Vitreous Inflammatory Reaction Research Articles

Leptospiral uveitis- "Transition 'from epidemic to endemic form" difficulties in laboratory confirmations.

Leptospirosis is a waterborne zoonotic disease that primarily causes systemic illness, followed by uveitis. After heavy flooding in Madurai district, an epidemic outbreak of systemic and ocular leptospirosis occurred in 1994. Our data shows a transition to endemicity after each epidemic. The aim of this study is to report the clinical signs, epidemic outbreaks, and persistent endemicity of leptospiral uveitis, as well as the diagnostic dilemmas associated with it. A retrospective analysis of clinical signs was conducted using medical records of leptospiral uveitis patients over a period of 27 years (1994-2020) in a tertiary care eye hospital. The clinical workup of uveitis included a detailed clinical history, systemic, and ophthalmic examination. Microagglutination tests (MATs) was done at the Centers for Disease Control and Prevention (CDC) in Atlanta and later in our regional laboratory. Serum samples were collected from human systemic leptospirosis cases and a small group of animals in and around Madurai. The first epidemic outbreak resulted in 200 seropositive patients. Subsequent epidemic outbreaks occurred in 1997, 1998, 2001, 2005, and 2012, with Madurai experiencing multiple outbreaks. However, the disease remained endemic, with 25-50 patients being observed per year in between the peaks. Ocular examination revealed acute non-granulomatous uveitis (94.9%), pan uveitis (59.8%), vitreous inflammatory reaction (55.4%), retinal vasculitis (29.5%), disc hyperemia (20.9%), and hypopyon. (16.2%). New serovars emerged every year, resulting in decreased sensitivity of the MAT. Over time, the MAT started to miss diagnoses. The persistent endemicity of leptospiral uveitis emphasizes the need for accessible diagnostic tests. The low performance of the MAT can be attributable to the use of an older panel. The incorporation of new isolates in the MAT by a national laboratory will improve the accuracy of diagnosis.

Triamcinolone acetonide induces sterile endophthalmitis in patients with intermediate uveitis: A case report series.

Due to their anti-inflammatory, antiangiogenic and antiedematous properties, corticosteroids have been commonly used in the treatment of retinal diseases. Intravitreal administration of steroids offers the maximal drug efficacy and the lowest risk of systemic side effects. The authors report three cases of presumed sterile endophthalmitis induced by triamcinolone acetonide (TA) in three eyes with intermediate non-infectious uveitis. Each patient received a single intravitreal injection of TA of 4 mg. Because of the intense vitreous inflammatory reaction, retina examination and the optical coherence tomography could not be performed, although vitreous opacities were observed on the ocular ultrasound. The dense vitreous opacity is a defining factor, the anterior segment inflammation is mild to moderate and a hypopyon is present, which may be a sterile inflammatory reaction or the triamcinolone material itself. In cases of sterile endophthalmitis, the visual acuity increases progressively as the intraocular inflammation diminishes. Local treatment with topical antibiotics, prednisolone acetate and cycloplegic eyedrops is recommended to control the inflammatory reaction.

Regulatory T cells and IL-17A levels in noninfectious uveitis.

Regulatory T cells (Tregs) have been intensively studied in a myriad of autoimmune diseases. As for noninfectious uveitis (NIU), results have been contradictory, and studies have failed to demonstrate a consistent reduction in Treg cell frequency in patients with active disease. The present study aims to characterize T lymphocyte subsets, including naïve and memory Tregs as well as their respective CD39 expression, in the peripheral blood of NIU patients. Inflammatory as well as suppressive cytokine profiles were also evaluated. T cell subpopulations were evaluated by multiparametric flow cytometry using anti-CD3, anti-CD4, anti-CD45, anti-CD45RA, anti-CD197, anti-CD25, anti-CD127, and anti-CD39. Treg cells were defined as CD3 + CD4+CD25hiCD127low. A multiplex bead-based immunoassay was used to determine TNF-α, IFN-ɣ, IL-17A, IL-10, and TGF-β levels. Twenty-nine patients with active NIU were included as well as 15 sex- and age-matched controls. There were no significant differences in T lymphocyte subsets, including Tregs, between patients and controls. However, patients with a lower grade of anterior chamber or vitreous inflammatory cellular reaction showed higher memory Treg counts than controls, with no respective increase in CD39+ expression, and a tendency for higher IL-17A levels (p = 0.06). This IL-17A elevation was present in the total NIU group (p = 0.08) as well as a positive correlation between IL-17A levels and the absolute counts of memory Tregs (p = 0.013; R = 0.465). Patients with higher IL-17A levels also showed higher serum concentrations of memory (p = 0.001) and naïve (p = 0.003) Tregs as well as elevated TNF-α (p < 0.0001) and IFN-ɣ (p = 0.016) levels. Negative correlations were observed between IL-10 and TGF-β levels and the percentages of memory (p = 0.030; R = - 0.411) and total CD39+ Tregs (p = 0.051; R = - 0.373) in the peripheral blood of NIU patients. Our results showed that total Treg levels were not reduced in patients with NIU. Further characterization of Treg subsets, including memory Tregs and respective CD39 expression, may provide additional insight on the role of Treg cells in NIU. Consistent high levels of circulating IL-17A in NIU patients are in accordance with previous studies and reinforce this cytokine's vital role in uveitis pathogenesis and its possible use as a therapeutic target.

Birdshot Retinochoroidopathy: Prognostic Factors of Long-term Visual Outcome

To determine the prognostic factors of long-term visual outcome in birdshot retinochoroidopathy (BRC). Design: Retrospective case series. StudyPopulation: Successive HLA-A29+ BRC patients whose latest visit was between May and August 2013 at a single tertiary center (Pitié-Salpétrière Hospital, Paris). Endpoint visual status (remission or deterioration) was determined for each patient based on clinical and ancillary data from the latest visit including optical coherence tomography (OCT), automated visual field (AVF), and angiograms. MainOutcome Measure: Epidemiologic, clinical, OCT, AVF, angiographic, and electrophysiological data at baseline were correlated to final visual status. Fifty-five patients were included. Mean observation period was 8 years (range: 0.6-23 years). Mean disease duration was 9.8 years (range: 1.2-32.7 years). Female-to-male sex ratio was 1.6:1. Factors of good visual prognosis (remission vs deterioration) included at baseline: late age of disease onset (49.5 vs 45 years, P= .05), presence of vitreous inflammatory reactions >2+ (35.9% vs 6.2%, P= .04), vascular leakage on fluorescein angiograms (FA) (44.4% vs 12.5%, P= .03), absence of macular pigment epithelium atrophy on FA (88.9% vs 62.5%, P= .05), and presence of macular edema on OCT (33.3% vs 6.2%, P= .04). Preserved electrooculography light peak and Arden ratio (P= .06) and presence of choroidal spots on infracyanine green angiograms (80.0% vs 53.3%, P= .08) seemed associated with the best prognoses. This study suggests a series of prognostic factors of long-term visual outcome in BRC. Keeping in mind the insidious evolution of the disease, knowledge of such prognostic factors should help tailor the treatment and monitoring of birdshot patients.

Clinical and multimodal imaging characteristics of acute Vogt-Koyanagi-Harada disease unassociated with clinically evident exudative retinal detachment.

The purpose of this study was to describe the clinical and multimodal imaging findings in acute Vogt-Koyanagi-Harada (VKH) disease without clinically evident exudative retinal detachment (ERD). We retrospectively reviewed the charts of 18 patients (36 eyes), diagnosed with acute VKH disease without clinically evident ERD. All patients underwent complete ophthalmic examination, fundus photography, optical coherence tomography (OCT), B-scan ultrasonography, fluorescein angiography (FA), and indocyanine green angiography (ICGA). Of 18 patients, twelve (66.7 %) were female and 6 (33.3 %) were male. Mean age was 39 years (range, 23-60). Ten patients had been referred with an erroneous diagnosis of primary optic nerve disorder (8; 44.4 %) or isolated anterior uveitis (2; 11.1 %). Anterior chamber or vitreous inflammatory reaction was noted in 22 eyes (61.1 %), each. Fundus findings included optic disc swelling in 30 eyes (83.3 %), retinal striae in 20 eyes (55.5 %), and yellowish deep lesions in 3 eyes (8.3 %). OCT showed a shallow, localized subclinical ERD in 18 eyes (50 %), and retinal pigment epithelial folds in 23 eyes (63.9 %). B-scan ultrasonography showed diffuse, low- to medium-reflective choroidal thickening in all eyes. FA disclosed delayed choroidal perfusion in at least one eye of all patients (100 %), mild pinpoint leakage in 21 eyes (58.3 %), optic disc hyperfluorescence in 35 eyes (97.2 %) and choroidal folds in 13 eyes (36.1 %). ICGA findings included delayed choroidal perfusion in 24 eyes (66.7 %), decrease in the number of large choroidal vessels in 36 eyes (100 %), fuzzy choroidal vessels in 35 eyes (97.2 %), and hypofluorescent dark dots in 28 eyes (77.8 %). The association of bilateral optic disc edema with retinal striae and intraocular inflammatory reaction highly suggests acute VKH disease. A multimodal imaging approach including fundus photography, OCT, B-scan ultrasonography, FA, and ICGA provides important clues for the definite diagnosis and help differentiate VKH disease from primary optic nerve disorders.

Ocular Involvement Following Postnatally Acquired Toxoplasma gondii Infection in Southern Brazil: A 28-Year Experience

To determine the incidence of, and risk factors for, ocular involvement among people known to have postnatally acquired Toxoplasma gondii infection in a region of southern Brazil where there is a high prevalence of endemic disease. Retrospective longitudinal cohort study. Records of 302 patients with serologic evidence of recent T gondii infection (a positive anti-T gondii IgM antibody test) from Erechim, Rio Grande do Sul state, Brazil (1974-2002) were analyzed. The incidence of ocular involvement was calculated in terms of person-years (PY) of follow-up. Risk factors for ocular involvement were analyzed using log-rank and Fisher exact tests. At initial ocular examination (baseline), 30 patients (9.9%) had intraocular inflammation only (anterior chamber cells and flare, vitreous inflammatory reactions, retinal whitening), without clinically apparent necrotizing retinochoroiditis. At baseline, men were more likely to have ocular involvement (P= .043) and antiparasitic treatment was associated with less ocular involvement (P= .015). Follow-up examinations were performed on 255 patients (median follow-up, 13.7months [range 0.4-261.9months]). Among those without ocular involvement at baseline, the incidence of necrotizing retinochoroiditis was 6.4/100 PY. Patients >40 years of age at first IgM test had a greater risk of incident necrotizing retinochoroiditis (hazard ratio= 4.47, 95% CI= 1.67-11.93, P= .003) than younger patients. The incidence of recurrent necrotizing retinochoroiditis was 10.5/100 PY. Isolated intraocular inflammatory reactions can be an initial manifestation of T gondii infection, with necrotizing retinochoroiditis occurring months oryears later. Male sex and older age are risk factors for toxoplasmic retinochoroiditis. Antitoxoplasmic treatment may protect against early ocular involvement.

Assessment of the effect of intravitreal triamcinolone acetonide on the chorioretinal and vitreous inflammatory reaction to cryotherapy in rabbits

OBJETIVO: Avaliar a resposta inflamatória em coróide, retina e vítreo nos olhos de coelhos submetidos à crioterapia seguida de injeção intravítrea de triancinolona acetonida e comparar com os olhos de coelhos que foram submetidos à crioterapia seguida de injeção intravítrea de solução salina. MÉTODOS: Trata-se de um estudo prospectivo caso-controle. Foram realizados procedimentos cirúrgicos em 11 coelhos albinos, sendo excluídos os animais que não completaram o pós-operatório ou apresentaram complicações intra ou pós-operatórias. Todos os coelhos foram submetidos à peritomia [...]

Intraocular Inflammation Associated with Ocular Toxoplasmosis: Relationships at Initial Examination

To describe characteristics of intraocular inflammation in eyes with active ocular toxoplasmosis and to identify relationships between signs of inflammation, complications (including elevated intraocular pressure [IOP]), other disease features, and host characteristics. Multicenter, retrospective, cross-sectional study. We reviewed the medical records of 210 patients with toxoplasmic retinochoroiditis at seven international sites (North America, South America, and Europe) for information from the first examination at each site during which patients had active retinal lesions. Signs of inflammation included anterior chamber (AC) cells and flare and vitreous humor cells and haze. Retinal lesion characteristics included size (< or =1 disc area [DA] or >1 DA) and presence or absence of macular involvement. AC cells and flare were related to vitreous inflammatory reactions (P < or = .041). One or more signs of increased inflammation were related to the following factors: older patient age, larger retinal lesions, and extramacular location. In 30% of involved eyes, there was evidence of elevated IOP (despite use of glaucoma medications by some patients); other complications were uncommon. IOP of more than 21 mm Hg was associated with both increased AC cells and elevated flare (both P < or = .001) and with macular involvement (P = .009). Inflammation seemed to be more severe among patients in Brazil than among those at other sites. There is substantial variation between patients in the severity of intraocular inflammation associated with ocular toxoplasmosis, attributable to multiple host- and disease-related factors. Results suggest that disease characteristics also vary in different areas of the world. Elevated IOP at initial examination reflects the severity of inflammation.

Longitudinal Cohort Study of Patients with Birdshot Chorioretinopathy. IV. Visual Field Results at Baseline

To describe visual field parameters at baseline examination of 80 participants in a longitudinal cohort study of birdshot chorioretinopathy and to identify relationships between these parameters and visual acuity, symptoms, clinical findings, and results of laboratory tests. Single-center cross-sectional study. Standardized Fastpac, full-threshold Humphrey 30-2 (Carl Zeiss Meditec, Dublin, California, USA) visual field studies were performed for both eyes of all patients. A standardized protocol identified foveal threshold and mean deviation, specified categories of total deviation, and assigned visual field pattern descriptors. These parameters were compared with best-corrected visual acuity (BCVA), symptoms, color confusion score (CCS), cataract, vitreous inflammatory reactions, retinal vasculitis, birdshot lesion characteristics, and ocular coherence tomography (OCT) and fluorescein angiography parameters. Each visual field parameter was closely related to the others, although mean deviation could be abnormal in the presence of a near normal foveal threshold. Mean deviation was related to BCVA, but the correlation was moderate (the Spearman correlation, -0.55; P < .001). It was also related to CCS and the symptoms of blurry vision, poor contrast sensitivity, and nyctalopia. The most common visual field patterns were multiple foci and arcuate defects. Among clinical and laboratory findings, visual field parameters were most closely related to absence of the third highly reflective band on OCT (P < .001). Patients with birdshot chorioretinopathy may have a variety of visual field abnormalities, even with normal BCVA. Abnormalities seem to be associated with retinal damage. Automated visual field testing may provide objective measures for monitoring disease activity.

Avaliação clínica e incidência de endoftalmite infecciosa e não-infecciosa após injeção intravítrea de acetonida de triancinolona

To report the incidence of infectious and noninfectious endophthalmitis after intravitreal injection of 4 mg of triamcinolone acetonide (Kenalog - 40 mg/ml; 0.1 ml) and to evaluate distinguishing characteristics that may assist the clinician in differentiating these entities. Observational nonconcurrent prospective study. Charts of 121 patients (154 injections) who consecutively underwent intravitreal injection of triamcinolone acetonide to treat various chorioretinal diseases were evaluated. All procedures were performed in an operating room with careful antiseptic protocol. Two eyes (1.29%/injection and 1.65%/patient) presented a noninfectious endophthalmitis characterized by decreased vision, hyperemia, hypopyon and vitreous inflammatory reaction, on the first day after the injection. These eyes were treated with topical and subconjunctival corticosteroids with complete resolution of the inflammatory reaction. In the present case series, no case of infectious endophthalmitis occurred. Despite being relatively rare, noninfectious endophthalmitis can be associated with intravitreal injection of triamcinolone simulating an infectious endophthalmitis. In selected cases, the differential diagnosis can be made solely by clinical evaluation.

Longitudinal Cohort Study of Patients With Birdshot Chorioretinopathy II: Color Vision at Baseline

To describe color vision at the baseline examination of 80 participants in a longitudinal cohort study of birdshot chorioretinopathy and to identify relationships between color vision and visual acuity, symptoms, and ophthalmic signs. Single center cross-sectional study. Color vision was evaluated with the desaturated Lanthony 15-Hue test. Relationships were sought between the square root of the color confusion scores (CCS) and the following factors: best-corrected visual acuity (BCVA), symptoms, cataract, vitreous inflammatory reactions, retinal vasculitis, cystoid macular edema (CME), and birdshot lesion characteristics. When compared with published, age-matched normal control subjects, 49 patients (61.3%; 76 eyes [47.5%]) had abnormal CCS values. Abnormal CCS values were found in nine of 51 phakic eyes (18%) with normal BCVA (>or=1.0) and without cataract. Although most eyes did not have classifiable defects, 30 eyes (18.8%) had tritan (blue-yellow) defects (88% of eyes with classifiable defects). With the use of multivariate analyses, there were significant associations between increased CCS values and the symptoms of altered color vision (P = .005) and altered contrast sensitivity (P = .015). There was a significant, but weak, relationship between CCS values and birdshot lesion morphologic condition (P = .049), but no relationships were found with other lesion characteristics or with vitreous inflammatory reactions, retinal vasculitis, or CME. The Lanthony 15-Hue test provides an objective technique to assess complaints of altered color vision in people with birdshot chorioretinopathy. Color vision can be abnormal in eyes with normal visual acuity; therefore, this parameter may be useful as an additional measure for monitoring the disease.

Chorioretinal involvement in patients with West Nile virus infection

Purpose To characterize and analyze the chorioretinal manifestations of West Nile virus (WNV) infection. Design Prospective, noncomparative case series. Participants Twenty-nine consecutive patients with serologically confirmed WNV infection in the setting of an outbreak of the disease. Methods The average duration of systemic symptoms before ophthalmic examination was 10 days (range, 2–30 days). All participants underwent a detailed ophthalmic examination at presentation and regularly throughout follow-up, including dilated biomicroscopic fundus examination, fundus photography, and fluorescein angiography. Results A typical multifocal chorioretinitis was observed in 20 of 29 patients (69%) bilaterally at presentation and developed later during follow-up in 3 patients (10.3%), bilaterally (n = 1) or unilaterally (n = 2). Multifocal chorioretinitis was associated with mild vitreous inflammatory reaction in all cases. Other findings included intraretinal hemorrhages (21 patients [72.4%]), white-centered retinal hemorrhages (7 patients [24.1%]), focal retinal vascular sheathing (3 patients [10.4%]), marked diffuse retinal arterial sheathing (1 patient [3.4%]), retinal vascular leakage (5 patients [17.2%]), optic disc swelling (2 patients [6.9%]), optic disc staining (6 patients [20.7%]), segmental zones of retinal pigment epithelium changes (1 patient [3.4%]), and nonproliferative diabetic retinopathy (7 patients [24.1%]). The posterior segment findings related to WNV disease had a self-limited course in all patients. Conclusions Chorioretinal involvement, frequently asymptomatic and self-limited, is common in patients with acute WNV infection. The unique pattern of multifocal chorioretinitis in patients with systemic symptoms suggestive of WNV can help to establish the diagnosis while serologic testing is pending. Therefore, a systematic ocular evaluation, including dilated fundus examination and fluorescein angiography in selected cases, is recommended in patients with clinically suspected WNV infection.

Treatment of immune recovery vitritis with local steroids

AIMSTo report a series of patients requiring treatment for falling visual acuity associated with immune recovery vitritis, a recently described syndrome of a predominantly vitreous inflammatory reaction in patients with...

Immune recovery uveitis

Potent antiretroviral therapy can result in substantial improvement in the immune function of patients with AIDS. In some patients with preexisting cytomegalovirus (CMV) retinitis, a consequence of this improved immune function is increased intraocular inflammation. This phenomenon, termed `immune recovery uveitis', is characterized by anterior segment and vitreous inflammatory reactions. It can lead to the development of chronic, vision-limiting complications, including macular edema and epiretinal membrane formation. The frequency with which immune recovery uveitis occurs and risk factors for its development have not yet been clarified. There is evidence that these inflammatory reactions are directed toward CMV antigens in ocular tissues, although specific disease mechanisms remain poorly understood. Macular edema and decreased vision may respond, at least transiently, to corticosteroid therapy, but successful long-term treatment strategies have not been established. Immune recovery uveitis is currently one of the most common causes of new vision loss in patients with AIDS-related CMV retinitis.

Transient vitreous inflammatory reactions associated with combination antiretroviral therapy in patients with AIDS and cytomegalovirus retinitis

To report the observation that a transient vitreous inflammatory reaction may develop in the eyes of patients with acquired immunodeficiency syndrome (AIDS), cytomegalovirus retinitis, and an increased CD4+ T-lymphocyte count during treatment with antiretroviral therapy including a protease inhibitor. We reviewed the medical records of eight patients with AIDS and cytomegalovirus retinitis who developed vitreous inflammatory reactions greater than those usually seen with this disease. Vitreous inflammatory reactions obscured the view of the posterior pole in all patients. No iris nodules, synechiae, glaucoma, or cystoid macular edema were observed. Six patients had unilateral cytomegalovirus retinitis, and, in each, the inflammation occurred only in the eye with cytomegalovirus retinitis. The vitreous inflammatory reactions were associated with clinically inactive cytomegalovirus retinitis in six patients, with disease reactivation in one patient, and were present at diagnosis of active disease in one patient. Cytomegalovirus retinitis has not recurred in any of these patients since their episodes of vitreous inflammation. Vitreous inflammation developed in all eight patients after a substantial increase in CD4+ T-lymphocyte counts caused by combination antiretroviral therapy. Five patients had CD4+ T-lymphocyte counts of greater than 100 cells per microl at the time the vitreous inflammatory reaction developed. No other causes of uveitis were found. Patients with AIDS and cytomegalovirus retinitis may develop transient intraocular inflammation associated with combination antiretroviral therapy. We believe that this inflammation reflects an improved immune response against cytomegalovirus.

Chronic multifocal retinal infiltrates in patients infected with human immunodeficiency virus

To describe the clinical features of a disorder characterized by chronic multifocal retinal infiltrates and uveitis in individuals with human immunodeficiency virus (HIV) disease. We reviewed the medical records of HIV-infected patients with multifocal retinal infiltrates of unknown cause seen by investigators at four institutions. The following data were collected: demographic characteristics, presenting signs and symptoms, laboratory test results, and course of disease. We identified 26 HIV-infected patients (50 involved eyes) with this syndrome. Median CD4+ T-lymphocyte count at presentation was 272 per microl (range, 7 to 2,118 per microl). The most common presenting symptom was floaters. Median visual acuity of involved eyes at presentation was 20/20 (range, 20/15 to 20/100) and remained stable (median, 20/20; range, 20/15 to 20/70) after a median follow-up period of 9 months (range, 0 to 110 months). Typical retinal lesions were gray-white or yellow, irregular in shape, and less than 200 microm in greatest dimension. All were located in the midperiphery or anterior retina and enlarged slowly or remained static in size. Mild to moderate anterior chamber or vitreous humor inflammatory cells were present in 47 of 50 eyes (26 of 26 patients). Retinal lesions possibly responded to zidovudine but not to acyclovir or ganciclovir. Anterior chamber and vitreous humor inflammatory reactions responded to topical or periocular injections of corticosteroid. Uveitis with chronic multifocal retinal infiltrates is a distinct clinical entity of unknown cause that occurs in HIV-infected patients. Retinal lesions may respond to antiretroviral therapy. Visual prognosis is good.

Uveitis Associated With an Epidemic Outbreak of Leptospirosis

To define uveitis associated with leptospirosis in a clinical setting. We present the clinical features of 73 consecutive cases of uveitis linked clinically to an outbreak of systemic leptospirosis in patients with antibodies to Leptospira species who were examined from January to September 1994. In 73 patients, the pattern of ocular involvement was unilateral in 35 and bilateral in 38. Panuveitis was seen in 106 eyes (95.5%), retinal periphlebitis in 57 eyes (51.4%), and hypopyon in 14 eyes (12.6%). Anterior uveitis alone without hypopyon was observed in three eyes (2.7%), whereas vitreous inflammatory reaction alone was seen in two eyes (1.8%). Sixty of 73 patients (82.2%) or 91 of 111 eyes (82.0%) were followed up for 8 months. Final visual acuity was 6/6 (20/20) in 47 eyes (52%) and improved during treatment, although not up to 6/6, in 15 eyes (16%). Twenty-eight eyes (31%) maintained same vision, and one eye showed deterioration of vision. Uveitis associated with leptospirosis may manifest as unilateral or bilateral uveitis, anterior uveitis, or panuveitis. The prognosis is generally good in this entity, even when the inflammation is severe. Awareness of this disease in endemic areas is important in order to differentiate it from other uveitic entities, especially in young male patients in whom other immunologic uveitides are also common.

The Progressive Outer Retinal Necrosis Syndrome: A Variant of Necrotizing Herpetic Retinopathy in Patients with AIDS

The progressive outer retinal necrosis syndrome is a recently recognized variant of necrotizing herpetic retinopathy. This report characterizes more fully its clinical features and course. Using standardized clinical criteria, patients with progressive outer retinal necrosis syndrome from four institutions were identified. Patient records were reviewed retrospectively for the following data: medical and demographic characteristics, presenting symptoms, physical findings, course, responses to treatment, and outcomes. Thirty-eight patients (65 involved eyes) were studied. All had acquired immune deficiency syndrome. A known history of cutaneous zoster was documented in 22 (67%) of 33 patients. Median CD4 lymphocyte count was 21/mm3 (range, 0-130/mm3). Median follow-up was 12 weeks. The most common presenting symptom was unilateral decreased vision (35 of 65 eyes, 54%); median visual acuity at presentation was 20/30 (range, 20/20 to no light perception [NLP]). Anterior chamber and vitreous inflammatory reactions were absent or minimal in all patients. Typical retinal lesions were multifocal, deep opacities scattered throughout the periphery, although macular lesions also were present in 21 eyes (32%) at diagnosis. Lesions progressed rapidly to confluence. Initial intravenous antiviral therapy appeared to reduce disease activity in 17 (53%) of 32 eyes, but treatment did not alter final visual outcome. Visual acuity was NLP in 42 (67%) of 63 eyes within 4 weeks after diagnosis. Retinal detachment occurred in 43 (70%) of 61 eyes, including 13 (93%) of 14 eyes that received prophylactic laser retinopexy. The progressive outer retinal necrosis syndrome is characterized by features that distinguish it from cytomegalovirus retinopathy, acute retinal necrosis syndrome, and other necrotizing herpetic retinopathies. Visual prognosis is poor with current therapies.

Ocular Toxoplasmosis Misdiagnosed as Cytomegalovirus Retinopathy in Immunocompromised Patients

Cytomegalovirus (CMV) and Toxoplasma gondii both cause necrotizing retinopathy in immunosuppressed hosts. Because of the high prevalence of serum antibodies to these agents in the general population and the risks associated with retinal biopsies, diagnosis of these infections is usually based on clinical findings alone, but the two infections can be confused with one another because of similar clinical features. Accurate diagnosis is critical, however, because both diseases are treatable but require different medical therapies. Case histories were reviewed for five immunosuppressed patients with necrotizing retinopathy, which was initially diagnosed incorrectly as CMV retinopathy but was subsequently found to be toxoplasmic retinochoroiditis. Correct diagnosis was based on retinal biopsy (2 cases) or rapid response to antiparasitic drug therapy (3 cases). Factors were sought that might help differentiate toxoplasmic retinochoroiditis from CMV retinopathy at presentation. In all cases, the character of retinal opacification (densely opaque, thick) and the appearance of lesion borders (smooth, nongranular) was different from that typically seen with CMV retinopathy. These cases also were characterized by prominent anterior chamber and vitreous inflammatory reactions (four of five cases) and relative lack of retinal hemorrhage. One patient subsequently developed CMV retinopathy; characteristics of the two lesions in the same eye highlighted the differences between these two infections. Clinicians should consider ocular toxoplasmosis as a cause of necrotizing retinopathy in immunosuppressed patients and consider an empiric course of antiparasitic therapy for lesions with features described in this report.

Ocular Toxoplasmosis in Patients with the Acquired Immunodeficiency Syndrome

In seven of eight cases of presumed ocular toxoplasmosis in patients with AIDS, the diagnosis was supported by a reduction or resolution of intraocular inflammation and healing of necrotic retinal lesions after initiation of antiparasitic drug therapy including one or more of the following medications: pyrimethamine, sulfadiazine, clindamycin, tetracycline, or spiramycin. In two cases the diagnosis was confirmed histologically. The cases differed clinically and histopathologically from those in immunocompetent patients. There was no evidence that disease originated in preexisting retinochoroidal scars. Lesions frequently were bilateral and multifocal. Vitreous inflammatory reaction was a common clinical finding, but histopathologic examination demonstrated scant retinal inflammation in areas of necrosis. Ocular toxoplasmosis in these patients with AIDS probably resulted from newly acquired infection or dissemination of organisms from nonocular sites of disease. Infections became clinically inactive with drug therapy in all treated patients, but reactivation and progression of disease occurred when therapy was stopped in two of three patients. Severe retinal necrosis led to retinal tears or detachment in three cases. Ocular lesions were the first manifestation of Toxoplasma gondii infection in four of five patients with evidence of multisystem infection.