Evidence and Consensus-Based Imaging Guidelines in Tubercular Choroiditis

PURPOSE: To develop imaging-based statements and consensus recommendations for the application of multimodal imaging in tubercular choroiditis (TBC). DESIGN: International expert committee-led consensus agreement using a modified nominal group technique with further refinement from literature review and full task force voting. PARTICIPANTS: International expert committee of uveitis and retina specialists from the Multimodal Imaging in Uveitis (MUV) task force. METHODS: The MUV task force convened a group of international experts to develop a set of standardized imaging criteria for TBC. Cases with focus on tubercular serpiginous-like choroiditis (TB SLC) and tuberculomas/tubercles were provided by expert members to develop a review case portfolio of both active and inactive disease with longitudinal follow-up. Cases included color fundus photography, fundus autofluorescence, fundus fluorescein angiography, indocyanine green angiography, OCT, and OCT angiography. The case portfolio was reviewed by all members, and through a structured nominal group technique and guided by a literature review, the group refined descriptive statements characterizing active, evolving, and inactive lesions until consensus was achieved. MAIN OUTCOME MEASURES: Imaging statements and consensus guidelines describing features of TB SLC and tuberculoma/tubercle in relation to diagnosis, monitoring, and detection of disease complications. RESULTS: The case portfolio included 31 cases, and the group achieved consensus on defining distinct imaging features of TB SLC and choroidal tuberculomas/tubercles. For TB SLC, key features of active lesions included yellow-white multifocal or placoid lesions with hyperautofluorescent edges on fundus autofluorescence, outer retinal hyperreflectivity, and focal choroidal thickening on OCT. Both indocyanine green angiography and OCT angiography highlight lesions that are often more extensive than those seen clinically. Choroidal tuberculomas were defined as solitary, lobulated masses often associated with subretinal fluid and retinal neovascularization, whereas tubercles appear as multiple small lesions associated with disseminated tuberculosis. Consensus-based guidelines were established to use these multimodal imaging features for diagnosis, monitoring response to treatment, and detecting complications. CONCLUSIONS: The MUV imaging guidelines for TBC extend existing diagnostic frameworks by systematically integrating multimodal imaging features for disease characterization and monitoring. These consensus-based recommendations enhance phenotypic classification, improve assessment of disease activity, and provide clinically relevant endpoints for evaluating treatment response. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.