration of the pros and cons and discussion of these with the patient. There are sufficient medications for ocular diseases that can be given when indicated following published guidelines and experiences. This review focuses on the course and therapy of glaucoma, diabetic retinopathy and uveitis during pregnancy.

Toxoplasma retinochoroiditis in pregnancy: Using current evidence to inform management

Toxoplasma retinochoroiditis in pregnancy may create considerable patient anxiety and is a dilemma for the treating ophthalmologist. A case report highlighting this clinical issue is presented followed by a review of the literature. Consensus in relation to the management of toxoplasma retinochoroiditis in pregnancy is lacking and is discussed.

Clinical features of ocular toxoplasmosis during pregnancy

PURPOSE

To evaluate the ocular characteristics of active ocular toxoplasmosis (OT) during pregnancy in nine female patients and to compare these attacks with those in the nonpregnant periods.

METHODS

Retrospective analysis of active OT during pregnancy and the nonpregnant periods. Outcome measurements consisted of the duration of attacks, the size of the retinal lesions, treatment strategies, and diverse ocular features and outcomes.

RESULTS

The 9 patients had 10 attacks during pregnancy and 24 attacks while not pregnant. One woman had recurrences during several pregnancies, and in total, three female patients had attacks only when pregnant. In general, the severity of the attacks during the pregnant and nonpregnant periods did not differ.

CONCLUSION

The attacks during pregnancy were not distinctively different in severity, duration, or outcome from the OT attacks outside pregnancy.

Patterns of exacerbations of chronic non-infectious uveitis in pregnancy and puerperium

PURPOSE

To determine patterns of exacerbations of recurrent non-infectious uveitis during pregnancy and puerperium.

DESIGN

Retrospective cohort study.

METHODS

The medical records of 32 women with a history of chronic non-infectious uveitis, who were pregnant during their follow-up at the Ocular Immunology and Uveitis Service of the Massachusetts Eye and Ear Infirmary, from 1983 through 2003, were reviewed. The uveitis relapse rate during pregnancy was compared to the relapse rate during pregnancy-free periods in these women and to the relapse rate in a control group of women of childbearing age with recurrent non-infectious uveitis.

RESULTS

Among the 32 women who were pregnant during follow-up (40 pregnancies), the rate of flare-ups during pregnancy (1.0 recurrence per year) was lower than that observed during non-pregnant periods (2.4 per year; p<0.001) and lower than that observed in the non-pregnant control group (3.1 per year; p<0.001). Flare-ups were most frequent in the first trimester of pregnancy and decreased markedly in the second and third trimesters (2.3, 0.5, and 0.4 recurrences per year, respectively; p<0.001).

CONCLUSIONS

Pregnancy is associated with lower numbers of flare-ups of non-infectious uveitis compared to the non-pregnant state. If flare-ups do occur during pregnancy, they happen predominantly in the first trimester.