1. Acute choroidal ischemia and Toxoplasmic Retinochoroiditis Acute choroidal ischemia and Toxoplasmic Retinochoroiditis Sonia Attia, MD Imen Ksiaa, MD Moncef Khairallah, MD Department of ophthalmology Fattouma Bourguiba University Hospital Faculty of Medicine, University of Monastir Monastir, Tunisia

2. Ocular History A 35-year-old woman A 35-year-old woman January 2004: Blurred vision OD of 7-day duration January 2004: Blurred vision OD of 7-day duration 2000: same problem in OD 2000: same problem in OD

3. January 2004: First Presentation Visual acuity OD 20/200, OS 20/20 Visual acuity OD 20/200, OS 20/20 Mild anterior chamber inflammatory reaction OD Mild anterior chamber inflammatory reaction OD 3+ vitritis OD 3+ vitritis OD No cells in anterior chamber or vitreous OS No cells in anterior chamber or vitreous OS Fundus OD: Presumed recurrent toxoplasmic retinochoroiditis Fundus OD: Presumed recurrent toxoplasmic retinochoroiditis Serology for toxoplasmosis: positive Serology for toxoplasmosis: positive

4. The large white retinal lesion was considered to be an active toxoplasmic focus Arrows delineate a geographic white retinal lesion 2.5 DD in size, adjacent to an old pigmented scar located along the superior vascular arcade. This large white retinal lesion was centered with a a very small retinal « infiltrate » ( arrowhead)

5. Fluorescein angiography Early-phase FA shows a well demarcated area of choroidal hypofluorescence Late-phase FA angiogram shows peripheral hyperfluorescence and persistent central hypofluorescence of the area. Note the accumulation of dye in subretinal space (arrows)

6. ICG angiography Early ICG angiogram demonstrates a well delineated area of choroidal hypofluorescence larger than that shown by FA

7. Treatment The patient was treated with a combination of pyrimethamine, azithromycin, folinic acid, and prednisone. The patient was treated with a combination of pyrimethamine, azithromycin, folinic acid, and prednisone.

8. One month after One month after Visual acuity: 20/20 Visual acuity: 20/20 There was a small atrophic retinochoroidal scar surrounded with mild retinal pigment epithelium changes Follow-up

9. Final diagnosis : Acute choroidal ischemia associated with toxoplasmic retinochoroiditis : The large geograhic white retinal lesion seen at presentation was ischemic rather than inflammatory in nature and was centered with a small white retinal lesion (arrow), which was the actual focus of RC

10. Final diagnosis Acute choroidal ischemia associated with toxoplasmic retinochoroiditis Angiographic features and evolution were consistent with choroidal hypoperfusion Angiographic features and evolution were consistent with choroidal hypoperfusion

11. Conclusion Clinicians should be aware of the association of toxoplasmic RC and acute choroidal ischemia that may explain a transient or permanent decrease in vision in patients with RC sparing the fovea Clinicians should be aware of the association of toxoplasmic RC and acute choroidal ischemia that may explain a transient or permanent decrease in vision in patients with RC sparing the fovea Choroidal ischemia can only be suspected clinically Choroidal ischemia can only be suspected clinically FA and ICGA are necessary to establish a definitive diagnosis of choroidal ischemia FA and ICGA are necessary to establish a definitive diagnosis of choroidal ischemia