Clinical manifestations and prognosis of choroidal tuberculoma_Chinese Journal of Ocular Fundus Diseases

Authors：

Jiang Tingting , Chen Wenwen , Liu Wei , Chen Qian ,  Chang Qing

Department of Ophthalmology, Shanghai Eye & ENT Hospital of Fudan University, Shanghai 200031, China;

Corresponding author：

Chang Qing, Email: qngchang@aliyun.com

Keywords：

Choroidal tuberculoma; Tuberculosis; Prognosis

DOI：

10.3760/cma.j.cn511434-20230605-00253

Video：

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Objective To investigate the clinical features and prognosis of patients with choroidal tuberculoma. Methods A retrospective and observational study. From 2011 to 2022, 15 patients (16 eyes) with choroidal tuberculoma diagnosed and treated in Department of Ophthalmology, Shanghai Eye & ENT Hospital of Fudan University were included. The patients underwent examinations including best corrected visual acuity (BCVA), fundus color photography, optical coherence tomography (OCT), fluorescein fundus angiography (FFA), and indocyanine green angiography (ICGA). Chest CT examination, purified protein derivative test and interferon-γ release test were also performed. BCVA was performed using the Snellen visual acuity chart, which was converted to Logarithm of the minimum angle of resolution (logMAR) visual acuity when recorded. All the patients received antitubercular therapy and the duration was 12-15 months. Thirteen patients were combined with oral corticosteroids. The average follow-up time was 36 months. Rank sum test was used to compare logMAR BCVA before and after treatment. Results Among the 15 patients, 5 were male and 10 were female; 1 case was bilateral involvement; 7 patients had a strong positive tuberculin skin test; 8 patients had a positive interferon-γ release assay. Six patients had pulmonary tuberculosis. One patient had peritoneal tuberculosis. Lesions were located in the posterior pole in 12 eyes, 1 eye with papillary tuberculoma. Peripheral lesions were found in 4 eyes. There were 9 eyes each with anterior segment inflammation or vitreous inflammation; 7 eyes were with exudative retinal detachment. OCT examination revealed a hyporeflective thickening of the choroidal stroma, the corresponding elevation of the retina, and often accompanied by subretinal fluid. FFA revealed hyperfluorescence of the mass and fluorescence accumulation with subretinal fluid at the late stage. ICGA revealed hypofuorescence of the lesion. The lesions subsided after treatment, and there was no recurrence during follow-up period. Cataract surgery was performed in 4 eyes due to complicated cataract. One eye undergone vitrectomy due to secondary rhegmatogenous retinal detachment. Anti-vascular endothelial growth factor therapy was performed in 1 eye due to secondary choroidal neovascularization. Ocular wall perforation occurred in 1 eye, and the condition was stable after treatment. Before treatment, the average logMAR BCVA was 1.02±0.57, which improved to 0.31±0.35 after treatment. The difference between the mean logMAR BCVA before and after treatment was statistically significant (P＜0.05). Conclusions Combination of medical history, clinical manifestations, laboratory tests, and imaging can assist in the diagnosis of choroidal tuberculoma. The main manifestations are subretinal yellowish-white lesions in posterior pole. Standardized anti-tuberculosis therapy can effectively improve the prognosis of vision.

Citation： Jiang Tingting, Chen Wenwen, Liu Wei, Chen Qian, Chang Qing. Clinical manifestations and prognosis of choroidal tuberculoma. Chinese Journal of Ocular Fundus Diseases, 2023, 39(9): 741-746. doi: 10.3760/cma.j.cn511434-20230605-00253 Copy

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2.	Jiang T, Zhang X, Zhou M, et al. Prognosis of ocular tuberculosis following long-term antitubercular therapy[J]. J Ocul Pharmacol Ther, 2021, 37(4): 241-247. DOI: 10.1089/jop.2020.0100.
3.	陈君毅, 王晓艳, 李华, 等. 脉络膜结核瘤一例[J]. 中华眼底病杂志, 2000, 16(1): 58. DOI: 10.3760/j.issn:1005-1015.2000.01.035.Chen JY, Wang XY, Li H, et al. A case of choroidal tuberculoma[J]. Chin J Ocul Fundus Dis, 2000, 16(1): 58. DOI: 10.3760/j.issn:1005-1015.2000.01.035.
4.	曾苗, 陈晓, 宋艳萍, 等. 脉络膜结核瘤一例[J]. 中华实验眼科杂志, 2017, 35(9): 791-792. DOI: 10.3760/cma.j.issn.2095-0160.2017.09.005.Zeng M, Chen X, Song YP, et al. A case of choroidal tuberculoma[J]. Chin J Exp Ophthalmol, 2017, 35(9): 791-792. DOI: 10.3760/cma.j.issn.2095-0160.2017.09.005.
5.	马可, 唐健, 黄永志, 等. 双眼脉络膜结核瘤一例[J]. 中华眼底病杂志, 2011, 27(3): 291-292. DOI: 10.3760/cma.j.issn.1005-1015.2011.03.027.Ma K, Tang J, Huang YZ, et al. A case of binocular choroidal tuberculoma[J]. Chin J Ocul Fundus Dis, 2011, 27(3): 291-292. DOI: 10.3760/cma.j.issn.1005-1015.2011.03.027.
6.	Agrawal R, Gunasekeran DV, Agarwal A, et al. The collaborative ocular tuberculosis study (COTS)-1: a multinational description of the spectrum of choroidal involvement in 245 patients with tubercular uveitis[J]. Ocul Immunol Inflamm, 2020, 28(Suppl): S38-48. DOI: 10.1080/09273948.2018.1489061.
7.	Tsui J, Ho M, Lui G, et al. The clinical presentation and treatment outcomes of ocular tuberculosis: a 5-year experience in an endemic area[J]. Int Ophthalmol, 2021, 41(9): 3199-3209. DOI: 10.1007/s10792-021-01886-y.
8.	Demirci H, Shields CL, Shields JA, et al. Ocular tuberculosis masquerading as ocular tumors[J]. Surv Ophthalmol, 2004, 49(1): 78-89. DOI: 10.1016/j.survophthal.2003.10.009.
9.	王光璐, 张风, 孟淑敏, 等. 脉络膜转移癌的眼底血管造影[J]. 中华眼底病杂志, 2002, 18(2): 92-95. DOI: 10.3760/j.issn:1005-1015.2002.02.002.Wang GL, Zhang F, Meng SM, et al. Fundus angiography in metastatic carcinomas of choroid[J]. Chin J Ocul Fundus Dis, 2002, 18(2): 92-95. DOI: 10.3760/j.issn:1005-1015.2002.02.002.
10.	史雪辉, 杨丽红, 王光璐. 孤立性脉络膜血管瘤的荧光素钠吲哚青绿同步眼底血管造影[J]. 中国实用眼科杂志, 2007, 25(3): 289-291. DOI: 10.3760/cma.j.issn.1006-4443.2007.03.017.Shi XH, Yang LH, Wang GL. Simultaneous fundus fluorescein and indocyanine green angiography in circumscribed choroidal hemangiomas[J]. Chin J Pract Ophthalmol, 2007, 25(3): 289-291. DOI: 10.3760/cma.j.issn.1006-4443.2007.03.017.
11.	Invernizzi A, Mapelli C, Viola F, et al. Choroidal granulomas visualized by enhanced depth imaging optical coherence tomography[J]. Retina, 2015, 35(3): 525-531. DOI: 10.1097/IAE.0000000000000312.
12.	Agarwal A, Aggarwal K, Pichi F, et al. Clinical and multimodal imaging clues in differentiating between tuberculomas and sarcoid choroidal granulomas[J]. Am J Ophthalmol, 2021, 226: 42-55. DOI: 10.1016/j.ajo.2021.01.025.
13.	Salman A, Parmar P, Rajamohan M, et al. Optical coherence tomography in choroidal tuberculosis[J]. Am J Ophthalmol, 2006, 142(1): 170-172. DOI: 10.1016/j.ajo.2006.01.071.
14.	Pichi F, Smith SD, Neri P, et al. Choroidal granulomas visualized by swept-source optical coherence tomography angiography[J]. Retina, 2021, 41(3): 602-609. DOI: 10.1097/IAE.0000000000002864.
15.	Pichi F, Sarraf D, Morara M, et al. Pearls and pitfalls of optical coherence tomography angiography in the multimodal evaluation of uveitis[J/OL]. J Ophthalmic Inflamm Infect, 2017, 7(1): 20[2017-10-05]. https://pubmed.ncbi.nlm.nih.gov/28983872/. DOI: 10.1186/s12348-017-0138-z.
16.	Aksoy FE, Altan C, Basarir B. Multimodal imaging of a choroidal granuloma as a first sign of tuberculosis[J/OL]. Photodiagnosis Photodyn Ther, 2020, 29: 101580[2019-10-17]. https://pubmed.ncbi.nlm.nih.gov/31629876/. DOI: 10.1016/j.pdpdt.2019.101580.
17.	Agarwal A, Agrawal R, Gunasekaran DV, et al. The collaborative ocular tuberculosis study (COTS)-1 report 3: polymerase chain reaction in the diagnosis and management of tubercular uveitis: global trends[J]. Ocul Immunol Inflamm, 2019, 27(3): 465-473. DOI: 10.1080/09273948.2017.1406529.
18.	Agrawal R, Testi I, Mahajan S, et al. Collaborative ocular tuberculosis study consensus guidelines on the management of tubercular uveitis-report 1: guidelines for initiating antitubercular therapy in tubercular choroiditis[J]. Ophthalmology, 2021, 128(2): 266-276. DOI: 10.1016/j.ophtha.2020.01.008.
19.	Agrawal R, Gupta B, Gonzalez-Lopez JJ, et al. The role of anti-tubercular therapy in patients with presumed ocular tuberculosis[J]. Ocul Immunol Inflamm, 2015, 23(1): 40-46. DOI: 10.3109/09273948.2014.986584.
20.	Al-Mezaine HS, Al-Muammar A, Kangave D, et al. Clinical and optical coherence tomographic findings and outcome of treatment in patients with presumed tuberculous uveitis[J]. Int Ophthalmol, 2008, 28(6): 413-423. DOI: 10.1007/s10792-007-9170-6.
21.	Bansal R, Gupta A, Gupta V, et al. Role of anti-tubercular therapy in uveitis with latent/manifest tuberculosis[J]. Am J Ophthalmol, 2008, 146(5): 772-779. DOI: 10.1016/j.ajo.2008.06.011.
22.	Yasaratne BM, Madegedara D, Senanayake NS, et al. A case series of symptomatic ocular tuberculosis and the response to anti-tubercular therapy[J]. Ceylon Med J, 2010, 55(1): 16-19. DOI: 10.4038/cmj.v55i1.1703.
23.	Lou SM, Larkin KL, Winthrop K, et al. Lack of consensus in the diagnosis and treatment for ocular tuberculosis among uveitis specialists[J]. Ocul Immunol Inflamm, 2015, 23(1): 25-31. DOI: 10.3109/09273948.2014.926936.
24.	Khalsa A, Kelgaonkar A, Basu S. Anti-TB monotherapy for choroidal tuberculoma: an observational study[J]. Eye (Lond), 2022, 36(3): 612-618. DOI: 10.1038/s41433-021-01505-1.
25.	Kee AR, Gonzalez-Lopez JJ, Al-Hity A, et al. Anti-tubercular therapy for intraocular tuberculosis: a systematic review and meta-analysis[J]. Surv Ophthalmol, 2016, 61(5): 628-653. DOI: 10.1016/j.survophthal.2016.03.001.
26.	Jain S, Agarwal A, Gupta V. Resolution of large choroidal tuberculoma following monotherapy with intravitreal Ranibizumab[J]. Ocul Immunol Inflamm, 2020, 28(3): 494-497. DOI: 10.1080/09273948.2019.1582786.
27.	陈绪攀. 结核性全眼球炎并发眼球壁穿孔1例[J]. 临床眼科杂志, 2009, 17(3): 219. DOI: 10.3969/j.issn.1006-8422.2009.03.038.Chen XP. Tuberculous panophthalmitis complicated by ocular wall perforation: a case report[J]. J Clin Ophthalmol, 2009, 17(3): 219. DOI: 10.3969/j.issn.1006-8422.2009.03.038.
28.	Huang X, Qin X, Luo Z, et al. Tuberculous choroiditis masquerading as sympathetic ophthalmia: a case report[J]. Intractable Rare Dis Res, 2020, 9(3): 171-174. DOI: 10.5582/irdr.2020.03015.

1. Sharm A, Thapa B, Lavaju P. Ocular tuberculosis: an update[J]. Nepal J Ophthalmol, 2011, 3(3): 52-67. DOI: 10.3126/nepjoph.v3i1.4280.
2. Jiang T, Zhang X, Zhou M, et al. Prognosis of ocular tuberculosis following long-term antitubercular therapy[J]. J Ocul Pharmacol Ther, 2021, 37(4): 241-247. DOI: 10.1089/jop.2020.0100.
3. 陈君毅, 王晓艳, 李华, 等. 脉络膜结核瘤一例[J]. 中华眼底病杂志, 2000, 16(1): 58. DOI: 10.3760/j.issn:1005-1015.2000.01.035.Chen JY, Wang XY, Li H, et al. A case of choroidal tuberculoma[J]. Chin J Ocul Fundus Dis, 2000, 16(1): 58. DOI: 10.3760/j.issn:1005-1015.2000.01.035.
4. 曾苗, 陈晓, 宋艳萍, 等. 脉络膜结核瘤一例[J]. 中华实验眼科杂志, 2017, 35(9): 791-792. DOI: 10.3760/cma.j.issn.2095-0160.2017.09.005.Zeng M, Chen X, Song YP, et al. A case of choroidal tuberculoma[J]. Chin J Exp Ophthalmol, 2017, 35(9): 791-792. DOI: 10.3760/cma.j.issn.2095-0160.2017.09.005.
5. 马可, 唐健, 黄永志, 等. 双眼脉络膜结核瘤一例[J]. 中华眼底病杂志, 2011, 27(3): 291-292. DOI: 10.3760/cma.j.issn.1005-1015.2011.03.027.Ma K, Tang J, Huang YZ, et al. A case of binocular choroidal tuberculoma[J]. Chin J Ocul Fundus Dis, 2011, 27(3): 291-292. DOI: 10.3760/cma.j.issn.1005-1015.2011.03.027.
6. Agrawal R, Gunasekeran DV, Agarwal A, et al. The collaborative ocular tuberculosis study (COTS)-1: a multinational description of the spectrum of choroidal involvement in 245 patients with tubercular uveitis[J]. Ocul Immunol Inflamm, 2020, 28(Suppl): S38-48. DOI: 10.1080/09273948.2018.1489061.
7. Tsui J, Ho M, Lui G, et al. The clinical presentation and treatment outcomes of ocular tuberculosis: a 5-year experience in an endemic area[J]. Int Ophthalmol, 2021, 41(9): 3199-3209. DOI: 10.1007/s10792-021-01886-y.
8. Demirci H, Shields CL, Shields JA, et al. Ocular tuberculosis masquerading as ocular tumors[J]. Surv Ophthalmol, 2004, 49(1): 78-89. DOI: 10.1016/j.survophthal.2003.10.009.
9. 王光璐, 张风, 孟淑敏, 等. 脉络膜转移癌的眼底血管造影[J]. 中华眼底病杂志, 2002, 18(2): 92-95. DOI: 10.3760/j.issn:1005-1015.2002.02.002.Wang GL, Zhang F, Meng SM, et al. Fundus angiography in metastatic carcinomas of choroid[J]. Chin J Ocul Fundus Dis, 2002, 18(2): 92-95. DOI: 10.3760/j.issn:1005-1015.2002.02.002.
10. 史雪辉, 杨丽红, 王光璐. 孤立性脉络膜血管瘤的荧光素钠吲哚青绿同步眼底血管造影[J]. 中国实用眼科杂志, 2007, 25(3): 289-291. DOI: 10.3760/cma.j.issn.1006-4443.2007.03.017.Shi XH, Yang LH, Wang GL. Simultaneous fundus fluorescein and indocyanine green angiography in circumscribed choroidal hemangiomas[J]. Chin J Pract Ophthalmol, 2007, 25(3): 289-291. DOI: 10.3760/cma.j.issn.1006-4443.2007.03.017.
11. Invernizzi A, Mapelli C, Viola F, et al. Choroidal granulomas visualized by enhanced depth imaging optical coherence tomography[J]. Retina, 2015, 35(3): 525-531. DOI: 10.1097/IAE.0000000000000312.
12. Agarwal A, Aggarwal K, Pichi F, et al. Clinical and multimodal imaging clues in differentiating between tuberculomas and sarcoid choroidal granulomas[J]. Am J Ophthalmol, 2021, 226: 42-55. DOI: 10.1016/j.ajo.2021.01.025.
13. Salman A, Parmar P, Rajamohan M, et al. Optical coherence tomography in choroidal tuberculosis[J]. Am J Ophthalmol, 2006, 142(1): 170-172. DOI: 10.1016/j.ajo.2006.01.071.
14. Pichi F, Smith SD, Neri P, et al. Choroidal granulomas visualized by swept-source optical coherence tomography angiography[J]. Retina, 2021, 41(3): 602-609. DOI: 10.1097/IAE.0000000000002864.
15. Pichi F, Sarraf D, Morara M, et al. Pearls and pitfalls of optical coherence tomography angiography in the multimodal evaluation of uveitis[J/OL]. J Ophthalmic Inflamm Infect, 2017, 7(1): 20[2017-10-05]. https://pubmed.ncbi.nlm.nih.gov/28983872/. DOI: 10.1186/s12348-017-0138-z.
16. Aksoy FE, Altan C, Basarir B. Multimodal imaging of a choroidal granuloma as a first sign of tuberculosis[J/OL]. Photodiagnosis Photodyn Ther, 2020, 29: 101580[2019-10-17]. https://pubmed.ncbi.nlm.nih.gov/31629876/. DOI: 10.1016/j.pdpdt.2019.101580.
17. Agarwal A, Agrawal R, Gunasekaran DV, et al. The collaborative ocular tuberculosis study (COTS)-1 report 3: polymerase chain reaction in the diagnosis and management of tubercular uveitis: global trends[J]. Ocul Immunol Inflamm, 2019, 27(3): 465-473. DOI: 10.1080/09273948.2017.1406529.
18. Agrawal R, Testi I, Mahajan S, et al. Collaborative ocular tuberculosis study consensus guidelines on the management of tubercular uveitis-report 1: guidelines for initiating antitubercular therapy in tubercular choroiditis[J]. Ophthalmology, 2021, 128(2): 266-276. DOI: 10.1016/j.ophtha.2020.01.008.
19. Agrawal R, Gupta B, Gonzalez-Lopez JJ, et al. The role of anti-tubercular therapy in patients with presumed ocular tuberculosis[J]. Ocul Immunol Inflamm, 2015, 23(1): 40-46. DOI: 10.3109/09273948.2014.986584.
20. Al-Mezaine HS, Al-Muammar A, Kangave D, et al. Clinical and optical coherence tomographic findings and outcome of treatment in patients with presumed tuberculous uveitis[J]. Int Ophthalmol, 2008, 28(6): 413-423. DOI: 10.1007/s10792-007-9170-6.
21. Bansal R, Gupta A, Gupta V, et al. Role of anti-tubercular therapy in uveitis with latent/manifest tuberculosis[J]. Am J Ophthalmol, 2008, 146(5): 772-779. DOI: 10.1016/j.ajo.2008.06.011.
22. Yasaratne BM, Madegedara D, Senanayake NS, et al. A case series of symptomatic ocular tuberculosis and the response to anti-tubercular therapy[J]. Ceylon Med J, 2010, 55(1): 16-19. DOI: 10.4038/cmj.v55i1.1703.
23. Lou SM, Larkin KL, Winthrop K, et al. Lack of consensus in the diagnosis and treatment for ocular tuberculosis among uveitis specialists[J]. Ocul Immunol Inflamm, 2015, 23(1): 25-31. DOI: 10.3109/09273948.2014.926936.
24. Khalsa A, Kelgaonkar A, Basu S. Anti-TB monotherapy for choroidal tuberculoma: an observational study[J]. Eye (Lond), 2022, 36(3): 612-618. DOI: 10.1038/s41433-021-01505-1.
25. Kee AR, Gonzalez-Lopez JJ, Al-Hity A, et al. Anti-tubercular therapy for intraocular tuberculosis: a systematic review and meta-analysis[J]. Surv Ophthalmol, 2016, 61(5): 628-653. DOI: 10.1016/j.survophthal.2016.03.001.
26. Jain S, Agarwal A, Gupta V. Resolution of large choroidal tuberculoma following monotherapy with intravitreal Ranibizumab[J]. Ocul Immunol Inflamm, 2020, 28(3): 494-497. DOI: 10.1080/09273948.2019.1582786.
27. 陈绪攀. 结核性全眼球炎并发眼球壁穿孔1例[J]. 临床眼科杂志, 2009, 17(3): 219. DOI: 10.3969/j.issn.1006-8422.2009.03.038.Chen XP. Tuberculous panophthalmitis complicated by ocular wall perforation: a case report[J]. J Clin Ophthalmol, 2009, 17(3): 219. DOI: 10.3969/j.issn.1006-8422.2009.03.038.
28. Huang X, Qin X, Luo Z, et al. Tuberculous choroiditis masquerading as sympathetic ophthalmia: a case report[J]. Intractable Rare Dis Res, 2020, 9(3): 171-174. DOI: 10.5582/irdr.2020.03015.

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