Ocular Toxoplasmosis Associated with Unilateral Pigmentary Retinopathy That May Mimic Retinitis Pigmentosa: Diagnostic Dilemmas

We report a unique case of coexisting pigmentary retinopathy and ocular toxoplasmosis in a young male patient. A 23-year-old man presented with sudden visual deterioration in the left eye (LE). The fundus findings revealed bone spicule-shaped pigment deposits, a slightly pale optic disc, arteriole constriction, cystoid macular edema with an epiretinal membrane, and two small inflammatory chorioretinal scars in the right eye, with a concentric narrowing of the visual field and a nonrecordable multifocal electroretinogram (ERG). An active inflammatory lesion at the border of a pre-existing chorioretinal scar in the macula was found in the LE, with a central scotoma in the visual field. Moreover, the patient tested positive for anti-Toxoplasma gondii immunoglobulin G antibodies and showed positive results in polymerase chain reaction testing of aqueous humor. Fluorescein angiography revealed hyperfluorescence in the early phase with fluorescein leakage. A multifocal ERG of the LE showed selective loss of responses from the central 10 degrees. Genetic testing revealed heterozygosity in the RP1 and CELSR1 genes. Our case illustrates challenges in the diagnosis of unilateral pigmentary retinopathy. Based on the typical toxoplasmic lesions in the LE and two scars likely caused by inflammation, our patient was diagnosed with pigmentary retinopathy probably related to toxoplasmosis. Genetic consultation did not confirm the diagnosis of retinitis pigmentosa, but more advanced tests might be needed to definitively exclude it.

Intra-Arterial Chemotherapy: New Hope for Adult Retinoblastoma Treatment—A Case Report and Brief Review

Background. Adult retinoblastoma (RB) is a rare intraocular tumor, leading to delayed diagnosis and, eventually, enucleation of the involved eyes. Therefore, this diagnosis should be considered if attributable signs and symptoms occurred. Here, the authors report a case of an adult group D RB, treated successfully with intra-arterial chemotherapy (IAC) as primary treatment followed by cryotherapy. The authors briefly review the literature on the prognosis and management of adult RB. Case Presentation. A 22-year-old man has noticed floaters in his right eye for 2 months. Right eye examination revealed diffuse white spherical calcified vitreous seeds in all quadrants and a large white endophytic mass in the superonasal quadrant with engorged feeding vessels. Based on clinical data, the group D RB tumor was classified and the IAC was started with 2 medications, melphalan (5 mg) and topotecan (1 mg), for 3 cycles. Trans-scleral triple freeze-thaw cryotherapy was used as an adjunctive treatment at the latest hospital visit. Thirteen months after the last treatment, the RB tumor showed type 4 regression (flat chorioretinal scar) and no evidence of recurrence was identified. Conclusion. It seems that IAC, as the first line of treatment, either alone or in conjunction with adjuvant therapies may allow us to salvage the globe of adult patients involved with RB.

Papillitis and Neuroretinitis as Atypical Presentations of Ocular Toxoplasmosis

We report three cases of optic nerve toxoplasmisis, an unusual form of ocular toxoplasmosis. In one patient the optic nerve involvement occurred in an eye with a toxoplasmic chorioretinal scar and choroidal neovessels in the supramacular area, subretinal fibrosis, and pigment epitheium detachment. The other two patients had papilledema without healed or active chorioretinal lesions, but both had retinal hemorrhage and macular involvement. The diagnosis was based on clinical examination and elavated serum toxoplama antibodies. Optical coherence tomography helped uncover the structural chorioretinal changes. All three patients were treated with a combination of oral antitoxoplasmic drugs, oral prednisone, and intravitreal injection of bevacizumab. Visual acuity improved in all of them. Optic nerve involvement in ocular toxoplasmosis must be considered when papilledema occurs both in isolation and in the presence of an active or scarred chorioretinal lesion.

Choroidal Tuberculoma in a Healthy Immunocompetent Patient

Introduction: Ocular tuberculosis as choroidal tuberculoma is a rare event. It creates a clinical diagnostic dilemma when there is no systemic involvement. Case: A 22-year-old man presented with the chief complaints of discomfort and blurring of vision of right eye for one week. On fundus examination under mydriatics of his right eye, a solitary mass which measured approximately 2DD (Disc Diameter) was appreciated at the superotemporal quadrant with the surrounding localized retinal detachment. Choroidal tuberculoma was suspected by a positive Mantoux test. Physician consultation and laboratory investigations ruled out the pulmonary and systemic manifestation of tuberculosis and other aetiology. Anti-tubercular treatment was started and this led to the improvement of vision and shrinkage of the choroidal mass into a flat chorioretinal scar at 3 months of anti-tubercular treatment . Conclusion: Solitary choroidal tuberculoma though rare, can occur in a healthy, immunocompetent patient.

The Diagnostic Conundrum of Retinitis and a Pigmented Scar

We report a finding of a pigmented chorioretinal scar with acute retinal necrosis (ARN) caused by herpes simplex virus 2 (HSV-2) infection rather than toxoplasma, creating an initial diagnostic dilemma. A 53-year-old functionally monocular male presented with painless floaters and blurry vision in his seeing eye over a period of 4 days. An exam demonstrated anterior chamber (AC) reaction, vitritis, multifocal patches of whitening, and an occlusive retinal vasculitis. A superior pigmented chorioretinal scar with overlying contracted vitreous was noted in the periphery with no adjacent retinal whitening. The patient was treated for both ARN and toxoplasma chorioretinitis until PCR study of the vitreous and AC returned positive for HSV-2 and negative for toxoplasmosis. Management consisted of a dual therapy regimen of both oral and intravitreal antiviral agents as well as oral corticosteroids. The patient’s clinical course was complicated by rhegmatogenous retinal detachment within 2 weeks after symptom onset, requiring pars plana vitrectomy with silicone oil and intraoperative intraocular incubation with foscarnet. We review emerging evidence for pigmented chorioretinal scars in ARN specifically caused by HSV-2, as well as diagnostic and treatment dilemmas in the management of ARN and ARN detachments.

Measurement of the Active Toxoplasma Retinochoroiditis Lesion Size During the Disease Course With Swept Source Optical Coherence Tomography Angiography: A Retrospective Image Analysis

Purpose To measure the lesion size reduction in eyes with active toxoplasma retinochoroiditis during the disease course with swept- source optical coherence tomography angiography (SS-OCTA). Methods We retrospectively analyzed the chorioretinal lesion size in a group of 14 eyes with a single active toxoplasma retinochoroiditis lesion.SS-OCTA was performed at the baseline and follow -up in all eyes. The 6x6 mm choriocapillaris slab images were evaluated with an image analysis (Matlab). The number of black and white pixels in a 1500µm-diameter circle centered on each active lesion was counted at the time of baseline examination and at the first follow-up visit when the chorioretinal scar formation was noticed. Results Fourteen eyes with a single active toxoplasmosis retinochoroiditis lesion were included. Ten patients were female and three,male. Mean age was 29.1 ± 14.9 years. Active lesions were at the macula in five eyes, at the periphery in six eyes and juxtapapillary in three eyes. At the initial examination lesion area was observed as an area with a decreased flow signal on SS-OCTA.There was perilesional capillary disruption in superficial and deep capillary plexi together with a diffuse capillary network attenuation and non-detectable flow signal zones in the choriocapillaris slabs. In addition to sulfamethoxazole-trimethoprim and azithromycine combination oral corticosteroids were only co-administered in five (35%) eyes with macular involvement. The chorioretinal scar formation was observed in four to 16 weeks. At the time of inactivity, original lesion was diminished in size when compared to its baseline in all study eyes (p = 0.001) with a mean black pixel reduction percentage of 21.8%. The reduction was 15.4% in eyes with macular lesion, 31.6% with peripheral lesions and 18.1% with juxtapapillary lesions (p = 0.001, p = 0.032, p = 0.028, p = 0.043, respectively). Visual acuity was correlated with black pixel reduction percentage in eyes with macular lesion (r = 0.56, p < 0.001). Conclusion Active toxoplasma retinochoroiditis lesion size diminished with the healing process as expected and this could be monitorized with an OCTA based image analysis technique. Macular lesions showed less reduction in lesion size despite the addition of oral corticosteroids in contrast to peripheral and juxtapapillary lesions.

Successful Treatment of a Case of Unilateral Endogenous Klebsiella pneumoniae Endophthalmitis

A 52-year-old woman with diabetes was examined for acute visual loss and ocular pain in oculus dexter (OD). Two weeks earlier, a nephrostomy catheter was inserted for the treatment of nephrolithiasis and 10 days after this procedure she suffered an acute myocardial infarction. During hospitalisation, she developed a high fever andKlebsiella pneumoniaewas detected in the blood cultures. On eye examination, mild corneal oedema, minimal hypopyon, vitritis and subretinal abscess of 3DD size at the uppertemporal retina were noted in the right eye. Single intravitreal injection of vancomycin, ceftazidime and clindamycin was given in addition to systemic antibiotic treatment for 14 days. Intraocular inflammation resolved rapidly within days and she regained a visual acuity of 8/10 with a residual chorioretinal scar 2 months later. Endogenous endophthalmitis can be treated successfuly if the diagnosis can be established early enough and treated accordingly.