Spontaneous separation of inflammatory epiretinal membrane in a patient with toxoplasmic retinochoroiditis.

Although spontaneous resolution of inflammatory epiretinal membrane (ERM) has been reported in young,[1] there is no such report for ERM associated with ocular toxoplasmosis. We report a rare case of spontaneous resolution of an ERM associated with toxoplasmic retinochoroiditis in a young patient with good visual improvement.

Case Report

A 24-year-old female presented with diminution of vision in left eye since 3 days. On examination, best-corrected visual acuity (BCVA) was 6/6 in right eye and 6/12 in left eye. Right eye examination was normal. Left eye examination revealed mild anterior chamber reaction, 2+ vitritis, optic disc edema, and juxtapapillary patches of retinochoroiditis [Figure 1]. On blood investigations, serum toxoplasma IgG titer came positive and IgM was negative. A diagnosis of toxoplasma retinochoroiditis was made and the patient was started on Tab clindamycin 300 mg four times a day and Tab azithromycin 250 mg two times a day. Tab prednisolone 1 mg/kg body weight was started (in tapering doses) on the third day of therapy after obtaining physician's clearance. After 3 weeks, examination revealed quiet anterior chamber, decreased vitritis, and resolving lesions of retinochoroiditis with development of thick ERM [Figure 2]. Because the resultant traction was causing distortion of foveal contour with decreased vision, the patient was explained about possible need of vitrectomy and ERM peeling surgery in future. On 3 weekly follow-up visits, retinochoroiditis lesions were seen to be resolving with spontaneous contraction of posterior vitreous face and lifting of ERM [Figure 3]. As the lesions healed, the ERM was noted to resolve completely [Figure 4]. Figure 5a depicts the optical coherence tomography (OCT) scan at presentation showing incomplete posterior vitreous detachment (PVD), attached to the thick ERM. Figure 5b depicts OCT scan after healing of lesions, showing presence of complete PVD, separation of ERM, and restoration of normal foveal contour. Left eye BCVA improved to 6/6. The oral treatment was stopped and the patient was advised to remain under regular follow-ups.

Figure 1

Red-free fundus photograph of left eye showing retinochoroiditis lesions superior to optic disc and vitreous haze temporal to disc without any epiretinalmembrane

Figure 2

Red-free fundus photograph showing development of thick epiretinal membrane over the posterior pole extending inferiorly and temporally

Figure 3

Red-free fundus photograph showing spontaneous contraction of posterior vitreous face and lifting of epiretinal membrane with healing of retinochoroiditis lesions

Figure 4

Red-free fundus photograph showing near-complete healing of retinochoroiditis lesions and total regression of epiretinal membrane

Figure 5

OCT scans of left eye showing (a) incomplete posterior vitreous detachmentwith thick epiretinal membrane and associated retinal thickening anddistortion and (b) absence of epiretinal membrane with residual wrinklingofinternal limiting membrane and significant resolution of retinal thickening

Discussion

The spontaneous resolution of ERM has been reported earlier, in presence[1] and absence of preexisting PVD.[23] Although spontaneous separation is more commonly described for idiopathic ERM,[23] Schadlu and associates reported the same for inflammatory ERM associated with intermediate uveitis.[1] Inflammatory ERM secondary to toxoplasmic retinochoroiditis, although uncommon, often does not resolve and needs surgical removal.[45] Adan and associates reported visual improvement after vitrectomy and membrane peeling in two patients with ERM associated with ocular toxoplasmosis.[4] When we noted the thick ERM developing in our patient, we also explained the option of future surgery to her. However, on regular follow-up visits, as the retinochoroiditis lesions showed regression, ERM gradually contracted and separated spontaneously along with PVD.

Desatnik and associates proposed that the more immature and dynamic cellular composition of ERM in young patients may be responsible for the higher rate of spontaneous membrane detachment than is seen in elderly.[3] They advocated conservative approach for patients with idiopathic ERM and only mild visual disturbances.[3] It may also be advisable to wait for spontaneous resolution of an inflammatory ERM before planning any surgical intervention, especially till complete healing of all inflammatory lesions is over.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.