Atypical Ocular Toxoplasmosis: Multifocal Segmental Retinal Arteritis (Kyrieleis Arteritis) and Peripheral Choroidal Leision

A 45-year-old immunocompetent man with a two-week history of unilateral painful red eye was referred to the university hospital for further investigation. High intraocular pressure, corneal edema, large pigmented keratic precipitates, cells and flares in the anterior chamber, patches of iris transillumination with atrophy, multifocal segmental retinal arteritis (SRA) or Kyrieleis arteritis, and peripheral choroidal elevation with overlying vitritis without adjacent old scars were observed. Toxoplasmosis, varicella-zoster virus, herpes simplex, and cytomegalovirus serologies (IgG) were positive. More detailed history-taking revealed that the patient consumed grilled rats in Ghana where rats are eaten more regularly. Toxoplasmosis diagnosis was assumed. The patient was successfully treated according to local guidelines with azithromycin 500 mg/day for five weeks. No recurrence or new lesion was observed during the six-month follow-up period.

Optical Coherence Tomography in Inflammatory and Neoplastic Lesions Deforming the Choroidal Profile

The choroid is the main part of the uvea, the vascular layer of the eye that lies between the retina and the sclera. The high vascular component of the choroid makes this structure susceptible to inflammation in multisystemic diseases, as well as the most common site of metastasis in the eye. Therefore, the choroid is involved in many pathological conditions, from uveitis to intraocular tumors. Differentiating between inflammatory and neoplastic lesions deforming the choroidal profile can sometimes be challenging. In addition, scleral disorders can also deform the choroidal profile. Choroidal imaging includes ophthalmic ultrasonography, indocyanine green angiography, and optical coherence tomography (OCT). Recent advances in choroidal imaging techniques, such as enhanced depth imaging optical coherence tomography (EDI-OCT) and swept-source optical coherence tomography (SS-OCT), have facilitated an in-depth analysis of the choroid. The purpose of this review article is to report on and highlight the most common OCT findings to help in the differential diagnosis between inflammatory and neoplastic lesions deforming the choroidal profile.

OCT Angiography in Noninfectious Uveitis: A Description of Five Cases and Clinical Applications

BACKGROUND

Optical coherence tomography angiography (OCTA) is a noninvasive imaging modality used to analyze the retinochoroidal vasculature and detect vascular flow. The resulting images can be segmented to view each vascular plexus individually. While fluorescein angiography is still the gold standard for the diagnosis of posterior uveitis, it has limitations, and can be replaced by OCTA in some cases.

METHODS

This case series describes five patients with posterior noninfectious uveitis and their description by OCTA.

RESULTS

Cases included lupus retinopathy (n = 1) for which OCTA showed ischemic maculopathy as areas of flow deficit at the superficial and deep capillary plexus; choroidal granulomas (n = 1) with a non-detectable flow signal in the choroid; active punctate inner choroiditis and multifocal choroiditis (n = 1) with OCTA that showed active inflammatory chorioretinal lesions as non-detectable flow signals in choriocapillaris and choroid; dense type 2 inflammatory secondary neovascularization (n = 1) associated with active choroiditis; and acute posterior multifocal placoid pigment epitheliopathy (APMPPE) (n = 1) without flow abnormalities at the superficial and deep retinal plexuses but non-detectable flow at the levels of the choriocapillaris and choroid.

CONCLUSIONS

Ophthalmologists can use OCTA to identify inflammatory changes in retinal and choroidal vasculature, aiding in the diagnosis, management, and monitoring of posterior uveitis.

Choroidal granulomas due to Bartonella henselae infection: A case series

PURPOSE

To report a case series of 3 patients with choroidal granulomas due to Bartonella henselae infection in order to raise awareness about this etiology in the differential diagnosis of choroidal granulomas.

METHODS, PATIENTS

A retrospective case series of patients with choroidal granulomas due to Bartonella henselae infection who consulted between 2018 and 2020. Data were collected from the medical records (demographics, visual acuity (VA), laboratory tests, treatment, imaging).

RESULTS

Patients were a 48-year old man, a 14-year old girl and a 31-year old man. They all had a choroidal granuloma seen on optical coherence tomography (OCT) and angiography. The laboratory work-up revealed a positive serology for Bartonella henselae in all patients.

CONCLUSION

On multimodal imaging choroidal granulomas in B Henselae appeared as single or multiple, uni or bilateral round yellowish lesions. Fluorescein and indocyanine green angiography of the granuloma showed respectively a late staining and a hypofluorescence. On EDI-OCT choroidal granuloma appeared as a round hyporeflective lesion in the choroid with a retinal elevation. The exclusion of other diagnosis, the natural course and the serology must lead the ophthalmologist to evoke the diagnosis.

Sub-Tenon Injection of Triamcinolone Acetonide for Choroidal Mass in Sarcoidosis: A Case Report

Purpose

To report the clinical course of a sub-tenon injection of triamcinolone acetonide for treatment of an asymptomatic choroidal mass in sarcoidosis.

Methods

This was a retrospective, non-comparative interventional case study.

Results

A 36-year-old Japanese man with sarcoidosis presented with an asymptomatic choroidal mass lesion associated with subretinal fluid accumulation in his left eye, but without any other sign of intraocular inflammation in either of his eyes. He had started systemic steroid administration for thrombocytopenia 2 days prior to being examined. After a single sub-tenon injection of triamcinolone acetonide (20 mg) the subretinal fluid was completely absorbed and the choroidal granuloma began to shrink in size. After the injection, the granuloma became a scar without any complication or recurrence over the next 34 months.

Conclusion

Sub-tenon injection of triamcinolone acetonide might be an effective treatment for choroidal granuloma in sarcoidosis.

Imaging in Tubercular Choroiditis: Current Concepts

PURPOSE

Ocular tuberculosis has protean clinical manifestations. Because of its varied clinical presentation, multimodal imaging is very important to characterize the disease activity, presence of inflammation, determining therapeutic response, and detection of complications.

METHODS

Narrative review.

RESULTS

In this review, various imaging modalities employed in the management of ocular tuberculosis including fluorescein angiography (FA), indocyanine green angiography (ICGA), optical coherence tomography (OCT), and optical coherence tomography angiography (OCTA) have been reviewed. Not only do these imaging tools complement each other in providing a comprehensive assessment of the pathology, they also help in gaining valuable insights regarding the evolution of the disease.

CONCLUSIONS

Fundus imaging plays a vital role in the diagnosis and management of patients with posterior uveitis due to tuberculosis. Fundus imaging may have a useful role in defining clinical endpoints for ocular tuberculosis in the future.

Yellow Subretinal Lesions following Initiation of Antituberculosis Therapy in A Tubercular Choroidal Granuloma: A Sign of Paradoxical Worsening?

PURPOSE

To describe the presentation and management of atypical subretinal lesions following initiation of antitubercular therapy for a tubercular choroidal granuloma.

CASE REPORT

An 18-year-old female was diagnosed with choroidal granuloma and shallow exudative retinal detachment in the left eye. Biopsy from a cervical lymph node was positive for tuberculosis. She was treated with antitubercular therapy (ATT) and oral steroids. After one week of therapy exudative detachment increased markedly and discrete yellowish-white subretinal lesions appeared first in the inferior periphery, then temporally and later involved the macula leading to a drop in visual acuity. A diagnosis of paradoxical worsening was considered and she was managed with a higher dose of oral corticosteroids, intravitreal methotrexate and intravitreal ranibizumab. The granuloma healed and the subretinal lesions as well as exudative detachment gradually resolved with improvement in visual acuity.

CONCLUSION

Subretinal yellow-white lesions may develop as a paradoxical response to ATT.

Inflammatory choroidal neovascular membrane after healed tuberculous choroidal granuloma

Objective: To present a case of choroidal granuloma masquerading as intraocular tumor that healed on anti-tuberculous treatment but led to the development of inflammatory choroidal neovascular membrane (CNVM). Method: A 42-year-old female patient with past history of hysterectomy presented with diminution of vision in the right eye. Fundus examination in the right eye showed a yellowish white choroidal mass with associated bullous retinal detachment superotemporal to fovea. Left eye fundus was normal. Fundus flourescein angiography showed early and late hyperflourescence with late pooling in serous detachments. Complete systemic evaluation did not yield a clue to diagnosis. Positron emission tomography scan (PET scan) showed enlarged lymph nodes in cervical, mediastinal and peritoneal regions. Lymph node biopsy showed caseating granulomas. Results: The granuloma subsided and a scar formed 5 months after starting anti-tuberculous treatment with improvement in vision. Six months later, the vision deteriorated again with the development of a choroidal neovascular membrane (CNVM) at the margin of the scar. The CNVM resolved and all the signs of activity subsided after giving intravitreal antivascular endothelial growth factor (anti-VEGF) injections. Conclusions: Making a diagnosis of tuberculous granuloma in a case of choroidal mass lesion is a challenge. PET scan helps in identifying metabolically active lymph nodes appropriate for biopsy. Healed scars of tuberculous choroid lesions should be followed closely to detect the development of CNVM.

Clinical Profile of Patients with Tubercular Subretinal Abscess in a Tertiary Eye Care Center in Southern India

PURPOSE

To retrospectively analyze clinical features, laboratory investigations, treatment and visual outcomes in patients with tubercular subretinal abscess.

METHODS

A total of 12 eyes of 12 patients receiving a diagnosis of subretinal abscess, between 2004 and 2014, were included for this retrospective study.

RESULTS

The mean age of the presentation was 29.75 ± 16.72 years (range: 14-62 years) and seven (58.3%) were male. The most common anterior segment presentation was anterior uveitis (75%). The mean BCVA at presentation was 1.62 (in logMAR). A tuberculin skin test was positive in seven patients (58.3%) and five patients had a history of pulmonary tuberculosis. Polymerase chain reaction for the Mycobacterium tuberculosis genome was positive in 6 of 11 eyes from aqueous aspirate (54%) and 4 of 7 eyes from vitreous aspirates (57.14%). All patients were started on systemic steroids and an anti-tubercular regimen. The mean duration of follow-up was 134.28 days. The mean BCVA at final presentation was 1.19 (in logMAR). Chorioretinal scar was the most common finding after resolution.

CONCLUSIONS

Subretinal abscess is a rare manifestation of ocular tuberculosis. A high degree of suspicion and timely management of the condition can prevent loss of vision.

Tuberculous uveitis in China

PURPOSE

To assess tuberculous uveitis in Chinese patients.

METHODS

The hospital-based observational case series study included patients who attended a third-referral hospital and presented with chronic and recurrent uveitis without primarily detected aetiology. The patients underwent the tuberculin skin test (TST) and/or interferon gamma release test (IGRA). Patients with positive test results received standard antituberculous therapy. Patients who responded to the therapy and did not show recurrence of uveitis in the follow-up period were diagnosed as tuberculous uveitis and formed the study group. The remaining patients were diagnosed as non-tuberculous uveitis and formed the control group. The clinical characteristics were compared between both groups.

RESULTS

The study group with tuberculous uveitis included 46 patients and the non-tuberculous group 38 patients. Multifocal choroiditis [n = 9 (20%) versus n = 1(3%); p = 0.04] and retinal vasculitis [n = 25(54%) versus 8 = (21.1%); p = 0.002] were significantly more common in the study group. Of 25 patients with retinal vasculitis in the study group, 11 patients (44%) additionally showed choroiditis lesions, compared with only one (13%) of eight patients in the control group (p = 0.01). In multivariate regression analysis, multifocal choroiditis [odds ratio (OR): 32.1], choroidal granuloma (OR: 21.4) and retinal vasculitis (OR: 11.2) were independent predictors of tubercular uveitis.

CONCLUSIONS

About 50% of a group of 84 patients with primarily unexplained chronic posterior uveitis had tuberculosis and showed multifocal choroiditis, choroidal granuloma and retinal vasculitis. These features had a high predictive value for the diagnosis of tuberculous uveitis. Tuberculosis is an important part in the differential diagnosis of unexplained uveitis.