Maurice F. Rabb » Decreased Central Vision

A 24 year old white male presented with a two week history of decreased central vision in his left eye. He did not have any other ocular complaints. His ocular history revealed that he had poor vision in his right eye since childhood. He denied previous ocular trauma and surgery. His medical history was significant only for a hospitalization at 2 years of age for an illness unknown to him. He was not using any medications. Socially, he was heterosexual and did not smoke, drink alcohol or use intravenous drugs. Review of systems was non-contributory.

Best corrected visual acuity was 20/60 in his right eye and 20/400 in his left eye with low myopic correction in both eyes. Pupils, motility, anterior segments and intraocular pressures were normal in both eye. Dilated funduscopic exam of the right eye revealed a large area of chorioretinal scarring centered around the optic nerve with distinct pigmentary migration within the area of scarring. A small island of retinal tissue involving the foveal avascular zone appeared to be spared. Rare, pigmented vitreous cells were observed. In the left eye, chorioretinal scarring similar to that seen in the right was noted around the disc, especiially nasally. In addition, there was a large, yellow-white subretinal lesion that involved the fovea and appeared to be contiguous with a preveious scar. Moderate vitreous cells were also present. The retinal periphery anterior to the equator was normal in both eyes.

Laboratory investigations consisting of a complete blood count, an erythrocyte sedimentation rate, RPR, FTA-ABS, angiotensin converting enzyme, rheumatoid factor, antinuclear antibody and chest X-ray were normal. However skin testing for tuberculosis (PPD-Mantoux; 5 TU) was positive with 24 mm of induration noted (>10 mm being highly reactive).

Upon review of medical records obtained from another hospital, it was determined that his childhood illness was tuberculosis and that it had been treated appropriately. The patient was referred to the Infectious Disease service for evaluation. It was felt that the degree of induration on skin testing was highly suspicious for a subclinical rractivation of TB and subsequently the patient was started on rifampin (600 mg qd), isoniazid (300 mg qd) and pyrazinamide (500 mg bid). Four weeks after initiation of therapy, there was nearly complete resolution of the subretinal infiltrate with improvement of vision to 20/40 in the left eye.