Table 1 A review of published cases of vision loss in Cryptococcal meningitis (Cases, reported after year 2000 and those who had a MRI done, were included)
Reference | HIV status | Summary of case | MRI | Suggested cause of vision loss | Outcome |
|---|---|---|---|---|---|
Ng et al. [22] | Positive | A 39-year-old Chinese man presented with bitemporal headache, giddiness and vomiting over a period of 2 days. There was no Cryptococcus detected by Indian ink examination of the CSF but CSF culture grew Cryptococcus neoformans. The patient was treated with amphotericin, and then to fluconazole. | Normal | increased intracranial pressure | irreversible blindness in both eyes |
Positive | A 36-year-old Chinese man presented with subacute onset of severe headache and confusional state. CSF microscopy with Indian ink examination showed Cryptococcus. Eight days after starting IV amphotericin, he complained of bilateral blurring of vision and had a seizure. A repeat lumbar puncture showed raised opening CSF pressure of more than 40 cm and 20 mL of CSF was withdrawn. During follow up, concentric diminution of visual field in both eyes was recorded. A lumbo-peritoneal shunt was done. | CT was normal | Increased intracranial pressure | Normal vision | |
Mohan et al. [23] | Positive | A 41-year-old male with a history of cryptococcal meningitis admitted with severe headache. On the 6th day, He had complete loss of hearing, vision loss as well as bilateral facial palsy and bilateral sixth nerve palsy. Bilateral papilledema was seen. CSF opening pressure was 460 mm H2O. Amphotericin and Flucytosine were given. Repeated lumbar punctures were done but pressure remained over 500 mm H2O. Ommaya reservoir placed. There was dramatic clinical improvement of the patient. | Hydrocephalus | Increased intracranial pressure | Regained his vision partially |
Hong et al. [7] | Positive | A 58-year-old man presented with acute vision loss. Patient had normal CSF opening pressure and fundus. He received antiretroviral and antifungal agents. | Normal | Possibly, direct fungal infiltration of the optic nerve, optic chiasm, or optic tracts | Vision improved |
Milman et al. [24] | Positive | 25-year-old patient developed headaches, seizures, altered mental status, and visual loss. Lumbar puncture showed markedly increased opening CSF pressure; cryptococcal organisms were identified by India ink preparation and in culture. Despite treatment with amphotericin and fluconazole, visual loss progressed. | leptomeningeal and optic nerve enhancement without hydrocephalus | increased intracranial pressure | Improved with bilateral optic nerve sheath fenestration. |
Muslikhan et al. [25] | Negative | A 17-year-old boy presented with blurring of vision in both eyes and diplopia for 3 weeks. Extraocular muscles movement showed bilateral sixth nerve palsies. Discs were hyperaemic and slightly elevated. Lumbar puncture revealed high opening pressure >300 mmH(2)O. CSF showed Cryptococcus neoformans. IV amphotericin and fluconazole were given. | CT scan of the brain was normal | high intracranial pressure | His vision was improved to 6/6 in both eyes with recovery of peripheral visual field. |
De Socio et al. [26] | Positive | A 32-year-old man with disseminated Cryptococcosis was being treated with antiretroviral therapy. On day 7 he had a unilateral vision loss. | retrobulbar neuritis | IRIS leading to optic nerve neuritis following anti-retroviral therapy | At 3 months, vision was normal After starting ART and IV methyl-prednisolone |
Duggan and Walls [27] | Positive | A 39-year-old man with AIDS presented with recent onset of headache, dizziness, and syncope. CSF showed C neoformans. Amphotericin and flucytosine were started. On day 2, the patient had several episodes of complete loss of vision bilaterally. Drainage of CSF to decrease ICP resulted in the immediate return of vision. External ventricular drain was placed and later optic nerve sheath fenestration. | optic nerve edema or neuritis | high intracranial pressure | permanent vision loss |
Positive | A 39-year-old African female with AIDS presented with headache, neck pain, and altered mental status of 3 days. CSF showed C neoformans. On hospital day 2, the patient complained of sudden complete loss of vision bilaterally. Retinal microvasculopathy was noted. | Normal | Retinal microvasculopathy | Patient died | |
Espino Barros Palau et al. [28] | Out of three cases one was HIV positive | A 46-year-old male had bilateral optic atrophy. He had been well until 3 months prior when he experienced vision loss, headache, nausea, and fever. | Normal | Intracranial hypertension | serial lumbar drain |
A 43-year-old female presented with 3 weeks of headache, horizontal diplopia, and bilateral vision loss. Patient had renal transplantation requiring immunosuppression in 2005. CSF opening pressure was markedly elevated. Amphotericin B and flucytosine were initiated. | Diffuse leptomeningeal enhancement and punctate areas of enhancement in the pons and basal ganglia. | ||||
A 35-year-old male presented with 1 month of bilateral progressive vision loss. Ophthalmoscopy showed peripapillary subretinal fluid extending into the macula bilaterally. Both optic discs had edema. CSF opening pressure was elevated. Amphotericin B and flucytosine were started. | Multiple T2-hyperintense lesions throughout the cerebral hemispheres, brainstem, and cerebellum as well as with leptomeningeal enhancement. | ||||
Portelinha et al. [29] | Negative | A 52-year-old woman with headaches, vomiting and fatigue for 3 weeks. She was diagnosed with cryptococcal meningitis and treated with antifungal therapy. She also had decreased vision in the left eye, bilateral sixth nerve palsy and papilloedema. A ventriculo-peritoneal shunt was placed and methylprednisolone was started. | Signs of intracranial hypertension as well as multiple parenchymal lesions and optic nerve sheath enhancement. | high intracranial pressure and optic nerve fungal infiltration | In spite of the control of intracranial pressure there was a decrease in vision in the right eye and deterioration of visual fields. |
Ghatalia et al. [30] | Positive | A 34 year old man of vision loss in a patient with Cryptococcal meningitis and normal ICP. | Abnormal circumferential enhancement within the bilateral optic nerve sheaths. | IRIS leading to optic nerve neuritis | Vision improved with corticosteroids |
Merkler et al. [31] | Negative | A 38-year-old woman presented with bilateral vision loss. Empiric steroids resulted in improvement in visual acuity, while tapering steroids, she had visual loss again. | Multiple areas of ill-defined enhancement in the optic chiasm and tracts. | Invasion of the optic apparatus by Cryptococcus neoformans | One year later, symptom free. |