Neuroretinitis

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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Nov 9, 2016 | Posted by in OPHTHALMOLOGY | Comments Off on Neuroretinitis
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