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PHOTO ESSAY
Year : 2019  |  Volume : 67  |  Issue : 10  |  Page : 1713-1714

Managing a recurrence of choroidal tuberculoma two years following primary therapy


Department of Uvea and Vitreo-Retina Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Date of Submission26-Mar-2019
Date of Acceptance17-May-2019
Date of Web Publication23-Sep-2019

Correspondence Address:
Dr. M Dheepak Sundar
Department of Uvea and Vitreo-Retina Services, House No 6, 1st Floor, Gautam Nagar, New Delhi - 110 049
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_562_19

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  Abstract 


Keywords: Anti VEGF, choroidal tuberculoma, tuberculoma recurrence


How to cite this article:
Chawla R, Sundar M D, Sharma A, Hasan N. Managing a recurrence of choroidal tuberculoma two years following primary therapy. Indian J Ophthalmol 2019;67:1713-4

How to cite this URL:
Chawla R, Sundar M D, Sharma A, Hasan N. Managing a recurrence of choroidal tuberculoma two years following primary therapy. Indian J Ophthalmol [serial online] 2019 [cited 2019 Oct 17];67:1713-4. Available from: http://www.ijo.in/text.asp?2019/67/10/1713/267454



A 25-year-old female was diagnosed to have pulmonary tuberculosis two years before and had received Anti-tubercular treatment (ATT) for the same. During her initial presentation, she had extra-foveal healed choroidal granulomas (CG) [Figure 1]a with a best-corrected visual acuity (BCVA) of 20/30 in the Left eye (LE). She recently presented with diminution of vision in her LE (BCVA – 20/200). Fundus showed reactivation of CG with an exudative retinal detachment [Figure 1]b and [Figure 1]c. A fresh systemic work up did not reveal active systemic tuberculosis. The mantoux test remained positive. The patient was restarted on ATT with additional oral steroid therapy. Due to poor response and steroid related side effects an intra-vitreal injection of bevacizumab was given to help in early resolution of exudation. Slow tapering of steroids was initiated. At 3 months follow up significant reduction of the exudative component with partial resolution of the granuloma was seen. After 6 months of ATT the entire fluid resolved, the granuloma showed regression [Figure 1]d and the BCVA improved to 20/40.
Figure 1: (a) Initial Fundus picture of the left eye during the primary presentation showing healed choroidal granulomas (CG) infero-temporal to the fovea. (b and c) Two years after her initial presentation, the patient had recurrence over the preexisting CGs characterized by exudative retinal detachment (arrow marks) spreading laterally and inferiorly to the lesion. (d) With multimodal treatment approach including the effective use of intra-vitreal anti vascular endothelial growth factor (bevacizumab) the exudation resolved over a period of three months

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Vascular endothelial growth factor (VEGF) expression is found to be increased at the site of an active tubercular CG. The up-regulation of VEGF occurs due to the induced production by the on site cytokines and/or as a secondary response to tissue hypoxia caused by inflammatory vascular obstruction.[1] The VEGF in turn accelerates angiogenesis and exudation at the target site which is the highly vascularized chorio-retinal juncture as in our case. Thus, anti-VEGF agents can promote resolution of exudation. The effective use of anti-VEGFs in tubercular granuloma have been documented before.[2],[3]

It is difficult to say whether anti-VEGF assisted in resolution of the tubercular granuloma. However, it definitely seems to have enhanced the resolution of the exudative component. We also want to highlight the importance of follow up in cases of resolved CGs. Other than Choroidal neo-vascularization, recurrence can also be seen in large lesions.

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.
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. 1
    
2.
Chawla R, Venkatesh P, Tripathy K, Chaudhary S, Sharma SK. Successful management of proliferative diabetic retinopathy and multiple choroidal tubercles in a patient with miliary tuberculosis. J Ophthalmic Vis Res 2018;13:210.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
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;2013. pii: bcr2013200255. doi: 10.1136/bcr-2013-200255.  Back to cited text no. 3
    


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