Patient Presentation: A 12-year-old girl presented to a paediatric eye clinic with pain, redness, photophobia and decreased vision of the right eye. She denied trauma, recent travel, or sick contacts. She had no past ocular or medical history. She was on no medications. Visual acuity was 20/50 OD and 20/20 OS. There was no RAPD. IOP was 10 mmHg OD and 12 mmHg OS. Anterior segment exam revealed 1+ conjunctival injection with granulomatous keratic precipitates inferiorly, 4+ cells, focal posterior synechiae, a clear lens and 1+ vitreous cells in the right eye. The left eye anterior segment examination was unremarkable. Her optic nerves and macula were normal. Fundus photography was taken and is shown below:
A superonasal hyperpigmented chorioretinal scar with an adjacent white retinal lesion at the border was found in the right eye (not imaged). There was associated vitritis. The left eye also demonstrated a hyperpigmented chorioretinal scar superior to the optic nerve.
A 5-line raster OCT was taken over the lesion in the left eye and is shown below:
Question 1: What is the main finding in the OCT above?
Question 2: Based on the exam findings and OCT imaging, what is the most likely diagnosis?
Question 3: Based on the patient age and ocular exam, is this considered congenital ocular toxoplasmosis?
After consultation with Infectious Disease, the patient was diagnosed with ocular toxoplasmosis and treated with Double Strength (DS) Septra (sulfamethoxazole and trimethoprim) for 6 weeks. The presence of bilateral retinal scars with active chorioretinitis and vitritis suggested reactivation of latent infection, confirmed with positive serology.
However, 1 year later, the patient returned with redness, pain, and decreased vision in the left eye. Her visual acuity was 20/20 OD and 20/40 OS. IOP was 18 OD and 38 OS. There was no RAPD. Fundus photos were taken at this visit and are shown below:
An OCT over the lesion in the left eye was taken and is shown below:
Question 4: What is the main finding in the OCT above?
Fundus examination demonstrated the hallmark “headlight in a fog” lesion, with the white focal retinitis adjacent to an old toxoplasmosis chorioretinal scar and overlying vitritis, as well as diffuse vasculitis. The patient was diagnosed with recurrent toxoplasmosis chorioretinitis and associated hypertensive uveitis.
Question 5: What is the classic treatment for ocular toxoplasmosis?
Learn the OCT imaging features of ocular toxoplasmosis
Understand the treatment options for ocular toxoplasmosis