Neuroretinitis Anna-Maria Gerlach, Werner Inhoffen Deshka Doycheva, Manfred Zierhut Centre of Ophthalmology University of Tuebigen Germany Ocular History 35 years old female patient dark spot in the central visual field of the OS since 1 week in the past no ocular problems referring ophthalmologist: toxoplasmosis of both eyes with new activity on the OS General History psoriasis no other diseases known August First Presentation Visual acuity:OD 1.0, OS 0.3 Anterior segment: OD/OS quiet Fundus: OD: peripapillar scaring, macula regular, disseminated, partly pigmented retinal scars in the mid to outer periphery OS: peripapillar infiltrates, macular star, disseminated, partly pigmented retinal scars in the mid to outer periphery Ocular Examination First Presentation OD Ocular Examination First Presentation OS First Presentation - OCT Macular edema close to the optic disc: thickening of retina between both plexiform layers, exsudation in the fotoreceptor layer close to the fovea: Hard exsudates in Henle and outer plexiform layer Neurosensory edema subfoveal with infiltration Elevation of the pigment epithelium subfoveal First Presentation - OCT OD OS First Presentation - FLA OD 40 s 2 min 7 min 3 min 7 min First Presentation - FLA OS 30 s 50 s 6 min 2 min 6 min Diagnosis Neuroretinitis of unclear Origin Etiology of Neuroretinitis Infectious etiology Viral infection (e.g. Coxsackie B, EBV, HSV, VZV) Bacteria (e.g. Bartonella, M. tuberculosis, Borrelia, Leptospira) Parasites (e.g. Toxoplasma, Toxocara) Non-infectious etiology e.g. inflammatory bowel disease, sarcoidosis, Polyarteriitis nodosa Diagnostics Thorax X-ray: no hiliar or mediastinal lymphadenopathy or other signs of sarcoidosis or tuberculosis Thorax X-ray: no hiliar or mediastinal lymphadenopathy or other signs of sarcoidosis or tuberculosis Quantiferone test: negative Quantiferone test: negative Serologic testing for Bartonella, Lues and Borrelia: negative Serologic testing for Bartonella, Lues and Borrelia: negative Working Hypothesis Neuroretinitis presumably caused by toxoplasmosis Therapy Oral Clindamycin 4x 300 mg Oral Prednisolone 1x 60 mg initially, slow reduction in weekly steps Follow up - After 1 week Visual acuity:OD 1.0, OS 0.4 Anterior segment: OD/OS quiet Fundus: OD: stable situation, no signs of activity OS: subretinal lesion in regression, no fresh active lesions Follow-up After 1 Week OCT OS28/08/2014 OS04/09/ m 344 m Follow up - After 1 week OCT Beginning resolution of the hard exsudates and other observations Hyperreflective foci in the outer segments Follow up - After 3 Weeks Visual acuity: OD 1.0, OS 0.6 Anterior segment: OD/OS quiet Fundus: OD: stable situation, no signs of activity OS: further regression of subretinal lesion, no fresh active lesions Follow up - After 3 Weeks OCT OS28/08/2014 OS18/09/ m 256 m Follow up - After 3 weeks OCT Good resolution of the macular edema Close to the optic disc still mild exsudation No neurosensory edema Still incomplete resolution of the outer segment layer Hard exsudates only in the outer plexiform layer Follow up - After 3 Weeks OS Perimetry OD>OS: Enlarged blind spot Follow up - After 3 Weeks OCT OS18/09/2014 OS08/10/ m 240 m Autofluorescence first presentation after 3 weeks Autofluorescence first presentation after 3 weeks Follow up - After 9 Weeks OCT OS 245 m Follow up Last Visit after 9 Weeks Visual acuity: OD 1.2, OS 0.8 Visual acuity: OD 1.2, OS 0.8 Fundus: OS few residual hard exsudates, central lesion scarred, no fresh active lesions Fundus: OS few residual hard exsudates, central lesion scarred, no fresh active lesions OCT: further decrease of central retinal thickness and resolution of exsudates OCT: further decrease of central retinal thickness and resolution of exsudates Conclusion - Neuroretinitis is characterized by optic disc edema is characterized by optic disc edema often associated with peripapillar serous retinal detachment and macular star formation often associated with peripapillar serous retinal detachment and macular star formation can be caused by a variety of infectious and non- infectious conditions or idiopathically can be caused by a variety of infectious and non- infectious conditions or idiopathically treatment depends on the presumed or confirmed cause treatment depends on the presumed or confirmed cause In most cases a spontaneous regression with recovery of the visual acuity occurs. In most cases a spontaneous regression with recovery of the visual acuity occurs.