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An 81-Year-Old Man With Multifocal Choroidal Lesions

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

An 81-year-old Mexican man was evaluated in the retina clinic for scattered subretinal lesions in the right eye. He complained of a gradual decline in his vision bilaterally over the past 2 years. He denied flashes, floaters, or eye pain but endorsed a chronic cough. He had no known ocular or medical history and took no systemic medications. He was born and raised in Mexico prior to his immigration to the United States 5 years before presentation. He worked as a farmer and denied recent illnesses, contacts with illnesses, alcohol or tobacco use, and having pets. His visual acuity was 20/60 OD and 20/40 OS with normal intraocular pressures. His slitlamp examination results were notable for mild nuclear sclerosis in both eyes and were negative for conjunctival or corneal lesions. He had round, reactive pupils and no anterior chamber inflammation in either eye. Dilated fundus examination results revealed a few pigmented anterior vitreous cells, a normal optic disc, and flat and large yellowish chorioretinal lesions with overlying pigment scattered throughout the macula and periphery in the right eye (Figure). The left eye had several similar chorioretinal lesions in the superotemporal periphery.

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Ocular tuberculosis

C. Interferon-γ release assay

An interferon-γ release assay (TB gold; QuantiFERON) was performed and the patient received a positive result. Chest radiography was then performed, revealing a left lower lobe infiltrate. The patient received a diagnosis of ocular tuberculosis (TB) from a pulmonary primary source.

Human leukocyte antigen haplotyping is not the preferred next step because while specific HLA haplotypes may be associated with certain conditions, haplotyping is an expensive test that should be used judiciously. For example, Behçet disease is a clinical diagnosis, and its association with HLA-B51 is of limited diagnostic consequence.1 Similarly, whereas HLA-A29 positivity has a strong association with birdshot chorioretinopathy,1 haplotyping alone is generally not considered diagnostic.2 Empirical steroids would not be the preferred next step because this patient lacked the findings suggestive of active inflammation. The few pigmented anterior vitreous cells did not constitute vitritis and the chorioretinal lesions did not appear to be actively inflamed. Moreover, it is important to consider infectious causes before treatment with steroids. While certain idiopathic white dot syndromes may require no treatment, observation would not be the preferred next step, as it is important in this case to evaluate for systemic infection and autoimmunity first.

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Article Information

Corresponding Author: Levi N. Kanu, MD, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, 1855 W Taylor St, Ste 1.145 (MC 648), Chicago, IL 60612 (levi.kanu@gmail.com).

Published Online: August 15, 2019. doi:10.1001/jamaophthalmol.2019.3054

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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Wolfensberger  TJ, Piguet  B, Herbort  CP.  Indocyanine green angiographic features in tuberculous chorioretinitis.  Am J Ophthalmol. 1999;127(3):350-353. doi:10.1016/S0002-9394(98)00325-0PubMedGoogle ScholarCrossref
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M  A, El-Asrar  A, Abouammoh  M, Al-Mezaine  HS; M A.  Tuberculous uveitis.  Middle East Afr J Ophthalmol. 2009;16(4):188-201. doi:10.4103/0974-9233.58421PubMedGoogle Scholar
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Sanghvi  C, Bell  C, Woodhead  M, Hardy  C, Jones  N.  Presumed tuberculous uveitis: diagnosis, management, and outcome.  Eye (Lond). 2011;25(4):475-480. doi:10.1038/eye.2010.235PubMedGoogle ScholarCrossref
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Patel  SS, Saraiya  NV, Tessler  HH, Goldstein  DA.  Mycobacterial ocular inflammation: delay in diagnosis and other factors impacting morbidity.  JAMA Ophthalmol. 2013;131(6):752-758. doi:10.1001/jamaophthalmol.2013.71PubMedGoogle ScholarCrossref
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