"Dark Cherry-Red Spot" from Ophthalmic Artery Occlusion, a Possible Initial Manifestation of Active Tuberculosis

In patients with tuberculosis (TB), involvement of the optic nerve has been associated with either arachnoiditis exudation in chronic meningitis or with tuberculoma1-2, however a central retinal or ophthalmic artery occlusion is rarely seen3. We describe a patient with unilateral vision loss and a "dark cherry-red spot," which led to the diagnosis of an ophthalmic artery occlusion (OAO). Soon after he was diagnosed with active pulmonary TB, raising the possibility that OAO was the initial presentation of his TB.

172 “Dark Cherry-Red Spot” from Ophthalmic Artery Occlusion, a Possible Initial Manifestation of Active Tuberculosis Ariel Axelbaum 1, Tatiana Hathaway 2, Joseph Rizzo III3 Massachusetts Eye and Ear Institute, 2 Mass Eye and Ear, 3 , Massachusetts Eye and Ear, Harvard Medical School, Boston, MA. 1 Introduction: In patients with tuberculosis (TB), involvement of the optic nerve has been associated with either arachnoiditis exudation in chronic meningitis or with tuberculoma1-2, however a central retinal or ophthalmic artery occlusion is rarely seen3. We describe a patient with unilateral vision loss and a “dark cherry-red spot,” which led to the diagnosis of an ophthalmic artery occlusion (OAO). Soon after he was diagnosed with active pulmonary TB, raising the possibility that OAO was the initial presentation of his TB. Description of Cases: A 27-year-old male with G6PD developed painless fluctuating vision loss of the left eye which then became constant. His exam showed visual acuity of 2/80 OS with fundoscopy revealing an unusually “dark cherry-red spot” without swelling of the optic nerve head. Fluorescein angiogram showed very delayed filling of the "watershed" zone between the nasal and temporal choroidal beds, and very delayed retinal arterial filling. He was diagnosed with an ophthalmic artery occlusion. His workup pointed towards an embolic etiology but, other than a PFO, no source of emboli or hypercoagulability was found and he was started on clopidogrel for secondary stroke prevention. During his hospitalization, MRI brain and orbits showed left perineuritis, workup of which included a screening T spot test which resulted positive for TB. CTA chest showed multiple pulmonary nodules and bronchoalveolar lavage PCR was positive for TB. Due to the perineuritis and concern for active pulmonary TB, he was started on oral prednisone and 4 drug regimen for TB, though with no reported vision improvement to date. Conclusions, including unique features of the case: A “dark cherry-red spot” has not been previously described but led to the discovery of an OAO in a patient who would soon be diagnosed with active pulmonary TB. His workup for embolic risk factors was unrevealing, introducing the potential that the OAO was the initial manifestation of active TB. References: 1. Scott RM, Sonntag VKH, Wilcox LM, et al. Visual loss from optochiasmatic arachnoiditis after tuberculous meningitis. J Neurosurg 1977; 46: 524–526. 2. Lana-Pexioto MA, Bambirra EA, Pittella JE. Optic nerve tuberculoma. Arch Neurol 1980; 37: 186–187 3. Venkatesh, P., Garg, S.P., Verma, L., Lakshmaiah, N.C., Lakshminarayan, P., Singh, R.P. and Tewari, H.K., 2001. Combined optic neuropathy and central retinal artery occlusion in miliary tuberculosis. Retina, 21(4), pp.375-377. Keywords: Vascular disorders, Neuro-ophth & infectious disease (eg, AIDS, prion), Orbit/ocular pathology Financial Disclosures: The authors had no disclosures. Grant Support: None. Contact Information: None provided. 2024 Annual Meeting Syllabus | 227