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Yap A, Kearns H, Sims JL, Niederer RL. Visual outcomes and prognostic factors in ischaemic retinal vasculitis. Br J Ophthalmol 2024:bjo-2024-325775. [PMID: 39089847 DOI: 10.1136/bjo-2024-325775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/22/2024] [Indexed: 08/04/2024]
Abstract
PURPOSE Our aim was to describe the visual outcomes and determine the clinical factors in ischaemic retinal vasculitis (IRV) that were predictive of a poor visual prognosis or infectious aetiology. METHODS Retrospective cohort study of consecutive presentations of IRV to Auckland District Health Board from 2009 to 2022. RESULTS The median age at presentation was 39.2 years and 108 (53.7%) were women. The total median follow-up was 4.8 years. Infectious aetiology was present in 151 eyes (52.1%). Moderate visual loss (20/50 to 20/200) occurred in 20 eyes (6.9%) and severe visual loss (≤20/200) occurred in 41 eyes (14.1%). Median visual acuity was 20/30 (IQR 20/25 to 20/100) on presentation and 20/25 (IQR 20/20 to 20/50) at final follow-up. Retinitis (HR 4.675 p=0.048) and cystoid macular oedema (CME) (HR 7.265 p<0.001) were significantly associated with vision loss. There was concurrent macular ischaemia in 26 eyes (19.4%) and CME in 52 eyes (17.9%). Retinitis was predictive of infectious aetiology (p=0.006) and cotton wool spots for non-infectious aetiology (p<0.001). Retinal haemorrhage (HR 5.580 p=0.001), retinal vein occlusion (HR 5.071 p=0.001) and quadrants of ischaemia (HR 2.222 p=0.025) were significantly associated with vitreous haemorrhage. CONCLUSION In patients with IRV, 21% of affected individuals sustained moderate-to-severe vision loss over 5 years. Ultra-widefield fluorescein angiography can be used to quantify the risk of neovascular complications and guide treatment.
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Affiliation(s)
- Aaron Yap
- Department of Ophthalmology, The University of Auckland, Auckland, New Zealand
- Department of Ophthalmology, Auckland District Health Board, Auckland, New Zealand
| | - Helen Kearns
- Department of Ophthalmology, Auckland District Health Board, Auckland, New Zealand
| | - Joanne L Sims
- Department of Ophthalmology, Auckland District Health Board, Auckland, New Zealand
| | - Rachael L Niederer
- Department of Ophthalmology, The University of Auckland, Auckland, New Zealand
- Department of Ophthalmology, Auckland District Health Board, Auckland, New Zealand
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2
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Artiaga JCM, Azarcon CP, Levina FD, Bromeo AJ, Mesina BVQ, Arcinue CA. Considerations in the management of ocular toxoplasmosis in pregnancy: a review of literature. Eye (Lond) 2024; 38:1262-1268. [PMID: 38191658 PMCID: PMC11076467 DOI: 10.1038/s41433-023-02916-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 11/27/2023] [Accepted: 12/20/2023] [Indexed: 01/10/2024] Open
Abstract
Ocular toxoplasmosis is the most common cause of infectious posterior uveitis. Available literature is still conflicting regarding the incidence of recurrence during pregnancy as various calculations were employed in the different published studies. Although earlier reports have suggested a difference in presentation and an increase in severity during pregnancy, newer studies appear to show otherwise. Further diagnostic testing, including serologic and intraocular fluid sampling, may be indicated to increase the diagnostic accuracy in this special population of patients. The management of ocular toxoplasmosis during pregnancy is challenging as the foetus is additionally considered in the choice of treatment. Traditionally preferred anti-toxoplasmosis regimens containing antifolate drugs, such as pyrimethamine and trimethoprim-sulfamethoxazole, cannot be used routinely in pregnant patients, especially during the first trimester. This review includes literature on alternative treatments for ocular toxoplasmosis during pregnancy, including spiramycin and intravitreal treatment options.
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Affiliation(s)
- Jose Carlo M Artiaga
- Department of Ophthalmology and Visual Sciences, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines.
| | - Corrina P Azarcon
- Section of Ophthalmology, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Faye D Levina
- Department of Ophthalmology and Visual Sciences, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | | | - Bryan Vincent Q Mesina
- Department of Ophthalmology and Visual Sciences, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Cheryl A Arcinue
- Department of Ophthalmology and Visual Sciences, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
- Asian Eye Institute, Makati City, Philippines
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3
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Goh EJH, Putera I, La Distia Nora R, Mahendradas P, Biswas J, Chee SP, Testi I, Pavesio CE, Curi ALL, Vasconcelos-Santos DV, Arora A, Gupta V, de-la-Torre A, Agrawal R. Ocular Toxoplasmosis. Ocul Immunol Inflamm 2023; 31:1342-1361. [PMID: 36095008 DOI: 10.1080/09273948.2022.2117705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 08/14/2022] [Accepted: 08/22/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Ocular toxoplasmosis is the leading cause of posterior uveitis worldwide, affecting individuals acrossdifferent age groups. The key to reducing vision loss includes prompt diagnosis and treatment. However, despite the prevalence of ocular toxoplasmosis, there has been little consensus regarding its pathophysiology,clinical features, diagnosis, and especially management. METHODS The data sources were literature reviews, including Pub Med and Medline databases. Search terms included toxoplasmosis, retinitis, vasculitis, vitritis, uveitis alone or in combination with, serum, aqueous, vitreous eye, ocular and review. RESULTS In this review paper, we have sought to provide an overview of the pathophysiology, epidemiology, and clinical features of the disease, both based on current literature and our own clinical experience. We have also discussed the use of serology, ocular fluid, and ophthalmic investigations that could further facilitate the diagnosis of ocular toxoplasmosis.Different management strategies have been reported worldwide, including newer approaches such as local therapy. CONCLUSION A better understanding of critical aspects of ocular toxoplasmosis will hopefully lead to reduced morbidity, including blindness associated with this condition.
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Affiliation(s)
- Eunice Jin Hui Goh
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore
| | - Ikhwanuliman Putera
- Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo Kirana Eye Hospital, Jakarta, Indonesia
- Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Rina La Distia Nora
- Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo Kirana Eye Hospital, Jakarta, Indonesia
- Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Soon-Phaik Chee
- Department of Ocular Inflammation and Immunology, Singapore National Eye Centre, Singapore
- Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
- Neuroscience Research Group (NEUROS), NeuroVitae Center, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Ilaria Testi
- Moorfields Eye Hospital, NHS Foundation Trust, London, UK
| | | | - Andre Luiz Land Curi
- Infectious Ophthalmology Laboratory, Evandro Chagas National Institute of Infectious Diseases-FIOCRUZ, Rio de Janeiro, Brazil
| | - Daniel Vitor Vasconcelos-Santos
- Departamento de Oftalmologia e Otorrinolaringologia e Laboratório de Ciências Visuais, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Hospital São Geraldo, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Programa de Pós-graduação em Ciências da Saúde, Infectologia e Medicina Tropical, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Atul Arora
- Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishali Gupta
- Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Alejandra de-la-Torre
- Neuroscience Research Group (NEUROS), NeuroVitae Center, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore
- Singapore Eye Research Institute, The Academia, Singapore
- Department of Ophthalmology & Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
- Moorfields Eye Hospital, NHS Foundation Trust, London, UK
- Lee Kong Chian School of Medicine, Singapore
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Souza GM, de Souza CE, Passos RM, Nascimento HMD, Belfort R. Recurrence of Ocular Toxoplasmosis after Vitrectomy: Case Report and Review. Ocul Immunol Inflamm 2023; 31:416-420. [PMID: 35081011 DOI: 10.1080/09273948.2022.2026408] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this study is to report one case of ocular toxoplasmosis (OT) recurrence after vitrectomy and review the scientific basis about it. CASE REPORT A 58-year-old male patient with previous OT, properly treated, underwent vitrectomy due to macular hole. During follow-up, patient evolved with recurrence of the OT. After 1 year, patient presents visual acuity of 20/200 and extensive macular scar. CONCLUSION There is no consensus on using perioperative antiparasitic therapy aiming recurrence prophylaxis. Studies with better statistical design are necessary to evaluate the recurrence risk after ocular surgeries and the possible recommendation of prophylaxis, especially in countries where the strains are more virulent and the recurrence more common.
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Affiliation(s)
- Guilherme Macedo Souza
- Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, São Paulo, Brazil
| | - Carlos Eduardo de Souza
- Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, São Paulo, Brazil
| | - Renato Magalhães Passos
- Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, São Paulo, Brazil
| | | | - Rubens Belfort
- Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, São Paulo, Brazil
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Aksu-Ceylan N, Cebeci Z, Altinkurt E, Kir N, Oray M, Tugal-Tutkun I. Interferon Alpha-2a for the Treatment of Cystoid Macular Edema Secondary to Acute Retinal Necrosis. Ocul Immunol Inflamm 2022; 30:1788-1797. [PMID: 34348058 DOI: 10.1080/09273948.2021.1957121] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE To report the results of interferon (IFN) α-2a treatment in patients with cystoid macular edema (CME) secondary to acute retinal necrosis (ARN). METHODS We reviewed the records of seven patients (eight eyes) who received IFNα-2a for post-ARN CME. The initial dose of IFNα-2a was 3 MIU/day and it could be tapered down to 3 MIU twice a week. Efficacy was assessed by central macular thickness (CMT) on spectral-domain optical coherence tomography and visual acuity. RESULTS Age range of seven patients (four men, three women) was 36-74 years. Mean CMT decreased from 477.9 ± 167.5 μm to 367.3 ± 120.5 μm at first week, and vision improved up to five lines in five eyes. CME relapsed after cessation of IFNα-2a in all and improved following reinstitution of treatment. Treatment was discontinued in one patient because of depression. Three patients electively discontinued treatment due to poor tolerability or lack of functional improvement. CONCLUSION IFNα-2a is an effective therapeutic option for post-ARN CME, though side effects such as fatigue, elevated liver enzymes, neutropenia, and depression may limit tolerability. Lower initial doses may be a better tolerated.
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Affiliation(s)
- Nihan Aksu-Ceylan
- Istanbul Faculty of Medicine, Department of Ophthalmology, Istanbul University, Istanbul, Turkey
| | - Zafer Cebeci
- Istanbul Faculty of Medicine, Department of Ophthalmology, Istanbul University, Istanbul, Turkey
| | - Emre Altinkurt
- Istanbul Faculty of Medicine, Department of Ophthalmology, Istanbul University, Istanbul, Turkey
| | - Nur Kir
- Istanbul Faculty of Medicine, Department of Ophthalmology, Istanbul University, Istanbul, Turkey
| | - Merih Oray
- Istanbul Faculty of Medicine, Department of Ophthalmology, Istanbul University, Istanbul, Turkey
| | - Ilknur Tugal-Tutkun
- Istanbul Faculty of Medicine, Department of Ophthalmology, Istanbul University, Istanbul, Turkey
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Dillon AB, Budoff G, McCannel CA, Tsui E, Pullarkat ST, Schwartz SD. Ocular Toxoplasmosis: No Stranger to the Masquerade Ball. JOURNAL OF VITREORETINAL DISEASES 2022; 6:391-398. [PMID: 37006900 PMCID: PMC9954925 DOI: 10.1177/24741264211056769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: This article illustrates multiple atypical manifestations of ocular toxoplasmosis masquerading as acute retinal necrosis and vitreoretinal lymphoma. Methods: Two case presentations are discussed, and the body of pertinent literature is reviewed and discussed. Results: In these cases, an extensive workup and attention to history lead to the correct diagnosis and management. Conclusions: Aggressive cases of ocular toxoplasmosis may present in a variety of phenotypes that may mimic other vision- and potentially life-threatening conditions, particularly in a milieu of inadequate endogenous and exogenous antimicrobial defenses.
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Affiliation(s)
- Alexander B. Dillon
- Vitreoretinal Surgery Service, UCLA Jules Stein Eye Institute, Los Angeles, CA, USA
| | - Greg Budoff
- Vitreoretinal Surgery Service, UCLA Jules Stein Eye Institute, Los Angeles, CA, USA
| | - Colin A. McCannel
- Vitreoretinal Surgery Service, UCLA Jules Stein Eye Institute, Los Angeles, CA, USA
| | - Edmund Tsui
- Uveitis Service, UCLA Jules Stein Eye Institute, Los Angeles, CA, USA
| | | | - Steven D. Schwartz
- Vitreoretinal Surgery Service, UCLA Jules Stein Eye Institute, Los Angeles, CA, USA
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Castaño BL, Silva AA, Hernandez-Velasco LL, Pinheiro APDS, Gibaldi D, Mineo JR, Silva NM, Lannes-Vieira J. Sulfadiazine Plus Pyrimethamine Therapy Reversed Multiple Behavioral and Neurocognitive Changes in Long-Term Chronic Toxoplasmosis by Reducing Brain Cyst Load and Inflammation-Related Alterations. Front Immunol 2022; 13:822567. [PMID: 35572567 PMCID: PMC9091718 DOI: 10.3389/fimmu.2022.822567] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Toxoplasma gondii infects one-third of the world population. For decades, it has been considered a silent lifelong infection. However, chronically T. gondii-infected persons may present psychiatric and neurocognitive changes as anxiety, depression, and memory loss. In a model of long-term chronic infection, behavioral alterations parallel neuroinflammation and systemic high cytokine levels, and may reflect brain cyst load. Recent findings support that in chronic infection an active parasite-host interplay involves an immune-mediated control of tissue cysts. Here, we tested the idea that etiological treatment in chronic phase may add advantage to intrinsic immune-mediated cyst control and impact behavioral changes. Thus, we combined sulfadiazine-plus-pyrimethamine (S+P), the first-choice therapy for toxoplasmosis, to study the association of brain cyst load and biological processes related to the immune response (neuroinflammation, blood-brain barrier -BBB- disruption and serum cytokine levels), with behavioral and neurocognitive changes of long-term chronic infection. Female C57BL/6 mice (H-2b) were infected (5 cysts, ME-49 strain) and treated with S+P from 30 to 60 days postinfection (dpi), compared with vehicle (Veh)-treated and noninfected controls. At endpoints (pre-therapy, 30 dpi; S+P therapy, 60 dpi; after ceased therapy, 90 dpi), independent groups were subjected to behavioral tests, and brain tissues and sera were collected. Multiple behavioral and neurocognitive changes were detected in the early (30 dpi) and long-term (60 and 90 dpi) chronic infection. S+P therapy resolved locomotor alterations, anxiety, and depressive-like behavior, partially or transiently ameliorated hyperactivity and habituation memory loss. Analysis after therapy cessation showed that S+P therapy reduced the number of stimuli required for aversive memory consolidation. S+P therapy resulted in reduced brain cyst load, neuroinflammation and BBB disruption, and lowered systemic Th1-cytokine levels. Correlation analysis revealed association between IFNγ, TNF and MCP-1/CCL2 serum levels, brain cyst load and behavioral and neurocognitive alterations. Moreover, principal-component analysis (PCA-2D and 3D projections) highlighted distinction between clusters (noninfected; Veh-treated and S+P-treated infected). Thus, our data suggest that S+P therapy added gain to intrinsic brain cyst control and, direct or indirectly, ameliorated inflammation-related alterations, traits associated with behavioral and neurocognitive alterations.
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Affiliation(s)
- Barrios Leda Castaño
- Laboratory of Biology of the Interactions, Oswaldo Cruz Institute/Fiocruz, Rio de Janeiro, Brazil
| | - Andrea Alice Silva
- Multiuser Laboratory for Research Support in Nephrology and Medical Sciences, Federal University Fluminense, Niterói, Brazil
| | | | | | - Daniel Gibaldi
- Laboratory of Biology of the Interactions, Oswaldo Cruz Institute/Fiocruz, Rio de Janeiro, Brazil
| | - José Roberto Mineo
- Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, Brazil
| | - Neide Maria Silva
- Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, Brazil
| | - Joseli Lannes-Vieira
- Laboratory of Biology of the Interactions, Oswaldo Cruz Institute/Fiocruz, Rio de Janeiro, Brazil
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9
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Yeom H, Park SH, Cho H, Shin YU. Recurrent Toxoplasma Retinitis Treated with Long-Term Oral Antibiotics. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2021. [DOI: 10.3341/jkos.2021.62.11.1565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
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Ong AP, Sims JL, Niederer RL. Infectious Uveitis after Local Steroid and/or Methotrexate Injections at A Tertiary Referral Center in New Zealand: A Case Series. Ocul Immunol Inflamm 2021; 30:1176-1180. [PMID: 33792480 DOI: 10.1080/09273948.2020.1860230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Aim: Infectious uveitis is one of the most visually devastating causes of uveitis worldwide and accounts for 19.6% of all cases of uveitis in New Zealand. With the burgeoning use of intravitreal injections, there has been a commensurate increase in the number of injection-related complications and reports of infectious uveitis following their administration in recent years. We present a case series of four patients with infectious uveitis after local injections.Method: We retrospectively reviewed the data of four patients (mean age, 67.25 ± 7.58 years) who presented to the department of ophthalmology at Auckland District Health Board with infectious uveitis which occurred or worsened after local triamcinolone acetonide (TA) and/or methotrexate (MTX) injections.Results: Three patients received local TA and one patient received intravitreal MTX. All patients were immunosuppressed prior to treatment. Two patients had toxoplasma chorioretinitis which worsened with local TA and one patient developed cytomegalovirus (CMV) retinitis after intravitreal TA. The last patient had syphilis retinopathy which worsened with intravitreal MTX. There were atypical presentations, as demonstrated by a case of presumed birdshot chorioretinopathy flare which tested positive for toxoplasma chorioretinitis with polymerase chain reaction (PCR).Conclusion: Uveitis due to infectious etiologies needs to be carefully excluded prior to the use of local steroid and/or methotrexate injections. Disease presentations may be atypical in the presence of marked immunosuppression following local therapy. Polymerase chain reaction (PCR) can play an important role in the diagnosis in this setting.
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Affiliation(s)
- Aaron Pc Ong
- Department of Ophthalmology, Southern District Health Board, Dunedin, New Zealand
| | - Joanne L Sims
- Department of Ophthalmology, Auckland District Health Board, Auckland, New Zealand
| | - Rachael L Niederer
- Department of Ophthalmology, Auckland District Health Board, Auckland, New Zealand.,The University of Auckland, Auckland, New Zealand
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11
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Mobini M, Ahmadzade-Amiri A, Ghasemian R, Torabizadeh Z, Fakhar M. Heerfordt-Waldenström syndrome, a rare presentation of sarcoidosis in a patient with old ocular toxoplasmosis. Infect Disord Drug Targets 2020; 21:629-633. [PMID: 32901589 DOI: 10.2174/1871526520666200909094500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 06/19/2020] [Accepted: 07/27/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND There are similarities between ophthalmic presentation of toxoplasmosis and sarcoidosis and there are some concerns of immunosuppressive treatments for sarcoidosis may lead to T. gondii reactivation. We report a rare case with acute sarcoidosis (Heerfordt-Waldenström syndrome) and past history of ocular toxoplasmosis from the North of Iran. CASE PRESENTATION The patient was a 36-year-old woman, with left painful eye and swollen parotid, right facial paresis, maculopapular rash in left eyebrow and erythema nodosa on both legs. Anti-Toxoplasma IgG antibody was positive and IgM was not detectable. Radiographic findings on chest revealed bilateral hilar lymphadenopathy. The initial treatment was sulfamethoxazole-trimethoprim to prevent recurrence of retinal toxoplasmosis and corticosteroid and mycophenolate mofetil for sarcoidosis. The patient showed clinical and vision improvement without recurrences during three months follow-up. DISCUSSION Ophthalmological examinations and laboratory test to rule out toxoplasmosis could be considered in known cases of sarcoidosis particularly in ocular sarcoidosis status. To the best of our knowledge this is first report of co-morbidity of ocular toxoplasmosis / sarcoidosis from Iran and possibly the world.
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Affiliation(s)
- Maryam Mobini
- Department of Internal Medicine, Diabetes Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari. Iran
| | - Ahmad Ahmadzade-Amiri
- Department of Ophthalmology, Diabetes Research Center, Mazandaran University of Medical Sciences, Sari. Iran
| | - Roya Ghasemian
- Department of Infectious Diseases, Antimicrobial Resistance Research Center, Mazandaran University of Medical Sciences, Mazandaran. Iran
| | - Zhila Torabizadeh
- Department of Pathology, Mazandaran University of Medical Sciences, Mazandaran. Iran
| | - Mahdi Fakhar
- Toxoplasmosis Research Center, Iranian National Registry Center for Toxoplasmosis (INRCT), Department of Parasitology, Mazandaran University of Medical Sciences, Sari. Iran
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Triningrat AAMP, Dewi RS, Juliari I, Susila NKN, Surasmiati NMA, Somia IKA. Management of Systemic Steroid in HIV Patient with Toxoplasma Papillitis. Open Access Maced J Med Sci 2019; 7:1821-1824. [PMID: 31316667 PMCID: PMC6614278 DOI: 10.3889/oamjms.2019.488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 05/26/2019] [Accepted: 05/27/2019] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Toxoplasmosis is a zoonotic disease caused by Toxoplasma gondii. Ocular manifestations are seen in both congenital and acquired toxoplasmosis. These can include focal inflammation within or around the optic nerve head (papillitis). Purpose of this study is evaluating the efficacy of systemic steroid in HIV patient with toxoplasma papillitis. CASE PRESENTATION We present a case report of a male, 46 years old with a decrease of visual acuity on the right eye for three weeks before admission to the hospital. An ophthalmology examination showed visual acuity of the right eye 1/60, mild dilatation of the pupil and posterior synechiae, vitreous was hazy, and fundus examination showed optic nerve head not well demarcated and hyperaemic with the good retina and macula reflex. Laboratory examination showed reactive anti-Toxoplasma immunoglobulin G. Patient had been treated with antiretroviral and anti-Toxoplasma drugs, then he was given steroid 250 mg intravenously four times per day for three days and tapering off orally. Visual acuity on the right eye improve from 1/60 became 6/60 after use of steroid on the third day. DISCUSSION Steroid can improve visual acuity for toxoplasma papillitis in this patient. But the long term and close follow up in steroid therapy is needed.
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Affiliation(s)
- AA Mas Putrawati Triningrat
- Ophthalmology Department, Faculty of Medicine, Udayana University, Sanglah Hospital, Denpasar, Bali, Indonesia
| | - Ratna Sari Dewi
- Ophthalmology Department, Faculty of Medicine, Udayana University, Sanglah Hospital, Denpasar, Bali, Indonesia
| | - Igam Juliari
- Ophthalmology Department, Faculty of Medicine, Udayana University, Sanglah Hospital, Denpasar, Bali, Indonesia
| | - NK Niti Susila
- Ophthalmology Department, Faculty of Medicine, Udayana University, Sanglah Hospital, Denpasar, Bali, Indonesia
| | - Ni Made Ayu Surasmiati
- Ophthalmology Department, Faculty of Medicine, Udayana University, Sanglah Hospital, Denpasar, Bali, Indonesia
| | - I Ketut Agus Somia
- Internal Medicine Department, Faculty of Medicine, Udayana Unoversity, Sanglah Hospital, Denpasar, Bali, Indonesia
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Jeong A, Park DG, Sagong M. Fulminant Toxoplasmic Chorioretinitis Following Intravitreal Dexamethasone Implantation. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2019. [DOI: 10.3341/jkos.2019.60.9.896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Areum Jeong
- Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea
| | - Dong-Geun Park
- Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea
| | - Min Sagong
- Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea
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Ahmed A, Sudharshan S, Gopal S, Majumder PD, Biswas J. Toxoplasma retinitis following intravitreal injection of triamcinolone acetonide: A case report and review of literature. Indian J Ophthalmol 2018; 66:1205-1208. [PMID: 30038184 PMCID: PMC6080440 DOI: 10.4103/ijo.ijo_142_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to report a case of atypical toxoplasma retinochoroiditis following intravitreal triamcinolone acetonide (IVTA) injection and to review the literature pertaining to toxoplasma retinochoroiditis following intravitreal injection of corticosteroid. Clinical data were collected from a 64-year-old male who developed toxoplasma retinitis 2 months after IVTA. A review of the literature was conducted to identify additional reports on similar cases. A 64-year-old male, known diabetic with nonproliferative diabetic retinopathy in both the eyes and optic atrophy in the left eye, presented with atypical retinitis inferior to the disc following IVTA. Real-time polymerase chain reaction and serology confirmed the toxoplasma etiology, and the patient was started on anti-toxoplasma therapy along with oral corticosteroid leading to regression of the lesion by 3 months. A high index of suspicion and proper microbiological diagnosis with appropriate antimicrobial therapy can aid in the management of toxoplasma retinochoroiditis following intravitreal injection of corticosteroid.
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Affiliation(s)
- Arshee Ahmed
- Department of Uvea, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | | | - Sriram Gopal
- Athreya Retinal Centre, Trichy, Tamil Nadu, India
| | | | - Jyotirmay Biswas
- Department of Uvea, Sankara Nethralaya, Chennai, Tamil Nadu, India
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SAFETY AND EFFICACY OF INTRAVITREAL DEXAMETHASONE IMPLANTS IN THE MANAGEMENT OF MACULAR EDEMA SECONDARY TO INFECTIOUS UVEITIS. Retina 2017; 36:1778-85. [PMID: 27183031 DOI: 10.1097/iae.0000000000001001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the safety and efficacy of intravitreal dexamethasone implants in the treatment of macular edema secondary to infectious uveitis. METHODS We retrospectively reviewed clinical records from three uveitis referral units in Spain. The main outcome measures were rate of reactivation of infection, improvements in visual acuity and resolution of macular edema, as measured by optical coherence tomography. RESULTS We included eight eyes from seven patients with a median age of 64 years (30-75). Etiologies of the infections were Herpes simplex virus-type 1, Varicela-Zoster virus, Treponema pallidum, Brucella mellitensis, Borrelia burgdorferi, Toxoplasma gondii, and cytomegalovirus. Median visual acuity was 20/160 (20/30-20/400) at baseline and 20/70 (20/25-20/200) at the last follow-up visit. Mean macular thickness was 516 μm (115) at baseline and 266.3 μm (40) at the last follow-up visit. Visual acuity improved in 100% of the eyes and none of the eyes showed macular edema at the last follow-up visit. Five patients required reinjections of the implant. Only one patient required antiglaucoma drops for a temporary increase in ocular pressure. There were no cases of reactivation of the infectious ocular disease. Median follow-up time was 18 months. CONCLUSION In this small case series of eyes with macular edema secondary to infectious uveitis, treatment with dexamethasone intravitreal implants was not associated with reactivation of the infectious ocular disease. Furthermore, significant improvements in visual acuity and macular thickness were observed in our patients.
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Jasper S, Vedula SS, John SS, Horo S, Sepah YJ, Nguyen QD. Corticosteroids as adjuvant therapy for ocular toxoplasmosis. Cochrane Database Syst Rev 2017; 1:CD007417. [PMID: 28125765 PMCID: PMC5369355 DOI: 10.1002/14651858.cd007417.pub3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Ocular infection caused by Toxoplasma gondii, a parasite, may result in inflammation in the retina, choroid, and uvea, and consequently lead to complications such as glaucoma, cataract, and posterior synechiae. OBJECTIVES The objective of this systematic review was to assess the effects of adjunctive use of corticosteroids to anti-parasitic therapy versus anti-parasitic therapy alone for ocular toxoplasmosis. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register (2016; Issue 11)), MEDLINE Ovid, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, MEDLINE Ovid Daily (January 1946 to December 2016), Embase (January 1980 to December 2016), Latin American and Caribbean Literature on Health Sciences (LILACS (January 1982 to December 2016)), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP; www.who.int/ictrp/search/en). We used no date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 7 December 2016. SELECTION CRITERIA We had planned to include randomized and quasi-randomized controlled trials. Eligible trials would have enrolled participants of any age who were immunocompetent and were diagnosed with acute ocular toxoplasmosis. Included trials would have compared anti-parasitic therapy plus corticosteroids versus anti-parasitic therapy alone, different doses or times of initiation of corticosteroids. DATA COLLECTION AND ANALYSIS Two authors independently screened titles and abstracts retrieved through the electronic searches. We retrieved full-text reports of studies categorized as 'unsure' or 'include' after we reviewed the abstracts. Two authors independently reviewed each full-text report for eligibility. Discrepancies were resolved through discussion. MAIN RESULTS We identified no completed or ongoing trial that was eligible for this Cochrane review. AUTHORS' CONCLUSIONS Although research has identified a wide variation in practice regarding the use of corticosteroids, our review did not identify any evidence from randomized controlled trials for or against the role of corticosteroids in the management of ocular toxoplasmosis. Several questions remain unanswered by well-conducted randomized trials in this context, including whether the use of corticosteroids as an adjunctive agent is more effective than the use of anti-parasitic therapy alone; if so, when corticosteroids should be initiated in the treatment regimen (early versus late course of treatment), and what would be the best dose and duration of steroid use.
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Affiliation(s)
- Smitha Jasper
- Christian Medical CollegeDepartment of OphthalmologySchell Campus, Arni RoadVelloreTamil NaduIndia632001
| | | | - Sheeja S John
- Christian Medical CollegeDepartment of OphthalmologySchell Campus, Arni RoadVelloreTamil NaduIndia632001
| | - Saban Horo
- Christian Medical CollegeDepartment of OphthalmologySchell Campus, Arni RoadVelloreTamil NaduIndia632001
| | - Yasir J Sepah
- Stanford UniversityByers Eye InstitutePalo AltoCaliforniaUSA
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Fine HF, Burke SP, Albini TA. Toxoplasmosis Retinitis Masquerading as Acute Retinal Necrosis. Ophthalmic Surg Lasers Imaging Retina 2016; 47:895-899. [DOI: 10.3928/23258160-20161004-01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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18
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Oray M, Ozdal PC, Cebeci Z, Kir N, Tugal-Tutkun I. Fulminant Ocular Toxoplasmosis: The Hazards of Corticosteroid Monotherapy. Ocul Immunol Inflamm 2015; 24:637-646. [DOI: 10.3109/09273948.2015.1057599] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Merih Oray
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Pinar Cakar Ozdal
- Ulucanlar Eye Education and Training Hospital Ophthalmology Clinic, Ankara, Turkey
| | - Zafer Cebeci
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Nur Kir
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Lima GSC, Saraiva PGC, Saraiva FP. Current Therapy of Acquired Ocular Toxoplasmosis: A Review. J Ocul Pharmacol Ther 2015. [PMID: 26226199 DOI: 10.1089/jop.2015.0059] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Caused by the parasite Toxoplasma gondii, ocular toxoplasmosis (OT) is the most common form of posterior infectious uveitis. Combined antiparasitic therapy is the standard treatment for OT, but several other schemes have been proposed. The purpose of the present study was to review the literature on the treatment of OT and provide ophthalmologists with up-to-date information to help reduce OT-related visual morbidity. In conclusion, no ideal treatment scheme was identified; currently prescribed therapeutic schemes yield statistically similar functional outcomes.
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Affiliation(s)
| | | | - Fábio Petersen Saraiva
- 1 Specialized Medicine Department, Federal University of Espirito Santo , Vitória, Brazil
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20
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The role of methotrexate in resolving ocular inflammation after specific therapy for presumed latent syphilitic uveitis and presumed tuberculosis-related uveitis. Retina 2014; 34:1451-9. [PMID: 24531737 DOI: 10.1097/iae.0000000000000080] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE This study was designed to investigate whether the antiinflammatory and antiproliferative activity of oral and intravitreal methotrexate (MTX) suppresses intraocular inflammation in patients with presumed latent syphilitic uveitis and presumed tuberculosis-related uveitis. METHODS Interventional prospective study including three cases with presumed latent syphilitic uveitis treated with intravenous penicillin and oral MTX, and two cases with presumed tuberculosis-related uveitis treated with standard antituberculosis therapy and intravitreal MTX injections. Treatment efficacy of all cases was assessed by best-corrected visual acuity, fundus fluorescein angiography, and optical coherence tomography. RESULTS Four eyes of 3 patients with presumed latent syphilitic uveitis had improved best-corrected visual acuity, suppression of intraocular inflammation, and resolution of cystoid macular edema in 6 months with oral MTX therapy. No recurrence of intraocular inflammation was observed in 6 months to 18 months of follow-up period after cessation of MTX. Two eyes of two patients with presumed tuberculosis-related uveitis showed improved best-corrected visual acuity, suppression of intraocular inflammation, and resolution of cystoid macular edema after intravitreal injections of MTX. No recurrence of intraocular inflammation was observed in 6 months to 8 months of follow-up period after cessation of antituberculous therapy. CONCLUSION For the first time in the treatment of presumed latent syphilitic uveitis and presumed tuberculosis-related uveitis, we believe that MTX might have an adjunctive role to suppress intraocular inflammation, reduce uveitic macular edema, and prevent the recurrences of the diseases.
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21
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Corticosteroids for the Treatment of Diabetic Macular Edema. CURRENT OPHTHALMOLOGY REPORTS 2014. [DOI: 10.1007/s40135-014-0051-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Jasper S, Vedula SS, John SS, Horo S, Sepah YJ, Nguyen QD. Corticosteroids as adjuvant therapy for ocular toxoplasmosis. Cochrane Database Syst Rev 2013; 4:CD007417. [PMID: 23633342 PMCID: PMC4269154 DOI: 10.1002/14651858.cd007417.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Ocular infestation with Toxoplasma gondii, a parasite, may result in inflammation in the retina, choroid, and uvea and consequently lead to complications such as glaucoma, cataract, and posterior synechiae. OBJECTIVES The objective of this systematic review was to assess the effects of adjunctive use of corticosteroids for ocular toxoplasmosis. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 9), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to October 2012), EMBASE (January 1980 to October 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to October 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We searched the reference lists of included studies for any additional studies not identified by the electronic searches. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 11 October 2012. SELECTION CRITERIA We planned to include randomized and quasi-randomized controlled trials. Eligible trials would have enrolled participants of any age who were immunocompetent and were diagnosed with active ocular toxoplasmosis. Included trials would have compared anti-parasitic therapy plus corticosteroids versus anti-parasitic therapy alone, or different doses or times of initiation of corticosteroids. DATA COLLECTION AND ANALYSIS Two authors independently screened titles and abstracts retrieved from the electronic searches. We retrieved full-text articles of studies categorized as 'unsure' or 'include' after review of the abstracts. Two authors independently reviewed each full-text article. Discrepancies were resolved through discussion. MAIN RESULTS The electronic searches retrieved 368 titles and abstracts. We reviewed 20 full-text articles. We identified no trials eligible for inclusion in this systematic review. AUTHORS' CONCLUSIONS Although research has identified wide variation in practices regarding use of corticosteroids, our systematic review did not identify evidence from randomized controlled trials for the role of corticosteroids in the management of ocular toxoplasmosis. Several questions remain unanswered by well-conducted randomized trials in this context, including whether use of corticosteroids is more effective than use of anti-parasitic therapy alone, when corticosteroids should be initiated in the treatment regimen (early versus late course of treatment), and which dosage and duration of steroid use is best. These questions are easily amenable to research using a randomized controlled design and they are ethical due to the absence of evidence to support or discourage use of corticosteroids for this condition. The question of foremost importance, however, is whether they should be used as adjunct therapy (that is, additional) to anti-parasitic agents.
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Affiliation(s)
- Smitha Jasper
- Department of Ophthalmology, Christian Medical College, Vellore, India
| | - Satyanarayana S Vedula
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sheeja S John
- Department of Ophthalmology, Christian Medical College, Vellore, India
| | - Saban Horo
- Department of Ophthalmology, Christian Medical College, Vellore, India
| | - Yasir J Sepah
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Quan Dong Nguyen
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Hazirolan D, Pleyer U. Think global--act local: intravitreal drug delivery systems in chronic noninfectious uveitis. Ophthalmic Res 2012; 49:59-65. [PMID: 23258374 DOI: 10.1159/000345477] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 10/27/2012] [Indexed: 01/08/2023]
Abstract
The eye is probably the most attractive site of the body for treatment using locally delivered therapeutic agents. An ideal indication for such an approach is noninfectious posterior uveitis. Since intraocular structures of the posterior segment are difficult to reach and are otherwise accessible only by systemic treatment, current interest is focused on the pros and cons of intravitreal drug delivery. Because of its chronic and recurrent nature, the long-term release of anti-inflammatory agents is a major treatment goal. Intravitreal injections, intravitreal implants and biodegradable devices are the most commonly used and approved approaches to deliver various agents to the vitreous. Because of their broad and potent effects, corticosteroids (CS) have been the first-line candidates for intraocular delivery. An increasing spectrum of CS preparations including nondegradable and biodegradable devices is currently available. Since repeated and long-term applications bear the risk of steroid-related complications such as increased intraocular pressure and cataract, alternative agents are currently being tested. Intravitreal injection of methotrexate, anti-VEGF (vascular endothelial growth factor), anti-TNFα (tumor necrosis factor α) and sirolimus have also been applied in patients with conflicting results. Intravitreal treatment has significantly reduced the incidence of adverse effects compared to systemic application, but due to greater ocular side effects there are still some limitations.
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Affiliation(s)
- Dicle Hazirolan
- Department of Ophthalmology, Ankara Training and Research Hospital, Ministry of Health, Ankara, Turkey
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