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Research Letters |

Photoreceptor Recovery Following Laser Photocoagulation and Albendazole in Diffuse Unilateral Subacute Neuroretinitis FREE

Ryan M. Tarantola, MD; Kori A. Elkins, MD; Christine N. Kay, MD; James C. Folk, MD
[+] Author Affiliations

Author Affiliations: Vitreoretinal Service, Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City.


Arch Ophthalmol. 2011;129(5):664-676. doi:10.1001/archophthalmol.2011.93.
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Published online

Diffuse unilateral subacute neuroretinitis is a rare condition that typically causes significant vision loss. Herein, we describe spectral-domain optical coherence tomographic (OCT) findings correlating with vision recovery following treatment of a patient with diffuse unilateral subacute neuroretinitis.

A 45-year-old man reported having progressive visual decline, floaters, and photopsias in the left eye for 2 months. One month prior, he was noted to have anterior segment inflammation. Treatment with topical and oral steroids did not halt his vision loss. He reported an unremarkable medical and ocular history. Review of systems revealed recent travel to Mexico and frequent outdoor activity in the northern United States.

Visual acuities measured 20/20 OD and 20/160 OS. A 1.2–log unit relative afferent pupillary defect was present in the left eye. Anterior segment examination findings were unremarkable. Dilated examination of the left eye demonstrated rare vitreous cells, optic nerve pallor, arteriolar attenuation, diffuse retinal pigment epithelial mottling, and a motile 1500-μm nematode in the papillomacular region (Figure 1A and B). Spectral-domain OCT demonstrated widespread outer retinal disruption, the nematode located in the inner retina, and an elevated epiretinal membrane (Figure 1C and D and Figure 2A). Photocoagulation of the worm was performed, avoiding the fovea (Figure 1E). The patient began treatment with a 30-day course of albendazole, 400 mg/d. Three days later, the worm had moved into the superior retina and was still motile. More aggressive photocoagulation was applied and the worm was successfully killed (Figure 1F).

Place holder to copy figure label and caption
Figure 1.

Fundus photographs, infrared photograph, and spectral-domain optical coherence tomographic image. A, Fundus photograph demonstrates mild optic nerve pallor, arteriolar attenuation, retinal pigment epithelial mottling, and a nematode in the papillomacular region. B, Higher-magnification fundus photograph shows the nematode. C, Infrared photograph demonstrates diffuse retinal pigment epithelial mottling in the macula and shows the nematode temporal to the fovea (arrow). D, Spectral-domain optical coherence tomographic image of a horizontal section inferior to the fovea shows widespread outer retinal disruption and a cross-section of the nematode located in the inner retina (arrow). Fundus photographs show the appearance of the nematode (arrow) following initial (E) and subsequent (F) laser photocoagulation.

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Figure 2.

Spectral-domain optical coherence tomographic images. A, A horizontal section through the fovea at the initial visit shows widespread outer retinal disruption (white arrow) and an elevated epiretinal membrane over the fovea (dark arrow). Images 1 month (B) and 3 months (C) following treatment demonstrate disruption of the photoreceptors in the papillomacular region secondary to prior photocoagulation and progressive restoration of the inner segment/outer segment junction (upper arrow) and photoreceptor architecture (lower arrow) in the fovea.

Graphic Jump Location

The patient reported significant subjective improvement, and his visual acuity measured 20/40 OS 1 month and 20/25 OS 3 months following the initial visit. Spectral-domain OCT showed disruption of the photoreceptors in the papillomacular region secondary to prior photocoagulation but progressive restoration of the normal inner segment/outer segment junction and photoreceptor architecture in the fovea (Figure 2B and C).

Diffuse unilateral subacute neuroretinitis was initially characterized by Gass et al1 and further described by Gass and Braunstein.2 Typically, patients initially have unilateral ocular inflammation, optic disc swelling, and chorioretinitis. This condition is caused by at least 2 separate nematodes of different sizes. It has been suggested that the smaller nematode, measuring approximately 500 μm in length, is Ancylostoma caninum and the larger nematode, measuring 1500 to 2000 μm in length, is Baylisascaris procyonis.24 Progression to optic atrophy, diffuse arteriolar attenuation, pigmentary degeneration, and significant vision loss occur if the nematode is not killed. The size of the nematode in this case is consistent with the larger worm.

Both antiparasitic medication and thermal laser photocoagulation can halt progression and may lead to visual improvement in some patients with diffuse unilateral subacute neuroretinitis.5,6 The treatment of choice is photocoagulation if the worm can be identified. At the initial laser treatment, the worm demonstrated rapid movement across the macula, propelling itself with a whipping movement. It was presumed to have been killed when movement ceased. However, 3 days later the worm migrated to the superior retina. At the second photocoagulation, there was minimal movement and more aggressive laser was applied. It is possible that albendazole treatment resulted in impaired motility or that the initial laser injured the nematode.

Spectral-domain OCT demonstrated the initial inner retinal location of the nematode, associated diffuse disruption of the outer retinal architecture, and an elevated epiretinal membrane. Following treatment, progressive restoration of the inner segment/outer segment junction and outer retinal architecture suggests photoreceptor recovery. Persistent optic nerve pallor and visual field loss are likely the result of permanent damage to the ganglion cells, nerve fiber layer, and retinal pigment epithelium. The foveal epiretinal membrane was not seen on subsequent spectral-domain OCT and may have represented an inflammatory change that resolved. These findings coincided with improved visual acuity and support evidence that early killing of the nematode can allow visual improvement correlating with anatomical changes seen on spectral-domain OCT.

Correspondence: Dr Tarantola, Vitreoretinal Service, Department of Ophthalmology and Visual Sciences, University of Iowa, 200 Hawkins Dr, Iowa City, IA 52242 (ryan-tarantola@uiowa.edu).

Financial Disclosure: None reported.

Funding/Support: This work was supported by Research to Prevent Blindness.

Role of the Sponsor: The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Gass  JDGilbert  WR  JrGuerry  RKScelfo  R Diffuse unilateral subacute neuroretinitis. Ophthalmology 1978;85 (5) 521- 545
PubMed Link to Article
Gass  JDBraunstein  RA Further observations concerning the diffuse unilateral subacute neuroretinitis syndrome. Arch Ophthalmol 1983;101 (11) 1689- 1697
PubMed Link to Article
Kazacos  KRVestre  WAKazacos  EARaymond  LA Diffuse unilateral subacute neuroretinitis syndrome: probable cause. Arch Ophthalmol 1984;102 (7) 967- 968
PubMed Link to Article
Goldberg  MAKazacos  KRBoyce  WMAi  EKatz  B Diffuse unilateral subacute neuroretinitis: morphometric, serologic, and epidemiologic support for Baylisascaris as a causative agent. Ophthalmology 1993;100 (11) 1695- 1701
PubMed Link to Article
Souza  ECCasella  AMNakashima  YMonteiro  ML Clinical features and outcomes of patients with diffuse unilateral subacute neuroretinitis treated with oral albendazole. Am J Ophthalmol 2005;140 (3) 437- 445
PubMed Link to Article
Garcia  CAGomes  AHGarcia Filho  CAVianna  RN Early-stage diffuse unilateral subacute neuroretinitis: improvement of vision after photocoagulation of the worm. Eye (Lond) 2004;18 (6) 624- 627
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Fundus photographs, infrared photograph, and spectral-domain optical coherence tomographic image. A, Fundus photograph demonstrates mild optic nerve pallor, arteriolar attenuation, retinal pigment epithelial mottling, and a nematode in the papillomacular region. B, Higher-magnification fundus photograph shows the nematode. C, Infrared photograph demonstrates diffuse retinal pigment epithelial mottling in the macula and shows the nematode temporal to the fovea (arrow). D, Spectral-domain optical coherence tomographic image of a horizontal section inferior to the fovea shows widespread outer retinal disruption and a cross-section of the nematode located in the inner retina (arrow). Fundus photographs show the appearance of the nematode (arrow) following initial (E) and subsequent (F) laser photocoagulation.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Spectral-domain optical coherence tomographic images. A, A horizontal section through the fovea at the initial visit shows widespread outer retinal disruption (white arrow) and an elevated epiretinal membrane over the fovea (dark arrow). Images 1 month (B) and 3 months (C) following treatment demonstrate disruption of the photoreceptors in the papillomacular region secondary to prior photocoagulation and progressive restoration of the inner segment/outer segment junction (upper arrow) and photoreceptor architecture (lower arrow) in the fovea.

Graphic Jump Location

Tables

References

Gass  JDGilbert  WR  JrGuerry  RKScelfo  R Diffuse unilateral subacute neuroretinitis. Ophthalmology 1978;85 (5) 521- 545
PubMed Link to Article
Gass  JDBraunstein  RA Further observations concerning the diffuse unilateral subacute neuroretinitis syndrome. Arch Ophthalmol 1983;101 (11) 1689- 1697
PubMed Link to Article
Kazacos  KRVestre  WAKazacos  EARaymond  LA Diffuse unilateral subacute neuroretinitis syndrome: probable cause. Arch Ophthalmol 1984;102 (7) 967- 968
PubMed Link to Article
Goldberg  MAKazacos  KRBoyce  WMAi  EKatz  B Diffuse unilateral subacute neuroretinitis: morphometric, serologic, and epidemiologic support for Baylisascaris as a causative agent. Ophthalmology 1993;100 (11) 1695- 1701
PubMed Link to Article
Souza  ECCasella  AMNakashima  YMonteiro  ML Clinical features and outcomes of patients with diffuse unilateral subacute neuroretinitis treated with oral albendazole. Am J Ophthalmol 2005;140 (3) 437- 445
PubMed Link to Article
Garcia  CAGomes  AHGarcia Filho  CAVianna  RN Early-stage diffuse unilateral subacute neuroretinitis: improvement of vision after photocoagulation of the worm. Eye (Lond) 2004;18 (6) 624- 627
PubMed Link to Article

Correspondence

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