Choroiditis - Types

Multifocal choroiditis and panuveitis

The symptoms of multifocal choroiditis and panuveitis are similar to the above-described manifestations of ocular histoplasmosis syndrome. It also includes chorioretinal foci of atrophy, peripapillary scars, choroidal neovascularization, and linear bands on the periphery. However, the main difference is that multifocal choroiditis and panuveitis are characterized by recurring signs of the inflammatory process and the emergence of new foci of chorioretinal atrophy, more numerous and smaller in size, as well as the appearance of foci of inflammation in the anterior and posterior parts of the vitreous body, inflammatory changes in the anterior chamber. The optic disc is edematous. In the acute phase of the disease, local exudative retinal detachment may occur. In patients with a long-term disease, inflammatory foci at various stages of development may be detected in the fundus.

Visual acuity is reduced. Perimetry reveals an expansion of the blind spot, and individual scotomas in the visual field. Improvement of the visual fields is possible during treatment.

The etiology has not been established, although the infectious and autoimmune nature of the disease cannot be ruled out.

In the acute phase and with the development of complications of the disease, treatment with corticosteroids is possible. There have been cases of self-healing even in the presence of choroidal neovascularization.

Tuberculous choroiditis

Tuberculous choroiditis develops at a young age against the background of primary tuberculosis. The cause of the disease is mycobacteria, which infect many organs.

In tuberculous lesions of the choroid, miliary and multifocal choroiditis are most often observed. Choroidal tubercles are yellowish or grayish-white. After treatment, one or more chorioretinal scars with clear edges remain, hyperfluorescent in FAG. Tuberculous-metastatic granulomatous chorioretinitis is characterized by a severe course with hemorrhages in the retina and infiltration of the vitreous body. Tuberculous-allergic chorioretinitis in the absence of Mycobacterium tuberculosis in the eye occurs as non-granulomatous inflammation. They have no clinical features, often developing in children and adolescents during the period of tuberculin test conversion.

Differential diagnostics are performed with other granulomatous infections: sarcoidosis, brucellosis, leprosy, toxoplasmosis, syphilis, fungal infection. In tuberculous choroiditis, the nature of histological changes depends on the stage of the tuberculous process. In primary tuberculosis, inflammation in the choroid occurs with diffuse lymphoid infiltration, the presence of epithelioid and giant cells. In secondary tuberculosis, the productive type of inflammation predominates, characterized by the formation of typical tuberculous granulomas with caseous necrosis.

Diagnosis is based on the detection of extraocular foci of tuberculosis, positive results of tuberculin tests and focal reactions of the eyes to the introduction of tuberculin.

Specific systemic treatment includes standard anti-tuberculosis therapy and antimycobacterial drugs (isoniazid, rifampicin, pyrazinamide, ethambutol, etc.). Corticosteroids may be used depending on the patient's immunological status and the course of the process. In tuberculous-allergic chorioretinitis, local and general non-specific anti-inflammatory and desensitizing therapy is performed.

Toxocariasis choroiditis

Toxocariasis choroiditis is caused by the larval form of Toxocara canis, a helminth from the ascaris group.

Ophthalmotoxocariasis can be a manifestation of a general disease with massive invasion of the body by larvae or the only clinical manifestation of helminthiasis.

A granulomatous inflammation focus forms around the larva at the site of its penetration into the eye. When the larva enters the eye through the vessels of the optic nerve, it usually settles in the paramacular zone. After the inflammation is eliminated, a granuloma forms in the area of the posterior pole of the eye. In early childhood, the process is more acute with a massive inflammatory reaction of the vitreous body, resembling retinoblastoma or endophthalmitis in clinical manifestations. In older children, adolescents and adults, the process is more benign with the formation of a dense protruding focus in the parapapillary region. When the larva enters the eye through the anterior ciliary artery system, a peripheral granuloma is formed. In this case, the process can be virtually asymptomatic.

In the acute phase of toxocariasis uveitis, the lesion appears as a cloudy, whitish, strongly protruding focus with perifocal inflammation and exudate in the vitreous body. Subsequently, the lesion becomes denser, its borders become clear, the surface is shiny. Sometimes a dark center is determined in it as evidence of the presence of larval remains. The lesion is often connected with the optic nerve head by a fibrous cord.

Diagnosis is based on typical ophthalmoscopic findings and detection of toxocariasis infection using enzyme immunoassay.

Treatment is often symptomatic, since antiparasitic drugs have little effect on the larval forms of helminths. In addition, the inflammation process often begins after the death and decomposition of the larvae due to their toxic effect on the surrounding tissues. Additional treatments include delimiting laser coagulation and surgical removal of the granuloma along with the adjacent scar tissue.

Candidal choroiditis

Candidal choroiditis is caused by the fungus Candida albicans. In recent years, the incidence of the disease has increased due to the widespread use of antibiotics and immunosuppressive drugs.

Patients complain of decreased vision and floating opacities before the eye. Ophthalmoscopically, the process resembles toxoplasmosis. On the fundus, protruding yellow-white foci with unclear boundaries of different sizes are detected - from small, like cotton wool balls, to foci several diameters of the optic nerve disk. The retina is primarily affected, and as the process progresses, it spreads to the vitreous body and choroid.

Diagnosis is based on a characteristic anamnesis (long-term use of high doses of antibiotics or steroid drugs) and the results of blood tests during the period of candilemia.

Treatment - local and systemic use of antifungal drugs (amphotericin B, orungal, rifamine, etc.), which are injected into the vitreous body. In severe cases, vitrectomy is performed - removal of the vitreous body.

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Syphilitic chorioretinitis

Syphilitic chorioretinitis can develop with both congenital and acquired syphilis.

Congenital retinal changes - multiple small pigmented and non-pigmented foci that give the fundus a salt-and-pepper appearance, or multiple larger atrophic foci in the choroid, more often on the periphery of the fundus. Less common are peripapillary atrophic changes in the retina and choroid in combination with its peripheral dystrophic changes.

In acquired syphilis, diseases of the retina and choroid develop in the second and third periods of the disease and occur as focal or diffuse chorioretinitis. Clinically, syphilitic chorioretinitis is difficult to distinguish from processes of other etiologies. For diagnosis, it is necessary to use serological reactions and take into account characteristic changes in other organs.

Differential diagnostics for congenital syphilis should be carried out with secondary dystrophies of other origin (for example, rubella retinopathy), as well as hereditary retinal dystrophies. In differential diagnostics with hereditary retinal dystrophies, family history and ERG examination are important: in pigment retinitis, it is not registered, in chorioretinitis it is normal or subnormal.

Diagnosis is based on the results of serological testing, which is carried out to identify specific infection.

Treatment of syphilitic eye lesions is carried out in conjunction with a venereologist.

Chorioretinitis in HIV infection

Chorioretinitis in HIV infection occurs as a superinfection against the background of severe immune disorders. Most often, the direct cause of eye damage is cytomegalovirus. Characteristic signs of chorioretinitis in HIV infection are significant prevalence of damage, necrotic nature of inflammation, hemorrhagic syndrome.

Diagnosis is based on characteristic clinical signs and detection of HIV. The prognosis for vision is unfavorable. Antiviral and immunotropic drugs are used in treatment.

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