Dilemmas in Serpiginous-Like Choroiditis

Choroiditis in the setting of tuberculosis (TB) can either be due to active infection or immune-related. Treatment with immunosuppression works well in both situations initially, but cases with active infection usually worsen within days to weeks. The extremely crucial decision of starting anti-tubercular (ATT) drugs is usually based on the morphology classical of TB, i.e., tuberculomas or multifocal choroiditis supported by laboratory or imaging evidence of active or past TB infection. We encountered a case where the initial success of treatment led to the extension of clinical follow-up visits and the patient developed fovea involving choroiditis in both eyes. This occurred while the patient was on systemic steroids and methotrexate along with intravitreal dexamethasone implants in both eyes. Initiation of ATT helped achieve the resolution of choroiditis, but visual acuity remained poor in the right eye. In this chapter, we have attempted to elucidate the dilemmas we faced at each stage in making the diagnosis of ocular TB and starting ATT.