Sir,

Treatment of ocular toxoplasmosis is highly controversial. Results of such treatment depend on host factors, such as age and immune status, as well as on parasite factors.1 The use of corticosteroids is even more debatable. Although most uveitis specialists agree that corticosteroid therapy without the concurrent use of antimicrobial agents can lead to severe ocular tissue destruction, patients who did well treated with corticosteroids alone have been seen.1

Aggressive cases, such as the one reported by Backhouse et al, have also been reported. It is important to note, however, that clinical deterioration did not occur immediately after the introduction of oral or intravitreal corticosteroids. On the contrary, in these two circumstances it appears that some improvement was initially observed. Of note, the antimicrobial agent was introduced 1 month following intravitreal triamcinolone acetonide. Taking into account that clinical picture worsening occurred only 2 weeks thereafter (6 weeks following intraocular injection), the temporal relationship strongly suggests that the intravitreal triamcinolone acetonide injection was not directly related to the outcome.

In our opinion, intravitreal corticosteroids should be used with caution in active ocular toxoplasmosis. Clinicians should avoid their use on recalcitrant, rapid worsening cases or those with questionable diagnosis. Intravitreal steroids without appropriate antimicrobial drugs should also be discouraged. On the other hand, there may be a role for them in patients with relatively controlled infection, as those we reported previously on this journal.2