Clinical and Biological Factors Associated With Recurrences of Severe Toxoplasmic Retinochoroiditis Confirmed by Aqueous Humor Analysis.

PURPOSE: To investigate clinical and biological factors influencing recurrences of severe toxoplasmic retinochoroiditis (TRC) confirmed by aqueous humor analysis. DESIGN: Retrospective case series. METHODS: Retrospective analysis of 87 subjects with severe TRC, proven by positive Goldmann-Witmer coefficient (GWC), Toxoplasma gondii (T. gondii) immunoblot, or T. gondii-specific polymerase chain reaction (PCR) in aqueous humor. Cases with immunosuppression or retinal scars without previous recorded episode were excluded. Time-dependent, clinical, treatment-related, and biological factors were explored by univariate and multivariate shared frailty survival analyses. RESULTS: Among 44 included subjects (age, 40.4 ± 17.6 years; follow-up, 8.3 ± 2.7 years), 22 presented recurrences. There was 0.11 recurrence/patient/year and mean disease-free interval was 5.0 ± 2.9 years. The risk of recurrence was higher immediately after an episode (P < .0001). Among recurrent cases, the risk of multiple recurrences was higher when the first recurrence occurred after longer disease-free intervals (P = .046). In univariate analysis, the recurrence risk declined with higher number of intense bands on aqueous T. gondii immunoblot (P = .006), and increased when venous vasculitis was present initially (P = .019). Multivariate analysis confirmed that eyes with more intense bands on immunoblot had fewer recurrences (P = .041). There was a near-significant risk elevation after pyrimethamine/azithromycin treatment (P = .078 and P = .054, univariate and multivariate). Intravenous corticosteroid administration, oral corticosteroid administration, aqueous GWC, and T. gondii PCR did not influence recurrences (P = .12, P = .10, P = .39, and P = .96, respectively). CONCLUSIONS: Recurrences of severe TRC are not random and may be influenced by clinical and biological factors possibly related to blood-retinal barrier alterations. These results may contribute to identifying biomarkers for TRC reactivation.

Ocular Lesions in Congenital Toxoplasmosis in Santa Isabel do Ivaí, Paraná, Brazil.

We verified clinical and psychopedagogic aspects of congenital cases with ocular sequelae, 13 years after toxoplasmosis outbreak in Santa Isabel do Ivaí, and current seroprevalence of this zoonosis in pregnant women. Audiologic and ophthalmologic evaluations were performed in congenital cases, in addition to collection of clinical and psychopedagogic data. In pregnant women, current seroprevalence was observed. Among affected teenagers, 2 of 5 are behind in school grade, and 4 of 5 reported learning difficulties, requiring psychopedagogic monitoring, as well as ocular complaints. We observed predominance of small, scarred, dispersed, type II chorioretinal lesions (hypopigmented halo and hyperpigmented central area), and 1 case of ocular relapse. All patients presented normal audiologic assessment. Among 131 pregnant women, 62 (47.3%) were seronegative and 39 (29.8%) were IgG reactive. Only 1 reported acquiring infection during the outbreak. This is one of the few studies in Brazil showing the outcome of congenital toxoplasmosis, a decade after infection, in one of the world's largest outbreaks.

Evaluation of the Goldmann-Witmer coefficient in the immunological diagnosis of ocular toxocariasis.

Ocular toxocariasis (OT) is a zoonotic parasitic infection mainly caused by the intraocular tissue invasion of second-stage Toxocara canis or Toxocara cati larva. Measuring specific anti-T. canis antibodies in the intraocular fluid (IF) can increase OT diagnosis accuracy using Goldmann-Witmer coefficient (GWC). However, there is no systemic evaluation of GWC application in the immunological diagnosis of OT. To assess GWC for the immunodiagnosis of ocular toxocariasis, paired IF and serum samples from 72 patients diagnosed with OT were retrospectively analyzed for specific anti-T. canis IgG by enzyme linked immunosorbent assay (ELISA). GWC values were calculated to determine intraocular specific IgG production. Clinical features and other laboratory data were recorded, and their correlations with GWC evaluated. Of the 72 OT patients, 60 (83.33%) showed intraocular specific IgG production confirmed by GWC, while intraocular nonspecific IgE production was found in 64/69 (92.75%) cases. No significant correlation was found among clinical features and IF specific IgG production. Values for peripheral blood samples were lower than those of intraocular fluid regarding OT screening, and vitreous humor samples showed increased local specific IgG and nonspecific IgE production compared with aqueous humor samples. Overall, our results indicate that GWC and intraocular IgE production have referential values in diagnosing ocular toxocariasis.

Protozoal infections of the cornea and conjunctiva in dogs associated with chronic ocular surface disease and topical immunosuppression.

OBJECTIVE: To describe five cases of protozoal keratitis or conjunctivitis in dogs with chronic preexisting ocular surface disease treated with long-term immunosuppression. ANIMALS STUDIED: Five dogs that developed corneal or conjunctival mass lesions. PROCEDURES: The database of the Comparative Ocular Pathology Laboratory of Wisconsin was searched for canine cases diagnosed with corneal or conjunctival protozoal infection. Five cases were identified, and tissues were examined using routine and special histochemical stains: immunohistochemical labels for Neospora caninum, Toxoplasma gondii, and Leishmania spp., and tissue sample PCR for Leishmania spp., Trypanosoma cruzi, tissue coccidia (i.e., T. gondii/Sarcocystis/Neospora), piroplasms, trichomonads, and Acanthamoeba. Electron microscopy was performed for two cases, and serology for N. caninum and T. gondii was available for three cases. RESULTS: Preexisting ocular diseases included keratoconjunctivitis sicca and pigmentary keratitis (n = 4) and pyogranulomatous meibomian adenitis (n = 1). All dogs were treated with tacrolimus or cyclosporine for at least 1.2 years. Dogs were presented with fleshy corneal or conjunctival masses that were clinically suspected to be neoplastic (n = 4) or immune mediated (n = 1). Histologic examination revealed granulomatous inflammation with intralesional protozoal organisms. Amoeba (n = 2), T. gondii (n = 2), or Leishmania mexicana (n = 1) were identified using molecular techniques. Serological tests were negative. CONCLUSIONS: Protozoal keratitis and conjunctivitis without systemic involvement appears rare and may be associated with chronic preexisting ocular surface disease treated with long-term immunosuppression. Based upon clinical appearance, lesions could be confused with neoplasia. This is the first report of amoebic keratoconjunctivitis in dogs and of L. mexicana in dogs in the United States.

ELISA-Confirmed Bilateral Ocular Toxocariasis with Different Features.

PURPOSE: To report a rare case of bilateral ocular toxocariasis with a different clinical presentation in each eye. CASE REPORT: A 56-year-old man presented with severe ocular pain and acute visual loss in the right eye (RE). His best-corrected visual acuity was hand motion in the RE and 20/30 in the left eye (LE). Slit-lamp examination showed a severe anterior chamber reaction in the RE and a moderate anterior chamber reaction in the LE. The fundus of the LE showed a posterior hemorrhagic granuloma with vascular sheathing whereas the fundus of the RE was not visible because of severe vitreous opacification. Blood laboratory testing disclosed hyperproduction of IgE but no eosinophilia. Serum enzyme-linked immunosorbent assay testing was positive for Toxocara canis IgG (1:38). Toxocara antibody was also detected in the aqueous humor from both eyes (RE, 1:321; LE, 1:254). The patient was treated with topical and oral steroids along with oral albendazole. Additionally, phacoemulsification, a therapeutic vitrectomy, and vitreous cultures were performed in the RE. During the vitrectomy, the fundus of the RE showed diffuse retinal vascular obstruction with sheathing. Toxocara antibodies were detected in the vitreous fluid from the RE (1:679). A laser barrier was placed around the granuloma in the LE. After 1 month of steroid therapy, a tapering schedule was started. At 6 months postoperatively, the fundi of both eyes were stable. The final best-corrected visual acuity was 8/20 in the RE and 20/20 in the LE. CONCLUSIONS: A rare case of bilateral ocular toxocariasis is reported with a different clinical presentation in each eye that was diagnosed using enzyme-linked immunosorbent assay analysis of intraocular fluids. Both eyes were successfully treated medically with a vitrectomy eventually being required in the RE.

Isolation of IgG antibodies to Toxocara in ankylosing spondylitis patients with acute anterior uveitis.

PURPOSE: Since few reports had been published on the prevalence of toxocariasis in ankylosing spondylitis (AS) patients with acute non-granulomatous anterior uveitis (ANGAU), the aim of this work was to determine the presence of antibodies against Toxocara canis in AS patients with ANGAU. METHODS: Thirty-six patients (14 female and 22 male) with AS were enrolled in the study. The history of ANGAU was accepted only if diagnosed by an ophthalmologist. The detection of IgG antibodies to T. canis was determined by enzyme-linked immunosorbent assay. In addition, antibodies to Ascaris lumbricoides were also tested to verify non-specific reactions. RESULTS: The prevalence of ANGAU in the AS patients was 58% (21 / 36), and 38% (8 / 21) of the patients with ANGAU were positive for antibodies to Toxocara, while 7% (1 / 15) of AS patients without ANGAU were positive for T. canis (p = 0.038, two tails; mid-p exact). No antibodies were detected to A. lumbricoides antigens in the serum samples of patients with AS. CONCLUSIONS: These data suggest that the seroprevalence of antibodies to T. canis is high in Mexican patients with AS-associated uveitis, suggesting a chronic asymptomatic toxocariosis, which could be associated with the pathogenesis of ANGAU; however, further larger-scale studies are needed to confirm this observation.

Unusual panuveitis in a child: toxocariasis associated with ocular myiasis.

Most panuveitis in children are caused by infectious agents. A detailed clinical history and clinical examination are helpful in the diagnosis, but specific techniques are sometimes required to identify the causing specimen. We report the first published case of panuveitis in a child caused by simultaneous ocular infection by Toxocara canis and a fly larva and the innovative use of immunodiffusion technique in the vitreous for the diagnosis.

A rare ocular complication after a heart transplant: toxoplasma retinitis.

Ocular infections after a heart transplant are rare; but when present, they generally appear during the first year after surgery. Ocular infections may cause significant loss of vision and morbidity if not diagnosed early. For that reason, heart transplant patients should undergo a routine visual examination during follow-up. We report our experience regarding the followup and treatment of a case of toxoplasma retinitis diagnosed in one of our heart transplant recipients.

Ocular parasitoses and their immunology.

Parasitic infections of the eye are a major cause of ocular diseases in many parts of the globe. The causative agents of ocular parasitoses include several species of unicellular protozoan and metazoan helminth parasites, which have a natural predilection for and utilize the eye as their habitat. At times ocular invasion by accidental or uncommon parasites may result in infections of unusual nature. In this review the authors discuss the various parasitic causal agents of eye diseases and the current status of immunology against ocular parasitoses.

Intraocular parasitic infections.

A parasite is a living organism that receives some of its basic nutritional requirements through intimate contact with another living organism. When the parasite reaches the eye, ocular complications occur due to mechanical, immunologic, or allergic reactions. When an ophthalmologist detects a parasite in the eye, it is often difficult to identify the exact organism. Lack of methodological uniformity in management of ocular parasitosis emphasizes the need for standardization, including construction of a management algorithm. Knowledge on immunoreactivity in systemic parasitology has grown remarkably, but translational research from bench to bedside needs to be improved. Newer molecular diagnostic techniques are essential for ophthalmic application. Many parasitic worms are developing resistance to available drugs, necessitating discovery of the next generation of anti-parasitic agents. The aim of this review is to understand the existing literature on ocular parasitosis, to highlight diagnostic and therapeutic advances, and to analyze the management algorithm on ocular parasitosis.

A case report of ocular toxocariasis.

Ocular toxocariasis is prevalent among children. The symptoms and signs may mimic other ocular pathologies such as malignancies and other infectious diseases (such as toxoplasmosis and syphilis). We presented a case of progressive blurring of vision in a single eye of a 9-year-old boy. The presence of anti-toxocara antibody in serum samples helps to confirmation the diagnosis in our patient. Despite of treatment, the boy had lost his vision on the affected eye.

Tear cytokines and chemokines in patients with Demodex blepharitis.

PURPOSE: The purpose of the study is to evaluate the causes of inflammation in Demodex-induced blepharitis by analyzing cytokine levels in lacrimal fluid. METHODS: Fifteen Demodex blepharitis patients were selected for assessment of tear cytokine concentrations. Fifteen Demodex-free blepharitis patients and 15 subjects with no ocular symptoms were selected as control groups. Minimally stimulated tear samples (20µl) were collected from each eye and analyzed using a Luminex® 200™ Total System for detection of IL-1ß, IL-5, IL-7, IL-12, IL-13, IL-17, granulocyte colony-stimulating factor (G-CSF), and macrophage inflammatory protein-1 beta (MIP-1ß). RESULTS: The concentration of IL-17 in tears was significantly higher in the Demodex blepharitis group than in the Demodex-free blepharitis group. Tear IL-7 and IL-12 levels show serial increases for these three groups (p<0.05). There were no significant differences in the other cytokines levels between both blepharitis groups. We confirmed that elevated cytokines normalized after treatments. CONCLUSIONS: Infestation of Demodex mites induces change of tear cytokine levels, IL-17 especially, which cause inflammation of the lid margin and ocular surface. These findings might increase our understanding of the mechanism of ocular discomfort and telangiectasias frequently found in Demodex blepharitis patients.

Priming of host resistance to protect cultured rainbow trout Oncorhynchus mykiss against eye flukes and parasite-induced cataracts.

In the present study, immunologically naive rainbow trout Oncorhynchus mykiss were experimentally exposed to a low-level Diplostomum spathaceum (Trematoda) infection to stimulate acquired resistance and, along with unexposed controls, were subsequently exposed to natural infection for 8 weeks. The priming of the host resistance, designed to simulate a procedure applicable in aquaculture, decreased the number of establishing parasites compared to untreated controls by the end of the experiment. This effect was slow and did not protect the fish against the parasite-induced cataracts. The results suggest that this type of priming of host resistance is probably inefficient in preventing the deleterious effects of D. spathaceum infection in aquaculture conditions.

Parasite-specific antibody profile in the aqueous humor of rabbits with ocular toxocariasis.

Human ocular toxocariasis is diagnosed using ophthalmologic and immunologic examinations. Many researchers have suggested that intraocular parasite-specific antibody levels are indicative of ocular toxocariasis, but little is known about the time course of the changes in these levels. We therefore investigated the anti-Toxocara canis antibody profile in the aqueous humor in an animal model of ocular toxocariasis. We intravitreally injected T. canis larvae into the right eye of 4 rabbits; 2 rabbits were orally administered T. canis eggs. We collected serum, aqueous humor, and tear samples weekly and determined the serum and aqueous humor levels of anti-T. canis immunoglobulin (Ig)G, IgA, IgM, and IgE antibodies and the tear IgG antibody level by enzyme-linked immunosorbent assay (ELISA). The severity of vitreous opacity and the aqueous humor IgG levels (measured using optical density [OD]) changed concordantly in the larvae-injected eyes; the OD exceeded 0.1 from 2-4 weeks after infection and remained elevated during active intraocular inflammation. However, the aqueous humor IgG levels were also elevated in 6 out of 8 eyes without intraocular larvae in both groups, and were low in 1 eye with live intravitreal larvae. In contrast, the serum IgG and IgM levels and the tear IgG levels increased in all rabbits, regardless of the presence of intraocular inflammation. Vitreous opacity occurred in all intravitreally infected eyes, but significant histopathological evidence of retinal damage was not detected. Thus, besides the presence of intraocular larvae, some other factors in the host may be required for the development of retinal lesions.

What is the importance of Demodex folliculorum in Behçet's disease?

Demodex folliculorum is an obligate parasite and commonly detected in patients with immune system deprivation. This study is planned to document the Demodex folliculorum prevalence among patients with Behçet's disease (BD). The patients who referred to the ophthalmology clinic were included in the study. Fourty patients with BD and 131 patients with refractive errors without any ocular and systemic disease were included. For parasite detection, 3 eyelashes from each inferior eyelid were epilated. Standardized skin surface biopsy (SSSB) was performed for detection of parasite at cheeks of patients. Samples were prepared with Hoyer's solution and investigated under the light microscope. There were 15 female and 25 male in BD group and 61 female and 70 male patients ine control group. Mean ages were 37.62 and 38.38 for BD and control groups, respectively. Demodex folliculorum prevalence at eyelashes was 65% for BD and 10% for control group. SSSB of cheek revealed 7.5% positivity for BD and 10% for control group patients. Statistical analysis documented a significant difference for eyelashes (p < 0.05) which could not be detected for skin results. Investigation of Demodex folliculorum in BD may be useful, even in patients without any complaint, for the treatment of ocular and eyelid discomforts of these patients.

Infectivity of Diplostomum spp. in Arctic charr: aspects of exposure duration and cercariae morphology.

The diplostomid flukes, Diplostomum spp., infect fish and cause cataract opacities in the eye lens. The effect of exposure dose on abundance of Diplostomum spp. eye flukes in fish is known, but the effect of the duration of cercariae exposure has not been studied. However, under natural conditions, the temporal window for a successful cercaria attachment on fish is very short and, consequently, differences in infectivity of eye fluke cercariae, in the short-exposure durations of a few seconds, are probably biologically the most meaningful. We investigated infectivity of Diplostomum spp. cercariae originating from snail hosts in 3 lakes (3 Lymnaea stagnalis populations and 1 Radix balthica population) in 6 exposure times, ranging from 5 sec to 15 min, in young-of-the-year Arctic charr Salvelinus alpinus. In addition, we compared the infectivity to the cross-morphology of the cercariae. In the long-exposure duration, i.e., > or = 5 min, infectivity of Diplostomum spp. did not vary between the snail host species (L. stagnalis and R. balthica) of the same lake or across the L. stagnalis populations of 3 different lakes. However, in the short-exposure duration, i.e., < or = 60 sec, Diplostomum spp. cercariae shed from L. stagnalis had higher infectivity than did cercariae from R. balthica of the same lake. This indicates that that there is an interaction between length of cercariae exposure and origin of Diplostomum spp., and that the duration of exposure may influence the results when fish are experimentally infected. Within a lake, cercariae shed from L. stagnalis were also smaller than cercariae shed from R. balthica.

Case of retinochoroiditis associated with porcine ascarids diagnosed by antibodies in subretinal fluid.

PURPOSE: To determine the cause of retinochorioditis in a patient with a granulomatous retinal exudate and an exudative retinal detachment. CASE: A 45-year-old man presented at another hospital with increased visual disturbances of the left eye. He was diagnosed with uveitis, and treated with topical steroids for 1 month. However, the uveitis worsened, and he was referred to our hospital. Ophthalmoscopy showed a yellowish-white granulomatous exudate, and an exudative retinal detachment in the lower peripheral retina. The retinal detachment worsened and affected the macula. Pars plana vitrectomy was performed, and the retina was reattached. During the surgery, ocular samples were collected for further examinations. The titers of antibodies against 12 kinds of ascaridis were examined, and elevated titers of specific antibodies against porcine ascarids were detected in the subretinal fluid, but not in the aqueous humor, vitreous, or serum. CONCLUSIONS: Vitrectomy with the collection of ocular samples, especially subretinal fluid, was a key procedure in the diagnosis and treatment of retinochoroiditis associated with the porcine ascarids.

Isolated optic neuritis from an identified Gnathostoma spinigerum.

PURPOSE: To describe a patient with isolated monocular optic neuritis caused by an identified Gnathostoma spinigerum infestation. CASE REPORT: A 21-year-old man developed a swollen eyelid and painful monocular visual loss of his left eye which did not improve after treatment by intravenous steroid and albendazole. A remarkable eosinophilia in his peripheral blood count was demonstrated. The patient subsequently found a live parasite emerged from his lower eyelid and it was successfully removed by himself. Gross and histopathology examinations of the obtained parasite was undertaken. The parasite was identified as Gnathostoma spinigerum. His blood test for Gnathostoma antibody was positive. DISCUSSION: The etiology of isolated optic neuritis in this patient was Gnathostoma spinigerum which was confirmed by the histopathology of the obtained parasite and the positive serologic test. CONCLUSIONS: We could identify the exact parasite that was proven to cause an isolated optic neuritis. The immediate removal of a causative parasite maynot result in an improvement of the injured tissue but is beneficial in preventing further destruction as well as future complications.

Fuchs heterochromic cyclitis and ocular toxocariasis.

PURPOSE: To report the association of Fuchs heterochromic cyclitis (FHC) and ocular toxocariasis in a young adult. DESIGN: Observational case report. METHODS: A 26-year-old patient was referred for the management of a unilateral intermediate uveitis associated with a lower peripheral subretinal fibrotic lesion near the pars plana. Diagnosis of FHC was clinically confirmed. Laboratory examination was performed to exclude an infectious condition. RESULTS: LISA assay detected significant levels of IgG directed against Toxocara canis. Toxoplasmic serology was negative, excluding this differential diagnosis. Other examinations, including complete blood cell count, urinalysis, serum angiotensin-converting enzyme, lysosyme, chest CT scan, and syphilis serology were noncontributive. CONCLUSIONS: Previous studies have reported on the association of FHC and other parasitic conditions, such as toxoplasmosis but also on herpetic ocular infections. Serologic analysis for toxocariasis may be proposed in patients with FHC and retinal scars in the absence of toxoplasmosis.

Following the migration of a Toxocara larva in the retina by optical coherence tomography and fluorescein angiography.

BACKGROUND: The Toxocara larva is known to migrate across the retina, but the layer in which it migrates and its effect on the retina has been unknown. CASE: An ocular Toxocara infection was diagnosed by an immunological test on a vitreous sample from a patient with a retinal lesion that had migrated. Optical coherence tomography (OCT) and fluorescein angiography (FA) were used in this investigation. OBSERVATIONS: Many small lesions were first detected in the peripheral retina, and vitrectomy was performed because of vitreous haze. Two peripapillary lesions were found during the vitrectomy. OCT of one lesion demonstrated a highly reflective mass located in the nerve fiber layer, and FA showed dye leakage from the lesion as well as hyperfluorescence of the disc. Three weeks later, another lesion was found in the macular area, and OCT and FA findings were the same as for the first lesions. Fluorescein leakage was also observed along the presumed path of the migrating larva. CONCLUSIONS: The movement of the lesion from the peripapillary area to the macular area suggested that a Toxocara larva had migrated across the retina. OCT images indicated that the larva moved in the nerve fiber layer, and FA showed that it caused severe inflammation along its pathway.