Treatment Strategies for Neuroretinitis: Current Options and Emerging Therapies
Purpose of review
To explore and critically appraise the published data on the current and emerging treatment modalities for neuroretinitis.
The optimum treatment strategy for neuroretinitis due to Bartonella henselae in immunocompetent individuals is not clear and a matter of debate. The role of systemic corticosteroids in infectious neuroretinitis and the optimum immunosuppressive regimen for use in recurrent idiopathic neuroretinitis also remains ill defined.
There is no class 1 evidence to support a specific treatment strategy for neuroretinitis. For uncomplicated B. henselae–associated neuroretinitis in immunocompetent patients, initiation of antibiotic and corticosteroid therapy remains controversial. In patients with severe vision loss and/or moderate to severe systemic symptoms, a 4- to 6-week regimen of doxycycline or azithromycin with rifampin may provide some benefit. The routine use of systemic corticosteroids in infectious neuroretinitis is not recommended. Targeted antimicrobial agents should be instituted in cases of neuroretinitis due to specific infectious etiologies (e.g., syphilis, Lyme disease, tuberculosis). Azathioprine may be beneficial in cases of recurrent idiopathic neuroretinitis. There is a need for collaborative, multicenter prospective studies to provide definitive guidelines regarding the use of antibiotics and corticosteroids and to evaluate future therapies in infectious and recurrent idiopathic neuroretinitis.
KeywordsNeuroretinitis Bartonella Disc edema Macular star Cat scratch optic neuropathy
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
Dr. Bhatti participated in the following two studies that involved human subjects: Schmalfuss IM, Dean CW, Sistrom C, Bhatti MT. Optic neuropathy secondary to cat scratch disease: distinguishing MR imaging features from other types of optic neuropathies. AJNR Am J Neuroradiol. 2005;26 (6):1310–6; Chi SL, Stinnett S, Eggenberger E, Foroozan R, Golnik K, Lee MS, et al. Clinical characteristics in 53 patients with cat scratch optic neuropathy. Ophthalmology. 2012;119 (1):183–7.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.•• Abdelhakim A, Rasool N. Neuroretinitis: a review. Curr Opin Ophthalmol. 2018;29(6):514–9. The most up-to-date review on all aspects of neuroretinitis including the different etiologies as well as treatment options. The authors discuss the pros and cons of antibiotics vs no antibiotics for the management of cat scratch neuroretinitis.PubMedGoogle Scholar
- 4.Kitamei H, Suzuki Y, Takahashi M, Katsuta S, Kato H, Yokoi M, et al. Retinal angiography and optical coherence tomography disclose focal optic disc vascular leakage and lipid-rich fluid accumulation within the retina in a patient with leber idiopathic stellate neuroretinitis. J Neuroophthalmol. 2009;29(3):203–7.PubMedGoogle Scholar
- 9.Reche-Sainz JA, Gracia Garcia-Miguel MT, Perez-Jacoiste MA. Papillitis and neuroretinitis of tuberculous etiology. Arch Soc Esp Oftalmol. 2019.Google Scholar
- 20.Davila PJ, Toledo A, Ulloa-Padilla JP, Izquierdo NJ, Emanuelli A. Unilateral neuroretinitis as a late-onset manifestation of the chikungunya fever: a case series. Retin Cases Brief Rep. 2017:1.Google Scholar
- 29.• Lee AR, El-Dairi MA. Anti-myelin oligodendrocyte glycoprotein optic neuritis or neuroretinitis? JAMA Ophthalmol. 2018;136(10):e182928. This case report highlights a patient with neuroretinitis who was discovered to have anti-MOG antibodies, indicating that anti-MOG ought to be excluded before labeling patients with idiopathic disease.PubMedGoogle Scholar
- 30.• Dalvin LA, Shields CL, Orloff M, Sato T, Shields JA. CHECKPOINT INHIBITOR IMMUNE THERAPY: systemic indications and ophthalmic side effects. Retina. 2018;38(6):1063–78 In this review, the authors highlight the ophthalmic complications of the newer chemotherapy agents, checkpoint inhibitors, including neuroretinitis.PubMedGoogle Scholar
- 36.Habot-Wilner Z, Zur D, Goldstein M, Goldenberg D, Shulman S, Kesler A, et al. Macular findings on optical coherence tomography in cat-scratch disease neuroretinitis. Eye (Lond). 2011;25(8):1064–8.Google Scholar
- 39.Yamanuha JJYMM. Bartonella neuroretinitis: a case report with new insights from fundus autofluorescence. J Clin Exp Ophthalmol. 2014:445.Google Scholar
- 45.• Habot-Wilner Z, Trivizki O, Goldstein M, Kesler A, Shulman S, Horowitz J, et al. Cat-scratch disease: ocular manifestations and treatment outcome. Acta Ophthalmol. 2018;96(4):e524–e32 Multicenter review of over 100 eyes that highlights the common ophthalmic manifestations of CSD. Additionally, the authors suggest antibiotics plus steriods improved acuity better than antibiotics alone.PubMedGoogle Scholar
- 57.Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of Bartonellosis. Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. 2017 [updated 05/07/2017. 1-5]. Available from: https://aidsinfo.nih.gov/guidelines/html/4/adult-and-adolescent-opportunistic-infection/329/bartonellosis. Accessed 1 May 2019.
- 61.Centers for Disease Control and Prevention - Bartonella infection (cat scratch disease, trench fever, and Carrión’s disease) 2014 [updated 12/14/2015]. Available from: https://www.cdc.gov/bartonella/clinicians/index.html. Accessed 1 May 2019.
- 64.Centers for Disease Control and Prevention - Lyme disease 2018 [updated 12/21/2018. Available from: https://www.cdc.gov/lyme/treatment/index.html. Accessed 1 May 2019.
- 67.The diagnosis, management and prevention of syphilis: an update and review – a clinical guidance document for use in the diagnosis and management of syphilis. Based on content from the 2015 CDC STD treatment guidelines, and developed by the NYC Department of Health and Mental Hygiene Bureau of Sexually Transmitted Infections and the NYC STD Prevention Training Center. March 2019.Google Scholar
- 68.Centers for Disease Control and Prevention - 2015 Sexually transmitted diseases treatment guidelines: Syphilis.2015.Google Scholar
- 71.Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, et al. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis. 2016;63(7):e147–e95.PubMedPubMedCentralGoogle Scholar
- 72.American Thoracic S, Cdc, Infectious Diseases Society of America. Treatment of tuberculosis. MMWR Recomm Rep. 2003;52(RR-11):1–77.Google Scholar
- 74.Biggs HM, Behravesh CB, Bradley KK, Dahlgren FS, Drexler NA, Dumler JS, et al. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain Spotted Fever and other spotted fever group rickettsioses, ehrlichioses, and anaplasmosis - United States. MMWR Recomm Rep. 2016;65(2):1–44.PubMedGoogle Scholar
- 75.Brett-Major DM, Coldren R. Antibiotics for leptospirosis. Cochrane Database Syst Rev. 2012;(2):CD008264.Google Scholar