Management of optic disc granuloma in a patient of miliary tuberculosis with intravitreal ranibizumab in addition to antitubercular therapy

A 32-year-old woman presented with decreased vision in the right eye for 2 weeks with best-corrected visual acuity (BCVA) of 6/18. She was diagnosed with miliary pulmonary tuberculosis elsewhere 1 month back and started on antitubercular therapy (ATT). Fundus of the right eye showed a vascularized elevated disc granuloma with peripapillary serous retinal detachment [Fig. 1a]. Optical coherence tomography (OCT) showed a large lobulated hyper-reflective mass located on the optic nerve head (ONH) with back-shadowing and subretinal fluid (SRF) detaching the fovea [Fig. 1b]. Fundus fluorescein angiography (FFA) showed a vascularized granuloma with increasing fluorescence and peripapillary pooling of the dye [Fig. 2a-c]. Left eye was unremarkable. Systemic investigations already performed revealed a negative Mantoux, sputum culture positive for Mycobacterium tuberculosis, and diffusely spread miliary nodules in both the lungs on high-resolution computed tomography (HRCT) chest [Fig. 2d]. Since the patient was diagnosed with miliary TB, systemic corticosteroids could not be initiated. The patient was administered two intravitreal ranibizumab injections at monthly interval leading to complete regression of granuloma and SRF with final BCVA of 6/6(p) at the end of 7 months while she was still on ATT [Fig. 1c-h].

Figure 1.

Horizontal white line passing through disc indicates OCT scan position. (a) Initial fundus picture showing vascularized disc granuloma and peripapillary SRF. (b) OCT showed a hyper-reflective mass on ONH (white arrow) and SRF detaching fovea. (c and d) Three weeks after first ranibizumab injection, there was reduction in volume of granuloma (white arrow) and SRF. (e and f) One month after second injection, infrared fundus image and OCT showed further regression of granuloma (white arrow) with minimal SRF (red arrows). (g and h) The granuloma (white arrow) and SRF resolved completely at 7 months

Figure 2.

(a-c) FFA showed a vascularised granuloma with increasing fluorescence in early, mid ,late phases and peripapillary pooling of dye in area of exudative retinal detachment.(d) Axial scan of HRCT chest-lung window showing bilateral diffuse, randomly distributed miliary nodular opacities

Discussion

Hypoxia-induced increased VEGF expression in tubercular granuloma as demonstrated in animal models enhances internal neovascularization allowing it to continue to grow and, hence, slow down the response or increase resistance to ATT.[1,2] Anti-VEGF agents have been used effectively as an adjunctive treatment in eyes with these kinds of granulomas.[3,4,5]

In our case, the diminution of vision was due to exudation caused by increased vascularity of the granuloma. Paradoxical reaction to ATT could be another reason. An effective response to intravitreal anti-VEGF suggests that it can be used as an alternative to systemic steroids for treating highly vascular tubercular disc or choroid granulomas with increased exudation as an adjunct to conventional antitubercular therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.