You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


Findings {#Sec1}
========

Introduction {#Sec2}
------------

The ocular involvement of tuberculosis is not uncommon but diverse. The ophthalmic presentation of ocular tuberculosis might be caused by direct infection or indirect immune-mediated hypersensitivity. There is an increasing incidence of tuberculosis even in the developed countries, due to migration from endemic areas and increase in the number of immunocompromised patients \[[@CR1]\]. Ocular tuberculosis can involve any tissue of the eyes and the orbit. The rich vascularity of uveal tissues permits easy hematogenous spread of infections from a caseous primary focus elsewhere in the body by eroding blood vessels or lymphatics. Tubercles can arise in the early stages of progression of TB and indicate hematogenous dissemination before the development of symptomatic ocular tuberculosis (TB) \[[@CR2]\]. Tubercular uveitis can exist even in the absence of systemic disease and could be due to hypersensitivity that develops towards the tubercle DNA. We report a case of choroidal tuberculoma in a patient with miliary tuberculosis and the features noted on imaging studies performed on this patient which include fundus fluorescein angiography (FFA), indocyanine green angiography (ICG), and optical coherence tomography (OCT).

Case report {#Sec3}
-----------

A 13-year-old girl presented with complaints of diminution of vision in her left eye for 3 weeks. On examination, her best corrected visual acuity for distance and near was 6/6 with N6 in her right eye and 6/24 and N6 with effort in her left eye, respectively. Slit lamp examination of the anterior segment and intraocular pressure were normal. Vitreous was normal with no cells or haze. Dilated fundus examination of the right eye revealed multiple, well-defined, yellow subretinal, healed choroidal tuberculomas (Figure [1](#Fig1){ref-type="fig"}). The left eye showed a single ill-defined, yellow subretinal lesion with dimensions of 20 × 16 mm located along the superotemporal arcade with surrounding edema and exudative retinal detachment. FFA showed diffuse hyperfluorescence in the early phase (Figures [2](#Fig2){ref-type="fig"} and [3](#Fig3){ref-type="fig"}) and pooling of dye in the late phase (Figure [4](#Fig4){ref-type="fig"}). ICG showed hypocyanescent lesions that corresponded to the choroidal tuberculomas (Figures [5](#Fig5){ref-type="fig"}, [6](#Fig6){ref-type="fig"}, and [7](#Fig7){ref-type="fig"}). OCT in the left eye showed serous detachment of the neurosensory retina involving the macular area (Figure [8](#Fig8){ref-type="fig"}). Systemic evaluation with high-resolution CT showed few small calcified mediastinal lymph nodes and evidence of splenic tuberculosis.Figure 1**Color fundus photo of the right eye showing multiple healed choroidal tuberculomas.**Figure 2**Color fundus photo of the left eye showing an active tuberculoma of the choroid.**Figure 3**OCT - left eye showing marked serous detachment of neurosensory retina superior and superotemporal to disc.** (Involvement of macula is seen)Figure 4**Early arteriovenous phase of fluorescein angiogram showing diffuse hyperfluorescence due to subretinal leakage of dye in the left eye.**Figure 5**Late arteriovenous phase of fluorescein angiogram of the left eye showing progressive subretinal pooling of dye.**Figure 6**Early-phase ICG of left eye showing a large hypocyanescent area superior and superotemporal to disc.**Figure 7**Late-phase ICG of the left eye showing a large hypocyanescent area superior and superotemporal to the disc.**The area is suggestive of a full-thickness lesion.Figure 8**Clinical photograph of left eye showing healing of lesion following ATT.**

An anterior chamber tap was performed and the aqueous humor was analyzed by staining for acid-fast bacilli, by polymerase chain reaction (PCR), and by real-time polymerase chain reaction (RT-PCR) kit to detect *Mycobacterium tuberculosis* (MTB) complex genome. DNA extraction from the aqueous humor was carried out using QIAMP DNA extraction kit (Qiagen, Venlo, the Netherlands) and RT-PCR for MTB was carried out using Genosen\'s MTB complex quantitative real-time PCR kit (Genome Diagnostics, Parwanoo, India). Aqueous humor analysis revealed the absence of acid-fast bacilli, and both PCR and RT-PCR were negative for tuberculosis genome. On the basis of clinical, angiographic, and radiological evidence, multiple healed choroidal tuberculomas in the right eye and active military choroidal tuberculoma in the left eye were diagnosed. Management with anti-tubercular treatment in the form of four drugs with isoniazid, ethambutol, pyrazinamide, and rifampicin for 3 months and isoniazid and rifampicin for 6 months was done. This was supplemented with prednisolone tablet 30 mg a day for 1 week tapered to 5 mg weekly to help resolve the surrounding choroidal inflammation along with ranitidine tablet and oral calcium supplements. On review after 3 months, the patient showed an improvement in her best corrected visual acuity to 6/6 and N6 in the left eye. On examination, the choroidal tuberculoma was found to have completely resolved, the ocular status was stable, and the only evidence of the lesion was pigmentation (Figure [9](#Fig9){ref-type="fig"}).Figure 9**Complete resolution of the lesion after ATT and oral steroids.**

Discussion {#Sec4}
----------

Choroiditis is the most common ocular manifestation in patients with pulmonary and systemic tuberculosis \[[@CR3]\]. A history of miliary tuberculosis, clinical examination, angiography, and radiological investigations led to the diagnosis of choroidal tuberculoma in our patient. In the absence of definite evidence, our diagnosis was presumptive and was based on presentation, systemic evaluation, and response to treatment. Choroidal tubercles are usually unilateral but may be solitary or multiple lesions, yellowish with indefinite borders located in the posterior pole, and may vary in their presentation with features such as associated hemorrhage, striae, or exudative retinal detachment \[[@CR4]\]. Generally, retinal vessels overlying these lesions appear normal but exudation and hemorrhage have been reported \[[@CR5]\]. Choroidal tuberculoma was found to have very little associated inflammation or retinal change in a patient with acquired immunodeficiency syndrome \[[@CR6]\]. It has been reported in association with glomerulonephritis \[[@CR7]\] and with meningoencephalitis \[[@CR8]\]. A case of pulmonary tuberculosis presenting with choroidal granuloma has been reported by Jabbour et al. \[[@CR9]\]. They noted an early hyperfluorescence within the lesion that increased in intensity and size over the subsequent phases as the dye leaked into the surrounding serous detachment and late leakage from the lesion. A variation was observed by Milea et al. \[[@CR10]\] who described early prolonged blockage and late moderate hyperfluorescence of the tuberculoma. Since there are no typical FFA findings for choroid tuberculoma, and varying appearances may be noted, FFA can contribute to exclusion of other causes. Tayanc et al. \[[@CR11]\] reported that ICG showed hypofluorescence of the choroidal tuberculoma in all phases which became less hypoflourescent after treatment and concluded that lesions detected by ICG were larger and more in number than those detected by FFA. Choroidal tuberculoma has been reported in association with AIDS \[[@CR12]\], tuberculosis of the spine, and miliary tuberculosis and masquerading as choroidal tumors \[[@CR13]\]. Rarely, patients present with ocular signs of isolated presumed choroidal tuberculoma masquerading as an intraocular tumor \[[@CR14]\] or choroidal melanoma \[[@CR15]\]. There is an increased likelihood of an association with central nervous system tuberculosis, and imaging studies are required in these patients to decide on the duration of anti-tubercular treatment (ATT) \[[@CR16]\]. However, a seemingly innocuous ocular involvement could be associated with significant systemic tuberculosis and thus requires thorough investigations. Choroidal tuberculomas can exist in the presence or absence of active disease, and even underlying latent tuberculosis has to be treated with ATT \[[@CR17]\]. These tubercles can sometimes remain asymptomatic and may not always incite inflammation but have rarely been reported to be associated with anterior uveitis \[[@CR18]\]. In TB granuloma, OCT reveals an area of localized adhesion between the choriocapillaris-RPE layer and overlying the neurosensory retina. This 'contact' sign is possibly due to inflammatory adhesions overlying the granuloma, and inflammatory cells appear as increased reflectivity in the deeper retinal layers over the granuloma \[[@CR19]\]. Syphilis, toxoplasmosis, sarcoidosis, brucellosis, histoplasmosis, hemangioma, metastasis, foreign body, and amelanotic melanoma are included in the differential diagnosis of choroidal tuberculoma. Histopathologic confirmation, which is needed for definite diagnosis of choroidal tuberculoma, is not practical; therefore, diagnosis of choroidal tuberculoma is usually presumptive and is based on clinical and laboratory findings \[[@CR20]\]. Isolated uveal tuberculoma can present in an otherwise healthy patient with negative systemic tuberculosis evaluation, and PCR can be used to confirm tuberculosis when other methods have failed \[[@CR21]\]. A vitreous or fine needle aspiration biopsy may be useful in clinching the etiological diagnosis in difficult situations. A high degree of clinical suspicion is important, especially in migrants from developing countries. Molecular diagnosis of tuberculosis by polymerase chain reaction is being increasingly used for diagnosis \[[@CR22]\]. Apart from angiography, detection of DNA and quantification of the mycobacterial load by RT-PCR in intraocular fluids is a development which can complement existing investigations in precise identification \[[@CR23]\].

Conclusion {#Sec5}
----------

A choroidal tuberculoma is one of the most common forms of ocular tuberculosis, and it is probably due to high blood supply of the choroid. This case highlights the fact that in some patients, analysis of the aqueous may not provide any clue to the confirmation of tubercular choroidal granuloma. An association between splenic tuberculosis and choroidal tubercles has not been reported till now. This patient was not very symptomatic despite chest and spleen involvement, thus proving that miliary tuberculosis has various forms of presentation. After the diagnosis of presumed or confirmed tuberculosis is established, surgical intervention should be avoided. Detection of choroidal inflammation can prevent visual loss as the ocular lesion resolves fully with timely management. Miliary tuberculosis was found as one of the most important independent factors linked to the development of ocular tuberculosis \[[@CR24]\]. Since delay in diagnosis and treatment results in poor prognosis and severe sequelae, effective therapy should be initiated as early as possible. Response to the treatment may be helpful to confirm the diagnosis of choroidal tuberculoma.

ATT

:   anti-tubercular treatment

DNA

:   deoxyribonucleic acid

FFA

:   fundus fluorescein angiography

ICG

:   indocyanine green angiography

MTB

:   *Mycobacterium tuberculosis*

OCT

:   optical coherence tomography

PCR

:   polymerase chain reaction

RT-PCR

:   real-time polymerase chain reaction

TB

:   ocular tuberculosis

**Competing interests**

The authors declare that they have no competing interests.

**Authors\' contributions**

RA drafted the manuscript. JB diagnosed and treated the patient. Both authors read and approved the final manuscript.

There was no source of funding and no other contributors apart from the authors.