Ocular toxoplasmosis associated with scleritis
A 26-year-old woman presented with complaints of sudden onset of severe pain, redness, and defective vision in her right eye since 10 days. There was no history of trauma or any prior symptoms in the affected eye. There was no history suggestive of any other systemic illness. She denied any history of intravenous or other drug use.\nShe gave history of being treated with oral medications, for decreased vision in her left eye, 5 years earlier.\nHer best corrected visual acuity was 20/200 in OD and 20/20 in OS. Intraocular pressure was normal in both eyes. Anterior segment examination of her right eye showed a diffuse non-necrotizing scleritis, localized inferiorly []. There were few fresh granulomatous keratic precipitates on the inferior cornea and 2+ cells and flare in the anterior chamber. Lens was clear. The anterior vitreous had 3+ cells. Anterior segment examination of the left eye was within normal limits.\nOcular fundus examination of the right eye revealed a 3+ vitreous haze suggestive of intense vitritis. Through the haze the disc was barely seen, but the characteristic “Headlight in Fog” appearance of macular retinochoroiditis was lacking. The inferior periphery, however, showed a circumferentially oriented large yellow lesion involving the inferonasal quadrant, with the posterior extent till the equator. Another similar lesion was noted in the superonasal periphery, discontinuous with the main lesion. Her left ocular fundus showed multiple confluent pigmented chorioretinal scars, starting in the periphery of the nasal to the inferotemporal quadrants, with tongue-shaped extensions posteriorly, beyond the equator. There were two round scars around one disc diameter in size above the superotemporal arcade [Figs. and ].\nB scan Ultrasonography of right eye revealed associated posterior scleritis, but without any evidence of retinal detachment [].\nIn view of intense vitritis with confluent peripheral retinitis in one eye of an otherwise healthy woman with similar location of scars in the other eye, a provisional diagnosis of acute retinal necrosis with scleritis was made. A vitreous tap was performed under aseptic precautions through the inferotemporal quadrant, avoiding the area of scleritis. She was empirically started on oral valacyclovir in the recommended dose. Topical Dexamethasone drops were started 6th hourly along with Homatropine eye drops instilled 12th hourly in the right eye. Oral steroids were added after 48 h of starting oral antivirals. The complete blood picture was normal; a purified protein derivative (PPD) test dose given on presentation was negative. Her chest X-ray was normal and systemic examination by a physician did not reveal any evidence of systemic tuberculosis or Diabetes mellitus.\nSerology for syphilis and Human immunodeficiency virus were negative.\nThe vitreous sample subjected to multiplex polymerase chain reaction (PCR) test, revealed the presence of Toxoplasma. The sample was negative for Herpes simplex virus, Herpes zoster virus, and Mycobacterium tuberculosis. She was started on oral trimethoprim/sulfamethoxazole (160 mg/800 mg b.i.d.) and Azithromycin (500 mg o.d.), along with oral steroids in the recommended doses. The antiviral, which had shown no response for 3 days, was stopped.\nOn review after a week, she was tolerating her treatment well and showing signs of improvement. At the end of 3 weeks, her visual acuity had improved to 20/30 in the affected eye.\nThe scleritis had completely resolved, and the areas of peripheral retinochoroiditis were scarring with pigmentation. She completed the course of antitoxoplasma treatment, and is currently asymptomatic.