Ocular tuberculosis

Epidemiology and Clinical Characteristics of Ocular Tuberculosis in the United States, 1993-2019

Background

Data regarding ocular tuberculosis (OTB) in the United States have not been previously reported. We evaluated trends of OTB compared with other extrapulmonary TB (EPTB).

Methods

We estimated the proportion of all EPTB cases (with or without concurrent pulmonary involvement) with OTB reported to the National Tuberculosis Surveillance System during 1993-2019. We compared demographics and clinical characteristics of people with OTB and other EPTB during 2010-2019. P values were calculated by chi-square test for categorical variables and Kruskal-Wallis for continuous variables.

Results

During 1993-2019, 1766 OTB cases were reported, representing 1.6% of 109 834 all EPTB cases: 200 (0.5% of 37 167) during 1993-1999, 395 (1.0% of 41 715) during 2000-2009, and 1171 (3.8% of 30 952) during 2010-2019. In contrast to persons with other EPTB, persons with OTB were older (median, 48 vs 44 years; P < .01), more likely to be US-born (35% vs 28%; P < .01), more likely to have diabetes (17% vs 13%; P < .01), and less likely to have HIV (1% vs 8%; P < .01). OTB was less likely to be laboratory confirmed (5% vs 75%; P < .01), but patients were more likely to be tested by interferon gamma release assay (IGRA; 84% vs 56%; P < .01) and to be IGRA positive (96% vs 80%; P < .01).

Conclusions

Reported OTB increased during 1993-2019 despite decreasing TB, including EPTB; the largest increase occurred during 2010-2019. OTB was rarely laboratory confirmed and was primarily diagnosed in conjunction with IGRA results. More research is needed to understand the epidemiology of OTB to inform clinical and diagnostic practices.

The Spectrum of Presumed Tubercular Uveitis in a Referral Eye Clinic in Qatar

PURPOSE

To analyze the clinical spectrum of patients with presumed tubercular uveitis in a referral eye clinic in Qatar.

METHODS

We retrospectively reviewed the clinical records of 50 patients (80 eyes) diagnosed with presumed ocular tuberculosis who presented to the uveitis clinic, department of Ophthalmology Hamad Medical Corporation, Qatar, from January 2014 till December 2019.

RESULTS

Mean age at presentation was 34.5 ± 9.3 years. Forty one patients were males (82%) and 30 patients had bilateral involvement (60%). Forty eyes (50%) had posterior uveitis, 21 eyes (26.3%) intermediate uveitis, 11 eyes (13.7%) panuveitis, and 8 eyes (10%) anterior uveitis. Ocular findings included vitritis in 82.5% of eyes, retinal vasculitis in 46.3% (92% of which were occlusive in nature), multifocal choroiditis in 18.8%, serpiginous-like choroiditis in 11.3%, Most common complications at presentation or during follow-up included macular edema in 32 eyes (40%), preretinal or optic disc neovascularization in 29 eyes (36.3%) and vitreous hemorrhage in 17 eyes (21.3%). Anti-tubercular treatment was provided to 46 patients (92%). Systemic corticosteroids and corticosteroid sparing agents were associated, respectively, in 39 patients (78%) and 14 patients (28%). After 1 year of follow up, inflammation was controlled, with a significant improvement in visual acuity (p < 0.0001).

CONCLUSIONS

In Qatar, tubercular uveitis has a broad spectrum of ocular features, with posterior and intermediate uveitis being the most common anatomic forms. Vitritis, multifocal choroiditis without or with a serpiginous-like pattern, and occlusive retinal vasculitis are the most common ocular findings. Main sight-threatening ocular complications are macular edema, posterior segment neovascularization, and vitreous hemorrhage.

Unilateral solitary choroidal tuberculoma as the presenting sign in disseminated tuberculosis in an immunocompetent patient

INTRODUCTION

Tuberculosis can involve any organ in the body including ocular tissue of which the uveal tissue is most commonly infected. Choroidal involvement ranges from choroidal tubercles to granulomas. This is one of the few cases of a solitary choroidal granuloma with no other systemic symptoms in an immunocompetent child.

METHOD

A case report.

RESULTS

A 12-year-old female, presented with diminution of vision in the left eye for a month. The anterior segment of her left eye was normal. A fundus examination revealed an isolated orangish-yellow choroidal mass, 4 DD in size, involving the posterior pole with overlying subretinal exudation. CT scan of the thorax showed large pulmonary, cervical and pancreatic lymph nodes, along with lytic lesions of the thoracic vertebrae. Excision biopsy of the cervical lymph nodes showed caseating granulomas with no e/o malignancies on histopathology. The patient was started on anti-tubercular therapy. Six months after the treatment, the lesion had reduced in size and her vision had improved.

CONCLUSION

Isolated choroidal tuberculomas can be present in eyes with little associated ocular inflammation and no other symptoms of systemic tuberculosis. High suspicion, early diagnosis and rapid initiation of medication are important for the treatment of ocular and systemic tuberculosis.

Laboratory Investigations in Infectious Uveitis

Laboratory investigations can play a significant role in the diagnosis and decision-making of infectious uveitis. Though direct demonstration of the infective organism remains the gold standard of diagnosis, it is not always possible with ocular tissues. Recent advancements in molecular techniques have made it possible to overcome these limitations and to identify the genomic DNA of pathogens associated with infectious uveitis. Techniques such as next-generation sequencing can analyze all DNA-based lifeforms, regardless of whether they are bacteria, fungi, viruses, or parasites and have been used in the laboratory diagnosis of intraocular inflammation. On the other hand, serological tests, though they dominate the diagnostic landscape of various infectious etiologies in uveitis in routine clinical practice, have varied specificities and sensitivities in different infectious uveitis. In this review, we focus on various methods of laboratory diagnosis of infectious uveitis and discuss the recent advances in molecular diagnosis and their role in various infectious clinical entities.

Ocular tuberculosis presenting with a conjunctival granuloma

An 18-year-old female patient was referred with complaints of tearing and redness in the left eye for 3 months after a mild ocular trauma with a turkey feather. She was treated with topical antibiotics and corticosteroids with no improvement. Slit-lamp examination of the left eye showed a vascularized lesion with a polypoidal appearance due to multiple contiguous micronodules on the temporal and inferior bulbar conjunctiva. Results of the anterior and posterior segment examination were unremarkable in both eyes. A biopsy specimen of the conjunctival mass showed multiple tuberculoid granulomas composed of epithelioid histiocytes with associated Langhan's type multinucleate giant cells and a necrotic nodule surrounded by histiocytes and giant cells. The Mantoux test was positive with induration of 15mm. The patient was prescribed antituberculosis therapy. Three months after treatment initiation, the conjunctival lesions had resolved. Mycobacterium tuberculosis should be considered in cases of unilateral chronic recalcitrant conjunctivitis. Biopsy of a conjunctival mass is of utmost importance to establish a definite diagnosis.

Surgically induced scleral necrosis associated with concomitant tuberculosis infection: a diagnostic challenge

Objective

Surgically induced scleral necrosis (SISN) is a potentially blinding sequela that may occur after any ocular procedure. SISN in the context of active tuberculosis is seldom seen. We report a case of a patient with asymptomatic tuberculosis who developed SISN after pterygium surgery.

Methods

A 76-year-old Mexican-mestizo woman from Veracruz, Mexico, was referred to our clinic because of severe disabling pain and scleral thinning in her right eye.

Results

Tubercular-related SISN was finally diagnosed and managed successfully with antitubercular therapy, topical and systemic corticosteroids.

Conclusion

Tuberculosis must be considered as a differential diagnosis of high-risk patients in the context of refractory SISN in endemic countries.

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.

Newer trends in tubercular uveitis: a case series with systemic correlation

AIM

To determine the spectrum of uveitis, causes of visual loss in systemic tuberculosis (TB), role of investigations and outcome after anti-TB therapy (ATT).

METHODS

A retrospective study was conducted on 250 patients with systemic TB at a referral center in Chennai, South India from April 2016 to May 2019. Systemic workup comprised of Mantoux, chest X-ray, polymerase chain reaction (PCR) and QuantiFERON (QFT) TB Gold. Aqueous humor analysis by nested PCR or real time PCR (RT-PCR) and ancillary ophthalmic investigations such as fundus fluorescein angiography, optical coherence tomography were performed.

RESULTS

Multifocal choroiditis and vasculitis were the most common manifestations (39% and 24% respectively) together accounting for 61% of cases and they had a higher risk of recurrence (3%). Pulmonary tuberculosis (PTB) was more frequently associated with uveitis (18%). Among those with extra-pulmonary tuberculosis (EPTB), uveitis occured in miliary TB (2%), bone (1%) and abdominal TB (1%). Complications such as cystoid macular edema, choroidal neovascular membranes and macular scarring caused visual loss. Aqueous humor analysis detected mycobacterium TB antigen. Collectively, systemic investigations such as chest X-ray, Mantoux test and those performed on blood samples such as PCR and QFT were positive in 39% of patients. In inconclusive patients, nested PCR and/or RT-PCR were done on aqueous humor samples and were diagnostic in 96%. A combination of tests was diagnostic in 92%. ATT in isolation in 71% and combined with corticosteroids in 29% was used for treatment of which signs of resolution and improvement in vision started as early as 6wk in those who were started immediately on corticosteroids and ATT and longer than 3mo in those on ATT alone. Prompt treatment with ATT and corticosteroids improved vision in 23% of our patients within 2mo. Vitritis with choroiditis causes cystoid macular oedema and requires longer duration of ATT. Vision improved in 69%. Complete resolution occurred in 75% and worsening in 12%.

CONCLUSION

A combination of investigations guided by clinical suspicion helps in precise diagnosis. In diagnostic dilemmas analysis of ocular samples is reliable and confirmatory. Screening all patients and a multidisciplinary approach in TB (active, healed or during treatment) is recommended.

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.

Clinical and Epidemiological Study on Tubercular Uveitis in a Tertiary Eye Care Centre in Italy

Purpose

To describe frequency, clinical characteristics, and visual prognosis of tubercular uveitis (TBU) in a nonendemic country.

Methods

We retrospectively reviewed 3743 charts of patients with endogenous uveitis visited from 2008 to 2018 at a tertiary referral centre in Rome, Italy. We included immunocompetent patients with diagnosis of TBU. Patients were divided in two groups: patients with history of uveitis without a previous diagnosis of TBU (group A) and patients at their first episode of TB uveitis (group B).

Results

TBU was diagnosed in 28 (0.75%) out of 3743 patients. Twelve (42.9%) patients came from tuberculosis endemic areas. All patients received specific antitubercular treatment (ATT) and were evaluated for a mean follow-up of 3.2 ± 2.9 years. Group A showed a greater number of ocular complications when compared with group B. ATT was effective in reducing the frequency of recurrences of uveitis in patients of group B.

Conclusion

Intraocular inflammation can be the first manifestation of tuberculosis. Our data highlight that early diagnosis and specific treatment of TBU may allow to decrease recurrences and to improve visual outcomes.

Presumed Intraocular Tuberculosis Manifesting as Unilateral Iris Granuloma

Ocular tuberculosis can manifest in a wide variety of clinical presentations. The prevalence is higher in endemic areas as a cause of granulomatous uveitis. While posterior segment manifestations are well known, anterior segment granulomas alone are relatively rare. We report two cases of unilateral iris granulomata in two young patients who presented with decreased vision and redness and were found to have well-circumscribed iris granulomas. Both underwent systemic evaluation and had a negative Mantoux test. Biopsy pathology of the lesions revealed granulomatous inflammation but were negative for PCR, staining, and culture for TB. One patient turned out to have multiple pulmonary lesions. The ocular condition initially worsened with steroid therapy alone and improved and resolved completely after starting a 9 months course of anti-tubercular therapy (ATT).

Collaborative Ocular Tuberculosis Study Consensus Guidelines on the Management of Tubercular Uveitis-Report 1: Guidelines for Initiating Antitubercular Therapy in Tubercular Choroiditis

TOPIC

An international, expert-led consensus initiative organized by the Collaborative Ocular Tuberculosis Study (COTS), along with the International Ocular Inflammation Society and the International Uveitis Study Group, systematically developed evidence- and experience-based recommendations for the treatment of tubercular choroiditis.

CLINICAL RELEVANCE

The diagnosis and management of tubercular uveitis (TBU) pose a significant challenge. Current guidelines and literature are insufficient to guide physicians regarding the initiation of antitubercular therapy (ATT) in patients with TBU.

METHODS

An international expert steering subcommittee of the COTS group identified clinical questions and conducted a systematic review of the published literature on the use of ATT for tubercular choroiditis. Using an interactive online questionnaire, guided by background knowledge from published literature, 81 global experts (including ophthalmologists, pulmonologists, and infectious disease physicians) generated preliminary consensus statements for initiating ATT in tubercular choroiditis, using Oxford levels of medical evidence. In total, 162 statements were identified regarding when to initiate ATT in patients with tubercular serpiginous-like choroiditis, tuberculoma, and tubercular focal or multifocal choroiditis. The COTS group members met in November 2018 to refine these statements by a 2-step modified Delphi process.

RESULTS

Seventy consensus statements addressed the initiation of ATT in the 3 subtypes of tubercular choroiditis, and in addition, 10 consensus statements were developed regarding the use of adjunctive therapy in tubercular choroiditis. Experts agreed on initiating ATT in tubercular choroiditis in the presence of positive results for any 1 of the positive immunologic tests along with radiologic features suggestive of tuberculosis. For tubercular serpiginous-like choroiditis and tuberculoma, positive results from even 1 positive immunologic test were considered sufficient to recommend ATT, even if there were no radiologic features suggestive of tuberculosis.

DISCUSSION

Consensus guidelines were developed to guide the initiation of ATT in patients with tubercular choroiditis, based on the published literature, expert opinion, and practical experience, to bridge the gap between clinical need and available medical evidence.

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.

Tuberculosis manifested as Parinaud’s oculoglandular syndrome

A 5-year-old male patient presented to the Sekuru Kaguvi Eye Hospital (SKH) with a painful discharging right eye (RE) for 1 year. Two months prior to presentation, he developed a non-productive cough, night sweats and loss of weight. On examination, a granulomatous follicular conjunctivitis and a corneal phlyctenule were noted in the RE, as well as ipsilateral preauricular lymphadenopathy. In collaboration with the paediatricians, a diagnosis of Parinaud’s oculoglandular syndrome (POGS) as a manifestation of tuberculosis was made. This is the first reported case of POGS and tuberculosis in Zimbabwe.

Clinical Features and Outcomes of Patients With Tubercular Uveitis Treated With Antitubercular Therapy in the Collaborative Ocular Tuberculosis Study (COTS)-1

Importance

Eradication of systemic tuberculosis (TB) has been limited by neglected populations and the HIV pandemic. Whereas ocular TB often presents as uveitis without any prior evidence of systemic TB, the existing uncertainty in the diagnosis of TB uveitis may perpetuate missed opportunities to address systemic TB.

Objective

To examine the clinical features of TB uveitis and the associations with response to antitubercular therapy (ATT).

Design, Setting, and Participants

This retrospective multinational cohort study included patients from 25 ophthalmology referral centers diagnosed with TB uveitis and treated with ATT from January 1, 2004, through December 31, 2014, with a minimum follow-up of 1 year.

Main Outcomes and Measures

Treatment failure, defined as a persistence or recurrence of inflammation within 6 months of completing ATT, inability to taper oral corticosteroids to less than 10 mg/d or topical corticosteroid drops to less than 2 drops daily, and/or recalcitrant inflammation necessitating corticosteroid-sparing immunosuppressive therapy.

Results

A total of 801 patients (1272 eyes) were studied (mean [SD] age, 40.5 [14.8] years; 413 [51.6%] male and 388 [48.4%] female; 577 [73.6%] Asian). Most patients had no known history (498 of 661 [75.3%]) of systemic TB. Most patients had bilateral involvement (471 of 801 [58.8%]). Common clinical signs reported include vitreous haze (523 of 1153 [45.4%]), retinal vasculitis (374 of 874 [42.8%]), and choroidal involvement (419 of 651 [64.4%]). Treatment failure developed in 102 of the 801 patients (12.7%). On univariate regression analysis, the hazard ratios (HRs) associated with intermediate uveitis (HR, 2.21; 95% CI, 1.07-4.55; P = .03), anterior uveitis (HR, 2.68; 95% CI, 1.32-2.35; P = .006), and panuveitis (HR, 3.28; 95% CI, 1.89-5.67; P < .001) were significantly higher compared with posterior distribution. The presence of vitreous haze had a statistically significant association (HR, 1.95; 95% CI, 1.26-3.02; P = .003) compared with absence of vitreous haze. Bilaterality had an associated HR of 1.50 (95% CI, 0.96-2.35) compared with unilaterality (HR, 1 [reference]), although this finding was not statistically significant (P = .07). On multivariate Cox proportional hazards regression analysis, the presence of vitreous haze had an adjusted HR of 2.98 (95% CI, 1.50-5.94; P = .002), presence of snow banking had an adjusted HR of 3.71 (95% CI, 1.18-11.62; P = .02), and presence of choroidal involvement had an adjusted HR of 2.88 (95% CI, 1.22-6.78; P = .02).

Conclusions and Relevance

A low treatment failure rate occurred in patients with TB uveitis treated with ATT. Phenotypes and test results are studied whereby patients with panuveitis having vitreous and choroidal involvement had a higher risk of treatment failure. These findings are limited by retrospective methods. A prospectively derived composite clinical risk score might address this diagnostic uncertainty through holistic and standardized assessment of the combinations of clinical features and investigation results that may warrant diagnosis of TB uveitis and treatment with ATT.

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

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.

Contribution of Dual Fluorescein and Indocyanine Green Angiography to the Appraisal of Presumed Tuberculous Chorioretinitis in a Non-endemic Area

PURPOSE

To assess the respective involvement of retina versus choroid in presumed ocular tuberculosis (POT) in a non-endemic area using dual fluorescein (FA) and indocyanine green angiography (ICGA).

METHODS

We retrospectively analyzed cases diagnosed with POT at the Centre for Ophthalmic Specialized Care, Lausanne, Switzerland. Angiography signs were quantified using an established dual FA and ICGA scoring system for uveitis.

RESULTS

Out of 1739 uveitis patients visited from 1995 to 2014, 53 (3%) were diagnosed with POT; of whom 28 patients (54 eyes) had sufficient data available to be included in this study. Of 54 affected eyes, 39 showed predominant choroidal involvement, 14 showed predominant retinal involvement and one had equal retinal and choroidal scores. Mean angiographic score was 6.97 ± 5.08 for the retina versus 13.48 ± 7.06 for the choroid (P < 0.0001). For patients with sufficient angiographic follow-up after combined anti-tuberculous and inflammation suppressive therapy, mean FA and ICGA scores decreased from 6.97 ± 5.08 to 3.63 ± 3.14 (P = 0.004), and 13.48 ± 7.06 to 7.47 ± 5.58 (P < 0.0001), respectively.

CONCLUSION

These results represent the first report of the respective contributions of retinal and choroidal involvement in POT. Choroidal involvement was more common, for which ICGA is the preferred examination. In cases of compatible uveitis with positive results of an interferon-gamma release assay, particularly in a region that is non-endemic for TB, dual FA and ICGA should be performed to help establish the diagnosis of ocular tuberculosis and improve follow-up.

Choroidal tuberculoma as a presenting sign of tuberculosis

Choroidal tuberculoma is a rare ocular form of tuberculosis (TB) that raises both a diagnostic and a therapeutical challenge, especially when occurring without other manifestations of the disease. This study reports the case of a 27-year-old woman who had a unilateral drop of vision (20/100) with ocular pain. Her fundus examination revealed an elevated juxtapapillary choroidal mass measuring 892 µm in diameter, as calculated by optical coherence tomography (OCT), and associated with a serous retinal detachment involving the macula. The diagnosis of choroidal tuberculoma was established by positive QuantiFERON-TB and tuberculin skin test. Laboratory and imaging workup ruled out pulmonary and systemic TB as well as other possible etiologies. Antituberculosis therapy was started and led to an improved visual acuity (20/30) and a shrinkage of the tuberculoma to a diameter of 499 µm at 3 months. This is one of the few reported cases of solitary choroidal tuberculoma in a patient with no other sign of TB. It sheds light on the place of OCT in the diagnosis and follow-up of the choroidal mass, in terms of measuring the size of the mass and revealing the associated serous retinal detachment and the distinctive “contact sign” between the neurosensory retina and the retinal pigment epithelium (RPE)–choriocapillaris layer surmounting the tuberculoma.

Clinical Patterns and Causes of Uveitis in a Referral Eye Clinic in Qatar

PURPOSE

To determine the patterns and causes of uveitis in a referral eye clinic in Qatar.

METHODS

A retrospective study was conducted on all cases of uveitis that presented to the Uveitis Clinic at Hamad Medical Corporation from March 2007 to February 2011. All patients had detailed ocular, medical examination, and uveitis work up.

RESULTS

The study included 310 patients. Anterior uveitis was noted in 53.2% of cases (165/310), followed by panuveitis 16.8% (52/310), intermediate uveitis 16.5% (51/310), and posterior uveitis 13.6% (42/310). Causes of uveitis were determined in 69.7% (216/310) of cases. The most commonly identified causes of uveitis in our study were presumed ocular tuberculosis (14.5%), Fuchs uveitis (11.0%), Behçet disease (7.4%), and VKH disease (6.8%).

CONCLUSIONS

Anterior uveitis is the most common anatomic/clinical form of uveitis in Qatar and the etiologic diagnosis of uveitis should focus in particular on presumed ocular tuberculosis, Fuchs uveitis, Behçet disease, and VKH disease.

Anti-tubercular therapy for intraocular tuberculosis: A systematic review and meta-analysis

Intraocular tuberculosis remains a diagnostic and management conundrum for both ophthalmologists and pulmonologists. We analyze the efficacy and safety of anti-tubercular therapy (ATT) in patients with intraocular tuberculosis and factors associated with favorable outcome. Twenty-eight studies are included in this review, with a total of 1,917 patients. Nonrecurrence of inflammation was observed in pooled estimate of 84% of ATT-treated patients (95% CI 79-89). There was minimal difference in the outcome between patients treated with ATT alone (85% successful outcome; 95% CI 25-100) and those with concomitant systemic corticosteroid (82%; 95% CI 73-90). The use of ATT may be of benefit to patients with suspected intraocular tuberculosis; however, this conclusion is limited by the lack of control group analysis and standardized recruitment and treatment protocols. We propose further prospective studies to better establish the efficacy of ATT and ascertain the factors associated with favorable treatment outcomes.

Evaluation of the Accuracy of T-SPOT.TB for the Diagnosis of Ocular Tuberculosis in a BCG-vaccinated, Non-endemic Population

PURPOSE

To determine the performance of T-SPOT.TB, an interferon gamma release assay test, in patients with ocular tuberculosis (TB) in a BCG-vaccinated, non-endemic population.

METHODS

We employed a nested case-control design. In total, 45 subjects were enrolled (23 patients with ocular tuberculosis and 22 patients with other causes of uveitis). A blood sample was collected from each subject, and T-SPOT.TB was executed. Laboratory professionals were blinded to the disease status of each subject.

RESULTS

Five patients were excluded because of indeterminate results. The calculated sensitivity and specificity were 0.80 and 0.85, respectively. The positive likelihood ratio was 5.33 and the negative likelihood ratio was 0.23. The overall accuracy of the test was 0.83.

CONCLUSIONS

T-SPOT.TB adequately diagnosed ocular TB. This technique is particularly useful in populations where BCG vaccinations are still mandatory.

Tuberculous Conjunctivitis in an Anophthalmic Socket

Tuberculous (TB) conjunctivitis was not an uncommon condition before the early 20(th) century but is currently a rare occurrence, especially in the developed countries. We report a 27-year-old Saudi female who underwent enucleation of the right eye at the age of 20 following a penetrating eye injury. She had a history of miliary TB that was treated at the age of 22. She was presented with chronic purulent discharge from her right an anophthalmic socket for 2 months. Cultures for bacteria and fungi were sterile. There was no response to empirical topical antibiotics and steroids. Direct microscopic examination of conjunctival scrapings with the Ziehl-Neelsen staining revealed no microorganisms. Histopathological examination revealed epithelioid granulomas. Polymerase chain reaction was negative for Mycobacterium tuberculosis DNA. TB conjunctivitis was suspected from the history of miliary TB and presence of epithelioid granulomas. The definitive diagnosis was made after prompt resolution of the ocular signs with no recurrence only after systemic anti-TB therapy.

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.

devR PCR for the diagnosis of intraocular tuberculosis

PURPOSE

To compare the efficacy of devR and MPB64 PCR in the diagnosis of intraocular tuberculosis.

METHODS

Prospective, nonrandomized study. Seventy-five patients were enrolled in 3 groups. Group A had 25 patients with presumed intraocular tubercular uveitis, group B had 25 controls with specific uveitis other than tubercular uveitis, and group C included 25 non-uveitic negative controls. The undiluted vitreous/aqueous samples were collected and subjected to PCR assay for devR and MPB64 gene sequence of Mycobacterium tuberculosis (MTB) to detect sensitivity and specificity.

RESULTS

devR PCR was positive in 16 (64%) out of 25 patients with presumed tubercular uveitis. MPB64 PCR was positive in 18 (72%) out of 25 patients with presumed tubercular uveitis. The sensitivity and specificity of devR were 64 and 100%, respectively. The sensitivity and specificity of MPB64 PCR were 72 and 100%, respectively.

CONCLUSION

devR PCR is not a better tool than MPB64 PCR for diagnosing intraocular tuberculosis.

Case report: atypical presentation of Mycobacterium tuberculosis uveitis preceding nodular scleritis

Background

Intraocular tuberculosis is uncommon and has various clinical presentations. Lack of specific clinical clues can make the diagnosis challenging. The purpose of this study is to report a clinical presentation of tuberculous iridocyclitis that mimics phacolytic glaucoma and has a distinctive inflammatory deposit in the inner side of the cornea. This report is the first to describe the progression of tuberculous iridocyclitis to nodular scleritis without evidence for extraocular tuberculous infection.

Case presentation

A 78-year-old, immunocompetent woman presented with subacute intraocular inflammation with high intraocular pressure, mimicking phacolytic glaucoma. Distinct pigment keratic precipitates were noted on the first visit. Even though the cataract extraction was uneventful and adequate anti-inflammatory drugs were given, the inflammation did not subside as expected. Seven weeks later, she developed two scleral abscesses, which were subsequently explored for microbiological investigation. The smears of the pus revealed positive acid-fast bacilli stain and PCR for Mycobacterium tuberculosis complex. Eventually, the pus culture grew Mycobacterium tuberculosis. Anti-tuberculosis medications were prescribed. After 1 month of treatment, the abscesses were cured. However, her visual acuity did not improve at the last visit.

Conclusions

This case revealed an unusual presentation and untreated course of tuberculosis iridocyclitis. Pattern of keratic precipitates may indicate the presence of tuberculosis.

Isolated Optic Disc Tuberculosis

We present a healthy male subject who developed progressive visual loss in the left eye initially diagnosed as optic neuritis. Upon suspicion of infectious etiology, testing was positive for tuberculosis. There were no signs or symptoms of active systemic tuberculosis infection. The patient responded swiftly to antimycobacterial therapy with return of vision and resolution of disc swelling. Positive purified protein derivative skin test, negative chest radiograph, negative systemic workup, negative workup for other causes of unilateral optic neuritis and quick response to mycobacterial therapy reaffirm the entity of isolated optic disc tuberculosis similar to isolated choroidal tuberculosis without systemic manifestation.

The usefulness of interferon-gamma release assay for diagnosis of tuberculosis-related uveitis in Korea

Purpose

To evaluate the usefulness of the interferon-gamma release assay (IGRA) for diagnosing tuberculosis (TB)-related uveitis (TRU).

Methods

Records from 181 patients with ocular signs and symptoms suggestive of TRU and intraocular inflammation of unknown etiology were reviewed. All subjects underwent clinical and laboratory testing, including IGRA, to rule out presence of underlying disease. A diagnosis of presumed TRU was made based on an internist's TB diagnosis and a patient's response to anti-TB therapy. Sensitivity, specificity, and positive predictive values of IGRA for TRU diagnosis were calculated. Clinical characteristics were compared between patients with positive and negative IGRA results.

Results

The sensitivity and specificity of IGRA for TRU were 100% and 72.0%, respectively. Mean age, percentage of patients with retinal vasculitis, and the anatomic type of uveitis were significantly different between patients with positive and negative IGRA results (all p ≤ 0.001). Positive IGRA rates and false-positive rates were significantly different between age and anatomic type groups (both p = 0.001). The positive predictive value of the IGRA among patients with intraocular inflammation was high (70%) when all of younger age (≤40 years), posterior uveitis, and retinal vasculitis were present.

Conclusions

The IGRA is useful for diagnosing TRU in the Korean population, especially when it is used as a screening test. Clinical characteristics, including younger age (≤40 years), posterior uveitis, and retinal vasculitis in IGRA-positive patients, increase the likelihood of the patient having TRU.

Trends in patterns of intermediate uveitis in a tertiary institution in Singapore

Purpose

The study aims to describe the characteristics and etiologic causes of intermediate uveitis (IU) patients seen by a tertiary eye center in Singapore over 8 years.

Methods

This was a retrospective analysis of the clinical records of consecutive new cases of IU that presented to the uveitis subspecialty clinic from 2004–2011 at Tan Tock Seng Hospital. Data collected included demographics, clinical and laboratory findings. Diagnoses were based on standardized clinical history, ophthalmological examination and investigations.

Results

There were 66 new cases of IU, comprising 5.7% of 1168 new uveitis patients. The median age of diagnosis was 40 years (mean 39.4±15.9), with largest subgroup of the patients in the age group of 41–60 years (36.4%). The majority was Chinese (57.6%), followed by Asian Indians (18.2%) and Malays (16.7%). The ethnicity distribution was dissimilar to our ethnic distribution in Singapore (p<0.001) with an increased incidence of IU in the Asian Indian population. Most were idiopathic (59.1%) in etiology, followed by tuberculosis (TB) (15.2%). Ocular complications developed in 21 patients (31.8%), with cystoid macular edema (CME) being the commonest (28.8%). Severe vitritis occurred in 9.1% of patients, and was significantly associated with TB-associated IU (p<0.001). There was a downward trend for the incidence of the proportion of IU patients over the total uveitis patients (p = 0.021), with Spearman’s rho of −0.786.

Conclusions

Despite the downward trend, TB-associated IU was still of higher prevalence compared to less endemic areas, emphasizing the need for increased TB surveillance. A high index of suspicion for TB-associated IU is required in patients with severe vitritis. Comparisons with other countries revealed disparities in the IU etiologies, indicating possible geographical differences. Prevalence of known immune-mediated etiologies of IU is less compared to the western population. Our study also suggests a probable predisposition of the Singapore local Indian population for IU.

More than a masquerade syndrome: atypical presentations of vitreoretinal lymphomas

PURPOSE

To present a population of patients sharing atypical manifestations of vitreoretinal lymphoma (VRL).

METHODS

Institutional case series in a single tertiary center. Patients with cytologically proven VRL, referred between November 2009 and May 2010, were retrospectively reviewed. Diagnosis of VRL was based on cytology of vitreous samples, immunohistochemistry, and molecular biology. Patients with confirmed VRL and clinical features different from the typical manifestations were included. Demographical and clinical characteristics of these patients were studied.

RESULTS

Twelve cases of VRL were diagnosed. Four cases (2M/2F) were considered atypical (A-VRL) in their presentations. Mean age for typical lymphoma (T-VRL) was 71.9 years (range: 62-87 years); mean age for A-VRL was 54 years (range: 50-59 years).

CONCLUSIONS

Diagnosis of VRL is challenging and diagnostic delay is frequent. The authors describe a series of patients sharing common characteristics, such as a younger age (p = 0.05), severe anterior chamber reaction, mild or no vitritis, and possible fulminant evolution.

[Treatment of presumed tuberculous uveitis affecting the posterior segment: diagnostic confirmation and long term outcomes]

OBJECTIVE

To determine the level of agreement with the presumed diagnosis and long term clinical outcomes after antituberculous therapy (ATT) in a group of patients with presumed tuberculous uveitis (PTU) affecting the posterior segment.

METHODS

Retrospective case series.

RESULTS

A total of 17 patients with chronic refractory or newly diagnosed uveitis affecting the posterior segment were included. All included patients were diagnosed with PTU and received ATT. Median follow-up after ATT was 34 months (range 2-60). Complete control of inflammation was observed in 14/17 patients (82.3%) during the treatment period, and only 4/17 patients (23.5%) had a uveitis relapse over the entire follow-up period after ATT. All patients who had uveitis relapses (4/4), but none from the remaining group (0/13), required immunosuppressive therapy of some kind after ATT. The response to ATT was able to confirm diagnosis of PTU in 14/17 (82.3%) included patients.

CONCLUSION

When a clinical suspicion of PTU affecting the posterior segment exists, ATT may be highly effective for both confirming the diagnosis and resolving the inflammatory process. Thus, ATT may offer additional advantages, such as preventing latent-tuberculosis reactivations due to immunosuppressive therapy, and decreasing the number and/or severity of uveitis relapses in some patients. Prospective, randomized studies including a larger number of patients are required to support these and other potential advantages of ATT in such patients.

Serpiginous choroiditis and infectious multifocal serpiginoid choroiditis

Serpiginous choroiditis (SC) is a posterior uveitis displaying a geographic pattern of choroiditis, extending from the juxtapapillary choroid and intermittently spreading centrifugally. The choroiditis involves the overlying retinal pigment epithelium, and the outer retina. This intraocular inflammation typically involves both eyes in otherwise healthy, middle-aged individuals with no familial or ethnic predilection. Pathogenesis is unclear; based on limited histopathologic studies, however, favorable response to immunosuppressive agents, and the absence of association with systemic or local infectious or noninfectious diseases, an organ-specific autoimmune inflammation seems likely to be the underlying process. Patients, particularly from tuberculosis-endemic regions, may present with fundus changes simulating SC, but show evidence of active tuberculosis and/or the presence of mycobacterial DNA in the aqueous humor. This has been referred to as serpiginous-like choroiditis, but we prefer the description multifocal serpiginoid choroiditis (MSC). We present the distinguishing features of SC and infectious multifocal serpiginoid choroiditis simulating SC. The distinction is crucial to avoid unnecessarily treating SC with antimicrobial agents. Advances in diagnostic and imaging modalities can help differentiate SC from MSC. Novel local and systemic treatment approaches improve the outcome and preserve vision in SC.

Clinical presentation, treatment, and outcomes in presumed intraocular tuberculosis: experience from Newcastle upon Tyne, UK

PURPOSE

To report the clinical manifestations and treatment outcomes of patients with presumed intraocular tuberculosis (TB) seen at the Newcastle Uveitis Service, Royal Victoria Infirmary, Newcastle upon Tyne, UK over a 10-year period.

METHODS

Retrospective review of case notes.

RESULTS

A total of 21 patients were identified. Occlusive retinal vasculitis was the commonest ophthalmological presentation (12 patients). Eight patients (38%) were found to have underlying active systemic TB (four with mediastinal lymphadenopathy, three with pulmonary TB, one with cutaneous TB). Constitutional or respiratory symptoms, elevated inflammatory markers, and an abnormal chest radiograph were poor indicators of active TB. Two patients had inactive intrathoracic TB. Eleven patients had latent TB. Eighteen patients received anti-tuberculous treatment. Final visual acuity was better than or equal to initial visual acuity in 14 out of 16 patients who completed at least 6 months of standard anti-tuberculous treatment.

CONCLUSIONS

Most patients with presumed intraocular TB have latent TB, but a significant minority has hitherto undetected active TB. Our series suggests that either proven or presumed intraocular TB occurs frequently in the absence of constitutional or respiratory symptoms, elevated inflammatory markers, or an abnormal chest radiograph. A minimum of 6 months standard anti-tuberculous treatment provides good visual outcomes in the majority of patients.