Spectral domain optical coherence tomography imaging of tubercular chorioretinitis and intraretinal granuloma. Intraretinal tuberculosis: a case report

Tubercular Retinitis and Retinal Vasculitis: Manifestations of a Shared Disease Spectrum

Isolated retinal involvement in ocular tuberculosis (TB) is not well understood and remains largely underreported. TB retinal lesions can be classified into two broad categories: retinal vasculitis and isolated retinal granuloma. TB retinal vasculitis is the more recognized phenotype and may present with perivascular infiltrates alone or alongside other ocular signs such as subvascular lesions, focal vascular tortuosity, and occlusive vasculitis. These additional signs are crucial for diagnosing TB retinal vasculitis in TB-endemic regions. However, isolated retinal granulomas due to TB are rarely documented and poorly characterized. In this review, we have described the various clinical phenotypes of retinal TB, including a multimodal overview of an isolated intraretinal granuloma. We propose that TB retinitis and retinal vasculitis are part of a disease continuum of retinal TB. To support our hypothesis regarding retinal TB, we draw inferences from historical data derived from histopathological examinations of the eye as well as clinical and experimental studies on cerebral TB vasculitis. We have also reviewed other sites of TB vasculitis, such as the skin and major vessels, including the aorta. Understanding TB vasculitis in the brain and other organs could potentially elucidate not only the pathogenesis of retinal TB but also the diagnosis and management of this condition.

Primary Tubercular Chorioretinitis Without a Pulmonary Focus: A Case Report

Ocular tuberculosis (TB) can affect various eye structures and may manifest independently of systemic TB. Typically, it arises from hematogenous dissemination from a primary focus; however, in exceptional instances, it may originate as a primary infection after epithelial injury. Diagnosing TB in an extrapulmonary site presents a significant clinical challenge. We present the case of a 33-year-old Bangladeshi female who presented with a deteriorating loss of vision in her left eye. A thorough neurologic examination and serological tests, the tuberculin skin test, a CT scan of the chest, ocular fundus photography, and optical coherence tomography were performed. Based on the clinical features and the outcome of appropriate tests, a presumptive diagnosis of ocular TB was made and later confirmed after initiating antitubercular therapy, which resulted in a marked improvement in the patient's vision a week later. This case is an illustration of the rare nature and unusual presentation of extrapulmonary TB in the form of tubercular chorioretinitis, diagnosed in a resource-limited setting. Tubercular chorioretinitis, characterized by inflammation of the choroid and retina due to TB infection, presents a diagnostic challenge, especially in resource-limited environments where access to advanced diagnostic tools may be restricted. Therefore, this case highlights the importance of considering TB as a potential cause of ocular manifestations, even in settings where TB prevalence might not be high, and underscores the need for increased awareness and diagnostic capacity for extrapulmonary TB in resource-limited areas. This case exemplifies the infrequent occurrence and atypical manifestation, presenting a learning opportunity for future clinicians.

PRESUMED INTRARETINAL TUBERCULOSIS: CASE REPORT WITH MULTIMODAL IMAGING INCLUDING OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY

PURPOSE

To report a case of presumed intraretinal tuberculosis evaluated with optical coherence tomography angiography.

METHODS

Case report.

RESULTS

A 61-year-old woman recently immigrated from China presented with round yellow-white retinal lesions in the left eye. The lesions were evaluated with multimodal imaging, including optical coherence tomography angiography. Subsequent serologic testing revealed a positive QuantiFERON-TB Gold test, whereas workup for other entities was negative. The patient was diagnosed with presumed intraretinal tuberculosis. She was started on systemic antitubercular therapy and the lesions regressed. The regression was documented with optical coherence tomography angiography.

CONCLUSION

Case reports of primary intraretinal tuberculosis are uncommon. To the best of our knowledge, this is the first case to demonstrate optical coherence tomography angiography findings of presumed intraretinal tuberculosis.

Photodynamic Therapy for the Treatment of Vascularized Intraretinal Tuberculoma

PURPOSE

To report a case of intraretinal tubercular granuloma successfully treated with photodynamic therapy (PDT).

METHODS

Retrospective case report. Multimodal imaging was performed at each follow-up visit.

RESULTS

The tuberculoma did not regress and did not significantly reduce its exudation after anti-tubercular therapy (ATT), systemic steroid therapy and intravitreal anti-VEGF. Second line treatment with PDT was attempted. The lesion showed a regression with reduced sub-retinal fluid and intra-retinal exudates. A second PDT was performed for reactivation of the lesion 5 months after the first treatment. Further regression of the lesion was observed.

CONCLUSION

PDT may be a valuable second-line therapeutic approach for vascularized intraretinal granulomas.

MULTIMODAL IMAGING OF AN INTRARETINAL TUBERCULAR GRANULOMATOUS NEURORETINITIS

PURPOSE

To report a rare case of an intraretinal tuberculoma and associated neuroretinitis.

METHODS

The patient was evaluated with various imaging modalities including fundus photography, fluorescein angiography, magnetic resonance imaging, and optical coherence tomography; her extensive laboratory workup returned positive for tuberculosis.

RESULTS

After initially presenting with no light perception, 13 weeks of antitubercular therapy allowed for visual acuity recovery to 20/30.

CONCLUSION

We demonstrate the spectral domain optical coherence tomography characteristics of an intraretinal tuberculoma.

Differences between Mycobacterium chimaera and tuberculosis Using Ocular Multimodal Imaging: A Systematic Review

Due to their non-specific diagnostic patterns of ocular infection, differential diagnosis between Mycobacterium (M.) chimaera and tuberculosis can be challenging. In both disorders, ocular manifestation can be the first sign of a systemic infection, and a delayed diagnosis might reduce the response to treatment leading to negative outcomes. Thus, it becomes imperative to distinguish chorioretinal lesions associated with M. chimaera, from lesions due to M. tuberculosis and other infectious disorders. To date, multimodal non-invasive imaging modalities that include ultra-wide field fundus photography, fluorescein and indocyanine green angiography, optical coherence tomography and optical coherence tomography angiography, facilitate in vivo examination of retinal and choroidal tissues, enabling early diagnosis, monitoring treatment response, and relapse detection. This approach is crucial to differentiate between active and inactive ocular disease, and guides clinicians in their decisional-tree during the patients’ follow-up. In this review, we summarized and compared the available literature on multimodal imaging data of M. chimaera infection and tuberculosis, emphasizing similarities and differences in imaging patterns between these two entities and highlighting the relevance of multimodal imaging in the management of the infections.

Clinical and Epidemiological Study on Tubercular Uveitis in a Tertiary Eye Care Centre in Italy

Purpose

To describe frequency, clinical characteristics, and visual prognosis of tubercular uveitis (TBU) in a nonendemic country.

Methods

We retrospectively reviewed 3743 charts of patients with endogenous uveitis visited from 2008 to 2018 at a tertiary referral centre in Rome, Italy. We included immunocompetent patients with diagnosis of TBU. Patients were divided in two groups: patients with history of uveitis without a previous diagnosis of TBU (group A) and patients at their first episode of TB uveitis (group B).

Results

TBU was diagnosed in 28 (0.75%) out of 3743 patients. Twelve (42.9%) patients came from tuberculosis endemic areas. All patients received specific antitubercular treatment (ATT) and were evaluated for a mean follow-up of 3.2 ± 2.9 years. Group A showed a greater number of ocular complications when compared with group B. ATT was effective in reducing the frequency of recurrences of uveitis in patients of group B.

Conclusion

Intraocular inflammation can be the first manifestation of tuberculosis. Our data highlight that early diagnosis and specific treatment of TBU may allow to decrease recurrences and to improve visual outcomes.