Sir,

I thank the authors for this interesting case report published recently.1 There are a few questions that need to be addressed including systemic work-up. The ‘vague’ nature of his presentation may have indicated a detailed medical history and referral to the physicians. Abdominal symptoms could indicate either liver or renal dysfunction and in such cases routine blood and urine tests to look for abnormal liver function tests and proteinuria as well as abdominal ultrasound are justified.

Although Eales disease is a diagnosis of exclusion, a history of contact with persons with active-treated tuberculosis and travel in ‘at risk’ areas needs to be elucidated.2 Systemic tuberculosis in an important condition to exclude and immunological tests such as the Mantoux test have a tendency to give variable results.3

We have previous experience of a case of a 25-year Caucasian man who presented with similar ocular symptoms and signs. His disease followed an aggressive course despite immunosuppressive medical therapy, laser treatment and vitreoretinal surgery. Our patient had abnormal liver function tests and proteinuria consistent with wide-spread tissue involvement with a negative Mantoux test. Prompt referral to the physicians following medical investigations with tuberculosis immunospot test demonstrated reactivity against Mycobacterium tuberculosis with significant response to triple therapy.4 We therefore suggest early referral to physicians in those patients with ischaemic vasculitis and systemic symptoms to exclude extrapulmonary tuberculosis as demonstrated in our case. Anti-VEGF agents have a specific activity to reduce oedema and inhibit angiogenesis and therefore therapy in the published case could have halted acute progression; however, it is possible that the disease process may have stabilized and resolved during the follow-up period.5