Spark ImageWise 38

A case of presumed ocular tuberculosis

Dr. Ravi Daberao, Dr. Sarang Lambat , Dr. Prabhat Nangia, Dr. Vinay Nangia.
Suraj Eye Institute, 559, New Colony, Sadar, Nagpur- 440001.

Case Description
A male, 65 years of age presented to us with complaints of sudden diminution of vision in left eye for 2 weeks. There was no history of diabetes mellitus or hypertension. Best corrected visual acuity was 6/9, N8 in the right eye (RE) with an addition of +3.00 DS for near vision and 6/60, N24 in the left eye (LE) with an addition of +3.00 DS for near vision. Slit lamp examination both eyes showed normal anterior segment. Intra-ocular pressure was 19 mmHg in both eyes.

Figure 1 – Colour fundus photograph of right eye showed clear media, circular disc with VCDR 0.3:1, normal blood vessels and macula.
Figure 2 – Colour fundus photograph of left eye showed clear media, circular disc with VCDR 0.3:1 and two retinitis lesions one (black arrow) just supertemporal to disc and second one (black arrow) along supero temporal arcade. These lesions are yellowish white in colour, irregular in shape, 1 disc diameter in size. Macular edema (yellow arrow) is also seen.
 Figure 3a and 3b – RE – Fundus fluorescein angiography showed normal dye transit.
Figure 4a – LE – Fundus fluorescein angiography showed initial hypoperfusion in area of retinitis (yellow arrow) in early venous phase
Figure 4b – LE – fundus fluorescein angiography of late phase shows leakage and staining in the area of involvement (yellow arrow).
Figure 4c – LE – Fundus fluorescein angiography of very late phase showed increased staining and leakage in the areas of retinitis (yellow arrow). A rim of hyper fluorescence around fovea is seen suggestive of macular edema (green arrow).
Figure 5 – LE -Spectral Domain OCT (SD-OCT) with horizontal line scan passing through fovea showed significant hypo reflectivity in subretinal space suggestive of neurosensory retinal detachment (yellow arrow) and multiple hyperreflective linear strands and round foci (red arrow) are seen in the subretinal space within area of neurosensory detachment.

Tests including X ray chest and Tuberculin test were negative.  Interferon gamma release assay (IGRA)-(QuantiFERON-TB Gold test) was the only test which showed high level of positivity. On the basis of this the patient was diagnosed as presumed ocular tuberculosis. Patient was given on 3 monthly doses anti-VEGF for the macular edema along with anti-tubercular treatment and systemic steroids.

Figure 6- LE – Spectral Domain OCT (SD-OCT) showed reduction in neurosensory detachment (yellow arrow) and hyperreflective foci (red arrow) with in the neurosensory detachment. It also showing an early epiretinal membrane (blue arrow). Vision also improved to 6/18.
Figure 7 – LE-Spectral Domain OCT (SD-OCT) showed further reduction in neurosensory detachment (yellow arrow) and hyperreflective foci (red arrow) with in the neurosensory detachment. Epiretinal membrane (blue arrow) is also seen more prominently. Vision had improved to 6/9.
 Figure 8 – LE-Spectral Domain OCT (SD-OCT) showed almost complete reduction in neurosensory detachment (yellow arrow) and minimal hyperreflective foci (red arrow) are seen. Epiretinal membrane (blue arrow) is now well formed and retracting away from perifoveal retinal surface ( blue arrow). Vision had improved to 6/6 p.


Our patient reported with blurring of vision due to macular edema as the retinitis was in the macular area. The common causes of retinitis includes viral, rickettsial, toxoplasma, candida and tuberculosis. Systemic workup along with aqueous polymerase chain reaction (PCR) needs to be done for a definitive diagnosis. This patient had positive test of IGRA which was highly suggestive of tubercular infection. Patient was advised anti tubercular treatment to take care of the systemic infection and anti-VEGF injection for the macular edema. Systemic steroids were also administered to prevent paradoxical reaction which can lead to increased inflammation after starting AKT. The patient responded well to the above line of treatment and since he presented to us in the early course of disease. Injection anti VEGF is a potent anti-inflammatory agent which works equally well in posterior segment inflammation in cases of uveitis related retinal oedema apart from anti-angiogenic effects.  

The eye is one of the extra-pulmonary sites of tuberculosis (TB) infection. Different clinical manifestations include anterior uveitis, serpiginous-like choroiditis, neuroretinitis, choroidal granuloma and retinal vasculitis. It represents a challenging diagnosis since 60% of patients with extra-pulmonary TB have no evidence of pulmonary infection. The diagnosis remains presumptive and it is based on clinical findings and evidence of pulmonary involvement or positive tuberculin skin test and/or interferon gamma release assay (IGRA)-QuantiFERON-TB Gold consistent with latent infection.


1.     Patricio MS, Portelinha J, Passarinho MP, Guedes ME. Tubercular retinal vasculitis. BMJ Case Rep. 2013 Jun 3;2013:bcr2013008924. doi: 10.1136/bcr-2013-008924. PMID: 23737572; PMCID: PMC3702819.

2. Shukla D, Kalliath J, Dhawan A. Tubercular Retinal Vasculitis: Diagnostic Dilemma and Management Strategies. Clin Ophthalmol . 2021;15:4681-4688

Dr. Sarang Lambat
Vitreoretinal services
Suraj Eye Institute
Email –

You cannot copy content of this page

× Hello!