Chasing shadows: case series of six posterior segment manifestations of ocular tuberculosis

Background: Ocular tuberculosis (OTB) is difficult to confirm microbiologically, so diagnosis often rests on characteristic posterior segment phenotypes supported by systemic immunologic evidence and therapeutic response. This case series from a high-prevalence setting illustrates the heterogeneity of posterior OTB and provides practical diagnostic anchors, treatment approaches, and complication surveillance that are directly applicable to routine uveitis care. Case Description: Six immunocompetent males (28-46 years) presented with posterior disease entities that included: choroidal granulomas with papillitis; multifocal choroiditis with venous occlusion; bilateral granulomatous sclerouveitis with inactive multifocal/serpiginous-like choroiditis; choroiditis with occlusive vasculitis; bilateral serpiginous-like choroiditis; and unilateral occlusive vasculitis with vitreous hemorrhage. Four reported prior incarceration, all were human immunodeficiency virus (HIV)-negative. Pulmonary involvement was absent or limited, though chest computed tomography (CT) revealed cavitary or nodular changes in some patients. Diagnostic support comprised a positive tuberculin skin test (TST) and/or interferon-gamma release assay (IGRA), multimodal imaging, and subsequent anti-tubercular response. All patients received standard RIPE (rifampin, isoniazid, pyrazinamide, ethambutol) therapy with a tapered oral corticosteroid course. Most eyes achieved inflammatory quiescence by nine months; visual outcomes ranged from 20/20 in quiescent eyes to limited improvement where macular scarring or ischemic detachment occurred. Conclusions: Posterior OTB may present without overt pulmonary disease and spans granulomatous, serpiginous-like, and occlusive vasculitic phenotypes. In endemic regions, early suspicion supported by TST/IGRA and multimodal imaging, followed by RIPE plus corticosteroids, can control inflammation and mitigate vision-threatening complications. Vigilance for secondary choroidal neovascularization (CNV) and timely surgical intervention is essential.