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Management of the neovascular choroidal membrane secondary to ocular toxoplasmosis
Manejo de la membrana neovascular coroidea secundaria a toxoplasmosis ocular
E. Martín García
, J.J. Chávarri García, L. Rodríguez Vicente, B. Jiménez del Río, S.M. Guallar Leza, J.L. del Río Mayor
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Servicio de Oftalmología, Hospital San Pedro, Logroño, La Rioja, Spain
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Martín García, J.J. Chávarri García, L. Rodríguez Vicente, B. Jiménez del Río, S.M. Guallar Leza, J.L. del Río Mayor" "autores" => array:6 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Martín García" "email" => array:1 [ 0 => "elisabetmaga@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.J." "apellidos" => "Chávarri García" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Rodríguez Vicente" ] 3 => array:2 [ "nombre" => "B." "apellidos" => "Jiménez del Río" ] 4 => array:2 [ "nombre" => "S.M." "apellidos" => "Guallar Leza" ] 5 => array:2 [ "nombre" => "J.L." "apellidos" => "del Río Mayor" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Oftalmología, Hospital San Pedro, Logroño, La Rioja, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo de la membrana neovascular coroidea secundaria a toxoplasmosis ocular" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 704 "Ancho" => 1405 "Tamanyo" => 132304 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0095" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Active chorioretinitis locus (asterisk) adjacent to a macular scar and an intraretinal hemorrhage in the LE (arrow). CNVM existence was confirmed by means of macular OCT.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Toxoplasmosis is an infectious disease caused by the <span class="elsevierStyleItalic">Toxoplasma gondii</span> parasite which constitutes the most frequent cause of posterior uveitis in our country.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Due to the high affinity of <span class="elsevierStyleItalic">T. gondii</span> with nervous tissue and retinal ganglion cells,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> its typical presentation is recurrent while the most characteristic lesion is that of a necrotizing retinochoroiditis locus adjacent to an existing pigmented scar. <span class="elsevierStyleItalic">T. gondii</span> also gives rise to a typical forms that need to be identified.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Late complications associated to ocular toxoplasmosis include cataracts, secondary glaucoma, cystic macular edema, epiretinal membrane, retina detachment, choroidal neovascular membrane (CNVM) and optical atrophy.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The prevalence of choroidal neovascular membrane in ocular toxoplasmosis cases ranges between 2 % and 19 % according to different series and constitutes one of the most important causes of visual acuity (VA) impairment in young patients.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The case of a young patients that developed CNVM in the context of ocular toxoplasmosis is described below.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinic case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">Male patient, age 12, diagnosed at birth with congenital toxoplasmosis after seroconversion of IgG and IgA toxoplasmosis antibodies in the mother at gestation week 34. Subsequently, treatment was established with Rovamycine® 1.5 million UI/4 capsules twice a day. Even though the patient did not present associated systemic symptoms at any point in time, after birth he was preventively treated with anti-toxoplasmosis drugs during his first 2 years of life. At present he was without treatment.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient visited the ophthalmological practice referred by the pediatrician after observing left eye (LE) significant VA impairment in a routine checkup. Ocular examination showed that the VA of the right eye (RE) was of 1 and <0.05 in the LE. Anterior segment did not exhibit relevant pathological details. Right eye ocular fundus showed an isolated temporal juxtaposed papillary inactive pigmented scar with less than one papillary diameter, while the left eye showed slight papillary paleness, minimum vitritis as well as an active chorioretinitis locus with one papilla diameter adjacent to an old pigmented macular scar and a large subretinal hemorrhage that reached the inferior temporal vascular arcade (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Angiofluorescein graph (AFG) and optical coherence tomography (OCT) confirmed CNVM.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">After establishing the diagnostic of CNVM secondary to ocular toxoplasmosis, oral treatment was initiated with sulfadiazin 500<span class="elsevierStyleHsp" style=""></span>mg/6<span class="elsevierStyleHsp" style=""></span>h, pyrimethamine 25<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h and folinic acid 10<span class="elsevierStyleHsp" style=""></span>mg/3 times a week. Forty-eight hours later, 1<span class="elsevierStyleHsp" style=""></span>mg/kg/day methylprednisolone was added. After initiating systemic treatment, one dose of intravitreal anti-VEGF (ranibizumab 0.5<span class="elsevierStyleHsp" style=""></span>mg) was administered in the LE. After 2 weeks LE VA recovered to reach 0.3 with partial hemorrhage reabsorption (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). At that time a second dose of 0.5<span class="elsevierStyleHsp" style=""></span>mg ranibizumab was considered, finally reaching a VA of 0.4 and complete disappearance of the hemorrhage, leaving a residual inactive pigmented scar (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The classic anti-toxoplasmosis prescription was maintained 6 weeks with progressive reduction of corticoid therapy and terminated one week before suspending pyrimethamine and sulfadiazine.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">At present the patient remains stable after more than 5 months of strict follow-up and is in preventive therapy with trimethoprim/sulfamethoxazole 800/160<span class="elsevierStyleHsp" style=""></span>mg/1 capsule /3 days a week on a permanent basis associated to folinic acid at 2 capsules of 5<span class="elsevierStyleHsp" style=""></span>mg every 2 days as well as serial analytics every 3 months.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">In 1977, Willerson et al. reported the first case of CNVM associated to an active locus of retinochoroiditis due to toxoplasmosis.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> CNVM generally appears on the edge of a previous toxoplasma scar although it could appear in active phases of the infection. Etiopathogeny is unknown although it is broadly accepted that it is caused by the rupture of Bruch’s membrane and the choriocapillary due to intense retinal inflammation.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The options for treating these CNVM depend on the location thereof and include observation, corticoids, laser photocoagulation, photodynamic therapy (PDT),<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> macular surgery<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and the application of anti-VEGF.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Anti-VEGF have been associated to the reactivation of old chorioretinal lesions and for this reason the prophylactic use of oral anti-toxoplasmosis drugs is recommended prior to intravitreal administration.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> One of the main benefits of the application of anti-VEGF compared to treatment with PTD, laser photocoagulation or macular surgery is that it substantially diminishes collateral damages on the healthy retina.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion, in cases of CNVM associated to ocular toxoplasmosis close follow-up of patients is very important as well as initiating treatment with anti-toxoplasmosis drugs associating intravitreal therapy with anti-VEGF as soon as possible in order to obtain the best anatomic and functional results.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1300362" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1199743" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1300363" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1199742" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinic case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-07-30" "fechaAceptado" => "2019-11-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1199743" "palabras" => array:5 [ 0 => "Toxoplasmosis" 1 => "Scar" 2 => "Neovascular membrane" 3 => "Anti-VEGF" 4 => "Treatment" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1199742" "palabras" => array:5 [ 0 => "Toxoplasmosis" 1 => "Cicatriz" 2 => "Membrana neovascular" 3 => "Anti-VEGF" 4 => "Tratamiento" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A 12-year-old patient diagnosed with congenital toxoplasmosis, with no systemic treatment at the time, who presented with a decreased visual acuity (VA) in his left eye (LE). On examination, VA in the LE was 0.05 and the fundus examination revealed a focus of chorioretinitis adjacent to a pigmented macular scar, as well as a large associated subretinal haemorrhage. After confirming the diagnosis of choroidal neovascular membrane secondary to ocular toxoplasmosis, treatment was started with systemic anti-toxoplasmosis drugs and two anti-VEGF intravitreal injections separated by one month. Finally, the patients had a VA in OI of 0.4, with reabsorption of the haemorrhage, leaving an inactive pigmented macular scar. The use of anti-VEGF intravitreal injections in cases of ocular toxoplasmosis has been associated with a reactivation of old lesions, so the prophylactic use of oral anti-toxoplasmosis drugs is recommended in these cases.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Paciente de 12 años diagnosticado de toxoplamosis congénita sin tratamiento sistémico en el momento actual que acude por disminución de agudeza visual (AV) por su ojo izquierdo (OI). A la exploración se objetiva una AV en su OI de 0,05 y al examen funduscópico un foco de coriorretinitis adyacente a una cicatriz macular pigmentada y una gran hemorragia subretiniana asociada. Tras confirmar el dignóstico de membrana neovascular coroidea (NVC) secundaria a toxoplasmosis ocular, se inicia tratamiento con fármacos antitoxoplásmicos sistémicos y dos dosis de AntiVEGF intravitreos separadas por un mes de diferencia. Finalmente, alcanza una AV en OI de 0,4 y se logra una reabsoción de la hemorragia quedando una cicatriz pigmentada macular inactiva. El uso de AntiVEGF intravitreos en cuadros de toxoplasmosis ocular se han asociado a la reactivación de antiguas lesiones, por lo que se recomienda el uso profiláctico de fármacos antitoxoplásmicos orales en estos casos.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martín García E, Chávarri García JJ, Rodríguez Vicente L, Jiménez del Río B, Guallar Leza SM, del Río Mayor JL. Manejo de la membrana neovascular coroidea secundaria a toxoplasmosis ocular. Arch Soc Esp Oftalmol. 2020;95:90–93.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 704 "Ancho" => 1405 "Tamanyo" => 132304 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0095" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Active chorioretinitis locus (asterisk) adjacent to a macular scar and an intraretinal hemorrhage in the LE (arrow). CNVM existence was confirmed by means of macular OCT.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 709 "Ancho" => 1405 "Tamanyo" => 135756 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0100" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Importante reabsortion de la hemorragia intrarretiniana (arrow) tras la primera dosis intravítrea de anti-VEGF.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 751 "Ancho" => 1405 "Tamanyo" => 122977 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0105" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Complete intraretinal hemorrhage resolution with residual inactive macular scar after second anti-VEGF dose.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Subretinal neovascularization in ocular toxoplasmosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.M. 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