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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 695-697

Optical coherence tomography angiography of intraretinal neovascularization in an eye with tubercular serpiginous-like choroiditis


Department of Uveitis and Ocular Inflammation, Vittala International Institute of Ophthalmology and Prabha Eye Clinic and Research Centre, Bengaluru, Karnataka, India

Date of Submission31-Jan-2022
Date of Acceptance25-Mar-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. Kalpana Babu
Prabha Eye Clinic and Research Centre, 504, 40th Cross, Jayanagar 8th Block, Bengaluru - 560 070, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_215_22

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  Abstract 


We present a case of a 28-year-old male who was diagnosed with bilateral tubercular multifocal choroiditis with intraretinal neovascularization adjacent to an area of choroiditis in the left eye. We present OCTA features of the neovascular complex before and after 4 months of treatment with anti-tubercular therapy and oral steroids. We speculate that the intraretinal neovascular complex noted in our case may be due to VEGF released by the underlying ischemic choroid.

Keywords: Choroiditis, intraretinal neovascularization, OCT, OCTA, serpiginous, tuberculosis, VEGF


How to cite this article:
Konana VK, Babu K. Optical coherence tomography angiography of intraretinal neovascularization in an eye with tubercular serpiginous-like choroiditis. Indian J Ophthalmol Case Rep 2022;2:695-7

How to cite this URL:
Konana VK, Babu K. Optical coherence tomography angiography of intraretinal neovascularization in an eye with tubercular serpiginous-like choroiditis. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 13];2:695-7. Available from: https://www.ijoreports.in/text.asp?2022/2/3/695/351137



Intraocular tuberculosis can present as multifocal choroiditis resembling serpiginous choroiditis, especially in countries endemic for tuberculosis.[1] Choroidal and retinal neovascularization as a complication of intraocular inflammation is a well-established entity.[2],[3] Retinal neovascularization due to ischemia in cases of retinal vasculitis secondary to tuberculosis is also well known.[4] In this case, we describe a rare case of intraretinal neovascularization in a case of serpiginous-like choroiditis secondary to presumed ocular tuberculosis.


  Case Report Top


A 28-year-old male presented with poor vision in the left eye for 15 days. His systemic history was not contributory. Best-corrected visual acuity was 6/6, N6 and 3/60, <N 36 in the right eye and left eye, respectively. Intraocular pressure in both eyes was normal. Anterior segment examination in both eyes was unremarkable. Fundus examination in the right eye showed a few creamy yellow lesions with multiple choroidal scars within the posterior pole just sparing the foveola [Figure 1]a. Left-eye fundus examination showed 2 + vitreous cells (SUN classification) and creamy-yellow subretinal lesions in the posterior pole, involving the fovea. A few grayish healing lesions were noted admixed with the active lesions. Temporal to the fovea, a vein with right angle bending with intraretinal arborising pattern was noted. This intraretinal vascular complex was surrounded by healed choroidal lesions [Figure 1]b. Fundus autofluorescence (FAF) in both eyes showed multiple hypoautoflorescent areas with hyperautofluorescent edges suggestive of healing lesions. Left-eye FAF showed minimal hyperautofluorescence at the macula corresponding to creamy-yellow lesions [Figure 1]c and [Figure 1]d. Optical coherence tomography angiogram (OCTA) in the right eye showed normal superficial, deep retinal capillaries and low-flow areas in choriocapillary slab suggestive of focal choroidal ischemia corresponding to areas of choroiditis [Figure 2]a, [Figure 2]b, [Figure 2]c. In the left eye, superficial capillary plexus showed capillary dropout superotemporal to the fovea and an abruptly ending large vessel temporal to fovea with abnormal vascular branching, deep capillary plexus showed barren tree-like branching and choriocapillary slab of OCTA shows multiple low-flow areas [Figure 3]a, [Figure 3]b, [Figure 3]c. Cross-sectional OCTA did not show any vasculature in the outer retina, thus ruling out retinochoroidal anastomosis [Figure 3]d. Mantoux test was negative, and serological tests revealed negative Quantiferon TB gold. High-resolution computerized tomography scan of the thorax showed bilateral ground glass appearance throughout the lung fields. He was started on anti-tubercular therapy (ATT) and tapering dose of oral prednisolone 40 mg/day based on the phenotypical pattern of the disease suggestive of presumed ocular tuberculosis. Four months later, his BCVA was 6/6, N6 and 6/9, N 8. Both-eye fundus examination showed a healing choroiditis lesion [Figure 4]a and [Figure 4]b. FAF showed an increase in hypoautofluorescent areas, suggesting that the choroidal lesions were healing [Figure 4]c and [Figure 4]d. OCTA in the left eye showed no change in the vascular pattern noted temporal to fovea [Figure 4]e and [Figure 4]f.
Figure 1: (a) Color fundus photo of right eye shows a few creamy yellow lesions with multiple choroidal scars. (b) Color fundus photo of left eye shows creamy yellow subretinal lesions involving the fovea with few choroidal scars. Temporal to the fovea, a vein with right angle bending with intraretinal arborising pattern was noted (white dotted circle). (c) Fundus autofluorescence (FAF) of right eye showed multiple hypoautoflorescent areas with hyperautofluorescent edges suggestive of healing lesions. (d) Left-eye FAF showed minimal hyperautofluorescence at the macula corresponding to creamy yellow lesions

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Figure 2: (a and b) Optical coherence tomography angiogram (OCTA) in the right eye showed normal superficial, deep retinal capillaries. (c) Choriocapillary slab of OCTA shows multiple low-flow areas (white arrows)

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Figure 3: (a) Superficial capillary plexus of OCTA shows capillary dropout superotemporal to the fovea and abruptly ending large vessel temporal to fovea with abnormal vascular branching. (yellow arrow). (b) Deep capillary plexus of OCTA shows barren tree-like branching (yellow dotted circle). (c) Choriocapillary slab of OCTA shows multiple low-flow areas. (d) Cross-sectional OCTA shows large-caliber vessels in inner retina and avascular outer retina (yellow dotted circle)

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Figure 4: (a and b) Both eyes color fundus photo at 4 months follow-up shows healing lesion. (c and d) FAF at 4 months follow-up shows an increase in hypoautofluorescent areas, suggesting that the choroidal lesions are healing. (e and f) Superficial and deep capillary plexus of the left eye OCTA shows unchanged branching intraretinal vessels temporal to the fovea

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  Discussion Top


Multifocal progressive serpiginous-like choroiditis secondary to tuberculosis is a well-established clinical entity in the literature.[1],[5] Choroiditis results in hypoperfusion, resulting in localized ischemia and increased expression of vascular endothelial growth factor (VEGF). Thayil et al. studied microbiological, histological, and clinical features of intraocular tuberculosis in guinea pigs following aerosol infection with Mycobacterium tuberculosis.[6] They noted that the choroidal tuberculous granulomas showed decreased oxygen tension, as evidenced by staining with the hypoxia-specific probe pimonidazole and expression of VEGF in the RPE and photoreceptors.[6] Expression of VEGF leads to the development of choroidal neovascular membrane and retinal angiomatosis proliferation (RAP).[7] Anti-VEGF agents have been used as an adjunctive agent in the treatment of tubercular granuloma along with ATT and immunosuppressive agents.[8],[9]

In our case, the arborizing intraretinal neovascularization is seen arising from an inferotemporal vein adjacent to healed choroiditis lesion. Intraretinal neovascularization seen in our case showed no evidence of exudation on optical coherence tomography (OCT). The neovascular complex in our case was noted only in the superficial and deep capillary plexus on OCTA, ruling out chorioretinal anastomosis. We hypothesize that the intraretinal neovascular complex noted in our case could be due to VEGF released by the underlying ischemic choroid. To the best of our knowledge, ours is the first report of OCTA in inner retinal intraretinal neovascularization in a case of serpiginous-like choroiditis.


  Conclusion Top


We present a rare case of intraretinal neovascularization in a case of tubercular multifocal choroiditis with OCTA features. We hypothesize that the intraretinal neovascular complex noted in our case could be due to VEGF released by the underlying ischemic choroid.

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.
Bansal R, Gupta A, Gupta V, Dogra MR, Sharma A, Bambery P. Tubercular serpiginous-like choroiditis presenting as multifocal serpiginoid choroiditis. Ophthalmology 2012;119:2334-42.  Back to cited text no. 1
    
2.
Dhingra N, Kelly S, Majid MA, Bailey CB, Dick AD. Inflammatory choroidal neovascular membrane in posterior uveitis-pathogenesis and treatment. Indian J Ophthalmol 2010;58:3-10.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Talat L, Lightman S, Tomkins-Netzer O. Ischemic retinal vasculitis and its management. J Ophthalmol 2014;2014:197675.  Back to cited text no. 3
    
4.
Manousaridis K, Ong E, Stenton C, Gupta R, Browning AC, Pandit R. Clinical presentation, treatment, and outcomes in presumed intraocular tuberculosis: Experience from Newcastle upon Tyne, UK. Eye 2013;27:480-6.  Back to cited text no. 4
    
5.
Vasconcelos-Santos DV, Rao PK, Davies JB, Sohn EH, Rao NA. Clinical features of tuberculous serpiginouslike choroiditis in contrast to classic serpiginous choroiditis. Arch Ophthalmol 2010;128:853-8.  Back to cited text no. 5
    
6.
Thayil SM, Albini TA, Nazari H, Moshfeghi AA, Parel JM, Rao NA, et al. Local ischemia and increased expression of vascular endothelial growth factor following ocular dissemination of Mycobacterium tuberculosis. PLoS One 2011;6:e28383.  Back to cited text no. 6
    
7.
Gupta V, Gupta A, Rao NA. Intraocular tuberculosis--An update. Surv Ophthalmol 2007;52:561-87.  Back to cited text no. 7
    
8.
Babu K, Murthy PR, Murthy KR. Intravitreal bevacizumab as an adjunct in a patient with presumed vascularised choroidal tubercular granuloma. Eye 2019;24:397-9.  Back to cited text no. 8
    
9.
Bansal R, Beke N, Sharma A, Gupta A. Intravitreal bevacizumab as an adjunct in the management of a vascular choroidal granuloma. BMJ Case Rep 2013;bcr2013200255. doi: 10.1136/bcr-2013-200255.  Back to cited text no. 9
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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