Author: Nuria Garcia Gallardo (Spain)
Co-authors: Francisco Javier Martinez Montes, Irene Garcia Del Moral, Juan Francisco Martinez Jerez
Purpose
To show that the administration of clindamycin by intravitreal injections is a safe therapeutic alternative in those cases of severe OT and / or in which there is a contraindication to systemic treatment with trimethoprim-sulfamethoxazole (TMP/SMX).
Setting/Venue
Ophthalmology Department. Hospital Universitario San Agustín, Linares-Jaén (Spain)
Methods
We present the case of a 17 years old patient who consults for blurred vision in the right eye (RE) of 24 hours of evolution. On examination, visual acuity (VA) is hand movement in the RE, with a relative afferent pupillary defect. The biomicroscopy identifies a tyndall of 1+. The intraocular pressure is unremarkable. Funduscopy reveals a focus of retinitis in the macula with underlying macular edema and an effacement of the papillary border. Vitritis or vasculitis were no associated. Optical coherence tomography (OCT), Fluorescein angiography (FA), complete blood test and serology, Mantoux and chest X-ray study were performed.
Results
The OCT showed a thickening and hyperreflectivity of the neurosensory retina and neurosensory detachment. FA revealed a contrast leak at the macular and papillary level, suggestive of retinochoroiditis, without signs of vasculitis in the peripheral retina. Due to diagnostic suspicion of OT, TMP/SMX 160/800mg was started every 12 hours. 72 hours later, the serological test showed IgG titers for toxoplasma, IgM and IgG for cytomegalovirus (CMV). Mantoux and chest X-ray study had no findings. Although the clinical and serological diagnosis confirmed the OT, the presence of IgM and IgG antibodies against CMV made it necessary to rule out concomitant CMV infection. A polymerase chain reaction (PCR) of aqueous humor sample was performed with a negative result for the Herpesviridae family. Thus, prednisone 30mg daily was added to TMP/SMX treatment and intravitreal injections of clindamycin (1mg/0.1ml) and dexamethasone (0.1mg/0.1ml) were indicated. VA improved to 0.6, with resolution of macular edema and papillitis, but with a scar at the foveal level. Two weeks later, our patient developed a generalized maculopapular rash and fever, possibly due to hypersensitivity to sulfonamides, so TMP/SMX was discontinued. Given the appearance of some intraretinal macular cysts, another dose of intravitreal clindamycin is indicated, with a good response.
Conlusions
OT is the most common cause of infectious posterior uveitis, and the diagnosis is made by clinical findings in the majority of the cases, with a serological confirmation of it. Despite being a self-limited disease with resolution within 4 to 8 weeks, an adequate treatment can reduce the size of the inflammatory foci and to provide a better visual result. The most used treatment is the oral combination of TMP/SMX. Nevertheless, there are certain cases in which intravitreal clindamycin supposes a safe therapeutic alternative: situations of sulfonamide allergy, gestation states, refractory patients to the classic treatment or localization on the macular region and / or optic nerve. In addition, studies have been published in which intravitreal treatment is useful as a first line. In the case of our patient, intravitreal clindamycin together with corticosteroid treatment helped us to control the macular focus, maintaining acceptable visual acuity.
Financial Disclosure
No financial interest.
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