Ocular manifestations of tuberculosis

Tuberculous ciliary body granuloma initially diagnosed as bullous retinal detachment: a case report

BACKGROUND

Ocular tuberculosis is a relatively rare extrapulmonary manifestation of tuberculosis. This vision-threatening disease is extremely challenging to diagnose, particularly because it can mimic other diseases. We report a case of tuberculous ciliary body granuloma initially diagnosed as bullous retinal detachment.

CASE REPORT

A 52-year-old female presented with bullous retinal detachment in her left eye, and ultrasound biomicroscopy (UBM) verified the presence of a lesion with ciliary body granulomatous inflammation. The T-SPOT was positive, and the purified protein derivative (PPD) test was strongly positive (diameter of 20 mm). Following the administration of oral anti-tuberculosis regimen combined with prednisone, the retina gradually became reattached, the ciliary body granuloma became significantly reduced in size, and the visual acuity of the patient noticeably improved.

CONCLUSIONS

Tuberculous ciliary body granulomas can cause bullous exudative retinal detachment and can be diagnosed with UBM. Early and full-course anti-tuberculosis treatment (ATT) combined with corticosteroid therapy can improve the patient prognosis.

Intraocular tuberculosis masquerading as ocular tumor: A case report

Tuberculosis is one of the most common pediatric problems, especially in the developing world. In spite of that, intraocular tuberculosis is a rare disease that can easily be confused with other noninfectious processes, even in regions where tuberculosis is rampant. Diagnosis is difficult, yet it is very important to provide effective antituberculosis treatment and avoid potentially sight-losing interventions. We present a case of a 2-year-old child with a positive contact history of tuberculosis who presented with progressively worsening seizures and constitutional symptoms for 6 months. Brain computed tomography revealed right frontotemporal region conglomerated ring-enhancing lesions with central necrosis consistent with tuberculosis. On the same scan, a calcified right retinal lesion with a contrast-enhancing soft tissue component was identified. A chest radiograph and abdominal sonography showed evidence of disseminated tuberculosis. Subsequently, antituberculosis treatment was initiated, and the right retinal lesion improved, thus leading to the imaging diagnosis of right intraocular tuberculosis. Early and accurate diagnosis of retinal tuberculosis is of paramount importance in avoiding potentially catastrophic interventions. Neuroimaging is a useful, noninvasive method to consider this difficult diagnosis and also for follow-up.

Tuberculosis of the eye, case series study

Tuberculosis of the eye represents a challenge throughout the world, and there is a continuous debate about its pathophysiology, diagnosis, and treatment. The present research represents an interventional prospective study focusing on the variable clinical presentations, and the diagnostic and therapeutic characteristics of ocular tuberculosis. Fifteen eyes from nine cases were diagnosed with ocular tuberculosis, treated, and followed up between 2010 and 2020. The diagnosis was based on (1) a compatible clinical picture, (2) highly positive Tuberculin skin test or a positive IGRA test (Interferon-Gamma Release Assays), (3) a dramatic response to anti-tuberculous drugs without systemic steroid. Mean age was 41.22±13.64 years; eight cases were females 89.8%, one male 11.1%. Only one case had preexisting pulmonary tuberculosis. Bilateral ocular involvement occurred in two thirds of cases (66.7%). The most common clinical presentation was intermediate uveitis (33.3%), followed by multifocal choroiditis (20%). All cases were cured without relapse for the 2–10 years of follow-up, after taking oral anti-tuberculous drugs for 6–12 months. No systemic steroids were given, only topical steroid drops, as indicated. In conclusion, ocular tuberculosis is a mysterious condition with a wide-range of clinical presentations and should be considered in the differential diagnoses of any type of intraocular inflammation, or any unexplained reduction in vision. Oral anti-tuberculous drugs with or without topical steroids are sufficient to improve vision, produce, cure, and prevent relapse.

The clinical presentation and treatment outcomes of ocular tuberculosis: a 5-year experience in an endemic area

PURPOSE

To report the clinical presentations of ocular tuberculosis infection (OTB) and the treatment regimen and outcome in an endemic area.

METHODS

This is a retrospective case series of patients with presumed OTB treated in a tertiary teaching hospital in Hong Kong in 2014-2019.

RESULTS

Among the nineteen patients recruited, the most common clinical presentation of OTB was retinal vasculitis (42.1%), followed by scleritis, intermediate uveitis, and choroidal tuberculoma (15.8% respectively). 94.7% and 94.4% of the subjects were treated with ATT and steroid, respectively, and 31.6% were put on systemic immunosuppressant prior to the initiation of ATT. Apart from those suffering from intermediate uveitis, most demonstrated good clinical response within 8 weeks of ATT initiation.

CONCLUSION

Ocular involvement of TB has been increasingly recognized, especially in endemic regions like Hong Kong. High index of suspicion is recommended for OTB in typical clinical phenotypes or recurrent/resistant ocular inflammation unresponsive to conventional therapy. TB retinal vasculitis was the most common presentation of OTB in this study and OTB generally requires treatment with either regional or systemic steroid together with ATT.

Characterization of and advanced diagnostic methods for ocular tuberculosis and tuberculosis

Tuberculosis (TB) is an airborne infection caused by Mycobacterium tuberculosis that usually affects the lungs. Timely treatment of active TB, diagnosis and prevention of latent TB are very important. However, extrapulmonary TB affects almost any tissues around the eye and orbit, and it then requires a high degree of suspicion to accurately diagnose. Diagnostic delays are common and may lead to morbidity. For ophthalmologists and infectious disease specialists, it is important to work together to accurately diagnose and treat ocular tuberculosis (OTB) to prevent vision loss. This review reports the latest advanced diagnostic methods for active TB and latent TB as well as various known manifestations of OTB. Important elements of diagnosis and treatment are also reviewed.

Endogenous Tuberculous Endophthalmitis and Panophthalmitis: A Systematic Review of Case Reports and Case Series

Purpose

To systematically review the characteristics of patients with endogenous tuberculous (TB) endophthalmitis and panophthalmitis in an effort to help clinicians with diagnosis and treatment.

Patients and Methods

We conducted a systematic literature search in MEDLINE/PubMed, EMBASE and Web of Science from inception to August 2020. References and abstracts were screened independently by two authors. Included studies were case reports and case series reporting endogenous TB endophthalmitis and panophthalmitis secondary to Mycobacterium tuberculosis complex (MTBC). Available-case analysis was employed to handle missing data.

Results

A total of 1343 articles were found using the search strategy. Following abstract screening, 51 articles were selected for full text-review, from which 26 were deemed eligible for inclusion in the study. Forty-four cases from 26 articles were included in the quantitative analysis. The median age of presentation was 29.5 (range: 1 to 81), and 11/44 patients (25.0%) were pediatric. Immunosuppression was seen in 9/36 cases (25.0%). Most patients (24/38, 63.2%) had no prior history of tuberculosis. Systemic symptoms were absent in half of the patients (16/32, 50.0%). Visual acuity was poor, with 23/27 cases (85.2%) being 20/200 or worse at presentation. Poor organ and visual outcomes were reported: 36/43 cases (83.7%) resulted in enucleation/evisceration or exenteration. Intraocular tumors were suspected in 5/34 cases (14.7%). Pulmonary tuberculosis was seen in 15/35 cases (42.8%), and miliary tuberculosis was seen in 7/35 cases (20.0%). The earliest source of TB diagnosis was through histopathologic specimen after eye removal in 32/44 cases (72.7%), vitreous specimen in 6/44 cases (13.6%) and aqueous specimen in 3/44 cases (6.8%).

Conclusion

TB endophthalmitis is a rare and sight-threatening manifestation of ocular tuberculosis. It can occur in apparently healthy individuals and can mimic intraocular tumors and other infectious etiologies. Diagnosis remains a significant challenge, which, often delayed, leads to profound visual loss. Early detection and treatment of intraocular tuberculosis may be associated with better ocular and systemic outcomes.

Tuberculosis: A Cunning Disease Presenting with Endopericarditis-Associated Bilateral Uveitis

Mycobacterium tuberculosis can spread through the entire body but rarely involves the eye. We report a patient with endophthalmitis in one eye and simultaneous retinal vasculitis in the fellow eye. Systemic work-up suggested infective endopericarditis. Polymerase chain reaction analyses of the vitreous and pericardial fluid were positive for M. tuberculosis. We initiated a four-drug antituberculous treatment regimen (isoniazid, ethambutol, pyrazinamide, and rifampin). After two weeks, we discontinued all the medications due to drug-induced hepatitis. We restarted isoniazid and rifampin, but hepatitis recurred. Finally, we chose isoniazid/ethambutol combination for 18 months, and also administered short-term systemic corticosteroid. His vision improved considerably with no recurrence of hepatitis or tuberculosis for 3 years after completion of treatment. Ocular tuberculosis can masquerade as other causes of intraocular inflammation, and a medical team consisting of an ophthalmologist and an infectious disease specialist might be needed for the diagnosis and management.

Indocyanine green angiographic findings in presumed intraocular tuberculosis

PURPOSE

To study features of Indocyanine green angiography (ICGA) in patients with presumed intraocular tuberculosis.

METHODS

Retrospective study of 48 consecutive patients (77 eyes) who underwent ICGA. The following signs were analysed: choroidal perfusion inhomogeneity, early hyperfluorescent stromal vessels, round or oval hypofluorescent dark dots (HDDs), hypofluorescent geographic lesions (HGLs), fuzzy or lost pattern of large stromal choroidal vessels, disc hyperfluorescence and diffuse late choroidal hyperfluorescence.

RESULTS

Among 44 eyes of 29 patients with no clinical evidence of choroidal involvement, only 7 eyes of 6 patients had no ICGA evidence of choroidal involvement. On the other hand, ICGA findings suggesting choroidal involvement were noted in 37 (84.1%) eyes of 23 patients in the form of HDDs in all 37 (100%) eyes, HGLs in 7 (18.9%) eyes, disc hyperfluorescence in 20 (45.5%) eyes, fuzzy stromal vessels in 17 (38.6%) eyes, early hyperfluorescent stromal vessels in 13 (29.5%) eyes, late pinpoint hyperfluorescence in 11 (25%) eyes and late diffuse choroidal hyperfluorescence in 7 (15.9%) eyes. Among 33 eyes of 19 patients with clinically evident choroidal involvement, the following findings were identified; HDDs in 12 (36.4%) eyes, HGLs in 10 (30.3%) eyes, both HDDs and HGLs in 9 (27.3%) eyes, disc hyperfluorescence in 11 (33.3%) eyes, early hyperfluorescent stromal vessels in 7 (21.2%) eyes, fuzzy stromal vessels in 6 (18.2%) eyes and late diffuse choroidal hyperfluorescence was present in 2 (6.1%) eyes.

CONCLUSIONS

ICGA is necessary in identifying and diagnosing subclinical tuberculous choroidal involvement. The most prevalent ICGA finding was persistent HDDs.

Ocular tuberculosis epidemiology, clinic features and diagnosis: A brief review

The spread of tuberculosis is directly related to the processes of globalization and migration. Tuberculosis has also been the main cause of fatality associated with antimicrobial resistance and also the main cause of death in people who have HIV infection. Additionally, tuberculosis smites the lungs in 80% of patients, and in the remaining 20% of patients the tuberculosis may smites other organs, such as the vision/eye. Ocular tuberculosis is a specific infectious disease of bacterial etiology with a chronic and persistent course, the prognosis of which is extremely doubtful. Even effective chemotherapy can be accompanied by a decrease in visual acuity, and clinical recovery is not always persistent. Ocular tuberculosis often leads to permanent disability and, as a result, the quality of life of patients decreases. A statistical reporting of this disease does not always reflect the true picture, since ocular tuberculosis sometimes develops against the background of an existing specific lesion in the lung tissue. Currently, ocular tuberculosis remains substantially a conjectural clinical diagnosis. This review paper presents an analytical review of the literature on the epidemiology, clinical features, and diagnosis methods of ocular tuberculosis. The results of recent studies that focused on the modern clinical manifestations of this pathology, its diagnosis, and complex therapy are systematized. The development of new rational regimens and pathogenetic treatment methods are also highlighted in this review.

Study of ocular manifestations in tuberculosis and its association with HIV AIDS in a tertiary care hospital

OBJECTIVE

To assess and understand the prevalence and clinical presentation of ocular morbidity in patients suffering from tuberculosis and compare it with ocular involvement in patients coinfected with tuberculosis and HIV AIDS.

MATERIALS AND METHODS

This was a non-comparative, observational, cross sectional study done on 580 patients, who were diagnosed cases of tuberculosis, pulmonary or extrapulmonary, on or off treatment, visiting the Ophthalmology OPD, Tuberculosis OPD and ART Centre of the institute in the period from March 2015 to March 2018, screened for ocular morbidity.

RESULTS

Out of 580, 408 patients had only tuberculosis and 172 had tuberculosis with HIV AIDS. 108 patients were found to have ocular involvement (18.6%) out of which 63 were males and 45 were females. The prevalence of ocular morbidity in patients with only tuberculosis was found to be 16.4% and in those having both tuberculosis and HIV AIDS was found to be 23.8%.

CONCLUSION

Our study concludes that posterior uveitis, pan uveitis, periphlebitis and vitritis are the most common ocular manifestations in tuberculosis. In patients with both tuberculosis and HIV most common ocular findings included vitritis and herpes zoster ophthalmicus. Our study also concludes that lower CD4 counts (less than 200) in HIV AIDS patient is significantly associated with ocular involvement.

Orbital Tuberculosis with Intracranial Extension

We report a case of orbital tuberculosis (OTB) with intracranial extension without active tuberculosis in the rest of the body organs or a history of tuberculosis infection. A 29-year-male patient presented with left-sided painful periorbital swelling with pus discharging sinus and visual impairment. Orbital computed tomography revealed contrast enhancing cystic mass lesion in the left orbit with erosion of the lateral and superior orbital wall with intracranial extension. After the failure of 3 weeks' course of oral antibiotics, the patient underwent left lateral orbitotomy, pus was drained out, and granulation tissues were excised. Histopathological examination confirmed OTB. The patient had received antituberculous treatment. Periorbital swelling completely disappeared and vision improved over a period of 2 weeks. OTB should be considered in differential diagnosis of periorbital swelling especially when it does not respond to oral antibiotics.

Tuberculous Uveitis Presenting with a Bullous Exudative Retinal Detachment: A Case Report and Systematic Literature Review

Purpose: To describe tuberculous uveitis (TU) presenting as a bullous retinal detachment (RD) and to perform a comprehensive literature review on TU with similar features. Methods: Observational case report and systematic literature review. Results: An 84-year-old woman presented with bilateral granulomatous uveitis and bullous RD in the left eye. The interferon gamma release assay was strongly positive, but all other tests were unremarkable. The patient was diagnosed with TU and started on anti-tubercular therapy (ATT) and systemic steroids with excellent treatment response. Twenty-six articles (32 cases) reported TU with exudative RD. Choroidal tuberculoma was the most common clinical manifestation, followed by optic disc edema and retinal exudate. Systemic steroids with ATT improved vision in more patients (78.6%) than ATT alone (50.0%) or oral steroids followed by ATT (50.0%). Conclusion: Atypical presentations of TU make diagnosis and treatment difficult. A high level of suspicion for TU is needed to minimize ocular morbidity.

Case Study

In the developing countries, incidence of systemic tuberculosis is very high, with over 8 million new cases each year. The incidence of tuberculous uveitis is also rising correspondingly. It is difficult to diagnose ocular tuberculosis because of the lack of specific ocular findings and specific confirmatory laboratory tests. However, in a developing country like India, where the prevalence of latent tuberculosis is high, uveitis of unexplained cause not fitting into known uveitis entities, in presence of Monteux positivity, is more likely to be tubercular in origin. Hence, early diagnosis and prompt treatment with antitubercular treatment may result in dramatic drop in recurrence and improve individual patient outcomes.

A Case of Presumed Tuberculosis Uveitis with Occlusive Vasculitis from an Endemic Region

In this report, we present a case with presumed unilateral tuberculosis uveitis from an endemic region. A 23-year-old male presented with decreased vision in his left eye for 15 days. Visual acuities were 1.0 in his right eye and 0.3 in his left eye. Ophthalmologic examination was normal for the right eye. Slit-lamp examination revealed 2+ cells in the vitreous without anterior chamber reaction in his left eye. Fundus examination revealed occlusive vasculitis and granuloma. His history revealed that he had a respiratory infection with fever 3 months ago while visiting his native country, Rwanda, and was treated with non-specific antibiotic therapy. His visual symptom started 2 weeks after his systemic symptoms resolved. Laboratory findings included 15 mm induration in purified protein derivative tuberculin skin test, HIV negativity, and parenchymal lesions in chest X-ray. Bronchoalveolar lavage was negative for acid-fast bacillus. A pulmonary disease consultant reported presumed tuberculosis because of the patient's history. Anti-tuberculosis treatment was initiated. The patient's visual acuity improved rapidly and his signs regressed. A careful history should be taken from patients with uveitis. Travel to tuberculosis-endemic areas may be important for diagnosis and should be asked about directly.

Intraocular manifestations of mycobacterium tuberculosis: A review of the literature

Mycobacterium tuberculosis: is most commonly associated with pulmonary infection. However, tuberculosis (TB) can also affect the eye. TB can affect nearly any tissue in the eye, and a high index of suspicion is required for accurate diagnosis, as many of the intraocular manifestations of TB can mimic other, more common diseases. Correct diagnosis is critical because systemic anti-tuberculosis treatment may be required, and vision loss or even loss of the affected eye can occur without proper treatment. Thus, it is important for ophthalmologists and infectious disease specialists to work together to accurately diagnose and treat intraocular TB. This article reports the various known presentations of intraocular TB and reviews important elements of diagnosis and treatment.

Tuberculous Posterior Sclero-Uveitis with Features of Vogt-Koyanagi-Harada Uveitis: An Unusual Case

Patient: Male, 32

Final Diagnosis: Ocular tuberculosis (tuberculous posterior sclero-uveitis with features of Vogt-Koyanagi-Harada uveitis)

Symptoms: Pain and progressive visual impairment of his left eye

Medication: Systemic anti-tuberculosis treatment (6-month course)

Clinical Procedure: Thorough ophthalmological and systemic exploration

Specialty: Ophthalmology

Two cases of eyelid tuberculosis - An uncommon presentation of ocular tuberculosis

Mycobacterium tuberculosis apart from being the causative agent of pulmonary tuberculosis is also notorious to cause tuberculosis at various sites in the human body and ocular tuberculosis is one of the extra pulmonary manifestations of this organism. The most common presentation of ocular tuberculosis is anterior uveitis or choroiditis caused by hematogenous infection or hypersensitivity after another organ infection. Eyelid involvement by tuberculosis is most of the times secondary to orbital involvement and often seen in the form of drainage sinus. Isolated eyelid tuberculosis is however uncommon. Here we report two such cases of eyelid tuberculosis in different age groups; first case in a young female and second case of an old aged female with different presentation. Fortunately both of them responded well to the antitubercular treatment.

Steroid treatment in ocular tuberculosis: A double-edged sword?

INTRODUCTION

We report the case of a Caribbean patient with an atypical presentation of bilateral tuberculous chorioretinopathy.

PATIENT AND METHODS

A 57-year-old woman, with hypertension and non-insulin dependent diabetes, was referred to our center for a sudden loss of vision in the right eye to hand motions. Ophthalmic examination revealed only right papilledema. Brain magnetic resonance imaging was normal. Laboratory examination revealed no signs of inflammation. A right non-arteritic acute anterior ischemic optic neuropathy was first suspected. One week later, the visual acuity (VA) in the left eye dropped from 10/10 to 5/10 with the appearance of papilledema on fundoscopic exam. This bilaterality led us to begin intravenous corticosteroids followed by transition to oral. This improved the left eye VA to 10/10. Numerous bilateral white patches in the posterior pole appeared secondarily, hypofluorescent in the intermediate and late phases of angiography.

RESULTS

The research of the etiology of uveitis showed a positive tuberculin skin test without any prior vaccination. The vitreous humor sample was negative on direct examination, by culture and by polymerase chain reaction (PCR).

DISCUSSION

Systemic corticosteroid therapy for ocular tuberculosis is not well described. It may theoretically treat the inflammatory portion of the lesions due to type IV hypersensitivity reaction as in meningeal and pericardial involvement.

CONCLUSION

The clinical spectrum of ocular tuberculosis is wide and the diagnosis should be considered in any intraocular inflammatory condition of a chronic or acute recurrent nature, whether or not responsive to steroids.

Orbital and external ocular manifestations of Mycobacterium tuberculosis: A review of the literature

Tuberculosis (TB) is an airborne infectious disease caused by Mycobacterium tuberculosis that most commonly affects the lungs. However, extrapulmonary manifestations of TB can affect the eye and surrounding orbital tissues. TB can affect nearly any tissue in the eye, and a high index of suspicion is required for accurate diagnosis. Systemic anti-tuberculosis treatment is required in cases of ocular TB, and steroids are sometimes necessary to prevent tissue damage secondary to inflammation. Delays in diagnosis are common and can result in morbidities such as loss of an affected eye. It is important for ophthalmologists and infectious disease specialists to work together to accurately diagnose and treat ocular TB in order to prevent vision loss. This article reports the various known presentations of orbital and external ocular TB and reviews important elements of diagnosis and treatment.

Tuberculous Panophthalmitis with Lymphadenitis and Central Nervous System Tuberculoma

Tuberculosis (TB) is a serious infectious disease that spreads globally. The ocular manifestations of TB are uncommon and diverse. TB panophthalmitis has been rarely reported. Here, we described a 38-year-old Thai man presenting with panophthalmitis of the right eye. Further investigation showed that he had concurrent TB lymphadenitis and central nervous system (CNS) tuberculoma, as well as HIV infection, with a CD4 cell count of 153 cells/mm³. Despite the initial response to antituberculous agents, the disease had subsequently progressed and enucleation was required. The pathological examination revealed acute suppurative granulomatous panophthalmitis with retinal detachment. Further staining demonstrated acid-fast bacilli in the tissue. Colonies of Mycobacterium tuberculosis were obtained from tissue culture. He was treated with antiretroviral agents for HIV infection and 12 months of antituberculous agents. Clinicians should be aware of the possibility of TB in the differential diagnosis of endophthalmitis and panophthalmitis, especially in regions where TB is endemic.

Ocular tuberculosis: current perspectives

The World Health Organization currently estimates that nearly two billion people, or one-third of the world’s population, are infected by tuberculosis, and that roughly 10% of the infected people are symptomatic. Tuberculosis affects the lungs in 80% of patients, while in the remaining 20% the disease may affect other organs, including the eye. Uveitis can be seen concurrently with tuberculosis, but a direct association is difficult to prove. Ocular tuberculosis is usually not associated with clinical evidence of pulmonary tuberculosis, as up to 60% of extrapulmonary tuberculosis patients may not have pulmonary disease. The diagnosis of tuberculous uveitis is often problematic and in nearly all reported cases, the diagnosis was only presumptive. Tuberculous uveitis is a great mimicker of various uveitis entities and it can be considered in the differential diagnosis of any type of intraocular inflammation. It is still unknown if ocular manifestations result from a direct mycobacterium infection or hypersensitivity reaction and this is reflected on the management of tuberculous uveitis. Prevalence of tuberculosis as an etiology of uveitis may reach up to 10% in endemic areas. Tuberculous uveitis is a vision-threatening disease that inevitably leads to blindness if not properly diagnosed and treated. The aim of this review is to illustrate the various clinical features and management of presumed tuberculous uveitis. The current review focuses on the diagnostic criteria, significance of tuberculin skin test, and use of systemic corticosteroids in the management of tuberculous uveitis as recommended in recent publications.

Primary tubercular chorioretinitis

The aim of this report is to emphasize that corticosteroids should not be prescribed when the etiological factors remain unidentified. A 34-year-old male visited our ophthalmology clinic suffering from blurred vision. Behçet's disease had been diagnosed 5 years prior, and the patient was taking an oral immunosuppressant and a systemic corticosteroid. Vitreous cell count and foci of chorioretinitis (apparently confined to the ocular fundus) were evident. A vitreous sample was subjected to polymerase chain reaction, which resulted in the identification of and Mycobacterium tuberculosis. Treatment with a combination of four anti-tuberculosis drugs was commenced. During the follow-up, the vitritis disappeared, and the foci of active chorioretinitis improved. Systemic and Sub-Tenon corticosteroid treatment should not be prescribed until vitreous and anterior chamber fluid samples have been evaluated in patients with uveitis. Some microbes are not detected on routine examination.

Ocular infections in sub-Saharan Africa in the context of high HIV prevalence

Healthy eyes and good vision are important determinants of populations' health across the globe. Sub-Saharan Africa is affected by simultaneous epidemics of ocular infections and human immunodeficiency virus (HIV). Ocular infection and its complications, along with cataract and ocular trauma, are common conditions in this region with great impact on daily life. In this review, we discuss the epidemiology, clinical manifestations and microbial aetiology of the most important infectious ocular conditions in sub-Saharan Africa: conjunctivitis, keratitis and uveitis. We focus specifically on the potential association of these infections with HIV infection, including immune recovery uveitis. Finally, challenges and opportunities for clinical management are discussed, and recommendations made to improve care in this neglected but very important clinical field.

A rare cause of blindness

BACKGROUND

Mycobacterium tuberculosis (TB) infection remains a serious problem in many underdeveloped countries. TB is largely perceived as a disease affecting the pulmonary system, yet despite declining cases of pulmonary TB in the United States (US), extrapulmonary infections are being reported at an increasing proportion of total TB cases. Moreover, due to the insidious nature of extrapulmonary TB (EPTB), it may not be readily recognized by emergency physicians, as it masquerades as more commonly encountered infectious or inflammatory processes.

OBJECTIVES

The incidence of ocular TB infection varies widely by geographic area, but has historically been low in the US. However, a resurgence of TB in developed European nations is cause for concern, as an increasing percentage of these infections have revealed ocular involvement.

CASE REPORT

We present a case report of blindness caused by Mycobacterium tuberculosis and highlight some of the challenges the emergency physician may encounter when diagnosing EPTB. The case includes the patient's treatment course and subsequent follow-up.

CONCLUSION

Loss of vision may be a presenting complaint for active tuberculosis infection.

Tuberculous uveitis

In recent years, ocular involvement due to TB has re-emerged. Tuberculous uveitis is a readily treatable disease and the consequences of delay in either ocular or systemic diagnosis can be very serious for the patient. It is important to have a high index of suspicion of the diagnosis in patients with unexplained chronic uveitis and this will be influenced by the socio-economic circumstances, family history, ethnic origin, and previous medical history of the patient. Treatment with antituberculous therapy combined with systemic corticosteroids resolves inflammation without recurrences after medical therapy.

Intraocular tuberculosis

Intraocular manifestations of tuberculosis (TB) are rare, but TB infection is common worldwide, especially in developing economies, and in immigrant populations and immunocompromised patients in developed nations. The current review focuses on the clinical characteristics and diagnostic modalities useful in the diagnosis of intraocular TB. Specifically, IFN-gamma Release Assays (IGRAs), antigen-detection assays, and polymerase chain reactions will be discussed. Clinical management of TB patients includes counseling and testing for HIV infection. The use of corticosteroids along with anti-tuberculous medications and special therapeutic considerations in immunocompromised patients are discussed.

Rare presentation of definitive ocular tuberculosis in an immunocompetent young patient

Ocular tuberculosis is not uncommon ocular presentation in our community nowadays. Rare presentations described mainly in the immunocompromised patients. The diagnosis of ocular TB is presumed in the vast majority of the cases of the intraocular TB. We are presenting a very rare presentation of definitive intraocular TB in a healthy 24-year-old male.

Experimental ocular tuberculosis in guinea pigs

OBJECTIVE

To develop an animal model of intraocular tuberculosis (TB) with features of pulmonary TB and extrapulmonary dissemination to the eye.

METHODS

Hartley strain guinea pigs were infected via an aerosol route with virulent Mycobacterium tuberculosis. One group of guinea pigs was infected with a relatively low bacterial inoculum and received no treatment. A second group of guinea pigs received high-dose infection and were treated with the first-line anti-TB drugs isoniazid, rifampin, and pyrazinamide. Development of ocular TB lesions was documented by histological analysis, acid-fast staining, and real-time polymerase chain reaction for M tuberculosis DNA.

RESULTS

Untreated guinea pigs developed pulmonary and extrapulmonary TB. Ocular TB, primarily involving the uvea, developed in 5 of 12 eyes (42%). Uveal granulomatous lesions showed the presence of acid-fast organisms and M tuberculosis DNA. In treated animals, none of the 8 eyes examined revealed the presence of acid-fast organisms; however, there was mild nongranulomatous uveitis in 4 eyes.

CONCLUSIONS

Mycobacterium tuberculosis delivered via aerosol to guinea pigs results in extrapulmonary dissemination to the eye. Of significance, intraocular changes in this model include granulomatous inflammation and the presence of acid-fast organisms, as seen in human cases of ocular TB. Clinical Relevance The guinea pig model may provide greater insight into the pathogenesis of intraocular TB and assist in the development of novel modalities to treat this global infectious disease.

A review of pediatric uveitis: Part I. Infectious causes and the masquerade syndromes

Uveitis is a manifestation of complex processes that can represent an infectious or a purely immune system modulated condition and may have grave effects on the eye. Much of the morbidity in these conditions is the result of the immune response to these stimuli. These infectious diseases may be successfully treated by addressing the inciting organism with recognized interventions. Treatment of the immune response to the organism often must be pursued simultaneously to minimize long-term complications caused by structural changes within the eye. Assisting the individual's immune response to eliminate the organism while minimizing the immune response's damaging effects remains a unique challenge drawing on both the science and the art of medicine. Several non-infectious conditions that are not autoimmune diseases may commonly masquerade as uveitis, leading to delays in appropriate treatment.

Clinical and optical coherence tomographic findings and outcome of treatment in patients with presumed tuberculous uveitis

PURPOSE

To define the clinical characteristics and optical coherence tomographic (OCT) features, and to assess the outcome of treatment, in patients with presumed tuberculous uveitis (PTU).

METHODS

All patients diagnosed with PTU at King Abdulaziz University Hospital between January 1998 and May 2006 were reviewed. The diagnosis was made when findings were consistent with possible intraocular tuberculosis with no other cause of uveitis suggested by history, symptoms, or ancillary testing, strongly positive tuberculin skin-test results, and response to antituberculous therapy.

RESULTS

Fifty-one patients (73 eyes) were identified. There were 34 males (66.7%) and 17 females (33.3%) with a mean age of 40.1+/-11.0 years (range 16-68 years). Fifty-eight eyes (79.5%) had panuveitis and 15 eyes (20.5%) had posterior uveitis at presentation. Clinical manifestations included vitritis (71.2%), macular edema (63%), retinal periphlebitis (35.6%), multifocal choroiditis (20.5%), and granulomatous anterior uveitis (17.9%). All patients received antituberculous therapy and systemic corticosteroids. After a mean follow-up of 18.9+/-21.9 months (range 6-96 months), all eyes showed resolution of inflammation, with no recurrences, associated with significant improvement in visual acuity (VA) (P=0.007). There was a significant positive correlation between initial and final VAs (r=0.7856, P<0.001). Thirty-one eyes with macular edema were examined at baseline and at follow-up with OCT. There were three patterns of macular edema: diffuse (DME) (28.5%), cystoid (29%), and serous retinal detachment (45.2%). Initial VA of 20/40 or better was significantly associated with central macular thickness (CMT) of 300 microm or less (P=0.0065) and DME (0.0484). At final follow-up, there was a significant reduction in CMT (P<0.001) associated with a significant improvement in VA (P=0.0091).

CONCLUSIONS

Antituberculous therapy combined with systemic corticosteroids leads to resolution of inflammation and elimination of recurrences of PTU. OCT is useful in monitoring the efficacy of treatment in patients with macular edema.

Anterior Segment and External Ocular Disorders Associated with Human Immunodeficiency Virus Disease

The eye is a common site for complications of human immunodeficiency virus (HIV) infection. Although cytomegalovirus retinitis remains the most prevalent of the blinding ocular disorders that can occur in individuals with the acquired immunodeficiency syndrome (AIDS), several important HIV-associated disorders may involve the anterior segment, ocular surface, and adnexae. Some of these entities, such as Kaposi sarcoma, were well described, but uncommon, before the HIV epidemic. Others, like microsporidial keratoconjunctivitis, have presentations that differ between affected individuals with HIV disease and those from the general population who are immunocompetent. The treatment of many of these diseases is challenging because of host immunodeficiency. Survival after the diagnosis of AIDS has increased among individuals with HIV disease because of more effective antiretroviral therapies and improved prophylaxis against, and treatment of, opportunistic infections. This longer survival may lead to an increased prevalence of anterior segment and external ocular disorders. In addition, the evaluation and management of disorders such as blepharitis and dry eye, which were previously overshadowed by more severe, blinding disorders, may demand increased attention, as the general health of this population improves. Not all individuals infected with HIV receive potent antiretroviral therapy, however, because of socioeconomic or other factors, and others will be intolerant of these drugs or experience drug failure. Ophthalmologists must, therefore, still be aware of the ocular findings that develop in the setting of severe immunosuppression. This article reviews the spectrum of HIV-associated anterior segment and external ocular disorders, with recommendations for their evaluation and management.

Ocular tuberculosis

We present an article on asymptomatic tuberculous choroiditis on screening. Discussions also include the manifestations, relevant investigations and management of ocular tuberculosis. Clinicians should be aware of these findings when treating such patients.