I am 42 years, male. Before 10 months, I was diagnosed with acute posterior uveitis- Chorioretinitis with macular edema in my right eye. I received an intraocular injection with a corticosteroid and was treated with Clindamycin for two weeks, without having any evidence of actual cause. Took long list of blood tests and nothing suspicious. I got a resolution of the macular edema after about three mouths and was having inflammation only around the nerve till a week ago when my uveitis started to worsening rapidly three weeks after periocular injection with Triamcinolone (my first periocular injection) and I am almost 100 % sure that the injection caused the acute re-inflammation.
I have read that for ocular toxoplasmosis is extremely risky a preciocular injection with Triamcinolone to be applied, but post-factum. My vision is currently very poor, not able to read with the right eye and before two days, I was able to. I am scared and not sure what to do. I know that in acute situations intraocular injections of corticosteroid is applied, but not sure how my eye will react to it this time. Is there a way to lower the effect or duration of the applied Triamcinolone? Is its duration of activity 3 to 4 weeks or three months?
Welcome to icliniq.com.
Sorry to hear about your condition and wish you quick recovery. Triamcinolone periocular injections are used in extreme situations and should be under the coverage of antibiotics, which usually are at least two groups, at the time of the injection and should be done under extreme caution. However, you mentioned that all the laboratory results came in negative and macular edema is rarely a finding in chorioretinitis. In order to better evaluate your condition and advise you properly please upload all the OCT scans that were done, the lab test results, ophthalmologist examination before and after the procedure.
Thank you for your reply.
What other antibiotic groups is good to be included with the periocular Triamconolone? I am currently taking Clindamycin 300 mg four times a day and Sulfamethoxazole Trimethoprim 800 160 mg twice a day due to presumed ocular toxoplasmosis (as all my blood tests are negative). I will attach an OCT before the Triamcinolone application and will send you the latest OCT sometime next week As I scheduled an appointment for another OCT after my condition dramatically worsened. I will also attach few of my blood tests.
I will be very, very thankful also if you can tell me about how my initial intraviteral injection with Dexamethasone was remarkably helpful on my uveitis (initial macular edma cleared and great improvement in general) and the recent periocular injection with Triamcinolone worsened the things so much (again macula edema)? Are those two corticosteroid injections acting differently? Do you think I might risk and apply another intraviteral injection with Dexamethasone as in the very beginning?
Welcome back to icliniq.com.
You did not mention that you were taking Sulfamethoxazole Trimethoprim in the first query and I thought you were on one drug only. The prescribed regimen is adequtate for the treatment of toxoplasmosis, which nonetheless has not been confirmed in any of the lab tests that I went through. The alternative treatments for toxoplasmosis would be Pyrimethamine 200 mg orally on day 1 followed by 50 mg daily for 4 weeks with Sulfadiazine 2 g orally as a loading dose followed by 1 g orally 4 times daily for 4 weeks (along with Folinic acid 15 mg orally twice a week and increased water intake with Bicarbonate sodium). Azythromycin 500 mg once daily for 4 weeks instead of Clindamycin along with the same Trimethoprim Sulfamethoxazole 160/800 twice daily for four weeks.
Considering that you have vision threatning lesions in the form of macular edema I would have went with intravitreal injection of Ranibizumab (anti vegf) or even Dexamethasone once I had you taking the antibiotics or start you on Prednisone 1.5 mg/kg/day orally and then taper it within four weeks or as your doctor preferred a periocular injection of 40 mg Triamcinolone is also indicated.
When it came to detection of viruses, toxoplasmosis was negative but infectious mononucleosis IgG was positive on 25.04.2019. Herpes Zoster IgG was high in 2 or more lab tests along with adenovirus IgG . All of this would not signify anything if in the past you have been vaccinated for these viruses and this is why the IgG is elevated so I would also like to know your history of vaccinations.
When it comes to infectious mononucleosis however, please include in the next update whether you have or are experiencing the following: episodes of fever, lymphadenopathy (swelling of the lymph nodes), pharingitis? Or currently experiencing malaise and fatigue, myalgia, headaches? Have you developed any rash after taking the antibiotics? I would like you to submit a lab test for epstein barr and liver function and undergo abdomen ultrasound with concentration on spleen and an orbit ultrasound to exclude a periorbital edema because ophthalmic complications might include conjunctivitis, episcleritis, and uveitis.
Clinically, the most commonly used intravitreal steroid is Triamcinolone Acetonide because of its durability and clinical efficacy associated with the stability of its depot formulation. However, Triamcinolone acetonide has been reported to have direct cytotoxicity on retinal cells in culture, might lead to an increase in intraoular pressure and therefore is injected in the periocular area to decrease that cytotoxic effect, whereas recent clinical researches show that the injection of 0.1 ml of Dexamethasone into the eye gives way better results because it is less toxic and provides the primary effect to the retina without causing systemic side effects and it delivers a supreme concentration of the drug and its efficacy for inflammation than when taking it orally.
As I mentioned earlier, it is very uncommon to use Dexamethasone intravitreally, although I support it more than having the patient take it orally, because there are injectable eye implants that slowly and safely release the steroid inside the eye. Triamcinolone however has been commonly used for macular edemas and to reduce ongoing inflammations inside the eye but also has its side effects. The purpose of injecting a steroid into the eye is reduce the inflammation and reduce the macular edema but for that purpose we have a way safer drug which is Ranibizumab (Lucentis) or Bevacizumab (Avastin) which acts quickly and has many additional benefits to the retina. I would advise your doctor to proceed with this injection if the macular edema has reocurred.
Thank you doctor,
My local doctor also adviced me to have intravitreal injection anti vegf. Do you think that anti vegf intravitreal injection will be effective as an intravitreal dexamethasone of 4 mg? I am now taking Clindamycin 300 mg four times a day and Sulfamethoxazole Trimethoprim 800 160 mg twice a day, also my doctor put me yesterday on oral Prednisolone 60 mg per day (I am about 80 kg so 0.75 mg per kg). Do you think that I might include Acyclovir for the herpetic suspects?
About the vaccinations for the herpetic diseases- I do not have such vaccinations, so I must have been going through all of them at some time in life - VZV, HSV 1, EBV and CMV. Yet no active IgM found. Toxoplasmosis blood tests are negative. As the doctors did not prove yet what is the actual cause of my uveitis, I am thinking they are just trying to presume one based on how my lesion(s) looks like and where are they located. So and they are presuming toxoplasmosis, but they are not sure, neither I. I was also thinking that EBV might be a potential candidate too, or HSV 1. I missed to mention that I also did a scan of my eye orbits along with the brain scan and nothing found- just my uveities which is also visible with the OCT scans. Back to my recent periocular injection with Triamcinolone- I have read that its extremely risky to apply long acting corticosteroids for toxoplasmosis (not sure about herpeses) as they may lead to uncontrolled acute inflamation. And my vision of the right eye started to worsen after the third week of the injection application and on the fourth week my central vision is now also very poor. How long do you think a periocular injection with Triamcinolone might take to stop acting? It did enough damage already, just hoping that whole mistaken process is stopping. My doctor is saying that it might be just the course of the diseases, but I doubt. My uveitis flared up a week after our summer vacation. I felt a short episode of fever right after doing a bath and I thought that is really strange to be feeling cold shakes as it was extreemly hot. Another wierd thing was that during one of our lunches I felt strong and aproximatly short pain in my upper and lower jaw from the right. Right after already having the uveities flare a day or two after that I was having а fever with a small increase of my body temperature (37.7 to 38 Celsius) for about a week or two. No swelling of the lymph nodes. No rashes after taking the antibiotics.
About myalgia - a week before our summer vacation I was having extreem back pain (at right again). So a local doctor shot me two injections of corticosteroids and few with Milgama (Vitamin B) around where my aches were. Now, I wonder if the corticosteroid injections could be what triggered after two weeks my uveitis. They were applied low right in my back. I did later a scan of my back and a discopathy was discovered at my lower right of spine. No rheumatological were found (I was hospitalized for detailed examination including spine scan and blood tests) as I was not sure if my back pain my be related with the uveitis onset. I do not have other diseases that I know about.
Welcome back to icliniq.com.
Now that I have seen the OCT I understand why your doctor initiated treatment without confirming the pathogen. I did not find the optic nerve OCT report though which is very important considering the significant changes are in the peripapillar area (next to the optic nerve). I would also advise to conduct a fluorescein angiography to detect the source of the leakage and localize the main lesion. Make sure the doctor provides you with a trend analysis of the optic nerve and macula if it is available on the device. That helps in evaluating the improvement or worsening of the condition. Anti vegf has more benefits than Dexamethasone when it comes to macular edema and should provide you with vision enhancements on the next day so if you are able to receive an injection earlier then better.
Antiviral drugs such as Acyclovir are quite toxic and are usually effective only in the beginning of the disease and not when it has already flared up. I would advise some immunostimulation instead. The presence of IgG of so many viruses at once and without any prior history of vacciniations still poses a question so I would advise you visit an infectionist or immunologist, maybe he will be able to shed some light. There you can get screened for epstein barr also. All the symptoms that happened during your vacation and after might play a key role in detecting the culprit. Although mononucleosis in adolescents usually cause pharyngitis and lymphadenopathy along with some other symptoms, there are some reports of choroioretinitis that primarily affects the retina in the same form it has affected yours, excluding it is important.
Triamcinolone usually takes 30 to 40 days for its effect to subside so you will have to be patient. I have to agree with your doctor nonetheless that it might be the course of the disease that is causng this because we still do not know the agent causing it. Please include along with the OCT reports the following data: uncorrected visual acuity, best corrected visual acuity, refraction, eye pressure (very important) before the inflamation and current one.
Thank you for your reply.
How long should the therapy against ocular toxoplasmosis be applied for a patience with macular edema like me? My current treatment includes: Clindamycin 300 mg four times a day and Sulfamethoxazole Trimethoprim 800 160 mg twice a day and oral Prednisolone 60 mg per day (0.75 mg per kg). I am at the end of the second week taking the antibiotics and first week on oral Prednisolone. I am feeling some improvements after the oral Prednisolone was included. The objects are less distorted when looking with the affected eye, but still reading a small text with it is extremely hard. Is it safe to continue for at least four weeks like that (by tapering slowly the oral Prednisolone) or I should also reduce the Clindamycin before that? Or it is better to proceed with my current treatment for more than four weeks?
Welcome back to icliniq.com.
The standard duration of treatment is four weeks on the same regimen for antibiotics and tapering of the prednisolone during those four weeks. However, and as I mentioned previously Pyrimethamine causes bone marrow suppression, so baseline and weekly cell counts should be checked. Also, Folinic acid should be administered with Pyrimethamine to minimize this side effect. I also mentioned that you should increase liquid intake along with bicarbonate. I would also add Essentiale Forte capsules to protect your liver.
Unfortunately, medications treat the diseases but might have drastic effects on the body also so please try and fulfill these recommendations and do not taper the medications by yourself. If you have not worn spectacles previously in your life then after the age of 40 you will require assistance in the form of reading spectacles and that is very normal. Once the macular edema has diminished fully you might want to get a prescription for reading glasses. In the meantime you could start using artificial tears four times a day to maintain a certain clarity. Do not use the eye drops before going to sleep.
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