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Show Journal of Seuro- OpUtlmlmolo^ ISi. h: 201 JO.,', IWH. (•) 1998 l. ippinum Willmms & Wilkins. Philadelphia Optic Disk Tubercle Ahmad M. Mansour The purpose of this ease report was to present a rare case of optie disk tubercle. The optic disk edema resolved on antitu-berculous therapy with recovery of vision. We concluded that visual loss from an optic disk tubercle can be the presenting sign of tuberculosis. Key Words: Optic disk tubercle. Tuberculosis is a systemic disease of protean manifestation with many cases of extrapulmonary involvement. The most common ocular findings include disseminated choroiditis, anterior granulomatous uveitis, and retinal vasculitis. We describe a case presenting with visual loss from granulomatous optic disk infiltration its the first sign of tuberculosis. CASK RKPORT A 29- year- old male architect noted marked visual loss in the left eye of 1 week's duration and mild visual loss in the right eye of 2 months' duration. He was placed on a high dose of systemic corticosteroids 3 days before presentation. Visual acuity was 6/ 9 in the right eye and 6/ 60 in the left eye with a moderate left afferent pupillary defect. The right eye had a mild iritis, whereas the left eye had a moderate granulomatous iritis. The right optie nerve head was mildly edematous with a temporal peripapillary flat choroidal yellowish lesion. The left optic-disk edema was severe, with a large yellowish nodular elevation on the nasal papillary edge. Sheathing of retinal veins and multiple flat round pigmented chorioretinal sears were noted at the equator bilaterally. Medical history was negative for cough, headache, fever, and weight loss. Physical and neurologic examinations were unremarkable. Serology for syphilis, human immunodeficiency virus ( HlV)- l and II1V- 2 were negative. A chest radiograph showed a nodule, and a purified protein derivative skin test was strongly positive with 5 cm of induration. Lumbar puncture and magnetic resonance imaging of the brain were not performed because signs Manuscript received May IW7; accepted November 1W7. from ihe Department of Ophthalmology. American University of Beirut. Beirut. Lebanon. Address correspondence and reprint requests to Dr. Ahmad Mansour, Department of Ophthalmology. American University of Beirut. Beirut. Lebanon. and symptoms of tuberculous meningitis ( malaise, apathy, anorexia, headache, nausea, and low- grade fever) were absent. Systemic corticosteroids were discontinued on presentation. He was started on isonia/. id, ethambutol, and rifampin. After 3 weeks of anlilubeiculous therapy, there was resolution of the afferent pupillary defect, quieting of the uveitis, and return of visual acuity to normal. The disk edema subsided in both eyes with a decrease in the size of the left peripapillary granuloma. Intravenous fluorescein angiography showed staining of the left peripapillary granuloma and optic disks ( bigs. 1- 5). Anlitubereulous therapy was tapered to isonia/. id and ethambutol and discontinued 8 months after presentation. The optic disk appearance was unchanged 2 years after presentation ( big. 6). DISCUSSION The most common ocular finding in tuberculosis is the choroidal tuberculoma that occurs either in pulmonary tuberculosis or in military tuberculosis ( 1,2). Choroidal tuberculomas appear as multiple yellowish nodules varying in size from one third the disk diameter to three disk diameters. Rarely, tuberculomas of the choroid represent the only manifestation of tuberculosis ( 3). Retinal vasculitis is the second fundus manifestation in tuberculosis ( 4). Disk edema in tuberculosis is uncommon. In 1,000 patients examined in a sanatorium, Glover ( 5) mentioned the presence of optic disk edema in four patients, all of whom had severe continuous headaches from tuberculous meningitis. In 65 patients with tuberculous meningitis, Mooney ( 6) noted optic disk edema in 17 patients ( 26%), and the edema was attributed to " external" or " internal" hydrocephalus from tuberculosis- related adhesions. In a review of 10,524 patients with tuberculosis, Donahue ( 7) found 145 patients ( 1.4%) with ocular tuberculosis and a single ease of tuberculosis of the optic nerve confirmed at necropsy. Lana- Peixolo et al. ( 8) presented a case of retrobulbar optic nerve tuberculoma detected at necropsy in a 1.5- year- old boy with tuberculous meningitis and disseminated miliary tuberculosis. Miller and Frenkel ( 9) reported on a 45- year- old man who presented with visual acuity loss, central scotoma, and a diagnosis of retrobulbar neuritis. At craniotomy, an optic nerve tumor was discovered, and pathologic examination 201 202 A. M. MANSOUR FIG. 1. The right posterior pole demonstrates minimal optic disk edema and flat chorioretinal scars along the vascular arcade ( study taken 2 months after presentation). FIG. 2. Intravenous fluorescein angiography shows multiple round defects of the retinal pigment epithelium around the vascular arcade of the right eye. Corkscrew- shaped retinal veins are noted ( study taken 2 months after presentation). FIG. 3. There is diffuse staining of the disk and retinal vessels in the right eye during the late transit of fluorescein angiography ( study taken 2 months after presentation). ,/ Nnira- Oi> lilli< ilmc: l. Vol. IS. No. .1. IWS FIG. 4. The left posterior pole demonstrates the whitish optic disk tubercle and an inferior retinal branch vein occlusion from periphlebitis. A superior peripapillary flat choroidal yellowish lesion is noted ( study taken 2 months after presentation). of the excised tumor was compatible with a tuberculoma. Arora et al. ( 10) presented the case of a 5- year- old girl who had extensive tuberculoma of the uvea, the retina, and the cut edge of the optic nerve after enucleation for a suspected retinoblastoma. We add another case of optic disk tubercle presenting with visual loss without a history of tuberculosis. Tuberculosis needs to be added to the list of inflammatory disorders of the optic nerve that manifest as infiltrative masses such as sarcoidosis, syphilis ( 11), toxocariasis, aspergillosis, candidiasis, and some bacteria ( 12). Visual pathway involvement by tuberculoma includes most of the region of the optic chiasm and the neighboring optic nerve. Thirty- one patients with optochiasmatic tuberculomas have been reported in the literature ( 13,14), all suffering from tuberculous meningitis. When there is associated optochiasmatic arachnoiditis with symptoms of chronic chiasmatic compression ( visual acuity loss, visual field constriction, and disk pallor), microsurgical decompression of the optic nerves and chiasm can yield prompt visual recovery ( 15). The visual pathways in the occipital, parietal, and temporal lobes FIG. 5. The optic disk tubercle stains during the late transit of fluorescein angiography in the left eye ( study taken 2 months after presentation). OPTIC DISK TUBERCLE 20J FIG. 6. Two years after presentation, the left optic disk edema has resolved with a residual nasal whitish peripapillary granuloma and a temporal choroidal scar. are not usually involved by tuberculomas. Such lesions can cause homonymous licmianopia and papilledema ( 16.17). The most recent Centers for Disease Control guidelines ( 18) for the therapy of active tuberculosis recommend an initial 60- day triple therapy ( isonia/. id, rifampin, and pyra/. inamide) followed by 120- day double therapy ( isonia/. id and rifampin). In tuberculous meningitis, a regimen of 9- month double therapy ( isoniazid and rifampin) was found to be effective ( 19). The optimal therapy for optic disk tubercle is not known, but based on the present case, a double drug therapy for 8 months appeals adequate. REFERENCES I. Mansour AVI. Military tuberculosis in a kidney grail and the choroid. Tubercle 1990: 71: 147- X. 2. Cangcmi l-' H. Friedman All. Josephbcrg R. Tuberculoma of the choroid. Ophlluiliiioloiix 1980: 87: 252- X. 3. Mansour AM. Ilayinond R. ( Toroidal tuberculomas without evidence of extraocular tuberculosis. Graefex Arch Clin Exp Ophthalmol l990; 22X: 3X2- 3. 4. Rosen I'll. Spalton 1X1. Graham FM. Intraocular tuberculosis. l- ixe 1990: 4: 4X6- 92. 5. Glover I. P. Some eye observations in tuberculous patients at the state sanatorium. ( Tesson. Pennsylvania. Am .1 Ophthalmol 1930; 13: 411 2. 6. Mooney A.!. Some ocular sequelae of tuberculous meningitis a preliminary survey. 19.53- 54. Am .1 Ophthalmol 1956: 41: 753- 6X. 7. Donahue 11C. Ophthalmologic experience in a tuberculosis sanatorium. Am J Ophlluilmol 1967: 64: 742- X. X. Lana- Pcixolo MA, Bambirra FA. Pitlclla . IP. Optic nerve tuberculoma: a case report. Arch Neurol 19X0: 37: 1X6- 7. 9. Miller BW. Frenkel M. Report of a ease o\ tuberculous retrobulbar neuritis and osteomyelitis. Am .1 Ophthalmol 1971: 71: 751- 6. 10. Arora VK, Dhaliwal U. Singh N. Bhatia A. Tuberculous optic neuritis histologically resembling leprous neuritis, hit .1 Leprosy 1995: 63: 454- 55. 1 I. Koff R. Gumma of the optic papilla- a case report. Am J Ophthalmol 1939; 22: 663- 5. 12. Mansour AM. Ansari N. Egwuagu CH. et al. Bacterial optic disk mass and toxoplasnhc- like encephalitis in an HIV seropositive subject. Craefes Arch Ophlluilmol 1993: 23 1: 66X- 7 I. 13. Schlernit/. auer DA. Hodges p'. l III. Bagan M. Tuberculoma of the left optic nerve and chiasm. Arch Ophlluilmol 1971 ; X5: 75 - X. 14. Felchworlh TW. Tuberculoma of the pituitary body, /(/• Med .1 1924: 1: 1 127. 15. Scott RM, Sonntag VKI1, Wilcox LM. Adelman I. S. Rockel Til. Visual loss from optochiasmalic arachnoiditis after tuberculous meningitis: ease report. ./ Neurosiir^ 1977: 46: 524- 6. 16. Anderson JM, Macmillan . IJ. Intracranial tuberculoma: tin increasing problem in Britain. ,/ Neurol Neiirosiiry I'sxchialrv 1975: 38: 194- 201. 17. Dastur IIM. Desai Al). A comparative study of brain tuberculomas and gliomas based upon 107 eases records of each. Brain 1965: X8: 375- 96. IX. American Thoracic Society. Control of tuberculosis in the United Slates. Am Rev Respir Pis 1992: 146: 1623- 33. 19. Phuapradil P. Vejjajiva A. Treatment of tuberculous meningitis: role of short course chemotherapy. 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