Author: Inês Passos (Portugal)
Co-authors: Tiago Morais Sarmento, João Garrido, Olga Berens, Rita Condesso, António Ramalho
Ocular Tuberculosis is a presumptive and clinical diagnosis when in presence of suggestive clinical and laboratorial findings, while excluding other causes of ocular inflammation. It can be caused by direct invasion by the tuberculosis bacilli or as a result of immunogenic reaction due to the extraocular infective foci. It´s incidence is highly variable, ranging from 1.4% to 18% in endemic areas, having a relatively low incidence rate in Portugal (19.2 cases/100000 inhabitants). It is still a challenging diagnosis, presenting mainly as posterior uveitis and having no pathognomonic findings. This paper aims to analyse a clinical case where retinal vasculitis coexists with macular edema in a patient with possible ocular tuberculosis.
The autors present a case of a 70 year old patient that came to our general ophthalmology appointment for progressive decreased visual acuity of the right eye for the past month. He presented a best corrected visual acuity of 1.30 logMAR, normal anterior segment and several exudates throughout the posterior pole and peripheral retina, with vascular sheating and no evidence of vitritis.
A retinography, an optical coherence tomography (OCT) and fluorescein angiography (FA) were promptly requested, as well as a full laboratory evaluation, chest x-ray and Interferon Gamma Release Assay (IGRA) test.
OCT revealed, in the right eye an extensive macular cystic edema with several hyperreflective spots surrounding it and a central macular thickness of 449 micras. FA showed marked leakage temporal to fovea, confirming also the vascular sheating and showing a peripheral temporal and inferior area of chorioretinal scarring. Chest-X ray revealed normal, as well as the extensive laboratory work-up, but the IGRA test came back positive. The patient latter confirmed having a positive exposure to a tuberculosis (TB) infected friend when he was 18 years of age. Ocular TB was assumed and anti-TB therapy was promptly iniciated. He also initiated a three intra-vitreal injections regimen with aflibercept. Four months after initial diagnosis, continuing his course of anti-TB treatment, intraretinal liquid was fully reabsorbed with maintenance of hard exsudates around the fovea, a central macular thickness of 335 micras and visual acuity of 1.0 logMAR.
This case represents a difficult setting of retinal vasculitis where an IGRA test and negative laboratory findings for other infeccious diseases shove us in the direction of an Ocular TB. Treatment was initiated as soon as possible with anti-vascular endothelial growth factor (anti-VEGF) therapy and a multidisciplinary approach was taken to also treat the patient with anti-bacillary combined therapy. The treatment showed complete reabsortion of subretinal fluid with maintenance of the hard exsudates near the foveal region.
The autors have no finantial disclosures.