Distinct recurrence pattern in a case of bilateral tubercular posterior uveitis: reporting a unique clinical morphology and management challenge

Intraocular tuberculosis has protean clinical manifestations and remains an important etiological differential for uveitis in an endemic region. A 27-year-old male presented with visual acuity of counting fingers close to face in right (OD) and 20/25 in left eye (OS). Examination revealed a choroidal granuloma in OS and healed serpiginous-like choroiditis in OD. Antitubercular therapy was started with systemic corticosteroids. Granuloma resolved completely; however, the patient presented with neuroretinitis and posterior scleritis, as first and second recurrence, respectively, within a oneyear period. These were managed with systemic corticosteroids and immunosuppressive therapy was added, after second recurrence. The patient responded well and maintains remission. This case presented a clinical challenge with distinct recurrence patterns of tubercular posterior uveitis in the same eye, which has not been reported before. Successful management entailed use of antitubercular therapy, corticosteroids, and immunosuppressive therapy in a step-ladder approach, resulting in preservation of vision and achieving long-term remission.

Large exudative retinal detachment with choroidal granuloma unmasking disseminated tuberculosis: imaging and management

A 26-year-old man presented with diminution of vision in the left eye associated with malaise and occasional mild fever. On fundus examination, the patient had left eye inferior bullous retinal detachment with choroidal granuloma. Systemic examination revealed a non-tender swelling on the right wrist. Correlating ophthalmic and systemic findings, a presumptive diagnosis of left eye exudative retinal detachment with choroidal tuberculoma and tubercular osteomyelitis of the right wrist was made. On imaging, asymptomatic multiorgan involvement was observed in the chest, abdomen and spine. The patient was started on antitubercular treatment along with peribulbar steroid. A reduction in size of exudative retinal detachment and tuberculoma with improvement in vision was noted on serial follow-ups. This case highlights the importance of thorough systemic evaluation in cases of ocular tuberculosis as the eye may not be the primary site but the early presenting feature of disseminated tuberculosis. Local posterior subtenon can be used for faster resolution of exudative retinal detachment and intraocular inflammation.

Managing solitary choroidal tuberculoma in an immunocompetent patient

Aim: We describe a case of young immunocompetent 18-year-old female patient who presented with sudden painless diminution of vision in left eye with vision of 20/100 on Snellen’s chart. Retinal evaluation showed a massive solitary choroidal granuloma. A positive Mantoux test (20X20 mm) was noted. The patient was started on anti-tubercular therapy and oral steroids and showed resolution of the granuloma with subretinal fluid at macula. After 3 months of oral therapy, the persistent subretinal fluid was managed with intravitreal injection of triamcinolone acetonide(2 mg). This case highlights favorable resolution of granuloma with oral therapy and a safer efficacy of triamcinolone acetonide in treating subretinal fluid due to choroidal tuberculoma with good visual outcome. Introduction: Choroidal tuberculoma is a rare ocular form of tuberculosis (TB) and is a diagnostic and a therapeutic challenge, especially when occurring without other manifestations of the disease.1,2 Involvement of the choroid occurs by direct infection or indirect immune‐mediated hypersensitivity and is the commonest clinical manifestation of intraocular TB.3 The presentation varies from a solitary choroidal granuloma (tuberculoma) to multiple choroidal tubercles, a subretinal abscess or choroiditis. We present a case of an immunocompetent patient, who presents with massive choroidal granuloma and responded to oral antitubercular and steroid therapeutic regimen. Visual acuity improved with intravitreal triamcinolone acetonide injection which resulted in resolution of subretinal fluid after 3 months

Intraocular tuberculosis, a challenge in diagnosis and treatment

Ocular tuberculosis (TB) is an extrapulmonary tuberculous condition and has variable manifestations. The incidence of TB is still high in developing countries, and a steady increase in new cases has been observed in industrial countries as a result of the growing number of immunodeficient patients and migration from developing countries. Choroidal granuloma is a rare and atypical location of TB. We present a case of a presumptive choroidal granuloma. This case exposes that diagnosis can be remarkably challenging when there is no history of pulmonary TB. The recognition of clinical signs of ocular TB is extremely important since it provides a clinical pathway toward tailored investigations and decision making for initiating anti-TB therapy and to ensure a close follow-up to detect the development of any complication.

Syphilitic chorioretinitis presenting as a choroidal granuloma

A rare case of syphilitic uveitis presenting as a choroidal granuloma is described in this case report. The clinical picture resembled that of a tubercular choroidal granuloma. However, the patient was positive for treponemal (treponema pallidum hemagglutination assay) as well as non-treponemal tests (venereal disease research laboratory test) for syphilis. Therefore, the patient was treated for ocular syphilis and responded to antisyphilitic therapy. There was a complete resolution of the lesion at the end of 14 days of treatment.