White Retinal Lesions Research Articles

Bilateral multifocal inner retinitis following a viral illness, likely Covid-19.

To describe a young female patient who presented with unilateral vision loss with multiple bilateral inner retinal lesions after a non-specific viral illness, likely Covid -19. Case Report: We reviewed the medical record, examined the retina, OCT images and fundus fluorescein angiogram of the patient along with the relevant medical literature. The patient presented to our Emergency Department at Moorfields Eye Hospital with a two-week history of new onset floaters and blurred vision in her right eye. On examination she was found to have a low grade bilateral vitritis, mild right optic nerve head swelling and multiple white inner retinal lesions in both eyes. Retinitis can be due to multiple infectious and non-infectious aetiologies. In this case report we discuss a case of rare multifocal inner retinitis from a non-specific viral illness - likely COVID -19.

SEROUS RETINAL DETACHMENT DUE TO CRYPTOCOCCOSIS IN AN IMMUNOCOMPETENT PATIENT

Purpose: To report a case of bilateral ocular cryptococcosis in an immunocompetent patient without neurologic findings. Methods: Case report. Results: A 30-year-old healthy Caucasian man presented with painless blurred vision in the left eye. Examination showed bilateral serous detachments and white retinal lesions. The visual acuity (VA) was 20/40 in the right eye and hand motions in the left eye. Neurologic workup and serologies were negative, and a computer tomography-positron emission tomography scan showed diffuse lymph node enlargement with metabolic activity and a suspected lymphoproliferative disorder. The myelogram and immunohistochemistry were normal. A biopsy of the cervical lymph nodes was positive for Cryptococcus neoformans. He was treated with antifungal medications and had complete resolution of the subretinal fluid and VA improvement. Conclusion: Cryptococcosis is a rare entity in an immunocompetent person. A systemic workup is necessary to diagnose cryptococcosis and initiate prompt treatment.

Case of acute retinal necrosis with rapid progression to proliferative vitreoretinopathy: A case report.

Acute retinal necrosis (ARN) was first reported in 1971 by Urayama et al as an acute uveitis accompanied by retinal arteritis and white retinal lesions in the peripheral retina that can progress to a rhegmatogenous retinal detachment (RRD). We have experienced a case of ARN that, unlike the common developmental course to an RRD associated with ARN, progressed to proliferative vitreoretinopathy (PVR) involving the entire retina in 2 days. The purpose of this report is to present our findings in the case of ARN with an atypical rapid time course. The patient was a 56-year-old woman who was treated for uveitis of unknown origin by her primary care physician. She was referred to our hospital because of a worsening of the fundus findings. Fundus examination in our hospital revealed vitreous opacities in the right eye, yellowish-white lesions extending around the retina, and some retinal hemorrhages. Because the retinal changes suggested ARN, we performed a polymerase chain reaction of the anterior atrial fluid and detected varicella-zoster virus. Then, the diagnosis of ARN was confirmed, and treatment was begun. At 1 month and a half after beginning the treatment, focal retinal traction was observed in the right fundus. Two days later, a circumferential PVR and a total retinal detachment were detected. We then performed vitrectomy with an encircling buckle and a silicone oil tamponade. Our examination 6 months postoperatively showed that the retina was attached and the BCVA was 20/200. Our findings of a case of ARN showed that the progression from a local vitreous traction to a full circumferential PVR can develop in 2 days.

An Unusual Chorioretinal Manifestation of Relapsing Polychondritis Coexisting with Scleritis: A Case Report

Purpose: To report an atypical chorioretinal manifestation concomitant with severe scleritis in a patient diagnosed with relapsing polychondritis. Methods: A 53-year-old male, with a six-month history of recurrent bilateral auricular cartilage inflammation was admitted to our hospital. Clinical and pathological examinations of the auricular cartilage led to the diagnosis of relapsing polychondritis. Results: Ophthalmological examination revealed a localized elevation in the superonasal quadrant of the left fundus, where the scleritis was more severe than in other regions. B-mode ultrasonography revealed choroidal thickening and subretinal lesions in this area, along with a white retinal lesion identified during the fundus examination. Further investigation using optical coherence tomography (OCT) unveiled subretinal and retinal lesions in the same region, with dispersed cells into the vitreous cavity in a fountain-like pattern. After treatment with systemic corticosteroids and cyclophosphamide, there was an improvement in scleritis, conjunctivitis, and retinal vasculitis; however, the white retinal lesion progressed to retinal atrophy. Concurrently, a decrease in the number of vitreous cells emanating from the area of fountain-like leakage was noted. Conclusions: Retinal manifestations of relapsing polychondritis are underrepresented in the literature. This report presents a unique case of relapsing polychondritis with a localized retinal manifestation observed on OCT imaging, thereby broadening our understanding of the potential localized retinal presentations associated with this disease.

Long-term follow-up of a healthy man with endogenous Streptococcus anginosus endophthalmitis

We report the long-term follow-up of an immunocompetent patient who presented with slowly progressive endogenous endophthalmitis secondary to Streptococcus anginosus. A 46-year-old healthy man presented with a two-month history of right eye iritis. On examination, visual acuity was 20/60 with intraocular pressure of 6 mm Hg. There was a small layer of hypopyon with non-granulomatous anterior uveitis and vitritis. On funduscopy, fluffy white peripheral retinal and pre-retinal lesions were noted in superonasal periphery. The patient denied any present or past illness. Diagnostic pars plana vitrectomy was performed. Culture and polymerase chain reaction of the vitreous sample were positive for Streptococcus anginosus. Intravitreal vancomycin and ceftazidime and systemic ceftriaxone were administered. Work-up which included blood and urine cultures, chest x-ray, echocardiography and abdominal ultrasound was unyielding. Subsequently and because of persistent post-infectious inflammatory reaction, intravitreal and oral steroids were administered in addition to oral azathioprine later on. After one year of follow-up, visual acuity was 20/20 with near vision of Jaeger 3 + and no signs of active uveitis were seen. Therefore, Streptococcus anginosus should be considered in the differential diagnosis of a slowly progressive endophthalmitis also in immunocompetent individuals.

A fluffy white retinal lesion in a woman with spondyloarthritis treated with tofacitinib

A fluffy white retinal lesion in a woman with spondyloarthritis treated with tofacitinib

Acute multifocal retinitis in a patient with Q fever (Coxiella Burnetii infection) with endocarditis

ObjectiveTo report acute multifocal retinitis in association with serologically-proven Coxiella (C) Burnetii infection (Q fever) with endocarditis.Material and methodsA single case report documented with multimodal imaging.ResultsA 67-year-old cattle breeder presented with a 2-week history of persistent fever, headache, and floaters in both eyes. On examination, his best-corrected visual acuity was 20/20, and there was 1+ vitreous cells in both eyes. Bilateral fundus examination showed multiple small superficial white retinal lesions scattered in the posterior pole and midperiphery associated with a few retinal hemorrhages. These retinal lesions did not stain on fluorescein angiography (FA) and showed focal hyperreflectivity and thickening primarily involving the inner retinal layers on optical coherence tomography (OCT). There also was a band-like hyper-reflective area in the middle retina consistent with paramacular acute middle maculopathy. Transthoracic echocardiogram (TTE) showed a mobile echodensity on the anterior aortic leaflet consistent with a diagnosis of endocarditis. Elisa assays performed on paired serum samples collected 2 weeks apart showed increase in antibodies against C burnetii from 60 IU/ml to 255 IU/ml. The patient was treated with doxycycline 100 mg twice a day for 18 months, with subsequent resolution of the endocarditis. Sequential ocular examinations showed gradual resolution of all acute retinal findings without visible scars.ConclusionAcute Q fever, caused by C burnetii infection, should be considered in the differential diagnosis of acute multifocal retinitis. A systematic cardiac assessment with echocardiography is essential for early diagnosis of associated endocarditis and for prompt administration of appropriate antibiotic treatment to improve clinical outcomes.

Accidentally diagnosed ocular abnormalities identified during close screening for retinopathy of prematurity.

To report the variety of ocular findings which have been identified serendipitously during the screening for retinopathy of prematurity (ROP) in a tertiary referral center during seven-year period. The charts of 1568 preterm infants who screened for ROP were reviewed retrospectively. Any ocular lesion except for ROP were noted. All infants had undergone routine ocular examination of the external eye, pupillary light reflex, anterior and posterior segment. Wide-angle digital retinal image acquisition system for any vitreoretinal pathology requiring a close follow-up had been utilized. Abnormal ocular findings other than ROP were diagnosed in 296 infants (19.2%). Tunica vasculosa lentis was the most common finding (25%) followed by vitreous or retinal hemorrhages (17.2%) and retinal white lesions (16.6%). Retina was the most frequently involved anatomic site. Other frequent ocular findings included optic disc cupping, congenital cataract, optic nerve hypoplasia, choroidal nevus, persistent fetal vasculature, lid hemangioma, and tilted disc. However, life-threatening pathologies such as lipemia retinalis and even retinoblastoma were also diagnosed. A duly ophthalmologic examination is mandatory in premature infants for ROP screening. During such examinations, ophthalmologists must be aware of coexisting ocular findings; which could be sight-threatening or even life-threatening.

Clinical profile and visual outcome of intraocular inflammation associated with cat-scratch disease in Japanese patients.

To evaluate intraocular inflammation in Japanese patients with cat-scratch disease (CSD). Retrospective clinical chart review. The cases of 15 consecutive patients (19 affected eyes) in Kochi Prefecture, Japan who were serologically positive for Bartonella henselae or Bartonella quintana infection in association with intraocular inflammation were reviewed. The clinical manifestations, ocular complications, and treatment modalities were recorded. The clinical charts and photographic records were also reviewed for evidence of optic disc lesions, macular star, foci of chorioretinitis, and other findings. Thirteen patients reported fever before or at the time of the initial presentation. Ten of 11 patients with decreased visual acuity manifested neuroretinitis, and the remaining patient showed retinochoroiditis with macular involvement. One patient with a visual field defect manifested branch retinal artery occlusion. Three patients without visual disturbance presented with fever of unknown cause. Discrete white retinal or retinochoroidal lesions were the most common findings (84% of eyes, 87% of patients), followed by retinal hemorrhage (63% of eyes, 80% of patients), optic disc lesions (63% of eyes, 73% of patients), serous retinal detachment (53% of eyes, 67% of patients), and macular star (47% of eyes, 60% of patients). White retinal or retinochoroidal foci were the most common ocular posterior segment manifestations of CSD in this patient population. A diagnosis of CSD should be suspected in patients with fever and chorioretinal white spots, and the absence of neuroretinitis or macular star does not exclude the possibility of intraocular inflammation in CSD.

The clinical spectrum of ocular bartonellosis: a retrospective study at a tertiary centre in Malaysia

BackgroundCat scratch disease (CSD) is a systemic illness caused by the gram-negative bacillus, Bartonella henselea, which can occasionally involve the ocular structures. The objective of this study is to evaluate the various clinical presentations of ocular bartonellosis at our institution. A retrospective review of the clinical records of 13 patients (23 eyes) with ocular manifestations of Bartonella infections over a 3-year period between January 2016 to December 2018 was undertaken at our institution.ResultsThe diagnosis was made based on clinical findings and in addition, with the support of the evidence of Bartonella hensalae IgG and/or IgM. Small retinal white lesions were the most common ocular findings in this series of patients (82.6% of eyes, 76.9% of patients). Neuroretinitis was the second most common finding (47.8% of eyes, 69.2% of patients), followed by exudative retinal detachment involving the macula (34.8% of eyes, 53.8% of patients) and Parinaud’s oculoglandular syndrome (17.4% of eyes, 23.1% of patients). Other findings like isolated optic disc oedema without macular star (8.7% of eyes, 15.4% of patients) and vitritis (4.3% of eyes, 7.7% of patients) were also observed. Ten patients (76.9%) had bilateral ocular involvement. Most of the patients were young, immunocompetent and had systemic symptoms like fever prior to their ocular symptoms. The visual acuity (VA) at initial presentation ranged from 6/6 to hand movement (mean, 6/20), and at final visit 6/6 to 6/60, (mean, 6/9). 91.7% of patients were treated with antibiotics. Only 2 patients received oral corticosteroids together with antibiotics due to very poor vision on presentation. The visual prognosis of ocular bartonellosis is generally good with 16 (88.9%) of 23 eyes having VA of 6/12 or better at final follow-up visit.ConclusionSmall foci of retinal white lesions were the most common manifestation of ocular bartonellosis in this series, followed by neuroretinitis, though an array of other ocular findings may also occur. Therefore, we should consider bartonella infection as a possible differential diagnosis in those patients.

Multimodal imaging of retinal metastasis masquerading as an acute retinal necrosis

BackgroundTo report the multimodal imaging and histology of a case of metastatic esophageal cancer with vitreoretinal involvement resembling acute retinal necrosis (ARN) in a patient receiving systemic chemotherapy.Case presentationA 69-year-old Japanese man with a history of stage 4 esophageal carcinoma, treated with three cycles of 5-fluorouracil (5-FU) and cisplatin (CDDP) chemotherapy as well as 30 sessions of radiation therapy, presented with new onset of blurry vision in the right eye (OD). Visual acuity was 20/200 OD. Fundus examination OD revealed 2+ nuclear cataract, veil-like vitreous opacity, a tractional retinal detachment, and white retinal lesions in the macula and periphery masquerading as an ARN. Due to the poor view and uncertainty regarding diagnosis, combined cataract extraction and 25 gauge pars plana vitrectomy was performed. Polymerase chain reaction and cytologic analysis were performed on the vitreous samples, which was negative for all infectious entities but positive for poorly differentiated malignant cells. The vitreous biopsy was consistent with the primary endoscopic esophageal biopsy. Ultra-wide view fundus imaging revealed multifocal white intraretinal lesions in the macula and periphery. Optical coherence tomography through these white opacities displayed hyper-reflective inner retinal lesions with no choroidal involvement, suggestive of retinal metastasis. Observation and palliative support was continued until the patient passed away 3 months after diagnosis.ConclusionRetinal metastasis may mimic infectious syndromes such as ARN and are associated with a very poor prognosis. Outside of the retina, no further central nervous system metastasis was found. 5-FU is known to cross the blood–brain-barrier but may be inadequate in preventing retinal metastasis.

Mediterranean Spotted Fever Complicated with Thrombosis of the Left Central Retinal Vein: A Case Report and Literature Review

We describe a case of Mediterranean spotted fever complicated with thrombosis of the left central retinal vein. A 41-year-old woman patient living in the city Scodra was referred to our hospital in October 2017 for high fever 40°C, muscular and articular pains, severe headache, maculopapular rash, chills, photophobia and visual loss in his left eye. Ocular examination showed vision acuity: OD 8/10, OS 2/10. Funduscopic examination complemented with fluorescein angiography showed: optic nerve papilla with clear contours, diffuse hemorrhages in the contest off retinal vein thrombosis, white retinal lesions, vascular sheathing and macular cystoids edema. R. conorii antibodies were identified by ELISA anti Rickettsia conorii IgM, IgG and Weil-Felix Ox-19 test. Investigation of other infective agents and the immunological panel were negative. After treatment with doxycycline 200 mg/day for 10 days vision acuity was OD: 8/10 OS: 6/10; FO: There are less hemorrhages in fluorescein angiograph and OCT showed a reduced macular cystoids edema. Mediterranean spotted fever should be considered in the differential diagnosis of a patient who presents with an acute febrile disease accompanied by maculopapular rash especially in the seasons of spring, summer or autumn.

Retinal astrocytic hamartomas: 2 cases of atypical clinical presentation

PurposeRetinal astrocytic hamartomas (RAH) are rare benign tumors found mainly in patients with phacomatosis. In these cases, RAH is a major diagnosis criteria.MethodsWe report the cases of two patients with 2 different clinical presentations.ResultsThe case 1 is an asymptomatic man without medical history. A voluminous white retinal lesion is discovered incidentally. The ultrasound shows intratumoral calcifications and autofluorescence imaging shows hyperautofluorescent calcified beads. Characteristic moth‐eaten spaces are seen on the SD‐OCT. The final diagnosis is isolated RAH.The case 2 is a 56 year old woman suspected of neurofibromatosis (NF) type 2. The fundoscopy found in both eyes a peripapillary whitish flat retinal lesion with blurred edges located on the surface of the retina. There is no autofluorescence nor hyperfluorescence. The diagnosis of plane RAH (= type 1) is made given the context.ConclusionsRAH must be known because of the impact on phacomatosis diagnosis. RAH are associated with Tuberous Sclerosis Complex in about 55% of cases and with NF type 1 and type 2 in 15% of cases. Nevertheless in 1/3 of cases it occurs in healthy subjects. Three types of RAH have been described (plan (case 1), multinodular (case 2) and intermediate). Classical appearance (=type II) is a yellowish nodular ‘mulberry‐like’ tumor. It is autofluorescent and hyperfluorescent in late frames of angiography. However, there are less typical presentations which is reported in case 2 and which makes discuss differential diagnosis.RAH can be a difficult diagnosis for which the clinical history and the multimodal imaging are essential. Neurological opinion and cerebral imaging should complete the investigation to search other diagnosis criteria of phacomatosis before concluding in an isolated form.

Presumed toxoplasmic central retinal artery occlusion and multifocal retinitis with perivascular sheathing

Central retinal artery occlusion (CRAO) and multifocal retinitis with perivascular sheathing are rare in ocular toxoplasmosis. We report a case of toxoplasmic CRAO and multifocal retinitis with perivascular sheathing. A healthy 83-year-old male developed left panuveitis. Funduscopic examination of the left eye showed a swollen optic disc and sheathing of the retinal artery with a dense vitreous haze and a white retinal lesion. Serum anti-toxoplasma antibodies were positive in a latex agglutination assay. Vitrectomy was performed to improve visualization of the retinal lesions and for examination of causative microorganisms. A postoperative fundus examination revealed CRAO with optic disc involvement and multifocal retinitis with perivascular sheathing. Qualitative multiplex polymerase chain reaction detected the Toxoplasma gondii B1 gene in ocular fluid from both the aqueous and vitreous humor. The presumed diagnosis of ocular toxoplasmosis was made and treatment was started with prednisone and acetylspiramycin with subsequent improvement. Two months later, the patient developed active retinochoroiditis in the left eye. After 6 weeks of anti-toxoplasma therapy, the disease involuted. Retinal vascular occlusions and multifocal retinitis with perivascular sheathing are rare in toxoplasmosis. This is the first case report of toxoplasmic CRAO and multifocal retinitis with perivascular sheathing. The diagnosis of ocular toxoplasmosis should be considered in patients with retinal artery occlusions and multifocal retinitis with perivascular sheathing associated with inflammation.

Changing Perspectives in Classifications of Hypertensive Retinopathy.

Hypertensive retinopathy represents the ophthalmic findings of end organ damage secondary to systemic arterial hypertension. The eye is a target organ as well as an established prognostic indicator of systemichypertension. Based on ophthalmoscopically visible alterations, several classifications, the majority of them grading hypertensive fundus changes into four stages have been suggested. The recognition of hypertensive retinopathy is important in cardiovascular risk stratification of hypertensive individuals. The review evaluates the changing perspectives in classification & prognostic significance of fundal lesions. consists of retinal vascular changes that are pathologically related to both transient & persistent microvascular damage from elevated blood pressure. Ocular changes can be the initial finding in an asymptomatic patient with hypertension necessitating primary referral. In other instances, asymptomatic patient may be referred to an ophthalmologist for visual problems caused by hypertensive changes. Elevation of systemic blood pressure causes both focal and generalized constriction of retinal arterioles mediated by autoregulation. These findings are relatively common in long standing hypertension. A prolonged duration of high blood pressure can be associated with a breakdown of inner blood retinal barrier with extravasation of plasma & RBCs . Retinal haemorrhages, cotton wool spots, intraretinal lipids & in severe cases , the development of macular star configuration of intraretinal lipid can be seen. Although its name implies only retinal involvement, changes in both choroid & optic nerve are observed. When choroidal vessels are severely affected by elevated blood pressure, as in acute hypertension, fibrinoid necrosis of choroidal arterioles can cause occlusion of areas of choriocapillaris, with a subsequent breakdown of outer blood retinal barrier. Ocular findings in accelerated hypertension are divided into three distinct categories: hypertensive retinopathy, hypertensive choroidopathy & hypertensive optic neuropathy. Ophthalmic findings in acute malignant hypertensive retinopathy include focal arterial narrowing, cotton wool spots, intraretinal transudates , macular edema and retinal haemorrhages. Cystoid macular edema, lipid deposits and arteriolar changes are signs of malignant hypertensive retinopathy (2) . Cotton wool spots are fluffy, elevated, tan white areas of retinal opacity occurring within a few disc diameters of optic nerve, caused by occlusion of terminal retinal arterioles. Cotton wool spots typically resolve in 3-6 weeks and are associated with permanent nerve fiber layer loss in the vicinity of the lesion (2) . Periarteriolar intraretinal transudates are tan white retinal lesions which resolve without residual retinal damage in 2-3 weeks (3) . Macular edema and subretinal fluid are retinal findings related to hypertensive choroidal changes affecting the retinal pigment epithelium, with alterations in the blood retinal barrier. Clinical changes from hypertensive choroidopathy are directly related to the release of endogenous vasoconstrictor agents (eg.,angiotensin II, epinephrine, vasopressin) during systemic hypertension. Angiographically, there is delayed, patchy choroida lfilling

Visual Loss Associated with Rickettsial Disease

Purpose: To characterize and analyze ocular involvement associated with visual loss in a cohort of patients with rickettsial disease.Methods: Retrospective study of 16 eyes of 14 patients.Results: Mean initial visual acuity (VA) was 20/63 (range, 20/800–20/25). White retinal lesions infiltrating inner retina was the most common finding occurring in 14 eyes (87.5%). It was associated with a serous retinal detachment (SRD), accurately detectable by optical coherence tomography, in 11 eyes (78.6%). Other findings included optic neuropathy in 7 eyes (43.75%), cystoid macular edema in 1 eye (6.25%), branch retinal artery occlusion in 1 eye (6.25%), and choroidal neovascularization in 1 eye (6.25%). Thirteen patients were treated with a 2-week course of oral doxycycline 200 mg/day. Mean final VA was 20/40.Conclusions: Inner retinitis, associated with mild vitritis and SRD, and optic neuropathy are the most common vision-threatening ocular manifestations of rickettsial disease.

Retinal structure in vitamin A deficiency as explored with multimodal imaging

To define the retinal structural abnormalities in a patient with vitamin A deficiency. The patient had a complete ophthalmic examination, electroretinography (ERG), short-wave fundus autofluorescence (SW-AF) and spectral domain optical coherence tomography (SD-OCT) imaging. Serum vitamin A levels were measured. A 63-year-old man with alcoholic cirrhosis, sclerosing cholangitis and chronic pancreatitis experienced blurred vision and nyctalopia for over a year. There was no family history of eye disorders or consanguinity. His best-corrected visual acuity was 20/20 in each eye; color vision as determined with Ishihara color plates was normal in each eye. Anterior segment examination was unremarkable. He was pseudophakic in both eyes. Standard ERGs showed non-detectable rod function, a cone-mediated dark-adapted response to the standard flash and borderline reduced cone function. Serum vitamin A levels were below 0.06 mg/L (normal 0.3-1.2 mg/L). Fundus examination revealed numerous round yellow-white lesions along the superior arcade and nasal to the optic nerve in both eyes. These lesions were hypoautofluorescent on SW-AF. SD-OCT cross sections demonstrated that they were focal disruptions distal to the ellipsoid band of the photoreceptors with hyperreflective images bulging up the ellipsoid and region. The retinal pigment epithelium and the inner retina appeared intact. Limited and gradual vitamin A supplementation for over a month (20 000 IU/day) led to a dramatic improvement in retinal function and to the resolution of the symptoms. The retinal lesions remained unchanged. Imaging of this patient with nyctalopia and severe rod dysfunction suggests that the retinal white lesions known to occur in vitamin A deficiency localize to the photoreceptor layer, particularly the outer segment. On OCT, they are reminiscent of lesions observed in genetic diseases with retinoid cycle dysfunction and of drusenoid subretinal deposits, an abnormality commonly associated with age-related macular degeneration.

Nocardia veterana endogenous endophthalmitis in a cardiac transplant patient

BackgroundEndogenous endophthalmitis secondary to Nocardia species is extremely rare but often portends a poor visual prognosis often owing to the advanced nature of disease at presentation and delay in diagnosis. Patients who are systemically immunosuppressed are at greatest risk and early suspicion of the role of this organism in patients with acute panuveitis is paramount.FindingsA 66-year-old cardiac transplant patient on oral prednisone, Myfortic, and tacrolimus developed unilateral panuveitis with a focal white subretinal and retinal lesion. His past medical history was notable for Aspergillus pneumonia and cytomegalovirus retinitis in the contralateral eye 12 months prior. Aqueous humor sampling for eubacterial, eufungal, and viral PCR testing, as well as vitreous cultures for bacteria and fungi were unsuccessful in the identification of a causative organism. Progressive enlargement of the lesion was noted despite intravitreal foscarnet, vancomycin, ceftazidime, and voriconazole. A pars plana vitrectomy and retinal and subretinal biopsy led to the identification of Nocardia veterana, a recently identified Nocardia species. A combination of linezolid, meropenem, azithromycin, ceftriaxone, and intravitreal amikacin resulted in eradication of the infection.ConclusionThis is the first reported case of N. veterana endogenous endophthalmitis in an immunosuppressed patient. Pars plana vitrectomy with a subretinal biopsy was required to establish a diagnosis, as other testing including aqueous PCR and vitreous cultures were negative. The poor visual outcome in our patient highlights the importance of early consideration of Nocardia in the differential diagnosis of panuveitis with subretinal disease in the context of immunosuppression.

A possible coincidence of cytomegalovirus retinitis and intraocular lymphoma in a patient with systemic non-Hodgkin’s lymphoma

PurposeTo present a possible coincidence of cytomegalovirus retinitis and intraocular lymphoma in a patient with systemic non-Hodgkin’s lymphoma.Case presentationA 47-year-old woman presented with decreased visual acuity associated with white retinal lesions in both eyes. A history of pneumonia of unknown aetiology closely preceded the deterioration of vision. Five years previously the patient was diagnosed with follicular non-Hodgkin’s lymphoma. She was treated with a chemotherapy regimen comprised of cyclophosphamide, adriamycin, vincristin, and prednisone with later addition of the anti-CD20 antibody rituximab. She experienced a relapse 19 months later with involvement of the retroperitoneal lymph nodes, and commenced treatment with rituximab and 90Y-ibritumomab tiuxetan. A second relapse occurred 22 months after radioimmunotherapy and was treated with a combination of fludarabine, cyclophosphamide, and mitoxantrone followed by rituximab. The patient experienced no further relapses until the current presentation (April, 2010).Pars plana vitrectomy with vitreous fluid analysis was performed in the right eye. PCR testing confirmed the presence of cytomegalovirus in the vitreous. Atypical lymphoid elements, highly suspicious of malignancy were also found on cytologic examination. Intravenous foscarnet was administered continually for three weeks, followed by oral valganciclovir given in a dose of 900 mg twice per day. In addition, the rituximab therapy continued at three monthly intervals. Nevertheless, cessation of foscarnet therapy was followed by a recurrence of retinitis on three separate occasions during a 3-month period instigating its reinduction to the treatment regime after each recurrence.ConclusionsCytomegalovirus retinitis is an opportunistic infection found in AIDS patients as well as in bone marrow and solid organ transplant recipients being treated with systemic immunosuppressive drugs. This case presents a less common incidence of cytomegalovirus retinitis occurring in a patient with non-Hodgkin’s lymphoma. We demonstrated a possible coexistence of cytomegalovirus retinitis and intraocular lymphoma in this particular patient. The final diagnosis was based on clinical manifestations together with the course of uveitis and its response to treatment alongside the results of vitreous fluid analysis. This report highlights the importance of intraocular fluid examination in cases with nonspecific clinical manifestations. Such an examination allows for the detection of simultaneously ongoing ocular diseases of differing aetiologies and enables the prompt initiation of effective treatment.

Acute worsening of retinal lesions during oral steroid treatement in a case of intracular lymphoma

AbstractPurpose Diagnosis and treatment of intraocular lymphoma remains a clinical challenge. Herein, we present a complicated case in which the diagnosis was made after the acute worsening of retinal lesions during oral steroid treatement.Methods A 49 year old woman complaning of progessive visual acuity decrease was referred with visual acuity of hand movements in the right eye accompanied by vitritis and two peripheral white retinal lesions with vasculitis. Futher examinations excluded the diagnosis of the main causes of infectious and non infectious uveitis and pathological examination of vitreous cells was not compatible with the diagnosis of lymphoma.Results Systemic steroid treatment were given with an initial improvement of the inflammatory conditions. However, a week later an acute worsening of the retinal lesions occured, taking the appearence of a very severe retinal necrosis. Another vitrectomy was thus performed to exclude again infectious causes but was negative for virus and toxo. Finally, the diagnosis of intraocular lymphoma was made on a 3rd diagnostic vitrectomy with retinal biopsy. The patient was treated with a series of intravitreous methotrexate injections followed by chemo‐ and radiotherapy.Conclusion Systemic administration of corticosteroids in patient with intraocular B lymphoma may lead to dramatic lesion extention preceeded by temporal clinical stabilisation or improvement.