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 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 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).
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.
Discussion
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.
ReadWise:
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 https://doi.org/10.2147/OPTH.S284613
Dr. Sarang Lambat
MS, FRF
Consultant
Vitreoretinal services
Suraj Eye Institute
Nagpur
Email – education@surajeye.org