Late vitreomacular traction in toxoplasma retinochoroiditis resolved by vitrectomy
A 17-year-old female presented to our department with progressive blurring of vision in the left eye. She had been diagnosed with chronic inflammatory bowel disease 3 years earlier and was in remission on azathioprine and mesalazine. The patient underwent best-corrected visual acuity testing, full ophthalmic slit-lamp examination of the anterior and posterior segments, spectral-domain optical coherence tomography (SD-OCT), and fluorescein angiography at baseline. A complete serologic search was performed to detect an infectious cause, and active toxoplasma retinochoroiditis was diagnosed. A classic treatment regimen of pyrimethamine and sulfadiazine plus steroids was started.\nDuring the ensuing observation period, the patient was evaluated every 2 months and underwent the same examinations performed at baseline except for fluorescein angiography. When the clinical course suddenly evolved toward a significant vitreoretinal traction due to retraction of the retinal scar, pars plana vitrectomy was considered. After written informed consent was obtained from the patient’s parents, a three-port pars plana vitrectomy was performed with a 23-gauge transconjunctival approach. The posterior hyaloid was removed intraoperatively using forceps and no attempt was made to remove the inner limiting membrane.\nOn presentation, visual acuity was 20/20 in the right eye and 1/20 in the left eye, with a mild relative afferent pupillary defect in the second one. No other neurologic signs or symptoms were detected. Anterior segment examination in both eyes was unremarkable and intraocular pressure was 16 mmHg. On biomicroscopic examination, the vitreous of the right eye was clear whereas the left eye exhibited mild inflammation. Fundus examination of the left eye showed a whitish yellow inflammatory lesion temporal to the macula surrounded by retinal edema with foveal involvement (). The lesion was apparently located under the retinal pigment epithelium and there was mild dilation of the retinal vessels of the macula. No other retinal lesion was detected in the peripheral retina. Fluorescein angiography showed early hypofluorescence in the central part of the lesion with progressive hyperfluorescence of the margins due to leakage and pooling of the dye ( and ).\nA serologic search for Toxoplasma gondii infection was positive for immunoglobulin G (55.4 UI/mL, reference value <10 UI/mL), whereas immunoglobulin M levels were normal, indicating prior exposure to Toxoplasma. A syphilis screen and other tests, including for toxocariasis, and rheumatologic tests were all negative. A presumptive diagnosis of toxoplasma retinochoroiditis with macular involvement was made, and a regimen of pyrimethamine, sulfadiazine, and steroids was started.\nPrompt reduction of the retinal edema was followed by gradual flattening and pigmentation of the lesion, with a progressive increase in visual acuity from 20/200 after 4 days to 20/40 after 20 days. Medical therapy was stopped after 45 days. In the following months, no relapse of retinochoroidal inflammation or vitreitis was observed, and visual acuity remained stable during the first 6 months of observation. At month 2, a thickening of the vitreoretinal interface, interpreted as an initial epiretinal membrane, developed above the macula, without significant vitreoretinal traction or macular edema detectable by SD-OCT. However, this finding prevented complete recovery of visual function.\nBy the 8-month follow-up visit, visual acuity had declined to 20/200, with an increase in metamorphopsia. Clinical observation and SD-OCT revealed hyper-reflectivity of the vitreoretinal interface, suggesting a thickening of the posterior hyaloid strongly adherent to several areas of the macula, inducing elevation and marked distortion of the entire macular area (). These ocular clinical findings were suggestive of an inactive scar-like lesion without any inflammatory reaction in the vitreous and anterior chamber, but complicated by significant vitreoretinal traction.\nAfter written informed consent was obtained from the patient’s parents, a 23-G pars plana vitrectomy was performed. The posterior hyaloid was removed intraoperatively using forceps, without difficulty. After having accurately verified that no epiretinal membrane was detectable in the entire macular area, no attempt was made to remove the inner limiting membrane. Vitrectomy was completed without complication in a total surgical time of 20 minutes. Visual acuity improved soon after surgery and reached 40/60 after 10 days. The macula remained flat and free of any signs of traction in the following 10 months, with stabilization of visual acuity to 20/20 ().