BASICS

DESCRIPTION

• Neuroretinitis is a condition characterized by optic disk swelling and hard exudates distributed in a star pattern centered around the fovea:

– Bartonella henselae, a gram negative bacillus associated with cat-scratch disease, is the most common infectious etiology of neuroretinitis.

EPIDEMIOLOGY

• All ages can be affected

• Most common in third or fourth decade

• No gender predilection

RISK FACTORS

History of contact with cat or kitten

ETIOLOGY

• Infectious causes: Bartonella henselae, syphilis, viral, toxoplasmosis, toxocariasis, histoplasmosis, Lyme disease

• Systemic inflammatory conditions such as sarcoidosis

COMMONLY ASSOCIATED CONDITIONS

• Cat-scratch disease

• Syphilis

• Sarcoidosis

DIAGNOSIS

HISTORY

• Eye complaints: Eye ache, worse with eye movement, blurry vision

• Systemic complaints: Symptoms of cat-scratch disease may include malaise, fever, muscle aches, headache

• Travel history

• Animal contacts

• Sexual history

• Note any ingestion of uncooked food

PHYSICAL EXAM

• Visual acuity varies from normal to light perception

• Abnormal color vision

• Afferent papillary defect

• Optic nerve edema

• Macular hard exudates in star configuration

• Splinter hemorrhages, retinal vessel occlusion may be seen

• Discrete, small yellow-white retinal or choroidal infiltrates

• Vitreous cells/posterior inflammation

• Patients with cat-scratch disease may exhibit lymphadenopathy, arthritis, meningitis, encephalitis, or may be asymptomatic

DIAGNOSTIC TESTS & INTERPRETATION

Lab

• Serologic testing for Bartonella henselae and other infectious etiologies

• ELISA for Bartonella henselae is available

Imaging

Fluorescein angiogram: Disk swelling/leakage, peripapillary vessel staining may be seen

Diagnostic Procedures/Other

Visual field test – cecocentral scotoma most common defect

DIFFERENTIAL DIAGNOSIS

• Optic neuritis

• Optic neuropathy

TREATMENT

MEDICATION

First Line

• For cat-scratch disease:

• Ciprofloxacin 750 mg PO b.i.d. for 3 weeks

• Consider erythromycin, azithromycin, doxycycline, rifampin

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

• Primary care doctor or infectious disease specialist

• Ophthalmologist

PROGNOSIS

• Usually a self-limited course with good visual prognosis.

• Optic nerve swelling usually improves over 6–8 weeks. Residual disk pallor may remain.

• Macular exudates resolve over 6–12 months.

• Symptoms of metamorphopsia or blurred vision may persist.

• Most patients do not experience recurrence in the same or fellow eye.

COMPLICATIONS

• Visual loss

• Systemic sequelae of a causative infectious or inflammatory agent

ADDITIONAL READING

• Reed JB, Scales DK, Wong MT, et al. Bartonella henselae neuroretinitis in cat scratch disease. Diagnosis, management, and sequelae. Ophthalmology 1998;105(3):459–466.

• Ormerod LD, Skolnick KA, Menosky MM, et al. Retinal and choroidal manifestations of cat-scratch disease. Ophthalmology 1998;105(6):1024–1031.

• Solley WA, Martin DF, Newman NJ, et al. Cat scratch disease: Posterior segment manifestations. Ophthalmology 1999;106(8):1546–1553.

• Ray S, Gragoudas E. Neuroretinitis. Int Ophthalmol Clin 2001;41(1):83–102.

CODES

ICD9

363.05 Focal retinitis and retinochoroiditis, juxtapapillary

CLINICAL PEARLS

• Neuroretinitis is characterized by optic nerve swelling and exudative macular star.

• Bartonella henselae is the most common infectious cause of neuroretinitis.

• Visual prognosis is often good and disease is self-limited.

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