Diagnosis of ocular tuberculosis: a role for new testing modalities?

Recurrent Tubercular Episcleritis

Ocular tuberculosis (TB) is one of the extrapulmonary manifestations of mycobacterium TB. Episcleritis is a rare entity that may affect patients in endemic areas of TB. In this paper, we report a case of presumed recurrent episcleritis attributed to TB. TB should be kept as a possible cause of recurrent simple episcleritis upon encountering patients with endemic backgrounds to prevent the complication sequalae and halt recurrence.

Incidence of ocular inflammation among patients with active tuberculosis or nontuberculous mycobacterial infections in a tertiary hospital in Japan

PURPOSE

This study aimed to elucidate the incidence of ocular involvement among patients with active tuberculosis (TB) or nontuberculous mycobacterial (NTM) infection in a hospital in Japan.

METHODS

Patients with active TB or NTM infection at Yoshijima Hospital from April 2017 to July 2018 were included in this retrospective study. All patients underwent ophthalmic examinations, including fundus evaluation under pupil dilation, before initiation of antibiotic therapy. Patients with ocular inflammation were regularly followed up by ophthalmologists.

RESULTS

In total, 101 patients with active TB and 27 patients with active NTM infection underwent ophthalmic examinations during the study period. Seven patients with TB (6.9%) had ocular inflammation; four had bilateral involvement. In these seven patients, ocular inflammation comprised anterior uveitis (n = 2), intermediate uveitis (n = 1), posterior uveitis (n = 4). Choroidal tubercles were observed in two patients with posterior uveitis. Female sex was associated with higher incidence of ocular inflammation among patients with TB. Conversely, no patients with NTM infection had ocular inflammation.

CONCLUSION

Ocular inflammation was present in approximately 7% of patients with active TB. Although TB choroiditis is presumed to be rare in Japan, approximately 30% of the patients with ocular inflammation exhibited choroidal lesions in this study. In contrast, no ocular inflammation was observed among patients with systemic NTM infection.

Bleb-related tuberculous endophthalmitis following combined phacoemulsification and trabeculectomy with mitomycin C

A one-eyed 67-year-old man with 20/400 vision, dense cataract, previously failed trabeculectomy and medically uncontrolled advanced glaucoma underwent a single-site phacoemulsification with repeat trabeculectomy and mitomycin C. One-week postoperatively, vision in the right eye improved to 20/120, good bleb and intraocular pressure (IOP) of 14 mm Hg. By third postoperative week, patient presented to the emergency with diminished vision, pain and redness in right eye of 2 days duration and was diagnosed to have bleb-related endophthalmitis (BRE). Vitreous biopsy, smear from the bleb were taken and underwent pars plana vitrectomy with intraocular antibiotic injection. Smears and cultures were negative however, aqueous DNA-PCR was positive for Mycobacterium tuberculosis Revisited history revealed treated pulmonary tuberculosis 3 years ago with a positive Mantoux test (17 mm) and hilar prominence on chest X-ray. One month after starting anti-tubercular therapy (ATT), the BRE resolved and vision improved to 20/60 with IOP of 14 mm Hg and the ATT was continued.

Solid lipid nanoparticles for ocular delivery of isoniazid: evaluation, proof of concept and in vivo safety & kinetics

AIM

Evaluation of solid lipid nanoparticles (SLNs) for ocular delivery of isoniazid (INH).

MATERIALS & METHODS

INH-SLNs were characterized for morphological, thermal, crystalline and nuclear magnetic resonance properties. In vitro release and ex vivo corneal permeability of INH-SLNs was also evaluated. Proof-of-concept uptake studies were performed in corneal and conjunctival cell lines and in vivo in rat eye using fluorescein-labeled SLNs. Antimycobacterial activity of INH-SLNs was confirmed. In vivo aqueous humor pharmacokinetics, toxicity and tolerance was performed in rabbit/rat eye.

RESULTS

INH-SLNs showed extended release (48 h), enhanced corneal permeability (1.6-times), five-times lower MIC, significant in vitro and in vivo uptake of fluorescein-labeled SLNs, 4.2-times ocular bioavailability (area under the curve) and in vivo acute and repeat dose safety.

CONCLUSION

INH-SLNs are an effective ocular delivery system.

Primary Conjunctival Tuberculosis Presenting as Dry Eye: A Rare Case Report and Review of the Literature

Primary conjunctival tuberculosis is very rare in the developed countries. In an endemic country like India, it should be considered in the differential diagnosis of any unusual conjunctival lesion with unilaterality, chronicity, and nonresolution of symptoms after steroid use. We present the case of a 52-year-old female who presented with unilateral itching and blurring of vision for 20 days. There were irregular nodular elevated areas with shrinkage of the lower palpebral conjunctiva. A biopsy of the lesion revealed necrotizing epithelioid cell granulomas along with Langhans type of giant cells. However, no acid-fast bacilli were seen on Ziehl-Neelsen stain. Systemic examination of the patient was normal, and there was no evidence of pulmonary tuberculosis. Polymerase chain reaction of conjunctival scrapings was positive for Mycobacterium tuberculosis. The patient was started on antitubercular drugs. We present this very rare case of primary tuberculosis of the conjunctiva presenting with dryness of the eye.

A retrospective cohort study of patients treated with anti-tuberculous therapy for presumed ocular tuberculosis

BACKGROUND

Uveitis involving the posterior segment is a significant and potentially blinding condition. The diagnosis and treatment of patients with uveitis associated with tuberculosis remains controversial, and commonly, patients are systemically well. Use of the interferon-gamma release assays has added to the controversy, as the significance of a positive test may be uncertain. We aim to report the outcomes of anti-tuberculous treatment in a cohort of patients treated in Birmingham, for presumed "ocular tuberculosis", based on clinical findings, systemic assessment and specific testing for tuberculosis.

RESULTS

We found that in our cohort of 41 patients treated between 2010 and 2014, the majority achieved disease-free remission, even in cases where anti-tuberculous treatment was delayed.

CONCLUSIONS

Despite controversy, this study strongly supports the use of anti-tuberculous therapy in such patients and highlights the need for formal prospective trials and treatment protocols.

Ocular tuberculosis in Hospital Universiti Sains Malaysia - A case series

INTRODUCTION

Ocular tuberculosis (TB) encompasses a broad spectrum of clinical manifestations affecting different structures of the eye. It is caused by Mycobacterium tuberculosis, a great ancient organism that induces various types of diseases and unfavorable outcomes if unrecognized and not well treated.

PURPOSE

To report the clinical profile of 34 ocular TB cases observed during 6 years period in Hospital Universiti Sains Malaysia (HUSM).

METHOD

A retrospective review of medical records from 34 patients diagnosed with ocular TB in HUSM from January 2011 until December 2016.

RESULTS

The mean age was 43 ± 14.6 years old. Both male and female affected in about 1:1 ratio. The majority of subjects were local Malays (91.2%). Risk factors included previous contact with pulmonary TB patients (38.2%), and patients with underlying diabetes mellitus (26.5%). Most patients showed normal chest radiography (79.4%). However they had positive Mantoux test (94.1%) and raised erythrocyte sedimentation rate (ESR) value (58.8%). Uveitis was the most common ocular manifestation of ocular TB (70.6%) while the rare ocular manifestations included optic perineuritis and optic neuritis, orbital apex syndrome, orbital cellulitis, sclerokeratitis, corneal ulcer and conjunctival abscess. All patients responded well to anti-TB treatment, but visual outcome was variable.

CONCLUSIONS

This review shows the diverse entity of ocular TB spectrum in an endemic area. Good clinical response to anti-tuberculous therapy supported the presumed diagnosis of ocular TB in majority of the cases.

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

Inflammatory choroidal neovascular membrane after healed tuberculous choroidal granuloma

Objective: To present a case of choroidal granuloma masquerading as intraocular tumor that healed on anti-tuberculous treatment but led to the development of inflammatory choroidal neovascular membrane (CNVM). Method: A 42-year-old female patient with past history of hysterectomy presented with diminution of vision in the right eye. Fundus examination in the right eye showed a yellowish white choroidal mass with associated bullous retinal detachment superotemporal to fovea. Left eye fundus was normal. Fundus flourescein angiography showed early and late hyperflourescence with late pooling in serous detachments. Complete systemic evaluation did not yield a clue to diagnosis. Positron emission tomography scan (PET scan) showed enlarged lymph nodes in cervical, mediastinal and peritoneal regions. Lymph node biopsy showed caseating granulomas. Results: The granuloma subsided and a scar formed 5 months after starting anti-tuberculous treatment with improvement in vision. Six months later, the vision deteriorated again with the development of a choroidal neovascular membrane (CNVM) at the margin of the scar. The CNVM resolved and all the signs of activity subsided after giving intravitreal antivascular endothelial growth factor (anti-VEGF) injections. Conclusions: Making a diagnosis of tuberculous granuloma in a case of choroidal mass lesion is a challenge. PET scan helps in identifying metabolically active lymph nodes appropriate for biopsy. Healed scars of tuberculous choroid lesions should be followed closely to detect the development of CNVM.

Latent tuberculosis-related scleritis: a case report

BACKGROUND

Scleritis is a painful inflammatory process centered in the sclera that may involve the cornea and the underlying uvea. The etiology is commonly idiopathic or autoimmune but some cases are associated with systemic infection such as tuberculosis.

CASE PRESENTATION

In this report, we describe an unusual case of a female Moroccan patient who had a long history of bilateral recurrent scleritis associated with peripheral keratopathy and anterior uveitis. The patient was diagnosed with latent tuberculosis and responded to antitubercular therapy administrated after exclusion of other aetiologies. This patient was finally diagnosed with latent tuberculosis- related scleritis.

CONCLUSIONS

Although systemic tuberculosis is reported as a possible cause of scleritis and other ocular inflammatory manifestations, assessment of the diagnosis of tuberculosis-related ocular inflammation is challenging especially in latent forms. The treatment is largely presumptive. However, a favorable response to antitubercular therapy without relapse is taken as evidence of the disease.

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.

Role of the Infectious Disease Consultant in Management of Patients With Tuberculosis-Associated Ocular Inflammation

Tuberculosis-associated ocular inflammation is a difficult disease to diagnose and treat. In the US, being foreign born was the significant risk factor. 74% of treated cases had stable or improved vision. Infectious disease and ophthalmology should provide multidisciplinary care.

Background. Tuberculosis is a disease with continued worldwide prevalence, morbidity, and mortality. Tuberculosis-associated ocular inflammation (TB-AOI) is a manifestation that can occur with pulmonary or extrapulmonary TB. Evaluation of these ocular presentations and treatment in the United States are limited. Our objective was to describe cases in an urban area and assess the role of the infectious diseases specialist in managing these complex patients.

Methods. We performed a retrospective case series of all patients referred to our infectious disease clinic for presumed TB-AOI from 2005 through 2013. Patients with ocular inflammation were determined to have presumed TB-AOI based on clinical presentation with correlative positive tuberculin skin test and/or QuantiFERON-TB Gold. Attempts were made to exclude other diagnoses. Data were collected and analyzed with respect to demographics, ocular manifestations, and treatment.

Results. Sixty eyes of 42 patients were included in the study; anterior uveitis was the most common site of involvement. The median age was 46 years, and 33 patients (79%) were foreign born. Forty patients (95%) received a course of antituberculous therapy with 38% experiencing treatment-related side effects. A 6-month duration was recommended in 78% cases. There was improvement or stability of the vision in 42 eyes (74%) of those treated.

Conclusions. Ocular involvement is an uncommon but important manifestation of TB. Our data further characterize TB-AOI cases in the United States. Treatment provides significant benefit to properly selected patients. A multidisciplinary approach, with care provided by ophthalmology and infectious disease providers, should be used to allow for the most efficacious treatment.

Tuberculous Orbital Apex Syndrome with Severe Irreversible Visual Loss

A 16-year-old girl presented with a unilateral red eye, progressive visual loss and diplopia. A detailed clinical assessment with appropriate investigations led to a diagnosis of Orbital Apex Syndrome (OAS) secondary to Tuberculosis (TB). We report this unusual case of TB OAS, which resulted in a poor visual outcome despite appropriate management.

The use of the QuantiFERON-tuberculosis gold test in the diagnosis of ocular tuberculosis

Ocular tuberculosis without systemic manifestations may rarely occur. The diagnosis of ocular tuberculosis is important because it has a wide spectrum of presentations and requires a multidisciplinary approach. The QuantiFERON-tuberculosis gold test is a new diagnostic test that may be useful in making a suitable diagnosis.

Comparison of patients with ocular tuberculosis in the 1990s and the 2000s

PURPOSE

To compare clinical findings in patients with ocular tuberculosis experienced during two different decades.

METHODS

Thirty-four patients with ocular tuberculosis were divided into two groups: a 1990s group (n = 18) and a 2000s group (n = 16), according to the dates of their first outpatient visit. The clinical profiles of the two groups were then compared.

RESULTS

More cases of the 1990s group had complications involving extraocular tuberculosis than those of the 2000s group. While various ophthalmic manifestations were observed clinically in the 1990s group, all retinal periphlebitis cases presented in the 2000s group. The proportion of patients who received antituberculous treatment was higher in the 1990s group, but the proportion who received oral corticosteroid therapy did not differ between the two periods. However, more patients underwent laser photocoagulation in the 2000s group. The percentage of eyes with final visual acuity better than 20/20 increased in the 2000s group.

CONCLUSIONS

The clinical outcome of patients with ocular tuberculosis was improved in the 2000s group, which may be attributable to the increase in active use of laser photocoagulation therapy.