1. Case conference Department of Ophthalmology and Visual Science
College of Medicine, The Catholic University of Korea
R3 YE Lee/ Ap.KS Kim
3년차 이용은입니다. case conference를 시작하겠습니다.
Hi, I’m Dr. Lee, 3rd year resident of ophthalmology
I’ll start a case conference on ocular toxocariosis

2. Case 1 52/M Chief complaint) Decreased VA(OD) for several months
Present illness)
R/O amblyopia (OS) due to optic nerve abnormality, since childhood
Previous lab & treatment : Toxoplasma IgM(-), IgG(+), ELISA 0.26
Ocular toxoplasma-targeted therapy for 2 months (trimethoprime/sulfamethoxazole), but no improvement of visual symptom.
52 years old man was presented with decreased visual acuity of right eye for several months.
He suffered poor visual acuity due to optic nerve abnormality since the childhood, but
Had no history of diabetes or hypertension
From his previous laboratory result, Toxoplasma IgM was negative but IgG was positive.
Under the impression of toxoplasmosis, he was treated with trimethoprime and sulfamethoxazole for two months But it had no effect on improving his visual symptom

3. Ocular exam
VA OD 0.5(1.0 x -0.75Ds) OS 0.08(n-c) IOP OD 19 OS 12 mmHg Cornea OU clear AC OD deep & cell(trace) OS deep & cell(-) Pupil OD round & nl sized Lens OU mild cortical opacity Fundus OD retinal infiltration, vitreous cell(+), yellow granulomatous lesion at superonasal area OS fibrosis (+)
Corrected visual acuity was 20/20 for right eye & 20/200 for left eye.
Anterior chamber inflammation was found at his right eye & fundus showed retinal infiltration, vitreous inflammation, and some flame-shaped hemorrhages.
And in his left eye, there was thick fibrosis between the fovea and the optic disc.

4. Fundus photo
This it the fundus photo, when he visited our clinic for the first time.

5. Impression & plan Impression Plan R/O toxoplasmosis(OD)
R/O other forms of endophthalmitis and uveitis (OD)
Bacteria : much more acute form of intraocular inflammation
Pars planitis or chronic cyclitis : elderly
Bilateral
R/O Coats’ disease(OD)
Retinal telangiectasia with yellow intraretinal and subretinal exudation
Vitreous cell (-)
R/O toxocariosis(OD)
Plan
Uveitis lab, Toxoplasma IgG/IgM/ELISA repeat, Toxocariosis IgG
Trimethoprime/sulfamethoxazole re-start
(Our) Impression was R/O toxoplasmosis or some kind of endophthalmitis and uveitis. But he had no other systemic disease such as Behcet’s disease or other rheumatis disease.
And for the Coats’ disease, it involves unilateral eye, and also can show retinal telangiectasia with yellow exudation, but no inflammatory reactions can be found in that(Coats’) disease.
In our case, the patient showed some vitreous inflammation, so Coats’ disease can be ruled out.
Next, we can thick (of) ocular toxocariosis.
We planned to do uveitis lab and repeat toxoplasma IgG,IgM, and ELISA test.
Toxocariosis IgG test was added(or also included). And to cover the toxoplasmosis, he started to take trimethoprime and sulfamethoxazole.

6. Fundus photo
다음 내원 시의 fundus photo 입니다. Vitreous inflammation은 많이 감소하였으며 optic disc 와 macula 사이에 retinal fold 가 관찰됩니다.
This is the fundus photo taken on his second visit
The vitreous inflammation has subsided (quiet a bit /or to some extent)
And we could see the retinal fold inbetween optic disc and the macula.

7. Retinal infiltrate increased at nasal area
그러나 경과 관찰하면서 nasal retina 부분에 infiltration이 증가하는 소견이 나타났습니다.
However, on his subsequent visits (or as time goes by)
We are beginning to see the retinal infiltration at nasal area is increasing

8. Progression of lesion Suspicious motile lesion
또한 이 yellowish lesion은 vessel arcade를 기준으로 볼 때 그 위치가 약간씩 변화하는 양상을 보였습니다.
And also, based on its vessel arcarde
The location of this yellowish lesion is changing (little by little /or 구체적으로 어떻게..)

9. Results Toxocariosis IgG from serum : positive
Diagnosis : Ocular toxocariosis(OD)
Plan
Change to Albendazole 400mg po bid
H-LON 30→20mg
시행한 혈액 검사 결과 toxocariosis IgG가 positive로 나왔고, 그 외의 lab에서는 특이 소견이 없었습니다. 그래서 최종 진단을 ocular toxocariosis로 확정한 후 약을 albendazole + steroid 로 바꾸었습니다.
The repeated labarotory result shows
Toxocariosis IgG positive, but
No other remarkable findings
So the final diagnosis was ocular toxocariosis
And we changed the medicine to albendazole and steroid

10. Progress note : AC cell(-), improvement of yellowish lesion, RPE atrophy
Albendazole을 복용하면서, 환자는 증상이 호전되었고 anterior chamber의 염증도 사라졌으며, yellowish granulomatous lesion은 점차 RPE atrophy로 남은 안저 소견입니다.
As he takes albendazole,
His visual symptome improves
And the inflammation of anterior chamber subsides
And finally these are the fundus photos showing
The yellowish granulomatous lesion has turned into RPE atrophy (scar or lesion?)

11. Case 2 40/M Chief complaint) Floater (OS) for 2 months
Present illness)
He visited Samsung medical center complaining for floater(OS)
→ R/O toxoplasmosis (OS)
→ Serum Toxoplasma IgG/IgM(-/-)
→ Trimethoprime/sulfamethoxazole & steroid po
→ No improvement!
2번째 증례입니다.40세 남자가 2달 전부터 시작된 좌안의 floater를 주소로 내원하였습니다. 그는 이전에 같은 증상으로 삼성 의료원에 방문하여 R/O toxoplasmosis 진단 하에 이미 trimethoprime / sulfamethoxazole 및 steroid 를 복용하였고, 당시 시행한 혈액 검사는 Toxoplasma IgG/IgM 모두 negative였습니다.
Second case presents a 40 year old male with chief complaints of floater for two months on his left eye.
He had visited Samsung medical center with the same chief complant
And was treated with trimethoprime and sulfamethoxazole
Under the impression of toxoplasmosis.
His both serum toxoplasma IgG and IGM were negative at that time

12. Ocular exam
VA OD 0.25(1.0 x -1.50Ds) OS 0.25(1.0 x -1.50Ds : -1.25Dc Ax 90) IOP OD 15 OS 11 mmHg Cornea OU clear AC OD deep & cell(-) OS deep & cell(trace) Pupil OD round & nl sized Lens OU clear Fundus OD nl optic disc c flat post.pole
양안 최대 교정 시력은 1.0 이었고, 좌안은 anterior chamber에 약간의 염증이 있었습니다.
His corrected visual acuity was 1.0 for both eyes
There was little inflammation sign in the anterior chamber

13. Fundus(OS) : Yellowish subretinal and retinal lesion at sup nasal area, vitreous opacity(+), traction band
좌측 안저 사진을 보시면, superionasal area에 yellowifh subretinal and retinal lesion 이 있으면서 vitreous opacity 가 있고, traction band 도 optic disc에서 post pole 까지 연결되어 보입니다.
On his left fundus photo,
We could notice yellowish sub retinal and retinal lesion /
And vitreous pacity /
And the traction band connects from optic disc to post pole

14. Impression & plan R/O ocular toxoplasmosis(OS)
R/O ocular toxocariosis(OS)
Plan
Repeat Toxoplasmosis IgM/IgG
Toxocariosis IgG
Keep trimethoprime/sulfamethoxazole
Impression은 R/O toxoplasmasis, R/O toxocariosis 로 보고, 역시 lab 과 함께 우선 검사 결과가 나오기 전까지 toxoplasmosis 에 대한 치료를 시행하였습니다.
Our primary impressions were to rule out toxoplasmosis and toxocariosis
And as same as in our first case
We run(/or did) the blood test
And start the treatment for toxoplasmois

15. Results After 2 weeks… Diagnosis : Ocular toxocariosis(OS) Plan
Toxocariosis IgG : positive!
Toxoplasmosis IgM/IgG (-/-)
Diagnosis : Ocular toxocariosis(OS)
Plan
Albendazole po for 10 days
Cut trimethoprime/sulfamethoxazole
H-LON 30→20→10→5mg
혈액 검사 결과 toxocariosis IgG 가 positive 였고, ocular toxocariosis 를 확진한 후 albendazole 로 투약 변경하였고, steroid 도 염증을 줄이기 위해 함께 처방 하였습니다.
After two weeks,
Blood test result shows positive toxocariosis IgG
So we conclude ocular toxocariosis as our final diagnoisis
And start albendazole thearapy and
Give steroid to reduce the inflammation (as well)

16. Fundus : decreased vitreous opacity & AC inflammation, scar change
Albendazole로 치료를 하면서 경과 관찰 결과 vitreous & ant.chamber 의 염증은 감소하였고, 망막의 infiltration 부분은 scar 로 남았습니다.
As we started the balbendazole theraphy,
The inflammation in vitreious and anterior chamber has subsided
And the infilation site in retina has regressed(or turned) to a scar

17. Ocular toxocariosis Review
여기부턴 한국말로 발표합니다~

18. Ocular toxocariosis First described by Wilder(1950)
Causal agents :Toxocara canis, Toxocara cati
Incidence : remained unknown
Almost always unilateral, children>adult
Sx. : strabismus, unilateral decreased VA, leukocoria
Definitive host : dogs and cats
Embryonated eggs being shed in dog and cat faeces → accidentally ingested by humans
Food-borne transmission : by ingesting encapsulated larvae in the raw meat(cows, sheep or chickens)
Toxocara canis egg

20. Clinical presentations
Chronic endophthalmitis(vitreous abscess)
Dense vitreous inflammatory response
Clarity of the media↓
Retinal detachment in most cases
Hypopyon
Posterior pole Toxocara “granuloma”
Initially, hazy vitreous and signs of acute inflammation
Ill-defined, hazy mass surrounding vitreous inflammation
Inflammatory masses become well defined and small(0.75-6mm in diameter)

21. Clinical presentations
Posterior pole Toxocara “granuloma”
"granuloma" with secondary fibrocellular membranes

22. Clinical presentations
3. Peripheral granulomatous inflammatory mass
Peripheral dense, white inflammatory mass
Inflammation may be much more diffuse
Appear as a "snow bank”
Fibrocellular bands
Localized traction
Prognosis : relatively good
4. Atypical presentations
Papillitis
Motile subretinal roundworm
Diffuse chorioretinitis.
Conjunctivitis, keratitis, focal iris nodules

23. Clinical presentations
Typical fibrocellular stalks
Localized traction

24. Peripheral retinal and vitreous lesion with traction band Retinal folds extending toward the macula

25. Intraocular Toxocara remnants surrounded by an inflammatory reaction consisting primarily of eosinophils.

26. Differential diagnosis
Retinoblastoma
Age<2 years
Sono or CT(tumor & calcium)
Other forms of endophthalmitis and uveitis
Typical bacterial infections : much more acute form of intraocular inflammation
Pars planitis or chronic cyclitis : elderly
Bilateral in 80% of cases
ROP
History of prematurity, bilateral
Familial exudative vitreoretinopathy
Bilateral, positive family history

27. Differential diagnosis
Coats’ disease
Same age group, unilateral
Retinal telangiectasia with yellow intraretinal and subretinal exudation
No signs of marked inflammation
Persistent hypertrophic primary vitreous
Retrolental fibrovascular mass
Within the first few weeks of life, microphthalmia, unilateral
Idiopathic optic neuritis
Laboratory studies may be required
Quite unusual in toxocariosis

28. Differential diagnosis
Toxoplasmosis
Toxoplasma gondii, an intracellular protozoa
Transmission
Ingestion of contaminated water and raw or undercooked meat, eggs and milk
Blood transfusion, organ transplantation and transplacenta
Reactivation of infection, immunologic reaction to parasite antigens or re-infection.
Fundus
Localizing necrotizing granulomatous retinochoroiditis at the edge of a pigmented retinal scar
Grey-white focus of retinal necrosis exudation
Choroiditis, retinal vasculitis, hemorrhage and vitreitis
Dx. : T. gondii DNA using PCR or detection of antibodies
IgM Ab (first week~a few months)
IgG Ab (second week~detectable for life)
IgA Ab (acute phase~more than one year)
IgE Ab (detectable during acute infection)

29. Laboratory diagnosis Definitive diagnosis Serologic exam Cytology
Histological exam : ideal
Serologic exam
ELISA for IgG to To.canis from serum or aqueous humor
Serum titer of 1:8 : sufficient to support a diagnosis of ocular toxocariosis if the patient has signs and symptoms
Aqueous humor : higher ELISA titers than in the serum
Cannot distinguish between past and current infection
IgG titer : tend to decrease when larvae are no longer viable in tissues
Cytology
Aqueous humor or vitrectomy specimens
Presence of eosinophils

30. Medical therapy Albendazole for 2-4 weeks
800mg/day for adult
400mg/day for children
Albendazole crosses the BBB : kill larval stages of Tocoxara
Combination of albendazole and oral steroids : inflammation ↓
Cycloplegic & topical steroid eyedrop : AC inflammation

31. Surgical therapy
Vitrectomy : to clear vitreous debris, relieve VMT, repair RD or intra-vitreal fibrovascular membrane proliferation
Laser therapy : to eradicate motile subretinal nematodes

32. Prevention Treatment of infected puppies
In untreated puppies, the prevalence of Toxocara infection = 100%
All puppies should be treated with appropriate antihelminthic agents before they are 4 weeks old
Public parks and children's playgrounds : covering with a clear vinyl sheet at night and on rainy days

33. Summary
Ocular toxocariasis is a major cause of visual loss in the young
Inflammatory response to the organism
ELISA testing of the serum or intraocular fluids
Medical and surgical therapy

34. Reference Retina chapter 90. Ocular toxocariasis
Human toxocariasis: diagnosis, worldwide seroprevalences and clinical expression of the systemic and ocular forms
Annals of Tropical Medicine & Parasitology, Vol. 104, No. 1, 3–23 (2010)
Nematode infections of the eye: toxocariasis, onchocerciasis, diffuse unilateral subacute neuroretinitis, and cysticercosis
Ophthalmology Clinics of North America – Volume 15, Issue 3(September 2002)