A healthy 48-year-old Caucasian male came to the emergency room with acute bilateral decrease visual acuity and floaters (Table 1). He denied ocular pain, fever, anorexia, and other systemic symptoms. BCVA in OD was 6/10 and in OS was 5/10. Biomicroscopic examination was unremarkable in both eyes. Dilated ocular fundus examination showed vitritis, vitreous haemorrhage, and extensive retinal venous vasculitis with haemorrhages in all retinal quadrants and macular edema (Figure 2). Fluorescein angiography showed bilateral severe occlusive venous vasculitis associated with paramacular, midperipheral, and peripheral retinal ischemia (Figure 3), and spectral domain optical coherence tomography (SD-OCT) revealed cystoid macular edema (CME) in both eyes (Table 1).
Investigation of the etiology included hemogram, inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), human leukocyte antigen (HLA) B51, lysozyme, angiotensin-converting enzyme (ACE), infectious serologic testing and hemoglobin electrophoresis, coagulation, and prothrombotic evaluation that were all unremarkable, except for tuberculin skin sensitive test (20 mm) and IGRA (>10) which were positive. X-ray and CT scan of the thorax also revealed unspecific small bilateral hilar ganglia (Table 1).
Eales' disease was suspected, and patient started complete quadruple antituberculosis treatment, which was maintained for nine months, associated with oral corticoid therapy (prednisolone 1 mg/Kg/day) with slow progressive withdrawal and subsequent introduction of oral methotrexate (20 mg/week) in order to achieve control of the disease. Serial treatment regime with anti-VEGF vitreous injections was also performed in both eyes (in a total of 11 in each eye). Laser photocoagulation was also required in both eyes over four sessions (Figure 2 and Table 1). This therapeutic approach allowed progressive clinical improvement.
After two years of follow-up, the patient maintains immunosuppression with oral methotrexate (20 mg/week) associated with prednisolone (2.5 mg/day) and achieved almost complete visual acuity recovery for 10/10 in both eyes, although with significant restriction of visual field, induced by both severe retinal ischemia and photocoagulation (Table 1).