MMF was effective in disease control in the majority of patients with intermediate and posterior uveitis and proved to be a useful second line immunosuppressant for refractory intraocular inflammatory disease with an acceptable profile of side-effects.
This report describes the case of a 59-year-old woman diagnosed with cytomegalovirus (CMV) retinitis. The diagnosis was suggested by a typical fundus appearance, and confirmed by a positive PCR for CMV of both serum and vitreous biopsy. HIV status was negative. The patient's medical history included thymoma followed by a thymectomy, recent multiple oral thrush infections, lower respiratory tract infections, urinary tract infections and severe weight loss. She had previously been treated for toxoplasma chorioretinitis and had vitrectomies for retinal detachment in the right eye. Immunological investigations revealed low T cells, almost absent B cells with reduced immunoglobulins consistent with the diagnosis of Good syndrome. The patient received treatment with intravenous ganciclovir, followed by maintenance valganciclovir, resulting in resolution of the ocular pathology. Immunoglobulin replacement therapy to boost the humoral immunity has been commenced.
Toxoplasma is a leading cause of posterior uveitis in immunocompetent patients manifesting as a focal posterior retinochoroiditis. The clinical diagnosis of ocular toxoplasmosis is usually straightforward. There is typically a fluffy white retinal lesion which may lie adjacent to a pigmented chorioretinal scar and a prominent vitreous, or additionally, anterior chamber cellular reaction. Several unusual presentations in ocular toxoplasmosis have been reported, including: papillitis, neuroretinitis, retrobulbar neuritis, retinal detachment and macular oedema. This is a case of presumed primary toxoplasma papillitis in a 14-year-old child with complete absence of vitritis at presentation that made the diagnosis challenging. This evolved into neuroretinitis that resolved upon introducing antitoxoplasma antibiotics.
Sir, Intravitreal Ranibizumab in the treatment of choroidal neovascularisation secondary to ocular toxocariasis in a 13-year-old boyWe report the first case of a choroidal neovascular membrane (CNV) secondary to toxocariasis successfully treated with intravitreal Ranibizumab leading to retention of good vision and no CNV recurrence.Case report A healthy 13-year-old boy with no past ophthalmic history presented with a 4-week history of floaters in his right eye associated with a 5-day history of blurred vision. Visual acuity was counting fingers and examination showed a mild anterior chamber reaction and vitritis. Fundal examination showed a pale area of chorioretinits inferotemporal to the disc with surrounding serous elevation involving the fovea and peripapillary region. Left eye examination was normal. A diagnosis of toxocara chorioretinitis was made after reporting that he played with his pet dog 4 weeks previously before eating sweets without washing his hands. Initial therapy consisted of prednisolone 60 mg, but despite an improvement in vision to 0.0 (LogMAR), it subsequently deteriorated to 0.5 after tapering the dose. Fundal examination showed juxtafoveal subretinal haemorrhage with an adjacent CNV diagnosed by fluorescein angiography (FFA) (Figure 1a-c). After an extensive discussion with the patient and family about treatment options, it was agreed to give an intravitreal injection of Ranibizumab. At 1 month, his vision had improved to 0.0 and there was significantly less membrane activity (Figure 1d-f). However, there was a continued small area of leakage and he received two further injections each 1 month apart. This resulted in no further leakage from the membrane and resolution of subretinal fluid confirmed by FFA and ocular coherence tomography (Figure 1g, h). His visual acuity at 12 months follow-up is -0.2.
DiscussionThis case highlights toxocariasis as a rare cause of CNV and demonstrates that Ranibizumab can be an effective treatment for inflammatory CNV in children. Randomised control trials assessing Ranibizumab in adults have found no statistical difference between treatment and control groups for systemic adverse events such as stroke, myocardial infarction, systemic haemorrhage, or hypertension.1,2 However, adverse events in children may be unpredictable as a lack of data Given the rarity of its use in children, performing a randomised control trial is unrealistic, but an alternative method would be to establish a central database that allows clinicians who use anti-vascular endothelial growth factor therapy in children to report results and complications.
Conflict of interestThe authors declare no conflict of interest.
References
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