This document describes a case of toxoplasmosis retinochoroiditis in a 26-year-old male who presented with sudden loss of vision in his left eye. Examination found inflammation and a white lesion in the left eye along with old scarring. Tests supported a diagnosis of toxoplasmosis. The patient was treated with systemic antiparasitic medications and steroids, along with topical steroids and cycloplegics. Toxoplasmosis results from infection by the protozoan Toxoplasma gondii and commonly causes posterior uveitis, with retinitis developing near old scars when immunity is suppressed.

1. I see too many flies…….
DR.GAYATREE MOHANTY
SR, DEPT. OF OPHTHALMOLOGY
KIIMS

2. HISTORY
 A 26 year-old male presented on Aug 27th, 2014
 C/o Sudden Diminution of Vision of Left Eye
since past 6 days associated with photophobia &
floaters.
 No h/o fever, night sweats, wt.loss, loss of appetite,
rashes, skin ulcers
 No h/o trauma
 No exposure to pets
 No h/o breathlessness or convulsion

3. ON EXAMINATION
The right eye had a
BCVA 6/6 ,normal
anterior segment &
normal fundus.

4. ON EXAMINATION OF THE LEFT EYE
BCVA: CF close
Anterior segment:
 Ciliary congestion,
 Keratic precipitates : Medium size,
Homogeneous scattered on corneal
endothelium.
 Anterior chamber: Cells +++ Flare +
 Pupil sluggishly reacting to light
 Posterior synechiae
 Pigments on lens

5. POSTERIOR SEGMENT:
 Vitreous condensations
 Grade 2 Vitreous haze.
Hazy media clouding
details of optic disc &
vessels
 Retinitis: Solitary white
fluffy lesion near an old
scar in
macula overshadowing
underlying vessels.

6. ON FFA:
 Staining of the
scar
 Leakage at the site
of retinitis.
 No s/o vasculitis

7. Provisional Diagnosis
TOXOPLASMA
RETINOCHOROIDITIS WITH
SPILL OVER ANTERIOR UVEITIS
AND VITRITIS.

8. INVESTIGATIONS

9. TREATMENT
 Prednisolone 1mg/kgbdwt/d P.O and tapered
 Pyrimethamine (50mg/d loading dose, 25mg/d
maintainance x 4 wks) P.O
 Sulfadiazine( 2gm loading dose, 1gm qid x 4wks)
P.O
 Folic acid 5mg/d
 Topical Prednisolone acetate 1% e/d
1hrly
 Atropine 1% e/d tid

10. TOXOPLASMOSIS

11. PATHOGENESIS
 Toxoplasma gondii
 Obligate intracellular protozoa
 Definite host: Cat
 Infectious agent: Sporozoites
 Intermediate host: Human
 Proliferative form: Tachyzoites
 Mode of Transmission:
1.Undercooked meat,
2.Contamination with cat litter
3.Transplacental transfer

12. PATHOGENESIS
 Acute systemic toxoplasmosis in
immunocompetent patient induce immune
response (T-cell response) Flu like illness.
 If reaches retina Tachyzoites convert into
Bradyzoites and when immunity
suppressed the Cyst ruptures

13. CLINICAL FEATURES
1. Congenital Toxoplasmosis
2. Acquired Toxoplasmosis
3. Toxoplasma
Retinochoroiditis

14. CONGENITAL TOXOPLASMOSIS
 Transmitted transplacentally
 Severity of disease depends on time of
maternal infestation
 1st Trimester:15% cases. Severe disease
leading to spontaneous abortion
 3rd Trimester: 40% cases. Subclinical disease
leading to Congenital toxoplasmosis

15. CONGENITAL TOXOPLASMOSIS
 Cerebral calcification
leading to convulsion
 Bilateral healed
chorioretinal scars:
central vision jeopardized
 Hydrocephalus
 Microcephaly
 Psychomotor retardation
 Organomegaly
 Jaundice
 Rashes and fever

16. ACQUIRED TOXOPLASMOSIS
 Subclinical: Most frequent
 Lymphadenopathic syndrome:
Rare & Self limiting.
Cervical lymphadenopathy, fever, malaise
& pharyngitis
 Meningoencephalitis: Convulsion & Altered
consciousness
 Exanthematous form: Rare

17. TOXOPLASMA
RETINOCHOROIDITIS
 Reactivation of previously encysted cyst
containing scars
 Cysts rupture to release several tachyzoites
into retinal cells and induce inflammation.
 Common age group: 10-35yrs.

18. TOXOPLASMA RETINITIS
 Unilateral sudden diminution of
vision, photophobia and floaters
 Spill over granulomatous ant.
uvietis
 Vitritis: Headlight in fog
 Retinitis: Unilateral central
solitary punched out lesion near
an old macular scar
 In immunocompromised:
Bilateral multiple foci of extensive
inflamm with no pre-existing scar

19. COMPLICATIONS
 Direct involvement of macula
 Involvement of Optic n. head
with juxtapapillary lesion
 Papillitis: Rare
 Occlusion of major blood
vessel
 Choroidal neovascularization
 Serous detachment
 Tractional RD: Vitreous
condensation
 Macular edema

20. DIAGNOSIS
 Clinical diagnosis
 Serological tests for Toxoplasma
 Sabin Feldman Test
 Immunofluorescent test
 Hemagglutination test
 Enzyme Linked Immunosorbent
Assay(ELISA)

21. DIFFERENTIAL DIAGNOSIS
Toxocariasis
Tuberculosis
Sarcoidosis

22. TREATMENT
 Self limiting disease
 Indications for T/t (American Uveitis
Society)
 Lesion involving Macula, Papillomacular
bundle, Optic n. head or Major blood
vessel
 Severe vitritis: Risk of tractional RD
Immunocompromised

23. TREATMENT REGIMEN
 Systemic Prednisolone 1mg/kgbdwt/d
 Pyrimethamine (50mg/d loading dose, 25mg/d
maintainance x 4 wks) along with
 Sulfadiazine( 2gm loading dose, 1gm qid x 4wks)
 Folinic acid 3-5mg/d
 Other systemic options: Clindamycin,
Cotrimoxazole, Azithromycin, Atovaquone
 Topical Prednisolone Acetate for anterior uveitis
 Cycloplegic

24. CONCLUSION
 Ocular toxoplasmosis is a common cause of
infectious posterior uveitis.
 Easily diagnosed clinically and lab. diagnosis
e.g ELISA for Toxoplasma Ab.
 Treatment is accompanied by resolution of
active infection in the majority of cases

25. THANK YOU