Classification of Intraocular Tuberculosis

Diagnosis and treatment of tuberculosis presenting as uveitis based on stochastic simulation in systems biology

Tuberculous uveitis can be a manifestation of extrapulmonary tuberculosis or an allergic reaction to tuberculosis infection. The clinical signs and symptoms of other uveitis causes are generic, making a false diagnosis simple. We present a brief introduction to theoretical modelling and simulation in systems biology and explore the consequences of TB uveitis if left untreated. Patients were admitted to our hospital with recurrent fever. They had a previous definitive diagnosis of binocular uveitis and a positive interferon gamma release assay (IGRA) test result. At the time, there was no antituberculosis medicine available, and immunosuppressive and glucocorticoid therapy did not work. After the admission, their pleural fluid tested positive for Mycobacterium tuberculosis. No other causes to explain the fever were found. A diagnosis of tuberculosis was made, and their body temperature normalized after antituberculosis treatment and closed chest drainage. Vigilance should be exercised to rule out tuberculous uveitis in cases of unexplained uveitis; this calls for IGRA screening, tuberculin skin testing, and cyst imaging. For patients with latent tuberculosis infections, it is recommended to administer antituberculosis treatment, after excluding other possible causes, and to avoid using glucocorticoids in isolation.

Host urinary biomarkers in HIV positive and HIV negative patients with tubercular uveitis and other uveitic diseases

PURPOSE

To determine if host urinary biomarker profiles could distinguish between tubercular uveitis (TBU) and other uveitic diseases (OUD) in patients with and without HIV infection.

METHODS

Concentrations of 29 different host biomarkers were measured in urine samples using the Luminex platform. Data were analyzed to describe differences between patients diagnosed with and without TBU and with and without HIV co-infection.

RESULTS

One-hundred-and-eighteen urine samples were collected and 39% participants were diagnosed as TBU+. Mean age TBU+ was 39.3±13.6 years with 45.7% males. Anterior and panuveitis and unilateral involvement were most common. 32.6% were TBU+HIV+ (median CD4+=215) while 40.2% were OUD+HIV+ (median CD4+=234). Only sVEGF3 was decreased in TBU+ versus OUD+ (p=0.03), regardless of HIV status. Some biomarkers were significantly raised in HIV+ TBU+ compared to HIV- TBU+: sIL-6Rα, CD30, sRAGE , sTNFR I&-II, IP-10, MIP-1β, sEGFR and Ferritin. HIV+ OUD+ had increased sVEGFR3, CD30, sIL-6Rα, IP-10, sTNFR I&-II, Ferritin and Haptoglobin compared to HIV- OUD+. VEGF-A (p = 0.04) was decreased in HIV+ OUD+ versus HIV- OUD+.

CONCLUSION

Decreased urinary concentrations of VEGFR3 were observed in TBU+ compared to TBU-. HIV+ individuals demonstrated increased concentrations of multiple urinary analytes when compared to HIV- patients with uveitis.

Diagnosis and Treatment of Tubercular Uveitis in Taiwan - Consensus of Expert Panels

There is currently a lack of guidelines with regard to tubercular uveitis (TBU) management in Taiwan. We therefore propose an evidence-based consensus on the management for TBU. The Taiwan Ocular Inflammation Society conducted a meeting that included nine ophthalmologist and one infection disease expert that focused on three broad areas of (1) nomenclature for TBU, (2) assessment and diagnosis for TBU, and (3) treatment of TBU. Brief literature review on TBU diagnosis and management was conducted that informed this panel meeting in order to make decisions on each consensus statements. In terms of our results, a consensus statements and recommendations for the diagnosis and management of TBU were developed. This consensus statement provides an algorithmic approach toward diagnosing and managing TBU. These statements are meant to enhance but not replace individual clinician-patient interactions and to facilitate real-world clinical practice improvement in terms of TBU patients care.

Evaluating Truenat Assay for the Diagnosis of Ocular Tuberculosis and Detection of Drug Resistance

BACKGROUND

Truenat MTB Plus assay was evaluated for diagnosing ocular tuberculosis (OTB) and detecting multi-drug resistant (MDR) and extremely-drug resistant (XDR) OTB.

METHODS

A total of 75 vitreous fluid specimens [five confirmed OTB, 40 clinically suspected OTB and 30 controls] were subjected to Truenat MTB Plus, multiplex PCR, and Xpert Ultra. Chips of Truenat were used for detecting rifampicin, isoniazid, fluoroquinolone and bedaquiline resistance. The performance was compared against culture, composite reference standard, and gene sequencing.

RESULTS

The overall sensitivity of TruePlus, MPCR, and Ultra in diagnosing OTB was 66.6%, 73.3%, and 55.5%, respectively. Out of six cases with mutations in rpoB gene, RifR was detected in five by TrueRif and four by Ultra. Three MDR and one XDR-OTB were reported by Truenat.

CONCLUSION

Truenat assay along with its strategic chips is a rapid and reliable tool for diagnosis of OTB and detection of drug resistance, including MDR and XDR-OTB.Abbreviations: OTB: Ocular tuberculosis; XDR: Extremely drug resistant; Ultra: Xpert MTB/RIF Ultra; Xpert: Xpert MTB/RIF; PCR: polymerase chain reaction; NAATs: Nucleic acid amplification tests; MDR: Multi Drug Resistant; NSP: National Strategic plan for elimination of tuberculosis; FqR: Fluoroquinolone resistant; BdqR: bedaquiline resistant; TrueRif: Truenat MTB Rif Dx; TruePlus: Truenat Plus; INH: Isoniazid; DST: Drug susceptibility testing; MGIT: Mycobacterial growth indicator tube; CRF: Composite reference standard; PPV: positive predictive value; NPV: negative predictive value; EPTB: extrapulmonary tuberculosis; VF: vitreous fluid; DNA: deoxyribonucleic acid; ATT: antitubercular therapy; RifR: Rifampicin resistance; RifS: Rifampicin susceptible; RifI: Rifampicin indeterminate.

Ocular Tuberculosis Diagnosis Through Biomarkers: Clinical Relevance of Serum C1q and Whole Blood Interferon Gene Signature Score

PURPOSE

To assess the clinical relevance of pathophysiology-based biomarkers, specifically serum C1q and whole blood interferon gene signature score (IGSS), in ocular tuberculosis (OTB) diagnosis by conducting an integrative analysis of clinical presentations and treatment response.

METHODS

This retrospective cohort study analysed data from 70 patients with suspected OTB at a tertiary care uveitis practice in Indonesia. Serum C1q levels and whole blood IGSS were quantified. Patients were categorized into four quadrants based on their biomarker profiles: quadrant 1 (high C1q & low IGSS), quadrant 2 (high C1q & high IGSS), quadrant 3 (low C1q & high IGSS), and quadrant 4 (low C1q & low IGSS). Characteristics of clinical presentations, work-up results, and treatment outcomes were explored according to the predefined quadrants.

RESULTS

We identified that the majority of OTB patients diagnosed with concurrent active pulmonary TB were in quadrant 1, 2, or 3 (20/23, 87.0%). Twenty-seven patients (27/47, 57.4%) with clinically undifferentiated uveitis were in quadrant 4 (p < 0.001). Among patients in quadrants 1, 2, and 3, completion of a full course of antitubercular treatment (ATT) was associated with a lower number of patients showing persistence or recurrence of ocular inflammation compared to those who were not fully treated with ATT (14.3% vs 85.7%, p = 0.001).

CONCLUSIONS

Based on the analysis of clinical features and treatment outcomes, patients with elevated levels of either or both serum C1q and whole blood IGSS may reflect active TB disease in the eye, necessitating full ATT management.

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

BACKGROUND

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

CASE REPORT

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

CONCLUSIONS

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

Evolution of research in diagnosis and management of uveitis over four decades in India

Uveitis and its complications are more common in the developing world, in which the condition occurs in up to 714 per 100,000 in the population and accounts for up to 25% of all blindness. In India, the ophthalmic sub speciality of uveitis greatly evolved in the last four decades. In the early decades most of the studies were epidemiological studies. In recent years, more research has been published due to tremendous advancements in clinical diagnosis, laboratory investigations and ancillary test and treatment modalities. In this review article, we did a medline search with key words 'uveitis' and 'India', and selectively incorporated articles showing the evolution of this sub-speciality in India.

Pattern of uveitis in a referral ophthalmology center in Northeastern Thailand

PURPOSE

To report the characteristics and epidemiology of uveitis in a university-based referral center in northeastern Thailand and review the uveitis patterns present in various regions worldwide.

METHODS

A retrospective review of all medical records for new patients visiting the uveitis clinic at Srinagarind hospital, Khon Kaen University, between August 2016 and June 2021, was conducted.

RESULTS

A total of 522 uveitis patients were included in this study. Disease etiologies were categorized as non-infectious 35.8% (187/522), infectious 32.8% (171/522), and undetermined cause 31.4% (164/522). Specific diagnoses were established in 68.6% of cases. Vogt-Koyanagi-Harada (VKH) (14.2%) was identified as the most common specific diagnosis, and tuberculosis (6.7%) ranked highest among infectious causes.

CONCLUSIONS

Although non-infectious uveitis is observed predominantly in this region, the proportion of infectious uveitis is relatively more common than in developed countries. We have found no cause for one-third of our patients despite the utilization of PCR and serology for diagnostic purposes.

Characteristics and outcomes of the duration of treatment with adjunctive corticosteroids in intraocular tuberculosis

Introduction

Intraocular tuberculosis (IOTB) is a common site of extrapulmonary tuberculosis and a main cause of infectious uveitis. It can result in severe visual morbidity if not recognized and treated properly. The clinical manifestations of IOTB are varied, and the duration of treatment is unclear. This study describes the clinical characteristics and outcomes of patients with IOTB and compares the duration of antituberculosis therapy (ATT) and steroid use.

Method

An 8-year retrospective study of IOTB patients in an endemic area of a tertiary hospital in Thailand. All patients had a complete treatment of ATT at least for 6 months.

Results

Forty-three patients with 57 eyes and a mean age of 43.72 years were included. Panuveitis (38.6 %), retinal phlebitis (31.6 %), and posterior uveitis (15.8 %) were common clinical characteristics. A significant difference between initial and final best corrected visual acuity (BCVA) after ATT in 6 months for therapy and at least 9 months for therapy was observed (p = 0.004, 0.003, respectively). Ninety point nine percent of patients who received ATT for 9 months achieved a successful treatment outcome, while 66.7 % of patients who received ATT for 6 months did (p = 0.056). Patients who received systemic and/or regional corticosteroids therapy during treatment had a higher rate of treatment failure (p < 0.001).

Conclusion

IOTB had a variety of clinical manifestations, including nongranulomatous inflammation. Patients who completed treatment with ATT for at least 6 months improved their final BCVA. There was no difference in treatment outcomes regarding the duration of treatment. Combined treatment with systemic and/or regional corticosteroids was significantly associated with failed treatment outcomes.

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.

Characteristics, Etiology, and Clinical Outcome of Retinal Vasculitis in Tertiary Hospital in Thailand

OBJECTIVE

To analyze characteristics, etiology, and outcome of retinal vasculitis in Central Thailand.

METHODS

A retrospective cohort study.

RESULTS

Retinal vasculitis was found in 10% of uveitis, 74 from 741 uveitis, noninfectious (64.9%) and infectious group (35.1%). The most common cause was Behcet's disease (48.6%). Behcet's disease was the most common cause of all types of vascular leakage on angiography, including capillary (80.4%), venous (56.3%), and arterial leakage (56%). Final visual acuity was 0.86 ± 0.97 logMAR. Cataract was the most frequent complication (42.5%). Acute clinical course (p = .025) and retinal neovascularization (p = .031) were associated with infectious group. Forty-three percent of vasculitis complicated by ischemia required photocoagulation (33%) and anti-VEGF injection (17%). Furthermore, 17% of vasculitis underwent vitrectomy.

CONCLUSION

One-half of the retinal vasculitis in Central Thailand were Behcet's disease. Acute onset and retinal neovascularization may suggest infectious etiology. Retinal ischemia should be cautious and undergo early interventions to prevent sight-threatening complications.

Long-term follow-up after treatment of tubercular uveitis: case series and review of the literature

Introduction

There is a scarcity of long-term follow-up data and management strategies for recurrent uveitis in tubercular uveitis (TBU), especially in cases extending beyond 10 years after the completion of initial antitubercular treatment (ATT).

Methods

This retrospective study involved five TBU patients who were initially treated with a combination of four-drug ATT for 6 months, and the five of them had more than 10 years of follow-up after uveitis resolution upon ATT completion. We describe the occurrence of recurrent uveitis and present our approach to managing these recurrent episodes.

Results

Recurrent uveitis and cystoid macular edema (CME) developed in three out of five included TBU patients with a median of 18 years (range 13-20 years) of follow-up. The anatomical sites of the recurrences were anterior, intermediate, and pan-uveitis. The recurrent episodes varied from 6 years to 15 years after ATT completion. Systemic or local corticosteroids/immunosuppressants successfully resolved all recurrent episodes, but one was also treated with the combination of isoniazid monotherapy again. Two patients needed anti-tumor necrosis factor-α therapy.

Conclusion

Long-term monitoring of TBU patients after ATT completion is warranted. Further well-designed studies with larger sample sizes are required to better estimate the risk of recurrences, investigate the underlying mechanism of recurrences, and identify biomarkers that predict who is at risk for recurrences.

Diagnostic efficacy of elevated serum angiotensin-converting enzyme and lymphopenia between presumed sarcoid uveitis and presumed tubercular uveitis

PURPOSE

To evaluate the diagnostic efficacy of elevated serum angiotensin-converting enzyme (sACE) and lymphopenia in presumed sarcoid and tubercular uveitis.

METHODS

A single-centre retrospective study was conducted on a cohort of 755 adult patients with uveitis between January 2019 and June 2020. Demographic, clinical and laboratory data were retrieved from our hospital database. Measurements of serum angiotensin-converting enzyme (sACE) and lymphocyte counts were analysed.

RESULTS

The mean age of the patients was 41 ± 13 years. Presumed sarcoid uveitis was diagnosed in 50 (7%) patients, presumed tubercular uveitis in 222 (29.4%) and other uveitic entities noted in 483 (64%). Intermediate and posterior uveitis were the most common anatomical diagnosis in presumed sarcoid uveitis (59% and 20%, respectively) and in presumed tubercular uveitis (46% and 38%, respectively). Elevated sACE was noted in 76% of presumed sarcoid uveitis and 46% in presumed tubercular uveitis. The combination of high serum angiotensin-converting enzyme along with lymphopenia was only in 17% in presumed sarcoid uveitis and 9.7% in presumed tubercular uveitis. sACE was found to be a significant risk factor for presumed sarcoid uveitis with an odds ratio of 3.603 (p < 0.002), and in presumed tubercular uveitis odds ratio was not significant with odds ratio of 1.19. Lymphopenia was not found to be a significant factor in both groups.

CONCLUSION

Elevated sACE activity was an independent risk factor for presumed sarcoid uveitis over lymphopenia alone or in combination with lymphopenia.

The immune response in tubercular uveitis and its implications for treatment: From anti-tubercular treatment to host-directed therapies

Tubercular uveitis (TB-uveitis) remains a conundrum in the uveitis field, which is mainly related to the diverse clinical phenotypes of TB-uveitis. Moreover, it remains difficult to differentiate whether Mycobacterium tuberculosis (Mtb) is present in the ocular tissues, elicits a heightened immune response without Mtb invasion in ocular tissues, or even induces an anti-retinal autoimmune response. Gaps in the immuno-pathological knowledge of TB-uveitis likely delay timely diagnosis and appropriate management. In the last decade, the immunopathophysiology of TB-uveitis and its clinical management, including experts' consensus to treat or not to treat certain conditions with anti-tubercular treatment (ATT), have been extensively investigated. In the meantime, research on TB treatment, in general, is shifting more toward host-directed therapies (HDT). Given the complexities of the host-Mtb interaction, enhancement of the host immune response is expected to boost the effectiveness of ATT and help overcome the rising burden of drug-resistant Mtb strains in the population. This review will summarize the current knowledge on the immunopathophysiology of TB-uveitis and recent advances in treatment modalities and outcomes of TB-uveitis, capturing results gathered from high- and low-burden TB countries with ATT as the mainstay of treatment. Moreover, we outline the recent progress of HDT development in the pulmonary TB field and discuss the possibility of its applicability to TB-uveitis. The concept of HDT might help direct future development of efficacious therapy for TB-uveitis, although more in-depth research on the immunoregulation of this disease is still necessary.

The Collaborative Ocular Tuberculosis Study (COTS) calculator-a consensus-based decision tool for initiating antitubercular therapy in ocular tuberculosis

OBJECTIVE

To introduce the Collaborative Ocular Tuberculosis Study (COTS) Calculator, an online clinical scoring system for initiating antitubercular therapy (ATT) in patients with ocular tuberculosis (TB).

METHOD

The COTS Calculator was derived from COTS Consensus (COTS CON) data, which has previously published consensus guidelines. Using a two-step Delphi method, 81 experts evaluated 486 clinical scenario-based questions, ranking their likelihood of initiating ATT in each specific scenario. Each scenario was a permutation of the results and/or availability of five following components-clinical phenotype, endemicity, two immunological (tuberculin skin test, interferon-γ release assay) and one radiological (chest X-Ray) test results-and a sixth component further stratifying three of the clinical phenotypes. The median scores and interquartile ranges (IQR) of each scenario were tabulated, representing the expert consensus on whether to initiate ATT in that scenario. The consensus table was encoded to develop the COTS Calculator.

RESULTS

The COTS Calculator can be accessed online at: https://www.oculartb.net/cots-calc . The attending physician can select the conditions present in the patient, which will generate a median score from 1 to 5. 114 out of 486 scenarios (24%) deliberated had a median score of 5 indicating expert consensus to initiate ATT.

CONCLUSION

The COTS Calculator is an efficient, low-cost, evidence and experience-based clinical tool to guide ATT initiation. While it holds substantial promise in improving standard-of-care for ocular-TB patients, future validation studies can help to as certain its clinical utility and reliability.

Usefulness of the QuantiFERON test for the diagnosis of tubercular uveitis and the predictions of response to antituberculosis treatment

AIMS

Few studies have evaluated the contribution of QuantiFERON test for the diagnosis of tubercular uveitis in non-endemic countries for tuberculosis (TB). The objective of the present study was to evaluate the value of the QuantiFERON test in a large cohort of patients with uveitis for both the diagnosis of tubercular uveitis and antituberculosis treatment (ATT) response prediction.

METHODS

A single-centre retrospective study including consecutive adult patients with uveitis who were prescribed a QuantiFERON test between January 2003 and December 2019 was performed. Adjusted ORs (aORs) were calculated between patients with uveitis responding and not responding to ATT according to the Collaborative Ocular Tuberculosis Study (COTS) group diagnostic criteria. Sensitivity (SE), specificity (Sp), and positive and negative predictive values of the QuantiFERON test were calculated.

RESULTS

A total of 1075 patients were included in the study; 178 (16.5%) were found positive using the QuantiFERON test. Among the 178 positive patients, 62 (35%) had a diagnosis of tubercular uveitis according to the updated COTS classification; all received ATT for 6 months; and 44/62 (71%) responded to ATT. A QuantiFERON test value of >2 IU/mL was associated with a greater chance of responding to ATT (aOR=36.7, 95% CI 7.2 to 185.9, p<0.001). The optimal threshold to maximise both Sp and SE for diagnosis of TB uveitis was 4 IU/mL.

CONCLUSION

One-sixth of the patients diagnosed with uveitis had a positive QuantiFERON test. The QuantiFERON threshold with the optimal SE and Sp for the diagnosis of tubercular uveitis was 4 IU/mL.

TRIAL REGISTRATION NUMBER

NCT03863782.

Presumed tuberculosis-related scleritis

AIMS

To evaluate the clinical characteristics and therapeutic outcome of patients with recurrent scleritis of unknown demonstrable aetiology and positive QuantiFERON-TB Gold In-Tube test (QFT).

METHODS

Retrospective chart review of the demographic, clinical, laboratory and therapeutic outcome data of 15 patients. Clinical characteristics as well as remission rate after standard antituberculous therapy (ATT) were assessed.

RESULTS

There were 9 men and 6 women with a mean age of 48.9 years (range, 32-73). Scleritis was diffuse in 10 patients (66.6%) and nodular in 5 patients (33.3%), 1 of them with concomitant posterior scleritis. It was bilateral in 7 patients (46.6%) and recurrent in all of them. Scleritis appeared after prior uveitis (10 patients, 66.6%) and/or with concomitant uveitis (5 patients, 33.3%) or peripheral keratitis (5 patients, 33.3%). Previous ocular surgery was found in 7 patients (46.6%). Previous extraocular tuberculosis (TB) infection or previous TB contact was detected in 11 patients (73.3%). No radiologic findings of active extraocular TB were detected. ATT was used in 15 patients, sometimes with the addition of systemic corticosteroids (5 patients) and methotrexate (1 patient); 14 patients achieved complete remission (93.3%).

CONCLUSION

Presumed TB-related scleritis may appear in recurrent scleritis of unknown origin and positive QFT. It may occur after prior uveitis and/or concomitantly with uveitis or peripheral keratitis, and it may be triggered by previous ocular surgery. No patients had evidence of concurrent active extraocular infection, although many had previous TB infection or TB contact. ATT was effective, sometimes with the addition of systemic corticosteroids and methotrexate.

Long-term visual acuity outcome of pediatric uveitis patients presenting with severe visual impairment

This study investigated the long-term visual acuity (VA) outcome in the eyes of children with uveitis and severe visual impairment (SVI; VA ≤ 20/200) at presentation. Fifty-one children [57 eyes; median age, 11 years; 51% female; median follow-up period, 36 months (interquartile range 14.9-64.4)] aged ≤ 16 years with uveitis managed at our tertiary center from January 2010 to July 2020 were reviewed. Uveitis mainly manifested as unilateral (74.5%), chronic course (82.4%), and panuveitis (43.1%). Ocular toxoplasmosis and toxocariasis were the most common diagnoses (9.8% each). At least one ocular complication at presentation was observed in 93% of the eyes. Overall, the mean logMAR VA improved from 1.8 at presentation to 1.2 at 5 years (P < 0.001). Common causes of poor vision included retinal detachment, atrophic bulbi, and optic atrophy. Predictive factors associated with less VA improvement over the follow-up period included preschool age of uveitis onset (P < 0.001), ocular symptoms duration before uveitis diagnosis ≥ 1 month (P = 0.004), and non-anterior uveitis (P = 0.047). The long-term VA outcome in uveitis-affected eyes with SVI at presentation was unfavorable. Younger age at uveitis onset, delayed presentation, and uveitis involving the posterior segment were associated with poorer VA outcome.

Role of Interferon-Gamma Release Assay for the Diagnosis and Clinical Follow up in Ocular Tuberculosis

PURPOSE

To assess the performance of interferon-gamma release assay (IGRA) associated with tuberculosis skin test (TST) for ocular tuberculosis (OTB) diagnosis and therapeutic decision making.

METHOD

One hundred and ninety-one patients with ocular inflammation were prospectively followed-up. Patients with clinical signs highly suspected of OTB, TST≥10 mm, and/or IGRA≥0.35 IU/mL received antitubercular therapy (ATT). Sensitivity (Se), specificity (Sp), and area under the curve (AUC) were assessed.

RESULTS

Seventy-two (37.7%) patients received ATT for presumed OTB. Combining TST and IGRA had Se=89.6%, Sp=99.2%, and AUC (0.98) significantly higher compared to TST (0.85, Z=6.3, p<.001) or IGRA (0.95, Z=2.5, p=.01). Prior history of corticosteroids or immunosuppressant with concomitantly oral prednisone and baseline IGRA> 2.0 IU/mL was associated significantly with more recurrences in ATT patients (p=.01)      .

CONCLUSION

Considering TST and IGRA together was more effective in assessing OTB diagnosis. The real value of the IGRA test to predict recurrences needs further studies.

Interferon-gamma release assay and chest X-ray to classify intraocular tuberculosis among clinically undifferentiated uveitis

BACKGROUND Tuberculosis (TB) is a common cause of intraocular inflammation in Indonesia. As no accurate biomarker can confirm the diagnosis, ophthalmologists often rely on systemic findings, such as tuberculin skin test, interferon-gamma release assay (IGRA), and chest X-ray (CXR) for TB suspicion. This study aimed to evaluate IGRA and CXR in classifying intraocular TB among patients with a clinically undifferentiated cause of uveitis. METHODS This cross-sectional study included 116 patients (a total of 163 affected eyes) with a clinically undifferentiated cause of uveitis. IGRA and CXR were performed as part of the workup. Data on visual acuity, anterior chamber inflammation grade, and anatomical classification of uveitis were recorded. As there were no confirmed ocular tuberculosis (OTB) in our cases, eyes were classified into probable OTB, possible OTB, and unclassified. RESULTS Overall, 93 patients (80.2%) with a clinically undifferentiated cause of uveitis had positive IGRA, whereas 10 (8.6%) had CXR results suggestive of TB. More than one-third of the patients were blind (visual acuity <3/60), and panuveitis was the commonest anatomical classification. A trend was identified in patients with panuveitis, who often showed ≥2+ cell anterior chamber inflammation (p for trend = 0.023), according to OTB criteria (probable OTB = 3/4, 75.0%; possible OTB = 44/67, 65.7%; unclassified = 2/9, 22.2%). Furthermore, the clinically undifferentiated uveitis cases were eligible to be stratified into probable (8.6%) and possible (75.0%) OTB categories after IGRA and CXR examinations. CONCLUSIONS The combination of IGRA and CXR is valuable for classifying and diagnosing TB-related uveitis. A multidisciplinary approach is essential when the cause of uveitis is unknown.

The Pattern of Uveitis in a Pediatric Population at a Tertiary Center in Thailand

PURPOSE

To describe the clinical characteristics and longitudinal pattern of visual acuity (VA) of pediatric patients with uveitis at a tertiary center in Thailand.

METHODS

We retrospectively reviewed the records of children with uveitis ≤16 years who presented to the clinic between January 2010 and June 2020.

RESULTS

The mean age at onset was 9.1(±4.3) years; the main characteristics were chronic (64.4%), unilateral (68.6%), and panuveitis (39%). The common etiologies were ocular toxoplasmosis (11.9%), herpetic uveitis (10.2%), and ocular toxocariasis (6.8%). Further, 40% of the eyes presented with VA of ≤20/200; mean VA at baseline improved from 0.93 to 0.72 logMAR at 3 months after presentation (P < .001), the baseline VA of ≤20/200 was significantly associated with poor VA outcome at 1 year.

CONCLUSION

Chronic, unilateral, and panuveitis represented the majority of our children with uveitis. Infectious etiology was common. Significant VA improvement can be achieved with optimum management.

Differences in biomarker concentrations in serum and urine of patients with Ocular Tuberculosis - A prospective descriptive study

PURPOSE

To describe biomarker concentrations in serum and urine of South African patients with ocular tuberculosis (OTB).

METHODS

A prospective study to compare 29 urine and serum biomarkers in 14 OTB patients at a tertiary eye clinic.

RESULTS

Median age of participants (7 male and 7 female) was 38.5 years (range 25-73) Most biomarker concentrations were significantly higher in serum than in urine (p < 0.01). Only 2 (IL-1RA and IL-2) showed higher concentrations in urine than serum (p < 0.01). Three biomarkers (sIL-2Ra, sTNFRI and IFNγ) showed no difference in concentration between urine and serum (p > 0.05).

CONCLUSIONS

Most biomarkers tested showed significant differences in concentration between serum and urine and therefore these 2 biofluids cannot be used interchangeably when studying biomarker profiles. One notable exception is IFNγ as its concentration did not differ between serum and urine.

Adjunctive Intravitreal Anti-vascular Endothelial Growth Factor and Moxifloxacin Therapy in Management of Intraocular Tubercular Granulomas

PURPOSE

To report pre and post treatment levels of VEGF-A in the aqueous humour of patients with intraocular tubercular granulomas and study the effect of a combined intravitreal anti-VEGF bevacizumab and moxifloxacin therapy on their regression.

METHODS

Aqueous samples of 10 consecutive patients with intraocular tubercular granulomas obtained before and after initiating treatment were subjected to ELISA for analysing intraocular VEGF-A levels. Intravitreal injections of bevacizumab and moxifloxacin were given weekly till complete regression of these granulomas. All patients received the usual four-drug ATT and oral corticosteroids.

RESULTS

Mean baseline VEGF-A level was 1004.27±411.40 pg/ml (401.32-1688.95) that reduced significantly to 27.62±46.86 pg/ml (6.9-131.83) at the last injection. Meannumber of intravitreal injections was 3.1 (2-4). We found significant correlation of decreasing levels of aqueous VEGF-A with the clinical regression of these tubercular granulomas.

CONCLUSIONS

Intraocular TB granulomas have high levels of VEGF-A. Weekly intravitreal injections of anti-VEGF bevacizumab with moxifloxacin as an adjunct to the standard care may cause prompt regression of tubercular granulomas.

ABBREVIATIONS

TB: Tuberculosis; IOTB: Intraocular tuberculosis; VEGF: Vascular endothelial growth factor; RD: Retinal detachment; Mtb: Mycobacterium tuberculosis; ATT: Antitubercular therapy; AMD: Age-related macular degeneration; SRF: Subretinal fluid; ELISA: Enzyme immunosorbent assay; PCR: Polymerase chain reaction; ONH: Optic nerve head; MDR-TB: Multidrug-resistant tuberculosis; pg/ml: picogram/milliliter; ESR: Erythrocyte sedimentation rate; CECT: Contrast enhanced computed tomography; DNA: Deoxyribonucleic acid; RNA: Ribonucleic acid; BSL: Biosafety level; BCVA: Best corrected visual acuity; HM: Hand movements; KP: Keratic precipitates; PSC: Posterior subcapsular cataract; PS: Posterior synechiae; CRA: Chorio-retinal atrophy; IVMP: Intravenous methyl prednisolone; OCT: Optical coherence tomography; RPE: Retinal pigment epithelium; FFA: Fundus fluorescein angiography; ICG: Indocyanine angiography; RAP: Retinal arterial proliferans.

Evaluation of the retinal and choroidal microvasculature changes in cases of sarcoid and tuberculosis-associated posterior uveitis using OCT angiography

PURPOSE

Using optical coherence tomography angiography (OCTA) to evaluate retinal microvascular changes in sarcoid and tuberculous (TB) posterior uveitis.

METHODS

Cross-sectional observational study includes 30 eyes. FFA and OCTA images were acquired. OCTA images were analyzed for areas of capillary hypo-perfusion, disorganization of the superficial and deep capillary plexuses (SCP and DCP) and intraretinal cystoid spaces and for measuring the size of the foveal avascular zone and vessel density (VD) in the SCP and DCP.

RESULTS

A total of 11 eyes were associated with TB and 19 with sarcoidosis. By OCTA, 100% had areas of capillary non-perfusion, 36.7% choroidal voids, 30% disorganization of the SCP and DCP and 26.6% intraretinal cystoid spaces. The VD of the DCP was significantly lower in the TB group. On comparing OCTA and FFA, parafoveal ischemia was detected more frequently on OCTA and macular edema more frequently on FFA (P =  < 0.001). The BCVA was not significantly correlated with the VD of the SCP or DCP.

CONCLUSION

OCTA can be used in detection of early microvascular changes, segmenting retinal layers and localizing abnormalities. The presence of these changes may aid in the diagnosis of TB and sarcoid uveitis, for prognosis, follow-up and may be the only choice when FFA is contraindicated.

Correlation of angiogenic growth factors and inflammatory cytokines with the clinical phenotype of ocular tuberculosis

PURPOSE

To determine the correlation of angiogenic growth factors and inflammatory cytokines with the clinical phenotype of ocular tuberculosis (OTB).

METHODS

Vitreous fluid was analysed for cytokines in patients with OTB and non-OTB uveitis using multiplex fluorescent bead-based flow cytometric assay. The clinical phenotypes were recorded and correlated with vitreous biomarkers.

RESULTS

Vitreous humour from OTB patients had elevated levels of interleukin-10 (IL-10), IL-17-A, interferon-gamma (IFN-γ), and tumour necrosis factor-alpha (TNF-α). Angiopoietin (Ang-2) levels were higher in the panuveitis phenotype. OTB posterior uveitis phenotype had relatively higher vascular endothelial growth factor (VEGF) levels and lower fibroblast growth factor (FGF) levels. Additionally, eyes with choroiditis and vasculitis had elevated levels of VEGF and Ang-2 with FGF downregulation. Both IFN-γ and IL-10 were upregulated in the choroiditis phenotype of OTB.

CONCLUSION

Angiogenic growth factors and inflammatory cytokines were altered in the vitreous humour of OTB patients. IFN-γ, VEGF, and IL-10 levels are increased in choroiditis and vasculitis phenotypes. Receiver operating characteristic (ROC) curve analysis further emphasized the importance of the IFN-γ assay in the diagnosis of OTB.

Colombian ocular infectious epidemiology study (COIES): presumed ocular tuberculosis incidence and sociodemographic characterization, 2015-2020

PURPOSE

This study aims to describe the incidence and geographical distribution of presumed ocular tuberculosis (POTB) in Colombia between 2015 and 2020 based on the Colombian Ministry of Health and Social Protection data.

METHODS

We conducted a claims-based study using the Integrated Social Protection Information System database from the Colombian Ministry of Health. We used the specific code of the International Classification of Diseases for Ocular Tuberculosis (A18.5) and tuberculosis from 2015 to 2020 to estimate the incidence and the demographic status of the disease in Colombia. We used STROBE guidelines.

RESULTS

During the 6 years of study, the crude unadjusted incidence was 0.2 new cases of POTB in one million consulting patients and 55 new cases of POTB in 100,000 patients with TB showing a decreasing pattern of the disease. From the 28 new cases, the mean age of presentation was 41.4 years (SD ± 25.3) with a female predominance (60.7% of the cases). Distribution by age shows a higher proportion of cases in groups 15-19 (14%), 20-24 (11%), 55-59 (11%), and 60-64 (11%) years of age. The geographic analysis showed a higher number of cases in Andean region, followed by the Caribbean and Pacific regions.

CONCLUSIONS

This is the first study that determines the incidence of POTB in a developing country from Latin America. POTB incidence in Colombia is lower than the reported worldwide. It could be attributed to a low burden of Tuberculosis in Colombia, underdiagnosis, and a low rate of immigration from countries with a high burden of TB.

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.

Prevalence of Positive QuantiFERON-TB Test among Sarcoid Uveitis Patients and its Clinical Implications in a Country Non-endemic for Tuberculosis

AIM

To report on the prevalence and clinical implications of positive QuantiFERON-TB (QFT) test results in the diagnostic evaluation of a cohort of consecutive sarcoid uveitis patients in France.

DESIGN

Retrospective cross-sectional study.

METHODS

This study included consecutive sarcoid uveitis patients who all underwent QFT testing.

RESULTS

A total of 234 patients were included in the study, among them 28 (12%) were QFT-positive. Previously treated tuberculosis (TB) was documented in 2 patients. QFT-positive patients were older (59 ± 16 years vs. 51 ± 18 years, p = .025) and more in proportion to suffer from chronic uveitis and panuveitis compared to QFT-negative patients. Moderate and severe visual impairment were significantly more frequent in the QFT-positive group (35.7% vs. 18.9%, p = .049 and 25.0% vs. 9.2%, p = .022, respectively).

CONCLUSION

The significant proportion of QFT-positive patients (12%) in this large series of sarcoid uveitis patients makes us suggest not to exclude the diagnosis of sarcoidosis in case of positive QFT in a low-endemic country for tuberculosis, and to manage these patients early by initiating without delay systemic steroids associated with latent tuberculosis therapy.

Histological Diagnosis of Ocular and Periocular Tuberculosis 1945 - 2020

BACKGROUND

Ocular tuberculosis is a rare but important differential diagnosis for inflammatory conditions of all eye tissues, including the ocular surface and adnexa. Tissue diagnostics may prove challenging as some ocular tissues are difficult to biopsy and the detection of pathogens may be insensitive. We were interested in how many cases in the archive of the ophthalmopathological laboratory had been diagnosed with (peri)ocular tuberculosis since 1945.

MATERIALS AND METHODS

Retrospective analysis of historical records and specimens of the ophthalmopathology laboratory of the eye department at Freiburg university hospital. Systematic re-evaluation of available slides for presence of granuloma, necrosis, giant cells, acid fast bacteria, and chronic as well as acute inflammation, plus comparison of current and historic evaluations. In addition, we describe a recent case with tuberculoma of the iris.

RESULTS

There were 50,418 records archived since 1945, of which 23 specimens taken from 22 patients had been diagnosed as (peri)ocular tuberculosis. Of these, 22 (96%) were archived and available for re-interpretation. Four specimens (17%) had been excised from children. The most common tissues were enucleated eye globes (10/23, 44%), followed by the lacrimal sac (5/23, 22%) and conjunctiva (2/23, 9%). The most frequent histopathological findings were granulomas (23/23, 100%), chronic inflammation (22/23, 96%), giant cells (21/23, 91%), and necrosis (14/23, 61%). An acute inflammatory response was found in 4/23 specimens (17%). Ziehl-Neelsen stains for acid-fast bacteria had been performed in five cases, of which three were positive (60%). The greatest discrepancy between current and historical findings related to the presence of necrosis (59% consensus). In other findings, the consensus was high (78 - 96%). In a recent case of a patient with wasting syndrome attributed to lymphoma, histopathological workup of an iris tumour led to the diagnosis of tuberculosis.

CONCLUSION

Ocular tuberculosis is a rare but important histopathological differential diagnosis. In the available specimens, the classic finding of necrotizing inflammation was rarest and showed least consensus on histological re-evaluation. Other typical findings, such as giant cells and a predominantly lymphocytic infiltrate, are sometimes not found even with proven presence of Mycobacterium tuberculosis. They should not be considered essential in cases where there is strong clinical suspicion.

Absence of Evidence as The Evidence Of Absence: The Curious Case of Latent Infection Causing Ocular Tuberculosis

Ocular tuberculosis (TB) is frequently considered as intraocular inflammation in the setting of latent TB, owing mainly to the absence of microbiological evidence of Mycobacterium tuberculosis in ocular fluid samples. Even though such lack of microbiological evidence, and of systemic signs of active TB disease, are suggestive of latent TB infection, molecular and rare histopathologic evidence of mycobacteria in the eye, and favourable response of ocular inflammation to anti-TB therapy point to the presence of active infection in ocular TB. Here, we discuss how intraocular inflammation in ocular TB is not merely an immunologic response to bacilli, but an active tuberculosis infection. We will discuss the reason for the frequent absence of microbiological evidence of TB in the eye in ocular TB and the diagnostic hierarchy to arrive at the diagnosis of this infectious uveitis entity.

Comparative Evaluation of GeneXpert MTB/RIF Ultra and GeneXpert MTB/RIF for Detecting Tuberculosis and Identifying Rifampicin Resistance in Pars Plana Vitrectomy Samples of Patients with Ocular Tuberculosis

BACKGROUND

Xpert MTB/RIF Ultra (Ultra) was evaluated for the first time on Ocular tuberculosis (OTB) samples and compared with Xpert.

METHODS

Seventy five vitreous fluid samples (3 confirmed OTB, 47 clinically suspected OTB, and 25 controls) were subjected to Ultra, Xpert and Multiplex-PCR and compared against culture, composite reference standard (CRS), and gene sequencing.

RESULTS

The sensitivity of Ultra was 50% in diagnosing OTB (100% against culture and 46.8% against CRS). The overall sensitivity of Xpert and MPCR was 16% and 72%, respectively. Xpert missed three culture-positive cases and MPCR detected additional 11. Ultra and Xpert missed two and four cases of RifR, respectively. A total of 13(59%) cases were reported 'trace' by Ultra in which RifR could not be evaluated.

CONCLUSION

Ultra outperformed Xpert in diagnosing OTB. The advantage of Ultra's simultaneous RifR detection is lost since the trace bacterial loads in the specimens cause indeterminate results of RifR testing.Abbreviations: OTB: Ocular tuberculosis; Ultra: Xpert MTB/RIF Ultra; Xpert: Xpert MTB/RIF, MPCR: multiplex polymerase chain reaction; NAATs: Nucleic acid amplification tests; MLAMP: multitargeted loop-mediated isothermal amplification; PPV: positive predictive value; NPV: negative predictive value; EPTB: extrapulmonary tuberculosis; VF: vitreous fluid; DNA: deoxyribonucleic acid; ATT: antitubercular therapy; RifR: Rifampicin resistance; RifS: Rifampicin susceptible; RifI: Rifampicin indeterminate.

Clinical Manifestations and Outcomes of Tubercular Uveitis in Taiwan—A Ten-Year Multicenter Retrospective Study

Background andObjectives: This 10-year multicenter retrospective study reviewed the clinical manifestations, diagnostic tests, and treatment modalities of tubercular uveitis (TBU), including direct infection and indirect immune-mediated hypersensitivity to mycobacterial antigens in Taiwan. Materials and Methods: This retrospective chart review of patients with TBU was conducted at 11 centers from 1 January 2008 to 31 December 2017. We used a multiple regression model to analyze which factors influenced best-corrected visual acuity (BCVA) improvement. Results: A total of 79 eyes from 51 patients were included in the study. The mean age was 48.9 ± 16.4 years. The mean change of LogMAR BCVA at last visit was −0.21 ± 0.45. Diagnostic tools used include chest X-ray, chest computed tomography, Mantoux test, interferon gamma release test (QuantiFERON-TB Gold test), intraocular fluid tuberculosis polymerase chain reaction, and bronchial alveolar lavage. The clinical manifestations included 48% posterior uveitis and 37% panuveitis. In the sample, 55% of the cases were bilateral and 45% unilateral. There was 60.76% retinal vasculitis, 35.44% choroiditis, 21.52% serpiginous-like choroiditis, 17.72% vitreous hemorrhage, 12.66% posterior synechiae, 6.33% retinal detachment, and 3.80% choroidal granuloma. Treatment modalities included rifampicin, isoniazid, pyrazinamide, ethambutol, oral steroid, posterior triamcinolone, non-steroidal anti-inflammatory drugs, vitrectomy, and immunosuppressants. BCVA improved in 53.2% of eyes and remained stable in 32.9% of eyes. In the final model of multiple regression, worse initial BCVA, pyrazinamide, and receiving vitrectomy predicted better BCVA improvement. Ethambutol was associated with worse visual outcomes. Seven eyes experienced recurrence. Conclusions: This is the largest 10-year multicenter retrospective study of TBU in Taiwan to date, demonstrating the distribution of clinical manifestations and clinical associations with better treatment outcomes. The study provides a comprehensive description of TBU phenotypes in Taiwan and highlights considerations for the design of further prospective studies to reliably assess the role of ATT and vitrectomy in patients with TBU.

Longitudinal follow-up of Choroidal Granulomas with Indocyanine Green Angiography And Optical Coherence Tomography Angiography: a lesion-based analysis

PURPOSE

To investigate choroidal granulomas visualized by indocyanine green angiography (ICGA) and Optical Coherence Tomography Angiography (OCTA) in response to treatment.

METHODS

Ten eyes of eight patients with tubercular, sarcoid or Vogt-Koyanagi-Harada associated choroidal granulomas were evaluated in this multicentric study. All patients underwent ICGA and OCTA at baseline, 1 and 3 months after treatment onset. Granulomas were identified as hypofluorescent lesions on intermediate ICGA phases. Late ICGA behavior and OCTA visualization were assessed.

RESULTS

On baseline intermediate ICGA, 222 choroidal granulomas were detected. Overall, 174/222 granulomas were detected on baseline OCTA images. At 1 month, 28% of lesions were healed and 48 late ICGA hyper-fluorescent lesions were identified. At 3 months, 63% of baseline lesions were healed, with 33 persistent late hyper-fluorescent lesions. OCTA sensitivity was reduced at 1 and 3 months compared to baseline. Some flow-voids detected on OCTA at 1 and 3 months did not correspond to any visible lesion on ICGA.

CONCLUSIONS

Different healing behaviors of choroidal granulomas were identified combining ICGA and OCTA analysis. Late ICGA hyper-fluorescent lesions may be the consequence of a possible fibrotic shift. Structural changes in the choroid may persist after active granulomas resolution resulting in persistent flow voids on OCTA.

Diagnostic value of lumbar puncture for the etiological assessment of uveitis: a retrospective cohort of 188 patients

AIM

To assess the relevance of lumbar puncture (LP) for the etiological diagnosis of uveitis and to establish predictive factors associated with its contributory use.

METHODS

We performed a retrospective study of patients with de novo uveitis who were referred to our tertiary hospital for etiological diagnosis of uveitis, between January 2003 and July 2018. We included patients who underwent a LP as part of the etiological assessment of uveitis. LP was considered as contributory if it led to the etiological diagnosis or to correct the initially suspected diagnosis.

RESULTS

One hundred eighty eight of the 1211 patients referred for evaluation (16%) had an LP, among these patients, 93 (49.4%) had abnormal results including 69 (36.7%) patients with hypercellularity, 69 (36.7%) with hyperproteinorachia, and 28 (14.9%) with oligoclonal bands and/or increased IgG index. LP was considered as contributing to the diagnosis in only 31 (16.4%) cases, among which there were 10 (5.3%) contributions to the etiological diagnosis and 21 (11.2%) modifications in the diagnosis classification. Multivariate analysis established that African ethnicity (p < 0.001), bilateral uveitis (p = 0.01), presence of macular edema or retinal serous detachment (p = 0.048), presence of retinal vasculitis (p < 0.001), presence of neurological signs or symptoms (p = 0.01), and contributing cerebral MRI (p < 0.001) were all significantly associated with a contributory LP. LP did not lead to any therapeutic modification.

CONCLUSION

LP direct contribution to the diagnosis was rare and most often detected non-specific abnormalities. LP should be performed only in cases of neurological clinical signs or symptoms, suspicion of multiple sclerosis, Vogt-Koyanagi-Harada, or syphilis.

Tubercular Uveitis in Uveitis Cases in a High TB and HIV Setting: A Prospective Cohort Study

Purpose

The diagnosis of tubercular uveitis (TBU) is difficult. The lack of a diagnostic gold standard has contributed to challenges in determining the true prevalence and clinical predictors of TBU. We aimed to determine the proportion of TBU cases in adults with uveitis and to examine clinical features associated with TBU.

Methods

A prospective cohort study of adult uveitis cases after exclusion of other specific etiologies. The diagnosis of TBU was based on a composite reference of: any clinical signs of uveitis; exclusion of other causes of uveitis; and positive QuantiFERON-Gold test, tuberculin skin test, and/or ocular TB polymerase chain reaction.

Results

Of 79 cases analyzed, 49 (62%) had TBU. Female sex (P = 0.001) and chronic uveitis (P = 0.006) cases were more common in the TBU group than the non-TBU group whereas diffuse choroiditis (P = 0.010) and HIV-positive (P = 0.001) cases were less common. Choroidal granulomas (P = 0.176) and serpiginous-like choroiditis (P = 0.292) were more common in TBU group, albeit not significantly. On univariate analysis, female sex (odds ratio, 5.1; P = 0.002), negative HIV status (odds ratio, 0.2; P = 0.001), and chronic uveitis (odds ratio, 4.1; P = 0.008) were associated with TBU. A negative HIV test was associated with TBU on multivariate analysis (P = 0.049).

Conclusions

A high proportion of cases had TBU. Our study did not significantly confirm some of the clinical features associated with TBU reported in other studies.

Translational Relevance

Our study highlights the difficulties in determining the proportion and clinical predictors of TBU, especially in the absence of a gold standard diagnostic test.

Tubercular Retinal Vasculitis: Diagnostic Dilemma and Management Strategies

Ocular tuberculosis (OTB) is a rare, extrapulmonary manifestation of systemic TB, which has been a global etiology of uveitis for centuries, though concentrated in the developing world. OTB remains difficult to diagnose clinically despite a plethora of conventional and modern investigations. Tubercular retinal vasculitis (TRV) is a common and specific presentation of OTB but is variably defined in the literature in terms of clinical profile and the investigations essential for diagnosis and treatment. Ironically, the need and duration of antitubercular treatment is uncertain for this manifestation of ocular TB. The rationale and utility for corticosteroids is similarly equivocal for TRV. This review attempts to tease out a commonsense approach from the best available evidence and consensus in the literature to suspect, investigate and diagnose TRV with reasonable certainty, and institute appropriate treatment with due ethnic and geographic considerations.

Global prevalence and clinical outcomes of tubercular uveitis: a systematic review and meta-analysis

Tubercular uveitis (TBU) is an inflammation/infection of the eye secondary to Mycobacterium tuberculosis infection. The difficulty in making the diagnosis has resulted in variable prevalence and clinical response rates. We aimed to determine the global prevalence of TBU in uveitis patients stratified by TB high-burden countries (HBCs) and non-HBCs and by geographic regions and the clinical response of TBU to antitubercular treatment We performed a systematic review and meta-analysis of TBU studies published in PubMed, Scopus and EMBASE, up to June 30, 2020. A random effects model was used for all meta-analyses. Of 5,018 articles identified, 70 prevalence studies (65,607 uveitis and 3,166 TBU cases) and 18 clinical outcome studies (1,570 TBU cases; 1,304 responded to anti-tubercular therapy [ATT]) were analyzed. The overall weighted prevalence of TBU was 4.0% (95% CI, 3-5); in TB HBCs it was 7.0% (95% CI, 5-11), non-HBCs 3.0% (95% CI, 2-4), and sub-Saharan Africa 11.0% (95% CI, 8-15). The overall weighted clinical response was 82.0% (95% CI, 75-89). Despite the difficulty in diagnosing TBU, the prevalence is expectantly higher in HBCs, and sub-Saharan Africa and the clinical outcome is poor. Standardization of diagnostic criteria and ATT is warranted in future cohort studies.

The Association between QuantiFERON-TB Gold Test and Clinical Manifestations of Uveitis in the United States

PURPOSE

To report the prevalence of QuantiFERON-TB Gold (QFT-G) positivity among uveitis patients compared to general population and to evaluate the differences in clinical features of uveitis.

DESIGN

Retrospective cohort study.

METHODS

SETTING: Institutional.

PATIENT POPULATION

418 consecutive new uveitis patients, regardless of clinical suspicion, were tested for QFT-G.

OBSERVATION PROCEDURES

Demographics, TB risk factors, clinical characteristics of uveitis were collected.

MAIN OUTCOME MEASURES

The frequency of QFT-G positivity among uveitis patients and characteristic clinical features among QFT-G positive patients.

RESULTS

QFT-G positivity was found in 60/418 patients with uveitis (14.4%, 95% CI: 11.18 - 18.14) higher than the general US population (5%, 95% CI: 4.2 - 5.8, p<.001). Age, gender and residence were similar between QFT-G positive and negative groups. Uveitis patients with positive QFT-G were more likely to be foreign born or have a recent travel history (OR:5.84; 95% CI: 2.83 - 12.05; p<.001). QFT-G positive patients were more likely to present with granulomatous uveitis (OR 2.90; 95%CI 1.36 - 6.21; p=.006). No significant association was found with specific clinical features such as choroiditis, retinal vasculitis, occlusive vasculitis, and serpiginoid choroiditis (p>.05 for each). Prevalence of TB-uveitis based on treatment response was 1.19%.

CONCLUSIONS

Our study demonstrates significantly higher prevalence of QFT-G positivity among uveitis patients compared to average US population. Characteristic signs of TB uveitis reported in endemic countries were not seen in this cohort. Implications of higher prevalence of QFT-G positivity among uveitis patients require further investigation.

Clinical features and management of presumed ocular tuberculosis: A long-term follow-up cohort study in a tertiary referral center in Brazil

PURPOSE

To evaluate the clinical features and management of presumed ocular tuberculosis (OTB).

METHOD

A prospective 3-year follow-up study of patients with ocular inflammation that performed Interferon-gamma release assay (IGRA) and tuberculin skin test (TST) was conducted in a tertiary referral center in Brazil. Patients with clinical signs highly suspect of OTB with a positive TST and/or IGRA with other causes ruled out were prescribed anti-tuberculosis therapy (ATT) during 9 months. Clinical features and treatment outcomes were recorded.

RESULTS

Seventy-two patients (mean age 48.3 ± 15.7 years) were included in the study, and most were female (65.3%, n = 47). Posterior uveitis (43.1%, n = 31) was the main clinical feature. Multifocal choroiditis (25%, n = 18) was the most common choroidal involvement. Concomitant oral prednisone (45.8%, n = 33) during ATT was associated with more recurrences (p = 0.04). A significant difference (p < 0.001) between initial and final best-corrected visual acuity after ATT conclusion was observed. Cure or remission was observed in 58 (85.3%) patients that completed follow-up (n = 68).

CONCLUSION

In our cohort some variation in demographics and ocular phenotypes of presumed OTB was observed. The high rates of cure or remission of our patients strongly support the ATT in presumed OTB. Oral corticosteroids during ATT were associated with higher recurrences rates.

The diagnostic value of polymerase chain reaction for ocular tuberculosis diagnosis in relation to antitubercular therapy response: a meta-analysis

BACKGROUND

Polymerase chain reaction (PCR) is currently considered the method of choice for diagnosing ocular tuberculosis. However, the sensitivity and specificity of PCR using ocular samples remain uncertain. Our meta-analysis aimed to review the diagnostic accuracy of PCR testing in confirming ocular tuberculosis, with responses to antitubercular therapy (ATT) as reference indices.

METHODS

A systematic literature search of the PubMed, EBSCOHost, Scopus, and Google Scholar databases was performed using the standardized PRISMA guideline. Observational studies reporting both PCR MTb positivity and ATT response were included. Meta-analysis was performed to estimate the pooled positivity rate, sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratios (DOR), and summary receiver operating curves (SROC).

RESULTS

The pooled positivity rate for PCR MTb was 0.55 (95% CI 0.44-0.67). The overall sensitivity and specificity were 88% (95% CI 83-92) and 71% (95% CI 60-80), respectively. The pooled DOR was 12.15 (95% CI 5.55-26.62). The area under the SROC was 0.83.

CONCLUSIONS

The diagnostic accuracy of PCR Mtb is not sufficient for use as a benchmark for ocular TB diagnosis routinely based on ATT response. A negative result may help avoid prescribing unnecessary ATT in dilemmatic cases.

Development and Validation of a Bayesian Network for Supporting the Etiological Diagnosis of Uveitis

The etiological diagnosis of uveitis is complex. We aimed to implement and validate a Bayesian belief network algorithm for the differential diagnosis of the most relevant causes of uveitis. The training dataset (n = 897) and the test dataset (n = 154) were composed of all incident cases of uveitis admitted to two internal medicine departments, in two independent French centers (Lyon, 2003-2016 and Dijon, 2015-2017). The etiologies of uveitis were classified into eight groups. The algorithm was based on simple epidemiological characteristics (age, gender, and ethnicity) and anatomoclinical features of uveitis. The cross-validated estimate obtained in the training dataset concluded that the etiology of uveitis determined by the experts corresponded to one of the two most probable diagnoses in at least 77% of the cases. In the test dataset, this probability reached at least 83%. For the training and test datasets, when the most likely diagnosis was considered, the highest sensitivity was obtained for spondyloarthritis and HLA-B27-related uveitis (76% and 63%, respectively). The respective specificities were 93% and 54%. This algorithm could help junior and general ophthalmologists in the differential diagnosis of uveitis. It could guide the diagnostic work-up and help in the selection of further diagnostic investigations.

Intraocular Tuberculosis: A Challenging Case Mimicking Wet Age-Related Macular Degeneration

An otherwise healthy 72-year-old Chinese patient diagnosed with exudative age-related macular degeneration and decreased vision in left eye was fully investigated. The retrospective analysis of past multimodal imaging revealed bilateral severe choroidal neovascularization and choroiditis associated with a positive tuberculin skin testing and interferon-gamma release assay (QuantiFERON-TB Gold - Cellestis^®, Chadstone, VIC, Australia) suggestive of latent ocular tuberculosis. The variable presentation and tests' results interpretation represent the greatest limitations in understanding and treating intraocular TB (IOTB). This may present without any other systemic symptoms, the intraocular tissues are of limited access to biopsies and other tests, including imaging and immunological tests, are of relative value. This case highlights how variable may be the presentation of IOTB, which can be easily misdiagnosed leading to a delayed treatment and worse prognosis.

Optic neuritis classification in 2021

Optic neuritis (ON) can be associated with inflammatory disease of the central nervous system or can be isolated, with or without relapse. It can also be associated with infectious or systemic disease. These multiple associations based on a variety of clinical, radiological, and biological criteria that have changed over time have led to overlapping phenotypes: a single ON case can be classified in several ways simultaneously or over time. As early, intensive treatment is often required, its diagnosis should be rapid and precise. In this review, we present the current state of knowledge about diagnostic criteria for ON aetiologies in adults and children, we discuss overlapping phenotypes, and we propose a homogeneous classification scheme. Even if distinctions between typical and atypical ON are relevant, their phenotypes are largely overlapping, and clinical criteria are neither sensitive enough, nor specific enough, to assure a diagnosis. For initial cases of ON, clinicians should perform contrast enhanced MRI of the brain and orbits, cerebral spinal fluid analysis, and biological analyses to exclude secondary infectious or inflammatory ON. Systematic screening for MOG-IgG and AQP4-IgG IgG is recommended in children but is still a matter of debate in adults. Early recognition of neuromyelitis optica spectrum disorder, MOG-IgG-associated disorder, and chronic relapsing idiopathic optic neuritis is required, as these diagnoses require therapies for relapse prevention that are different from those used to treat multiple sclerosis.

Longitudinal study of serpiginous choroiditis and serpiginous like choroiditis using wide field OCT angiography

PURPOSE

To assess the ability of wide field Swept Source OCTA (SS-OCTA) imaging to detect morphological variations in Serpiginous Choroiditis (SC) and Serpiginous Like Choroiditis (SLC) in response to treatment and also analyze these findings quantitatively using Image J software.

METHODS

Retrospective observational case series of nine eyes with clinical diagnosis of active SC and SLC, who underwent SS-OCTA and fundus autofluorescence (FAF) imaging at baseline and each follow up visit till 6 months. Morphological analysis was done by two independent graders and quantitative analysis to measure the size and intensity of lesion was done using publicly available Image J software at baseline and each follow up visit.

DESIGN

Retrospective observational case series.

RESULTS

Using SS-OCTA, all the active lesions followed a characteristic healing pattern. Active lesions appear well defined hypo flow void patches and as healing progressed, lesion became more ill-defined and iso-hyper- intense. Significant increase in mean intensity of the lesion could be apparent after 1 and 6 month of treatment. There was reduction in the size of lesions during follow up however this difference was not statistically significant.

CONCLUSION

SS-OCTA could be a useful noninvasive tool to study the treatment response in SC/SLC both morphologically as well as quantitatively. Quantitative parameters need to be designed in further research studies to aid in uniform management and follow up of uveitis cases.

Distinct recurrence pattern in a case of bilateral tubercular posterior uveitis: reporting a unique clinical morphology and management challenge

Intraocular tuberculosis has protean clinical manifestations and remains an important etiological differential for uveitis in an endemic region. A 27-year-old male presented with visual acuity of counting fingers close to face in right (OD) and 20/25 in left eye (OS). Examination revealed a choroidal granuloma in OS and healed serpiginous-like choroiditis in OD. Antitubercular therapy was started with systemic corticosteroids. Granuloma resolved completely; however, the patient presented with neuroretinitis and posterior scleritis, as first and second recurrence, respectively, within a oneyear period. These were managed with systemic corticosteroids and immunosuppressive therapy was added, after second recurrence. The patient responded well and maintains remission. This case presented a clinical challenge with distinct recurrence patterns of tubercular posterior uveitis in the same eye, which has not been reported before. Successful management entailed use of antitubercular therapy, corticosteroids, and immunosuppressive therapy in a step-ladder approach, resulting in preservation of vision and achieving long-term remission.

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.