Unilateral Toxoplasma retinochoroiditis with frosted branch angiitis: a multimodal imaging study

A woman in her late 30s presented with sudden diminution of vision, redness and pain in the right eye (OD) of 10 days' duration. Best corrected visual acuity (BCVA) was 20/160 in OD and 20/20 in the left eye (OS). Anterior segment of OD showed keratic precipitates, flare 3+, cells 2+ and a festooned pupil. Vitreous haze and cells were seen in OD. Frosted branch angiitis (FBA) was seen in all quadrants in OD and old Toxoplasma scar was seen in both eyes. Serum toxoplasma immunoglobulin G (IgG) was positive and IgM negative, and PCR of an aqueous humour sample was negative for Toxoplasma She was diagnosed with toxoplasa retinochoroiditis in OD and treated with intravitreal clindamycin injections, oral anti-Toxoplasma antibiotics and steroids. Three months later, her BCVA in OD was 20/40 with resolving inflammation. She presented 2 months later with a new focus of retinochoroiditis without FBA and an old Toxoplasma scar.

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.

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.

Ocular toxoplasmosis following anti-tumour necrosis factor-α therapy combined with oral methotrexate therapy: A case report and review of literature

Purpose: To report a case of ocular toxoplasmosis following long-term treatment with adalimumab and review the literature on ocular toxoplasmosis following anti-Tumour necrosis factor-α therapy. Method: A retrospective chart review of A 21-year-old male who developed retinochoroiditis in his left eye following adalimumab therapy combined with oral methotrexate. Result: A known patient of juvenile idiopathic arthritis (JIA) on adalimumab and oral methotrexate for the last four years presented to us with a blurring of vision for the last 15 days. Fundus examination of the left eye revealed severe vitritis and two patches of retinochoroiditis in the inferior part of the fundus. Subsequent investigations confirmed it to be a case of toxoplasma retinochoroiditis, and he responded to anti-toxoplasma treatment. A review of literature on a similar topic revealed five such cases, and the index case was the first such report in patients with JIA. Conclusion: The index case highlights the importance of early recognition and management of opportunistic infections in patients receiving biologicals.

Serous macular detachment in ocular toxoplasmosis: A review

Ocular toxoplasmosis, a disease of the eye caused by the protozoan parasite Toxoplasma gondii, represents a common cause of posterior uveitis. The Authors review the current Literature regarding the uncommon presentation of ocular toxoplasmosis as macular serous retinal detachment (SRD). It is imperative to keep in mind that inflammatory SRD is a possible presentation of toxoplasmic retinochoroiditis. Underestimation of this clinical scenario and treatment with steroids alone without appropriate antiparasitic drugs, could lead to devastating consequences.

Bacillary layer detachment as an inflammatory biomarker in toxoplasmosis retinochoroiditis: serial evolution on optical coherence tomography

We describe the clinical course and serial evolution of bacillary layer detachment (BALAD) on optical coherence tomography (OCT) in toxoplasmosis retinochoroiditis and its importance as an inflammatory biomarker. Colour fundus photography and swept-source OCT of the BALAD were done at the time of presentation and subsequently at 1 week, 2 weeks, 4 weeks and at 11 weeks. Treatment involved oral trimethoprim (160 mg) + sulphamethoxazole (800 mg) two times per day, started at presentation for 2 months. Oral prednisolone was started after 1 week at a dose of 50 mg a day and tapered weekly over the next 5 weeks. The BALAD initially increased after starting treatment with trimethoprim-sulphamethoxazole and regressed within 1 week after initiation of oral prednisolone. Best corrected visual acuity improved to 20/40 from 20/160 at presentation (Snellen equivalent). This suggests that BALAD is an indicator of an acute inflammatory event and the accumulated fluid is secondary to retinal and choroidal inflammation.

Outcomes of trimethoprim/ sulfamethoxazole treatment for ocular toxoplasmosis in Congolese patients

BACKGROUND

Ocular toxoplasmosis (OT) is the leading cause of infectious posterior uveitis in several areas worldwide. The combination of Trimethoprim/Sulfamethoxazole (TMP/SMX) has been presented as an attractive alternative to the "classic' treatment therapy (Pyrimethamine/Sulfadiazine).

METHODS

A prospective study was carried out between February 2020 and September 2021 in 2 ophthalmic centers in Kinshasa. This study aimed to describe TMP/SMX treatment outcomes for OT in a cohort of immunocompetent Congolese patients.

RESULTS

54 patients were included, with a mean age at presentation of 37.5 ± 13.6 years old and a Male-Female ratio of 1.45:1. Three patients (5.6%) presented a recurrence during the follow-up period. At the end of the follow-up, improvement in VA and resolution of inflammation concerned 75.9% and 77.5% of patients, respectively. Cataracts (3.7%), macular scars (3.7%), and vitreous opacities (3.7%) were the principal causes of non-improvement in VA. Treatment-related adverse events were present in 10 patients (18.5%); gastrointestinal (14.8%) and dermatological (3.7%) adverse events were the most frequent. Dermatological adverse events led to discontinuation of treatment.

CONCLUSION

TMP/SMX regimen appears to be a safe and effective treatment for OT in Congolese patients. The low cost and the accessibility of the molecules make this regimen an option for treating OT in resource-limited countries.

A new perspective in the treatment follow-up of toxoplasma retinochoroiditis: Infiltrate thickness measurement

BACKGROUND

This study aimed to describe the spectral domain optical coherence tomography (SD-OCT) findings of active lesions in toxoplasma retinochoroiditis cases and to examine the changes in retinochoroidal infiltrate thickness after treatment.

METHODS

A total of 21 newly diagnosed patients with ocular toxoplasmosis were included in this prospective study. A complete ophthalmologic examination and SD-OCT were performed at the first visit. The patients were followed up weekly, and the SD-OCT images were taken over the lesion at each visit for 6 weeks. The characteristics of the active retinochoroiditis focus at the first visit were determined, and the infiltrate thicknesses at all visits were analyzed.

RESULTS

A statistically significant BCVA difference was observed at the first visit and at the last visit 6 weeks later (p < 0.01). The first week after treatment showed a significant decrease in infiltrate thickness (113.904 ± 86.001 µm). In the following weeks, this decrease continued more softly. The thickness change at 6 weeks was significantly reduced (16.095 ± 14.784 µm) compared with the previous ones. Weekly infitrate thickness changes were compared among themselves; a statistically significant difference was found between the 1st and 2nd weeks and the 5th and 6th weeks (p = 0.035 and p = 0.007, respectively). Detached posterior vitreous in 71% (15/21) and increased posterior vitreous thickness in 76% (16/21) of active lesion were detected. All patients had 100% (21/21) increased retinal reflectivity and disorganized retinal layers, and choroidal hypo-reflectivity was observed in 86% (18/21).

CONCLUSION

SD-OCT is a useful imaging modality in the diagnosis and follow-up of ocular toxoplasmosis cases. Serial thickness measurements of toxoplasma retinochoroiditis lesions may help confirm our diagnosis and determine the need for treatment.

Current practice in the management of ocular toxoplasmosis

BACKGROUND

Ocular toxoplasmosis is common across all regions of the world. Understanding of the epidemiology and approach to diagnosis and treatment have evolved recently. In November 2020, an international group of uveitis-specialised ophthalmologists formed the International Ocular Toxoplasmosis Study Group to define current practice.

METHODS

192 Study Group members from 48 countries completed a 36-item survey on clinical features, use of investigations, indications for treatment, systemic and intravitreal treatment with antiparasitic drugs and corticosteroids, and approach to follow-up and preventive therapy.

RESULTS

For 77.1% of members, unilateral retinochoroiditis adjacent to a pigmented scar accounted for over 60% of presentations, but diverse atypical presentations were also reported. Common complications included persistent vitreous opacities, epiretinal membrane, cataract, and ocular hypertension or glaucoma. Most members used clinical examination with (56.8%) or without (35.9%) serology to diagnose typical disease but relied on intraocular fluid testing-usually PCR-in atypical cases (68.8%). 66.1% of members treated all non-pregnant patients, while 33.9% treated selected patients. Oral trimethoprim-sulfamethoxazole was first-line therapy for 66.7% of members, and 60.9% had experience using intravitreal clindamycin. Corticosteroid drugs were administered systemically by 97.4%; 24.7% also injected corticosteroid intravitreally, almost always in combination with an antimicrobial drug (72.3%). The majority of members followed up all (60.4%) or selected (35.9%) patients after resolution of acute disease, and prophylaxis against recurrence with trimethoprim-sulfamethoxazole was prescribed to selected patients by 69.8%.

CONCLUSION

Our report presents a current management approach for ocular toxoplasmosis, as practised by a large international group of uveitis-specialised ophthalmologists.

Toxoplasmic maculopathy with bacillary layer detachment in a pediatric patient

We report the case of a 14-year-old girl with ocular toxoplasmosis presenting with severe panuveitis with anterior segment involvement, moderate vitreous haze, focal retinochoroiditis, extensive retinal periphlebitis, and macular bacillary layer detachment. Toxoplasmosis treatment was complicated by Stevens-Johnson syndrome, which developed 8 days after starting trimethoprim-sulfamethoxazole.

Antibodies against Toxoplasma gondii positive in serum and aqueous humor to diagnose clinically suspected ocular toxoplasmosis: A case report

INTRODUCTION

Previously, diagnosis of ocular toxoplasmosis is based on clinical symptoms and Toxoplasma serology. Checking serological indicators often cannot reflect the real intraocular situation, and may even mislead clinicians to make wrong judgments.

PATIENT CONCERNS

A 38-year-old male patient visited our ophthalmology clinic with a chief complaint of decreased vision for about 5 days in his right eye.

DIAGNOSIS

Aqueous humor sample analysis found Toxoplasma DNA detectable, and Toxoplasma immunoglobulin G (IgG) and immunoglobulin M (IgM) to be positive. His serum Toxoplasma IgG was also positive (10.04 IU/mL; reference range: 0 to 7.2 IU/mL). Therefore, the final diagnose was ocular toxoplasmosis involving his right eye.

INTERVENTIONS

Oral prednisone 60 mg/day and azithromycin 0.25 g/day were started. Oral antibiotic treatment for toxoplasma was continued for 4 weeks, and prednisone followed by weekly stepwise tapering in steps of 10 mg/day.

OUTCOMES

The BCVA and fundus of right eye remained stable after treatment at follow-up.

CONCLUSIONS

This article reported a case of ocular Toxoplasma gondii infection diagnosis by serum and aqueous humor antibody tests. We provide some additional information on the T gondii infection diagnosis.

In vitro and in vivo anti−Toxoplasma activities of HDAC inhibitor Panobinostat on experimental acute ocular toxoplasmosis

Ocular toxoplasmosis (OT) is retinochoroiditis caused by Toxoplasma gondii infection, which poses a huge threat to vision. However, most traditional oral drugs for this disease have multiple side effects and have difficulty crossing the blood-retinal barrier, so the new alternative strategy is required to be developed urgently. Histone deacetylases (HDAC) inhibitors, initially applied to cancer, have attracted considerable attention as potential anti-Toxoplasma gondii drugs. Here, the efficacy of a novel HDAC inhibitor, Panobinostat (LBH589), against T. gondii has been investigated. In vitro, LBH589 inhibited the proliferation and activity of T. gondii in a dose-dependent manner with low toxicity to retinal pigment epithelial (RPE) cells. In vivo, optical coherence tomography (OCT) examination and histopathological studies showed that the inflammatory cell infiltration and the damage to retinal architecture were drastically reduced in C57BL/6 mice upon treatment with intravitreal injection of LBH589. Furthermore, we have found the mRNA expression levels of inflammatory cytokines were significantly decreased in LBH589–treated group. Collectively, our study demonstrates that LBH589 holds great promise as a preclinical candidate for control and cure of ocular toxoplasmosis.

Rate of recurrence of toxoplasmosis retinochoroiditis at a tertiary eye centre in Auckland

AIM

Our aim was to examine rate of recurrence of toxoplasmosis retinochoroiditis and risk factors for recurrence. No New Zealand epidemiological data on recurrence rates of toxoplasmosis retinochoroiditis have been previously published.

METHODS

Retrospective chart review of all patients with toxoplasmosis retinochoroiditis presented to Auckland District Health Board Department of Ophthalmology between 2006-2019.

RESULTS

One hundred and twenty-six eyes of 115 patients were included with a median age at initial diagnosis of 36.7 years (IQR 23.7-53.8). Fifty-nine patients were female (51.3%), and 16 patients (13.9%) were immunosuppressed. Twenty-six of the 86 patients tested (30.2%) were IgM positive at presentation. Mean follow-up was 6.1 years and 73 recurrences occurred during the follow-up period in 36 patients (31.3%). Treatment was initiated in 87.4% of cases, with oral cotrimoxazole or clindamycin the most common options. Recurrence occurred in 14.8% in the first year (95% CI 10.3%-21.0%), and the risk of recurrence was increased 2x for every previously documented recurrence (HR 2.00; p<0.001). There was no statistically significant increased risk of recurrence with age, IgM positivity, immunosuppression or macular involvement.

CONCLUSIONS

Toxoplasmosis retinochoroiditis had a 14.8% risk of recurrence in the first year, with each previous recurrence increasing the risk by two-times.

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.

Safety and efficacy of different antibiotic regimens in patients with ocular toxoplasmosis: systematic review and meta-analysis

BACKGROUND

Ocular toxoplasmosis (OT) is the most common cause of posterior uveitis, which leads to visual impairment in a large proportion of patients. Antibiotics and corticosteroids lower the risk of permanent visual loss by controlling infection and inflammation. However, there remains disagreement regarding optimal antibiotic therapy for OT. Therefore, this systematic review and meta-analysis were performed to determine the effects and safety of existing antibiotic treatment regimens for OT.

METHODS

MEDLINE, EMBASE, The Cochrane Central Register of Controlled Trials, LILACS, WHO International Clinical Trials Registry Platform portal, ClinicalTrials.gov, and Gray Literature in Europe ("OpenGrey") were searched for relevant studies; manual searches of reference lists were performed for studies identified by other methods. All published and unpublished randomized controlled trials that compared antibiotic schemes known to be effective in OT at any dosage, duration, and administration route were included. Studies comparing antibiotics with placebo were excluded. This review followed standard methodological procedures recommended by the Cochrane group.

RESULTS

Ten studies were included in the narrative summary, of which four were included for quantitative synthesis (meta-analysis). Interventions were organized into three groups: intravitreal clindamycin versus pyrimethamine + sulfadiazine, trimethoprim + sulfamethoxazole versus other antibiotics, and other interventions. The first comparison favored intravitreal clindamycin (Mean difference (MD) = 0.10 logMAR; 95% confidence interval = 0.01 to 0.22). However, this finding lacks clinical relevance. Other outcomes showed no statistically significant differences between the treatment groups. In general, the risk of performance bias was high in evaluated studies, and the quality of the evidence found was low to very low.

CONCLUSIONS

No antibiotic scheme was superior to others, and the selection of a treatment regimen depends on multiple factors; therefore, treatment should be chosen based on safety, sulfa allergies, and availability.

Ocular toxoplasmosis: phenotype differences between toxoplasma IgM positive and IgM negative patients in a large cohort

PURPOSE

To investigate the differences in demographics and clinical characteristics of patients diagnosed with ocular toxoplasmosis according to their IgM status.

METHODS

Retrospective case note analysis was carried out on patients who tested positive for serum Toxoplasma gondii-specific IgM antibodies (IgM+) as well as a comparator group who tested negative for serum IgM (IgM-), but positive for serum IgG. Patient demographics and clinical features were compared between the two groups to evaluate for any significant differences.

RESULTS

One hundred and six patients were included in the study between March 2011 and June 2018, consisting of 37 in the IgM +group and 69 in the IgM- group. Patients in the IgM +group were significantly older (51.1 vs 34.1 years, p<0.0001), more likely to present with central macular lesions (32% vs 12%, p=0.012), and more likely to develop rhegmatogenous retinal detachment (11% vs 1%, p=0.049). In contrast, patients in the IgM- group were more likely present with pain (20% vs 3%, 0.017) and exhibit more severe inflammation of the anterior chamber and vitreous (p<0.05). Overall, retinal lesions were more likely to be superotemporal (55%) and superonasal (31%). Furthermore, age was associated with larger (p=0.003) and more peripheral lesions (p=0.007).

CONCLUSIONS

This study demonstrated significant differences in clinical characteristics of ocular toxoplasmosis according to serum IgM status. IgM+ patients were older, less likely to report pain, had lower levels of intraocular inflammation, but were more likely to have macular involvement. We also found age to be correlated with larger and more peripheral lesions.

Intravitreal clindamycin as a therapeutic alternative in severe ocular toxoplasmosis

Ocular toxoplasmosis is a disease than have severe consequences on the eyesight. The aim of this study article is to present a bilateral ocular toxoplasmosis in a sulfamide allergic patient with unilateral activation and her favourable progression with intravitreal Clindamycin and oral steroids treatment. Weekly intravitreal Clindamycin treatment is shown to be a suitable therapeutic alternative in cases of severe ocular toxoplasmosis and/or in patients with a contraindication to classical treatment. Intravitreal Clindamycin treatment is a safe alternative with favourable clinical results.

Ocular Toxoplasmosis in a Tertiary Referral Center in Sydney Australia-Clinical Features, Treatment, and Prognosis

PURPOSE

The aim of this study was to provide a retrospective analysis of the presentation, demographics, and treatment regimens for ocular toxoplasmosis at a large tertiary referral uveitis center.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A total of 48 patients with ocular toxoplasmosis who presented to Sydney Eye Hospital participated in this study.

METHODS

This is a retrospective review of patient files who presented to Sydney Eye Hospital between 2007 and 2016 with clinical features consistent with ocular toxoplasmosis. Baseline risk factors and treatment details were recorded and analyzed. Main outcome measures were visual acuity and relapse rate compared with other studies in ocular toxoplasmosis.

RESULTS

The median age was 35.5 (interquartile range 21-50) with 30 (60%) patients having no previous symptomatic episodes or evidence of chorioretinal scarring. Visual acuity at presentation was 0.51 or 6/19 (SE 0.096) and at follow-up 0.31 or 6/12 (SE 0.094). Nine patients experienced a recurrence during the period of observation with median time to recurrence 2.2 years (SE 0.45) and the relapse rate was 0.09/person-years. Location of lesion was predominantly within the vascular arcades (n = 44) with macular involvement in 9 patients. Most patients received clindamycin therapy (n = 34) with pyrimethamine and sulfadiazine was used for those with macula involvement.

CONCLUSIONS

Patients with ocular toxoplasmosis had fewer recurrences compared with other published series and had better visual recovery. The majority of patients received clindamycin and oral prednisolone which were well tolerated with pyrimethazine and sulfadiazine reserved for those with macula-involving disease.

Antibiotic treatment for ocular toxoplasmosis: a systematic review and meta-analysis: study protocol

BACKGROUND

Ocular toxoplasmosis (OT) is the most common cause of posterior uveitis, leading to visual impairment in a high proportion of patients. Antibiotics and corticosteroids lower the risk of permanent visual impairment by reducing the size of the retinochoroidal scar, the risk of recurrence, and the severity and duration of acute symptoms. Although OT is a very common cause of infectious posterior uveitis, its treatment remains controversial. Through our systematic review and meta-analysis, we aim to provide the best possible evidence-based information on the safety and effectiveness of the different antibiotic regimes for OT.

METHODS

This systematic review protocol has been developed based on PRISMA-P guidelines for reporting systematic reviews evaluating health care interventions. We will include all published and unpublished randomized controlled trials (RCTs) comparing different antibiotics used for the treatment of OT. We will consider changes in visual acuity, number of recurrences, improvement or worsening of ocular inflammation, size of lesion, and adverse effects as our outcomes. Screening, data extraction, and quality assessment will be undertaken by two reviewers with disagreements resolved through discussion. Studies that compared antibiotics with placebo will be excluded. The reviews will be assessed for quality and relevance. We will assess the risk of bias in five domains according to Cochrane group's tool. The type of data will dictate measures of treatment effect. We will use a random-effects model to calculate our meta-analysis, as eligible studies represent clinically varied populations of participants.

DISCUSSION

The strength of our study will lie in the exhaustive and systematic nature of the literature search, as well as in its methods for assessing quality and analyzing RCT data. Considering the controversial efficacy of the treatment for OT, our study will contribute to improving the existing evidence on the effectiveness of different antibiotics. Future studies may be conducted to increase physicians' awareness of antibiotic therapies, improving the health of patients with OT.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018085468.

Toxoplasmic retinochoroiditis: The influence of age, number of retinochoroidal lesions and genetic polymorphism for IFN-γ +874 T/A as risk factors for recurrence in a survival analysis

Purpose

To analyze risk factors for recurrent toxoplasmic retinochoroiditis.

Design

Single center prospective case series.

Population and Methods

A total of 230 patients with toxoplasmic retinochoroiditis were prospectively followed to assess recurrences. All patients were treated with a specific drug regime for toxoplasmosis in each episode of active retinochoroiditis. Individuals with chronic diseases and pregnant women were excluded. Survival analysis by extended Cox regression model (Prentice-Williams-Peterson counting process model) was performed to evaluate the time between recurrences according to some potential risk factors: age, number of retinochoroidal lesions at initial evaluation, sex and interferon gamma +874 T/A gene polymorphism. Hazard Ratios (HR) and 95% confidence intervals (CI) were provided to interpret the risk effects.

Results

One hundred sixty-two recurrence episodes were observed in 104 (45.2%) patients during follow-up that lasted from 269 to 1976 days. Mean age at presentation was 32.8 years (Standard deviation = 11.38). The risk of recurrence during follow up was influenced by age (HR = 1.02, 95% CI = 1.01–1.04) and number of retinochoroidal lesions at the beginning of the study (HR = 1.60, 95% CI = 1.07–2.40). Heterozygosis for IFN-γ gene polymorphism at position +874 T/A was also associated with recurrence (HR = 1.49, 95% CI = 1.04–2.14).

Conclusion

The risk of ocular toxoplasmosis recurrence after an active episode increased with age and was significantly higher in individuals with primary lesions, which suggests that individuals with this characteristic and the elderly could benefit from recurrence prophylactic strategies with antimicrobials. Results suggest an association between IFN-γ gene polymorphism at position +874T/A and recurrence.

Current treatment of ocular toxoplasmosis in immunocompetent patients: a network meta-analysis

Ocular toxoplasmosis (OT) is the most frequent form of infectious posterior uveitis caused by the protozoan parasite Toxoplasma gondii. To evaluate the available evidence in peer-reviewed publications about the most effective therapy for OT in immunocompetent patients, herein a systematic literature search was conducted using Embase, PubMed, Google Scholar, and the Cochrane Central Register of Controlled Trials (CENTRAL) database from January 1987 to October 2017, with search terms "OT", "retinochoroiditis", "treatment", and "immunocompetent"; search filters "controlled clinical trial", "randomized clinical trial", and "clinical trial". The included studies were performed to evaluate the various treatment modalities of OT. Different treatment regimens were compared with regard to the improvement of visual acuity, the resolution of vitreous inflammation, recurrence, and side-effects. We independently extracted data and assessed eligibility and risk of bias using the preferred reporting items for systematic reviews and meta-analysis, and resolved any disagreement through discussion. A Bayesian network meta-analysis model was used to evaluate the interesting outcomes of all the interventions. Total 10 trials of treatments for OT were found to meet the inclusion criteria. Six trials of treatments including clindamycin, azithromycin, and trimethoprim-sulfamethoxazole (TMP-SMX) were compared with conventional therapy (the combination of pyrimethamine, sulfadiazine, and corticosteroids) for evaluation of the effect on visual acuity, vitreous inflammation, recurrence of OT, and side-effects. Two trials were compared TMP-SMX with placebo. One trial was compared azithromycin with TMP-SMX. And another trial was compared among treatments with clindamycin, P-S, TMP-SMX, and placebo. Based on our network meta-analysis, therapy with TMP-SMX seems to be an alternative treatment of OT in immunocompetent patients.

Early diagnosis and successful treatment of acquired toxoplasmosis infectious retinochoroiditis: A case report

RATIONALE

Toxoplasma gondii is distributed worldwide, infecting a large population. It can cause focal necrotic retinitis or retinochoroiditis in the human eyes and is one of the most common causes of posterior uveitis.

PATIENT CONCERNS

A 68-year-old patient with normal immunity was complained about blurred vision and black shadow in the right eye for 1 week.

DIAGNOSES

Combined Yellow-and-white bulged lesions in the fundus of the right eye with the Goldmann-Witmer coefficient = 2 and based on the serological indicators, we considered the diagnosis of T. gondii infection-induced retinochondritis.

INTERVENTIONS

Acetylspiramycin 0.4 QID × 3 weeks, concussive 20 days treatment after 3 days, for a total of 3 months, prednisone 20 mg/day with a weekly reduction of 5 mg for 1 month.

OUTCOMES

After oral acetylspiramycin, topical and systemic corticosteroids for 3 months, the retinal lesions were scarred, and inflammation of the anterior chamber and vitreum disappeared. After a 9-month follow-up, the visual acuity was 0.6, and no active lesions were observed in the fundus.

LESSONS

The immunocompetent elderly who are in contact with domestic cats may have an opportunistic infection with toxoplasmosis leading to primary retinochoroiditis. Prompt diagnosis and effective treatment can get a good clinical prognosis.

Corticosteroids as adjuvant therapy for ocular toxoplasmosis

BACKGROUND

Ocular infection caused by Toxoplasma gondii, a parasite, may result in inflammation in the retina, choroid, and uvea, and consequently lead to complications such as glaucoma, cataract, and posterior synechiae.

OBJECTIVES

The objective of this systematic review was to assess the effects of adjunctive use of corticosteroids to anti-parasitic therapy versus anti-parasitic therapy alone for ocular toxoplasmosis.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register (2016; Issue 11)), MEDLINE Ovid, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, MEDLINE Ovid Daily (January 1946 to December 2016), Embase (January 1980 to December 2016), Latin American and Caribbean Literature on Health Sciences (LILACS (January 1982 to December 2016)), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP; www.who.int/ictrp/search/en). We used no date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 7 December 2016.

SELECTION CRITERIA

We had planned to include randomized and quasi-randomized controlled trials. Eligible trials would have enrolled participants of any age who were immunocompetent and were diagnosed with acute ocular toxoplasmosis. Included trials would have compared anti-parasitic therapy plus corticosteroids versus anti-parasitic therapy alone, different doses or times of initiation of corticosteroids.

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles and abstracts retrieved through the electronic searches. We retrieved full-text reports of studies categorized as 'unsure' or 'include' after we reviewed the abstracts. Two authors independently reviewed each full-text report for eligibility. Discrepancies were resolved through discussion.

MAIN RESULTS

We identified no completed or ongoing trial that was eligible for this Cochrane review.

AUTHORS' CONCLUSIONS

Although research has identified a wide variation in practice regarding the use of corticosteroids, our review did not identify any evidence from randomized controlled trials for or against the role of corticosteroids in the management of ocular toxoplasmosis. Several questions remain unanswered by well-conducted randomized trials in this context, including whether the use of corticosteroids as an adjunctive agent is more effective than the use of anti-parasitic therapy alone; if so, when corticosteroids should be initiated in the treatment regimen (early versus late course of treatment), and what would be the best dose and duration of steroid use.

The Impact of Short-Term, Intensive Antifolate Treatment (with Pyrimethamine and Sulfadoxine) and Antibiotics Followed by Long-Term, Secondary Antifolate Prophylaxis on the Rate of Toxoplasmic Retinochoroiditis Recurrence

PURPOSE

To assess the impact of intensive antifolate treatment, followed by secondary antifolate prophylaxis (A-SP) on the recurrence rate of toxoplasmic retinochoroiditis (TRC). To investigate whether there are any other factors potentially predisposing for recurrence.

MATERIAL AND METHODS

A total of 637 medical records of TRC patients, who had been treated in the years 1994-2013 were reviewed. All patients were treated with pyrimethamine /sulfadoxine one 25mg/500mg tablet daily (P/S 25/500mg) for 21 days with a double loading dose for the first two days. From Day 2 the patients also received prednisone at a starting dose of 40mg and spiramycine 3 million IU three times daily, given for 10 days followed by azithromycin 500mg once daily for another 6 days. The analysis of the recurrence rate involved 352 patients who had completed 6-month secondary prophylaxis (P/S one 25 mg/500mg tablet twice a week).

RESULTS

When secondary antifolate prophylaxis (A-SP) was instituted immediately after the treatment for TRC, the probability of 3-year recurrence-free survival after the first course of A-SP was 90.9%. A recurrence was most likely approximately 3.5 years after the first treatment. A univariate Cox regression model demonstrated that a risk for recurrence was 2.82 times higher (p = 0.02) in patients with retinal scars. In the multivariate analysis, the risk for recurrence was 2.41 higher (p = 0.06). In patients with haemorrhagic lesions the risk for recurrence was lower, aRR = 0.17 (approaching borderline statistical significance p = 0.08).

CONCLUSIONS

With the institution of A-SP of immediately after the intensive treatment for TRC, i.e. when a reactivation was most likely, there was no recurrence during A-SP. Following A-SP the recurrence rates were low and recurrence-free periods tended to be longer. The treatment regimen employed had a beneficial effect on the recurrence interval as it reduced and delayed the highest probability of recurrence.

Host and Toxoplasma gondii genetic and non-genetic factors influencing the development of ocular toxoplasmosis: A systematic review

Toxoplasmosis is a cosmopolitan infection caused by the apicomplexan parasite Toxoplasma gondii. This infectious disease is widely distributed across the world where cats play an important role in its spread. The symptomatology caused by this parasite is diverse but the ocular affectation emerges as the most important clinical phenotype. Therefore, we conducted a systematic review of the current knowledge of ocular toxoplasmosis from the genetic diversity of the pathogen towards the treatment available for this infection. This review represents an update to the scientific community regarding the genetic diversity of the parasite, the genetic factors of the host, the molecular pathogenesis and its association with disease, the available diagnostic tools and the available treatment of patients undergoing ocular toxoplamosis. This review will be an update for the scientific community in order to encourage researchers to deploy cutting-edge investigation across this field.

Antibiotics versus no treatment for toxoplasma retinochoroiditis

BACKGROUND

Acute toxoplasma retinochoroiditis causes transient symptoms of ocular discomfort and may lead to permanent visual loss. Antibiotic treatment aims primarily to reduce the risk of permanent visual loss, recurrent retinochoroiditis, and the severity and duration of acute symptoms. There is uncertainty about the effectiveness of antibiotic treatment.

OBJECTIVES

To compare the effects of antibiotic treatment versus placebo or no treatment for toxoplasma retinochoroiditis.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision group Trials Register) (2016, Issue 1), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to February 2016), EMBASE (January 1980 to February 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to February 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 22 February 2016. We searched the reference lists of identified articles and contacted pharmaceutical companies for unpublished trials.

SELECTION CRITERIA

We included randomised controlled trials that compared any antibiotic treatment against placebo or no treatment. We excluded trials that included immunocompromised participants. We considered any antibiotic treatment known to be active against Toxoplasma gondii. Antibiotic treatment could be given in any dose orally, by intramuscular injection, by intravenous infusion, or by intravitreal injection.

DATA COLLECTION AND ANALYSIS

The primary outcomes for this review were visual acuity at least three months after treatment and risk of recurrent retinochoroiditis. Secondary outcomes were improvement in symptoms and signs of intraocular inflammation, size of lesion, and adverse events. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Four trials that randomised a total of 268 participants met the inclusion criteria. In all four studies antibiotic was administered orally.One study conducted in Brazil in both adults and children compared trimethoprim-sulfamexacocol over 20 months to no treatment and was judged to be at high risk of performance, detection, and attrition bias. The other three studies compared antibiotic treatment to placebo. We judged these three studies to be at a mixture of low or unclear risk of bias due to poor reporting. One study conducted in the US in adults studied pyrimethamine-trisulfapyrimidine for eight weeks; one study conducted in the UK in children and adults evaluated pyrimethamine for four weeks; and one study conducted in Brazil in adults investigated trimethoprim-sulfamethoxazole for 12 months. In the last study, all participants had active retinochoroiditis and were treated with antibiotics for 45 days prior to randomisation to trimethoprim-sulfamethoxazole versus placebo.Only the study in Brazil of trimethoprim-sulfamethoxazole over 12 months, in participants with healed lesions, reported the effect of treatment on visual acuity. People treated with antibiotics may have a similar change in visual acuity compared with people treated with placebo at one year (mean difference -1.00 letters, 95% confidence interval (CI) -7.93 to 5.93 letters; 93 participants; low-quality evidence).Treatment with antibiotics probably reduces the risk of recurrent retinochoroiditis compared with placebo (risk ratio (RR) 0.26, 95% CI 0.11 to 0.63; 227 participants; 3 studies; I(2) = 0%; moderate-quality evidence); similar results were seen for acute and chronic retinochoroiditis.The UK study of pyrimethamine for four weeks reported an improvement in intraocular inflammation in treated compared with control participants (RR 1.76, 95% CI 0.98 to 3.19; 29 participants; low-quality evidence). The study in Brazil of trimethoprim-sulfamethoxazole for 12 months stated that the severity of inflammation was higher in the comparator group when compared to the antibiotic-treated group but did not provide further details. In the US study of pyrimethamine-trisulfapyrimidine for eight weeks intraocular inflammation had almost completely resolved by eight weeks in all participants, however in this study all participants received steroid treatment.Two studies (UK and US studies) reported an increased risk of adverse events in treated participants. These were a fall in haemoglobin, leucocyte, and platelet count, nausea, loss of appetite, rash, and arthralgia.

AUTHORS' CONCLUSIONS

Treatment with antibiotics probably reduces the risk of recurrent toxoplasma retinochoroiditis, but there is currently no good evidence that this leads to better visual outcomes. However, absence of evidence of effect is not the same as evidence of no effect. Further trials of people with acute and chronic toxoplasma retinochoroiditis affecting any part of the retina are required to determine the effects of antibiotic treatment on visual outcomes.

Bilateral maculopathy in a patient with ataxia telangiectasia

We report a case of toxoplasmosis with bilateral maculopathy in a 7-year-old boy diagnosed with ataxia telangiectasia (AT) at age 6. AT manifests as ataxia, apraxia, telangiectasia, and dysarthria. Common ophthalmologic findings in AT include fine conjunctival telangiectasia. Patients also suffer from recurrent sinopulmonary infections; however, serious opportunistic infection is rarely diagnosed. At 8 years of age he developed disseminated Toxoplasma gondii (toxoplasmosis) infection and meningoencephalitis. This ophthalmologic finding and the subsequent toxoplasmosis meningoencephalitis have not been previously reported in AT.

The role of intravitreal trimethoprim/sulfamethoxazole in the treatment of toxoplasma retinochoroiditis

The authors evaluate the role of intravitreal trimethoprim/sulfamethoxazole in the treatment of toxoplasma retinochoroiditis (TRC) in four patients. Intravitreal injection of trimethoprim/sulfamethoxazole 1.28 mg/0.08 mL with dexamethasone 400 µg/0.1 mL was injected weekly or biweekly. After the initiation of treatment, a reduction in intraocular inflammation was observed clinically and on optical coherence tomography within 1 week. Three patients regained visual acuity of 20/20, and one patient improved to 20/40 with residual macular scarring. No evidence of retinal toxicity was noted on full-field electroretinogram. Intravitreal trimethoprim/sulfamethoxazole and dexamethasone combination may be an alternative treatment strategy in patients with TRC.

[Ocular toxoplasmosis - seeking a strategy for treatment]

AIM

To compare the effectiveness of treatment for ocular toxoplasmosis with pyrimethamine + clindamycin (or sulfadiazine) + a corticoid (Group 1), or azithromycin or a combination of azithromycin with a corticoid or a corticoid alone (Group 2). To determine the relapse rate depending on the treatment approach.

MATERIAL AND METHODS

A total of 25 patients treated for ocular toxoplasmosis over the last five years (2008-2013) were analyzed. Group 1 comprised 16 patients (3 were excluded) and Group 2 consisted of 6 patients.

RESULTS

Visual improvement was more rapid in Group 1 (day 10.7) than in Group 2 (significant improvement on day 29.6). There were 5 cases of relapse in Group 1; in 13 cases, no relapse was noted; all patients in Group 2 relapsed (a total of 13 relapses). Twenty-three patients were positive for specific IgG antibodies.

CONCLUSION

According to our experiences, pyrimethamine + clindamycin (or sulfadiazine) + a corticoid should be the treatment of choice in patients with ocular toxoplasmosis.

Corticosteroids as adjuvant therapy for ocular toxoplasmosis

BACKGROUND

Ocular infestation with Toxoplasma gondii, a parasite, may result in inflammation in the retina, choroid, and uvea and consequently lead to complications such as glaucoma, cataract, and posterior synechiae.

OBJECTIVES

The objective of this systematic review was to assess the effects of adjunctive use of corticosteroids for ocular toxoplasmosis.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 9), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to October 2012), EMBASE (January 1980 to October 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to October 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We searched the reference lists of included studies for any additional studies not identified by the electronic searches. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 11 October 2012.

SELECTION CRITERIA

We planned to include randomized and quasi-randomized controlled trials. Eligible trials would have enrolled participants of any age who were immunocompetent and were diagnosed with active ocular toxoplasmosis. Included trials would have compared anti-parasitic therapy plus corticosteroids versus anti-parasitic therapy alone, or different doses or times of initiation of corticosteroids.

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles and abstracts retrieved from the electronic searches. We retrieved full-text articles of studies categorized as 'unsure' or 'include' after review of the abstracts. Two authors independently reviewed each full-text article. Discrepancies were resolved through discussion.

MAIN RESULTS

The electronic searches retrieved 368 titles and abstracts. We reviewed 20 full-text articles. We identified no trials eligible for inclusion in this systematic review.

AUTHORS' CONCLUSIONS

Although research has identified wide variation in practices regarding use of corticosteroids, our systematic review did not identify evidence from randomized controlled trials for the role of corticosteroids in the management of ocular toxoplasmosis. Several questions remain unanswered by well-conducted randomized trials in this context, including whether use of corticosteroids is more effective than use of anti-parasitic therapy alone, when corticosteroids should be initiated in the treatment regimen (early versus late course of treatment), and which dosage and duration of steroid use is best. These questions are easily amenable to research using a randomized controlled design and they are ethical due to the absence of evidence to support or discourage use of corticosteroids for this condition. The question of foremost importance, however, is whether they should be used as adjunct therapy (that is, additional) to anti-parasitic agents.

The absence of vitreous inflammation: one more challenge in diagnosing toxoplasma papillitis

Toxoplasma is a leading cause of posterior uveitis in immunocompetent patients manifesting as a focal posterior retinochoroiditis. The clinical diagnosis of ocular toxoplasmosis is usually straightforward. There is typically a fluffy white retinal lesion which may lie adjacent to a pigmented chorioretinal scar and a prominent vitreous, or additionally, anterior chamber cellular reaction. Several unusual presentations in ocular toxoplasmosis have been reported, including: papillitis, neuroretinitis, retrobulbar neuritis, retinal detachment and macular oedema. This is a case of presumed primary toxoplasma papillitis in a 14-year-old child with complete absence of vitritis at presentation that made the diagnosis challenging. This evolved into neuroretinitis that resolved upon introducing antitoxoplasma antibiotics.

Ocular toxoplasmosis and retinal detachment: five case reports

BACKGROUND

Ocular toxoplasmosis is a potentially blinding cause of posterior uveitis. Retinal detachment is rare complication of ocular toxoplasmosis.

AIM

To report the clinical course and prognosis of retinal breaks and detachments occurring in patients with ocular toxoplasmosis.

PATIENTS AND METHODS

This study was a retrospective, non-comparative case series of five patients with ocular toxoplasmosis who had consulted us with retinal detachment.

RESULTS

All of the participants had retinal detachment after severe and treatment resistant toxoplasmic retinochoroiditis, leaving one of them with decreased visual acuity to light perception in spite of treatment and final visual acuity was 20/100 or better in four patients.

CONCLUSIONS

The functional prognosis for the patients with retinal detachment was poor. Careful retinal examination in ocular toxoplasmosis is warranted, especially in patients with severe intraocular inflammation.

[Optimization of complex treatment in ocular toxoplasmosis and concurrent infections]

137 patients (177 eyes) with verified toxoplasmic uveitis, retinitis, chorioretenitis were observed. Among them 65 patients had concurrent infections: tuberculosis, herpes simplex and chlamydia. Routine ophthalmologic, clinical and laboratory examination was performed. The results of intensive treatment in acute and chronic phases are presented, the staged drug pathogenic treatment including methods of specific therapy, based on differential approach to anti-inflammatory agents use, was provided. Early diagnosis and appropriate management including combined treatment of concurrent infections improves treatment efficacy and allows to achieve excellent results.

Severe hepatotoxicity and probable hepatorenal syndrome associated with sulfadiazine

PURPOSE. The case of a patient who developed hepatorenal syndrome during treatment with sulfadiazine for toxoplasmosis retinitis is reported.

SUMMARY

A 20-year-old Caucasian woman weighing 59 kg was admitted to the infectious diseases ward of a hospital in May 2009 with nausea, vomiting, and jaundice. In March 2009, she was diagnosed with toxoplasmosis retinitis and received sulfadiazine 3 g daily, pyrimethamine 50 mg daily, leucovorin 15 mg daily, and prednisolone 75 mg daily; she continued these medications for three weeks. After the development of gastrointestinal symptoms, she stopped taking the prescribed medications (five days before hospital admission). One day before hospital admission, her skin appeared jaundiced. At the time of admission, the patient had high transaminase levels, hyperbilirubinemia, abnormal prothrombin time and International Normalized Ratio values, and clinical evidence of acute fulminant hepatitis complicated by hepatorenal syndrome. Autoimmune hepatitis was excluded as a cause of her hepatotoxicity, as was Wilson's disease, herpes simplex virus, cytomegalovirus, hepatitis A virus, hepatitis E virus, and Epstein-Barr virus. She was diagnosed with probable drug-related fulminant hepatitis, presumably caused by sulfadiazine treatment. Lactulose 20 g was started for the prevention of encephalopathy. She received phytonadione 10 mg daily for three consecutive days, ranitidine 50 mg thrice daily, ciprofloxacin 250 mg twice daily, and acetylcysteine 600 mg thrice daily. The patient underwent hemodialysis five times during her hospital stay. Her symptoms gradually improved, and she was discharged on hospital day 20.

CONCLUSION

Probable hepatorenal syndrome requiring hemodialysis occurred in a patient receiving sulfadiazine for the treatment of toxoplasmosis retinitis.

Long-term outcome of children with congenital toxoplasmosis

OBJECTIVE

Maternal toxoplasmosis infection acquired during pregnancy carries significant risk of fetal damage. We aimed to assess the long-term outcome of children and young adults with congenital toxoplasmosis diagnosed and treated in utero.

STUDY DESIGN

This was a 20 year prospective study (1985-2005). All mothers received spiramycin, alone or associated with pyrimethamine-sulfadoxine, and underwent amniocentesis and monthly ultrasound screening. Infected children were followed every 3-6 months.

RESULTS

Of 666 liveborn children (676 mothers), 112 (17%) had congenital toxoplasmosis. Among these, 107 were followed up for 12-250 months: 79 were asymptomatic (74%) and 28 had chorioretinitis (26%). Only 1 child had a serious neurological involvement.

CONCLUSION

The percentage of chorioretinitis in treated children depends on length of follow-up, but this complication occurs mainly before the age of 5 years and almost always before the age of 10 years. Visual impairment was infrequently severe, and outcome appears consistently good. Long-term follow-up is recommended to monitor ocular and neurological prognosis, whatever the practical difficulties.

[The possibility of the treatment of bilateral macular edema without the anti VEGF treatment--a case report]

Aim of this case report is to present a case of a female patient with bilateral macular edema successfully treated by the systemic antibiotic.

MATERIAL AND METHODS

The authors present a case of 58 years old female with bilateral cystoid macular edema. In this patient, the central retinal thickness of the right eye was 550 microm, and 600 microm of the left eye. The best-corrected visual acuity (BCVA) of the right eye was 4/10 (0.4) and 4/12 (0.33) of the left eye. The patient underwent complex ophthalmologic examination. During the examination of the posterior pole, there were found no signs of the diabetic changes, or signs of the uveitis. The fluorescein angiography did not prove the presence of the choroidal neovascular membrane or vasculitis. The serological tests (toxoplasmosis, toxocariasis, borreliosis, syphilis--TPHA, RRR), and immunologic tests were performed as well. Toxoplasma positive IgG antibodies were found. According to these serological results, the systemic oral antibiotic treatment was started: clindamycin 300 mg three times daily for 14 days. After the termination of the treatment, improvement of the BCVA to 4/5 (0.8) in both eyes occurred. The OCT examination showed the foveolar depression in both eyes. Two months after the termination of the antibiotic treatment, the relapse of the macular edema occurred (BCVA 4/6 (0.66) in both eyes). According to the consultation with the doctor from the Department of Infectious Diseases, the treatment with clindamycin was started again (300 mg three times daily) for three weeks. After termination of this treatment, the foveolar depression on the OCT examination was evident and the BCVA was 4/4 (1.0) in both eyes (central retinal thickness of the right eye was 215 microm, and of the left eye it was 225 microm). This condition is stable and lasts for more than one year.

CONCLUSION

In the differential diagnosis of the bilateral macular edema also the inflammatory etiology should be always considered. According to our experience, the bilateral macular edema may be the only presentation of toxoplasmosis.

[Toxoplasmic central chorioretinitis]

Toxoplasma gondii is the most frequent cause of chorioretinitis in immunocompetent patients. This paper highlights the case of a 15 years old girl, an immunocompetent patient, with an active chorioretinal focus in the LE and a chorioretinal scar in the RE. Serologically, the IgG antiToxoplasma titre is increased, but the IgM antibodies are negative. It is the bilateral character of the lesions and the serology found that make this case special.

Atypical toxoplasmosis masquerading late occurrence of typical findings

PURPOSE

To report two unusual cases of ocular toxoplasmosis.

METHOD

Case series.

RESULTS

We describe one case of retinochoroiditis associated with branch retinal artery occlusion and a second case of optic disc edema with subsequent neuroretinitis. In both cases, the typical findings of ocular toxoplasmosis were not initially present, but became evident later during follow-up after the institution of antitoxoplasma treatment. The prompt response to antiparasitic treatment with visual improvement and late disclosure of typical findings confirmed the clinical suspicion of the diagnosis.

CONCLUSIONS

Ocular toxoplasmosis must be considered in the differential diagnosis of patients with unilateral branch retinal artery occlusion and neuroretinitis. Prompt initiation of specific antibiotic treatment can improve visual prognosis and reduce ocular complications.

Fuchs’ heterochromic iridocyclitis following bilateral ocular toxoplasmosis

PURPOSE

To describe the development of Fuchs' heterochromic iridocyclitis (FHI) following bilateral ocular toxoplasmosis in an Asian Indian female.

METHODS

Case report of a patient with bilateral ocular toxoplasmosis who developed bilateral Fuchs' heterochromic iridocyclitis.

RESULTS

Features characteristic of bilateral Fuchs' heterochromic iridocyclitis developed following several attacks of bilateral toxoplasmic retinochoroiditis in a 26-year-old Indian female patient.

CONCLUSION

Fuchs' heterochromic iridocyclitis can develop over a period of time in patients with ocular toxoplasmosis.

Ocular impairment of toxoplasmosis

The purpose of this review is to update the latest information about ocular toxoplasmosis. The infection can be congenital or acquired, but also depends about the immune condition of the patient and can affect the eye. Ocular symptoms are variable according to the age of the subject. Retinochoroiditis is the most common manifestation of toxoplasmic infection. Toxoplasmic retinochoroiditis typically affects the posterior pole, and the lesions can be solitary or multiple. Active lesions present as grey-white focus of retinal necrosis with adjacent choroiditis, vasculitis, hemorrhage and vitreitis. Anterior uveitis is a common finding. Atypical presentations include punctate outer retinitis, neuroretinitis and papillitis. Depending on the patient's age and the localization of the lesion, ocular symptoms vary usually presenting with reduced visual acuity or without symptoms. The laboratory diagnosis of toxoplasmosis is based on detection of antibodies and T. gondii DNA using polymerase chain reaction (PCR) which fulfillis clinical findings. Toxoplasmosis therapy includes antimicrobial drugs and corticosteroids. There are several regimens with different drug combinations including, among others, pyrimethamine, sulfadiazine, clindamycin, and trimethoprim-sulfamethoxazol.

The antitoxoplasma gondii antibodies incidence to the different ocular diseases patients cases of human ocular toxoplasmosis infections in Romania

Toxoplasmosis is an anthropo-zoonosis widely spread around the earth, whose ocular complications are very frequent and are often a first sign of infestation. This is a retrospective statistic research based on the clinical survey and periodic control of a lot of 135 patients with toxoplasmosis, out of which 90 presented ocular toxoplasmosis.

Longitudinal study of new eye lesions in treated congenital toxoplasmosis

OBJECTIVE

To determine the incidence of new chorioretinal lesions in patients with congenital toxoplasmosis who were treated throughout their first year of life.

DESIGN

Prospective longitudinal observation of a cohort.

PARTICIPANTS

One hundred thirty-two children were studied as part of the longitudinal observation.

METHODS

One hundred thirty-two children were treated during their first year of life with pyrimethamine, sulfadiazine, and leucovorin. They had eye examinations at prespecified intervals.

MAIN OUTCOME MEASURES

New chorioretinal lesions on fundus examination and fundus photographs.

RESULTS

The mean age (+/- standard deviation) is 10.8+/-5.1 years (range, 0.2-23). One hundred eight children have been evaluated for new chorioretinal lesions. Thirty-four (31%; 95% confidence interval, 23%-41%) of 108 children developed at least one chorioretinal lesion that was previously undetected. These occurred at varying times during their follow-up course. Fifteen children (14%) developed new central lesions, and 27 (25%) had newly detected lesions peripherally. Ten (9%) had more than one occurrence of new lesions developing, and 13 (12%) had new lesions in both eyes. Of those who developed new lesions, 14 children (41%) did so at age 10 or later.

CONCLUSION

New central chorioretinal lesions are uncommon in children with congenital toxoplasmosis who are treated during their first year of life. This finding contrasts markedly with earlier reports in the literature for untreated children or those treated for only 1 month near birth, in whom new lesions were much more prevalent (>/=82%). Our observation that 14 (41%) of the 34 children with new chorioretinal lesions had occurrences when they were 10 years or older indicates that long-term follow-up into the second decade of life is important in assessing the efficacy of treating toxoplasmosis during infancy.

INTRAVITREAL CLINDAMYCIN FOR TOXOPLASMIC RETINOCHOROIDITIS

PURPOSE

To report outcomes of off-label use of intravitreal clindamycin in the treatment of toxoplasmic retinochoroiditis.

METHODS

In a noncomparative, retrospective, interventional case series, we reviewed the charts of six consecutive patients with toxoplasmic retinochoroiditis who were treated with intravitreal injection of clindamycin (1.0 mg/0.1 mL) because of intolerance to or disease progression despite oral microbial treatment. The primary outcome measures were change in Snellen visual acuity, resolution of inflammation, and adverse events.

RESULTS

Injection of intravitreal clindamycin was associated with control of toxoplasmic retinochoroiditis and resolution of vitreous inflammation in all six patients. Five patients had improvement in visual acuity. One patient's vision was limited because of macular scarring. Four patients underwent concomitant pars plana vitrectomy (PPV) at the time of injection. One patient who had concomitant clindamycin injection and PPV developed a retinal detachment postoperatively.

CONCLUSION

Intravitreal clindamycin injection, alone or in conjunction with PPV, was associated with resolution of toxoplasmic retinochoroiditis in six patients.

ACUTE CHOROIDAL ISCHEMIA ASSOCIATED WITH TOXOPLASMIC RETINOCHOROIDITIS

PURPOSE

To describe eight patients with active toxoplasmic retinochoroiditis (RC) who had features suggestive of acute choroidal ischemia.

METHODS

A retrospective review of the clinical records of 23 consecutive patients with acute toxoplasmic RC was performed. All patients underwent detailed ophthalmic examination at presentation and throughout follow-up, including dilated biomicroscopic fundus examination, fundus photography, fluorescein angiography, and indocyanine green (ICG) angiography.

RESULTS

Of 23 patients, 8 (34.8%) had a large area of retinal whitening surrounding a small focus of RC. Fluorescein as well as ICG angiography showed a well demarcated geographic area of early choroidal hypofluorescence that extended beyond the clinical borders of the white retinal lesion, particularly by ICG angiography. Associated findings for these 8 patients included old retinochoroidal scars (7 [87.5%]), serous retinal detachment (3 [37.5%]), retinal hemorrhages (1 [12.5%]), and multiple satellite dark dots by ICG angiography (6 [75%]). Seven of eight patients were treated using a combination of antitoxoplasmic drugs and corticosteroids. All findings seen at the acute stage resolved in 2 weeks to 6 weeks. A small atrophic retinochoroidal scar replaced the active toxoplasmic lesion and was surrounded with mild or moderate retinal pigment epithelium changes that were associated with decreased final visual acuity in 2 patients (25%).

CONCLUSION

Patients with toxoplasmic RC may develop features suggestive of choroidal ischemia that can result in a transient or permanent decrease in vision. Choroidal ischemia can only be suspected clinically, and fluorescein angiography and ICG angiography are required to establish the definitive diagnosis.