Tuberculous uveitis

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.

Reggio Emilia (Northern Italy) Interdisciplinary Uveitis Clinic: What We Have Learned in the Last 20 Years

PURPOSE

To analyze the referral patterns and the clinical and therapeutic features of patients diagnosed with uveitis in an Italian tertiary referral center to provide a comparison with previously published series from the same center.

METHODS

Retrospective retrieval of data on all new referrals to the Ocular Immunology Unit in Reggio Emilia (Italy) between November 2015 and April 2022 and comparison with previously published series from the same center.

RESULTS

Among the 1557 patients, the male-to-female ratio was 1:1.27. Anterior uveitis was the most common diagnosis (53.7%), followed by posterior (21.6%), pan- (18.5%), and intermediate (6.2%) uveitis. The most identifiable specific diagnoses were anterior herpetic uveitis (18.4%), Fuchs uveitis (12.8%), and tuberculosis (6.1%). Infectious etiologies were the most frequent (34.1%) and were more diffuse among non-Caucasian patients (p < 0.001), followed by systemic disease-associated uveitis (26.5%), and ocular-specific conditions (20%). Idiopathic uveitis accounted for 19.4% of cases. Fuchs uveitis presented the longest median diagnostic delay (21 months). Immunosuppressants were administered to 25.2% of patients. Antimetabolites, calcineurin inhibitors, and biologicals were prescribed to 18.4%, 3%, and 11.4% of cases, respectively. Compared to our previous reports, we observed a significant increase in foreign-born patients and in infectious uveitis, a decrease in idiopathic conditions, and an increasing use of non-biological and biological steroid-sparing drugs.

CONCLUSIONS

The patterns of uveitis in Italy have been changing over the last 20 years, very likely due to migration flows. Diagnostic improvements and a more widespread interdisciplinary approach could reduce the incidence of idiopathic uveitis as well as diagnostic delay.

Gender differences in retinal diseases: A review

Gender medicine is a medical specialty that addresses gender differences in health and disease. Traditionally, medical research and clinical practice have often been focused on male subjects and patients. As a result, gender differences in medicine have been overlooked. Gender medicine considers the biological, psychological, and social differences between the genders and how these differences affect the development, diagnosis, treatment, and prevention of disease. For ophthalmological diseases epidemiological differences are known. However, there are not yet any gender-based ophthalmic treatment approaches for women and men. This review provides an overview of gender differences in retinal diseases. It is intended to make ophthalmologists, especially retinologists, more sensitive to the topic of gender medicine. The goal is to enhance comprehension of these aspects by highlighting fundamental gender differences. Integrating gender medicine into ophthalmological practice helps promote personalized and gender-responsive health care and makes medical research more accurate and relevant to the entire population.

Primary Tubercular Chorioretinitis Without a Pulmonary Focus: A Case Report

Ocular tuberculosis (TB) can affect various eye structures and may manifest independently of systemic TB. Typically, it arises from hematogenous dissemination from a primary focus; however, in exceptional instances, it may originate as a primary infection after epithelial injury. Diagnosing TB in an extrapulmonary site presents a significant clinical challenge. We present the case of a 33-year-old Bangladeshi female who presented with a deteriorating loss of vision in her left eye. A thorough neurologic examination and serological tests, the tuberculin skin test, a CT scan of the chest, ocular fundus photography, and optical coherence tomography were performed. Based on the clinical features and the outcome of appropriate tests, a presumptive diagnosis of ocular TB was made and later confirmed after initiating antitubercular therapy, which resulted in a marked improvement in the patient's vision a week later. This case is an illustration of the rare nature and unusual presentation of extrapulmonary TB in the form of tubercular chorioretinitis, diagnosed in a resource-limited setting. Tubercular chorioretinitis, characterized by inflammation of the choroid and retina due to TB infection, presents a diagnostic challenge, especially in resource-limited environments where access to advanced diagnostic tools may be restricted. Therefore, this case highlights the importance of considering TB as a potential cause of ocular manifestations, even in settings where TB prevalence might not be high, and underscores the need for increased awareness and diagnostic capacity for extrapulmonary TB in resource-limited areas. This case exemplifies the infrequent occurrence and atypical manifestation, presenting a learning opportunity for future clinicians.

Adolesan Bir Hastada Granülomatöz Üveit ile Seyreden Oküler Tüberküloz: Nadir Bir Olgu Sunumu

Tüberküloz tüm dünyada önemli bir halk sağlığı sorunu olarak devam etmektedir. Tüberküloz en sık akciğerleri tutar. Ancak çocuklarda erişkinlere göre ekstrapulmoner tutulum daha yaygındır. Ekstrapulmoner tutulum içinde göz tutulumu oldukça nadirdir. Oküler tüberküloz uveal traktın tamamının inflamasyonuna yol açabilir. Oluşturduğu granülomatöz üveit hastalığa özgü olmadığı için tüberküloz temas öyküsü ya da diğer sistemik belirtiler yoksa, ya da sorgulanmazsa pratikte gözden kaçabilmektedir. Bu yazıda granülomatöz üveit nedeni araştırılır iken pulmoner ve oküler tüberküloz tanısı konularak dörtlü anti tüberküloz ve metilprednizolon tedavisi ile hastalığı kontrol altına alınan adelösan bir olguyu sunacağız. Sonuç olarak, oküler tüberküloz önemli bir oküler morbidite nedenidir. Tanı ve takibi multidisipliner bir yaklaşım gerektirir.

Interferon-gamma release assays in tuberculous uveitis: a comprehensive review

Tuberculous uveitis (TBU) comprises a broad clinical spectrum of ocular manifestations, making its diagnosis challenging. Ophthalmologists usually require evidence from investigations to confirm or support a clinical diagnosis of TBU. Since direct isolation of the causative organism from ocular specimens has limitations owing to the small volume of the ocular specimens, resultant test positivities are low in yield. Immunodiagnostic tests, including the tuberculin skin test and interferon-gamma release assays (IGRAs), can help support a clinical diagnosis of TBU. Unlike the tuberculin skin test, IGRAs are in vitro tests that require a single visit and are not affected by prior Bacillus Calmette-Guerin vaccination. Currently, available IGRAs consist of different techniques and interpretation methods. Moreover, newer generations have been developed to improve the sensitivity and ability to detect active tuberculosis. This narrative review collates salient practice points as a reference for general ophthalmologists, such as evidence for the utilization of IGRAs in patients with suspected TBU, and summarizes basic knowledge and details of clinical applications of these tests in a clinical setting.

Insights into the molecular pathogenesis of ocular tuberculosis

Unclear pathogenic mechanisms underlying the ocular tuberculosis (OTB) has resulted in perplexity related to the diagnosis and management of the disease. Developments in experimental research and innovations in molecular diagnostics have recently provided a new understanding of disease pathogenesis and natural history. The current review focuses on the new insights into OTB pathogenesis, derived from in vivo and in vitro studies on Mycobacterium tuberculosis dissemination and localization into the eye, in combination with histopathological studies on chorioretinal tissue and vascular network. Advances in the knowledge of OTB have influenced disease management in the clinical setting and lead to reconsideration of the role of existing treatments and suggesting potential new therapeutic approaches.

Ocular tuberculosis: Where are we today?

Diagnosis and management of ocular tuberculosis (OTB) poses a significant challenge. Mixed ocular tissue involvement and lack of agreement on best practice diagnostic tests together with the global variations in therapeutic management contributed to the existing uncertainties regarding the outcome of the disease. The current review aims to update recent progress on OTB. In particular, the Collaborative Ocular Tuberculosis Study (COTS) group recently standardized a nomenclature system for defining clinical phenotypes, and also proposed consensus guidelines and an algorithmic approach for management of different clinical phenotypes of OTB. Recent developments in experimental research and innovations in molecular diagnostics and imaging technology have provided a new understanding in the pathogenesis and natural history of the disease.

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.

The Collaborative Ocular Tuberculosis Study (COTS)-1: A Multinational Descriptive Review of Tubercular Uveitis in Paediatric Population

PURPOSE

To examine disease profile of tubercular uveitis (TBU) in Paediatric population.

METHODS

Among 945 patients of the retrospective multinational study by the Collaborative Ocular Tuberculosis Study (COTS)-1, 29 Paediatric patients diagnosed with TBU were analyzed.

RESULTS

Mean age of disease presentation was 12.8 (range 4-18 years), with predominance of males (n = 14/20; 70.0%) and Asian ethnicity (n = 25/29; 86.2%). Posterior uveitis (n = 14/28; 50%) was the most frequent uveitis phenotype, with choroidal involvement occurring in 64.7% (n = 11/17). Incidence of optic disc edema and macular edema was higher in children (n = 8/18; 44.4% and n = 5/18; 27.8%, respectively) than in adults (n = 160/942; 16.9% and n = 135/942; 14.3%, respectively). Comparison of optic disc edema between subgroups showed a significant difference (P =.006). All patients received oral corticosteroids, most of them with antitubercular therapy. Treatment failure developed in 4.8% (n = 1/21).

CONCLUSIONS

Children have a more severe inflammatory response to the disease, and an intensive anti-inflammatory therapeutic regimen is required to achieve a positive treatment outcome.

The Collaborative Ocular Tuberculosis Study (COTS)-1: A Multinational Review of 165 Patients with Tubercular Anterior Uveitis

PURPOSE

The Collaborative Ocular Tuberculosis Study (COTS) Group sought to address the diagnostic uncertainty through retrospective cohort analysis of treatment regimens and therapeutic outcomes for patients with tubercular Anterior Uveitis (TAU) across international centers.

METHODS

Multicentre retrospective analysis of patients diagnosed with TAU between January 2004 to December 2014 that had a minimum follow-up of 1 year.

RESULTS

One hundred and sixty-five patients were included. One hundred and seven subjects received antitubercular therapy (ATT) (n = 107/165; 64.9%) with all the patients receiving topical steroid therapy. Treatment failure was noted in 17 patients (n = 17/165; 10.3%), more frequently described in patients that received ATT (n = 13/107, 12.2%), than those that did not receive ATT (n = 4/58, 6.9%).

CONCLUSION

In this retrospective study, addition of ATT did not have any statistically significant impact on outcome in patients with TAU.

MULTIMODAL IMAGING OF CHOROIDAL LESIONS IN DISSEMINATED MYCOBACTERIUM CHIMAERA INFECTION AFTER CARDIOTHORACIC SURGERY

PURPOSE

To explore morphologic characteristics of choroidal lesions in patients with disseminated Mycobacterium chimaera infection subsequent to open-heart surgery.

METHODS

Nine patients (18 eyes) with systemic M. chimaera infection were reviewed. Activity of choroidal lesions were evaluated using biomicroscopy, fundus autofluorescence, enhanced depth imaging optical coherence tomography, fluorescein angiography/indocyanine green angiography, and optical coherence tomography angiography. Relationships of choroidal findings to systemic disease activity were sought.

RESULTS

All 9 male patients, aged between 49 and 66 years, were diagnosed with endocarditis and/or aortic graft infection. Mean follow-up was 17.6 months. Four patients had only inactive lesions (mild disease). In all five patients (10 eyes) with progressive ocular disease, indocyanine green angiography was superior to other tests for revealing new lesions and active lesions correlated with hyporeflective choroidal areas on enhanced depth imaging optical coherence tomography. One eye with a large choroidal granuloma developed choroidal neovascularization. Optical coherence tomography angiography showed areas with reduced perfusion at the inner choroid. All 5 patients with progressive ocular disease had evidence of systemic disease activity within ±6 weeks' duration.

CONCLUSION

Choroidal manifestation of disseminated M. chimaera infection indicates systemic disease activity. Multimodal imaging is suitable to recognize progressive ocular disease. We propose ophthalmologic screening examinations for patients with M. chimaera infection.

The Eye as a Window to Systemic Infectious Diseases: Old Enemies, New Imaging

BACKGROUND

Syphilis, tuberculosis and toxoplasmosis are major infectious diseases worldwide; all of them are multisystem pathologies and share a possible ocular involvement. In this context, a fundamental help for the definitive diagnosis is provided by the ophthalmologist, through clinical evaluation and with the aid of a multimodal imaging examination.

METHODS

We hereby describe selected cases who came to our attention and were visited in our eye clinic. In all clinics, the use of retinal and optic disc multimodal imaging during ophthalmological evaluation allowed to make a diagnosis of an infectious disease.

RESULTS

In our tertiary referral center more than 60 patients with syphilis, tuberculosis and toxoplasmosis have been evaluated in the last two years: In 60% of cases the ophthalmological evaluation was secondary to a previous diagnosis of an infectious disease, while in the remaining cases the ophthalmologist, with the help of a multimodal imaging examination and clinical evaluation, represented the physician who leads to the diagnosis.

CONCLUSION

Our results confirm how in these life-threatening pathologies a prompt diagnosis is mandatory and may benefit from a multidisciplinary and multimodal imaging approach, especially during ophthalmological evaluation.

Clinical Profile and Treatment Response of Patients with Ocular Inflammation due to Presumed Ocular Tuberculosis: A Retrospective Study

Objectives:

Ocular tuberculosis is an extrapulmonary tuberculous infection and has varying manifestations which pose a huge challenge to diagnosis and treatment. The purpose of this study is to describe the various clinical manifestations of ocular inflammations due to tuberculosis and to assess the response to treatment following antituberculous therapy (ATT) and corticosteroids in these patients.

Materials and Methods:

We performed a retrospective analysis of 29 patients with presumed ocular tuberculosis who were started on ATT and completed follow-up of at least 6 months after ATT was initiated. The data collected were: age at presentation, sex, laterality, presence or absence of pulmonary/extrapulmonary tuberculosis, history of exposure to tuberculosis, site of ocular involvement and duration of illness, visual acuity at presentation and at 6-month follow-up, and response to treatment.

Results:

Most of the patients were of economically productive age, between 21-60 years. This most common presentation in our study population was unilateral nongranulomatous anterior uveitis. In spite of the delay between symptom onset and start of therapy, favorable response was noted in 79.3% of patients at completion of 6 months of ATT. The various reasons for the delay in start of therapy were also evaluated.

Conclusion:

In this case series, we presented the various ocular manifestations and the difficulties faced in the diagnosis of presumed ocular tuberculosis. Outcomes of ATT were favorable in most of our patients. Thus, the clinician should exercise a very high degree of suspicion and should not withhold a trial of ATT.

Current Practices in Ocular Tuberculosis: A Survey of Brazilian Specialists

Purpose: To describe the approach of Brazilian specialists in the diagnosis and treatment of tuberculosis-associated uveitis (TBU).Methods: Members of the Brazilian Uveitis Society received an electronic invitation to participate in an online questionnaire.Results: Of the 169 invited specialists, 78 answered the questionnaire. Specialists evaluated 5.6 patients with TBU annually. Tuberculin skin test (TST, 81%) was primarily used for diagnosis. Patients with presumed TBU should always be tested for syphilis and HIV according to 51 (88%) and 47 (81%) of respondents, respectively. Chest computed tomography (CT, 72%) was preferable to chest radiography (CXR) for diagnosis. A positive TST (81%) and CXR (60%) were the main indicators of anti-tuberculous therapy, with 34%, 39%, and 14% of specialists treating for 6, 9, and 12 months, respectively.Conclusions: TST remains the preferred method for TBU diagnosis and prompt treatment by Brazilian specialists, though there is no consensus regarding disease treatment and management.

Clinical Features and Prognostic Factors in Presumed Ocular Tuberculosis

PURPOSE

To characterize the clinical features in patients with presumed ocular tuberculosis (TB) and determine prognostic factors of visual outcomes and complications in this disease.

MATERIAL AND METHODS

Retrospective case series of 35 patients (29 females, 6 males) with presumed ocular TB from referral centers in Chile and Spain between 2002 and 2012. Medical records were reviewed, and data regarding clinical features, complications, best-corrected visual acuity (BCVA), duration of disease, extraocular manifestations, and therapy were retrieved. Prognostic factors for low vision (BCVA 20/50 or less), legal blindness (BCVA 20/200 or less), and complications (cataract, glaucoma, and macular lesion) were evaluated. To calculate correlations, we used Spearman's rank correlation test. To determine clinical predictors, we used the binary logistic regression test.

RESULTS

Anterior and non-granulomatous uveitis was the most common types of inflammation. Only 2 (5.7%) patients had respiratory symptoms, and 6 (17.1%) patients had an abnormal chest X-ray at diagnosis. All patients received combined antitubercular therapy with a mean duration of 6.9 ± 2.3 months. A longer duration of symptoms at diagnosis was associated with both low vision and legal blindness. Older patients had a higher risk of legal blindness. A longer duration of symptoms as well as anterior inflammation demonstrated an increased risk for cataract formation. The duration of the symptoms and baseline BCVA had a positive correlation with the final BCVA. Prognostic factors of macular lesions were not found.

CONCLUSIONS

The diagnosis of ocular TB can be difficult due to the lack of extraocular manifestations and the broad spectrum of ocular features. A longer duration of symptoms at diagnosis was associated with poorer visual outcomes and cataracts. Therefore, efforts should be made to avoid a delay in the diagnosis of ocular TB and to identify prognostic factors for visual outcomes and complications.

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.

Diagnosis of Ocular Tuberculosis

Ocular tuberculosis remains a presumptive clinical diagnosis, as the gold standard tests for diagnosing ocular tuberculosis are often not useful: Mycobacterium tuberculosis cultures require weeks to process on Lowenstein-Jenson media and have low yield from ocular samples; while acid-fast bacilli smears or polymerase chain reaction detection of M. tuberculosis DNA have low sensitivities. Thus, diagnosis is often based on suggestive clinical signs, which are supported by positive investigations: tuberculin skin test or interferon-gamma release assays; chest X-ray findings suggestive of pulmonary tuberculosis, and/or evidence of associated systemic tuberculosis infections in the absence of other underlying disease. The aim of this review is to provide an update on the methods of diagnosing ocular tuberculosis, and discuss the challenges of its diagnosis. We also suggest a step-ladder approach to a more accurate diagnosis of ocular tuberculosis by combining the available diagnostic tests.

Uveitis is predominantly of infectious origin in a high HIV and TB prevalence setting in rural South Africa

AIMS

To determine the burden of disease in a unique sample of patients with uveitis from a rural South African setting.

METHODS

Data in this cross-sectional study were collected from patients presenting with uveitis (n=103) at the ophthalmology outpatient department of three hospitals in rural South Africa. Demographic and clinical data were collected, and laboratory analysis of aqueous humour, serological evaluation and routine diagnostics for tuberculosis (TB) were performed.

RESULTS

Sixty-six (64%) participants were HIV infected. Uveitis was predominantly of infectious origin (72%) followed by idiopathic (16%) and autoimmune (12%). Infectious uveitis was attributed to herpes virus (51%), Mycobacterium tuberculosis (24%) and Treponema pallidum (7%) infection. HIV-infected individuals were more likely to have infectious aetiology of uveitis compared with HIV-uninfected individuals (83% vs 51%; p=0.001).

CONCLUSIONS

Microbial aetiology of uveitis is common in areas where HIV and TB are endemic. In these settings, a high index of suspicion for infectious origin of uveitis is warranted.

Treatment of severe non-infectious uveitis in high-risk conditions (Part 2): systemic infections; management and safety issues

INTRODUCTION

Management of patients with severe immune-mediated uveitis requires the use of immunosuppressive (IS) drugs in selected cases. This may be particularly challenging in certain patients with associated conditions, which may increase the risk of side effects or modify guidelines for the use of such drugs. Chronic viral and mycobacterial infections in the setting of non-infectious uveitis create a number of diagnostic but also therapeutic dilemmas to clinicians because they can be exacerbated by IS therapies with detrimental effects.

AREAS COVERED

In this review, we will focus on very specific chronic infections that can be affected by IS therapies: human immunodeficiency virus infection, chronic hepatitis virus infection and tuberculosis. The main aim of this review is to provide an updated and comprehensive practical guide for practitioners regarding the therapeutic decision-making and management of patients with non-infectious uveitis affected by the aforementioned infectious conditions.

EXPERT OPINION

Clinicians should be aware of the risk of viral and mycobacterial reactivation of an underlying infection during IS therapy. However, most of these conditions do not represent an absolute contraindication if one were able to apply an appropriate prior screening and close monitoring of such therapy.

Bilateral choroidal tuberculoma in miliary tuberculosis - report of a case

BACKGROUND

A choroidal mass or granuloma is a feature of ocular tuberculosis (TB). Tubercles can arise in the early stages of progression of TB and indicate hematogenous dissemination before the development of symptomatic disease. Tubercular subretinal granuloma is responsive to treatment with anti-tuberculosis therapy, and prompt treatment helps resolve the lesion completely.

FINDINGS

We report a case of a solitary large active choroidal tuberculoma in one eye and multiple healed tubercles in the other. The patient was an immunocompetent girl with splenic and miliary TB and had a relatively asymptomatic systemic status. Aqueous humor analysis by polymerase chain reaction (PCR) and real-time PCR (RT-PCR) was negative for the Mycobacterium tuberculosis genome. Based on clinical history and investigations, treatment with four-drug regimen of anti-tubercular treatment with concomitant corticosteroids was started, and total healing of the lesion occurred in 3 months.

CONCLUSIONS

This case highlights the fact that in some patients, analysis of the aqueous may not provide any clue to the confirmation of an active tubercular choroidal granuloma and an association between splenic tuberculosis and choroidal tubercles has never been reported in the past.

The role of sex in uveitis and ocular inflammation

Uveitides can be due to non-infectious and infectious etiologies. It has been observed that there is a gender difference with a greater preponderance of non-infectious uveitis in women than in men. This review will describe both non-infectious and infectious uveitides and describes some of the current autoimmune mechanisms thought to be underlying the gender difference. It will specifically look at non-infectious uveitides with systemic involvement including juvenile idiopathic arthritis, spondyloarthopathies, sarcoidosis, Behçet’s disease, and Vogt-Koyanagi-Harada disease and at uveitides without systemic involvement including sympathetic ophthalmia, birdshot chorioretinitis, and the white dot syndromes. Infectious uveitides like acute retinal necrosis, progressive outer retinal necrosis, and cytomegalovirus mediated uveitis will be mentioned. Different uveitides with female- or male- predominance are presented and discussed.

Tuberculous uveitis in China

PURPOSE

To assess tuberculous uveitis in Chinese patients.

METHODS

The hospital-based observational case series study included patients who attended a third-referral hospital and presented with chronic and recurrent uveitis without primarily detected aetiology. The patients underwent the tuberculin skin test (TST) and/or interferon gamma release test (IGRA). Patients with positive test results received standard antituberculous therapy. Patients who responded to the therapy and did not show recurrence of uveitis in the follow-up period were diagnosed as tuberculous uveitis and formed the study group. The remaining patients were diagnosed as non-tuberculous uveitis and formed the control group. The clinical characteristics were compared between both groups.

RESULTS

The study group with tuberculous uveitis included 46 patients and the non-tuberculous group 38 patients. Multifocal choroiditis [n = 9 (20%) versus n = 1(3%); p = 0.04] and retinal vasculitis [n = 25(54%) versus 8 = (21.1%); p = 0.002] were significantly more common in the study group. Of 25 patients with retinal vasculitis in the study group, 11 patients (44%) additionally showed choroiditis lesions, compared with only one (13%) of eight patients in the control group (p = 0.01). In multivariate regression analysis, multifocal choroiditis [odds ratio (OR): 32.1], choroidal granuloma (OR: 21.4) and retinal vasculitis (OR: 11.2) were independent predictors of tubercular uveitis.

CONCLUSIONS

About 50% of a group of 84 patients with primarily unexplained chronic posterior uveitis had tuberculosis and showed multifocal choroiditis, choroidal granuloma and retinal vasculitis. These features had a high predictive value for the diagnosis of tuberculous uveitis. Tuberculosis is an important part in the differential diagnosis of unexplained uveitis.

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.

Sex and reproduction in the transmission of infectious uveitis

Current data permit only speculations regarding sex differences in the prevalence of infectious uveitis between women and men because uveitis case surveys do not uniformly report gender data. Differences in prevalence that are reported in the literature could relate to simple differences in the number of women and men at risk for infection or to biological differences between men and women. Compared to other types of uveitis, infectious uveitis may be directly related to occupational exposures or sexual behaviors, which differ between women and men, and may mask actual biological differences in susceptibility to ocular manifestations of the infection and its prognosis. In infectious uveitis for which there is no element of sexual transmission and data is available, prevalence of ocular disease is roughly equal between women and men. Women also have a unique relationship with infectious uveitis in their role as mothers. Vertical transmission of infections such as herpes simplex, toxoplasmosis, and cytomegalovirus can produce severe chorioretinitis in neonates.

[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.

Three-dimensional spectral domain optical coherence tomography imaging of the retina in choroidal tuberculoma

INTRODUCTION

To study retinal imaging in choroidal tuberculoma by three-dimensional spectral domain optical coherence tomography (SD-OCT) for the first time.

METHODS

QuantiFERON-TB GOLD test, colour Doppler imaging, fluorescein angiography and SD-OCT were performed in an 18-year-old immunocompetent female patient.

RESULTS

Three-dimensional imaging over the choroidal lesion revealed marked retinal elevation. Subfoveal neurosensory detachment along with serous retinal detachment resulted from effusion of fluid from the underlying choroidal lesion. Granularity of the outer photoreceptor layer and proliferating retinal pigment epithelium cells indicated chronicity of the underlying choroidal lesion abutting the retina. Antitubercular therapy, after 2 weeks, resulted in a resolution of the subfoveal neurosensory detachment, reduction in the serous retinal detachment and a decrease in retinal elevation.

CONCLUSIONS

Three-dimensional SD-OCT allows a spatial visualisation and documentation of retinal elevation. It also allows a detailed visualisation of the secondary retinal pigment epithelial and intraretinal changes and is helpful in monitoring the response to medication.

Clinical spectrum of tuberculous optic neuropathy

PURPOSE

Tuberculous optic neuropathy may follow infection with Mycobacterium tuberculosis or administration of the bacille Calmette-Guerin. However, this condition is not well described in the ophthalmic literature.

METHODS

Ophthalmologists, identified through professional electronic networks or previous publications, collected standardized clinical data relating to 62 eyes of 49 patients who they had managed with tuberculous optic neuropathy.

RESULTS

Tuberculous optic neuropathy was most commonly manifested as papillitis (51.6 %), neuroretinitis (14.5 %), and optic nerve tubercle (11.3 %). Uveitis was an additional ocular morbidity in 88.7 % of eyes. In 36.7 % of patients, extraocular tuberculosis was present. The majority of patients (69.4 %) had resided in and/or traveled to an endemic area. Although initial visual acuity was 20/50 or worse in 62.9 % of 62 eyes, 76.7 % of 60 eyes followed for a median of 12 months achieved visual acuities of 20/40 or better. Visual field defects were reported for 46.8 % of eyes, but these defects recovered in 63.2 % of 19 eyes with follow-up.

CONCLUSION

Visual recovery from tuberculous optic neuropathy is common, if the diagnosis is recognized and appropriate treatment is instituted. A tuberculous etiology should be considered when evaluating optic neuropathy in persons from endemic areas.

Interplay between innate and adaptive immunity in the development of non-infectious uveitis

In vertebrates, the innate and adaptive immune systems have evolved seamlessly to protect the host by rapidly responding to danger signals, eliminating pathogens and creating immunological memory as well as immunological tolerance to self. The innate immune system harnesses receptors that recognize conserved pathogen patterns and alongside the more specific recognition systems and memory of adaptive immunity, their interplay is evidenced by respective roles during generation and regulation of immune responses. The hallmark of adaptive immunity which requires engagement of innate immunity is an ability to discriminate between self and non-self (and eventually between pathogen and symbiont) as well as peripheral control mechanisms maintaining immunological health and appropriate responses. Loss of control mechanisms and/or regulation of either the adaptive or the innate immune system lead to autoimmunity and autoinflammation respectively. Although autoimmune pathways have been largely studied to date in the context of development of non-infectious intraocular inflammation, the recruitment and activation of innate immunity is required for full expression of the varied phenotypes of non-infectious uveitis. Since autoimmunity and autoinflammation implicate different molecular pathways, even though some convergence occurs, increasing our understanding of their respective roles in the development of uveitis will highlight treatment targets and influence our understanding of immune mechanisms operative in other retinal diseases. Herein, we extrapolate from the basic mechanisms of activation and control of innate and adaptive immunity to how autoinflammatory and autoimmune pathways contribute to disease development in non-infectious uveitis patients.

Interferon-gamma release assay as a diagnostic test for tuberculosis-associated uveitis

BACKGROUND

To study the use of interferon-gamma release assay (IFN-γ) (IGRAs) as a diagnostic test for tuberculosis (TB)-associated uveitis (TAU).

DESIGN

Prospective cohort study.

PARTICIPANTS

Consecutive new patients (n=162) with clinical ocular signs suggestive of TAU, seen >1 year period at a single tertiary center.

METHODS

All subjects underwent investigations to rule out underlying disease, including T-SPOT.TB and tuberculin skin test (TST). Twenty-one subjects with underlying disease and three with interdeterminate T-SPOT.TB results were excluded. Those with T-SPOT.TB- or TST-positive results were referred to infectious diseases physician for evaluation. Anti-TB therapy (ATT) was prescribed if required. Patients' treatment response and recurrence were monitored for six months after completion of ATT, if given; or 1 year if no ATT was given.

MAIN OUTCOME MEASURE

Diagnosis of TAU.

RESULTS

Mean age of study cohort (n=138) was 46.8 ± 15.3 years. Majority were Chinese (n=80, 58.0%) and female (n=75, 54.3%). TST was more sensitive than T-SPOT.TB (72.0% vs 36.0%); but T-SPOT.TB was more specific (75.0% vs 51.1%) for diagnosing TAU. Patients with either a T-SPOT.TB (1.44; 95% confidence intervals (CI), 0.86-2.42) or TST (1.47; 95% CI, 1.12-1.94)-positive result are more likely to have TAU. The accuracy of diagnosing TAU increases when both tests are used in combination (area under the receiver operator curve=0.665; 95% CI, 0.533-0.795). Patients with both tests positive are 2.16 (95% CI, 1.23-3.80) times more likely to have TAU. Negative T-SPOT.TB or TST results do not exclude TAU (negative likelihood ratios <1.0).

CONCLUSIONS

We recommend using a combination of clinical signs, IGRA, and TST to diagnose TAU.