Chasing shadows: case series of six posterior segment manifestations of ocular tuberculosis

Ocular tuberculosis (OTB) is difficult to confirm microbiologically, so diagnosis often rests on characteristic posterior segment phenotypes supported by systemic immunologic evidence and therapeutic response. This case series from a high-prevalence setting illustrates the heterogeneity of posterior OTB and provides practical diagnostic anchors, treatment approaches, and complication surveillance that are directly applicable to routine uveitis care.

Six immunocompetent males (28-46 years) presented with posterior disease entities that included: choroidal granulomas with papillitis; multifocal choroiditis with venous occlusion; bilateral granulomatous sclerouveitis with inactive multifocal/serpiginous-like choroiditis; choroiditis with occlusive vasculitis; bilateral serpiginous-like choroiditis; and unilateral occlusive vasculitis with vitreous hemorrhage. Four reported prior incarceration, all were human immunodeficiency virus (HIV)-negative. Pulmonary involvement was absent or limited, though chest computed tomography (CT) revealed cavitary or nodular changes in some patients. Diagnostic support comprised a positive tuberculin skin test (TST) and/or interferon-gamma release assay (IGRA), multimodal imaging, and subsequent anti-tubercular response. All patients received standard RIPE (rifampin, isoniazid, pyrazinamide, ethambutol) therapy with a tapered oral corticosteroid course. Most eyes achieved inflammatory quiescence by nine months; visual outcomes ranged from 20/20 in quiescent eyes to limited improvement where macular scarring or ischemic detachment occurred.

Posterior OTB may present without overt pulmonary disease and spans granulomatous, serpiginous-like, and occlusive vasculitic phenotypes. In endemic regions, early suspicion supported by TST/IGRA and multimodal imaging, followed by RIPE plus corticosteroids, can control inflammation and mitigate vision-threatening complications. Vigilance for secondary choroidal neovascularization (CNV) and timely surgical intervention is essential.