Persistent placoid Maculopathy TB related Rupesh Agrawal, Carlos Pavesio Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom

Ocular History  45 year old male  ‘A black cloud nasally towards the central portion of his vision x 2 months’  flashes, headache

General History  no history of prior viral infection  dyslipidemia, anxiety  social history: worked in Asia for 13 years as an engineer

First Presentation – Ocular Examination  visual acuity: OD 6/5; OS 6/60  anterior chamber: trace cells OS  lens: 1+ NSC BOU  anterior vitreous: trace cells OS

First Presentation - Fundus  OD: normal, OS: coalescing lesions around the macula

First Presentation - Fundus  OS: pigmented lesions

First Presentation - Infrared  hyperfluorescent lesion at the macula

First Presentation - FFA  stippled hyperfluorescence of lesion, no leakage

First Presentation - FFA  hyperfluorescence, no leakage

First Presentation - ICGA  hypocyanescent lesion

First Presentation - ICGA  hypocyanescent lesion

Differential Diagnosis ‘Placoid choroidopathy’ ‘Placoid choroidopathy’ Persistent placoid maculopathy Persistent placoid maculopathy Acute posterior multiofcal placoid pigment epitheliopathy Acute posterior multiofcal placoid pigment epitheliopathy Serpiginious Choroiditis Serpiginious Choroiditis Ampiginous (relentless placoid choroidopathy) Ampiginous (relentless placoid choroidopathy) Sarcoidosis Sarcoidosis Infectious: Syphilis, TB, Toxoplasmosis Infectious: Syphilis, TB, Toxoplasmosis

First Diagnosis Persistent Placoid Maculopathy similar to macular serpiginous choroidopathy similar to macular serpiginous choroidopathy 6 th to 7 th decade 6 th to 7 th decade vision relatively good vision relatively good propensity of CNV propensity of CNV persistent hypofluorescence on ICG and FFA persistent hypofluorescence on ICG and FFA unknown etiology unknown etiology steroid may give some benefit steroid may give some benefit

First Presentation - Investigations CBC, U/E, LFT’s CBC, U/E, LFT’s HIV HIV Syphilis Syphilis Toxo IgM/IgG Toxo IgM/IgG QuantiFERON gold QuantiFERON gold CXR CXR ACE ACE

Results all negative but QuantiFERON + all negative but QuantiFERON +

Diagnosis atypical presentation of ocular TB as placoid pigment epitheliopathy atypical presentation of ocular TB as placoid pigment epitheliopathy

Treatment sent to Chest physicians to start treatment for TB sent to Chest physicians to start treatment for TB complete course of ATT – 4 drugs for 2 months and 2 drugs for 7months complete course of ATT – 4 drugs for 2 months and 2 drugs for 7months oral steroids – 60mg/day x 1week in tapering dose stopped after six months oral steroids – 60mg/day x 1week in tapering dose stopped after six months

Final Follow-up – After 18 Months No recurrence of inflammation within 6 months of complete course of ATT No recurrence of inflammation within 6 months of complete course of ATT VA: RE: 6/5, LE: 6/36 VA: RE: 6/5, LE: 6/36