Tumor vasoproliferativo associado à tuberculose ocular presumida: relato de caso

Abstract

Interventional case report. A 42-year-old female patient reported inflammation of the right eye 1 year ago, treated with oral prednisone for 30 days. She referred blurred vision in the right eye since childhood. Ophthalmologic examination showed 20/400 visual acuity in the right eye. Biomicroscopy and intraocular pressure were normal. Fundus examination showed vascularized elevated lesion, associated with serous retinal detachment and hard exudates at the inferior periphery. The lesion was surrounded by extensive area of hyperplastic retinal pigment epithelium. The macula showed attenuation of the foveal reflex. Ocular ultrasound showed a 2.25 mm height vascularized lesion. Serologic examination, hemogram and thorax RX were normal. PPD was considered strong reactor and tuberculosis was diagnosed after positive BK research. Considering the clinical aspects, the ocular diagnosis was vasoproliferative tumor associated with presumed ocular tuberculosis. Treatment with rifampicin, isoniazide and pyridoxine was started. We decided to treat the ocular tumor with cryotherapy and intravitreal triamcinolone injection (4 mg/ml). After 30 days, serous detachment was smaller and the tumor showed atrophic areas. Fluorescein angiography showed areas of vascular hyperfluorescence with slight extravasation and areas of blocked fluorescence due to RPE hyperplasia. Secondary vasoproliferative tumors are retinal glial proliferations and are associated with many ocular conditions that affect retina and choroid. Because of the great number of associated complications, with important visual loss, vasoproliferative tumors should be treated at the moment of diagnosis. Treatment of choice is cryotherapy. Intravitreal triamcinolone can be used as adjuvant treatment because of its angiogenic properties. Until the present moment, no ocular tuberculosis and vasoproliferative tumor association were reported in the literature. Treatment of secondary vasoproliferative tumors with cryoterapy and intravitreal triamcinolone appears as a new therapeutic choice. Further studies are necessary to prove the efficacy of this association.

Retinal vasoproliferative tumor

“…Figure 1 shows a large RVPT measuring 4.04 mm thick that was successfully treated by cryotherapy followed by one anti VEGF injection for macular edema after the tumor has regressed. A similar approach was successfully employed by Rodrigues et al who treated a 2.25 mm RVPT with cryotherapy, associated to triamcinolone intra vitreous injection (12) . Cryotherapy can cause some adverse effects like the persistence of macular edema and the occurrence of retinal detachment arising in a retinal tear adjacent to the scared area.…”

“…RVPTs may exhibit feeder vessels, although with less dilation and tortuosity than that seen on retinal capillary hemangioma, its major differential diagnosis (7,8,13) . Among other lesions that can be confoun ded with RVPTs are: choroidal amelanotic melanoma that can be dif ferentiated based on its choroidal location and typical echographic findings of low and decreasing internal reflectivity with choroidal shadowing; peripheral hemorrhagic and exsudative choroidopathy that usually occurs in older patients; and inflammatory lesions like uveal tuberculoma and granuloma due to sarcoidosis lesions that frequently are located in the periphery and frequently exhibit vi treous cells, just like a RVPT, but lack the typical vascular component and usually have a pale aspect (12,14) . Complementary tests include echography, fluorescein angiogra phy (FA) and optical coherence tomography (OCT).…”

“…There are a few reports of antiangiogenic intravitreous injections for RVPTs, like bevacizumab, ranicizumab and triamcinolone (9,12,29) . Although the exact effect of these substances on RVPTs is lacking, it seems reasonable to consider their use in association to or after other destructive modalities (like cryotherapy) when there is visual acuity decrease due to macular edema.…”

“…For instance, brachytherapy can be considered an indication in thicker tumors, but it should not be considered as the only possible treatment option specially when considered its costs and the fact that it is not available in most referral centers and that other modalities have been successfully employed, even for thicker tumors (31) . Probably a tumor located on a PDT amenable position, in a center where PDT is available, will be suitable for PDT treatment, whereas successive gentle cryotherapy sections can be successfully employed in thicker tumors specially if combined to intravitreous in jections of triamcinolone or anti VEGF agents (Figure 1) (9,12,31) . It is also important to note that immediately after treatment and for at least a few weeks after, it is common to find an increase in tumor dimensions that is probably caused by intratumoral inflammation or hemorrhage.…”

Retinal Vasoproliferative Tumor

“…RVPTs may exhibit feeder vessels, although with less dilation and tortuosity than that seen on retinal capillary hemangioma, its major differential diagnosis (7,8,13) . Among other lesions that can be confoun ded with RVPTs are: choroidal amelanotic melanoma that can be dif ferentiated based on its choroidal location and typical echographic findings of low and decreasing internal reflectivity with choroidal shadowing; peripheral hemorrhagic and exsudative choroidopathy that usually occurs in older patients; and inflammatory lesions like uveal tuberculoma and granuloma due to sarcoidosis lesions that frequently are located in the periphery and frequently exhibit vi treous cells, just like a RVPT, but lack the typical vascular component and usually have a pale aspect (12,14) . Complementary tests include echography, fluorescein angiogra phy (FA) and optical coherence tomography (OCT).…”