From Blinding Vitreous Hemorrhage to 20/20: Multimodal Management of Presumed Tubercular Retinal Vasculitis in a...

Tubercular retinal vasculitis (TRV) is an ocular manifestation of Mycobacterium tuberculosis that can lead to vision-threatening complications such as recurrent vitreous hemorrhage and cystoid macular edema (CME). Even after completing a full course of anti-tubercular therapy (ATT), persistent intraocular inflammation may drive delayed recurrences of CME, highlighting the need for vigilant, escalation-based management. We report a case of a 31-year-old Indonesian woman who presented with sudden-onset hand motion vision in her left eye. Fundus examination was obscured by dense vitreous hemorrhage, and B-scan ultrasonography confirmed an attached retina. Diagnostic workup revealed a positive interferon-γ release assay and apical infiltrates on chest radiography, with no alternative etiology, supporting a diagnosis of presumed TRV. The patient was treated with a standard nine-month course of ATT and tapering oral corticosteroids. Due to progressive retinal ischemia, pan-retinal photocoagulation was performed. Recurrent vitreous hemorrhages and persistent CME necessitated a posterior sub-Tenon triamcinolone injection and 23-gauge pars plana vitrectomy with endolaser at month 9. Fifteen months postoperatively, best-corrected visual acuity had improved to 20/20, with complete CME resolution. The purpose of this case report is to describe the management of TRV through a progressive escalation of therapy and to outline practical treatment considerations for clinicians working in tuberculosis (TB)-endemic regions. This case also illustrates that early ATT alone may be insufficient to prevent structural complications in TRV. A stepwise, multimodal approach combining systemic therapy, laser photocoagulation, periocular corticosteroids, and timely vitrectomy can restore excellent vision and reduce the risk of recurrent CME. Clinicians managing patients in TB-endemic areas should maintain close optical coherence tomography (OCT)-guided monitoring of CME and be prepared to escalate treatment promptly to prevent irreversible visual loss.