CASE OF THE MONTH: January 2024

Breakthrough Lesions

By Tobin Thuma, DO - PGY2 Ophthalmology Resident, Weill Cornell Medicine Israel Englander Department of Ophthalmology

Chief Complaint

  • Left eye blurry vision x 6 weeks

History of Present Illness

  • 42M, saw outside ophthalmologist 6 weeks ago
    • Diagnosed with uveitis OS
    • Started on steroids and cycloplegic
  • No improvement
  • 11/10: Saw retina for second opinion
    • Blurry vision OS>OD, floaters OS
    • Left eye mild injection

Exam

  • VA (cc) 20/20-3, 20/40-1 ph 20/20
  • IOP 12/9
  • PERRL
  • CVF full OU
  • EOMI







DFE


Differential Diagnosis

  • For chorioretinitis or other white lesions in the retina

  • Infectious:
    • Toxoplasmosis
    • Viral: CMV, HSV, rubella, West Nile virus
    • HIV related eye diseases
    • Tuberculosis
    • Toxocara
    • Syphilis
    • Bartonella
    • Fungal: Candida, Coccidioidomycosis, Presumed histoplasmosis
  • Inflammatory:
    • Sarcoidosis
    • Behcets disease
    • VKH
    • White dot syndromes: MEWDS, APMPPE, Birdshot, Multifocal choroiditis and panuveitis, AZOOR, Punctate inner choroiditis, Serpiginous choroiditis
  • Oncologic:
    • Lymphoma
    • Metastases
    • CAR
    • Melanoma
    • Lymphoma

History

  • Pt born in China
  • 6/8: Ureteral stenting for renal papillary necrosis/gross hematuria
  • 6/15: Admitted for postop recurrent fevers and perinephric hematoma
  • Course c/b parainfluenza, ARDS
  • 6/26: BAL revealed TB
  • 6/30: Started on RIPE therapy
  • 7/3: Inpatient ophthalmology evaluation, normal DFE

More History

  • 7/30: steroids tapered off
  • 8/7: ethambutol stopped
    • Floaters and blurry vision started
  • 8/30: pyrazinamide stopped as planned
    • Pt continued on rifampin and isoniazid

Back to the Present (11/10)

  • Patient sent from clinic to ED
    • ID workup and management
    • Workup for alternative etiologies
  • Continued on pred and cyclo BID OS

Workup


ID Management

  • Discussion with DOH
  • Continue RI
  • Start moxifloxacin
  • Start pyrazinamide
  • Start bactrim
  • Start prednisone
    • Immune reconstitution inflammatory syndrome (IRIS)
  • MRI brain wwo

Discharge

  • Patient stable on serial exams x 7 days
  • Patient discharged for outpatient monitoring
  • Patient followed closely on discharge
  • Most recent visit on 11/27

Outpatient Follow-up (11/27)

VA 20/30, 20/30





Diagnosis

  • Mycobacterium tuberculosis chorioretinitis of both eyes
  • Mycobacterial subretinal abscess of left eye
  • Follow-up scheduled for 12/11/23

MRI Brain 12/2/23


Neuro-ophthalmology 12/7

  • VA 20/40-2 ph 20/20-1, 20/40+2 ph NI
  • HVF: Subtle inferior nasal defect OS
  • Visual dysfunction likely 2/2 retinal findings
  • MRI orbits without optic nerve infiltration or compressive lesion

Case Summary

  • GU TB
  • Ureteral stenting
  • Hematogenous seeding
  • Spread to lungs
  • BAL w/TB
  • Start on RIPE
  • Taper to RI
  • Ocular seeding
  • Presentation to ophthalmology
  • Admission
  • Stable exams and TB therapy broadening
  • Discharge

A Question for the Audience

  • Should we suspect CNS involvement in patients with ocular TB?
    • Chorioretinitis
    • Subretinal abscess

Ocular TB Pearls

  • Ocular involvement in 1-2% of TB cases
    • Higher in endemic regions
  • Hematogenous spread = most common
  • Can be isolated to eye without systemic involvement
  • Most typical lesions:
    • choroidal granulomas
    • occlusive retinal vasculitis
    • multifocal serpiginous-like choroiditis
  • Culture is gold standard, but rarely possible
    • PCR used in some institutions
  • Treatment is with systemic antitubercular drugs, often with steroids





158 patients between 1994-2004 seen in India

66 (42%) posterior uveitis

57 (36%) anterior uveitis

18 (11%) panuveitis

17 (11%) intermediate uveitis



  • 354 patients
  • Top three complications of intraocular tuberculosis:
    • CME 107 (30%)
    • Glaucoma 99 (28%)
    • Cataract 71 (20%)