Optic nerve head granuloma and multidisciplinary challenges in the management of ocular tuberculosis

Dear Editor, We present an intriguing case of optic nerve head (ONH) granuloma or tuberculoma, highlighting the lack of consensus on antitubercular therapy (ATT) use in ocular tuberculosis, even in tuberculosis-endemic countries like India. A 58-year-old female with a history of tuberculosis exposure 32 years ago presented with rapid painless vision loss in her left eye (LE) for two months. The patient had a BCVA of 6/24 in her LE, sluggish pupillary reaction, and deranged color vision. The anterior and posterior segment of her right eye (RE) was normal, with a BCVA of 6/6. Examination of the patient’s LE revealed vitreous cells, gross optic disc edema associated with peripapillary and streak subhyaloid hemorrhage [Fig. 1a], peripheral constriction of visual fields on Humphrey’s perimetry, and magnetic resonance imaging revealed thickening of the left chorioretinal layers with normal optic nerve signal. Her Mantoux test and QuantiFERON TB gold test were positive, whereas radioimaging of the lungs was normal. The patient was advised pulse corticosteroid followed by oral steroids with ATT. However, chest physicians and infectious disease specialist advised against the need for ATT for latent tuberculosis. Despite the ophthalmologist’s recommendation, the patient refused to take ATT. At one and three-month follow-ups with corticosteroid treatment alone, the patient’s LE BCVA improved to 6/7.5, but there was no reduction in disc edema [Fig. 1b and c], and the visual field defect persisted. The condition was discussed again in detail with the patient, and along with a maintenance dose of 10 mg oral steroids, ATT was started. The patient was monitored closely [Fig. 1d and e]. At the final visit, one year since presentation, the patient’s LE BCVA was 6/6, optic disc edema had resolved [Fig. 1f], and there was improvement in the visual field.Figure 1: Serial fundus photographs of a patient of optic disc granuloma. (a). At presentation (b). After pulse corticosteroid (c). After 3 months of treatment with systemic corticosteroid alone. Antituberculosis treatment and treatment with oral corticosteroid 10 mg/day (d) At 6 month (e) At 9 month, and (f) At 1 year followupOur case highlights the knowledge gap and lack of consensus on the use of ATT in ocular tuberculosis that extends across other medical subspecialties.[1] It emphasizes the importance of multidisciplinary collaboration and regular updates on the latest guidelines for the diagnosis and management of ocular tuberculosis.[1,2] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.