Abstract
Purpose: To present a challenging case of tubercular uveitis in an asymptomatic patient, featuring unilateral occlusive vasculitis with a frosted branch angiitis phenotype and bilateral serpiginous-like choroiditis.
Methods: Case report with clinical photography.
Results: Routine fundus examination of an asymptomatic 26-year-old Pakistani man revealed a retinal vasculitis with frosted branch angiitis phenotype in the right eye and bilateral serpiginous-like choroiditis. A positive QuantiFERON-TB Gold assay, tuberculin skin test and a chest computed tomography resulted in the diagnosis of presumed tuberculous origin of the posterior uveitis. Four-drug anti-tubercular therapy combined with systemic corticosteroids were initiated. A paradoxical immune-mediated worsening followed, requiring an increase of systemic corticosteroid therapy. An accompanying vitreous hemorrhage was initially managed with intravitreal bevacizumab. However, persistent vitreous opacities and limited visual improvement necessitated a phacovitrectomy with intravitreal triamcinolone acetonide. Two weeks postoperatively mild visual improvement was observed, although inflammatory activity and occlusive vasculitis persisted. Administration of an additional dexamethasone intravitreal implant resulted in complete resolution of intraocular inflammation. The final BCVA of the right eye improved to 20/25 in the following months and remained stable two years after the initial presentation.
Conclusions: This case illustrates the therapeutic complexity of tubercular uveitis with phacovitrectomy and intravitreal dexamethasone implant proving effective in achieving disease control of paradoxical worsening.
Keywords
Dexamethasone intravitreal implant, Frosted branch angiitis, Occlusive vasculitis, Paradoxical immune-mediated worsening, Serpiginous-like choroiditis, Tuberculosis, Vitrectomy