Bilateral Atypical Optic Neuritis With Posterior Scleritis Secondary to Tuberculosis: Challenges in Management

Atypical optic neuritis and posterior scleritis can indicate extrapulmonary tuberculosis (TB) caused by Mycobacterium tuberculosis. We present a rare case of bilateral atypical optic neuritis accompanied by posterior scleritis secondary to TB. A 36-year-old gentleman presented with a four-day history of blurred vision in both eyes, along with pain during eye movements. His medical history included intermittent low-grade fever and a persistent cough lasting four months, accompanied by significant weight loss of 13 kg over two months. On examination, visual acuity in the right eye was 6/36, while perception of light (PL) was present in the left eye. A positive relative afferent pupillary defect was noted in the left eye, with reduced light brightness and red desaturation observed. Both anterior segments appeared normal. Fundoscopic examination revealed bilateral hyperemic swollen optic discs. Chest radiography showed opacities in the right upper and middle lung fields. MRI of the orbit and brain demonstrated enhancement of the optic nerves in both eyes, along with pronounced posterior scleritis. Sputum analysis for acid-fast bacilli suggested pulmonary involvement. Lumbar puncture results were unremarkable, with normal opening pressure and cytology. The patient was diagnosed with bilateral atypical optic neuritis and posterior scleritis secondary to pulmonary TB. He was promptly started on an antitubercular regimen. Systemic high-dose methylprednisolone was introduced five days later. However, his condition deteriorated to PL in both eyes with pale discs after two weeks. Despite a modified corticosteroid regimen, vision remained poor upon discharge. Atypical optic neuritis may overlap with posterior scleritis and cause severe, sight-threatening conditions. Early diagnosis and comprehensive management of TB are critical for improving outcomes and preventing long-term damage.