Fundus Photography, Fluorescein Angiography, and Indocyanine Green Angiography of Tuberculous Choroiditis
Author (s): Kristen Russell
Image or video:
Keywords/Main Subjects: Tuberculous Choroiditis
Diagnosis: Tuberculous Choroiditis
Description of Image:
Here we are showing the fundus photo, FA, and ICG from a 51 year old female. She was referred to uveitis clinic because her BCVA was 20/60 OS and she had a history of recurrent vitreous cell, floaters, and photophobia. Previously, she had several PPD’s (purified protein derivative) that were positive, however, her chest x-ray had remained negative. On exam, her right eye was normal, but her left eye had mutton fat keratic precipitates, posterior synechiae, 1-2+ cell in the anterior chamber, vitreous haze, loss of the foveal reflex and inferior punched out chorioretinal lesions. Her left fundus photo showed mild haze and intraretinal heme. On FA, there were numerous nasal lesions that demonstrated early hypofluorescence and late hyperfluorescence. The ICG had multiple hypo-fluorescent lesions which matched the FA. Her laboratory work-up revealed a positive QuantiFERON-TB Gold. She was started on ethambutol, isoniazid, pyrazinamide, and rifampin and within one month, BCVA returned to 20/30 OS.
Mycobacterium Tuberculosis can cause a variety of ocular manifestations ranging from retinitis to scleritis. However, the most common is focal or multifocal choroiditis. Patients often present with no history of active TB and only half have a positive chest x-ray (1). Instead, patients may report photopsias, floaters, or scotomas. On slit lamp exam, there will be signs of uveitis, such as mutton fat keratic precipitates, cell and flare, posterior synechiae, and vitreous cells. Fundus exam may reveal areas of atrophy or active choroidal lesions. On fluorescein angiography (FA), the active site will typically show early hypo-fluorescence but late hyperfluorescence—versus indocyanine green angiography (ICG), where the lesions remain hypo-fluorescent throughout the course of the study. The differential diagnosis for these symptoms and imaging studies includes syphilis, sarcoidosis, birdshot retinochoroidopathy, and Vogt-Koyanagi-Harada syndrome. A common work-up, therefore, might include a QuantiFERON-TB Gold, RPR, FTA-ABS, chest x-ray, ACE, HLA-A29, hearing screening, and lumbar puncture. If a patient is diagnosed with ocular tuberculosis, the treatment is anti-TB medication, sometimes in conjunction with systemic corticosteroids.
- Bennett, J. E., Dolin, R., Blaser, M. J., Mandell, G. L., & Douglas, R. G. (2015). Infectious Causes of Uveitis. In Mandell, Douglas, and Bennetts Principles and practice of infectious diseases. (pp 1423-1431). Elsevier Inc.
- American Academy of Ophthalmology. (n.d.). White Dot Syndromes: Multifocal Choroiditis and Panuveitis. Retrieved from https://www.aao.org/focalpointssnippetdetail.aspx
- Gupta, A., Bansal, R., & Gupta, V. (2014). Tuberculosis, Leprosy, and Brucellosis. In Ophthalmology (pp. 716-719). Elsevier Inc.
Faculty Approval by: Griffin Jardine, MD
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Disclosure (Financial or other): None