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Arch Ophthalmol. 2006;124:741-743.

Choroidal neovascularization (CNV) can arise secondary to the retinochoroiditis and macular scarring from ocular toxoplasmosis.^1-2 Treatment of CNV due to toxoplasmosis can include corticosteroids, cryotherapy, laser photocoagulation, submacular surgery, and verteporfin photodynamic therapy (PDT).^1-4 We describe 2 cases of CNV secondary to toxoplasmosis treated successfully with PDT.

Report of Cases
Case 1. A 20-year-old man with a diagnosis of congenital ocular toxoplasmosis with bilateral macular scars sought care because of a 9-month history of decreasing vision and metamorphopsia in the right eye. Visual acuity was 1/200 OD. Fundus examination results revealed a subfoveal chorioretinal scar with surrounding subretinal hemorrhage and exudate (Figure 1A). Fluorescein angiographic images identified central leakage from the CNV with surrounding blocked fluorescence corresponding to the hemorrhage (Figure 1B and C), while indocyanine green angiographic images were able to provide visualization through the hemorrhage. The eye was treated with PDT and the greatest linear dimension of the treatment spot included all of the hemorrhage.

View larger version (102K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 1. A, Baseline fundus photographs (OD, OS) show a macular scar with adjacent subretinal fluid, hemorrhage, and exudates in the right eye and a macular scar in the left eye. B and C, Baseline early- and late-phase fluorescein angiographic images showing leakage from choroidal neovascularization and hypofluorescence corresponding to hemorrhage. D, Posttreatment fundus photographs taken at 10 months showing a macular scar with no evidence of subretinal fluid, hemorrhage, or exudates. E and F, Posttreatment early- and late-phase fluorescein angiographic images taken at 10 months showing no evidence of leakage.

One week posttreatment, visual acuity improved to 20/200 OD. Six weeks posttreatment, a flat scar was present in the central macula with resolution of the hemorrhage and exudates. Six months posttreatment, visual acuity improved to 20/60 OD and has remained stable for more than 2 years (Figure 1D-F).

Case 2. A 15-year-old boy with a diagnosis of bilateral macular scars secondary to congenital ocular toxoplasmosis reported decreasing vision in his left eye. On examination, visual acuity was 20/100 OS. Fundus examination results revealed a macular scar with adjacent fibrosis, subretinal fluid, and hemorrhage (Figure 2A). Fluorescein angiographic images identified leakage from the CNV and blocked fluorescence corresponding to the hemorrhage (Figure 2B and C). Optical coherence tomographic images revealed increased retinal thickening and a highly reflective layer under the retina consistent with CNV (Figure 2D). The patient underwent PDT.

View larger version (173K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 2. A, Baseline fundus photographs (OD, OS) show a macular scar with adjacent fibrosis, subretinal fluid, and the rim of hemorrhage in the left eye and a macular scar in the right eye. B and C, Baseline early- and late-phase fluorescein angiographic images show leakage from choroidal neovascularization and the rim of hypofluorescence corresponding to hemorrhage. D, Baseline vertical optical coherence tomographic scan shows increased retinal thickening and a highly reflective subretinal complex. E, Posttreatment fundus photographs taken at 6 months show a macular scar and no evidence of subretinal fluid or hemorrhage. F and G, Posttreatment early- and late-phase fluorescein angiographic images taken at 6 months show no evidence of leakage. H, Posttreatment vertical optical coherence tomographic scan taken at 6 months shows diminished retinal thickness and a persistent highly reflective subretinal complex.

One month following treatment, visual acuity improved to 20/80 OS. Fundus examination results showed a flat chorioretinal scar and complete resolution of subretinal fluid and blood. The patient's visual acuity and clinical appearance remained stable through 18 months of follow-up (Figure 2E-H).

Comment
Compared with other treatments, PDT has the theoretical advantage of selectively occluding the CNV, even in the presence of small amounts of overlying blood, without causing significant damage to the unaffected retina and choroid. Thus, PDT has the potential for vision improvement, especially in younger patients as shown in our cases. Furthermore, only a single treatment was necessary in both of these cases, unlike the 3 to 4 treatments routinely needed during the first year in patients with neovascular age-related macular degeneration.⁴ The decreased need for retreatment with PDT in these toxoplasmosis cases is similar to the retreatment rate observed in younger patients with postinflammatory CNV. While improvement could have occurred without PDT, these lesions were not in the process of resolving as suggested by the duration and progression of vision loss and the presence of new hemorrhages. Photodynamic therapy was most likely responsible for the observed improvements owing to the temporal relationship between treatment and the resolution of the CNV. To our knowledge, this is the second report of CNV secondary to toxoplasmosis treated with PDT⁵; the first report demonstrating a sustained visual acuity benefit from a single treatment with PDT, and the first successful use of PDT to treat a predominantly hemorrhagic lesion.

AUTHOR INFORMATION
Correspondence: Dr Rosenfeld, Bascom Palmer Eye Institute, 900 NW 17th St, Miami, FL 33101 (prosenfeld{at}med.miami.edu).

Financial Disclosure: None.

Funding/Support: This study was supported by an unrestricted grant from Research to Prevent Blindness Inc, New York, NY, and grant P30 EY14801 from the National Institutes of Health, Bethesda, Md.

Robert Wirthlin, MD; Alice Song, MD; Julia Song, MD; Philip J. Rosenfeld, MD, PhD

REFERENCES
1. Willerson D, Aaaberg TM Sr, Reeser F, Meredith TA. Unusual ocular presentation of acute toxoplasmosis. Br J Ophthalmol. 1977;61:693-698. FREE FULL TEXT 2. Fine SL, Owens SL, Haller JA, Knox DL, Patz A. Choroidal neovascularization as a late complication of ocular toxoplasmosis. Am J Ophthalmol. 1981;91:318-322. PUBMED 3. Adan A, Mateo C, Wolley-Dod C. Surgery for subfoveal choroidal neovascularization in toxoplasmic retinochoroiditis. Am J Ophthalmol. 2003;135:386-387. PUBMED 4. Rosenfeld PJ, Saperstein DA, Bressler NM, et al. Photodynamic therapy with verteporfin in ocular histoplasmosis: uncontrolled open-label 2-year study. Ophthalmology. 2004;111:1725-1733. FULL TEXT | PUBMED 5. Oliveira LB, Reis PA. Photodynamic therapy-treated choroidal neovascular membrane secondary to toxoplasmic retinochoroiditis. Graefes Arch Clin Exp Ophthalmol. 2004;242:1028-1030. FULL TEXT | PUBMED

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