Title : An injection in time can preserve their 6/9 !
Abstract:
We present 2 similar cases of Toxoplasma Retinochoroiditis. A 32-year-old female and 21 year old male, who presented with sudden painless unilateral diminution of vision. On examining the female, her BCVA in affected right eye was 6/36 N36, the anterior segment was unremarkable, and fundus examination showed Grade 1 vitritis, a hyperemic disc with a parafoveal yellow white fluffy retinitis lesion. A diagnosis of Toxoplasma Retinochoroiditis was made, and she was started on systemic antitoxoplasma medications with oral steroids in tapering dose, and she was planned for an intravitreal clindamycin. 10 days later, her vision improved to 6/18 N18, and the lesion showed improvement clinically as well as on OCT imaging. However, following this, we lost the patient to follow up only to present 2 months later with a worsening of the condition clinically, despite a stable vision, which was maintained at 6/18 N18. In view of fovea fovea-threatening lesion, we planned an intravitreal clindamycin, for which the patient was not willing and was again lost to follow-up. She presented 4 months later with a drop in vision to 6/36 N36 and macular scarring causing distortion of neurosensory retina at the macula, which was also documented on the OCT. In contrast, our second patient, the 21-year-old male presenting with similar complaints, had come to us for a second opinion with existing blood reports revealing a positivity for Toxoplasma IgG antibody. His BCVA in the affected right eye was 6/48 N36 with decreased colour vision and contrast sensitivity. The anterior segment was unremarkable. On fundus examination, there was grade 1 vitritis, with disc hyperemia and edema and a full thickness yellow white retinitis lesion located superotemporal to the disc. We promptly started him on systemic azithromycin, a combination of sulfamethoxazole and trimethoprim and steroids on tapering dose and planned for an intravitreal clindamycin. He was reviewed 3 days later with improving lesion and an intravitreal clindamycin injection was given. 1 week post-injection, his vision improved to 6/18 N18 with a clinically improving lesion correlating with corresponding OCT findings. Interestingly, at 1-month follow-up, his vision was restored at 6/6(p) N6, colour vision and contrast sensitivity were noted to be normal, and the only sequelae noted on OCT imaging were a remnant Epiretinal membrane. The two contrasting outcomes in the above two cases of Toxoplasma Retinochoroiditis with lesions involving zone 1 and treated without and with intravitreal clindamycin respectively, highlight the importance of this modality of treatment despite adequate systemic therapy. In the current era of multimodal imaging and improved outcomes with local therapies, it may be prudent to exercise a lower threshold for treating with intravitreal clindamycin while dealing with vision-threatening lesions in Toxoplasma Retinochoroiditis.
