Chasing shadows: case series of six posterior segment manifestations of ocular tuberculosis

Introduction

Tuberculosis (TB) remains a significant global health concern. According to the World Health Organization (WHO), approximately 10.6 million people were diagnosed with TB and 1.4 million died from the disease in 2021 (1). While pulmonary involvement is the most common form, extrapulmonary TB accounts for approximately 30% of cases, with ocular manifestations representing a rare but clinically significant subset (2,3). Ocular tuberculosis (OTB) can be manifested as diverse types of uveitis and may reflect the activity of the bacillus or a hypersensitivity reaction to it (2,4).

Diagnosing OTB is particularly challenging due to the difficulty of isolating the infectious agent in ocular samples. Most diagnoses are presumptive, relying on supportive evidence such as a positive tuberculin skin test (TST), interferon-gamma release assay (IGRA), or radiographic findings of pulmonary TB (5). Timely recognition and treatment are critical, as untreated OTB can lead to significant visual morbidity (2). The standard treatment regimen, combining RIPE (rifampin, isoniazid, pyrazinamide, and ethambutol) therapy, has demonstrated efficacy in controlling inflammation and preventing recurrence (6). However, variations in presentation and response to therapy underscore the need for detailed case documentation to guide clinical decision-making.

This study presents a series of presumed OTB cases, highlighting the spectrum of clinical presentations involving the posterior segment of the eye, the diagnostic challenges, and the therapeutic outcomes. We present this article in accordance with the AME Case Series reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-91/rc).

Case presentation

Case 1

A 35-year-old male presented with sudden vision loss in his right eye (OD), accompanied by periocular pain for 9 days. Best-corrected visual acuity (BCVA) was counting fingers at close range in the OD and 20/25 in the left eye (OS). Examination of the OD revealed ciliary injection, granulomatous keratic precipitates (KPs), anterior chamber reaction, +1 vitritis, optic disc edema with hyperemia, and multiple yellowish nodular choroidal lesions (Figure 1A). The examination of the OS was unremarkable.

Figure 1 Optic disc edema with choroidal granulomas and improvement after therapy in the right eye. (A) Color fundus photography shows an elevated, hyperemic optic disc (blue arrow), multifocal choroidal nodular lesions, and choroidal folds (black arrows). (B) Optical coherence tomography shows optic disc edema (blue arrow) and an elevated subfoveal choroidal lesion (yellow arrow). (C) Follow-up optical coherence tomography shows interval reduction of the choroidal granuloma.

Fluorescein angiography showed hyper- and hypofluorescent spots in the posterior pole of the OD, with optic disc leakage; the OS appeared normal. Optical coherence tomography (OCT) revealed optic disc edema in OD, an elevated choroidal lesion in the subfoveal region, and subretinal fluid nasal and temporal to the optic disc (Figure 1B).

Diagnostic tests were ordered, including serologies, TST, and chest CT. Laboratory tests ruled out toxoplasmosis, syphilis and human immunodeficiency virus (HIV), but TST was positive (35 mm). Chest CT identified small bilateral pulmonary nodules (<0.5 cm), alongside scattered laminar atelectasis in the lower lobes.

Based on clinical and image findings, a diagnosis of presumed OTB was made, and RIPE treatment (rifampin, isoniazid, pyrazinamide, and ethambutol) was initiated, in association with oral corticosteroid tapered during the initial four weeks of treatment. Follow-up evaluation indicated improvement in the choroidal granulomas (Figure 1C).

After nine months of treatment, OD visual acuity improved to 20/80. Examination of the anterior segment of the OD showed no signs of active inflammation. Fundus examination revealed a clear vitreous, pink optic disc with sharp margins, tortuous vessels, and improvement of the yellowish subretinal lesions.

Case 2

A 28-year-old male, a former inmate, presented with decreased visual acuity in OS for 15 days. Initial examination showed a BCVA of 20/20 in OD and counting fingers at 50 cm in OS. Slit-lamp examination of OD was unremarkable. OS revealed a clear conjunctiva, granulomatous KPs inferiorly, anterior chamber reaction +1, Koeppe nodules, and vitreous cells.

Fundus examination of the OD was unremarkable. OS showed vitritis +2, a well-defined optic disc, multiple yellowish subretinal nodular lesions, associated to adjacent intraretinal hemorrhages in the superior temporal vessels (Figure 2A). Laboratory investigation showed negative results for HIV and syphilis and a positive TST (18 mm). Chest CT revealed no pathological findings. Based on clinical findings, epidemiological factors, and the positive TST, a presumed diagnosis of OTB was made, specifically multifocal choroiditis accompanied by signs of venous occlusion. Treatment with RIPE in association with oral corticosteroid tapered during the initial four weeks of treatment was initiated.

Figure 2 Multifocal choroiditis with venous involvement progressing to macular atrophy in the left eye. (A) Color fundus photography shows vitreous inflammation, multiple yellowish subretinal lesions (green arrows), and intraretinal hemorrhages along the superotemporal vessels (blue arrow). (B) Color fundus photography shows an atrophic macular lesion.

One month later, the patient returned, reporting persistent visual disturbances in the OS. He had been on the RIPE regimen for one month, but his visual acuity remained unchanged. OS showed an extensive atrophic appearance of the retina and an atrophic macular lesion (Figure 2B). The patient reported visual improvement with the ongoing RIPE regimen one month later. His BCVA was 20/20 in OD and 20/150 in OS. The patient was treated for 9 months.

Case 3

A 46-year-old male, a former inmate, with a complaint of ocular pain and blurred vision in OD for 2 weeks, with a history of similar episodes, the last occurring 4 years prior. His personal history includes previous treatment for hepatitis C, and his family history reveals contact with pulmonary tuberculosis (his mother was treated for the disease).

BCVA was 20/80 in OD and 20/30 in OS. Anterior segment evaluation revealed diffuse scleritis and vitreous cells +1 in OD. The OS showed a flare. Fundus examination of the OD revealed multiple confluent yellowish subretinal lesions in the central macula, and pigment mobilization in three areas (Figure 3A).

Figure 3 Posterior pole subretinal lesions with outer-retinal disruption and deep vascular abnormalities in the right eye. (A) Color fundus photography shows macular folding and multiple yellowish subretinal lesions in the posterior pole; hyperpigmented lesions temporal to the fovea are indicated (yellow arrows). (B) Optical coherence tomography shows disruptions of the outer retina and pigment epithelial detachments. (C) Optical coherence tomography angiography shows abnormal networks within the deep capillary plexus. (D) Color fundus photography shows subretinal yellowish lesions with pigment mobilization in the right eye (blue arrows); the left eye shows a stable temporal hyperpigmented lesion (yellow arrows). BRM, bruch’s membrane; ILM, inner limiting membrane; IPL, inner plexiform layer; OCT, optical coherence tomography; OPL, outer plexiform layer; RPE, retinal pigment epithelium; SLO, scanning laser ophthalmoscopy.

Laboratory workup indicated negative Venereal Disease Research Laboratory (VDRL) test, treponemal tests, and HIV. OCT revealed multiple outer retinal disruptions and pigment epithelial detachments in OD, choroidal thinning, disorganization of the outer retinal layers, and choroidal folds with subretinal fluid along the papillomacular bundle in OS (Figure 3B). Optical coherence tomography angiography (OCTA) showed deep plexus vascular networks in OD (Figure 3C). The OS displayed macular folding and several yellowish subretinal lesions in the posterior pole, with a hyperpigmented lesion temporal to the fovea (Figure 3D). Chest CT revealed no pathological findings. Given these findings, a provisional diagnosis of bilateral granulomatous sclerouveitis with inactive multifocal/serpiginous-like choroiditis, likely secondary to TB, was made.

Laboratory workup revealed positive IGRA, and RIPE therapy was initiated. Subsequent follow-up showed improvement in vision (BCVA improved to 20/40 in OD and 20/30 in OS), with no pain or signs of inflammatory activity. OD examination findings still revealed subretinal yellowish lesions with pigment mobilization, while OS showed a stable hyperpigmented lesion temporal to the fovea (Figure 3D). Autofluorescence and OCT findings demonstrated no active changes, consistent with an inactive disease state.

After completing the nine-month RIPE therapy associated with oral corticosteroids tapered for 5 weeks, the patient reported stable visual acuity. Examination findings indicated a stable, inactive state with no signs of reactivation. The patient was advised to continue regular follow-ups to monitor for potential recurrence or complications associated with chronic choroiditis.

Case 4

A 34-year-old male presented with a three-week history of progressive, painless visual decline in OD. The patient reported no history of previous systemic diseases, TB contact, or previous similar episodes, and he works as a doorman. His past medical history was unremarkable. Laboratory evaluations for HIV, toxoplasmosis and syphilis were negative. IGRA was positive. Chest CT showed no abnormal findings.

Ophthalmologic examination revealed BCVA of 20/30 in OD and 20/20 in OS, with intraocular pressures within normal limits. Examination of OD showed ciliary injection, inferior fine KPs, anterior chamber reaction, and vitreous cells. The OS exam was unremarkable. Fundoscopy in OD revealed rounded, yellowish subretinal lesions in the mid-periphery, intraretinal hemorrhages, and adjacent venous beading and sheathing (Figure 4A).

Figure 4 Occlusive retinal vasculitis with choroiditis and secondary choroidal neovascularization in the right eye. (A) Color fundus photography shows rounded yellowish subretinal lesions in the mid-periphery (yellow arrow) with intraretinal hemorrhages (blue arrow), venous beading, and perivascular sheathing (black arrow). (B) Fundus autofluorescence shows hypoautofluorescent scars corresponding to previously active lesions. The red arrow indicates the focal site of active vasculitis. (C) Optical coherence tomography shows subretinal fluid caused by active choroidal neovascularization.

Based on the clinical findings and a positive IGRA result, a diagnosis of choroiditis and vasculitis secondary to presumed TB was made. RIPE was initiated with a planned nine-month course, in association with oral corticosteroid tapered during the initial four weeks of treatment.

Four months later, his visual acuity improved to 20/30 in OD, with clear media and improvement of fundus findings. Fundoscopic findings revealed cicatricial changes in the superior temporal arcade with faint peripheral hemorrhages, indicating quiescent disease. Angiography imaging demonstrated hypoautofluorescent scars correlating with prior active lesions (Figure 4B).

Three months later, OCT revealed the development of choroidal neovascularization in the superior temporal arcade, and anti-vascular endothelial growth factor (VEGF) therapy was indicated (Figure 4C). The patient received his first anti-VEGF injection, which resulted in stabilization of vision and no further fluid accumulation on OCT. His most recent evaluation showed bilateral visual acuity of 20/20. OD displayed well-demarcated optic disc margins and residual cicatricial subretinal lesions without signs of active inflammation. The choroid remained stable with no leakage, and the retina was fully attached. The patient was advised to continue his prescribed anti-tubercular therapy for 9 months.

Case 5

A 28-year-old male, former inmate, and deliveryman presented with painless low visual acuity in OS, persisting for approximately 2.5 years. He reported no history of ocular or systemic diseases. Notably, he did not seek medical attention when his symptoms first appeared.

Ophthalmologic evaluation showed a BCVA of 20/20 in OD and hands motion in OS. Slit-lamp examination was normal in both eyes. Fundus examination revealed a classic late-stage serpiginous-like geographic choroiditis in both eyes, with macular involvement in OS (Figure 5A). No signs of inflammatory activity were detected, confirmed by the extensive hypoautofluorescence.

Figure 5 Bilateral serpiginous-like choroiditis with asymmetric macular involvement. (A) Color fundus photography of both eyes shows late-stage serpiginous-like geographic choroiditis; the left eye has marked macular involvement, whereas the right eye shows similar choroidal lesions without direct macular compromise. (B) Optical coherence tomography of the right eye shows loss of the outer retina and the retinal pigment epithelium with macular sparing (yellow arrow). (C) Optical coherence tomography of the left eye shows subretinal hyperreflectivity with fibrotic change at the macula (green arrow).

OCT in OD revealed loss of outer retinal and retinal pigment epithelium (RPE) architecture, sparing the macula (Figure 5B). OCT in OS showed subretinal hyperreflectivity with signs of fibrosis in the macular region (Figure 5C).

Laboratory work-up revealed positive IGRA. This patient also presented a large cavitation in chest CT, compatible with sequelae of pulmonary tuberculosis. The diagnosis of bilateral posterior uveitis, a serpiginous-like choroiditis secondary to TB, was made, and RIPE therapy was initiated, associated with oral corticosteroids tapered during the initial 5 weeks of treatment.

Case 6

A 29-year-old male presented with a sudden, painless decrease in vision in OS for the past 7 days. He denied other ocular or systemic symptoms. His personal history was notable for a period of incarceration from 2012 to 2016, and he reported daily use of cocaine and cannabis. His past ocular and family history were unremarkable.

BCVA was 20/20 in OD and 20/80 in OS. Slit-lamp examination of OS revealed vitreous cells. Fundoscopy revealed attenuated vessels, increased vascular tortuosity in the superior temporal arcade, perivascular sheathing, ghost vessels, and hemorrhages at multiple levels (vitreous, pre-retinal, and intraretinal), with macular changes consistent with a macular pucker (Figure 6). The retina was attached. Given the findings, a diagnosis of unilateral occlusive vasculitis was considered.

Figure 6 Advanced occlusive retinal vasculitis with multilevel hemorrhage and macular pucker in the left eye. Color fundus photography shows attenuated vessels and increased tortuosity in the superotemporal arcade, with perivascular sheathing and ghost vessels (green arrows). Vitreous, preretinal, and intraretinal hemorrhages are present, and macular changes consistent with an epiretinal membrane (macular pucker) are indicated (blue arrow).

Laboratory investigation showed normal blood counts, renal function, and inflammatory markers. Rheumatologic panels and serologies for HIV and syphilis were negative. However, TST was positive at 17 mm. Chest CT revealed multiple nodules, some calcified, with a large cavitation in the upper lobe of the right lung. The diagnosis of unilateral infectious vasculitis associated with TB was established.

Unfortunately, the patient did not take RIPE or the corticosteroid therapy as indicated, and three months later, there was an increased vitreous hemorrhage and visual acuity decreased to hand motion in OS. Ultrasonography confirmed the presence of a retinal detachment with tent-like tractions. The RIPE therapy was finally started associated with oral corticosteroid tapered during the initial 6 weeks of treatment. The patient underwent pars plana vitrectomy. Intraoperative findings revealed mixed retinal detachment, diffuse retinal ischemia, and extensive inflammatory membranes in the periphery and posterior pole. Retinectomy and drainage of subretinal fluid were performed, followed by silicone oil tamponade to stabilize the retina. Postoperatively, after the conclusion of the 9-month RIPE regimen, the patient’s visual acuity improved to counting fingers at 1 meter.

Ethical consideration

All procedures performed in this case series were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case series and accompanying images was not obtained from the patients or the relatives after all possible attempts were made.

Discussion

This case series highlights the varied clinical presentations of OTB, including multifocal choroiditis, choroidal granulomas, serpiginous-like choroiditis, occlusive retinal vasculitis, scleritis, and papillitis. The six patients in were all male, with ages ranging from 28 to 46 years, representing a relatively young demographic often affected by OTB. None of the six patients in this case series tested positive for HIV, as confirmed by serological investigations. Four patients had positive epidemiology due to a history of previous incarceration. Our findings align with prior reports describing the diverse ocular manifestations of TB (7-10). All cases in this series were treated with the RIPE regimen for 9 months associated with oral corticosteroid tapered during the initial weeks of treatment. This approach demonstrated significant efficacy in controlling inflammation. The use of adjunctive corticosteroids is supported by the guidelines of the Collaborative Ocular Tuberculosis Study Consensus Group, which recommend their use concomitantly with or shortly after initiating RIPE therapy (6). In our series, corticosteroid adjunctive therapy contributed to the reduction of posterior segment inflammation and improved clinical outcomes without notable adverse effects. This reinforces the recommendation of the guideline that corticosteroids are an essential component in managing inflammatory responses associated with OTB (6).

Positive results on IGRA or TST, coupled with clinical response to RIPE therapy, supported the presumed OTB diagnoses. Notably, pulmonary findings were observed in only three cases, underscoring that pulmonary involvement is often absent in OTB and is not a prerequisite for clinical suspicion (3). This highlights the importance of maintaining a high degree of suspicion based on ocular findings and supportive immunologic tests, particularly in regions with a high prevalence of TB (3).

This study presents limitations. Although anterior chamber tap and vitreous biopsy are rapid and practical diagnostic tools, they were not performed due to a lack of institutional resources. In our high-prevalence setting, presumptive diagnosis remains acceptable. The retrospective nature and small sample size may limit the generalizability of findings. Moreover, long-term follow-up was unavailable for all cases, precluding a comprehensive evaluation of recurrence rates and long-term visual outcomes. Future prospective studies with larger cohorts are needed to validate these findings.

Conclusions

In conclusion, OTB demonstrates a wide range of phenotypic manifestations, particularly in the posterior segment, including choroidal granulomas, multifocal choroiditis, serpiginous-like choroiditis, and occlusive retinal vasculitis. Notably, these presentations often occur in the absence of pulmonary symptoms. OTB should remain a diagnostic consideration, especially in regions with high TB prevalence. Early recognition and initiation of the RIPE regimen associated with oral corticosteroids are essential for controlling inflammation, preventing complications, and improving visual outcomes.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the AME Case Series reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-91/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-91/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-91/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this case series were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case series and accompanying images was not obtained from the patients or the relatives after all possible attempts were made.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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