Good morning

Fungal uveitis
Dr. Anumeha

Presumed Ocular Histoplasmosis

Pathogenesis:

Caused by Histoplasma capsulatum By inhalation of infective mycelia or spores with dust particles POHS represents an immunologic mediated response in individuals previously exposed to fungus Inc prevalence of HLA-B7 and HLA-DR2

Key features are:

Occurs From area, endemic for histoplasmosis Whites 20-50 years of age Fundus picture: Multiple peripheral atrophic scars Macular disciform scar Peripapillary choroidal scars Linear peripheral streak lesions Lack of aqueous and vitreous inflammation HLA-B7-and HLA-DR2-positive patients

Multiple peripheral atrophic scars

vary in number, shape, size, and pattern are at the level of the outer retina(retinal pigment epitheliuminner choroid) usually 0.2 to 0.7 DD in size mostly nonpigmented, but central pigment clumps, peripheral pigmentation, or diffuse pigmentation may be seen occur bilaterally usually remains unchanged through out life

Peripheral atrophic scar

Peripapillary choroidal scars and macular scars

Peripapillary scars raises suspicion of disciform maculopathy also FAngio of inactive scars shows loss of pigment epithelium and choriocapillaris in the area of the scar. neovascularization with asymptomatic leakage is seen occasionally. Hemorrhagic peripapillary choroidal neovascularization may also occur, with permanent loss of central vision if spread to the macula occurs

Peripapillary scars with associated choroidal neovascularization extending into the macula

Peripheral linear streak lesions

variable length, width, and pigmentation in the equatorial region and oriented parallel to the ora serrata result from loss of choriocapillaris and retinal pigment epithelium and appear to represent a linear aggregation of peripheral atrophic histoplasmosis spot The linear distribution at the equator is because anterior and the posterior choroids are supplied separately and the watershed zone is at the equator

Linear peripheral streak lesion

Macular choroidal neovascularization

Brings the patient to the ophthalmologist

Symptoms:

Metamorphopsia blurred vision, or loss of central vision

Fundus shows: Rarely, choroidal neovascularization can occur in the macula without a prior scar or pigmentary change. These macular lesions can also cause RD but most are hemorrhagic lesions. It is usually 1 disc diameter or less in size and is greenish gray in color.

D/d: o Granulomatous disease of the fundus:

Tuberculosis Sarcoidosis Coccidioidomycosis Cryptococcosis

o o o o

Multifocal choroiditis with panuveitis High myopia Punctate inner choroidopathy Birdshot chorioretinopathy

Diagnosis: Histoplasmin skin test: clinically helpful lasts lifetime ocular lesion may reactivate aft this Serological tests: Complement fixation is quantity test Antibodies are present up to2- 5 yrs aft infec Chest Xray: Calcifications seen of previous infec FFA

Prognosis:

If untreated choroidal neovascular membranes in the macula result in a final visual acuity <6/60

second eye macula involvement occurs in about 12% of cases within 5 years and 22% within 10 years after involvement of the first eye The visual result is dependent on--- location of the lesion in relation to the fovea, size of the membrane, age of the patient, and initial visual acuity. atrophic choroidal scars in the macula of the second eye is a much greater risk factor for developing a macular disciform lesion

T/t

Laser photocoagulation of choroidal neovascularization it is effective when the extent of the new vessels is well defined and does not extend beneath the fovea both argon and krypton laser are used Corticosteroids may be beneficial if new vessels are beneath the fovea Surgical removal of subfoveal neovascularization is still experimental.

FFA showing leakage with foveal involvement

After t/t with laser photocoagulation closure of choroidal neovascular membrane

Candidiasis
Caused by candida albicans Occurs in three main groups: IV drug addicts Pts with long term indwelling catheters Immunocompromised pts

C/f

Gradual u/l blurring of vision Floaters

Signs:

Focal or multifocal chorioditis Small,round, white slightly elevated lesions with indistinct borders Enlargement of lesions and extension into vitreous making cotton ball colonies Chronic endoph Retinal necrosis and RD

Multifocal candida retinitis with cotton ball vitreous colonies

D/D of Candida Endophthalmitis

Endogenous bacterial endophthalmitis Toxoplasmin retinochoroiditis Primary intraocular lymphoma Cytomegalovirus retinitis Syphilitic chorioretinitis Aspergillus endophthalmitis

Treatment Oral 5-flucytosine 150 mg daily + Ketoconazole 200-400mg daily for 3 weeks In resistant cases IV amphoterecin-B in 5%dextrose Pars plana vitrectomy: in endop cases Intravitreal inj of ampho is also given.

Caused by cryptococcus neoformans (encapsulated cyst) Present in soil contaminated with pigeon droppings Mode of transmission is inhalation Occurs in cell mediated immune dysfunction and aids pts Histologically, there is usually acute and granulomatous inflammation S/s Meningitis assoc manifes-most common Papilloedema Optic neuropathy Ophthalmoplegia Ptosis 6th N palsy

Cryptococcosis

Earliest clinical manifestation is multifocal chorioretinitis Lesions vary in size, and there may be overlying retinitis and vitritis In severe cases, vascular sheathing, mutton fat keratic precipitates, or endophthalmitis can occur

multifocal necrotizing lesions of the retina.

T/t IV amphotericin B or oral fluconazole and oral 5-flucytosine

Aspergillosis
Caused by mold aspergillus Found in decaying veg matter Infection by inhalation of spores In immuno-compromised host:: abuse intravenous drugs, alcoholic patients organ transplant recipients patients on chemotherapy for malignancy

Presentation

rapid onset of pain and visual loss. yellowish infiltrate: in the macula beginning in the choroid and subretinal space. retinal vascular occlusion and full-thickness retinal necrosis. Intraretinal hemorrhages usually occur. dense vitritis varying degrees of cell in AC, flare hypopyon The macular lesions heals to form a central atrophic scar. In severe infection, subretinal abscess and endophthalmitis occurs

T/T
systemic treatment with intravenous amphotericin B intravitreal injection of 510 g of amphotericin B.may be reinjected weekly Intravitreal corticosteroids may be used

Thank you