Choroidal Tuberculoma : "The Great Masquerader" Where Prompt Management Can Save Vision

Ocular manifestations of Tuberculosis are often underdiagnosed, despite being fairly common in developing South-East Asian nations. The presentations are varied while some might eventually develop potentially irreversible blindness, often missed due to a lack of detailed ocular examination by the clinicians. Interestingly, ocular manifestations sometimes may be the only presentation of Tuberculosis in patients. 

Our study shall highlight the importance of early identification and prevention of irreversible complications of choroidal tuburculoma, which may preclude the need for ocular surgical interventions and at the same time reduce financial burden in resource limited settings.  

The patient, a 46 year old female, resident of a suburb in southeast delhi, of a low socio-economic status, presented to a tertiary care hospital in Delhi with complaints of pain, sudden diminution of vision associated with redness in the right eye since the past 1 day. 

She had no known comorbidities and no  other systemic complaints were present. However gave contact history of tuberculosis.She was a non smoker with no addictions. No significant family history was present. 

V/A (AIDED):R/E 6/9, L/E 6/6 

Slit Lamp Examination:R/E: Shallow AC depth( Van Hericks I),L/E : Normal Depth 

Tonometry:R/E 32mm Hg ; L/E 18 mmhg   

Pupils: RAPD( Grade II)

Anterior chamber:B/E:cells 2+ & flare 2+ with fine KP

Lens :B/E:Clear

Gonioscopy(Modified Schaeffers Grade):R/E: Grade 0-1 L/E: 3-4 

AS OCT:R/E: Shallow Anterior chamber; L/E Normal Anterior Chamber depth

B-Scan:R/E Hyperechoecity seen s/o choroidal effusion and exudative Retinal Detachment? Choroidal granuloma

Fundus:R/E Grade II papilloedema, subretinal fluid collection ? choroidal lesion with exudative retinal detatchment 

OCT Macula:R/E Choroidal hyperintesity noted sectorally

Suspicion for TB; Sputum for AFB, Mantoux, Chest X ray , CBC, ESR,IOP lowering drugs were started .

Sputum for AFB : 2 consecutive samples + TRUNAAT testing +

Chest xray : increased bronchovascular markings in b/l lung fields

ESR : 75 mm Hg in 1st hour. Mantoux : +14 mm

Tuberculosis confirmed: patient was started on ATT + steroids as discussed with Internal Medicine team.

Treatment started : ATT+ Tab Prednisolone( 1mg/ kg ) OD+ E/O Atropine (1%) TDS+Tab Acetazolamide 250 mg TDS+ E/D moxifloxacin(0.5%)+dexamethasone (0.1%) 6 times a day

1st follow up :after 2 weeks: V/A 6/9,IOP :17 mm Hg in right eye,Steroids tapered. 

2nd follow up :at 1 month: V/A 6/6, IOP :18mm Hg, Fundus:Papilloedema improved to grade I, minimal subretinal fluid collection. 

Patient improved symptomatically,ATT was continued. No ocular complaints at 2 month follow up visit. 

Unilateral eye involvement with raised pressures warrant an absolute need for detailed ophthalmological examination to look for potentially reversible causes for diminution of vision. 

B-scan and UBM testing in resource abundant settings are helpful in early identification of underlying pathology. 

Ocular manifestations of Tuberculosis should always be ruled out in low socio-economic populations especially in developing nations like India, where a high clinical suspicion & rapid initiation of treatment can prove to be vital in saving the potentially irreversible vision loss for the patient. 

Early medical management at times succeds in preventing complications needing complex ocular surgical interventions, thereby, reducing financial burden.