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Putera I, Schrijver B, Ten Berge JCEM, Gupta V, La Distia Nora R, Agrawal R, van Hagen PM, Rombach SM, Dik WA. The immune response in tubercular uveitis and its implications for treatment: From anti-tubercular treatment to host-directed therapies. Prog Retin Eye Res 2023:101189. [PMID: 37236420 DOI: 10.1016/j.preteyeres.2023.101189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 05/28/2023]
Abstract
Tubercular uveitis (TB-uveitis) remains a conundrum in the uveitis field, which is mainly related to the diverse clinical phenotypes of TB-uveitis. Moreover, it remains difficult to differentiate whether Mycobacterium tuberculosis (Mtb) is present in the ocular tissues, elicits a heightened immune response without Mtb invasion in ocular tissues, or even induces an anti-retinal autoimmune response. Gaps in the immuno-pathological knowledge of TB-uveitis likely delay timely diagnosis and appropriate management. In the last decade, the immunopathophysiology of TB-uveitis and its clinical management, including experts' consensus to treat or not to treat certain conditions with anti-tubercular treatment (ATT), have been extensively investigated. In the meantime, research on TB treatment, in general, is shifting more toward host-directed therapies (HDT). Given the complexities of the host-Mtb interaction, enhancement of the host immune response is expected to boost the effectiveness of ATT and help overcome the rising burden of drug-resistant Mtb strains in the population. This review will summarize the current knowledge on the immunopathophysiology of TB-uveitis and recent advances in treatment modalities and outcomes of TB-uveitis, capturing results gathered from high- and low-burden TB countries with ATT as the mainstay of treatment. Moreover, we outline the recent progress of HDT development in the pulmonary TB field and discuss the possibility of its applicability to TB-uveitis. The concept of HDT might help direct future development of efficacious therapy for TB-uveitis, although more in-depth research on the immunoregulation of this disease is still necessary.
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Affiliation(s)
- Ikhwanuliman Putera
- Department of Ophthalmology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands; Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
| | - Benjamin Schrijver
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Vishali Gupta
- Retina and Uvea Services, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rina La Distia Nora
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Ophthalmology and Visual Sciences Academic Clinical Program, Duke NUS University, Singapore; Singapore Eye Research Institute, Singapore; Moorfields Eye Hospital, London, United Kingdom
| | - P Martin van Hagen
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands; Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - S M Rombach
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Willem A Dik
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands
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Betzler BK, Putera I, Testi I, La Distia Nora R, Kempen J, Kon OM, Pavesio C, Gupta V, Agrawal R. Anti-tubercular therapy in the treatment of tubercular uveitis: A systematic review and meta-analysis. Surv Ophthalmol 2023; 68:241-256. [PMID: 36272559 DOI: 10.1016/j.survophthal.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/26/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
We quantitatively evaluated the efficacy of antitubercular therapy (ATT) in tubercular uveitis (TBU) patients. Main outcome measures include inflammation recurrence, inflammation reduction, complete resolution of inflammation, improved visual acuity (VA), ability to taper corticosteroids to < 10 mg/day without inflammatory progression, and use of adjunctive immunosuppressants while on ATT. This review is prospectively registered in PROSPERO (CRD42020206845). Forty-nine studies reporting data for 4,017 TBU patients were included. In comparative studies, the odds ratio (OR) of inflammatory recurrence was 0.33 (95%CI:0.19-0.60) for TBU patients treated with ATT±corticosteroid versus no ATT. For TBU patients treated with ATT±corticosteroid, the pooled absolute incidences of inflammatory recurrence, inflammatory reduction, complete resolution of inflammation, and visual acuity improvement were 13% (n=310/2,216; 95%CI:9-18), 81% (n=217/276; 95%CI: 62-95), 83% (n=1,167/1,812; 95%CI: 77-89), and 65% (n=347/542; 95%CI:51-78), respectively. Corticosteroids were tapered to <10 mg/day without inflammatory progression in 91% (n=326/395; 95%CI:78-99) of patients, 9% (n=121/1,376; 95%CI:6-13) of whom were administered concomitant immunosuppressive agents alongside ATT. We conclude that treatment of TBU with ATT±corticosteroid is associated with a high level of control or improvement of inflammation. More prospective studies with detailed reporting of ATT regimens, patient subgroups, and outcomes are required to better evaluate ATT effectiveness.
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Affiliation(s)
| | - Ikhwanuliman Putera
- Department of Ophthalmology, Faculty of Medicine Universitas Indonesia, Indonesia; Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Rina La Distia Nora
- Department of Ophthalmology, Faculty of Medicine Universitas Indonesia, Indonesia; Erasmus Medical Center, Rotterdam, The Netherlands
| | - John Kempen
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, MA, United States; Myungsung Christian Medical Center (MCM) Eye Unit, MCM General Hospital and Myungsung Medical School, Addis Ababa, Ethiopia; Department of Ophthalmology, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia
| | - Onn Min Kon
- Chest and Allergy Clinic, St Mary's Hospital, Imperial College Healthcare National Health Service Trust, London, England
| | | | - Vishali Gupta
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rupesh Agrawal
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Singapore Eye Research Institute, Singapore; Duke-NUS Medical School, Singapore.
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Betzler BK, Gunasekeran DV, Kempen J, Smith JR, McCluskey P, Nguyen QD, Pavesio C, Gupta V, Agrawal R. The Historical Evolution of Ocular Tuberculosis: Past, Present, and Future. Ocul Immunol Inflamm 2022; 30:593-599. [PMID: 34752203 DOI: 10.1080/09273948.2021.1992446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/06/2021] [Indexed: 10/19/2022]
Abstract
Ocular involvement is a rare manifestation of tuberculosis. Four key issues historically faced by clinicians when diagnosing and treating ocular tuberculosis - diagnostic uncertainty, naturally heterogeneous presentations, limitations of existing laboratory diagnostic tools, and non-uniform treatment guidelines - continue to test today's physicians. Unparalleled scientific and clinical developments over the past century have greatly expanded the knowledge surrounding this challenging ophthalmic condition. Experience with large volumes of cases at tuberculosis-endemic centres has led to recent growth in knowledge and physician experience, perhaps more so in developing countries. Looking forward, the role of diverse new technologies, including artificial intelligence and proteomics, will advance ocular tuberculosis research. Efforts have been made to address the lack of standardized nomenclature, diagnostic uncertainty, and unvalidated, geographically variable treatment guidelines.
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Affiliation(s)
- Bjorn Kaijun Betzler
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Singapore Eye Research Institute, Singapore, Singapore
| | - Dinesh Visva Gunasekeran
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
- Moorfields Eye Hospital and Biomedical Research Centre, Institute of Ophthalmology, University College London, London, UK
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - John Kempen
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, USA
- MyungSung Christian Medical Center (MCM) Eye Unit, MCM General Hospital and MyungSung Medical School, Addis Ababa, Ethiopia
| | - Justine R Smith
- Flinders University College of Medicine and Public Health, Adelaide, Australia
| | - Peter McCluskey
- Save Sight Institute, Sydney Eye Hospital, Sydney, Australia
| | - Quan Dong Nguyen
- Byers Eye Institute, Stanford Medical School, Stanford, California, USA
| | - Carlos Pavesio
- Moorfields Eye Hospital and Biomedical Research Centre, Institute of Ophthalmology, University College London, London, UK
| | - Vishali Gupta
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rupesh Agrawal
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Singapore Eye Research Institute, Singapore, Singapore
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
- Moorfields Eye Hospital and Biomedical Research Centre, Institute of Ophthalmology, University College London, London, UK
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Alene KA, Wangdi K, Colquhoun S, Chani K, Islam T, Rahevar K, Morishita F, Byrne A, Clark J, Viney K. Tuberculosis related disability: a systematic review and meta-analysis. BMC Med 2021; 19:203. [PMID: 34496845 PMCID: PMC8426113 DOI: 10.1186/s12916-021-02063-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 07/14/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The sustainable development goals aim to improve health for all by 2030. They incorporate ambitious goals regarding tuberculosis (TB), which may be a significant cause of disability, yet to be quantified. Therefore, we aimed to quantify the prevalence and types of TB-related disabilities. METHODS We performed a systematic review of TB-related disabilities. The pooled prevalence of disabilities was calculated using the inverse variance heterogeneity model. The maps of the proportions of common types of disabilities by country income level were created. RESULTS We included a total of 131 studies (217,475 patients) that were conducted in 49 countries. The most common type of disabilities were mental health disorders (23.1%), respiratory impairment (20.7%), musculoskeletal impairment (17.1%), hearing impairment (14.5%), visual impairment (9.8%), renal impairment (5.7%), and neurological impairment (1.6%). The prevalence of respiratory impairment (61.2%) and mental health disorders (42.0%) was highest in low-income countries while neurological impairment was highest in lower middle-income countries (25.6%). Drug-resistant TB was associated with respiratory (58.7%), neurological (37.2%), and hearing impairments (25.0%) and mental health disorders (26.0%), respectively. CONCLUSIONS TB-related disabilities were frequently reported. More uniform reporting tools for TB-related disability and further research to better quantify and mitigate it are urgently needed. PROSPERO REGISTRATION NUMBER CRD42019147488.
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Affiliation(s)
- Kefyalew Addis Alene
- Faculty of Health Sciences, Curtin University, Kent St, Bentley, Perth, 6102 Western Australia Australia
- Telethon Kids Institute, 15 Hospital Ave, Nedlands, Perth, Western Australia 6009 Australia
- Research School of Population Health, The Australian National University, 62 Mills Road, Acton, Canberra, ACT 2601 Australia
| | - Kinley Wangdi
- Research School of Population Health, The Australian National University, 62 Mills Road, Acton, Canberra, ACT 2601 Australia
| | - Samantha Colquhoun
- Research School of Population Health, The Australian National University, 62 Mills Road, Acton, Canberra, ACT 2601 Australia
| | - Kudakwashe Chani
- Research School of Population Health, The Australian National University, 62 Mills Road, Acton, Canberra, ACT 2601 Australia
| | - Tauhid Islam
- World Health Organization (WHO) Regional Office for the Western Pacific, The Philippines, Manila, Philippines
| | - Kalpeshsinh Rahevar
- World Health Organization (WHO) Regional Office for the Western Pacific, The Philippines, Manila, Philippines
| | - Fukushi Morishita
- World Health Organization (WHO) Regional Office for the Western Pacific, The Philippines, Manila, Philippines
| | - Anthony Byrne
- St Vincent’s Hospital, Sydney, 406 Victoria St, Darlinghurst, Sydney, 2010 New South Wales Australia
- The University of New South Wales, Randwick, Sydney, 2031 New South Wales Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University, 14 University Drive, Robina, 4266 Queensland Australia
| | - Kerri Viney
- Research School of Population Health, The Australian National University, 62 Mills Road, Acton, Canberra, ACT 2601 Australia
- Karolinska Institutet, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
- The University of Sydney, University Road, Camperdown, Sydney, 2066 New South Wales Australia
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Jiang T, Zhang X, Zhou M, Jiang R, Chang Q. Prognosis of Ocular Tuberculosis Following Long-Term Antitubercular Therapy. J Ocul Pharmacol Ther 2021; 37:241-247. [PMID: 33524301 DOI: 10.1089/jop.2020.0100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: This study presents clinical features and prognosis after long-term (12-18 months) antitubercular therapy (ATT) in patients with ocular tuberculosis (OTB) in East China, an endemic area of tuberculosis. Methods: This retrospective study reviewed data from OTB patients treated at the Eye and ENT Hospital of Fudan University from 2008 to 2018. All the patients completed a minimum follow-up of 6 months after the cessation of ATT. Results: Sixty-six patients with OTB were studied. The ocular manifestations included retinal vasculitis (51.6%), choroiditis (24.2%), panuveitis (23.2%), intermediate uveitis (7.4%), scleritis (5.3%), anterior uveitis (2.1%), and optic neuropathy (1%). Except for two patients (ATT for 6 months), all other patients (64/66, 96.97%) received ATT for at least 12 months (6 patients for 12 months, 30 patients for 15 months, and 28 patients for 18 months). Treatment in conjunction with oral corticosteroids was used in 48 patients (72.7%). The average initial best-corrected visual acuity (BCVA) was 0.8 ± 0.64 (LogMAR), which improved to 0.31 ± 0.35 (LogMAR) at the last follow-up (P < 0.05). The final BCVA was significantly associated with the initial BCVA and the duration of clinical symptoms. A complete remission of uveitis was achieved in 97% of the patients. Conclusions: This study observed a favorable prognosis with long-term ATT regimens. Patients with better baseline visual acuity and a shorter duration of clinical symptoms before diagnosis had a better prognosis.
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Affiliation(s)
- Tingting Jiang
- Department of Ophthalmology, Eye Institute, Eye and ENT Hospital, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China.,NHC Key Laboratory of Myopia (Fudan University), Key Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
| | - Xiaozhe Zhang
- Department of Ophthalmology, Eye Institute, Eye and ENT Hospital, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China.,NHC Key Laboratory of Myopia (Fudan University), Key Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
| | - Min Zhou
- Department of Ophthalmology, Eye Institute, Eye and ENT Hospital, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China.,NHC Key Laboratory of Myopia (Fudan University), Key Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
| | - Rui Jiang
- Department of Ophthalmology, Eye Institute, Eye and ENT Hospital, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China.,NHC Key Laboratory of Myopia (Fudan University), Key Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
| | - Qing Chang
- Department of Ophthalmology, Eye Institute, Eye and ENT Hospital, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China.,NHC Key Laboratory of Myopia (Fudan University), Key Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
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Betzler BK, Gupta V, Agrawal R. Clinics of ocular tuberculosis: A review. Clin Exp Ophthalmol 2021; 49:146-160. [DOI: 10.1111/ceo.13847] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/16/2020] [Accepted: 08/18/2020] [Indexed: 01/06/2023]
Affiliation(s)
- Bjorn Kaijun Betzler
- Yong Loo Lin School of Medicine National University of Singapore Singapore Singapore
| | - Vishali Gupta
- Advanced Eye Centre Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Rupesh Agrawal
- Yong Loo Lin School of Medicine National University of Singapore Singapore Singapore
- National Healthcare Group Eye Institute Tan Tock Seng Hospital Singapore Singapore
- Moorfields Eye Hospital, National Health Service Foundation Trust London UK
- Singapore Eye Research Institute Singapore Singapore
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Ma RQ, Gan L, Bi YW, Yuan YF, Ren H, Qian J. Clinical and laboratory features of PCR-confirmed periocular tuberculosis in China. Int J Ophthalmol 2018; 11:1865-1869. [PMID: 30450320 DOI: 10.18240/ijo.2018.11.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 09/04/2018] [Indexed: 11/23/2022] Open
Abstract
Experts lack knowledge of periocular tuberculosis (TB) in China. Nested polymerase chain reaction (PCR) shows advantages in diagnosis of extrapulmonary TB. Our study aims to explore the clinical and laboratory features of PCR-confirmed periocular TB. We retrospectively reviewed medical records of presumptive periocular TB and performed nested PCR test to confirm diagnosis. Nine cases were recruited. Clinical symptoms were chronic and insidious. Eight cases achieved favorable visual acuity, while one underwent enucleation due to fungal-TB panophthalmitis. Sensitivity of caseous necrosis, acid-fast bacilli (AFB) staining and interferon γ release assay (T-SPOT) test are 33.3%, 44.4% and 85.7% respectively. Low lymphocyte percentage (P=0.019) and high monocyte-lymphocyte ratio (P=0.042) positively correlate with AFB staining. Male gender (P=0.048) and Langhans giant cell (P=0.048) positively correlate with caseous necrosis. To conclude, traditional TB ancillary tests are not as sensitive as nested PCR technique. Several factors facilitate diagnosis including male gender, decreased lymphocytes, and typical Langhans giant cells.
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Affiliation(s)
- Rui-Qi Ma
- Department of Ophthalmology, Eye & ENT Hospital of Fudan University, Shanghai 200031, China.,NHC Key Laboratory of Myopia (Fudan University), Shanghai 200031, China.,Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai 200031, China
| | - Lu Gan
- Department of Ophthalmology, Eye & ENT Hospital of Fudan University, Shanghai 200031, China.,NHC Key Laboratory of Myopia (Fudan University), Shanghai 200031, China.,Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai 200031, China
| | - Ying-Wen Bi
- Department of Ophthalmology, Eye & ENT Hospital of Fudan University, Shanghai 200031, China
| | - Yi-Fei Yuan
- Department of Ophthalmology, Eye & ENT Hospital of Fudan University, Shanghai 200031, China
| | - Hui Ren
- Department of Ophthalmology, Eye & ENT Hospital of Fudan University, Shanghai 200031, China
| | - Jiang Qian
- Department of Ophthalmology, Eye & ENT Hospital of Fudan University, Shanghai 200031, China
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