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June 14, 2021
Authored by Burton Wisotsky, MD:
A 51 year old woman was referred for vision loss in her right eye. The patient noted a fogging of her vision with central loss over the past month. Medical history is significant for systemic lymphoma (CLL) for which she had previously been treated with chemotherapy and was in remission. Ocular history is unremarkable. On examination, VA was OD: CF and OS: 20/20. IOP’s were normal. There was mild anterior segment inflammation OD as well as moderate vitritis. The left anterior segment was normal. Bscan of OD showed PVD with prominent and inflamed posterior hyaloids, but no retinal detachment:
DFE of the left eye was normal. In the right eye, details of the retina were hazy, but there appeared to be an active yellowish white lesion in the macula with surrounding inflammation:
The findings were concerning. There appeared to be both an area of active posterior retinitis as well as vitritis and retinal vasculitis. Diffrential diagnosis includes intraocular lymphoma vs inflammatory lesion vs infection. Infections could be parasitic, bacterial, viral, or fungal. We elected to treat the patient aggressively and scheduled a diagnostic and therapeutic vitrectomy. The decision was made to get a definitive diagnosis of the retinal lesion and at the same time possibly improving the vision by removing the hazy vitreous. The surgery was uneventful and the vitreous specimen was sent for analysis in the microbiology lab, pathology lab, and for polymerase chain reaction. We were expecting a diagnosis of intraocular lymphoma. To our surprise, the testing came back consistent with toxoplasmosis. The patient likely had an exposure to toxoplasmosis as a child, and the immunodeficiency resulting from the lymphoma allowed it to reactivate. Once we got the results we started her on oral prednisone and double strength bactrim. The infection and inflammation gradually subsided and the medications were tapered to off. While the overall haze improved, the macular scar remained and vision never improved beyond 20/400:
