A 45-year-old male patient presented with the complaints of gradual painless diminution of vision in the right eye for the last 15 days. There was no history of fever, backache, weight loss, contact, or any other associated systemic illness. The best corrected visual acuity was 6/60, N36 (Snellen’s chart) in the right eye and 6/6, N6 in the left eye.
Anterior segment examination was within normal limits in both the eyes. Fundus examination of the right eye showed a hyperemic optic disc with severe perivasculitis involving the major vessel arcades with macular edema along with exudation at the posterior pole. The left eye showed an infero-temporal branch retinal vein occlusion with retinal hemorrhages (Fig. 1). Applanation tonometry recorded an intraocular pressure (IOP) of 10 mm Hg (mmHg) in both the eyes.
The patient was investigated including a complete hemogram, which was within normal limits except a raised ESR of 24 mm (mm) in the first hour. An induration of 25 × 25 mm was seen on TST with five purified protein derivative (PPD) units. Immunoglobulin G (IgG) titres for cytomegalovirus (CMV) and herpes simplex virus (HSV) were positive. Immunoglobulin M (IgM) titres for both CMV and HSV were within normal. Serum angiotensin converting enzyme (ACE) levels were raised to 82 μl (μL). On evaluation the patient was not immunocompromised.
Contrast-enhanced computed tomography (CECT) of the thorax showed multiple non-necrotic, non-calcified mediastinal lymph nodes, fibrosis in the right middle lobe and a small sub-pleural nodule in the posterior segment of the right upper lobe.
Transabdominal endoscopic ultrasound (EUS) guided biopsy from the sub-carinal lymph nodes was done and sent for culture and histopathology which showed epithelioid cell granulomas and lymphoid cells with necrosis. Ziehl-Neilsen staining was negative for acid-fast bacilli, and there was no evidence of atypical cells.
Systemic anti-tubercular treatment was initiated with 600 mg of isoniazid, 450 mg of rifampicin, 1200 mg of pyrazinamide, and 750 mg of ethambutol along with oral prednisolone at 1 mg/kg body weight and topical prednisolone acetate (1%) eye drops four times a day.
At 1-month follow up the BCVA in the right eye was 6/12,N8 in the right eye and 6/6,N6 in the left eye. IOP was 16 mm of Hg in both the eyes. Fundus examination of both eyes showed hyperemic optic disc with persistent vasculitis. Fundus fluorescein angiography (FFA) was done which showed leakage from the vessels and late leakage of the disc in both the eyes. The patient was asked to continue the same treatment and follow up monthly.
At 3 months follow up, the BCVA was 6/9,N8 in the right eye and 6/6,N6 in the left eye. Fundus examination of the right eye showed a hyperemic disc with hard exudates at the macula with resolving exudation and retinal hemorrhages along the vessels in the right eye and the left eye showed resolving retinal hemorrhages along the inferotemporal arcade. In the right eye, FFA showed minimal leakage at the disc with very mild hyperfluorescence along the vessels in the late phase suggestive of resolving vasculitis and the left eye showed no leakage at the optic disc with areas of hyperfluorescence along the vessel walls suggestive of resolving vasculitis (Fig. 2). There was no evidence of neovascularization at the disc or elsewhere. The patient was followed monthly, and there was evidence of gradual decrease in the vasculitis in both the eyes (Fig. 3).
Follow up at 6 months the BCVA in the right eye was 6/9,N8 and in the left eye 6/6,N6. On fundus examination the right eye showed mild pallor of the optic disc with persistence of the hard exudates at the macula and areas of vasculitis with complete resolution of the retinal hemorrhages. The left eye shows resolving retinal hemorrhages along the inferotemporal quadrant with resolving vasculitis.
Follow up at 1 year the BCVA in the right eye was 6/9,N6 and in the left eye was 6/6,N6. Fundus examination of the right eye showed mild pallor of the optic disc with a few exudates at the macula, and the left eye showed formation of collaterals.