Neuroretinitis With Severe Macular Edema in Dual Infection: Challenges in Management.

Neuroretinitis is a potentially vision-threatening condition distinguished by swelling of the optic disc followed by the emergence of a macular star pattern. The majority of these clinical observations are typically linked to infections caused by bacteria, parasites, or viruses. We report a case of dual infections in neuroretinitis complicated with severe macular edema. A 49-year-old lady presented with sudden onset left eye blurring of vision of one-week duration. Visual acuity was 6/6 in the right eye and 6/60 in the left eye. There was a left positive relative afferent pupillary defect with impaired optic nerve functions. A fundoscopy of the left eye showed optic disc swelling with a macular star. The right optic disc was also swollen. Vasculitis changes were observed in both posterior poles. The ocular coherence tomography of the left eye revealed the existence of macular edema, subretinal fluids, and an epiretinal membrane that extended from the optic disc to the fovea. Serological examinations were positive for toxoplasma and herpes simplex virus type 1. The patient was started on oral azithromycin, oral acyclovir, and oral corticosteroids. Left macular edema persisted despite the treatment. The patient was given a trial of a single injection of intravitreal ranibizumab. A remarkable reduction of subretinal fluids was seen post-intravitreal injection and continuation of medications. Intravitreal ranibizumab has shown significant outcomes in neuroretinitis with severe macula edema.

Light After Darkness: A Case Report of Isolated Optic Perineuritis.

This is a report on remarkable visual recovery from blindness in a case of isolated optic perineuritis (OPN). A 68-year-old Chinese lady presented with a two-week history of progressive painless bilateral vision loss. Her vision was 6/18 on the right eye and no perception of light (NPL) on the left eye with positive relative afferent pupillary defect (RAPD). Fundus showed hyperaemic and swollen optic disc bilaterally. MRI of the brain and orbit revealed hyperintense periventricular white matter lesions, possibly early changes of multiple sclerosis (MS), and perineural enhancement of optic nerve bilaterally, consistent with OPN. All other investigations were negative. Intravenous methylprednisolone 1g/day for three days was started, followed with oral prednisolone, tapered in three months. At the third month of follow-up, her vision had improved to 6/12 on the left and 6/9 on the right. The hyperaemic and swollen disc has resolved. Intravenous megadose corticosteroid treatment is an effective first-line treatment for OPN.

Unilateral Proptosis and Bilateral Compressive Optic Neuropathy in a Meningioma Patient.

Unilateral proptosis can be a sign of a potential threat to vision or life. Here, we report a case of unilateral proptosis with bilateral asymmetrical compressive optic neuropathy. A 36-year-old Malaysian indigenous female presented with painless right-eye proptosis associated with progressive blurring of vision for the past month. She had painless progressive left-eye vision loss for eight years. There was marked right-eye proptosis with partial ophthalmoplegia. The optic nerve functions were significantly reduced in the left eye with a positive relative afferent pupillary defect (RAPD). Humphry perimetry showed a right superior nasal field defect. Brain imaging showed two different masses located at the suprasellar and right greater wing of the sphenoid extraaxial lesion likely representing a meningioma. She was diagnosed with bilateral compressive optic neuropathy secondary to intracranial mass and was referred to the neurosurgical team for further intervention. This case highlights that painless proptosis with early vision loss of the fellow eye may be the early presenting symptom of meningioma, without any symptoms of raised intracranial pressure. Brain imaging is warranted to rule out any intracranial pathology if a visual field defect is present.

Atypical Ocular Toxoplasmosis With Remote Vasculitis and Kyrieleis Plaques.

Retinal vasculitis is common in ocular toxoplasmosis (OT) and typically occurs in the same quadrant as retinochoroiditis. This is a case of atypical ocular toxoplasmosis with remote vasculitis distant from the retinochoroiditis lesion. Examination of the left fundus showed the classic posterior segment finding of "headlight in the fog" in the absence of a chorioretinal scar. Retinal vasculitis was noted in all four quadrants at the periphery far from the retinitis area. A presumptive diagnosis of acute panuveitis secondary to ocular toxoplasmosis was made despite the enzyme-linked immunosorbent assay (ELISA) for Toxoplasmosis antibody being pending. The patient was treated empirically with oral sulfamethoxazole-trimethoprim for eight weeks and received both oral and topical corticosteroids. His symptoms and ocular signs have significantly improved. This case report highlights an atypical remote localization of vasculitis with the classic appearance of retinochoroiditis and vitritis, which is highly due to toxoplasmosis. Early initiation of antibiotic therapy is recommended despite pending serology to ensure a good final visual and ocular outcome.

Ocular sporotrichosis from a tertiary referral center in Malaysia and review of literature in Southeast Asia.

Ocular sporotrichosis is rare in Malaysia and Southeast Asia and is increasingly reported in endemic areas of Brazil and Peru. We describe six cases of ocular sporotrichosis involving the bulbar conjunctiva and lid with a literature review on ocular sporotrichosis in Southeast Asia. In these series, four patients presented with similar findings of granulomatous lesion at the palpebral conjunctiva within 1-3 weeks. There was one case mistakenly diagnosed as conjunctival concretion due to its multiple yellowish nodules on the palpebral conjunctiva and another case as chalazion due to swelling of the lower lid. All patients showed immunocompetence. Four patients had an immediate contact with sick cats, one patient had a history of skin scratched by a healthy cat, and another patient had a history of gardening without direct contact with cat. Culture from conjunctival biopsy obtained from five patients and from ruptured lower lid nodules of one patient yielded Sporothrix schenckii. The patients were successfully treated with oral itraconazole 200 mg twice daily. Two patients developed symblepharon after completing treatment, while four patients showed good results without any sequelae.

Ocular Sporotrichosis with Limbal Stem Cell Deficiency: An Impostor with Blinding Sequelae.

Sporotrichosis is a chronic granulomatous fungal infection caused by Sporothrix schenckii. Inoculation of the fungus through breached skin or mucosa typically results in nodular ulceration of the cutaneous and subcutaneous tissue as well as its draining lymphatic nodules. However, reports on ocular involvement have recently increased. We describe a severe case of diffuse granulomatous conjunctivitis involving bulbar and palpebral conjunctiva, resulting in inevitable damage to the limbal stem cells. Isolation of S. schenckii from a conjunctival swab confirmed the diagnosis of sporotrichosis. A 6-month course of oral antifungal therapy was given through which the patient fully recovered. However, extensive corneal conjunctivalization secondary to total limbal stem cell deficiency has caused almost complete blindness in the affected eye. Clinical suspicion of this zoonotic disease is essential for early diagnosis and prompt treatment to prevent ocular surface complication and blindness.

Caecocentral Scotoma: A Rare Presentation of Optic Perineuritis.

Optic perineuritis (OPN) is a subtype of optic neuritis (ON) in which the inflammatory process involves meningeal sheath surrounding the optic nerve. Clinically, OPN simulates ON. However, in contrast to ON, patient with OPN shows sparing of central vision, improves dramatically with high-dose corticosteroid, are more likely to experience recurrence after stopping treatment. We report a rare case of caecocentral scotoma observed in a female with typical ON symptoms. Her magnetic resonance imaging showed features in line with OPN. She was treated with intravenous methylprednisolone 1 g/day for five days followed by slow tapering dose of oral prednisolone for one month. Her vision improved dramatically with a resolution of visual field defect. No relapses seen within two years of follow-up.