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Editor,—An 85 year old white woman presented with progressive asthenia, fever, coughing, and dyspnoea. Chest roentgenogram showed interstitial pulmonary infiltrates and right pleural effusion. Cultures of the bronchoalveolar lavage fluid subsequently confirmed the presence ofMycobacterium tuberculosis.
On admission, best corrected visual acuity was 20/400 in a right amblyopic eye and 20/50 in the left eye. Biomicroscopic examination revealed no sign of anterior or posterior inflammation. Multiple choroidal lesions (Fig 1) were present in both eyes. The choroidal lesions were deep, white-yellowish, with indistinct borders. Fluorescence angiography (FA) revealed early nodular hypofluorescence, and late moderate hyperfluorescence (Fig 2). Indocyanine green (ICG) angiography revealed prolonged hypofluorescence and in the late stage images, moderate delineation of the lesions by a peripheral hyperfluorescent ring (Fig 3).
Multiple choroidal granulomas in the left posterior pole.
(A) Early prolonged blockage and (B) late moderate hyperfluorescence of the choroidal lesions on fluorescein angiography.
ICG angiograms reveal early (A) and late (B) phase blockage by the choroidal granulomas.
COMMENT
Ocular tuberculosis may occur by haematogenic spread from a pulmonary focus. Choroidal tuberculomas are rare ophthalmic findings even in miliary tuberculosis.1 Previous reports indicate that these lesions have prolonged hypofluorescence in FA, and late mild hyperfluorescence.2 3
Only one description of ICG angiography in a case with presumed ocular tuberculosis has been reported previously in the literature.4 We found similar angiographic characteristics in our case, which represents, to our knowledge, the first ICG angiography description of multiple choroidal tuberculomas in microbiologically confirmed miliary tuberculosis. Hypofluorescence in ICG images may be due to a masking effect of the choroidal vessels by the overlying granulomas.
Ophthalmic examination may be contributive when disseminated tuberculosis is suspected. In this case ICG angiography, which was performed to assess the choroidal involvement, showed prolonged hypofluorescence.