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A Retinal Detachment After International Travel

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 58-year-old man was referred for evaluation of a retinal detachment in his left eye. His visual acuity on presentation was 20/20 in the right eye and hand motion only in the left eye. Examination of the right eye was normal. Anterior segment examination of the left eye revealed around 30 cells per high-power field of a 1 mm × 1 mm light beam and diffuse stellate-appearing keratic precipitates. Posterior examination results showed a vitreous cell that precluded a clear view of the posterior pole and inferior snow banking. Most notable was a large, white, preretinal lesion in the inferior macula and a near-total retinal detachment with no identifiable retinal break and shifting subretinal fluid (Figure).

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Ocular and disseminated toxoplasmosis with toxoplasmic myocarditis

B. Obtain aqueous sample for cultures and polymerase chain reaction

On presentation, an aqueous sample was obtained and sent for cultures and polymerase chain reaction (PCR) (answer B). The focal, white, macular lesion with moderate overlying vitritis resembled the “headlight-in-the-fog” appearance of toxoplasma retinitis rather than a bacterial endophthalmitis (answer A). Surgical repair was deferred because of concern for active infectious retinitis (answer C). Given suspected infectious cardiomyopathy, serum toxoplasma IgG and IgM antibodies were drawn, infectious disease was consulted, and the patient started empirical treatement with oral trimethoprim-sulfamethoxazole. Systemic steroids (answer D) were deferred to avoid exacerbation of suspected disseminated toxoplasmosis.

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Article Information

Corresponding Author: James P. Dunn, MD, Retina Division, Wills Eye Hospital, 840 Walnut St, Ste 1020, Philadelphia, PA 19107 (jpdunn@willseye.org).

Published Online: December 16, 2021. doi:10.1001/jamaophthalmol.2021.2733

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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2.
Holland  GN .  Ocular toxoplasmosis: a global reassessment, part II: disease manifestations and management.   Am J Ophthalmol. 2004;137(1):1-17. doi:10.1016/S0002-9394(03)01319-9PubMedGoogle Scholar
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Song  A , Scott  IU , Davis  JL , Lam  BL .  Atypical anterior optic neuropathy caused by toxoplasmosis.   Am J Ophthalmol. 2002;133(1):162-164. doi:10.1016/S0002-9394(01)01211-9PubMedGoogle ScholarCrossref
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Eyles  DE , Coleman  N .  Antibiotics in the treatment of toxoplasmosis.   Am J Trop Med Hyg. 1953;2(1):64-69. doi:10.4269/ajtmh.1953.2.64PubMedGoogle ScholarCrossref
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Holland  GN , Lewis  KG .  An update on current practices in the management of ocular toxoplasmosis.   Am J Ophthalmol. 2002;134(1):102-114. doi:10.1016/S0002-9394(02)01526-XPubMedGoogle ScholarCrossref
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Bosch-Driessen  LH , Karimi  S , Stilma  JS , Rothova  A .  Retinal detachment in ocular toxoplasmosis.   Ophthalmology. 2000;107(1):36-40. doi:10.1016/S0161-6420(99)00013-5PubMedGoogle ScholarCrossref
8.
Bosch-Driessen  LEH , Berendschot  TTJM , Ongkosuwito  JV , Rothova  A .  Ocular toxoplasmosis: clinical features and prognosis of 154 patients.   Ophthalmology. 2002;109(5):869-878. doi:10.1016/S0161-6420(02)00990-9PubMedGoogle ScholarCrossref
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Hofman  P , Drici  MD , Gibelin  P , Michiels  JF , Thyss  A .  Prevalence of toxoplasma myocarditis in patients with the acquired immunodeficiency syndrome.   Br Heart J. 1993;70(4):376-381. doi:10.1136/hrt.70.4.376PubMedGoogle ScholarCrossref
10.
Albrecht  H , Stellbrink  HJ , Fenske  S , Schäfer  H , Greten  H .  Successful treatment of Toxoplasma gondii myocarditis in an AIDS patient.   Eur J Clin Microbiol Infect Dis. 1994;13(6):500-504. doi:10.1007/BF01974642PubMedGoogle ScholarCrossref
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