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JAMA Ophthalmology Clinical Challenge
November 2015

Management of Choroidal Granulomas Involving the Macula in Corticosteroid-Intolerant Patients

Author Affiliations
  • 1Vitreoretinal Service, Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics, Iowa City
JAMA Ophthalmol. 2015;133(11):1351-1352. doi:10.1001/jamaophthalmol.2015.1951

A man in his 40s with a history of chronic blurry vision in both eyes (worse in the right eye) had latent extrapulmonary tuberculosis that had been treated with antitubercular therapy 1 year earlier. Oral prednisone provided visual improvement. However, the therapy was complicated by avascular hip necrosis that required total hip arthroplasty, and his visual symptoms recurred with corticosteroid tapering.

At presentation, his visual acuity was 20/150 OD and 20/15 OS. The anterior segment was normal in both eyes. Dilated ophthalmoscopic examination of the right eye revealed a diffuse subretinal yellow mass and an exudative retinal detachment temporal to the fovea (Figure 1). Ophthalmoscopic examination of the left eye was normal. B-scan of the right eye showed a dome-shaped choroidal lesion with an apical height of 3.4 mm and medium to high internal reflectivity. Fluorescein angiography demonstrated heterogeneous leakage, and optical coherence tomography of the macula showed subretinal fluid with irregular retinal and choroidal thickening. Results from extensive workup for infectious and autoimmune etiologies (including serum angiotensin-converting enzyme, lysozyme, lumbar puncture, magnetic resonance imaging of the brain and orbits, and computed tomography of the chest) were negative, except for positive purified protein derivative skin testing and positive interferon-γ release assay (QuantiFERON-TB Gold; Cellestis, Inc).