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PHOTO ESSAY
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 287-289

Tale of a choroidal tuberculoma: Bacillary layer detachment at presentation and late choroidal neovascularization


Department of Retina and Vitreous, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India

Date of Submission27-May-2021
Date of Acceptance24-Jul-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Jahnara Jaffar
Department of Retina and Vitreous, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Tirunelveli - 627 001, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1425_21

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  Abstract 


Keywords: Bacillary layer detachment, choroidal granuloma, choroidal neovascular membrane, OCT angiography, ocular tuberculosis


How to cite this article:
Abdul Khadar SM, Jaffar J, Shah V, Gunderia A. Tale of a choroidal tuberculoma: Bacillary layer detachment at presentation and late choroidal neovascularization. Indian J Ophthalmol Case Rep 2022;2:287-9

How to cite this URL:
Abdul Khadar SM, Jaffar J, Shah V, Gunderia A. Tale of a choroidal tuberculoma: Bacillary layer detachment at presentation and late choroidal neovascularization. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Jan 19];2:287-9. Available from: https://www.ijoreports.in/text.asp?2022/2/1/287/334876



A 26-year-old man presented to us with complaints of sudden onset diminution of vision in his left eye for 2 days. The best-corrected visual acuity in the right eye was 20/20 and in the left eye was 20/200. The anterior segment examination in both eyes was unremarkable. Fundus examination of the right eye was normal. Fundus examination of the left eye showed a subretinal lesion measuring half disc diameter located superior to the fovea and another cystic lesion at the fovea [Figure 1]a and [Figure 1]b. Optical coherence tomography (OCT) passing through the subretinal lesion showed dome-shaped elevation of the retina [Figure 1]c. Spectral-domain optical coherence tomography (SD-OCT) passing through the center of fovea showed a cystic lesion in the outer retina. The floor of the cystic lesion was formed by a discontinuous hyperreflective line continuous with the flanking ellipsoid zone. External limiting membrane coursed anterior to the cystic structure. The split was noted to be at the hyporeflective myoid zone [Figure 1]d. Based on a positive Mantoux test, he was diagnosed with presumed ocular tuberculosis with choroidal granuloma. He was started on a trial of AKT 4 with four antituberculosis drugs after obtaining informed consent. Follow-up visit 1 week later, visual acuity improved to 20/100. Fundus showed resolving granuloma going for scar formation [Figure 2]a. SD-OCT revealed resolution of the bacillary layer detachment [Figure 2]b]. The patient was advised to continue the antituberculosis therapy. Review at 2 months of completing the four drug regime, visual acuity has improved to 20/30. Fundus showed scar superior to fovea, minimal subretinal fluid, and a small hemorrhage [Figure 3]a. OCT and OCT angiography performed during this visit confirmed the presence of a choroidal neovascular membrane (CNVM) [Figure 3]b, [Figure 3]c, [Figure 3]d. The patient was started on three drug regime of antituberculosis therapy and administered intravitreal Bevacizumab injection after informed consent. Review after 1 month revealed regressing CNVM [Figure 4]. The visual acuity was stable at 20/30. The patient was advised repeat injection of Bevacizumab.
Figure 1: (a and b) Fundus photograph and multicolor image of the left eye. Red star denotes choroidal granuloma superior to fovea. Black star denotes cystic structure at fovea, the bacillary layer detachment. (c) Spectral-domain optical coherence tomography (SD-OCT) scan passing through the choroidal granuloma showing choroidal elevation. (d) SD-OCT scan passing through the cystic structure. The floor of the cystic structure is formed by a thin line of hyperreflectivity and is flanked by ellipsoid on both sides. There is amorphous material inside the cystic structure. The external limiting membrane is seen coursing anterior to it. Note the choroidal elevation under the bacillary layer detachment

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Figure 2: (a) Fundus photograph after 1 week of antituberculosis treatment showing resolving granuloma. (b) SD-OCT passing through the fovea, showing resolved bacillary layer detachment; two hyperreflective lines are seen corresponding to the rim of the old bacillary layer detachment

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Figure 3: (a) Fundus photograph taken 2 months after initiating antituberculosis therapy, showing a pigmented scar. Arrowhead shows a small hemorrhage. Star showing surrounding subretinal fluid. (b) SD-OCT taken at the same visit, presence of intraretinal edema with multiple intraretinal cystic spaces in inner and outer retina. (c) SD-OCT showing the presence of subretinal fluid. (d) OCT angiography demonstrating a neovascular complex in the avascular zone

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Figure 4: (a and b) SD-OCT images showing reduction in intraretinal edema and subretinal fluid after intravitreal injection of Bevacizumab. (Upper image is preinjection; lower image is postinjection). (c and d) OCT angiography image showing a reduction in the size of the neovascular complex in the avascular zone: panel (c) is preinjection and panel (d) is postinjection

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  Discussion Top


Bacillary layer detachment is a presumed split at the level of photoreceptor myoid zone between the ellipsoid and the external limiting membrane.[1] It has been reported in both inflammatory conditions like toxoplasma chorioretinitis, Vogt Koyanagi Harada disease, acute posterior multifocal placoid pigment epitheliopathy, and noninflammatory conditions like pachychoroid-associated serous chorio-retinopathy and trauma.[1],[2],[3],[4] Markan et al.[5] have described a similar case of tuberculoma with bacillary layer detachment.

Our case also developed a CNVM in the resolving phase. The appearance of a small hemorrhage near the resolving granuloma prompted us to perform an OCT angiography, which revealed the presence of a CNVM. The patient was followed-up with OCT angiography, which demonstrated a reduction in the size of the CNVM complex after antivascular endothelial growth factor injection.


  Conclusion Top


Akin to many inflammatory conditions, bacillary layer detachment can be a presenting feature in choroidal tuberculoma. We want to stress the role of OCT angiography in the timely diagnosis and follow-up of CNVM in intraocular tuberculosis.

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.
Mehta N, Chong J, Tsui E, Duncan JL, Curcio CA, Freund KB, et al. Presumed foveal bacillary layer detachment in a patient with toxoplasmosis chorioretinitis and pachychoroid disease. Retin Cases Brief Rep 2021;15:391-8.  Back to cited text no. 1
    
2.
Agarwal A, Freund KB, Kumar A, Aggarwal K, Sharma D, Katoch D, et al. Bacillary layer detachment in acute Vogt-Koyanagi-Harada disease: A novel swept-source optical coherence tomography analysis. Retina 2021;41:774-83.  Back to cited text no. 2
    
3.
Tekin K, Teke MY. Bacillary layer detachment: A novel optical coherence tomography finding as part of blunt eye trauma. Clin Exp Optom 2019;102:343-44.  Back to cited text no. 3
    
4.
Kohli GM, Bhatia P, Shenoy P, Sen A, Gupta A. Bacillary layer detachment in hyper-acute stage of acute posterior multifocal placoid pigment epitheliopathy: A case series. Ocul Immunol Inflamm 2020:1-4. doi: 10.1080/09273948.2020.1823423. Online ahead of print.  Back to cited text no. 4
    
5.
Markan A, Aggarwal K, Gupta V, Agarwal A. Bacillary layer detachment in tubercular choroidal granuloma: A new optical coherence tomography finding. Indian J Ophthalmol 2020;68:1944-6.  Back to cited text no. 5
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