Spectrum of Ocular Tuberculosis: Pathophysiology, Diagnosis and Management: A Case Series

Abstract

Background: Tuberculosis (TB) represents a rare aetiological factor in the development of choroidal neovascularisation (CNV), a process largely mediated by vascular endothelial growth factor (VEGF). Evidence from experimental animal models of intraocular TB has demonstrated increased VEGF expression in the retinal pigment epithelium (RPE), where Mycobacterium tuberculosis can persist by inhibiting phagolysosome fusion. Choroidal neovascular membranes (CNV) are characterised by the pathological proliferation of new blood vessels and may result in significant visual impairment. A range of pathological alterations involving the RPE and Bruch’s membrane can contribute to CNV formation. In this case series, we present three patients who developed ocular manifestations of tuberculosis and describe their subsequent clinical management. Aims: To describe the various Ocular manifestations in Tuberculosis and its treatment. In this case series we highlight three patients who developed ocular manifestation of tuberculosis and describe their subsequent management. Place of Study: Department of Ophthalmology, Regional Institute of Ophthalmology, Bhimrao Ambedkar Memorial Hospital, Pt. JNM, Raipur, Chhattisgarh, India Methodology: We have described three patients with ocular manifestation of tuberculosis,one patient presented with RE-TB(Tubercular) Chorioretinitis with CNVM with CME.LE - TB (Tubercular) Chorioretinitis.There was history of tuberculosis in father 5 years back and taken course of anti tuberculosis treatment (ATT) for 6 months. Rubella IgM was positive, MANTOUX test – induration 20mm was positive, TB Quantiferon gold test was positive. Patient was started on ATT for 9 months, RE -Injection posterior subtenons triamcinolone acetonide was given. Patient was started on oral steroids 20 mg in tapering doses, Intravitreal ranbizumab 0.5 mg in 0.05 ml injection was given one month later. After 1 month there was improvement in her vision in right eye, which was counting finger 5 meters and left eye 6/6. Second case presents a 20yr old male presented with diplopia since 3 days, deviation of LE towards nasal side since 3 days. Fundus examination revealed choroidal granuloma. Third case presented with optic neuritis. Conclusion: While tubercular chorioretinitis is a known entity, the occurrence of CNVM with CME in a pediatric patient with presumed ocular tuberculosis represents a rare and noteworthy manifestation. Ocular tuberculosis as a cause of chorioretinitis. TB is a well-recognized cause of posterior uveitis and chorioretinitis, especially in endemic countries. Pediatric presentation (13 years) of bilateral tubercular chorioretinitis, which is rare compared to adults. Concurrent presence of active choroidal tubercle, multifocal chorioretinitis, Inflammatory CNVM with CME, in the same eye, which is infrequently reported. Macular CNVM as the presenting cause of severe vision loss. Asymmetric bilateral disease, Right eye with active inflammation and CNVM, Left eye showing only healed lesions.