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A Case of Pulmonary Tuberculosis Presenting with a Choroidal Tuberculoma
A Case of Pulmonary Tuberculosis Presenting with a Choroidal Tuberculoma NABIL M. JABBOUR, MD, BISHARA FARIS, MD, CLEMENT L. TREMPE, MD
Abstract: A 17-year-old woman was referred because of a choroidal mass, with marked decrease in vision, in her left eye. Her medical history was negative. However, preliminary examination revealed a positive skin tuberculin test (PPD) and a chest x-ray picture of pulmonary tuberculosis. Bronchoscopy documented the diagnosis. Findings of other systemic investigations were negative. Fluores~ein angiographic findings were compatible with the clinical diagnosis of a choroidal tuberculoma. A regimen of antituberculous medications was started, and both the choroidal and the pulmonary lesions gradually subsided . To our knowledge this is the first reported case of nonmiliary tuberculosis that presented solely with a choroidal lesion . [Key words: choroidal tuberculoma, pulmonary tuberculosis.] Ophthalmology 92:834-837, 1985
Uveal involvement in tuberculosis has been described in the primary, recurrent, and miliary forms of this disease.'-6 The common findings are uveitis (iritis, iridocyclitis, and/or choroiditisf and choroidal tuberculomas (solitary or multiple).2.8.9 The reports are controversial and ambiguous. The fraction of endogenous uveitis cases considered to be of tuberculous origin varies widely,7.10 the presentation of the tuberculomas" as well as the systemic manifestations of the disease' 2.13 are pleomorphic, and the roles played by immunologic, bacteriologic, and epidemiologic variables are unknown. We present a case of pulmonary tuberculosis that came to medical attention because of visual symptoms. To the best of our knowledge, this is the first report of a presumed choroidal tuberculoma leading to the diagnosis and treatment of pulmonary tuberculosis. From the Department of Ophthalmology, American University, Beirut, Lebanon, and the Eye Research Institute of Retina Foundation, and the Retina Associates , Boston. Presented in part at the Eighty-eighth Annual Meeting of the American Academy of Ophthalmology, Chicago, Illinois, October 30-November 3, 1983. Reprint requests to Library, Eye Research Institute, 20 Staniford SI., Boston, MA 02114.
834
CASE REPORT In March 1981, a 17-year-old woman complained of acute redness in her left eye accompanied by blurring of vision. She was given systemic antibiotics for two weeks and then was started on oral steroids (80 mg p{ednisone daily). One month later she received laser treatment to her left eye. Although the redness had subsided eight to ten days following the onset of symptoms, vision in the left eye continued to deteriorate. On June 25, 1981, while taking 30 mg oral prednisone daily, she was examined by the authors and subsequently admitted to the hospital. The right eye was asymptomatic and completely normal. The left eye had a visual acuity of counting fingers at 2.5 m, intraocular tension of 8 mmHg by applanation tonometry, normal anterior segment with a noninjected conjunctiva, a clear cornea and anterior chamber, normal iris with a round reactive pupil, normal clear lens, 360 0 open angle with no synechiae, and no evidence of uveitis. Fundus examination revealed a huge subretinal granuloma-like lesion temporal to the fovea, measuring about four disc diameters. There was a high overlying sensory detachment bisecting the fovea and a blot of hemorrhage inferior to the macula. Photocoagulation scars were seen surrounding the lesion, which had grown beyond the scars in some areas. Fluorescein angiographic findings are shown in Figure I. Findings of a review of systems and of a physical examination were negative except for a questionable history of weight loss
JABBOUR, et al
•
PULMONARY TUBERCULOSIS
Fig J . Auoresceinangiographic findings of the left eye at the time of presentation. A, arterial phase of the fluorescein angiogram showing early hyperfluorescence of the choroidal lesion with a surrounding ring of marked hypofluorescence. Note hlot of hemorrhage and pbotocoagulation scars. B, arteriovenous phase, showing increased hyperfluorescence of the core lesion and accumulation of dye in the subretinal (serous) space. C, mid-transit, showing a normal disc, retinal vessels, and capillary-free zone. Note further leakage superior and inferior to the fovea. D, late transit, showing persistence of hyperfluorescence in the three concentric zones corresponding to early hyperfluorescent core, serous detachment, and surrounding late leakage.
Fig 2. Composite photograph of the left fundu s, four months after the conclusion of a one-year course of antituberculous therapy.
of 2 to 3 kg over the past four months. The patient denied any history of fever, cough, or night sweats. Positive laboratory findings included a sedimentation rate of 35 mm/hr and chest x-ray evidence of azygous node enlargement in the right paracentral region wth small infiltrates in the right upper and
left lower lobes, and a small right pleural effusion. By the time the results of the tuberculin skin test done on admission became available and turned out to be positive, steroids had been tapered to 15 mg/day. Chest tomography was compatible with the diagnosis of pulmonary tuberculosis. Smears and cultures of three sputum and three gastric aspirate samples were negative for mycobacterium. Findings of a battery of noninvasive tests, including serologic titers and scans, were negative. Because the patient refused further studies, such as a pleural tap, she was started on a therapeutic trial of 300 mg isoniazid and 1000 mg ethambutol by mouth daily. Five weeks later, the chest x-ray started to show signs of improvement. The course was followed by serial fundus photography, indirect ophthalmoscopy, and chest x-rays. During the second month of treatment, the choroidal lesion started to decrease in size, and by the third month it was about 25% smaller than when therapy was started. This reaction to treatment was considered a positive diagnostic test for both the pulmonary and the ocular involvement. The regimen of antituberculous drugs was continued. Early in the course of therapy, the findings of a bronchoscopy were compatible with the diagnosis of tuberculosis. After one year of treatment, both the chest · and the choroidal lesions had scarred down and showed no sign of activity even several months after the cessation of therapy (Fig 2).
DISCUSSION Choroidal tuberculomas have been reported in patients with pulmonary tuberculosis,2.4 although they are clas835
0'1
\;J
00
(Pre)arterial filling of tumor net
Masking
Greyish, yellowish patches (variable elevations)
Orange-red tumor
Whitish-greyish variable pigment change
Metastatic tumor
Choroidal hemangioma
Foreign body
* Lesion of interest.
RPE = retinal pigment epithelium; R = retina; S = sclera.
Masking of choroidal fluorescence (when small)
Double circulation
Orange pigment
Depends on associated injuries
Leakage into surrounding area
Possible staining of edge
Multiloculated pattern (cystoid spaces in overlying retina)
Variable RPE change (when advanced)
Tumor staining
Staining at level of tuberculoma, RPE, and subretinal space
Normal retinal vessels and optiC disc
Hyperfluorescence of tuberculoma surrounding hypoftuorescence ring
Choroidal melanoma
Late
Mid
Early
Globular, subretinal, whitish mass with or without overlying serous retinal detachment
Color /Monochromatic
Isolated choroidal tuberculoma
Condition
Fluorescein Angiography
Variable
A* B
Shadowing, reverberation
No excavation
Solid mass(es), no excavation
Choroidal excavation
Solid elevated mass: silent zone with absent scleral echo due to absorption by inflammatory cells
Ultrasonography
(If magnetic, can do dynamic)
V At Jut
J0j
Associated serous retinal detachment
Table 1. Differential Diagnosis of Isolated Choroidal Tuberculoma 18.19
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JABBOUR, et al
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sically described in association with miliary tuberculosis and tuberculous meningitis. 8,9 The chain of events between primary and miliary tuberculosis is still unclear, but it is believed that a primary (usually asymptomatic) infection is carried to other loci via bacteremia. The final outcome depends on the immune status of the host, the virulence of the organism, and the severity and recurrence of the hematogenous spread, 14,15 Theoretically, local seeding in the uveal tract is feasible during any phase of the disease. 6 ,9 The choroidal tuberculomas reported in the literature occurred either in patients known to have tuberculosis (active or inactive), or at autopsy. 12.15,16 Occasionally, choroidal tuberculomas have been found in enucleated eyes.ll,170ur case is a unique example of how the choroidal involvement can lead to the diagnosis of pulmonary tuberculosis. Although the number of cases of endogenous uveitis considered to be of tuberculous origin has always been overestimated,? many choroidal tubercles have been discovered only at autopsy. The presentation and findings in our case should serve to arouse a degree of suspicion in similar cases that might be either missed or misdiagnosed. Early diagnosis ' and therapy are of systemic as well as ocular advantage and may save lives as well as eyes; tuberculomas misdiagnosed as tumors have resulted in some unnecessary enucleations. II, 17 Fluorescein angiography is helpful, and our findings agree with those of Cangemi et at,2 but we do not think that the pattern is strictly pathognomonic. Table 1 clearly shows that although ultrasonography is extremely helpful in the differential diagnosis of foreign bodies, choroidal melanomas, hemangiomas, and metastatic tumors, the pattern is not typical for choroidal tuberculomas. Fluorescein angiography yields more differential findings, but it cannot distinguish between isolated granulomas of tuberculous origin and those of sarcoidosis, unless other features of ocular sarcoid, such as intravitreal, preretinal, and focal retinal nodules and perivascular candle-wax dripping exudates are present Fluorescein angiographic and ultrasonographic findings in Toxocara infection were also not included in the table, because this condition can present with localized disciform macular detachment, papillitis, peripheral retinal (or pars plana) mass, vitritis, endophthalmitis, retinal detachment, and/or cataract Rarely the organism is seen, and sometimes a retinochoroidal anastomosis can be demonstrated. Clinical evaluation with local and systemic assessment (serology; radiology, etc.) provide helpful ancillary data.
PULMONARY TUBERCULOSIS
However, in the absence of any definite diagnostic tool (cytology and pathology) in vivo, the role of therapeutic trials for choroidal tuberculomas cannot be overstressed. Tuberculin skin test is a must, especially before starting systemic steroids. Moreover, local treatment (be it with drugs or laser) as well as systemic treatment (conventional antibiotics or steroids) in the absence of a diagnosis may worsen, or at best modify, the clinical picture, making the correct diagnosis more difficult to . reach.
REFERENCES 1. Saari M. Disciform detachment of the macula. III. Secondary to inflammatory diseases. Acta Ophthalmol 1978; 56:510-7. 2. Cangemi FE, Friedman AH, Josephberg R. Tuberculoma of the choroid . Ophthalmology 1980; 87:252-8. 3. West CS, Vainisi SJ, Vygantas CM, Beluhan FZ. Intraocular granu· lomas associated with tuberculosis in primates. J Am Vet Med Assoc 1981; 179:1240-4. 4. Shimomura Y, Tada R, Yuasa T. Ocular disorders in pulmonary tuberculosis. Folia Ophthalmol Jpn 1979; 30:1973-8. 5. Doden W. Die Augentuberkulose. Prax Klin Pneumol 1977; 31 :713-
6. 6. Heydenreich A. Die Augentuberkulose. Z Gesamte Inn Med 1978; 33:735-8. 7. Duke·Elder S. System of Ophthalmology. Vol. IX: Diseases of the Uveal Tract. St Louis: CV Mosby, 1966; 257. 8. Cernea P, lonescu M, Constantin C. Aspects actuels dans Ie tuberculome choroidien. Ann Ottalmol 1976; 102:25-30. 9. Massaro D, Katz S, Sachs M. Choroidal tubercles; a clue to hematogenous tuberculosis. Ann Intern Med 1964; 60:231-41. 10. Woods AC. Endogenous Uveitis. Baltimore: Williams & Wilkins, 1956; 50-9, 137- 50. 11 . Blodi FC. Ein Tuberkulom der Aderhaut, ein Melanom vortauschend. Klin Monatsbl Augenheilkd 1977; 170:845-9. 12. Bates JH. Diagnosis of tuberculosis. Chest 1979; 76(6 Suppl):75763. 13. Glassroth J, Robins AG, Snider DE Jr. Tuberculosis in the 1980s. N Engl J Med 1980; 302:1441-50. 14. Rich AR. The Pathogenesis of Tuberculosis, 2nd ed. Springfield, III: Charles C Thomas , 1951 . 15. Bottiger LE, Nordenstam HH, Wester PO. Disseminated tuberculosis as a cause of fever of obscure origin. Lancet 1962; 1: 19-20. 16. Bottiger LE, Nordenstam HH, Wester PO. Miliartuberkulos--en bortglamd diagnos? Nord Med 1961; 66:1719-21. 17. Shammas HF, Burton TC, Weingeist TA. False-positive results with the radioactive phosphorus test. Arch Ophthalmol 1977; 95:2190-2. 18. Gass JDM. Stereoscopic Atlas of Macular Diseases; Diagnosis and Treatment, 2nd ed. St Louis: CV Mosby; 1977,234-312,344-66. 19. Coleman DJ, Lizzi FL, Jack RL. Ultrasonography of the Eye and Orbit. Philadelphia: Lea & Febiger, 1977; 197-238.
837
Abstract: A 17-year-old woman was referred because of a choroidal mass, with marked decrease in vision, in her left eye. Her medical history was negative. However, preliminary examination revealed a positive skin tuberculin test (PPD) and a chest x-ray picture of pulmonary tuberculosis. Bronchoscopy documented the diagnosis. Findings of other systemic investigations were negative. Fluores~ein angiographic findings were compatible with the clinical diagnosis of a choroidal tuberculoma. A regimen of antituberculous medications was started, and both the choroidal and the pulmonary lesions gradually subsided . To our knowledge this is the first reported case of nonmiliary tuberculosis that presented solely with a choroidal lesion . [Key words: choroidal tuberculoma, pulmonary tuberculosis.] Ophthalmology 92:834-837, 1985
Uveal involvement in tuberculosis has been described in the primary, recurrent, and miliary forms of this disease.'-6 The common findings are uveitis (iritis, iridocyclitis, and/or choroiditisf and choroidal tuberculomas (solitary or multiple).2.8.9 The reports are controversial and ambiguous. The fraction of endogenous uveitis cases considered to be of tuberculous origin varies widely,7.10 the presentation of the tuberculomas" as well as the systemic manifestations of the disease' 2.13 are pleomorphic, and the roles played by immunologic, bacteriologic, and epidemiologic variables are unknown. We present a case of pulmonary tuberculosis that came to medical attention because of visual symptoms. To the best of our knowledge, this is the first report of a presumed choroidal tuberculoma leading to the diagnosis and treatment of pulmonary tuberculosis. From the Department of Ophthalmology, American University, Beirut, Lebanon, and the Eye Research Institute of Retina Foundation, and the Retina Associates , Boston. Presented in part at the Eighty-eighth Annual Meeting of the American Academy of Ophthalmology, Chicago, Illinois, October 30-November 3, 1983. Reprint requests to Library, Eye Research Institute, 20 Staniford SI., Boston, MA 02114.
834
CASE REPORT In March 1981, a 17-year-old woman complained of acute redness in her left eye accompanied by blurring of vision. She was given systemic antibiotics for two weeks and then was started on oral steroids (80 mg p{ednisone daily). One month later she received laser treatment to her left eye. Although the redness had subsided eight to ten days following the onset of symptoms, vision in the left eye continued to deteriorate. On June 25, 1981, while taking 30 mg oral prednisone daily, she was examined by the authors and subsequently admitted to the hospital. The right eye was asymptomatic and completely normal. The left eye had a visual acuity of counting fingers at 2.5 m, intraocular tension of 8 mmHg by applanation tonometry, normal anterior segment with a noninjected conjunctiva, a clear cornea and anterior chamber, normal iris with a round reactive pupil, normal clear lens, 360 0 open angle with no synechiae, and no evidence of uveitis. Fundus examination revealed a huge subretinal granuloma-like lesion temporal to the fovea, measuring about four disc diameters. There was a high overlying sensory detachment bisecting the fovea and a blot of hemorrhage inferior to the macula. Photocoagulation scars were seen surrounding the lesion, which had grown beyond the scars in some areas. Fluorescein angiographic findings are shown in Figure I. Findings of a review of systems and of a physical examination were negative except for a questionable history of weight loss
JABBOUR, et al
•
PULMONARY TUBERCULOSIS
Fig J . Auoresceinangiographic findings of the left eye at the time of presentation. A, arterial phase of the fluorescein angiogram showing early hyperfluorescence of the choroidal lesion with a surrounding ring of marked hypofluorescence. Note hlot of hemorrhage and pbotocoagulation scars. B, arteriovenous phase, showing increased hyperfluorescence of the core lesion and accumulation of dye in the subretinal (serous) space. C, mid-transit, showing a normal disc, retinal vessels, and capillary-free zone. Note further leakage superior and inferior to the fovea. D, late transit, showing persistence of hyperfluorescence in the three concentric zones corresponding to early hyperfluorescent core, serous detachment, and surrounding late leakage.
Fig 2. Composite photograph of the left fundu s, four months after the conclusion of a one-year course of antituberculous therapy.
of 2 to 3 kg over the past four months. The patient denied any history of fever, cough, or night sweats. Positive laboratory findings included a sedimentation rate of 35 mm/hr and chest x-ray evidence of azygous node enlargement in the right paracentral region wth small infiltrates in the right upper and
left lower lobes, and a small right pleural effusion. By the time the results of the tuberculin skin test done on admission became available and turned out to be positive, steroids had been tapered to 15 mg/day. Chest tomography was compatible with the diagnosis of pulmonary tuberculosis. Smears and cultures of three sputum and three gastric aspirate samples were negative for mycobacterium. Findings of a battery of noninvasive tests, including serologic titers and scans, were negative. Because the patient refused further studies, such as a pleural tap, she was started on a therapeutic trial of 300 mg isoniazid and 1000 mg ethambutol by mouth daily. Five weeks later, the chest x-ray started to show signs of improvement. The course was followed by serial fundus photography, indirect ophthalmoscopy, and chest x-rays. During the second month of treatment, the choroidal lesion started to decrease in size, and by the third month it was about 25% smaller than when therapy was started. This reaction to treatment was considered a positive diagnostic test for both the pulmonary and the ocular involvement. The regimen of antituberculous drugs was continued. Early in the course of therapy, the findings of a bronchoscopy were compatible with the diagnosis of tuberculosis. After one year of treatment, both the chest · and the choroidal lesions had scarred down and showed no sign of activity even several months after the cessation of therapy (Fig 2).
DISCUSSION Choroidal tuberculomas have been reported in patients with pulmonary tuberculosis,2.4 although they are clas835
0'1
\;J
00
(Pre)arterial filling of tumor net
Masking
Greyish, yellowish patches (variable elevations)
Orange-red tumor
Whitish-greyish variable pigment change
Metastatic tumor
Choroidal hemangioma
Foreign body
* Lesion of interest.
RPE = retinal pigment epithelium; R = retina; S = sclera.
Masking of choroidal fluorescence (when small)
Double circulation
Orange pigment
Depends on associated injuries
Leakage into surrounding area
Possible staining of edge
Multiloculated pattern (cystoid spaces in overlying retina)
Variable RPE change (when advanced)
Tumor staining
Staining at level of tuberculoma, RPE, and subretinal space
Normal retinal vessels and optiC disc
Hyperfluorescence of tuberculoma surrounding hypoftuorescence ring
Choroidal melanoma
Late
Mid
Early
Globular, subretinal, whitish mass with or without overlying serous retinal detachment
Color /Monochromatic
Isolated choroidal tuberculoma
Condition
Fluorescein Angiography
Variable
A* B
Shadowing, reverberation
No excavation
Solid mass(es), no excavation
Choroidal excavation
Solid elevated mass: silent zone with absent scleral echo due to absorption by inflammatory cells
Ultrasonography
(If magnetic, can do dynamic)
V At Jut
J0j
Associated serous retinal detachment
Table 1. Differential Diagnosis of Isolated Choroidal Tuberculoma 18.19
~
(1)
JJ
m
z c s::
•
f\.)
to
m
E s::
(§
•
-"
~ Ul
~
C
c....
•
8-<
§
»
I
o
JABBOUR, et al
•
sically described in association with miliary tuberculosis and tuberculous meningitis. 8,9 The chain of events between primary and miliary tuberculosis is still unclear, but it is believed that a primary (usually asymptomatic) infection is carried to other loci via bacteremia. The final outcome depends on the immune status of the host, the virulence of the organism, and the severity and recurrence of the hematogenous spread, 14,15 Theoretically, local seeding in the uveal tract is feasible during any phase of the disease. 6 ,9 The choroidal tuberculomas reported in the literature occurred either in patients known to have tuberculosis (active or inactive), or at autopsy. 12.15,16 Occasionally, choroidal tuberculomas have been found in enucleated eyes.ll,170ur case is a unique example of how the choroidal involvement can lead to the diagnosis of pulmonary tuberculosis. Although the number of cases of endogenous uveitis considered to be of tuberculous origin has always been overestimated,? many choroidal tubercles have been discovered only at autopsy. The presentation and findings in our case should serve to arouse a degree of suspicion in similar cases that might be either missed or misdiagnosed. Early diagnosis ' and therapy are of systemic as well as ocular advantage and may save lives as well as eyes; tuberculomas misdiagnosed as tumors have resulted in some unnecessary enucleations. II, 17 Fluorescein angiography is helpful, and our findings agree with those of Cangemi et at,2 but we do not think that the pattern is strictly pathognomonic. Table 1 clearly shows that although ultrasonography is extremely helpful in the differential diagnosis of foreign bodies, choroidal melanomas, hemangiomas, and metastatic tumors, the pattern is not typical for choroidal tuberculomas. Fluorescein angiography yields more differential findings, but it cannot distinguish between isolated granulomas of tuberculous origin and those of sarcoidosis, unless other features of ocular sarcoid, such as intravitreal, preretinal, and focal retinal nodules and perivascular candle-wax dripping exudates are present Fluorescein angiographic and ultrasonographic findings in Toxocara infection were also not included in the table, because this condition can present with localized disciform macular detachment, papillitis, peripheral retinal (or pars plana) mass, vitritis, endophthalmitis, retinal detachment, and/or cataract Rarely the organism is seen, and sometimes a retinochoroidal anastomosis can be demonstrated. Clinical evaluation with local and systemic assessment (serology; radiology, etc.) provide helpful ancillary data.
PULMONARY TUBERCULOSIS
However, in the absence of any definite diagnostic tool (cytology and pathology) in vivo, the role of therapeutic trials for choroidal tuberculomas cannot be overstressed. Tuberculin skin test is a must, especially before starting systemic steroids. Moreover, local treatment (be it with drugs or laser) as well as systemic treatment (conventional antibiotics or steroids) in the absence of a diagnosis may worsen, or at best modify, the clinical picture, making the correct diagnosis more difficult to . reach.
REFERENCES 1. Saari M. Disciform detachment of the macula. III. Secondary to inflammatory diseases. Acta Ophthalmol 1978; 56:510-7. 2. Cangemi FE, Friedman AH, Josephberg R. Tuberculoma of the choroid . Ophthalmology 1980; 87:252-8. 3. West CS, Vainisi SJ, Vygantas CM, Beluhan FZ. Intraocular granu· lomas associated with tuberculosis in primates. J Am Vet Med Assoc 1981; 179:1240-4. 4. Shimomura Y, Tada R, Yuasa T. Ocular disorders in pulmonary tuberculosis. Folia Ophthalmol Jpn 1979; 30:1973-8. 5. Doden W. Die Augentuberkulose. Prax Klin Pneumol 1977; 31 :713-
6. 6. Heydenreich A. Die Augentuberkulose. Z Gesamte Inn Med 1978; 33:735-8. 7. Duke·Elder S. System of Ophthalmology. Vol. IX: Diseases of the Uveal Tract. St Louis: CV Mosby, 1966; 257. 8. Cernea P, lonescu M, Constantin C. Aspects actuels dans Ie tuberculome choroidien. Ann Ottalmol 1976; 102:25-30. 9. Massaro D, Katz S, Sachs M. Choroidal tubercles; a clue to hematogenous tuberculosis. Ann Intern Med 1964; 60:231-41. 10. Woods AC. Endogenous Uveitis. Baltimore: Williams & Wilkins, 1956; 50-9, 137- 50. 11 . Blodi FC. Ein Tuberkulom der Aderhaut, ein Melanom vortauschend. Klin Monatsbl Augenheilkd 1977; 170:845-9. 12. Bates JH. Diagnosis of tuberculosis. Chest 1979; 76(6 Suppl):75763. 13. Glassroth J, Robins AG, Snider DE Jr. Tuberculosis in the 1980s. N Engl J Med 1980; 302:1441-50. 14. Rich AR. The Pathogenesis of Tuberculosis, 2nd ed. Springfield, III: Charles C Thomas , 1951 . 15. Bottiger LE, Nordenstam HH, Wester PO. Disseminated tuberculosis as a cause of fever of obscure origin. Lancet 1962; 1: 19-20. 16. Bottiger LE, Nordenstam HH, Wester PO. Miliartuberkulos--en bortglamd diagnos? Nord Med 1961; 66:1719-21. 17. Shammas HF, Burton TC, Weingeist TA. False-positive results with the radioactive phosphorus test. Arch Ophthalmol 1977; 95:2190-2. 18. Gass JDM. Stereoscopic Atlas of Macular Diseases; Diagnosis and Treatment, 2nd ed. St Louis: CV Mosby; 1977,234-312,344-66. 19. Coleman DJ, Lizzi FL, Jack RL. Ultrasonography of the Eye and Orbit. Philadelphia: Lea & Febiger, 1977; 197-238.
837