DIAGNOSTIC DILEMMAPresenting Author: Dr Gunja Chowdhury

Co Author: Dr Aratee Palsule

Deenanath Mangeshkar Hospital & Research Centre,Pune

A 39 year old obese female presented in September 2015 with unilateral painful diminution of vision in the right eye since 1 month.

Examination: BCVA : Right eye: 6/12 with +1.50DS,N10 Left eye: 6/6 with +0.25DS/-0.50x180,N6 Anterior segment (Both eyes): WNL Pupils circular reacting to light,No RAPD IOP: Right eye-16mmhg Left eye-18mmhg Fundus Examination: Left eye: WNL Right eye: Hyperemic disc, foveal reflex dull

29.9.2015

Provisional diagnosis:Posterior scleritis

ESR 21mm/hrp ANCA , c ANCA negative

Lipid profile, TFT, Urine routine, Hemogram, BSL

–WNLRPR Non reactive.

USG Bscan WNL, No T sign OCT RNFL shows disc

oedemaOCT macula WNL

FFA:Right eye: Early

hypofluoroscence with mottled

hyperfluoroscence temporal to fovea and hyperfluoroscence of

disc in late phase.Left eye: WNLTreatment:

Oral steroids (Tab Wysolone 60mg) which

caused temporary improvement.

Work up done:

A month later, while she was on tab wysolone 30mg, she presented with right eye increased disc oedema, chorioretinal folds and tenderness of superior orbital rim. Vision was 6/9, N10.

27.10.15

Provisional Diagnosis: Tubercular neuroretinitis

OCT

WORK UP DONE:

1. Mantoux test was positive (40mm).2. Quantiferon TB gold was positive (5.68).3. HRCT Thorax-WNL4. Haemogram (TLC 23900, ESR 27 mm/hr)5. CRP 8.9 mg/dl

TREATMENT: Anti-tubercular drugs Clavum 625 mg x 14

days (raised TLC) Tab Wysolone 30mg OD

continued

Patient was reviewed after 15 days. Vision remained same (6/9, N10).

MRI brain and orbit showed effacement of perioptic CSF space around right optic nerve without any definite swelling of optic nerve and signal abnormality,which appeared to be of doubtful significance

Steroid was stepped up to 60 mg daily and slowly tapered.

There was macular star formation, perineural inflammation and soft exudates around the disc.

This is not the patient’s photo but it looked exactly the same

By December 2015 Right eye fundus showed vitreous cells+, hyperemic disc, reduced oedema and exudates.Steroids gradually tapered and stopped on 23-2-2016.ATT continued.

FOLLOW UP ON 15.4.16.

• BCVA:

Right eye: 6/6p,N6 (-0.25DS ADD+0.75DS)

Left eye: 6/6,N6 (Plano ADD +0.75DS)

• Colour Vision Normal (Both eyes)

• Anterior Segment WNL (Both eyes)

• Fundus Examination

Right eye:

Disc, Margins distinct, Minimal hrperaemia & exudates

Left eye : WNL

ATT Cont.

A month later

17.5.16.

19.5.16.

24.5.16.

1 7.5.16 :• sudden DOV in RE • vn- fc 3mts, n<36• RAPD +• Vit Haze + cells ++ • retinochoroiditis patch inferotemporal to

the disc, intra and subretinal oedema and soft exudates suggesting Ocular Toxoplasmosis

• started on tab bactrim ds bd stat• Planned Vit Biopsy and PCR But Improved in two days19.5.16:• vn 6/18,N 12• No RAPD• Toxoplasma IGG-3.32, IGM 0.43• Oral steroids 80mg daily added24.5.16: Vn 6/12,N 10

1 month later (on 17.6.16.), while still on Tab Cotrimoxazole BD, ATT, Tab Wysolone 7.5mg daily Her Right eye vision was 6/6p,N6. The retinochoroiditis patch reduced.•

But 3 fluffy exudative lesions developed nasal to the disc.Tab wysolone was reduced to 5mg daily.

On 28.6.16.She presented with Nodular Episcleritis.Vision remained same.

Fundus examination showed a new minimally elevated yellowish intra retinal lesion temporal to fovea and minimal increase in disc hyperemia.

Soft exudates seen nasally were persistent.Started on ketorolac eyedrops and tab wysolone increased to 7.5mg daily.

1. TORCH titres done showed inconclusive results( CMV IgG borderline +ve)2. ACE, ANA WNL3. FFA done on 1.7.16 showed :

Late hyperfluorescence inferotemporal to the disc s/o toxoplasma lesionHyperfluorescence seen temporallyHyperfluorescent disc

No leakage from fluffy lesions seen nasallyClinically the lesions reduced by now

Same treatment was continued.

After 2 weeks episcleritis resolved, fundus showed vitreous cells, minimal disc hyperaemia

Tab Cotrimoxazole reduced to 1 tab every third day and tab wysolone was tapered and stopped on 2.8.16.

Retinochoroiditis patch resolving

Nasal soft exudate like lesions resolving 4 new snowball like lesions appearing in the extreme superotemporal periphery.

On 23.8.16

DISCUSSION:

Ocular tuberculosis most commonly manifests as uveitis. It may also cause a wide spectrum of optic nerve involvement of which papillitis is the commonest. Literature reported only 9 cases of tubercular neuroretinitis and rarely as the presenting feature. But our patient presented as posterior scleritis initially and then as neuroretinitis. Its recurrence is rare and that to with superadded toxoplasmosis.

Thus the treating ophthalmologist needs to have a high index of suspicion, battery of investigations at hand and an open mind considering possible co existent infections even in an immunocompetent individual.

Despite with on going treatment with various class of drugs , our patient kept on presenting with novel clinical findings at subsequent follow up visits which has made the exact etiological diagnosis a real challenge in her case.

Thus sometimes patient may not fit into the exact picture of a definite etiological diagnosis. Hence it is required to manage it accordingly at each step of a new presentation even without arriving at a final etiological diagnosis.

Ref:Yu Mao, Xiao Yan Peng, Qi Sheng You, Hong Wang, Meng Zhao and Jost B. Jonas. Tuberculous uveitis in China. Acta Ophthalmologica.2014;e393-7.