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 Table of Contents    
CASE REPORT
Year : 2019  |  Volume : 12  |  Issue : 1  |  Page : 42-45  

Serial swept-source optical coherence tomography: Tale of a choroidal tuberculoma


1 Department of Uvea and Medical Retina, Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, Tamil Nadu, India
2 Department of Uvea, Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, Tamil Nadu, India

Date of Web Publication30-Jan-2019

Correspondence Address:
Dr. Jyotirmay Biswas
Department of Uvea, Medical and Vision Research Foundations, Sankara Nethralaya, 18, College Road, Chennai - 600 006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ojo.OJO_183_2018

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   Abstract 


Choroidal tuberculoma is a solitary elevated choroidal mass-like lesion regarded often characteristic of intraocular tuberculosis. Serial swept-source optical coherence tomography (SS-OCT) is a very important tool in monitoring the course of choroidal tuberculoma and allows in early detection of complications such as choroidal neovascular membrane (CNVM). We describe a 26-year-old young Indian female, who presented with a solitary choroidal mass lesion in the left eye. Based on positive Mantoux test, biopsy of cervical lymph nodes showing acid-fast bacilli and radiographic findings, a diagnosis of choroidal tuberculoma was made. Serial SS-OCT during subsequent follow-up visits up to 14 months demonstrated the characterization of the lesion and assessment of response to antitubercular therapy and oral steroid. The patient was subsequently diagnosed to have concurrent CNVM and successfully treated with two anti-vascular endothelial growth factor intravitreal injections.

Keywords: Antitubercular therapy, choroidal tuberculoma, ocular tuberculosis, swept-source optical coherence tomography


How to cite this article:
Mistry S, Majumder PD, Biswas J. Serial swept-source optical coherence tomography: Tale of a choroidal tuberculoma. Oman J Ophthalmol 2019;12:42-5

How to cite this URL:
Mistry S, Majumder PD, Biswas J. Serial swept-source optical coherence tomography: Tale of a choroidal tuberculoma. Oman J Ophthalmol [serial online] 2019 [cited 2019 Mar 21];12:42-5. Available from: http://www.ojoonline.org/text.asp?2019/12/1/42/251032




   Introduction Top


Choroid is a most commonly affected structure in intraocular tuberculosis and believed to be involved by hematogenous spread of Mycobacterium tuberculosis bacilli. Multifocal choroidal tubercles are the most common clinical manifestation of intraocular tuberculosis. Choroidal tuberculoma is a solitary elevated choroidal mass-like lesion regarded often characteristic of intraocular tuberculosis. Clinically, it manifests as solitary yellowish subretinal mass lesion often surrounded by subretinal fluid (SRF).

Optical coherence tomography (OCT) allows high-resolution cross-sectional imaging of the retina, which helps in spatial evaluation and documentation of inflammatory lesions of the retina and choroid. OCT has been found to be an important tool in evaluating changes in the retina and overlying retinal pigment epithelium (RPE) in patients with choroidal tuberculoma and monitoring response to the treatment.[1],[2] Swept-source OCT (SS-OCT; Deep range imaging (DRT)-OCT, Topcon Japan) is the latest milestone in retinal and choroidal imaging. The present case report illustrates the utility of serial SS-OCT in the management of choroidal tuberculoma. In addition to evaluating and monitoring response to the treatment, serial monitoring with SS-OCT has demonstrated how a vision-threatening complication like choroidal neovascular membrane (CNVM) can be diagnosed and managed early.


   Case Report Top


A 26-year-old Asian Indian female presented with sudden blurring of vision in the left eye for 1 week. She was diagnosed to have tubercular lymphadenitis and was on treatment with anti-tubercular therapy (ATT) for the past 3 months. Her cervical lymph node biopsy showed necrotizing granulomatous inflammation with the presence of acid-fast bacilli on histopathology. On examination, her best-corrected visual acuity (BCVA) was 6/6 in the right eye and 6/9 in the left eye. Slit-lamp examination showed quiet anterior chamber in both eyes and presence of cells in anterior vitreous of the left eye. Fundus examination of the right eye was within normal limit, and the left eye revealed a subretinal mass approximately of 1.5 disc diameter in size near superotemporal arcade with surrounding SRF extending till fovea [Figure 1]a. SS-OCT of the left eye [Figure 2]a revealed the mass to be a lobulated, homogeneous, hyporeflective thickening of choroid with size of 1359 μm × 4047 μm, giving rise to a dome-shaped appearance of the overlying retina with subretinal moderate reflective echoes with surrounding SRF. A diagnosis of choroidal tuberculoma was made, and she was started on oral steroid (1 mg/kg/day) in tapering doses with continuation of ATT. Two weeks following treatment, her BCVA in the left eye improved to 6/6. Fundus examination of the left eye did not show any significant change in the size of choroidal tuberculoma [Figure 1]b, but SS-OCT revealed a decrease in the size of tuberculoma to 1139 × 3960 μm [Figure 2]b.
Figure 1: Color fundus photograph of the left eye. (a) At presentation, the left eye shows a subretinal mass approximately of 1.5-disc diameter in size located near superotemporal arcade with surrounding subretinal fluid extending till fovea. (b) At 2-week follow up, the choroidal tuberculoma did not show any significant change in the size. (c) At the last follow-up visit, a regressed and partially scarred tuberculoma is seen

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Figure 2: Serial swept-source optical coherence tomography images of a case of choroidal tuberculoma of the left eye. (a) The left eye at presentation shows a lobulated, homogeneous, hyporeflective mass located in choroid with size of 1359 × 4047 μm, giving rise to a dome-shaped appearance of the overlying retina with a discrete subretinal hyperreflective lesion with surrounding subretinal fluid. (b) At 2 weeks, tuberculoma size is 1139 × 3960 μm. (c) At 10 weeks, there is slight decrease in the size of the tuberculoma (1087 × 3584 μm) with increase in surrounding subretinal fluid. Serial swept-source optical coherence tomography clearly outlines two medium reflective lesions, one located between the retinal pigment epithelium layer and Bruch's membrane and other located above the retinal pigment epithelium layer. (d) At 14 weeks, 1-month postanti-vascular endothelial growth factor injection, the tuberculoma size is 1058 × 3223 μm with partial resolution of subretinal fluid. (e) At 5-month follow-up from the day of presentation, there is complete resolution in subretinal fluid with decrease in the size of tuberculoma to 979 × 2978 μm. (f) At 7 months, tuberculoma size is 625 × 2950 μm. The overlying retinal pigment epithelium shows a discontinuity and the choroidal neovascular membrane complex is stable without any evidence of activity. (g) At 11 months, tuberculoma size is 529 × 3540 μm. The choroidal neovascular membrane complex has slightly increased in size. (h) At 12 months, tuberculoma size is 509 × 2994 microns. There is an increase in size of the choroidal neovascular membrane complex and the presence of subretinal fluid. (i) At 14 months, 2-month postanti-vascular endothelial growth factor injection, the tuberculoma size is reduced to 400 × 2391 microns with resolution of subretinal fluid and presence of scarring choroidal neovascular membrane

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She came with a complaint of deterioration of vision in the left eye after 10 weeks of initial presentation and BCVA in the left eye was documented as 6/15. Fundus examination of the left eye did not reveal any significant change in the size of the tuberculoma, but there was an increase in SRF surrounding the tuberculoma. There was slight decrease in size of the tuberculoma (1087 × 3584 μm) with increase in SRF in SS-OCT of the left eye. SS-OCT clearly outlined two medium reflective lesions, one located between the RPE layer and Bruch's membrane and other located above the RPE layer [Figure 2]c. Fundus fluorescein angiography (FFA) of the left eye showed a small area of hypofluorescence overlying the lesion surrounded by hyperfluorescence in the early phase with progressive staining of lesion in late phase [Figure 3]. A diagnosis of CNVM was made, and she received an injection of intravitreal bevacizumab in the left eye. One-month postinjection, her BCVA improved to 6/9 and fundus examination of her left eye showed decrease in size of the tuberculoma with partial resolution of SRF surrounding the tubercle. The size of the tuberculoma on SS-OCT was approximately 1058 × 3223 μm [Figure 2]d. She was advised to continue ATT and maintenance dose of oral prednisolone of 10 mg/day. At 5-month follow-up from the day of presentation, her BCVA improved to 6/6 and SS-OCT showed complete resolution in SRF with decrease in the size of the tuberculoma to 979 × 2978 μm [Figure 2]e.
Figure 3: Fundus fluorescein angiography of the left eye at 10 weeks of presentation. (a) A small area of hypofluorescence overlying the lesion surrounded by hyperfluorescence in the early phase. (b and c) There is progressive staining of lesion in the late phase

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She was reviewed again after 7 months and her BCVA in the left eye was 6/5. SS-OCT demonstrated a further decrease in size of the tuberculoma to 625 × 2950 μm [Figure 2]f. The overlying RPE showed a discontinuity, and the CNVM complex was stable without any evidence of activity. The patient was asked to continue ATT, and oral corticosteroids were maintained at dosage of 5 mg/day.

On her subsequent visits on 11 and 12 months, SS-OCT revealed a progressive decrease in size of the choroidal tuberculoma to 529 μm × 3540 μm [Figure 2]g and 509 μm × 2994 μm [Figure 2]h, respectively. SS-OCT at 12 months of her follow-up also revealed an increase in size of the CNVM and presence of SRF. She received another intravitreal injection of anti-vascular endothelial growth factor (VEGF) and was continued on ATT and oral corticosteroid at a dose of 5 mg/day. She was last seen at 14 months. On examination, her BCVA was maintained to 6/5 in the left eye and fundus examination revealed a regressed and partially scarred tuberculoma in the left eye [Figure 1]c. Size of the choroidal tuberculoma had regressed to 400 × 2391 microns in SS-OCT [Figure 2]i with scarring of CNVM. The patient was continued on ATT medications and oral corticosteroids were maintained at 5 mg/day. The patient was informed to remain under close follow-up and the possible need of anti-VEGF injections in the future was explained.


   Discussion Top


A tuberculoma represents rapid multiplication of tubercular bacilli with extensive local tissue destruction leading to progressive, liquefied caseation necrosis on histopathology.[3] Monitoring of progression choroidal tuberculoma is of paramount importance as further progression can lead to subretinal abscess formation, breakdown of the tuberculoma into the vitreous cavity or perforation of the globe.[3],[4]

OCT characteristics of choroidal granuloma have been reported by various authors.[1],[2],[5] Salman et al.[5] demonstrated that overlying tuberculous choroidal granulomas, there is an area of localized adhesion between the choriocapillaris-retinal pigment epithelial layer and the overlying neurosensory retina. This was termed as “contact” sign on OCT, and it is attributable to inflammatory adhesions overlying the granuloma that causes the neurosensory retina to stick to the RPE at that point. These inflammatory cells appear on OCT as increased reflectivity in the deeper retinal layers over the granuloma.

At 2 weeks following treatment, fundus examination did not show any significant change in the size of choroidal tuberculoma, but SS-OCT revealed a decrease in size of tuberculoma to 1139 × 3960 μm. Notably, the vertical diameter decreased more (in percentage) than the horizontal one. This response to treatment of choroidal granulomas has been previously described and explains why OCT is more sensitive than funduscopic examination or other imaging techniques such as indocyanine green (ICG) in detecting early response to treatment in these lesions.[6]

Our case showed that serial monitoring of choroidal tuberculoma can effectively monitor the progress of the lesion. We erred in diagnosing the CNVM at initial visit which we initially thought as subretinal precipitates. When the CNVM was diagnosed at 10-week follow-up, we retrospectively outlined the presence of an early existing CNVM in OCT images of the patient. Our case thus also highlights the need for a strong suspicion of CNVM complex in patients with choroidal tuberculoma which can often be missed. In our patient, an early FFA or ICG would have been more conclusive about the CNVM. We picked up the CNVM as medium hyperreflective lesion located between the RPE layer and the Bruch's membrane 10-week follow-up [Figure 1]c. It is also important to note that angiographic characteristics of a CNVM can be masked due to perilesional edema and pose diagnostic dilemma as seen in our case. Anti-VEGF may help in both resolution of perilesional edema and reduction of granuloma vascularity.

Various studies on choroidal tuberculoma with enhanced depth imaging-OCT have already been described in the literature.[2],[6],[7] However, this was the first study using SS-OCT as an imaging tool in studying the morphology and the progression of such lesion. Our report showed that SS-OCT can effectively document the changes and progression of lesion in choroidal granuloma. However, SS-OCT is relatively an expensive imaging modality, and serial imaging with SS-OCT may add serious financial burden to the patient. Furthermore, compliance of the patient is another important factor, and in the absence of any specific ocular symptoms, abstinence from regular monitoring may lead to increased risk of developing sight-threatening complications associated with choroidal tuberculoma. We believe proper explanation of the disease process; risk of the complications and proper counseling may help in such scenarios.

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.
Saxena S, Singhal V, Akduman L. Three-dimensional spectral domain optical coherence tomography imaging of the retina in choroidal tuberculoma. BMJ Case Rep 2013;2013:bcr2012008156.  Back to cited text no. 1
    
2.
Invernizzi A, Mapelli C, Viola F, Cigada M, Cimino L, Ratiglia R, et al. Choroidal granulomas visualized by enhanced depth imaging optical coherence tomography. Retina 2015;35:525-31.  Back to cited text no. 2
    
3.
Majumder PD, Biswas J, Bansal N, Ghose A, Sharma H. Clinical profile of patients with tubercular subretinal abscess in a tertiary eye care center in Southern India. Ocul Immunol Inflamm 2018;26:353-7.  Back to cited text no. 3
    
4.
Biswas J, Madhavan HN, Gopal L, Badrinath SS. Intraocular tuberculosis. Clinicopathologic study of five cases. Retina 1995;15:461-8.  Back to cited text no. 4
    
5.
Salman A, Parmar P, Rajamohan M, Vanila CG, Thomas PA, Jesudasan CA, et al. Optical coherence tomography in choroidal tuberculosis. Am J Ophthalmol 2006;142:170-2.  Back to cited text no. 5
    
6.
Invernizzi A, Agarwal A, Mapelli C, Nguyen QD, Staurenghi G, Viola F, et al. Longitudinal follow-up of choroidal granulomas using enhanced depth imaging optical coherence tomography. Retina 2017;37:144-53.  Back to cited text no. 6
    
7.
Rostaqui O, Querques G, Haymann P, Fardeau C, Coscas G, Souied EH, et al. Visualization of sarcoid choroidal granuloma by enhanced depth imaging optical coherence tomography. Ocul Immunol Inflamm 2014;22:239-41.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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