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

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

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

Fulminant toxoplasmic retino-choroiditis following intravitreal triamcinolone administration.

We report two cases of fulminant toxoplasmic retinochoroiditis following intravitreal triamcinolone acetonide (IVTA) administration. Case 1: A 42-year-old female received IVTA for presumed non-infectious panuveitis. Within 2 months, she developed diffuse macular retinochoroiditis with optic disc edema. Upon starting anti-toxoplasmic therapy (ATT), her intraocular inflammation resolved with catastrophic damage to the disc and macula. Case 2: A 30-year-old male received IVTA for presumed reactivation of previously scarred toxoplasmic retinochoroiditis. Despite simultaneous ATT, within 6 weeks, he developed extensive, multifocal macular retinochoroiditis. He continued to require ATT for 18 months and later underwent vitrectomy with silicone oil placement for severe epiretinal proliferation. Aqueous tap polymerase chain reactions were found positive for Toxoplasma gondii in both cases. In conclusion, IVTA administration can lead to fulminant toxoplasmic retinochoroiditis even when used with appropriate ATT. Extreme caution should be exercised while administering depot corticosteroids in eyes with panuveitis of unknown origin.

Combination photodynamic therapy and bevacizumab for choroidal neovascularization associated with toxoplasmosis.

A 14-year-old girl presenting with visual loss in both eyes was diagnosed to have healed toxoplasma retinochoroiditis in the right eye with active choroidal neovascularization (CNV) secondary to toxoplasmosis in the left. She underwent combination photodynamic therapy (PDT) and intravitreal bevacizumab as primary treatment. PDT was performed as per the ‘Treatment of Age-related Macular Degeneration by Photodynamic therapy’ study protocol and was followed by intravitreal bevacizumab after 2 days. CNV regressed at 8 weeks of follow-up and remained stable at 8 months of follow-up. The initial visual acuity improved from 20/120 to 20/30. Combination therapy with PDT and intravitreal bevacizumab appears to be effective in the treatment of CNV secondary to toxoplasma retinochoroiditis.

Intraretinal worm documented by optical coherence tomography in a patient with diffuse unilateral subacute neuroretinitis: case report / Larva intrarretiniana documentada pela tomografia de coerência óptica em um paciente com neurorretinite subaguda difusa unilateral: relato de caso

Our purpose is to report a case of diffuse unilateral subacute neuroretinitis (DUSN) in which an ophthalmoscopically visible worm was found and optical coherence tomography (OCT) scans allowed the precise localization of the parasite in the intraretinal layers. Our findings suggest that the parasite moves in the inner portions of the retina possibly explaining the severe degenerative neural changes that it causes.

Nosso objetivo é relatar um caso de neurorretinite subaguda unilateral difusa (DUSN), onde uma larva oftalmoscopicamente visível foi detectada e, através do escaneamento pela tomografia de coerência óptica (OCT), foi possível estabelecer a localização precisa do parasita entre as camadas da retina. Nossos resultados sugerem que o movimento do parasita nas camadas mais internas da retina possa explicar as graves alterações neuronais degenerativas encontradas.

Retinal nerve fiber layer atrophy as relevant feature for diffuse unilateral subacute neuroretinitis (DUSN): case series / Atrofia das camadas de fibras nervosas da retina como característica relevante na neurorretinite subaguda difusa unilateral (DUSN): série de casos

PURPOSE: To report the findings of optical coherence tomography (OCT) in three cases of diffuse unilateral subacute neuroretinitis (DUSN). METHODS: Three young patients with confirmed diagnosis of diffuse unilateral subacute neuroretinitis were followed-up using Stratus® OCT. RESULTS: Optical coherence tomography findings included retinal nerve fiber layer atrophy and focal edema where the worm was initially lodged. In two patients we could identify the worm by optical coherence tomography as an area of hiper-reflectivity. The worms were laser photocoagulated and post-treatment optical coherence tomography scanning revealed improvement of edema, nerve fiber layer thinning and a retinal hyper-reflectivity where laser had been applied. CONCLUSION: The main finding reported here is the potential of optical coherence tomography in detecting the presence of retinal nerve fiber layer atrophy and focal retinal edema in areas affected by the worm. Optical coherence tomography can be used to distinguish diffuse unilateral subacute neuroretinitis from other mimicking diseases like punctate outer retinitis, when there are no retinal fiber layer atrophy.

OBJETIVO: Demonstrar os achados da tomografia de coerência óptica em três casos de neurorretinite subaguda difusa unilateral (DUSN). MÉTODOS: Os pacientes com diagnóstico confirmado de neurorretinite subaguda difusa unilateral realizaram seguimento pré e pós-tratamento por meio da tomografia de coerência óptica, Stratus® OCT. RESULTADOS: Os achados marcantes da tomografia de coerência óptica foram a atrofia das camadas de fibras nervosas da retina e edema da retina localizado em áreas nas quais a larva esteve. Em dois pacientes pôde-se localizar a larva no espaço sub-retiniano por meio da tomografia de coerência óptica, que se traduziu por pequena área densa (hiperrefletividade). As larvas foram fotocoaguladas a laser e os achados da tomografia de coerência óptica após o tratamento demonstrou melhora do edema, afinamento das camadas de fibras nervosas e hiperrefletividade no local da aplicação do laser. CONCLUSÃO: Os principais achados na tomografia de coerência óptica foram a atrofia difusa das camadas de fibras nervosas e o edema localizado nas áreas afetadas pela larva. A tomografia de coerência óptica pode ser usado para diferenciar neurorretinite subaguda difusa unilateral de doenças que a simulam, como retinite punteada externa, que não manifesta alterações das camadas de fibras nervosas.

Tratamento clínico da neurorretinite subaguda difusa unilateral com albendazol / Clinical treatment of diffuse unilateral subacute neuroretinitis with albendazole

OBJETIVO: Descrever a evolução de uma série de casos de neurorretinite subaguda difusa unilateral (NSDU) tratados com albendazol. MÉTODOS: Relato de série de casos intervencionista. Os autores desenvolveram protocolo de ensaio clínico não controlado, para estudar a evolução clínica de casos de neurorretinite subaguda difusa unilateral tratados com albendazol. Segundo os critérios do protocolo, foram selecionados seis pacientes até o momento desta publicação, que serão descritos separadamente. RESULTADOS: Dos seis pacientes estudados, quatro apresentavam larva. Todos os seis pacientes tratados com a droga anti-helmíntica apresentaram melhora da acuidade visual e das lesões coriorretinianas multifocais. As larvas identificadas nos pacientes foram inativadas com o tratamento. Nenhum efeito colateral foi observado. CONCLUSÕES: A terapia anti-helmíntica com albendazol parece ser benéfica e segura para pacientes com neurorretinite subaguda difusa unilateral. Mais estudos são necessários para avaliar a eficácia do albendazol no tratamento da neurorretinite subaguda difusa unilateral.

PURPOSE: To describe the evolution of a series of cases of diffuse unilateral subacute neuroretinitis (DUSN) treated with albendazole. METHODS: Interventional case series. The authors developed a non-randomized clinical trial protocol to investigate the clinical evolution of diffuse unilateral subacute neuroretinitis cases treated with albendazole. According to protocol criteria up to now, six patients were selected that will be described separately. RESULTS: Of the six studied patients, four presented the worm. All six patients treated with the antiparasitic drug showed improvement of visual acuity and of chorioretinal scars. During the weeks of treatment, evidence of worm inactivation was documented for the four patients with visible worms. No adverse drug side effects were observed. CONCLUSIONS: The antiparasitic drug albendazole seems to be beneficial and safe in patients with diffuse unilateral subacute neuroretinitis. More studies are necessary to evaluate the effectiveness of albendazole in the treatment of diffuse unilateral subacute neuroretinitis.