When Orange is the New Black – “Blurry Eyes”
by Majo Joseph
When you have a child who presents to your ED with blurry vision, how confidently can you do a fundus exam? Fundus exam had been considered to be an integral part of physical examination in children. Many physicians are not confident with their fundoscopic skills as a result of increased rate of sub-specialist referral and therefore less hands-on experience. We report a case which emphasizes the importance of learning a potential vision- and life-saving skill.
Our patient is a 13 year-old Hispanic female with no significant past medical history who presented to Peds ED for blurring of vision in the right eye. She reports hitting herself in her right eye with the backpack strap. Two days later, she noticed that she had problems seeing the chalkboard at school. She also noticed floaters in her visual field. She had mild photophobia, but she denied any headaches, weakness, numbness or discharge from her eyes.
Family history was unremarkable.
She was born in Eucador and moved to US at the age of 7.
She was not on any medications and not known to have any allergies.
Visual acuity on the right side 20/60. PERRLA b/l, EOM normal, mild conjunctival injection. No hyphen. The fundus exam which showed “diffuse haziness”.
The remainder of the physical exam including neurologic exam was normal.
The fundus examination along with the history of trauma prompted emergent consultation for a detailed ophthalmology exam. It showed hazinesss of fundus suggestive of vitrietis and marked hypo-pigmented lesion and some hyper-pigmentation which pointed towards an infectious process in the eye – Ocular Toxoplasmosis.
(Abnormal – hypopigmentation and hyperpigmentation)
The patient was started initially on “classic therapy” with pyrimethamine, sulfadiazine, folinic acid along with cyclopentolate and prednisolone drops and then transitioned to trimethoprim-sulfamethoxazole. Her toxoplasma IGG came back positive which confirmed the diagnosis. Further history revealed that she plays with her neighbor’s cat frequently. The patient tolerated the treatment well. The lesion showed regression within a month, and her visual recovery was excellent.
Ocular Toxoplasmosis is caused by Toxoplasma gondii, an infectious, obligate intracellular parasitic protozoan. It can produce an intense inflammatory reaction in the retina, overlying vitreous, and underlying choroid. It is typically contracted by eating raw ground beef or rare lamb, working with meat, drinking unpasteurized goat’s milk or contaminated water, or having 3 or more kittens.
There is a 10-20% lifetime incidence of infection in northern hemisphere and up to 50% in the equatorial countries – it is more prevalent in hot, humid climates. There is a reported 22.5% seropositivity found in US (NHANES data).
Cystoid macular edema
Optic atrophy secondary to optic nerve involvement
Recurrence can occur due to rupture of dormant retinal cysts resulting in inflammation
The goal of treatment is to arrest multiplication of the parasite during active retinochoroiditis in order to minimize damage to retina and optic nerve. Classic therapy includes pyrimethamine with folinic acid. The addition of folinic acid guards against leukopenia and thrombocytopenia (weekly CBC monitoring). Other medications used are sulfa drugs, steroids, macrolides and intravitreal injections of clindamycin and dexamethasone.
Ocular Toxoplasmosis is a major threat to vision on a local and global scale. It is important to appreciate the significant morbidity associated with this disease especially abroad. Early diagnosis and appropriate treatment yields an excellent visual outcome.
Arun, Veena, A. Gwendolyn Noble, and Toxoplasmosis Study Group. “Cataracts in congenital toxoplasmosis.” Journal of American Association for Pediatric Ophthalmology and Strabismus 11.6 (2007): 551-554.
Atmaca, Leyla S., et al. “Fluorescein and indocyanine green angiography in ocular toxoplasmosis.” Graefe’s Archive for Clinical and Experimental Ophthalmology 244.12 (2006): 1688-1691.
Holland, Gary N. “Ocular toxoplasmosis: a global reassessment: part II: disease manifestations and management.” American journal of ophthalmology 137.1 (2004): 1-17.
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