Vitreomacular Traction From a Preretinal granuloma

Case Presentation summary A 38-year-old Ethiopian man with a history of anterior uveitis in the right eye for 7 months presented to his retina specialist with anterior chamber inflammation, vitritis, optic disc edema, and a yellow focus of chorioretinitis in the right eye. His prior workup was also notable for a history of antinuclear antibody positivity. The patient was promptly referred to the Emory Eye Center for additional workup and management. On his initial presentation to the Emory Eye Center, the patient’s visual acuities were 20/25 in the right eye and 20/20 in the left eye. Slit lamp examination of the right eye showed 1+ anterior chamber cell, trace flare, and trace anterior vitreous cell. The patient’s dilated funduscopic examination showed a fusiform-shaped yellow lesion in the preretinal space with a surrounding granuloma. There was a ring of exudates surrounding this lesion with extension into the temporal parafoveal region (Figure 1). A fluorescein angiogram showed leakage corresponding to the area of the chorioretinal lesions and spectral-domain optical coherence tomography (SD-OCT) revealed an area of focal thickening superotemporal to the fovea (Figure 2). Because of concern for an infectious etiology, a uveitis workup was performed to identify a potential pathogen that could result in the unusual disease appearance. Chest x-ray, rapid plasma reagin, syphilis immunoglobulin G (IgG), angiotensin-converting-enzyme level, lysozyme, comprehensive metabolic panel, and complete blood count were normal. However, quantiferon-TB was positive, toxoplasmosis IgG antibody was positive at 17.3 IU/ mL (reference 0-6.4 IU/mL) and toxocariasis IgG antibody was also positive at 2.76 (normal reference <0.299). Because of the preretinal granuloma appearance of the lesion, which differed from the distinct appearances of toxoplamosis (ie, “headlight in a fog” or activation adjacent to a pigmented scar) and tuberculosis (ie, tuberculous choroidopathy, focal granuloma isolated to the choroid) and the similarity of the lesion to peripheral granulomas more commonly seen with ocular toxocariasis, albendazole 200 mg twice daily was initiated. Three weeks later, the patient complained of increased visual distortion. The visual acuity had declined to 20/100. Funduscopic examination showed interval improvement in the exudation and preretinal fibrosis in the region of the fusiform-shaped yellow lesion. SD-OCT showed moderate epiretinal membrane (ERM) with retinal thickening and intraretinal edema. A repeat serum toxocariasis antibody remained elevated at 3.14. Albendazole was continued, Vitreomacular Traction From a Preretinal granuloma