1. Neuroretinitis Anna-Maria Gerlach, Werner Inhoffen Deshka Doycheva, Manfred Zierhut Centre of Ophthalmology University of Tuebigen Germany

2. Ocular History  35 years old female patient  dark spot in the central visual field of the OS since 1 week  in the past no ocular problems  referring ophthalmologist: „toxoplasmosis of both eyes with new activity on the OS“

3. General History  psoriasis  no other diseases known

4. August 2014 - First Presentation  Visual acuity:OD 1.0, OS 0.3  Anterior segment: OD/OS quiet  Fundus:  OD: peripapillar scaring, macula regular, disseminated, partly pigmented retinal scars in the mid to outer periphery  OS: peripapillar infiltrates, macular star, disseminated, partly pigmented retinal scars in the mid to outer periphery

5. Ocular Examination – First Presentation OD

6. Ocular Examination – First Presentation OS

7. First Presentation - OCT  Macular edema  close to the optic disc:  thickening of retina between both plexiform layers, exsudation in the fotoreceptor layer  close to the fovea:  Hard exsudates in Henle and outer plexiform layer  Neurosensory edema subfoveal with infiltration  Elevation of the pigment epithelium subfoveal

8. First Presentation - OCT OD OS

9. First Presentation - FLA OD  40 s  2 min  7 min  3 min  7 min

10. First Presentation - FLA OS  30 s  50 s  6 min  2 min  6 min

11. Diagnosis Neuroretinitis of unclear Origin

12. Etiology of Neuroretinitis  Infectious etiology  Viral infection (e.g. Coxsackie B, EBV, HSV, VZV)  Bacteria (e.g. Bartonella, M. tuberculosis, Borrelia, Leptospira)  Parasites (e.g. Toxoplasma, Toxocara)  Non-infectious etiology  e.g. inflammatory bowel disease, sarcoidosis, Polyarteriitis nodosa

13. Diagnostics Thorax X-ray: no hiliar or mediastinal lymphadenopathy or other signs of sarcoidosis or tuberculosis Thorax X-ray: no hiliar or mediastinal lymphadenopathy or other signs of sarcoidosis or tuberculosis Quantiferone test: negative Quantiferone test: negative Serologic testing for Bartonella, Lues and Borrelia: negative Serologic testing for Bartonella, Lues and Borrelia: negative

14. Working Hypothesis Neuroretinitis presumably caused by toxoplasmosis

15. Therapy  Oral Clindamycin 4x 300 mg  Oral Prednisolone  1x 60 mg initially,  slow reduction in weekly steps

16. Follow up - After 1 week  Visual acuity:OD 1.0, OS 0.4  Anterior segment: OD/OS quiet  Fundus:  OD: stable situation, no signs of activity  OS: subretinal lesion in regression, no fresh active lesions

17. Follow-up – After 1 Week OCT OS28/08/2014 OS04/09/2014 375 µm 344 µm

18. Follow up - After 1 week OCT  Beginning resolution of the hard exsudates and other observations  Hyperreflective foci in the outer segments

19. Follow up - After 3 Weeks  Visual acuity: OD 1.0, OS 0.6  Anterior segment: OD/OS quiet  Fundus:  OD: stable situation, no signs of activity  OS: further regression of subretinal lesion, no fresh active lesions

20. Follow up - After 3 Weeks OCT OS28/08/2014 OS18/09/2014 375 µm 256 µm

21. Follow up - After 3 weeks OCT  Good resolution of the macular edema  Close to the optic disc still mild exsudation  No neurosensory edema  Still incomplete resolution of the outer segment layer  Hard exsudates only in the outer plexiform layer

22. Follow up - After 3 Weeks OS

23. Perimetry  OD>OS: Enlarged blind spot

24. Follow up - After 3 Weeks OCT OS18/09/2014 OS08/10/2014 256 µm 240 µm

25. Autofluorescence first presentation after 3 weeks Autofluorescence first presentation after 3 weeks

26. Follow up - After 9 Weeks OCT OS 245 µm

27. Follow up – Last Visit after 9 Weeks Visual acuity: OD 1.2, OS 0.8 Visual acuity: OD 1.2, OS 0.8 Fundus: OS few residual hard exsudates, central lesion scarred, no fresh active lesions Fundus: OS few residual hard exsudates, central lesion scarred, no fresh active lesions OCT: further decrease of central retinal thickness and resolution of exsudates OCT: further decrease of central retinal thickness and resolution of exsudates

28. Conclusion - Neuroretinitis is characterized by optic disc edema is characterized by optic disc edema often associated with peripapillar serous retinal detachment and macular star formation often associated with peripapillar serous retinal detachment and macular star formation can be caused by a variety of infectious and non- infectious conditions or idiopathically can be caused by a variety of infectious and non- infectious conditions or idiopathically treatment depends on the presumed or confirmed cause treatment depends on the presumed or confirmed cause In most cases a spontaneous regression with recovery of the visual acuity occurs. In most cases a spontaneous regression with recovery of the visual acuity occurs.