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PHOTO ESSAY
Year : 2020  |  Volume : 68  |  Issue : 9  |  Page : 1946-1947

Management of optic disc granuloma in a patient of miliary tuberculosis with intravitreal ranibizumab in addition to antitubercular therapy


Vitreoretina and Uvea Services, Centre for Sight Eye Institute, New Delhi, India

Date of Submission10-Mar-2020
Date of Acceptance11-May-2020
Date of Web Publication20-Aug-2020

Correspondence Address:
Dr. Pooja Bansal
Consultant Vitreoretina and Uvea, Centre for Sight Eye Institute, Sector-9, Dwarka , New Delhi -110 075
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_508_20

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  Abstract 


Keywords: Antitubercular therapy, anti-VEGF, miliary tuberculosis, optic disc granuloma, ranibizumab


How to cite this article:
Bansal P, Narula R. Management of optic disc granuloma in a patient of miliary tuberculosis with intravitreal ranibizumab in addition to antitubercular therapy. Indian J Ophthalmol 2020;68:1946-7

How to cite this URL:
Bansal P, Narula R. Management of optic disc granuloma in a patient of miliary tuberculosis with intravitreal ranibizumab in addition to antitubercular therapy. Indian J Ophthalmol [serial online] 2020 [cited 2020 Sep 28];68:1946-7. Available from: http://www.ijo.in/text.asp?2020/68/9/1946/292573



A 32-year-old woman presented with decreased vision in the right eye for 2 weeks with best-corrected visual acuity (BCVA) of 6/18. She was diagnosed with miliary pulmonary tuberculosis elsewhere 1 month back and started on antitubercular therapy (ATT). Fundus of the right eye showed a vascularized elevated disc granuloma with peripapillary serous retinal detachment [Figure 1]a. Optical coherence tomography (OCT) showed a large lobulated hyper-reflective mass located on the optic nerve head (ONH) with back-shadowing and subretinal fluid (SRF) detaching the fovea [Figure 1]b. Fundus fluorescein angiography (FFA) showed a vascularized granuloma with increasing fluorescence and peripapillary pooling of the dye [Figure 2]a, [Figure 2]b, [Figure 2]c. Left eye was unremarkable. Systemic investigations already performed revealed a negative Mantoux, sputum culture positive for Mycobacterium tuberculosis, and diffusely spread miliary nodules in both the lungs on high-resolution computed tomography (HRCT) chest [Figure 2]d. Since the patient was diagnosed with miliary TB, systemic corticosteroids could not be initiated. The patient was administered two intravitreal ranibizumab injections at monthly interval leading to complete regression of granuloma and SRF with final BCVA of 6/6(p) at the end of 7 months while she was still on ATT [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f, [Figure 1]g, [Figure 1]h.
Figure 1: Horizontal white line passing through disc indicates OCT scan position. (a) Initial fundus picture showing vascularized disc granuloma and peripapillary SRF. (b) OCT showed a hyper-reflective mass on ONH (white arrow) and SRF detaching fovea. (c and d) Three weeks after first ranibizumab injection, there was reduction in volume of granuloma (white arrow) and SRF. (e and f) One month after second injection, infrared fundus image and OCT showed further regression of granuloma (white arrow) with minimal SRF (red arrows). (g and h) The granuloma (white arrow) and SRF resolved completely at 7 months

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Figure 2: (a-c) FFA showed a vascularised granuloma with increasing fluorescence in early, mid ,late phases and peripapillary pooling of dye in area of exudative retinal detachment.(d) Axial scan of HRCT chest-lung window showing bilateral diffuse, randomly distributed miliary nodular opacities

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  Discussion Top


Hypoxia-induced increased VEGF expression in tubercular granuloma as demonstrated in animal models enhances internal neovascularization allowing it to continue to grow and, hence, slow down the response or increase resistance to ATT.[1],[2] Anti-VEGF agents have been used effectively as an adjunctive treatment in eyes with these kinds of granulomas.[3],[4],[5]

In our case, the diminution of vision was due to exudation caused by increased vascularity of the granuloma. Paradoxical reaction to ATT could be another reason. An effective response to intravitreal anti-VEGF suggests that it can be used as an alternative to systemic steroids for treating highly vascular tubercular disc or choroid granulomas with increased exudation as an adjunct to conventional antitubercular therapy.

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;2013:e28383.  Back to cited text no. 1
    
2.
Datta M, Via LE, Kamoun WS, Liu C, Chen W, Seano G. Anti-vascular endothelial growth factor treatment normalizes tuberculosis granuloma vasculature and improves small molecule delivery. Proc Natl Acad Sci U S A 2015;112:1827-32.  Back to cited text no. 2
    
3.
Invernizzi A, Franzetti F, Viola F, Meroni L, Staurenghi G. Optic nerve head tubercular granuloma successfully treated with anti-VEGF intravitreal injections in addition to systemic therapy. Eur J Ophthalmol 2015;25:270-2.  Back to cited text no. 3
    
4.
Bansal R, Beke N, Sharma A, Gupta A. Intravitreal bevacizumab as an adjunct in the management of a vascular choroid granuloma. BMJ Case Rep 2013;2013:bcr2013200255.  Back to cited text no. 4
    
5.
Jain S, Bajgai P, Tigari B, Sharma K, Sharma A, Gupta V, et al. Bevacizumab for paradoxical worsening treatment adjunct in HIV patient with choroid tuberculoma. J Ophthalmic Inflamm Infect 2016;6:42.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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