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Show j. Clin. NeUnl-l'phth.l/nwl 2: 100-112.. 1°82. Treatment of ToxocaraI Optic Neuritis RICHARD MOLK, M.D. Abstract An 8-year-old male with poor vision from presumed tOllocaral optic neuritis is presented. The diagnosi is supported by positive erum ELISA testing. Subtenon's depot injections of Kenalog resulted in ellcellent improvement and final visual acuity of 20120. Early diagnosis with serum ELISA tests and vigorous treatment with subtenon's steroids are recommended. The f,)lIowing C.lse is the first successful treatment )f to,\,KJral optic neuritis to my knowledge. Case Report An ~-year-old male was referred to the Geisinger MedIcal Center with d chief compldint of blurriness ,n his left eye. The onset WdS sudden. pdinless. and nonprogressiYe. The patient described a large black spot in front of his left eye present since awakening 1 week previously. Past history was remarkable for dn acute unexplained febrile illness with cough for several days' duration approximately 2 year,; earlier. He had both CdtS and young dogs dt home. The referring ophthdlmologist found a visual acuity of 20/400 and a questiondbly positive afferent pupillary defect in the left eye. He dilated both pupils dnd described a peripapilld ry white exudate over the left optic nerve hedd. At our examination the ViSUdl dcuity was 20/20 in the right eye dnd 20/300 in the left eye. Refrdction and pinhole yielded no improvement. The pupils were still dilated from the previous eXdmination. Versions were full. Slit-lamp eXdmination showed a mild (1+) degree of cells without flare in the anterior chamber. There were occasional cells floating in the anterior vitreous of the left eye. Direct ophthdlmoscopy demonstrated J dense, white, fluffy hdze overlying the optic nerve heJd with obscuration of the vessels (Fig. I). Fine white retinal folds extended rddidlly towdrd the m.1cula, where mild edema WdS present. Hard cxud<1tE's From the O('pdrtm('nl uf OphlhJlm"I,,~y. C('i"n~('r M('d'l".,1 (enler. Ddnville. P('nnsylvdnIJ. lune 1982 were present in a m<1cular star configuration. The .nterillies Jppe.Hed within normdl limits but the veins were engorged compared to the right eye. The peripheral fundus w.as eXdmined using indirect ophthJlmoscopy with scleral depression dnd demonstrated no abnorm.alities. An ultr.asound showed no cdlcification. Neuroretinitis was diagnosed, serum specimens sent to the Center for Dise.ase Control in Atlanta for Toxocara titers by the ELISA method, and therapy instituted. Kenalog 40 mg was placed subtenons while dwaiting the laboratory results. Reexdmination 1 week later revealed a visual acuity improvement to 20/100. The anterior ch.amber showed mild inflammation, as did the anterior vitreous. Little change was noted in fundus examin. ation, except for a slight incre.ase in the number of hdrd exud.ates in the macula. An additional 40 mg of Ken.alog WdS injected in the subtenons space. Topical Pred Forte 1% and Scopalamine '/4% were begun. Two weeks l.ater the acuity was 20/60. The anterior chdmber w.as free from inflammation. The exuddtes overlying the optic nerve had decreased .Ind the macular st.ar was re.absorbing (Fig. 2). The Toxocara titer by serum ELISA test w.as positive at I :32. The CSc. eosinophil count, dnd toxoplasmosis tests were within normal limits. The fundoscopic exam showed mild improvement. One month later dn\)ther small .lrea of white exudative inflammation had occurred overlying the inferior temporal arteriole .lnd venule (Fig. 3). The visudl Jcuity W.IS unch.lOged .1t 20/('10. At 4-months follow-up off .Ill medications, the visudl acuity had improved t\) 20/25 without correction. Refractive error \vas plan,) in e.Ich eve. Pupils were redctive, equal. round . .Ind showed a mild (1 +) .Iffercnt defect in the left eve. The visual fi<>ld eX.lmin.ltion discll)sed .l IJrge i·rregul.ar inferior field l·ut. Th<> disc W.lS now c1e.Ir e,\(ept for J sm.lll gr.1yish-white veil llYN the _uperior n.asal l./u.Irt<>r. A f(,w h.Ird exud.ltes rem.lined from the m.ll"ul.H st.Ir (Fig. 4). fin.ll ex.ln1in.Ition .It ,g months showed a quiet whitE' I('ft eye with 20/20 visu.11 acuity. Pupil ex. Imination still dl?monstr.ated d 1+ .Ifferent defect on thl.' left. Red desaturJtion w.as present on the left. Although Amsler's grid w.as reported .as norm. ll to both I.'yes, it .appeared clearer dnd brighter 109 Journal of Clinical Neuro-ophthalmo!ogy Mol\.. Figure 5. Find] e'l.Jm .It 8 rnunth~. to the unaffected right eye. Colors and lights appeared dimmer to the left eye. Fundus examination showed a small vitreal strand from the superior nasal quarter of the disc to an area of choroidal atrophy contiguous with the disc. A bright fov{'JI reflex with only a few remaining hJrd {'xudJte was present (Fig. 51. Peripheral fundus examination was unremarkable. Discussion Helenor Wilder fir t demonstrJted intrdllCulJr nemiltode larvae in 1950' Nichol subsequ<-ntly identified four of Wilder's specimens as ToxocJrJ second-stage larvae." Since that time, many VdrJOUS intraocular involvements and reactions hav(' been reported. In 1970 Bird, Smith, and Curtin reported the first case of Toxocaral optic neuritis with confirmation by pathological sp{'cimen:' Their pJtient was a 4-year-old female. Final vision before enucleation was no light perception, despite two sepilrate COurses of oral Prednisone. June 1982 The other ca e of Toxocaral optic neuritis in the Iiterdlure was report{'d by Phillips .md M.\cKenZie in IQ73.' Their case occurred in .1 ~S-ye.H-(\ld femJle. A ~- to 3-week Cl'Ur. e "f systemic ,'ortisnne ,Ind diethyk.HbJm.lzine (.In .lnthelminth) WJS given WIthout Sliccess. Interim ",su.11 .\Cuitv w.,s recorded .1. 20/400. Fin.11 progoc'sis f<>r \'isi,,'n W.'s poor .llth"ugh n,l Jctual figure fnlm the LIst visit was published. Our patient presented with .1 p",'r "iSll.11 acuity (20/300) Jnd .I sh,'rt dur.lti,'n "f his disease AI· though there is nt' p.lth"l,'gic.ll specimen to Clln· firm the di,lgl1l'sls lIne'llllv,'e.,II\'. th,' p.ltll·nt's serum d'·In'"'str.ltl·d .In ,·n7vll1l'·lin\..,·d 1l1HllUll,'s,'r· bent ass.lY level (ELI~A I '"f 1:3~ USing the d.ltJ published by Sh'l,ld,. dh'Q;. .lnd FedermJn. the LI A test is 100% spe,"ifi, hH Toxocara .It J titer llf 1:8 <>r greater.:' ('oll.lrd et .11. cited a Q5"" specifi ity fl>r titers of 1:32." Berroc.ll r{'ported .I titer of greater th.1I1 1:4 .15 di.lgmlstie in patients with clinical OCUIM tOXOC.Hia. is dnd d titer ~reater than I: 16 as diagno tic of vi ccr.ll to ocara.' A titer of 1:32 111 is therefore 05-100% specific for Toxocaral infectilln. nl'S,lVi~ny. VlllIl'r, .lnd Woodruff reportl'd d ~.l'% indJl"Kl' llf positive serum EUSA titers .1111llng <)~~ hl',llthy ,ldults in Gre.lt Britdin.K Bernll'. ll rl'lxlrtl'd .l b5% incidencl' of ELISA titers ~rl'.ltl'r th,ln or l'qu.l1 to I:32 in a population of 671 suhj('(ts in Puerto Rico.!' Therefore, 2.5-6.5% of the c1inir.llly nMm.l1 population will show d positive ELISA test, indicdting prior or mild infl'ction. In our Cdse, the history of exposure to young dogs .lnd .In unexplained febrile pulmonary infection, lOUpled with the positive ELISA test (1 :32), lends support to the didgnosis of ocul,u Toxocariasis in this patient. The author speculates it WdS the early vigorous treatment with subtenons depot of Kenalog (40 mg twice, 1 week apdrt) which effected the patient's rdpid improvement. The two previously reported Cdses of ToxocdrdJ optic neuritis were treated with oral Prednisone with poor visual outcome. Precedence for the subconjunctival route was established by Nolan in 1968:" After unsuccessful treatment with systemic Prednisolone for 1 month, he switched to monthly injections of subconjunctival Depomedrone for a patient with peripheral Toxocdrdl granuloma. Dramatic improvement was noted. Final visual acuity was 20/15. [n our case, final acuity was 20/20. By using the serum ELISA test, the diagnosis of Toxocara may be confirmed within 3 weeks of sending the specimen to the Center of Disease Control in Atlanta. It is recommended that early diagnosis with ELISA be combined with repeated subtenons depot injections of Kenalog (40 mg dose). References 1. Wilder, H.: Nematode endophthalmitis. Trans. Am. ACdd. Ophthalmol. Otolaryngol. 55: 99-109, 1950. 2. Nichols, R. L.: The etiology of visceral larva migrans. I. Diagnostic morphology of infective second stage toxOC.Ha larvae. /. Parasito/. 42: 349-362, 1956. 3. Bird, A., Smith, J. l., and Curtin, V.: Nematode optic neuritis. Am. ]. Ophtha/mol. 69: 72-77, 1970. 4. Phillips. C I., and MacKenzie, A. D: Toxocara larval pdpillitis. Br. Med.]. 1: 154-155, 1973. 5. Shields, J.• Felberg, N., and Federman, J.: Discussion of presentation by Dr. Zane F. Pollard, et al. Ophthdlmology 86: 750, 1979. o. Pollard. Z.. Jarrett, W., Hagler. W., Allain, D.. and Schantz, P.: ELISA for diagnosis of ocular toxocarlaSIS. Ophthalmology 86: 743. 1979. 7. Bf:'rrocal, 1.; Prevalence of toxocara canis in babies and In adults as determined by the ELISA test. Trans. Am. Ophthalmol. Soc. 78: 376-413, 1980. 8. DeSavlgny. D. H.. Voller. A., Woodruff. A. W.: Toxocariasis: Serological diagnosis by enzymf:' immunoassay. /. Clin. Pathol 32: 284-288, 1979. 9. Berrocal. ].; Prevalence of toxocara canis in babies and In adults as determaned bv the ELISA test. Trdns. Am. Ophtha/mol. Soc. 18; 376-413, 1980. 10. I\:olan. J.: Chronic toxocaral endophthalmitis. Successful tredtment of a case With subconjunctival depot corticosteroids. Br. /. Ophthalmol. 52: 276277. 1908. WrIte for reprints to: Richard Mol\... M.D.. Department (If Ophthdlmologv. Gelsonger Medical Center. D':ln\'ille. Penn yl\'ania 17821 Joumdl of Clinical Neuro-ophthalmology |
