Association of Mycobacterium tuberculosis in the causation of Eales' disease: an institutional experience

Ocular tuberculosis masquerading as atypical ocular toxoplasmosis

Ocular tuberculosis is a great mimicker of various uveitis entities. We present a case of a 29-year-old male who came in with blurring of vision and floaters in the left eye. On examination, the left eye had anterior chamber cells and vitritis associated with retinitis. He had no other symptoms. The initial presentation was consistent with ocular toxoplasmosis, and he was started on oral sulfamethoxazole-trimethoprim and showed a good response to the treatment. However, work-up revealed negative toxoplasma antibody titers but a positive M. tuberculosis interferon-gamma release assay test and Mantoux test, making the diagnosis of ocular tuberculosis more likely. The patient was shifted to antituberculous therapy, which eventually resulted in the resolution of the inflammation with a recovery of the visual acuity. The diagnosis of ocular tuberculosis requires a detailed medical history as well as microbiologic and immunologic studies. A high index of suspicion by the treating ophthalmologist is necessary to reveal the diagnosis.

Adjuvant Intravitreal Bevacizumab for Retinal Neovascularization in Eales' Disease Associated With Latent Mycobacterium Tuberculosis

We report a case of bilateral Eales' disease managed with intravitreal bevacizumab. A 32-year-old woman with a history of bacillus Calmette-Guerin vaccine, administered when she was 10 years old, presented with a five-day history of a scotoma in the temporal field of her right eye. A dilated fundus exam and fluorescein angiography showed bilateral retinal peripheral capillary non-perfusion, retinal neovascularization in the right eye, and deep intraretinal hemorrhages in the left eye. Her laboratory workup resulted in a positive QuantiFERON-TB Gold test (Cellestis Ltd, Carnegie, Victoria, Australia). Chest computed tomography showed a calcified granuloma in her right lung. Angiographic-guided pan-retinal photocoagulation was performed, and intravitreal injections of bevacizumab (1.25 mg/0.05 mL) were administered in both eyes over the course of three months. The intraretinal hemorrhages resolved after three months of therapy. Three months following treatment, the patient showed normal fundus findings without any evidence of recurrence and a visual acuity of 20/20 in both eyes. Intravitreal bevacizumab in combination with angiography-guided pan-retinal photocoagulation may be efficacious in select patients with Eales' disease.

A Curious Case of Occlusive Retinal Vasculitis in a Young Individual Associated with COVID-19 Vaccination

A 23-year-old man presented with the blurring of vision in the left eye for 4 days. Best-corrected visual acuity was 6/6 N6 in both eyes. Examination revealed an unremarkable right eye while the left eye showed occlusive retinal vasculitis with no retinitis, choroiditis, or macular involvement. Fundus fluorescein angiography confirmed the same. History revealed the patient had received 2nd dose of Covishield vaccination 4 weeks before the onset of symptoms. Blood investigations were negative for infectious or any systemic autoimmune disease. Serum homocysteine and serum CMV IgG levels were grossly increased while tests for antiphospholipid syndrome were weakly positive. He responded well to a combination of intravitreal and oral antivirals, oral steroids for vasculitis and tablets Clopilet and Homin. This case is extremely intriguing in terms of the involvement of the adenoviral vector vaccine either as a causative factor or being just a coincidental finding.

Infection, Infectious Agents and Vascular Disease

BACKGROUND

Infectious agents may be involved in the pathogenesis of vascular disease and related complications. The aim of this review is to analyze the most relevant information on the common infections related to vascular disease, discussing the main pathophysiological mechanisms.

METHODS

In the current review, the most important evidence on the issue of infections and vascular disease is searched on Medline, Scopus, and ScienceDirect database.

RESULTS

Among infectious agents, herpesviruses, parvovirus B19, hepatitis viruses, human immunodeficiency virus, severe acute respiratory syndrome coronavirus 2, treponema pallidum, mycobacterium tuberculosis, pseudomonas aeruginosa, staphylococcus aureus, and candida albicans seem to particularly related to vascular disease.

CONCLUSION

Infectious agents may affect vessel's homeostasis and functionality, both on the arterial and venous side, by means of several pathophysiological mechanisms such as dysregulation in vasomotor function, thromboembolic complications, initiation and progression of atherosclerosis, alteration of perivascular adipose tissue, recruiting inflammatory cells and molecules.

Intravitreal Aflibercept as a Rescue Therapy for Retinal Neovascularization and Macular Edema due to Eales Disease

We report the rescue effect of intravitreal aflibercept injections on retinal neovascularization and macular edema due to Eales disease. Case 1 was a 36-year-old female. Intravitreal aflibercept was administered as rescue therapy after persistent retinal neovascularization following retinal photocoagulation, periocular triamcinolone, and intravitreal ranibizumab injection. Retinal neovascularization initially regressed, but recurred after 5 months along with macular edema. Two more intravitreal aflibercept injections were given, and retinal neovascularization with macular edema regressed. Her vision improved to 20/25 and remained stable after 43 months. Case 2 was a 27-year-old female. Intravitreal aflibercept was administered after persistent retinal neovascularization and macular edema following periocular triamcinolone injection. The macular edema initially subsided but recurred after 3 months. Intravitreal aflibercept injections were then administered once every three months to maintain her vision 20/20. The patient has been followed up for 28 months. Intravitreal aflibercept was effective as a rescue therapy in the treatment of Eales disease to regress retinal neovascularization, though repeated injections were necessary in cases of recurrence.

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

BACKGROUND

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

RESULTS

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

CONCLUSIONS

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

Review of people with retinal vasculitis and positive QuantiFERON®-TB Gold test in an area nonendemic for tuberculosis

PURPOSE

To assess the frequency of a positive QuantiFERON^®-TB Gold test (quantiferon) among patients with retinal vasculitis in an area nonendemic for tuberculosis (TB); to review clinical characteristics and management of affected individuals.

METHODS

Consecutive patients with retinal vasculitis and a positive quantiferon were retrospectively analyzed. Demographics, clinical data, laboratory, imaging findings, and therapy were evaluated.

RESULTS

Among 49 patients with retinal vasculitis, 12 (24%) had a positive quantiferon. Median age was 37 years, there were five female patients. Five individuals (42%) had previously lived in a country endemic for TB. Retinal vasculitis was occlusive in six patients (50%). On chest imaging, pulmonary tuberculosis was suspected in one patient (8.3%). Treatment modalities included full antitubercular treatment (n = 1), isoniazid prophylaxis (n = 6), systemic corticosteroids (n = 8), and laser treatment (n = 5). After a median follow-up of 27.5 months, inflammation was inactive (n = 6) or recurrently present (n = 6). No patient lost ≥ 2 lines of best-corrected visual acuity during follow-up.

CONCLUSIONS

The quantiferon test is recommended in the evaluation of people with retinal vasculitis. Interpretation of a positive result can be challenging in a country nonendemic for TB. The majority of patients with quantiferon-positive retinal vasculitis were found to have latent TB.

Retina and the tubercle Bacillus: Four decades of our journey and current understanding

Tuberculosis continues to be a major pandemic with enormous public health implication. Involvement of ocular tissues in the form of tubercles, tuberculomas, panophthalmitis, and iris granulomas are well recognized as definitive manifestations of tuberculosis. For these lesions, confirmatory evidence is available in the form of demonstration of acid-fast Bacillus on Ziehl-Neelsen staining. For other retinochoroidal disorders such as central serous chorioretinopathy, retinal vasculitis, and presumed ocular tuberculosis, hard evidence about the role of Mycobacterium tuberculosis is lacking. In this review, work done at our center over the past four decades in the form of experimental animal studies, nucleic acid amplification assays and clinical studies regarding the above retinochoroidal pathologies and the tubercle Bacillus is presented. It is possible that revisiting experimental animal studies may be a way forward in the current scenario of ambiguity about the cause-effect relationship between M. tuberculosis and few of the retinochoroidal disorders.

Retinal vasculitis

PURPOSE OF REVIEW

Ophthalmologists and rheumatologists frequently have a miscommunication among themselves, and as a result differ in their opinion for patients consulting them with retinal vasculitis. This report seeks to establish a common understanding of the term, retinal vasculitis, and to review recent studies on this diagnosis.

RECENT FINDINGS

The genetic basis of some rare forms of retinal vascular disease has recently been described. Identified genes include CAPN5, TREX1, and TNFAIP3; Behçet's disease is a systemic illness that is very commonly associated with occlusive retinal vasculitis; retinal imaging, including fluorescein angiography and other newer imaging modalities, has proven crucial to the identification and characterization of retinal vasculitis and its complications; although monoclonal antibodies to interleukin-17A or interleukin-1 beta failed in trials for Behçet's disease, antibodies to TNF-alpha, either infliximab or adalimumab, have demonstrated consistent benefit in managing this disease. Interferon treatment and B-cell depletion therapy via rituximab may be beneficial in certain types of retinal vasculitis.

SUMMARY

Retinal vasculitis is an important entity for rheumatologists to understand. Retinal vasculitis associated with Behçet's disease responds to monoclonal antibodies that neutralize TNF, but the many other forms of noninfectious retinal vasculitis may require alternate therapeutic management.