603
Brief Communications October 2013
Figure 5: Pre‑operative fundus photo of patient one
Figure 6: Post‑operative fundus photo of patient one
References
6. Yamanishi S, Emi K, Motokura M, Oshima Y, Nakayama M, Watanabe M. Visual outcome of macular hole surgery with internal limiting membrane peeling. Nihon Ganka Gakkai Zasshi 2001;105:788‑93.
1. Gass JD. Idiopathic senile macular hole. Its early stages and pathogenesis. Arch Ophthalmol 1988;106:629‑39. 2. Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol 1991;109:654‑9. 3. Benson WE, Cruickshanks KC, Fong DS, Williams GA, Bloome MA, Frambach DA, et al. Surgical management of macular holes: A report by the American Academy of Ophthalmology. Ophthalmology 2001;108:1328‑35. 4. Michalewska Z, Michalewski J, Adelman RA, Nawrocki J. Inverted internal limiting membrane flap technique for large macular holes. Ophthalmology 2010;117:2018‑25. 5. Freeman WR, Azen SP, Kim JW, el‑Haig W, Mishell DR 3rd, Bailey I. Vitrectomy for the treatment of full‑thickness stage 3 or 4 macular holes. Results of a multicentered randomized clinical trial. The Vitrectomy for Treatment of Macular Hole Study Group. Arch Ophthalmol 1997;115:11‑2.
Clinical utility of 18 Fluorodeoxyglucose (FDG)‑PET/CT scans in patients with suspect ocular tuberculosis Salil Mehta Systemic imaging of patients with suspect ocular tuberculosis include chest X‑rays and computed tomography (CT) scans. Reports have suggested a role for 18 fluorodeoxyglucose‑positron emission tomography/CT (FDG‑PET/CT) scans. We report on the clinical utility of 18 FDG PET/CT in two patients. Case 1:
7. Park DW, Sipperley JO, Sneed SR, Dugel PU, Jacobsen J. Macular hole surgery with internal‑limiting membrane peeling and intravitreous air. Ophthalmology 1999;106:1392‑7. 8. Enaida H, Hisatomi T, Hata Y, Ueno A, Goto Y, Yamada T, et al. Brilliant blue G selectively stains the internal limiting membrane/brilliant blue G‑assisted membrane peeling. Retina 2006;26:631‑6.
Cite this article as: Mahalingam P, Sambhav K. Surgical outcomes of inverted internal limiting membrane flap technique for large macular hole. Indian J Ophthalmol 2013;61:601-3. Source of Support: Nil. Conflict of Interest: None declared.
A 38‑year‑old female patient presented with recurrent anterior uveitis. A 18 FDG‑PET scan revealed metabolically active supraclavicular and chest lymph nodes. An aspiration cytology of the cervical lymph node revealed caseating granulomas suggestive of tuberculosis. Case 2: A 58‑year‑old female patient presented with recurrent anterior uveitis. A 18 FDG‑PET scan revealed metabolically active lymph nodes in the neck. A biopsy of the cervical lymph node revealed epithelioid granulomas suggestive of tuberculosis. Both patients were started on standard antitubercular therapy with a subsequent marked reduction of activity. PET/CT scans may suggest the sites of safe high‑yield biopsies. Key words: Ocular, positron emission tomography, tuberculosis
Access this article online Quick Response Code:
Department of Ophthalmology, Lilavati Hospital and Research Centre, Mumbai, India Correspondence to: Dr. Salil Mehta, Department of Ophthalmology, Lilavati Hospital and Research Centre, A 791, Bandra Reclamation, Bandra (West), Mumbai ‑ 400 052, India. E‑mail: [email protected] Manuscript received: 05.07.12; Revision accepted: 06.05.13
Website: www.ijo.in DOI: 10.4103/0301-4738.121091 PMID: ***
604
Indian Journal of Ophthalmology
Systemic imaging of patients with suspect ocular tuberculosis forms a crucial part of the evaluation. Modalities used include chest X‑rays (that image the parenchyma) and computed tomography (CT). Modalities used include chest x-rays (that image the parenchyma) and computed tomography (that image both the parenchyma and the mediastinum). Recent reports have suggested a role for 18 fluorodeoxyglucose (FDG)‑positron emission tomography (PET)/CT due to more extensive and potentially more sensitive imaging.[1] We report on the clinical utility of 18 FDG‑PET/CT in two patients.
Case Reports Case 1 A 38‑year‑old female patient presented with a history of recurrent attacks of bilateral pain, redness, and visual loss since the past 2 years. Previous investigations included a complete blood count and a mantoux test, and had 1 month ago, been started on empirical antitubercular therapy (based on a “positive” result) along with topical corticosteroid therapy. Her best corrected visual acuity was counting fingers at 2 meters in the right eye and counting fingers close to her face in her left eye. Slit lamp examination of her right eye revealed fresh nongranulomatous keratic precipitates with a severe anterior chamber reaction (cells 2+, flare 2+). The anterior chamber was shallow with 360° adherence of the iris to the capsule of a complicated cataract. There was significant forward bowing of the iris diaphragm with peripheral anterior synechiae. There was significant iris neovascularization seen. Similar findings were seen in the left eye but there was a more marked shallowing of the anterior chamber with extensive irido‑corneal touch. There was no fundal view but an ultrasound showed an anatomically normal posterior segment. The intraocular pressure was 10 and 8 mmHg. A repeat mantoux test showed induration of 21×18 mm. Her total and differential blood counts, tests for serum creatinine,
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serum calcium, serum angiotensin converting enzyme, and serological tests to detect HIV infection were normal. A 18 FDG‑PET scan revealed a metabolically active, large 3×2.2 cm heterogenous right supraclavicular, partially necrotic, lymph node (SUV max 6.6) [Figure 1a,1b]. There were metabolically active lymph nodes in the chest (right paratracheal [1.0×1.5 cm; SUV max 5.5] and subcarinal [1.5 × 2.6 cm; SUV max 7.7]) but the lungs were clear. Minimally metabolically active nodes were seen in the axilla. She underwent ultrasound guided fine needle aspiration cytology of the right cervical lymph node that was highlighted on the PET/CT scan. The microscopic examination revealed caseating granulomas suggestive of tuberculosis. A Transcription Mediated Amplification (TMA) polymerase chain reaction (PCR) for mycobacterium tuberculosis genome had a positive result. She was started on a standard four drug antitubercular regimen along with topical and periocular steroid therapy. On last follow up one month later there was a marked reduction of clinical anterior chamber activity. Case 2 A 58‑year‑old female patient presented with a history of persistent pain, redness accompanied by bilateral visual loss since the past one and one half years. Previous significant medical history included surgery for pituitary macroadenoma 26 years ago. Previous investigations included a mantoux test that had been reported as “positive” but the patient had declined to start antitubercular therapy. Her best corrected visual acuity was counting fingers at 6/12 in the right eye and 6/36 in her left eye. Slit lamp examination of her right eye revealed multiple fresh nongranulomatous keratic precipitates with a severe anterior chamber reaction (cells 2+, flare 2+). The anterior chamber had a normal depth but there were extensive posterior synechiae with a complicated cataract. similar findings were seen in the left eye. The disc and the retina were normal in either eye. The intraocular pressure was 10 and 12 mmHg.
Figure 1: (a) Fused axial PET/CT image of the cervical region of Case 1 showing the right supraclavicular lymph node (arrow) (b) Fused PET/ CT coronal scan of Case 1 showing the right supraclavicular lymph node (arrow)
Brief Communications October 2013
605
Systemic evaluation revealed palpable cervical and axillary lymph nodes. A repeat mantoux test showed an induration of 22× ×25 mm. Her total and differential blood counts, tests for serum creatinine, serum calcium, serum angiotensin converting enzyme and serological tests to detect human immunodeficiency virus (HIV) infection were normal.
and safer to biopsy than lung tissue and these accurately targeted invasive biopsies returned an adequate yield of disease‑involved tissue. Nodes/tissue that were reactive and likely to return noncontributory biopsies were thus not sampled. Conventional chest imaging may not have been able to suggest these biopsy sites for us.
A 18 FDG‑PET scan revealed several metabolically active, bilateral level 5 lymph nodes in the neck, the largest on the left side measuring 1.6 ×1.8 cm with SUV max 5.5 and the largest on the right measuring 1.4 cm with a SUV max 5.2. The lungs and mediastinum were clear. Several metabolically inactive nodes were seen bilaterally in the axilla.
Confirmatory tubercular histopathology permitted appropriate treatment and potentially allowed for better visual and anatomical outcomes. Similarly, PET/CT scans would have permitted an accurate targeting of active sites of disease for biopsy, from the thoracic cavity as well.
She underwent an ultrasound guided biopsy of a right posterior cervical lymph node suggested by the PET/CT scan. The microscopic examination revealed several medium sized epithelioid granulomas with occasional central necrosis suggestive of tuberculosis. She was started on standard four drug therapy along with topical and periocular corticosteroids. Two months later there was a marked reduction of clinical anterior chamber activity.
Discussion The clinical pictures were of active chronic or recurrent uveitic disease with vision threatening complications including complicated cataract. These patients were immunocompetent individuals receiving empirical antitubercular or symptomatic immunosuppressive treatment, without a confirmatory etiological diagnosis in either case. We reinvestigated both these patients in order to achieve an etiological diagnosis. A strongly positive mantoux test prompted a thorough evaluation for evidence of systemic tuberculosis. Conventional techniques of systemic imaging include mainly chest imaging (chest X‑rays or chest CT scans), to detect pulmonary or mediastinal disease. Tissue/bacteriological sampling is then done with sputum stains/cultures (if lung field disease is suspected) or thoracoscopy if mediastinal disease is suspected. Sputum and Bronchoalveolar lavage studies are not very sensitive (65%),[2] whereas thoracoscopic biopsies carry a risk of injuries to the great vessels or severe hemorrhaging (0-8%).[3] We chose to utilize the newer modality of whole body PET/CT scans. These identified metabolically active lymph nodes and tissues in the cervical region in both patients, in addition to the chest cavity in one patient. These peripheral (cervical) areas of inflammation were easier
A suggestive clinical picture with confirmatory evidence of tuberculosis from a systemic site should permit a high degree of evidence to initiate antitubercular treatment. This may, in some cases, negate the need to conduct invasive studies on aqueous/vitreous fluids that carry a risk of ocular morbidity. Increasingly, PET/CT scans are used to accurately define the full extent of systemic involvement, yield material for culture and sensitivity studies (to allow an early diagnosis of drug‑resistant tuberculosis) or even potentially to monitor the healing process. PET/CT scans may suggest the sites of safe high‑yield biopsies, thus yielding confirmatory histopathology, cultures, or PCR samples.
References 1. Doycheva D, Deuter C, Hetzel J, Frick JS, Aschoff P, Schuelen E, et al. The use of positron emission tomography/CT in the diagnosis of tuberculosis‑associated uveitis. Br J Ophthalmol 2011;95:1290‑4. 2. World Health Organization. Approaches To Improve Sputum Smear Microscopy For Tuberculosis Diagnosis. Geneva: Expert Group Meeting Report. Available from: http://www.who.int/tb/ laboratory/egmreport_microscopymethods_nov09.pdf. [Last accessed on 2009 Oct 31]. 3. Farrow PR, Jones DA, Stanley PJ, Bailey JS, Wales JM, Cookson JB. Thoracic lymphadenopathy in Asians resident in the United Kingdom: Role of mediastinoscopy in initial diagnosis. Thorax 1985;40:121‑4.
Cite this article as: Mehta S. Clinical utility of 18 Fluorodeoxyglucose (FDG)-PET/CT scans in patients with suspect ocular tuberculosis. Indian J Ophthalmol 2013;61:603-5. Source of Support: Nil. Conflict of Interest: None declared.
Copyright of Indian Journal of Ophthalmology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Brief Communications October 2013
Figure 5: Pre‑operative fundus photo of patient one
Figure 6: Post‑operative fundus photo of patient one
References
6. Yamanishi S, Emi K, Motokura M, Oshima Y, Nakayama M, Watanabe M. Visual outcome of macular hole surgery with internal limiting membrane peeling. Nihon Ganka Gakkai Zasshi 2001;105:788‑93.
1. Gass JD. Idiopathic senile macular hole. Its early stages and pathogenesis. Arch Ophthalmol 1988;106:629‑39. 2. Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol 1991;109:654‑9. 3. Benson WE, Cruickshanks KC, Fong DS, Williams GA, Bloome MA, Frambach DA, et al. Surgical management of macular holes: A report by the American Academy of Ophthalmology. Ophthalmology 2001;108:1328‑35. 4. Michalewska Z, Michalewski J, Adelman RA, Nawrocki J. Inverted internal limiting membrane flap technique for large macular holes. Ophthalmology 2010;117:2018‑25. 5. Freeman WR, Azen SP, Kim JW, el‑Haig W, Mishell DR 3rd, Bailey I. Vitrectomy for the treatment of full‑thickness stage 3 or 4 macular holes. Results of a multicentered randomized clinical trial. The Vitrectomy for Treatment of Macular Hole Study Group. Arch Ophthalmol 1997;115:11‑2.
Clinical utility of 18 Fluorodeoxyglucose (FDG)‑PET/CT scans in patients with suspect ocular tuberculosis Salil Mehta Systemic imaging of patients with suspect ocular tuberculosis include chest X‑rays and computed tomography (CT) scans. Reports have suggested a role for 18 fluorodeoxyglucose‑positron emission tomography/CT (FDG‑PET/CT) scans. We report on the clinical utility of 18 FDG PET/CT in two patients. Case 1:
7. Park DW, Sipperley JO, Sneed SR, Dugel PU, Jacobsen J. Macular hole surgery with internal‑limiting membrane peeling and intravitreous air. Ophthalmology 1999;106:1392‑7. 8. Enaida H, Hisatomi T, Hata Y, Ueno A, Goto Y, Yamada T, et al. Brilliant blue G selectively stains the internal limiting membrane/brilliant blue G‑assisted membrane peeling. Retina 2006;26:631‑6.
Cite this article as: Mahalingam P, Sambhav K. Surgical outcomes of inverted internal limiting membrane flap technique for large macular hole. Indian J Ophthalmol 2013;61:601-3. Source of Support: Nil. Conflict of Interest: None declared.
A 38‑year‑old female patient presented with recurrent anterior uveitis. A 18 FDG‑PET scan revealed metabolically active supraclavicular and chest lymph nodes. An aspiration cytology of the cervical lymph node revealed caseating granulomas suggestive of tuberculosis. Case 2: A 58‑year‑old female patient presented with recurrent anterior uveitis. A 18 FDG‑PET scan revealed metabolically active lymph nodes in the neck. A biopsy of the cervical lymph node revealed epithelioid granulomas suggestive of tuberculosis. Both patients were started on standard antitubercular therapy with a subsequent marked reduction of activity. PET/CT scans may suggest the sites of safe high‑yield biopsies. Key words: Ocular, positron emission tomography, tuberculosis
Access this article online Quick Response Code:
Department of Ophthalmology, Lilavati Hospital and Research Centre, Mumbai, India Correspondence to: Dr. Salil Mehta, Department of Ophthalmology, Lilavati Hospital and Research Centre, A 791, Bandra Reclamation, Bandra (West), Mumbai ‑ 400 052, India. E‑mail: [email protected] Manuscript received: 05.07.12; Revision accepted: 06.05.13
Website: www.ijo.in DOI: 10.4103/0301-4738.121091 PMID: ***
604
Indian Journal of Ophthalmology
Systemic imaging of patients with suspect ocular tuberculosis forms a crucial part of the evaluation. Modalities used include chest X‑rays (that image the parenchyma) and computed tomography (CT). Modalities used include chest x-rays (that image the parenchyma) and computed tomography (that image both the parenchyma and the mediastinum). Recent reports have suggested a role for 18 fluorodeoxyglucose (FDG)‑positron emission tomography (PET)/CT due to more extensive and potentially more sensitive imaging.[1] We report on the clinical utility of 18 FDG‑PET/CT in two patients.
Case Reports Case 1 A 38‑year‑old female patient presented with a history of recurrent attacks of bilateral pain, redness, and visual loss since the past 2 years. Previous investigations included a complete blood count and a mantoux test, and had 1 month ago, been started on empirical antitubercular therapy (based on a “positive” result) along with topical corticosteroid therapy. Her best corrected visual acuity was counting fingers at 2 meters in the right eye and counting fingers close to her face in her left eye. Slit lamp examination of her right eye revealed fresh nongranulomatous keratic precipitates with a severe anterior chamber reaction (cells 2+, flare 2+). The anterior chamber was shallow with 360° adherence of the iris to the capsule of a complicated cataract. There was significant forward bowing of the iris diaphragm with peripheral anterior synechiae. There was significant iris neovascularization seen. Similar findings were seen in the left eye but there was a more marked shallowing of the anterior chamber with extensive irido‑corneal touch. There was no fundal view but an ultrasound showed an anatomically normal posterior segment. The intraocular pressure was 10 and 8 mmHg. A repeat mantoux test showed induration of 21×18 mm. Her total and differential blood counts, tests for serum creatinine,
Vol. 61 No. 10
serum calcium, serum angiotensin converting enzyme, and serological tests to detect HIV infection were normal. A 18 FDG‑PET scan revealed a metabolically active, large 3×2.2 cm heterogenous right supraclavicular, partially necrotic, lymph node (SUV max 6.6) [Figure 1a,1b]. There were metabolically active lymph nodes in the chest (right paratracheal [1.0×1.5 cm; SUV max 5.5] and subcarinal [1.5 × 2.6 cm; SUV max 7.7]) but the lungs were clear. Minimally metabolically active nodes were seen in the axilla. She underwent ultrasound guided fine needle aspiration cytology of the right cervical lymph node that was highlighted on the PET/CT scan. The microscopic examination revealed caseating granulomas suggestive of tuberculosis. A Transcription Mediated Amplification (TMA) polymerase chain reaction (PCR) for mycobacterium tuberculosis genome had a positive result. She was started on a standard four drug antitubercular regimen along with topical and periocular steroid therapy. On last follow up one month later there was a marked reduction of clinical anterior chamber activity. Case 2 A 58‑year‑old female patient presented with a history of persistent pain, redness accompanied by bilateral visual loss since the past one and one half years. Previous significant medical history included surgery for pituitary macroadenoma 26 years ago. Previous investigations included a mantoux test that had been reported as “positive” but the patient had declined to start antitubercular therapy. Her best corrected visual acuity was counting fingers at 6/12 in the right eye and 6/36 in her left eye. Slit lamp examination of her right eye revealed multiple fresh nongranulomatous keratic precipitates with a severe anterior chamber reaction (cells 2+, flare 2+). The anterior chamber had a normal depth but there were extensive posterior synechiae with a complicated cataract. similar findings were seen in the left eye. The disc and the retina were normal in either eye. The intraocular pressure was 10 and 12 mmHg.
Figure 1: (a) Fused axial PET/CT image of the cervical region of Case 1 showing the right supraclavicular lymph node (arrow) (b) Fused PET/ CT coronal scan of Case 1 showing the right supraclavicular lymph node (arrow)
Brief Communications October 2013
605
Systemic evaluation revealed palpable cervical and axillary lymph nodes. A repeat mantoux test showed an induration of 22× ×25 mm. Her total and differential blood counts, tests for serum creatinine, serum calcium, serum angiotensin converting enzyme and serological tests to detect human immunodeficiency virus (HIV) infection were normal.
and safer to biopsy than lung tissue and these accurately targeted invasive biopsies returned an adequate yield of disease‑involved tissue. Nodes/tissue that were reactive and likely to return noncontributory biopsies were thus not sampled. Conventional chest imaging may not have been able to suggest these biopsy sites for us.
A 18 FDG‑PET scan revealed several metabolically active, bilateral level 5 lymph nodes in the neck, the largest on the left side measuring 1.6 ×1.8 cm with SUV max 5.5 and the largest on the right measuring 1.4 cm with a SUV max 5.2. The lungs and mediastinum were clear. Several metabolically inactive nodes were seen bilaterally in the axilla.
Confirmatory tubercular histopathology permitted appropriate treatment and potentially allowed for better visual and anatomical outcomes. Similarly, PET/CT scans would have permitted an accurate targeting of active sites of disease for biopsy, from the thoracic cavity as well.
She underwent an ultrasound guided biopsy of a right posterior cervical lymph node suggested by the PET/CT scan. The microscopic examination revealed several medium sized epithelioid granulomas with occasional central necrosis suggestive of tuberculosis. She was started on standard four drug therapy along with topical and periocular corticosteroids. Two months later there was a marked reduction of clinical anterior chamber activity.
Discussion The clinical pictures were of active chronic or recurrent uveitic disease with vision threatening complications including complicated cataract. These patients were immunocompetent individuals receiving empirical antitubercular or symptomatic immunosuppressive treatment, without a confirmatory etiological diagnosis in either case. We reinvestigated both these patients in order to achieve an etiological diagnosis. A strongly positive mantoux test prompted a thorough evaluation for evidence of systemic tuberculosis. Conventional techniques of systemic imaging include mainly chest imaging (chest X‑rays or chest CT scans), to detect pulmonary or mediastinal disease. Tissue/bacteriological sampling is then done with sputum stains/cultures (if lung field disease is suspected) or thoracoscopy if mediastinal disease is suspected. Sputum and Bronchoalveolar lavage studies are not very sensitive (65%),[2] whereas thoracoscopic biopsies carry a risk of injuries to the great vessels or severe hemorrhaging (0-8%).[3] We chose to utilize the newer modality of whole body PET/CT scans. These identified metabolically active lymph nodes and tissues in the cervical region in both patients, in addition to the chest cavity in one patient. These peripheral (cervical) areas of inflammation were easier
A suggestive clinical picture with confirmatory evidence of tuberculosis from a systemic site should permit a high degree of evidence to initiate antitubercular treatment. This may, in some cases, negate the need to conduct invasive studies on aqueous/vitreous fluids that carry a risk of ocular morbidity. Increasingly, PET/CT scans are used to accurately define the full extent of systemic involvement, yield material for culture and sensitivity studies (to allow an early diagnosis of drug‑resistant tuberculosis) or even potentially to monitor the healing process. PET/CT scans may suggest the sites of safe high‑yield biopsies, thus yielding confirmatory histopathology, cultures, or PCR samples.
References 1. Doycheva D, Deuter C, Hetzel J, Frick JS, Aschoff P, Schuelen E, et al. The use of positron emission tomography/CT in the diagnosis of tuberculosis‑associated uveitis. Br J Ophthalmol 2011;95:1290‑4. 2. World Health Organization. Approaches To Improve Sputum Smear Microscopy For Tuberculosis Diagnosis. Geneva: Expert Group Meeting Report. Available from: http://www.who.int/tb/ laboratory/egmreport_microscopymethods_nov09.pdf. [Last accessed on 2009 Oct 31]. 3. Farrow PR, Jones DA, Stanley PJ, Bailey JS, Wales JM, Cookson JB. Thoracic lymphadenopathy in Asians resident in the United Kingdom: Role of mediastinoscopy in initial diagnosis. Thorax 1985;40:121‑4.
Cite this article as: Mehta S. Clinical utility of 18 Fluorodeoxyglucose (FDG)-PET/CT scans in patients with suspect ocular tuberculosis. Indian J Ophthalmol 2013;61:603-5. Source of Support: Nil. Conflict of Interest: None declared.
Copyright of Indian Journal of Ophthalmology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
