LONGITUDINAL FOLLOW-UP OF TUBERCULAR SERPIGINOUS-LIKE CHOROIDITIS USING OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY.

PURPOSE: To analyze and describe serial follow-up of choriocapillaris alterations in tubercular serpiginouslike choroiditis (SLC) using optical coherence tomography angiography (OCTA) and to compare it with multimodal imaging. METHODS: In this prospective cohort study, patients with active tubercular SLC underwent OCTA using Optovue RTVue XR Avanti and other imaging techniques including enhanced-depth imaging OCT (EDI-OCT) (Heidelberg Spectralis; Heidelberg Engineering, Heidelberg, Germany), fundus autofluorescence, fluorescein angiography, and indocyanine green angiography. Serial imaging was performed for a total follow-up of 3 months. Choriocapillaris alterations at the site of lesions were analyzed on OCTA imaging, and their mean lesion areas were calculated. RESULTS: Twenty-six eyes (26 patients; 20 males; mean age: 32.68 ± 10.56 years) were included. Fourteen eyes had active multifocal lesions (n = 39), whereas 12 eyes had active placoid lesions (n = 12). At baseline, OCTA showed hyporeflective flow deficit lesions corresponding to the hypofluorescent lesions on indocyanine green angiography in all eyes. In the multifocal type of SLC, the mean lesion area decreased in all eyes compared with baseline, and lesions with a lesion area less than 0.1 mm2 on OCTA showed near-complete resolution with minimal choriocapillaris atrophy. In comparison, all eyes with a placoid type of SLC showed no significant reduction in the lesion area and showed extensive choriocapillaris atrophy. CONCLUSION: Optical coherence tomography angiography has the unique ability to demonstrate pathological flow impairment at the level of choriocapillaris in active tubercular SLC. Serial OCTA analysis reveals that large tubercular SLC lesions result in choriocapillaris atrophy as the lesions heal, whereas smaller multifocal lesions show resolution of choriocapillaris hypoperfusion with minimal atrophy.

Optical Coherence Tomography Features of Tuberculous Serpiginous-like Choroiditis and Serpiginous Choroiditis.

OBJECTIVE: To investigate optical coherence tomography (OCT) characteristics of tuberculous serpiginous-like choroiditis (Tb-SLC) and serpiginous choroiditis (SC) and to perform OCT to differentiate between these conditions. METHODS: This retrospective, case-control study examined consecutively enrolled patients with active Tb-SLC or SC. Patients underwent comprehensive ocular examinations and imaging (OCT, color fundus photography, autofluorescence imaging, fluorescein angiography, and indocyanine green angiography). Findings were examined and compared between eyes with SC and Tb-SLC. RESULTS: Nine patients with active Tb-SLC (14 eyes) and 8 with active SC (12 eyes) were included. The following OCT findings were observed significantly more often in the Tb-SLC group than in the SC group: vitreal hyper-reflective spots [5 Tb-SLC eyes (36%), no SC eyes; P = 0.02], intraretinal edema [11 Tb-SLC eyes (79%), 3 SC eyes (25%); P = 0.01], sub-retinal pigment epithelium (RPE) drusenoid deposits [11 Tb-SLC eyes (79%), 2 SC eyes (17%); P < 0.01], and choroidal granulomas [8 Tb-SLC eyes (57%), 2 SC eyes (17%); P = 0.03]. A hyporeflective, wedge-shaped band was observed more often in the SC group [5 Tb-SLC eyes (36%), 9 SC eyes (75%); P = 0.045] than in the Tb-SLC group. The incidence of other OCT signs did not differ between the groups and included outer nuclear layer hyper-reflection, outer retinal tabulation, and choriocapillaris point-like hyper-reflection. CONCLUSION: Vitreal hyper-reflective spots, intraretinal fluid, sub-RPE drusenoid deposits, and choroidal granulomas on OCT images may indicate Tb-SLC. Additionally, a hyporeflective, wedge-shaped band may indicate SC. Therefore, OCT is likely helpful in differentiating between Tb-SLC and SC.

NOVEL FINDINGS ON OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN PATIENTS WITH TUBERCULAR SERPIGINOUS-LIKE CHOROIDITIS.

PURPOSE: To analyze and describe the imaging characteristics of tubercular serpiginous-like choroiditis using optical coherence tomography angiography (OCTA) and to compare these findings with multimodal imaging. METHODS: In this prospective cross-sectional study, multimodal imaging was performed in subjects with tubercular serpiginous-like choroiditis using OCTA (Optovue RTVue XR Avanti), enhanced-depth imaging OCT (Heidelberg Spectralis), fundus autofluorescence, fluorescein angiography, and indocyanine green angiography. Distinct morphologic features of the retinochoroidal vasculature at the sites of choroiditis lesions were analyzed on OCTA imaging. Multimodal imaging analysis was performed to study the changes observed on OCTA. RESULTS: Eighteen eyes (18 subjects, 16 males) were included in the study. The en face OCTA images demonstrated discrete areas of flow void beneath the retinal pigment epithelium-Bruch membrane layer suggestive of choriocapillaris hypoperfusion that corresponded well with indocyanine green angiography, especially in the chronic phase. Additional information such as areas of preserved choriocapillaris, vascular tufts, and tangled vessels were observed using OCTA among lesions in advanced stages of healing. Compared with indocyanine green angiography, the areas of choriocapillaris atrophy appeared better defined on OCTA and correlated well with enhanced-depth imaging OCT. CONCLUSION: The OCTA images provide high-resolution structural information of the retinochoroidal vasculature in tubercular serpiginous-like choroiditis. Morphologic information obtained from OCTA images correlates well with and supplements other imaging techniques such as indocyanine green angiography and enhanced-depth imaging OCT.

LONGITUDINAL FOLLOW-UP OF CHOROIDAL GRANULOMAS USING ENHANCED DEPTH IMAGING OPTICAL COHERENCE TOMOGRAPHY.

PURPOSE: To assess the ability of enhanced depth imaging optical coherence tomography (EDI-OCT) in detecting variations in the structure and size of choroidal granulomas in response to treatment and to compare these findings with indocyanine green angiography (ICGA). METHODS: EDI-OCT and ICGA images of choroidal granulomas in eyes of patients diagnosed with tubercular or sarcoid uveitis were obtained at baseline and follow-up visits. Two independent masked observers analyzed the lesions to compare changes in their structural features such as shape, reflectivity, and margins, among others, through time. The size of each lesion was manually measured on EDI-OCT and ICGA images at all the visits. In addition, longitudinal assessment of choroidal area was performed on the EDI-OCT images during the course of follow-up. RESULTS: Twenty-eight granulomas (16 tubercular and 12 sarcoid; 7 patients) were included in the study. Using EDI-OCT, significant decrease in the mean size of lesions could be appreciated after 1 month of treatment (0.29 mm at baseline vs. 0.18 mm at 1 month; P < 0.001). However, ICGA did not reveal significant decrease in lesion size at 1 month compared with baseline (0.94 vs. 0.76 mm; P = 0.07). The granulomas followed a characteristic healing pattern in which the antero-posterior extent (depth) decreased first, followed by decrease in their lateral extent. Apart from size, the choroidal granulomas did not show significant changes in their morphological features on EDI-OCT with treatment. CONCLUSION: EDI-OCT may be more sensitive than ICGA in detecting early variations in the size of choroidal granulomas. Morphometric analyses of choroidal granulomas on EDI-OCT may be very useful in monitoring the response to treatment in patients with choroidal granulomas.

Nasolacrimal tuberculosis: case report highlighting the need for imaging in identifying and managing it effectively.

PURPOSE: To report a rare case of nasolacrimal tuberculosis, conduct a literature review, and to suggest an optimal management plan. METHODS: A 39-year old Zimbabwean female presented with a 3-year history of left epiphora, haemolacria and medial canthal mass. On ophthalmic examination there was no lateral displacement of the left globe. The initial management was external dacryocystorhinostomy. Histology of the biopsy was inconclusive and her symptoms did not improve. This prompted a referral to otolaryngology. Nasal examination revealed a friable mass of the middle turbinate. CT scan showed paranasal sinus and lacrimal sac destruction and lateral displacement of the globe. Endoscopic sinus surgery confirmed the CT findings, allowed a biopsy taken, and the histology showed prominent caseating granulomatous inflammation. Microbiological cultures confirmed nasolacrimal tuberculosis. CONCLUSION: We report a case of primary tuberculosis affecting the nasolacrimal apparatus presenting with a medial canthal mass. This report highlights the need for high index of suspicion, and initial CT imaging in order to avoid invasive procedures such as external dacryocystorhinostomy, which may cause extra surgical morbidity and delay diagnosis and treatment.

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.

Miliary tuberculosis and choroidal tuberculoma in a three-month old baby girl: Diagnosis and follow-up of a case. / Tuberculosis miliar y tuberculoma coroideo en una niña de 3 meses: diagnóstico y seguimiento de un caso.

A three-month old baby girl presented with fever of unknown origin and with signs of worsening of this episode. Funduscopy showed a solitary choroidal lesion in her left eye, as well as extraocular lesions suggesting disseminated tuberculosis. A favourable outcome was achieved after quadruple antibiotic course and cortisone therapy. Disseminated tuberculosis should be considered in cases of fever of unknown origin in children with an unsatisfactory evolution. Ocular examination is mandatory, due to the possible posterior uveitis signs that can help with early diagnosis and treatment of some diseases.

Retinal vascular tumor and peripheral retinal vasculitis in the setting of systemic tuberculosis.

Tuberculosis commonly affects the eye by causing neovascularization, peripheral vasculitis, and choroidal tubercles. The authors describe a 28-year-old man with systemic tuberculosis who presented with a retinal vascular tumor, peripheral retinal vasculitis, retinal neovascularization, and vitreous hemorrhage causing acute vision loss. He was successfully treated with systemic anti-tuberculosis medications, retinal photocoagulation, and focal ablative diode laser to the tumor. Ophthalmologists should consider performing a purified protein derivative test and a chest x-ray for any patient with a history suspicious for tuberculosis who presents with a vascular tumor.

Enhanced Depth Imaging by High-Resolution Spectral Domain Optical Coherence Tomography in Tubercular Multifocal Serpiginoid Choroiditis.

Purpose: To report the choroidal changes by enhanced depth imaging optical coherence tomography (EDI-OCT) in tubercular multifocal serpiginoid choroiditis (MSC). Methods: Prospective study of 20 patients (23 eyes) with active MSC who underwent simultaneous fundus autofluorescence and EDI-OCT imaging at regular visits. Results: Eyes with acute lesions demonstrated diffuse choroidal thickening at presentation, which decreased significantly as the lesions healed. Additionally, the region of (thickened) choroid just beneath the active choroiditis lesion demonstrated a localized area of mixed reflectivity (a central hyperreflectivity surrounded by a zone of hyporeflectivity), suggesting choroidal involvement deeper to choriocapillaris. Once the lesions healed, the choroid under the scar showed a localized thinning, along with outer retinal layers loss. Conclusion: EDI-OCT highlighted diffuse and localized choroidal structural changes in MSC as the lesions evolved from acute to healed stage, providing an adjunct to clinical examination for monitoring response to therapy.

Long-Term Outcomes of Oral Anti-Tubercular Therapy in Patient with Tubercular Dacryoadenitis: A Case Series.

Purpose: To describe the clinico-radiological features and long-term outcomes in patients with tubercular dacryoadenitis (TbD) Methods: Retrospective, observational study of TbD patients who underwent a thorough clinical examination, orbital imaging study, and tailored ancillary investigations. Polymerase chain reaction (PCR) and microscopy were done in specific cases. A 4-drug anti-tubercular therapy (ATT) was started and clinical response was monitored in all. Patients with a minimum follow-up of 6 months "off-ATT" were included. Results: All patients were women and three presented with pain, blepharoptosis, and bilateral involvement. In all, ESR was raised, Mantoux test was positive and orbital imaging revealed enlarged lacrimal gland/s. Positive PCR and granulomatous inflammation on microscopy were seen in two patients. At a mean follow-up of 17.25 months, all women responded with no relapse or clinical recurrence. Conclusion: Bilateral lacrimal gland enlargement, positive Mantoux & PCR with early response to ATT may provide sufficient evidence for diagnosing TbD.

Utility of routine chest radiography in ocular tuberculosis and sarcoidosis.

BACKGROUND: Tuberculosis (TB) and sarcoidosis commonly present with pulmonary and ocular involvement. Routine chest radiography (CXR) is recommended in the workup for suspected intraocular TB (IOTB) or intraocular sarcoidosis (IOS); however, data on the utility of CXR in this setting are lacking. METHODS: A post-hoc analysis was performed of a prospectively collected data set comprising 104 patients with uveitis of unknown cause. A pulmonologist and thoracic radiologist, blinded to the final diagnosis, independently reported these CXRs as being in keeping with TB or sarcoidosis. RESULTS: CXRs were reported as normal/indeterminate (n = 88), probable/previous TB (n = 9) or possible/probable sarcoidosis (n = 8), with a 96% inter-observer concordance. CXRs were more often abnormal in IOS than in IOTB (5/8 vs. 5/34, P = 0.01). CXR had a sensitivity of 14.7%, specificity of 94.3%, positive predictive value (PPV) of 55.6% and negative predictive value (NPV) of 69.5% for IOTB, compared with a sensitivity of 62.5%, specificity of 96.9%, PPV of 62.5% and NPV of 96.9% for IOS. Overall diagnostic accuracy was 54.5% (58.1% in human immunodeficiency virus [HIV] positive participants) in the case of IOTB and 79.9% for IOS. CONCLUSION: CXR had high specificity and NPV for IOS, and poor overall diagnostic accuracy for IOTB, including in the HIV-positive population.

Role of Endoscopic Ultrasound in the Management of Tubercular Uveitis.

PURPOSE: To evaluate the role and safety of endoscopic ultrasound-guided fine-needle aspiration cytology (EUS-FNAC) in patients of tubercular uveitis. DESIGN: Interventional case series Methods: Thirty patients suspected of tubercular uveitis that underwent EUS-FNAC were enrolled in the study. The patient details recorded were age, gender, systemic history, ocular complaints and clinical manifestations. The details of the investigations - skin test, X-Ray chest, CECT (contrast enhanced computed tomography) of chest and findings on EUS-FNAC were also recorded. RESULTS: Thirty patients with suspected tubercular uveitis showed mediastinal lymphadenopathy on CECT-chest and underwent EUS-FNAC. A total of 27 patients showed tubercular lymphadenitis and three patients showed reactive lymphadenopathy. Ziehl-Neelsen (ZN) staining was positive for acid-fast bacilli in four cases and culture was positive in one case. There were no noted complications of EUS-FNAC. CONCLUSION: EUS-FNAC is a safe and efficacious procedure for confirming the diagnosis of tubercular uveitis and should be routinely employed wherever available.

Observed Patterns of Systemic Disease on PET/CT Scan in Patients with Presumed Ocular Tuberculosis: Findings and Hypotheses.

PURPOSE: To report the clinical, investigational and PET/CT scan findings of patients with presumed ocular tuberculosis and suggest a hypotheses for the pathogenesis. METHODS: Retrospective case review. Included were 10 males and 17 females with an age range: 23-71 years. RESULTS: Clinical findings include granulomatous or non-granulomatous anterior uveitis, intermediate uveitis, panuveitis, vasculitis, and multifocal serpiginous-like choroidopathy. A total of 13 PET/CT scans were normal and 14 showed systemic disease. The commonest finding was metabolically active lymphadenopathy and was seen in 14 patients. Mediastinal lymphadenitis was seen in 12 patients, 3 patients had abdominal/pelvic lymphadenopathy and 3 patients had additional cervical lymphadenopathy. Two patients had only cervical lymphadenitis. One patient had lung parenchymal disease and one had bone/joint disease. The commonest pathology was lymphadenitis. CONCLUSIONS: Uveitis is part of an immune response to mycobacteria that manifests as lymphadenitis in the chest/abdomen and as a uveitis.

Intravitreal Bevacizumab for Choroidal Neovascular Membrane at the Edge of a Healed Choroidal Tuberculoma.

The authors present a 36-year-old female with pulmonary tuberculosis who developed a choroidal tuberculoma in the left eye. The choroidal tuberculoma successfully resolved with visual gain following oral anti-tubercular and oral steroid therapy leaving behind a chorioretinal scar. One year after the completion of anti-tubercular treatment, she developed visual loss due to the development of a secondary choroidal neovascular membrane at the fovea. This was treated successfully with one intravitreal injection of bevacizumab in the left eye. The fovea remained free of fluid until the last follow-up 10 months after the intravitreal injection. Intravitreal bevacizumab may be an effective modality for treating secondary choroidal neovascular membranes that may form at the edge of a healed choroidal tuberculoma.

Multimodal Imaging in Ocular Tuberculosis.

Intraocular tuberculosis presents a diagnostic challenge because of its protean clinical manifestations. Thus, it becomes imperative to distinguish chorioretinal inflammation due to tuberculosis from other infectious as well as non-infectious posterior uveitis since the clinical manifestations of these entities may be quite similar. With advancing technology, a number of novel imaging modalities are available today that enable in vivo near-histologic assessment of the chorioretinal tissue, greatly aiding the clinician in establishing a diagnosis and monitoring the therapeutic response of tubercular lesions. Techniques such as ultra-wide field fundus photography, fluorescein and indocyanine green angiography, optical coherence tomography and most recently, optical coherence tomography angiography, provide valuable information that helps in advancing our knowledge regarding the pathogenesis and natural history of the disease. The index review describes how these techniques supplement each other, and highlights the relevance of multimodal imaging in the management of intraocular tuberculosis.

Tuberculosis presenting as an orbital mass.

A 15-year-old male adolescent underwent surgical exploration for a mass lesion of the left orbit. Orbital and pulmonary tuberculosis were postoperatively diagnosed on the basis of radiologic and histopathologic findings, a positive tuberculin skin test reaction, and positive cultures for Mycobacterium tuberculosis. This case emphasizes the point that tuberculosis should be considered in the differential diagnosis of orbital masses.