Ophthalmology: Current and Future Developments: Volume 3: Diagnostic Atlas of Retinal Diseases E-Book
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- Herausgeber: Bentham Science Publishers
- Kategorie: Fachliteratur
- Serie: Ophthalmology: Current and Future Developments
- Sprache: Englisch
This 3 volume set offers a comprehensive compilation which presents detailed information about ophthalmic (retinal, vitreous and macular) diseases. Key features of this set include:
Emphasis on practical features of clinical diagnosis
Concise and didactic presentation of key manifestations of diseases designed for rapid reference and target recall
A vast selection of illustrations to sharpen clinical problem-solving skills
Step by step treatment approaches to enhance the reader’s ability to handle medical cases
Citations or relevant research articles in each chapter for further reading
The third volume of this set covers eye infections (bacterial and viral), inflammatory disorders and neoplasms. Written by a group of retina specialists, this book is an excellent resource for knowledge about retinal disorders. The streamlined format and evidence based medicine presented in the volume make this book the perfect reference for medical students, residents, general ophthalmologists and retina specialists.
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Seitenzahl: 240
Veröffentlichungsjahr: 2017
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Ophthalmology:
Current and Future Developments
(Volume 3)
(Diagnostic Atlas of Retinal Diseases)
Edited by
Mitzy E. Torres Soriano
Gerardo García Aguirre
Co-Edited by
Maximiliano Gordon
Veronica Kon Graversen
BENTHAM SCIENCE PUBLISHERS LTD.
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PREFACE
We are honored to contribute to the information and education of ophthalmology stu-dents around the world. We have attempted to distill the current knowledge of medical practice and basic science retina research into a diagnostic atlas of retinal diseases. This is a quick-reference atlas eBook of the retina, edited by specialists in the field, essential to any practicing ophthalmologist or resident who has more than a passing interest in diseases and treatment of the retina.
This e-book includes contributors from Mexico, Venezuela, Argentina, Brazil, United States, Denmark, Spain, Italy, Costa Rica and Peru. It is divided into three volumes: Volume I, retinal vascular diseases, choroidal neovascularization related diseases, vitreomacular interface, and other macular disorders; Volume II, traumatic retinopathies, diseases of vitreous, peripheral degenerations, retinal detachment, pediatric retinal diseases, and retinal dystrophies; and Volume III, posterior uveitis, tumors of the retina, and choroid.
This diagnostic atlas eBook of retinal diseases contains full-color, high quality images of the most frequent retinal pathologies with a brief and comprehensive review of retinal diseases. Each chap-ter includes essentials of diagnosis, differential diagnosis and treatment. The format is concise, well organized, and didactic, without being exhaustive.
We hope and expect that our atlas of retina will facilitate in providing patients with the best pos-sible care.
ACKNOWLEDGEMENTS
We would like to express our gratitude to Judy Soriano, who provided support with english composition and edition.
To our friends and colleagues without whose contribution would not have been possible to real-ize this project.
We also want to thank the staff of Bentham Science for their help and support and give us the opportunity to publish this eBook.
DEDICATION
This e-book is specially dedicated to Guillermo Manuel Gordon, MD. He inspired us to always work hard and try our best. He was a friend and a recognized ophthalmologist of Rosario-Argentina, who died on May 2nd, 2015.
CONFLICT OF INTEREST
The authors confirm that they have no conflict of interest to declare for this publication.
List of Contributors
Ocular Toxoplasmosis
Ocular toxoplasmosis is caused by the protozoan parasite Toxoplasma gondii. Infections may be acquired congenitally or through the ingestion of infected raw meat, contaminated vegetables or water. A significant proportion of the world population (approximately the third) is infected by T. gondii which is responsible for the majority of infectious uveitis cases, which in some countries might be up to 50%. It is the main cause of infectious posterior in immunocompetent individuals, and the second most common in patients with HIV/AIDS [1 - 3].
ESSENTIALS OF DIAGNOSIS
Clinical presentation in immunocompetent individuals varies according to the age of the patient and the size, location and severity of the retinochoroidal lesions. Symptoms usually include floaters and decreased visual acuity, which may be secondary to vitreous inflammation or to macular involvement. In immuno-compromised patients, the presentation may vary [4].
The disease may result from congenitally acquired toxoplasmosis or newly acquired infection. Toxoplasmosis usually affects a single eye, causing one or more lesions. Sometimes, lesions in different stages may be observed in the same eye (Fig. 1) [4 - 6].
Typical active lesions appear as yellowish or whitish areas of retinal inflammation (Fig. 2), with adjacent choroiditis, vasculitis, papillitis (Fig. 3), hemorrhage and vitritis. The primary infection occurs in the retina, but other structures such as the choroid, vitreous or anterior chamber may be involved. After the active phase, there is atrophy of the retina and the choroid that leaves a well-circumscribed round punched-out scar (Fig. 4). There is pigment clumping and chorioretinal atrophy that allows the visualization of underlying sclera.
Toxoplasmosis may present atypically, causing punctate outer retinal toxoplasmosis, retinal vasculitis, retinal vascular occlusions, rhegmatogenous or serous retinal detachments, unilateral pigmentary retinopathy, neuroretinitis and additional forms of optic neuropathy, peripheral retinal necrosis and scleritis. Ocular complications, seen more frequently in children, include choroidal neovascularization, cataract, glaucoma, optic nerve atrophy and retinal detachment [4 - 6].
The diagnosis of ocular toxoplasmosis is usually clinical, since presentation is usually typical [7]. There is no reliable diagnostic test to identify toxoplasmic uveitis. Positivity of anti-T gondii IgG antibodies does not confirm the toxoplasmic etiology, but a negative IgG generally discards the possibility. Positivity of these antibodies usually persist for many years after the primary infection. Other diagnostic tool is looking for the presence of T. gondii DNA in the vitreous using polymerase chain reaction, which is especially useful in eyes with atypical presentation [4].
DIFFERENTIAL DIAGNOSIS
Diseases that cause focal retinitis should be considered in the differential diagnosis, such as CMV, herpes simplex virus, herpes zoster virus, fungal retinitis (candidiasis, blastomycosis), septic retinitis, ocular toxocariasis, sarcoidosis, syphilis and tuberculosis. Punctate outer retinal toxoplasmosis should be differentiated from the white dot syndromes [4].
MANAGEMENT
Although ocular toxoplasmosis is usually self-limited, treatment should be initiated as soon as the diagnosis is made in order to avoid scarring, which is the usual cause of long-term visual impairment [8]. The treatment of choice is the combination of systemic antimicrobial drugs and corticosteroids. Antimicrobial agents used most frequently include trimethoprim and sulfamethoxazole, sulfadiazine and pyrimethamine or clindamycin and sulfadiazine [4, 9]. Oral prednisolone (1 mg/kg daily) is started at the third day of treatment and tapered over two to six weeks [7, 10, 11]. Intravitreal clindamycin injection and possibly steroids may be indicated for patients that have contraindication for systemic therapy specific for toxoplasmosis [12]. Treatment with spiramycin should be initiated immediately after diagnosis of recently acquired maternal infection [4].
CONFLICT OF INTEREST
The author confirms that author has no conflict of interest to declare for this publication.
ACKNOWLEDGEMENTS
Declared none.
REFERENCES
[1]Soheilian M., Heidari K., Yazdani S., Shahsavari M., Ahmadieh H., Dehghan M.. Patterns of uveitis in a tertiary eye care center in Iran., Ocul. Immunol. Inflamm..2004; 12(4): 297-310. [http://dx.doi.org/10.1080/092739490500174] [PMID: 15621869][2]Perkins E.S.. Ocular toxoplasmosis., Br. J. Ophthalmol..1973; 57(1): 1-17. [http://dx.doi.org/10.1136/bjo.57.1.1] [PMID: 4574554][3]Burnett A.J., Shortt S.G., Isaac-Renton J., King A., Werker D., Bowie W.R.. Multiple cases of acquired toxoplasmosis retinitis presenting in an outbreak., Ophthalmology.1998; 105(6): 1032-1037. [http://dx.doi.org/10.1016/S0161-6420(98)96004-3] [PMID: 9627653][4]Da Mata A.P., Orifice F.. , ; Toxoplasmosis.. In: Foster C.F., Vitale A.T., editors. Diagnosis and treatment of uveitis.. Philadelphia: Saunders; 2002.[5]Mets M.B., Holfels E., Boyer K.M., Swisher C.N., Roizen N., Stein L., Stein M., Hopkins J., Withers S., Mack D., Luciano R., Patel D., Remington J.S., Meier P., McLeod R.. Eye manifestations of congenital toxoplasmosis., Am. J. Ophthalmol..1996; 122(3): 309-324. [http://dx.doi.org/10.1016/S0002-9394(14)72057-4] [PMID: 8794703][6]La Hey E., Rothova A., Baarsma G.S., de Vries J., van Knapen F., Kijlstra A.. Fuchs heterochromic iridocyclitis is not associated with ocular toxoplasmosis., Arch. Ophthalmol..1992; 110(6): 806-811. [http://dx.doi.org/10.1001/archopht.1992.01080180078032] [PMID: 1596229][7]Dodds E.. , . Focal points: Clinical Modules for ophthalmologists.. Vol. XVII. San Francisco: American Academy of Ophthalmology; 1999. Ocular toxoplasmosis: clinical presentation, diagnosis and therapy..[8]Bosch-Driessen L.E., Berendschot T.T., Ongkosuwito J.V., Rothova A.. Ocular toxoplasmosis: clinical features and prognosis of 154 patients., Ophthalmology.2002; 109(5): 869-878. [http://dx.doi.org/10.1016/S0161-6420(02)00990-9] [PMID: 11986090][9]Nussenbleatt R.B., Whitcup S.M.. , . Uveitis. Fundamentals and Clinical Practice.. 3rd ed. St. Louis: Mosby; 2004.[10]Rothova A., Meenken C., Buitenhuis H.J., Brinkman C.J., Baarsma G.S., Boen-Tan T.N., de Jong P.T., Klaassen-Broekema N., Schweitzer C.M., Timmerman Z., et al. Therapy for ocular toxoplasmosis., Am. J. Ophthalmol..1993; 115(4): 517-523. [http://dx.doi.org/10.1016/S0002-9394(14)74456-3] [PMID: 8470726][11]Holland G.N., O’Connor R., Belfort R., Remington J.S.. , . Toxoplasmosis.. St. Louis: Mosby Year Book; 1996.[12]Lasave A.F., Díaz-Llopis M., Muccioli C., Belfort R. Jr, Arevalo J.F.. Intravitreal clindamycin and dexamethasone for zone 1 toxoplasmic retinochoroiditis at twenty-four months., Ophthalmology.2010; 117(9): 1831-1838. [http://dx.doi.org/10.1016/j.ophtha.2010.01.028] [PMID: 20471684]Ocular Tuberculosis
Tuberculosis (TB) is a clinical disease caused by infection with Mycobacterium tuberculosis and is characterized pathologically by granuloma formation [1]. TB may affect the eye by direct invasion of the tubercle bacillus following hematogenous dissemination, or via a hypersensitivity reaction to the bacillus located elsewhere in the body [2].
Ocular TB is not common; since the 1980’s, it is considered as an etiology of uveitis from 0-4%.
Ocular TB may not be associated with clinical evidence of pulmonary TB; up to 60% of patients with extrapulmonary TB may not have been diagnosed with pulmonary TB [3, 4].
ESSENTIALS OF DIAGNOSIS
Extraocular TB can appear on the external eye as a lid abscess or manifest as chronic blepharitis or atypical chalazia. It can present as a mucopurulent conjunctivitis with regional lymphadenopathy. It can also present as a phlyctenule (an inflammatory nodule at the junction of the cornea and sclera), infectious keratitis, interstitial keratitis, or as an infectious scleritis. Rarely, the orbital disease can also occur [4] (Fig. 1). All of these presentations are rare and are easy to diagnose as material can be obtained for culture and biopsy [2 - 7].
Intraocular TB often involves delicate structures that are difficult or impossible to biopsy or culture. It may present as unilateral or bilateral granulomatous iritis or iridocyclitis with mutton-fat keratic precipitates and/or granulomatous nodules of the iris (Koeppe or Busacca nodules). Broad-based posterior synechiae and hypopyon may be observed. Intermediate uveitis can also occur. More commonly, intraocular TB presents with involvement of the posterior part of the eye. Vitritis, retinitis and/or choroiditis, and retinal vasculitis would be the presenting clinical scenario. Choroidal lesions including granulomas are probably the most common findings in confirmed cases of ocular TB and can be an early sign of disseminated disease [3, 4]. Choroidal tubercles are solitary, or few in number, yellowish lesions typically elevated centrally with poorly defined borders, and commonly situated in posterior pole (Figs. 2 and 8). Inflammatory cells and subretinal fluid may be present (Fig. 3). Tubercles can be solitary or miliary. Multifocal lesions predominantly present in choroid are also common (Figs. 4 and 5) and sometimes can simulate “Serpiginous-like choroiditis” with two distinct patterns (Fig. 6): one with multifocal discrete choroidal lesions that are initially noncontiguous and later progress to form diffuse lesions with an active edge resembling serpiginous choroiditis, and a solitary, diffuse plaque-like lesion with an amoeboid extension [7]. The retina involvement alone is rare.
The retina is often involved in setting of choroidal TB as retinochoroiditis. Exudative retinal hemorrhagic periphlebitis in a patient with uveitis is highly suggestive of tubercular etiology. The optic nerve may be swollen mimicking an ischemic optic neuropathy. It can also present as an optic neuritis or papillitis [2 - 7] (Fig. 7).
Choroidal tubercles are hypofluorescent in fluorescein angiography (FA), but become hyperfluorescent in late phase (Figs. 2D, 3 B-D, 4 B-C, 5, 6 B-C, 9). OCT scans through the area of suspected granuloma revealed an elevation of the choroid with an area of localized contact between the choriocapillaris-retinal pigment epithelium complex and the overlying neurosensory retina (“contact sign”) despite the presence of subretinal fluid around the lesion (Fig. 10) [8].
