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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 308-309

Preretinal exudates in ocular tuberculosis


1 Department of Retina and Vitreous, Pushpagiri Vitreo-Retina Institute, Hyderabad, Telangana, India
2 Retina-Vitreous Service, L V Prasad Eye Institute, Bhubaneswar, Odisha, India

Date of Submission18-May-2020
Date of Acceptance20-Nov-2020
Date of Web Publication01-Apr-2021

Correspondence Address:
Dr. Anup Kelgaonkar
Consultant, Retina-Vitreous Service, L V Prasad Eye Institute, Bhubaneswar - 751 024, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1354_20

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  Abstract 


Preretinal exudates have been described in various ocular diseases. We present a case of preretinal exudates in tubercular retinal vasculitis with an inflammatory choroidal neovascular membrane (CNVM). The patient was treated with a tapering dose of oral corticosteroids, antitubercular therapy. Inflammatory CNVM which develops in active disease or during regression can be treated with intravitreal bevacizumab. In our case, the resolution of exudates was seen within 8 weeks of starting the treatment without any scar formation. In conclusion, we report a picture of exudates in a novel plane (preretinal) concerning tubercular vasculitis.

Keywords: Preretinal exudates, tubercular retinal vasculitis, inflammatory CNVM


How to cite this article:
Govindahari V, Raghavendra Rao K, Kelgaonkar A. Preretinal exudates in ocular tuberculosis. Indian J Ophthalmol Case Rep 2021;1:308-9

How to cite this URL:
Govindahari V, Raghavendra Rao K, Kelgaonkar A. Preretinal exudates in ocular tuberculosis. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Apr 14];1:308-9. Available from: https://www.ijoreports.in/text.asp?2021/1/2/308/312327



Retinal vasculitis includes inflammation of retinal arteries or veins or both. It could be either idiopathic or secondary to various diseases. Diagnosis is made clinically, which can be confirmed by fluorescein angiography. Sometimes vasculitis is associated with preretinal exudates, choroidal neovascular membrane (CNVM), and their presence is also described in many infectious and autoimmune diseases. In this case report, we report the presence of preretinal exudates in tubercular vasculitis.


  Case Report Top


A 40-year-old male, presented with complaints of diminished vision in the right eye (RE) for 1 year. The best-corrected visual acuity (BCVA) was 20/125 in RE and 20/20 in the left eye (LE). The anterior segment of both eyes (BE) was unremarkable. Fundus examination of RE revealed mid-peripheral periphlebitis in all quadrants, focal vascular tortuosity, and sub-vascular active as well as healed (pigmented) chorioretinitis lesions. Loss of foveal reflex due to the presence of subfoveal grayish-white membrane was noted. Fluffy clumps of exudates were noted in the preretinal plane temporal to fovea and along the inferotemporal arcade. LE examination revealed segmental sheathing of blood vessels in the periphery and multiple subvascular active and healed chorioretinitis lesions along the arcades. Optical coherence tomography (OCT) of RE demonstrated preretinal hyperreflective foci corresponding to the fluffy exudates and loss of foveal contour due to subfoveal hyperreflective lesion with associated intraretinal and subretinal fluid suggesting CNVM. LE OCT revealed few cystoid spaces at the fovea and the presence of hyperreflective inner retinal focus (suspected inner retinal infarct) with altered outer retinal integrity temporal to fovea [Figure 1]a. A working diagnosis of active retinal vasculitis was made and the patient was subjected to investigations. Tuberculin skin test showed 17 mm of induration and a high-resolution computerized tomography scan of the thorax showed consolidation of the lung secondary to suspected tubercular infection. On further questioning, the patient's mother received antitubercular therapy (ATT) for pulmonary tuberculosis in the past. Diagnosis of BE probable active tubercular retinal vasculitis with inflammatory CNVM in RE was made. The patient was started on ATT along with a tapering dosage of oral steroids (Tab. prednisolone 1 mg/kg body weight) and intravitreal bevacizumab (IVB) in RE. Four weeks after initiation of treatment, regression of exudates was observed along with hemorrhage associated with CNVM. Optical coherence tomography angiography (OCTA) shows the presence of a vascular net in the outer retina slab, suggestive of persistent CNVM [Figure 1]b. Resolution of fluffy preretinal exudates without scarring occurred over the next 8 weeks and retinal vasculitis in 3 months [Figure 2]. ATT was completed over 6 months while oral steroid was tapered over 3 months. The patient also received sectoral laser in areas with sclerosed vessels and a total of five IVB injections for CNVM in RE over the next 9 months. During the last follow-up, 9 months from the presentation, BCVA in RE was 20/25p with healed retinal vasculitis and scarred CNVM.
Figure 1: Imaging on presentation: (a) A, B: Both eyes fundus picture revealed vascular sheathing (arrowhead), active (circle), and healed (star) chorioretinitis lesions. In addition, the right eye (RE) fundus picture (FP) with the subfoveal grayish-white membrane (dotted arrow), exudates (arrow). C: RE Optical coherence tomography (OCT) with preretinal hyperreflective foci suggesting exudates (arrow), the subfoveal hyperreflective lesion (dotted arrow), subretinal fluid (star). D: Left eye OCT with cystoid spaces at the fovea (star), hyperreflective inner retinal focus (arrow). (b) Imaging during 4 weeks follow-up. A: Fundus picture of the right eye (RE) shows the presence of subfoveal grayish-white membrane (dotted arrow) with associated hemorrhage (star), presence of fluffy exudates (arrow), sheathing of blood vessels (arrowhead), subvascular active (circle), and healed (star) retinitis lesions. B: RE optical coherence tomography with preretinal hyperreflective foci corresponding to exudates (arrow), the subfoveal hyperreflective lesion (dotted arrow), and subretinal fluid (star). C: RE OCT-angiography revealed the presence of vascular net in the outer retina slab (dotted arrow)

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Figure 2: Subsequent follow-up images: Color fundus picture (CFP) and optical coherence tomography (OCT) (6 mm radial scan) of the right eye (RE) at initial presentation showing the presence of fluffy exudate (arrow, a) and hyperreflectivity (arrow, b). CFP and OCT (12 mm radial scan) of RE at 1-month follow-up showing decreased exudation (arrow, c) and hyperreflectivity (arrow, d). CFP and OCT (12 mm radial scan) of RE on 2-month follow-up showing resolution of exudation (arrow, e) and hyperreflectivity (arrow, f)

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  Discussion Top


The etiology of retinal vasculitis includes idiopathic, infectious, autoimmune, and neoplastic disorders. Tuberculosis (TB) is a common suspect in endemic countries like India.[1] In TB endemic countries like India, clinical predictors of TB vasculitis are characterized by the sub-vascular lesions either active or healed (pigmented scars), focal vascular tortuosity, and vascular occlusion.[2] Secondary changes include fibrovascular proliferation, vitreous hemorrhage, or tractional detachment. Histopathology of the chorioretinitis lesions shows the presence of intraretinal granulomas secondary to activated microglial cells.[3] Treatment includes ATT, oral corticosteroids in controlling collateral inflammatory damage, sectoral laser, and vitreoretinal surgery. Inflammatory CNVM can occur less frequently. Sometimes type 2 CNVM can occur following a healed multifocal serpiginoid choroiditis and type 3 CNVM in active tubercular granulomas.[4] These can be managed with anti-vascular endothelial growth factor (anti-VEGF).[5],[6] Patient compliance is needed for better management as many drugs are used.

Preretinal exudates have been described in various conditions like ocular syphilis, Behcet's disease, Bartonellosis, familial exudative vitreoretinopathy, and neoplastic disorders.[7] In syphilis, they can occur irrespective of underlying placoid retinitis. In neoplastic disorders, their occurrence is presumed to be an accumulation of lymphocytes.[6] In TB, intraretinal perivascular exudates (segmental or confluent), exudates in the subhyaloid and subretinal space simulating pseudohypopyon have been reported which are presumed to be secondary to accumulation of inflammatory cells.[8],[9] This case report describes preretinal exudate as yet another clinical sign in the wide-spectrum of tubercular uveitis. Mostly these could be inflammatory, but due to absent histopathological confirmation; fibrin deposits or localized granulomas cannot be ruled out. Further studies are warranted to determine the histopathological composition of these exudates. In our case, we started both ATT and oral corticosteroids for the treatment of vasculitis along with IVB for CNVM, which lead to the regression of exudates without leaving any scar. It is hence difficult to understand and attribute the resolution of these exudates to a specific therapeutic agent.


  Conclusion Top


In conclusion, we report the occurrence of preretinal exudates in tubercular retinal vasculitis with a hitherto unreported picture of a preretinal exudate which resolved following ATT.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gupta V, Gupta A, Rao NA. Intraocular tuberculosis-- an update. Surv Ophthalmol 2007;52:561-87.  Back to cited text no. 1
    
2.
Kaza H, Tyagi M, Pathengay A, Basu S. Clinical predictors of tubercular retinal vasculitis in a high-endemic country. Retina 2020. doi: 10.1097/IAE.0000000000002829.  Back to cited text no. 2
    
3.
Basu S, Mittal R, Balne PK, Sharma S. Intraretinal tuberculosis. Ophthalmology 2012;119:2192-3.  Back to cited text no. 3
    
4.
Bansal R, Basu S, Gupta A, Rao N, Invernizzi A, Kramer M. Imaging in tuberculosis-associated uveitis. Indian J Ophthalmol 2017;65:264-70.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Talat L, Lightman S, Tomkins-Netzer O. Ischemic retinal vasculitis and its management. J Ophthalmol 2014;2014:197675.  Back to cited text no. 5
    
6.
Agarwal A, Invernizzi A, Singh RB, Foulsham W, Aggarwal K, Handa S, et al. An update on inflammatory choroidal neovascularization: Epidemiology, multimodal imaging, and management. J Ophthalmic Inflamm Infect 2018;8:13.  Back to cited text no. 6
    
7.
Sihota R, Paul AH, Chandna R. Preretinal 'hypopyon'. Br J Ophthalmol 1997;81:91-2.  Back to cited text no. 7
    
8.
Abu El-Asrar AM, Herbort CP, Tabbara KF. Differential diagnosis of retinal vasculitis. Middle East Afr J Ophthalmol 2009;16:202-18.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Chawla R, Tripathy K, Meena S, Behera AK. Subretinal hypopyon in presumed tubercular uveitis: A report of two cases. Middle East Afr J Ophthalmol 2018;25:163-6.  Back to cited text no. 9
[PUBMED]  [Full text]  


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