Retinal Vasculitis in the Setting of Mycobacterium tuberculosis Exposure: Clinical Course and Management of Three Cases

Abstract

Introduction: Retinal vasculitis in the setting of positive Mycobacterium tuberculosis (mTB) exposure represents an important diagnostic dilemma. Tubercular retinal vasculitis (TRV) is a recognized clinical entity, but it previously lacked diagnostic consensus. It shares clinical features with cases diagnosed as Eales disease. A precise distinction between the entities is lacking. Historically, Eales disease represented an idiopathic, obliterative retinal vasculitis seen in young males. Research has identified a potential relationship of Eales to mTB exposure, but the exact role of the organism is unclear, and the label “Eales disease” is reserved for truly idiopathic cases. We present the clinical course of 3 patients with retinal vasculitis and mTB exposure who were managed prior to group consensus guidelines for management of TRV. We discuss the evolving clinical meaning of Eales disease and review consensus TRV management guidelines. Case Presentation: The clinical course of 3 patients with retinal vasculitis and mTB exposure were reviewed. Two patients were male, and 1 was female. Mean age at presentation was 56.8 years. Mean follow-up was 119.5 months. Mean presenting visual acuity was Snellen 20/25 in the right eye and 20/30 in the left eye. Mean visual acuity at final visit was 20/30 in both eyes. All 3 patients received antitubercular therapy (ATT). Two patients underwent retinal laser photocoagulation in one or both eyes. Two patients experienced multiple episodes of vitreous hemorrhage. One patient underwent pars plana vitrectomy for non-clearing vitreous hemorrhage in both eyes. Conclusion: The cases demonstrate the potential diagnostic and management variability created by the overlapping features of Eales disease and TRV. All 3 cases had some form of positive mTB testing (radiologic, immunologic, or both) and received different ATT regimens. Case 1 was labeled Eales disease, and cases 2 and 3 were labeled TRV. All 3 had favorable outcomes but only with control of the inflammation and neovascular complications. Recent consensus guidelines now provide guidance on ATT initiation in cases of TRV.