A Rare Case of Optic Neuritis by Relapse of Choroidal Tuberculoma

Abstract

Solitary choroidal tuberculoma is a rare disease which possesses diagnostic and therapeutic challenges. There is a dearth of literature discussing its presentation and outcome. We present a 28 years-old female presented with unilateral drop in vision (20/80) in left eye for last 15-days. Fundoscopy showed positive vitreous cells with choroidal granulomatous lesion involving inferotemporal arcade and extending into posterior pole. Positive QuantiFERON test and tuberculin-skin-test established the diagnosis of tuberculosis. There was no past history of tuberculosis. Laboratory and radiological examination revealed no evidence of systemic tuberculosis. Treatment was initiated with first line Anti-Tubercular Treatment (ATT) and oral steroids. Choroidal lesion regressed for 2-months and visual acuity was maintained at 20/30. Subsequently relapse was noted with a new tubercular granuloma causing optic neuritis with relative afferent pupillary defect. Sudden worsening of visual acuity to hand movement perception was noted. Intravenous methyl prednisolone showed partial remission of inflammation and resolution of granuloma was noted at the end of 6-months of ATT. However, secondary optic atrophy could not be averted and the visual acuity at the end of treatment was 20/500. This is one of the rare cases of relapsed choroidal granuloma showing atypical location of tuberculosis and presenting as sight threatening optic neuritis. A 28 years old female presented with painless blurring of vision for 15 days in left eye. Her best corrected visual acuity measured on Snellen's chart was 20/80 and N18 for distant and near vision respectively in left eye. Right eye was normal with a visual acuity of 20/20 and N6 for distant and near vision. Anterior segment was normal on slit lamp examination and intraocular pressure was normal. Vitreous showed grade 1 haze (according to National Eye Institute Grading System for Vitreous Haze). On fundus examination, there was an illdefined, elevated yellow (slightly pigmented) subretinal