活动性眼弓形虫病临床特征及预后分析

Clinical features and prognostic analysis of active ocular toxoplasmosis

摘要

目的 回顾性分析活动性眼弓形虫病的临床特征及其治疗预后。方法 收集经眼内液及血清学检测被确诊为眼弓形虫病的患者的临床资料进行回顾性分析。结果 12例(13眼)中男2例(3眼)、女10例(10眼)，首诊年龄17~73(37.4±16.7)岁。随访6~32个月，中位数8个月。首诊时伴眼前节炎症12眼(92.3%)，其中3眼(23.1%)伴虹膜后粘连；4眼(30.8%)继发高眼压；所有患者的玻璃体均有不同程度炎性混浊，其中3眼(23.1%)玻璃体重度混浊，导致眼底几乎完全窥不见。眼底表现具有多样性，10眼(76.9%)可见脉络膜视网膜坏死性病灶，其中3眼(23.1%)坏死病灶累及黄斑区，病灶位于黄斑外伴发黄斑水肿2眼；5眼(38.5%)视盘水肿，其中2眼视盘旁黄白色病灶约1/2 PD；活动性病灶旁有色素性视网膜脉络膜瘢痕者6眼(46.2%)。8眼(61.5%)首次就诊后进行眼内液寄生虫检测确诊；其余4例(5眼，38.5%)首诊漏诊，其中2例(2眼)为视神经水肿显著伴视盘旁局部病灶者，1例(1眼)坏死病灶范围较大，几乎累及整个鼻上象限，1例(2眼)玻璃体重度浑浊无法窥及眼底，这4例患者自初诊至采集眼内液检测确诊间隔时间分别为0.87、7.77、0.45及1个月。确诊后的患者均接受了全身及局部抗生素和糖皮质激素的综合治疗，其中3例患者接受了玻璃体切除手术。随访期间，1例患者病情持续恶化，另1例在治疗后稳定2年病情复发并加重。其余11眼经治疗后病情好转并保持稳定，末次就诊时logMAR BCVA较初诊时有所改善。其中继发黄斑前膜2眼、继发玻璃体黄斑牵拉1眼。结论 弓形虫眼病临床表现及病变类型复杂多样，视网膜脉络膜坏死性炎症病灶位置及范围差异较大，其中视盘旁小病灶因视盘高度水肿容易被临床忽视，坏死病灶范围广泛者也具有迷惑性；此外，炎症易累及玻璃体、视神经及黄斑。患者预后与病灶严重程度密切相关。临床需结合患者病史、症状、影像学、实验室检查，对于可疑患者应及时进行眼内液及血清弓形虫抗体或DNA检测，以期及时确诊及治疗，改善预后。

Abstract

Objective To retrospectively analyze the clinical characteristics and treatment outcomes of active ocular toxoplasmosis. Methods Clinical data were retrospectively analyzed from patients diagnosed with ocular toxoplasmosis. The diagnosis was confirmed through intraocular fluid and serological testing. Results The study included 12 cases (13 eyes), comprising 2 males (3 eyes) and 10 females (10 eyes). The age at initial diagnosis ranged from 17 to 73, with a mean of 37.4±16.7 years. The follow-up period ranged from 6 to 32 months, with a median duration of 8 months. At the initial visit, 12 eyes (92.3%) showed anterior segment inflammation, including 3 eyes (23.1%) with posterior synechiae. 4 eyes (30.8%) developed secondary ocular hypertension. All patients exhibited varying degrees of vitreous inflammatory haze, with 3 eyes (23.1%) showing severe vitreous opacity that nearly completely obscured the fundus view. Fundus manifestations were diverse. 10 eyes (76.9%) displayed necrotizing chorioretinal lesions, including 3 eyes (23.1%) with macular involvement. 2 eyes exhibited macular edema alongside extramacular lesions. 5 eyes (38.5%) had optic disc edema, among which 2 eyes showed yellowish-white peripapillary lesions approximately half a disc diameter in size. 6 eyes (46.2%) presented with pigmented chorioretinal scars adjacent to active lesions. Diagnosis was confirmed by intraocular fluid testing in 8 eyes (61.5%) during their first visit. However, 4 cases (5 eyes, 38.5%) were initially missed. Among them, 2 cases (2 eyes) showed significant optic nerve edema with peripapillary lesions; 1 case (1 eye) had a large necrotizing lesion involving nearly the entire superonasal quadrant; and 1 case (2 eyes) had severe vitreous opacity that prevented fundus examination. The intervals from initial visit to confirmatory intraocular fluid testing for these 4 cases were 0.87, 7.77, 0.45, and 1.0 months, respectively. All diagnosed patients received systemic and topical antibiotic, as well as corticosteroid therapy, with 3 cases undergoing vitrectomy. During follow-up, 1 patient experienced continuous deterioration, and another had recurrence with worsening after 2 years of stability. The remaining 11 eyes showed improvement and remained stable, with better logMAR BCVA at the last visit compared to initial presentation. Two eyes developed epiretinal membranes, and 1 eye developed vitreomacular traction. Conclusion Ocular toxoplasmosis presents complex and varied clinical manifestations. Necrotizing chorioretinal inflammatory lesions differ greatly in location and size. Specifically, small peripapillary lesions may be overlooked because of severe optic disc edema, while extensive necrotic lesions might cause diagnostic confusion. Moreover, inflammation frequently affects the vitreous, optic nerve, and macula. Patient prognosis largely depends on lesion severity. Clinical diagnosis should comprehensively consider patient history, symptoms, imaging, and laboratory tests. In suspected cases, timely testing of intraocular fluid and serum for Toxoplasma antibodies or DNA is essential. This approach facilitates early diagnosis and treatment, thereby improving patient outcomes.

关键词

眼弓形虫病 / 临床体征 / 葡萄膜炎 / 眼内液检测 / 预后

Key words

Ocular toxoplasmosis / Clinical signs / Uveitis / Intraocular fluid testing / Prognosis

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基金资助

陕西省重点研发计划项目(2021SF-162)

西安市人民医院 ( 西安市第四医院 ) 科研孵化基金项目(LH-18)

国际糖尿病交流与实践专项基金(Z-2017-26-2302)

陕西省科技厅一般项目(2022SF-409)