Intravitreal Clindamycin and Dexamethasone Combined with Systemic Oral Antitoxoplasma Therapy versus Intravitreal Therapy Alone in the Management of Toxoplasma Retinochoroiditis: A Retrospective Study

Clinical outcomes of intravitreal treatment for ocular toxoplasmosis: systematic review and meta-analysis

BACKGROUND

Ocular toxoplasmosis is the leading cause of infectious posterior uveitis worldwide, accounting for 30-50% of all cases in immunocompetent patients. Conventional treatment is associated with adverse effects and does not prevent recurrence. Intravitreal drug administration can improve disease outcomes and reduce side effects. Herein, we conducted a systematic review and meta-analysis on the efficacy of intravitreal injections for treating ocular toxoplasmosis.

METHODS

The systematic search was conducted using PubMed, SciELO, and Google Scholar with the descriptors "ocular toxoplasmosis" AND "intravitreal". We analyzed studies that met the inclusion criteria, i.e., experimental cases in patients treated intravitreally for ocular toxoplasmosis. Considering the systematic review, we focused on the number of intravitreal injections, the therapeutic drug class, and the presence of preexisting conditions. To assess the efficacy of intravitreal injections, a meta-analysis was performed using visual acuity, side effects, disease recurrence, and inflammatory responses as variables.

RESULTS

Intravitreal injection-induced side effects were rarely observed (0.49% [0.00, 1.51%] ). The use of antiparasitic and anti-inflammatory drugs afforded improved visual acuity (99.81% [98.60, 100.00%]) and marked effectiveness in treating ocular toxoplasmosis.

CONCLUSIONS

Intravitreal injections may facilitate the successful treatment of ocular toxoplasmosis. However, clinicians should carefully evaluate the presence of preexisting conditions for ocular toxoplasmosis or previous diseases, as these can impact the decision to administer intravitreal injections.

Recurrent Toxoplasma Retinitis Treated with Long-Term Oral Antibiotics

Purpose: The purpose of this case was to report the inhibition of toxoplasma retinitis reactivation with long-term, low-dose antibiotics.Case summary: A 76-year-old woman complained of poor vision and floaters in her right eye. The corrected visual acuity (LogMAR) of the right eye was 0.5, and there was an area of yellow infiltration and dye leakage on the retinal fluorescein angiography images. Toxoplasma IgG were detected in the serum, the patient was diagnosed with toxoplasma retinitis, and the patient was advised oral trimethoprim-sulfamethoxazole, clindamycin, and steroids. Her visual acuity improved and the inflammation resolved. However, she again had decreased visual activity and retinal inflammation in her right eye after 5 months. The inflammation improved with oral steroids, but she was shifted to intravitreal dexamethasone because of the side effects of systemic steroids. Although the inflammation improved initially, there was worsening of inflammation (evidenced by vitreous opacity) after 2 months, which was treated with oral antibiotics. After vitrectomy for the removal of residual vitreous opacity, antibiotics were stopped because of the stable disease course. After discontinuation of the antibiotics, inflammation was noted again, and low-dose trimethoprim-sulfamethoxazole was administered. Low-dose antibiotics were continued for 5 months and the disease remained stable without any retinal inflammation.Conclusions: Long-term, low-dose oral antibiotics may prevent reactivation of recurrent toxoplasma retinitis.

Macular Infarction following Intravitreal Clindamycin Injection : A Case Report

Purpose

To report a case of Toxoplasma retinochoroiditis that was complicated by macular infarction following intravitreal clindamycin injection.

Methods

A 32-year-old otherwise healthy woman with the diagnosis of reactivation of Toxoplasma retinochoroiditis in her right eye, underwent intravitreal clindamycin injection. Shortly after injection, the visual acuity deteriorated, and the fundus examination revealed an extensive area of macular necrosis accompanied by vascular occlusion.

Results

The patient was observed. Unfortunately, the condition did not improve over time and resulted in a large area of retinal atrophy.

Conclusion

Macular infarction should be considered a rare but disastrous complication that can result in severe, irreversible visual loss.

[Intravitreal clindamycin injection in toxoplasma retinochoroiditis: About 9 cases in the ophthalmology department of the CHU de Bordeaux]

INTRODUCTION

Toxoplasma retinochoroiditis (TRC) is the main cause of posterior uveitis in immunocompetent patients. Several studies have shown safety and efficacy of treatment with intravitreal clindamycin injection in patients with contraindications, inadequate response or side effects with classic oral therapy. The goal of this study is to describe anatomic and functional results of local treatment with intravitreal clindamycin injection.

MATERIALS AND METHODS

We performed an observational, retrospective, single-center study in the ophthalmology service of Bordeaux university medical center between December 2017 and January 2020 on management of toxoplasma retinochoroiditis by intravitreal clindamycin injection. We analyzed the efficacy of this treatment on improvement in visual acuity, decrease in size of the retinal lesion and decrease in macular thickness.

RESULTS

A total of 10 eyes of 9 patients were injected. Only a single injection was required in 9 of the 10 cases. Injections demonstrated improvement in the 3 study criteria; visual acuity went from a mean of 1 LogMAR (1.07±0.77) pre-injection to 0.4 LogMAR (0.43±0.53) at 6 months, lesion size decreased by 51%, and macular thickness decreased by 78μm over the follow-up period.

CONCLUSION

Intravitreal clindamycin injections are safe and effective for the treatment of TRC. They offer an alternative in patients with allergies, side effects or inadequate response to classic oral therapy.

<p>Intravitreal Clindamycin as First-Line Therapy for Toxoplasmic Retinochoroiditis: A Case Series</p>

Purpose

Materials and Methods

Results

Conclusion

Optical coherence tomography angiography findings in macular toxoplasma retinochoroiditis: A case report

Purpose

To report the optical coherence tomography angiography (OCT-A) findings in a patient with macular toxoplasma retinochoroiditis (TRC).

Observations

A 14-year old female presented with a 2-week history of decreased vision of her right eye. Upon presentation, on the right eye, visual acuity was 20/200 and the fundus revealed 2+ vitritis and an active parafoveal area of retinitis superotemporally. Toxoplasma serology revealed positive IgG and negative IgM. Initial treatment consisted of intravitreal clindamycin (1.0mg in 0.1 mL) with dexamethasone (1.0 mg in 0.1 mL) along with oral trimethoprim/sulfamethoxazole, azithromycin and prednisone; of which the trimethoprim/sulfamethoxazole was discontinued 4 days into therapy due to a pruritic rash. Six-weeks after the presentation, the oral prednisone had been tapered off, and all therapy discontinued. The patient had complete resolution of TRC and recovered 20/20 vision. OCT-A analysis of the right macula, performed after completion of treatment, revealed preservation of foveal perfusion along a parafoveal area of ischemia, superotemporally, at the superficial and deep retinal vascular complexes, including the choriocapillaris.

Conclusion and Importance

In macular TRC, OCT-A may help to assess therapeutic outcomes from a vascular perspective. To our knowledge, our case represents the first description in the medical literature of OCT-A findings in macular TRC.