Letter to the Editor
Macular toxoplasmosis and intravitreal clindamycin: An alternative to oral treatment
Toxoplasmosis macular y clindamicina intravítrea: una alternativa al tratamiento oral
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B) La tomografia de coherencia optica (OCT) inicial evidencia un desprendimiento del neuroepitelio junto a una lesión hiperreflectiva retiniana. C) La retinografía tras 2 inyecciones intravítreas de clindamicina y dexametasona muestra una cicatriz atrófica. D) La OCT correspondiente a la retinografía anterior evidencia una reducción focal severa del grosor de la retina neurosensorial con una marcada hiperreflectividad indirecta subyacente.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S. Martínez Castillo, R. Gallego-Pinazo, E. Francés-Muñoz, R. Dolz-Marco, A. Vázquez Polo, M. Díaz-Llopis" "autores" => array:6 [ 0 => array:2 [ "nombre" => "S." "apellidos" => "Martínez Castillo" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Gallego-Pinazo" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "Francés-Muñoz" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Dolz-Marco" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Vázquez Polo" ] 5 => array:2 [ "nombre" => "M." 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The image shows the incapacity of the patient of opening the arguments regardless of the front must traction with eyebrow raising. (B) The same patient after the placement of the neuromuscular bandage over the frontal and orbicular muscles. In this image, the patient achieves adequate ocular opening with relaxation of the frontal muscle. (C) Details of the placement of the neuromuscular bandage.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "R. Dolz-Marco, D. Salom-Alonso, S. García-Delpech, R. Gallego-Pinazo, M. Díaz-Llopis" "autores" => array:5 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "Dolz-Marco" ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Salom-Alonso" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "García-Delpech" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Gallego-Pinazo" ] 4 => array:2 [ "nombre" => "M." 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Martínez Castillo, R. Gallego-Pinazo, E. Francés-Muñoz, R. Dolz-Marco, A. Vázquez Polo, M. Díaz-Llopis" "autores" => array:6 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Martínez Castillo" "email" => array:1 [ 0 => "s.martinez@comv.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "R." "apellidos" => "Gallego-Pinazo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Francés-Muñoz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "R." "apellidos" => "Dolz-Marco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "A. Vázquez" "apellidos" => "Polo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "M." "apellidos" => "Díaz-Llopis" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Universitario y Politécnico La Fe, Valencia, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Farmacia, Hospital Universitario y Politécnico La Fe, Valencia, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Facultad de Medicina, Universidad de Valencia, Spain" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Toxoplasmosis macular y clindamicina intravítrea: una alternativa al tratamiento oral" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1040 "Ancho" => 1402 "Tamanyo" => 163476 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) The initial retinography reveals a site of macular yellowish-white retinitis. (B) The initial Optic Coherence Tomograpy (OCT) evidences a neuroepithelium detachment next to a retinal hyper-reflective lesion. (C) Retinography after 2 intravitral clindamycin and dexamethasone injections reveals an atrophic scar. (D) An OCT of the previous retinography evidences a severe focal reduction of the neurosensory retina thickness with marked underlying indirect hyper-reflectiveness.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Toxoplasmosis is the most frequent cause of posterior uveitis in immunocompetent patients.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It usually appears as a focal retinitis, generally around a chorioretinal scar, and is accompanied by vitritis. Even though the nature of the lesions is self-limited, treatment is indicated in lesions that threaten the macula or the optic nerve–zone 1, as well as in peripheral lesions associating intense vitritis. In addition to the typical prescription with sulphadiazin, pyrimethamine and folinic acid, which associate well-known risks such as leukopenia and thrombopenia, the simplest and most widely known oral prescription is trimetropim-sulphametoxazole in association with folic acid. Occasionally, this treatment also causes adverse reactions such as skin rashes and gastrointestinal and hematological alterations. In our service we treated 2 toxoplasmosis cases in zone one and by means of weekly intravitreal injections of clindamycin (1<span class="elsevierStyleHsp" style=""></span>mg/0.1<span class="elsevierStyleHsp" style=""></span>ml) and dexamethasone (0.4<span class="elsevierStyleHsp" style=""></span>mg/0.1<span class="elsevierStyleHsp" style=""></span>ml), assisted with aqueous humor paracentesis. In the first case, in a 30-year-old pregnant woman, visual acuity (VA) improved from finger counting at 1 m in the LE to 0.2 after 2 injections in the course of 3 weeks (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>); in the second case, a 34-year-old male exhibited oral intolerance to sulphamides, VA improved from hand movement in the RE to 0.30 after a single injection in the course of 15 days (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Intravitreal clindamycin is prepared with a clindamycin phosphate vial (Clindamicina Combino Pharm EFG), extracting 0.2<span class="elsevierStyleHsp" style=""></span>mm from this vial and adding 2.8<span class="elsevierStyleHsp" style=""></span>ml of 0.9% sodium chloride, injecting 0.1<span class="elsevierStyleHsp" style=""></span>ml in the vitreous (1<span class="elsevierStyleHsp" style=""></span>mg/0.1<span class="elsevierStyleHsp" style=""></span>ml). Intravitreal dexamethasone is prepared on the basis of a dexamethasone vial (Fortecortin), taking directly from this vial 0.1<span class="elsevierStyleHsp" style=""></span>ml (0.4<span class="elsevierStyleHsp" style=""></span>mg/0.1<span class="elsevierStyleHsp" style=""></span>ml).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Various authors have proposed the use of intravitreal clindamycin injections in association with dexamethasone in ocular toxoplasmosis cases. The mean number of intravitreal injections to achieve resolution of chorioretinitis varies between authors, ranging from one injection<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> to 3 injections,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> with a mean interval between the injections of 2 weeks,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> without differences being found in the results of oral or intravitreal therapy.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">To conclude, intravitreal clindamycin injection (1<span class="elsevierStyleHsp" style=""></span>mg/0.1<span class="elsevierStyleHsp" style=""></span>ml) associated to dexamethasone (0.4<span class="elsevierStyleHsp" style=""></span>mg/0.1<span class="elsevierStyleHsp" style=""></span>ml) is safe and provides good results in a short period of time, thus constituting an alternative to oral treatment in addition to providing greater comfort to the patient and an approved systemic safety profile. It also reduces the follow-up visits and hematological control requirements. This therapeutic alternative should be considered in ocular toxoplasmosis cases in gestating women, sulphamide allergic patients, resistance to oral treatment or those evidencing zone 1 involvement. The most widely used administration pattern is weekly although in our experience it is convenient to monitor the response of each patient on the basis of the visual changes and the tomographic appearance of the infectious site.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Martínez Castillo S, et al. Toxoplasmosis macular y clindamicina intravítrea: una alternativa al tratamiento oral. Arch Soc Esp Oftalmol. 2012;87:92–4.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1040 "Ancho" => 1402 "Tamanyo" => 163476 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) The initial retinography reveals a site of macular yellowish-white retinitis. (B) The initial Optic Coherence Tomograpy (OCT) evidences a neuroepithelium detachment next to a retinal hyper-reflective lesion. (C) Retinography after 2 intravitral clindamycin and dexamethasone injections reveals an atrophic scar. (D) An OCT of the previous retinography evidences a severe focal reduction of the neurosensory retina thickness with marked underlying indirect hyper-reflectiveness.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1028 "Ancho" => 1402 "Tamanyo" => 156602 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) The initial retinography reveals a site of macular yellowish-white retinitis with a chorioretinal pigmented scar under the inferior temporal arch. (B) The initial OCT evidences foveal hyper-reflective thickening. (C) After one intravitreal clindamycin and dexamethasone injection the patient exhibited remission of the inflammatory condition. (D) OCT after beginning the intravitreal treatment evidences a normalization of the retinal thickness which confirms the deactivation of the site.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Toxoplasmosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.A. Bonfioli" 1 => "F. Orefice" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/08820530500231961" "Revista" => array:6 [ "tituloSerie" => "Semin Ophthalmol" "fecha" => "2005" "volumen" => "20" "paginaInicial" => "129" "paginaFinal" => "141" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16282146" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Randomized trial of intravitreal clindamycin and dexamethasone versus pyrimethamine, sulfadiazine, and prednisolone in treatment of ocular toxoplasmosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Soheilian" 1 => "A. Ramezani" 2 => "A. Azimzadeh" 3 => "M.M. Sadoughi" 4 => "M.H. Dehghan" 5 => "R. Shahghadami" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ophtha.2010.04.020" "Revista" => array:6 [ "tituloSerie" => "Ophthalmology" "fecha" => "2011" "volumen" => "118" "paginaInicial" => "134" "paginaFinal" => "141" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20708269" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intravitreal clindamycin and dexamethasone for zone 1 toxoplasmic retinochoroiditis at twenty-four months" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.F. Lasave" 1 => "M. Díaz-Llopis" 2 => "C. Muccioli" 3 => "R. Belfort Jr." 4 => "J.F. Arevalo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ophtha.2010.01.028" "Revista" => array:6 [ "tituloSerie" => "Ophthalmology" "fecha" => "2010" "volumen" => "117" "paginaInicial" => "1831" "paginaFinal" => "1838" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20471684" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735794/0000008700000003/v1_201305091036/S2173579412000825/v1_201305091036/en/main.assets" "Apartado" => array:4 [ "identificador" => "8723" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735794/0000008700000003/v1_201305091036/S2173579412000825/v1_201305091036/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579412000825?idApp=UINPBA00004N" ]
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