OSLI Retina

October 2016

Issue link: http://osliretina.healio.com/i/737622

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Page 8 of 95

Practical Retina Incorporating current trials and technology into clinical practice October 2016 · Vol. 47, No. 10 895 Toxoplasmosis Retinitis Masquerading as Acute Retinal Necrosis by Samuel P. Burke, MS, and Thomas A. Albini, MD Masquerade syndromes in ophthal- mology, as originally described, are conditions that simulate inflamma- tory diseases but are, in fact, neoplas- tic. The term now has broadened to include non-neo- plastic etiologies, as well. Necrotizing ret- initis is a rare and potentially blind- ing condition that can be challenging to diagnose and to treat. In this in- stallment of Practical Retina, Samuel P. Burke, MS, and Thomas A. Albini, MD, from Bascom Palmer Eye Insti- tute present a case of toxoplasmosis retinitis that masqueraded as acute retinal necrosis and did not respond to initial antiviral therapy. The authors provide an overview of the appropriate workup of necro- tizing retinitis and define both typical and atypical presentations. A treat- ment algorithm is presented with dis- cussion regarding the strength of the evidence supporting each modality. Masquerade syndromes often rep- resent uncommon presentations of uncommon diseases and therefore re- quire an astute clinician for a prompt and accurate diagnosis and institu- tion of appropriate therapy. Hoawrd FIne Practical Retina Co-Editor A 71-year-old white wom- an with rheumatoid arthri- tis treated with abatacept (Orencia; Bristol-Myers Squibb, New York, NY), methotrexate, and low- dose prednisone pres- ents for a second opinion regarding acute retinal necrosis (ARN) in her right eye. Four months prior to presentation, she received the diagnosis of ARN com- plicated by vitreous hemorrhage and underwent pars plana vit- rectomy and endolaser. She was treated with oral valacyclovir (Valtrex; GlaxoSmithKline, Brentfort, United Kingdom) (1,000 mg three times per day) but continued to lose vision. She presented to our clinic with best-corrected visual acuity (BCVA) of 20/100 in the right eye. Anterior segment examination of the right eye was remarkable for fine inferior keratic precipitates and 2+ anterior chamber cells. Dilated examination of the right eye showed 2+ anterior vitreous cells, a perfused optic nerve head without evidence of edema or pallor, atrophic scars in the macula, an area of preretinal hemorrhage along the inferior vascular arcade, diffuse vascular attenuation, 360° of panretinal photocoagulation, and a peripheral area of retinal whitening with overlying vitreous haze extending from the 9 o'clock meridian to the 12 o'clock meridian (Figure). The patient underwent anterior chamber paracentesis, intravitreal injection of ganciclovir, and was continued on oral valacyclovir. The anterior chamber fluid was sent for polymerase chain reaction (PCR) analysis for herpes simplex virus (HSV), varicella zoster virus (VZV), cytomegalovirus (CMV), and Toxoplasma gondii genomes; the results were positive only for toxoplasma. Serology was remarkable for a positive Thomas A. Albini Samuel P. Burke doi: 10.3928/23258160-20161004-01

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