Steroid treatment in ocular tuberculosis: A double-edged sword?

We report the case of a Caribbean patient with an atypical presentation of bilateral tuberculous chorioretinopathy.

A 57-year-old woman, with hypertension and non-insulin dependent diabetes, was referred to our center for a sudden loss of vision in the right eye to hand motions. Ophthalmic examination revealed only right papilledema. Brain magnetic resonance imaging was normal. Laboratory examination revealed no signs of inflammation. A right non-arteritic acute anterior ischemic optic neuropathy was first suspected. One week later, the visual acuity (VA) in the left eye dropped from 10/10 to 5/10 with the appearance of papilledema on fundoscopic exam. This bilaterality led us to begin intravenous corticosteroids followed by transition to oral. This improved the left eye VA to 10/10. Numerous bilateral white patches in the posterior pole appeared secondarily, hypofluorescent in the intermediate and late phases of angiography.

The research of the etiology of uveitis showed a positive tuberculin skin test without any prior vaccination. The vitreous humor sample was negative on direct examination, by culture and by polymerase chain reaction (PCR).

Systemic corticosteroid therapy for ocular tuberculosis is not well described. It may theoretically treat the inflammatory portion of the lesions due to type IV hypersensitivity reaction as in meningeal and pericardial involvement.

The clinical spectrum of ocular tuberculosis is wide and the diagnosis should be considered in any intraocular inflammatory condition of a chronic or acute recurrent nature, whether or not responsive to steroids.