Sir,

We read with great interest the paper by Sanghvi et al1 and would like to commend the authors for a well-presented case series of presumed tuberculous uveitis. However, in their series of 27 patients, no cases of choroidal tuberculoma were presented. All cases of tuberculosis-related uveitis seen in the Ocular Oncology Service are associated with choroidal tuberculoma as it masquerades as choroidal melanoma2 We present one such case.

Case report

A 24-year-old Indian man with active miliary tuberculosis presented with a hyperemic amblyopic right eye. He had started standard quadruple anti-tuberculosis therapy (ATT),3 but could not tolerate pyrazinamide. After 10 days, he stopped all treatment.

Best-corrected visual acuity was 6/24 OD. The anterior chamber had 4+ cells and fine keratic precipitates. Intraocular pressures were normal. An amelanotic choroidal mass with associated bullous retinal detachment was seen superotemporally to the fovea (Figure 1a and b). B-mode ultrasound scan revealed a lesion of low internal reflectivity with internal blood flow, measuring 11.5 × 18.2 mm with a height of 7.6 mm (Figure 1c).

Figure 1
figure 1

Fundus photographs and B mode ultrasound scans. (a–c) Initial presentation. Extensive bullous retinal detachment extending temporally and inferonasally (a, b). Elevated lesion (7.6 mm) with low internal reflectivity and associated-retinal detachment (c). Two months after ATT treatment (d). Height of lesion reduced to 1.9 mm and extensive retinal detachment. One year after ATT treatment: lesion height at 1.9 mm with associated calcification (e).

Full size image

Two hourly g. Maxidex and g Cyclopentolate bd were commenced. A contrast-enhanced MRI of the brain and spinal cord indicated the presence of tuberculomas in the right parietal and occipital lobes. The patient was immediately started on ATT CNS protocol treatment, ethambutol, rifampicin, isoniazide, and prothionamide for a year.3 After 2 months, the choroidal mass height reduced to 1.9 mm (Figure 1d). A repeated MRI indicated regression of the occipital lesion, and no new infiltrations.

One year later, visual acuity was hand motions due to a white cataract. Intraocular inflammation had resolved, but the eye was hypotonic. The cerebral and choroidal tuberculomas were not active. B-mode ultrasound showed extension of the retinal detachment; however, the tuberculoma was inert, calcified with no change in height (Figure 1e). No systemic toxicity developed.

Comment

There is a very strong association with choroidal tuberculoma and CNS tuberculosis. These patients require an urgent MRI of the brain and spine to search for a neurologically debilitating or life threatening mass lesion. Miliary TB is typically treated with only 6 months of anti-TB medication, whereas the CNS treatment protocol is for 12 months.3