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A Middle-aged Man With Macular Lesions and Vitritis

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

A 55-year-old US-born man with a history of cataract surgery in both eyes 3 years ago presented with worsening blurriness, photopsia, floaters, and intermittent eye redness for the past year, worse in the left eye. He was otherwise well. The referring physician was treating him with prednisolone eye drops for cystoid macular edema after recent left Nd:YAG capsulotomy. His best-corrected visual acuity was 20/20 OD and 20/30 OS with intraocular pressures of 20 mm Hg OD and 26 mm Hg OS. The anterior segments showed well-positioned posterior chamber intraocular lens implants with open posterior capsules. Dilated fundus examination revealed a small peripheral hypoautofluorescent chorioretinal scar in the right eye. In the left eye, there was trace vitreous haze and 2+ anterior vitreous cell. Multifocal chorioretinal scars extended from the left optic nerve into the macula in each quadrant (Figure 1). These lesions showed variable hypoautofluorescence and hyperautofluorescence. On indocyanine green angiography (ICGA), the confluent hypoautofluorescent lesions showed loss of the choriocapillaris and prominent large choroidal vessels, whereas the mottled hypoautofluorescence and hyperautofluorescent lesions appeared to block the underlying fluorescence. Routine laboratory testing was unremarkable except for a positive interferon-gamma release assay for Mycobacterium tuberculosis. A chest radiograph was normal.

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Tuberculous serpiginouslike choroiditis

C. Refer to the health department for 4-drug antituberculous treatment

Observation is not the preferred choice. It would be appropriate for acute posterior multifocal placoid pigment epitheliopathy (APMPPE), which might present with similar deep, plaquelike lesions; however, APMPPE is a bilateral disease in which ICGA displays uniform early- and late-phase hypofluorescence. Systemic corticosteroids followed by immunosuppression assumes this is serpiginous choroidopathy, which can present in a single eye with expanding peripapillary lesions and similar imaging but usually with less vitreous cell. Immunosuppression is not preferred owing to the need to consider other diagnoses.

Primary vitreoretinal lymphoma (PVRL) can present with creamy subretinal infiltrates with vitritis, but the cellular infiltrates are typically thick rather than atrophic. The choroid is not affected in PVRL; therefore, neuroimaging and lumbar puncture are not preferred as initial management. Additional history revealed several trips to Laos with possible exposure to tuberculosis in an endemic region. Referral for treatment of extrapulmonary tuberculosis was based on risk factors, positive interferon gamma release assay, clinical findings, and imaging. Ocular manifestations of tuberculosis serpiginouslike choroiditis (SLC) are well-described.13 Tuberculosis SLC is similar to noninfectious serpiginous choroiditis in selectively damaging the inner choroid, retinal pigment epithelium, and outer retina. Helicoid or placoid lesions extend from the optic nerve head in both, but multifocal lesions and more vitreous cell are typical of tuberculosis SLC.

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Article Information

Corresponding Author: Janet L. Davis, MD, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, 900 NW 17th St, Miami, FL 33101 (jdavis@med.miami.edu).

Published Online: May 12, 2022. doi:10.1001/jamaophthalmol.2022.0270

Conflict of Interest Disclosures: None reported.

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

References
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