Iris Granuloma Dr Mamta Agarwal Dr J Biswas

History 44yr / M 44yr / M C/O mild redness, decreased vision & mass C/O mild redness, decreased vision & mass in the right eye x 3-4 months in the right eye x 3-4 months No h/o any surgery, trauma. No h/o any surgery, trauma. No systemic illness No systemic illness

Clinical findings BCVA OD - 6/9 OS – 6/6 BCVA OD - 6/9 OS – 6/6 SLE OD SLE OD Aqueous cells & flare 1+ Aqueous cells & flare 1+ Mutton fat keratic precipitates Mutton fat keratic precipitates Lobulated, pinkish – white mass with irregular surface extending from 7 – 9 clock hours in the inferotemporal quadrant Lobulated, pinkish – white mass with irregular surface extending from 7 – 9 clock hours in the inferotemporal quadrant

Slit lamp photograph Mass in the anterior chamber Mutton Fat KPs OD

Gonioscopy

Ultrasound biomicroscopy Mass lesion involving ciliary body and iris, extending three clock hours in inferotemporal quadrant

Investigations Laboratory tests Laboratory tests Complete blood count - normal Complete blood count - normal ESR – 43 mm Ist hr ESR – 43 mm Ist hr Serum ACE – 92.2U/L (12-68) Serum ACE – 92.2U/L (12-68) Mantoux test – Negative Mantoux test – Negative

Investigations Chest X ray Chest X ray Hilar lymphadenopathy & parenchymal lesions suggestive of ‘Sarcoidosis’ Hilar lymphadenopathy & parenchymal lesions suggestive of ‘Sarcoidosis’ Cervical lymphadenopathy Cervical lymphadenopathy

Aqueous tap Lane 1 & 2 : Negative Control M. tuberculosis Lane 3: AC tap Positive for M. tuberculosis Lane 4: M. tuberculosis( H37Rv) Positive control DNA Agarose gel photograph showing the amplified products of Mycobacterium tuberculosis 242 bp

Differential diagnosis Tuberculosis Tuberculosis Sarcoidosis Sarcoidosis

Sarcoidosis CXR Hilar lymphadenopathy S. ACE High ESR Raised Mantoux test negative Cutaneous anergy

Tuberculosis Mantoux test Negative Mantoux test Negative S.ACE High (granulomatous reaction ) S.ACE High (granulomatous reaction ) ESR Raised ESR Raised AC Tap AC Tap PCR Mycobacterium tuberculosis - positive

Treatment Anti Tubercular therapy Systemic & topical steroids

After 5 months Complete resolution of the granuloma OD

Other options of treatment…… ? Treated with ATT alone ? Treated as Sarcoid only ? Biopsy from the lesion itself ? Excision biopsy

Conclusion TB & sarcoidosis can present as granuloma of the iris. Polymerase chain reaction of the intraocular fluids can help in the diagnosis.