33 BEST OF BEST PAPERS OF ALL SESSIONS

T
uberculosis is a communicable disease
caused by Mycobacterium tuberculosis or
related members of the TB complex. About 10%
of infected individuals become symptomatic of
which 1-2% present as uveitis. 90% remain
infected for the rest of their lives without
manifesting the disease.
2
Though ocular
tuberculosis is rare, incidence of pulmonary and
extrapulmonary TB has increased - in part
because of the rapid spread of AIDS.
3
Ocular TB
is defined as an infection by M. tuberculosis in
the eye, around the eye, or on its surface.
2
Classically it has been divided into two types
based on its pathogenesis: primary and
secondary. Primary disease implies that the eye
is the initial port of entry while in secondary
disease the organisms spread to the eye
hematogenously. Primary disease includes
conjunctival, corneal, and scleral disease, while
tuberculous uveitis is a common manifestation of
secondary disease.
4
The TB bacillus is highly
aerobic, with an affinity for oxygenated tissues.
Thus, tuberculosis frequently affects apices of
lungs as well as the choroids, which has the
highest blood flow rate in the body. The most
common clinical findings of intraocular TB
include solitary or multiple choroidal nodules,
choroiditis and retinal vasculitis.
5,8-10
The
choroidal nodules suggest direct hematogenous
infection while vasculitis and choroiditis are
more likely to be result of immune
hypersensitivity. Tuberculous anterior uveitis is
typically granulomatous and accompanying
vitritis is not uncommon.
2
TB should be
considered in differential diagnosis of chronic
anterior granulomatous uveitis with or without
posterior segment involvement. Absence of
clinically evident pulmonary TB does not rule out
the possibility of ocular TB, as 60% of patients
with extra pulmonary TB have no evidence of
pulmonary tuberculosis.
6
To analyse the clinical profile, treatment and
visual outcome in patients with evidence of
systemic tuberculosis and uveitis suspected as
tubercular uveitis presenting with varied ocular
manifestations in a tertiary eye care centre
between January 2007 and December 2007.
Materials and Methods
This was a retrospective, non-comparative,
interventional type study. 45 eyes of 27 patients
were analysed. The patients were presumed to
have tuberculous uveitis if they fulfilled one of
the following criteria:
1. uveitis with prior documented history of
systemic tuberculosis.
2. uveitis with corroborative evidence of
systemic disease with positive Mantoux skin
test and chest radiograph.
3. PCR analysis for M. tuberculosis from
aqueous or vitreous sample.
4. Positive Quantiferon gold test for M.
tuberculosis.
5. FNAC from hilar or cervical lymphnode
positive for cytology.
A detailed history was elicited and a complete
ocular examination was conducted for all
patients. The following demographic and
AUTHORSS PROFILE:
DR. JYOTIRMAY BISWAS: M.S., PGIMER, Chandigarh; Fellow, VR
Surgery, Sankara Nethralaya, Chennai; Fellow, Ophthalmic Pathology,
Doheny Eye Institute, Southern California, USA. Presently Director,
Dept. of Uveitis and Head, Dept. of Ophthalmic Pathology, Sankara
Nethralaya, Chennai.
This paper was conferred with the NARSING A RAO Award for the BEST PAPER of UVEA Session.
Clinical Profile of Tubercular Uveitis in A Tertiary Care
Ophthalmic Centre
Dr. Jyotirmay Biswas, Dr. Renu Athanikar, Dr. Sudharshan. S., Miss. Kaleemannisha
(Presenting Author: Dr. Renu Athanikar)
BEST PAPER
OF
UVEA
SESSION
medical data was recorded : patient age, gender,
medical history, laterality of disease, initial visual
acuity, ocular findings like anterior segment
flare, cells, keratic precipitates, synaechiae,
associated vitritis if present, morphologic
description of choroidal lesions and additional
features if any. Chest X-ray and Mantoux test
were done in all patients. USG B scan showing
choroidal mass was done in 16 eyes. Aqueous tap
was done in 8 eyes. Vitreous tap was done in 4
eyes. FNAC was done in 1 patient. Quantiferon
gold test was done in 1 patient. All patients were
treated with anti tuberculous treatment and
steroids (topical/periocular/systemic). Patients
were followed up regularly upto a period of 1
year and treatment response was assessed based
on visual acuity and status of anterior and
posterior segment inflammation.
Results
45 eyes of 27 patients were analysed. Age range
was 7 to 62 years, mean age of presentation being
32.3 years. Presentation was bilateral in 18
(66.66%) patients and unilateral in 9 (33.33%)
patients. 9 (33.33%) patients had prior
documented history of systemic tuberculosis
while 18 (66.67%) patients had no previous
history of tuberculosis. Clinical presentations
included: choroidal granuloma in 22 eyes (48.88
%), intermediate uveitis in 9 eyes (20%),
granulomatous anterior uveitis in 6 eyes
(13.33%), panuveitis in 3 eyes (6.7%), multifocal
choroiditis in 4 eyes (8.9%) and serpiginous like
choroiditis in 1 eye (2.2%). Chest X-ray and
Mantoux test were done in all patients while
polymerase chain reaction (PCR) on
aqueous/vitreous samples, fine needle aspiration
cytology (FNAC), Quantiferon gold test were
done in selected patients. Most common
modality of treatment was a combination of anti
tuberculosis treatment (ATT) and steroids
(topical/periocular/oral). Vision improved in 60
% in eyes, remained stable in 13.33% eyes and
deteriorated in 26.66 % eyes.
Discussion
Ocular tuberculosis presents a complex clinical
problemdue to a wide spectrumof presentations
and difficulty in diagnosis.
5,6,7
Uveitis is the most
common ocular manifestation and can present as
anterior, posterior, or panuveitis
1
of which the
most common is choroiditis as shown in a study
by Nagini Sarvananthan et al.
12
But our study
revealed choroidal granuloma as the commonest
presentation. Samson MC
1
et al reported that
tubercular anterior uveitis is typically
granulomatous and may occur with or without
posterior segment involvement which coincides
with our study. Tuberculous uveitis has varied
presentations such as choroidal granuloma,
intermediate uveitis, granulomatous anterior
uveitis, panuveitis, multifocal choroiditis and
serpiginous like choroiditis as seen in our study.
Thus a high index of suspicion should be present
to pick up TB uveitis and prompt treatment with
anti tuberculous drugs should be started. Gupta
et al
13
reported a series of seven cases with
serpiginous like choroiditis. All seven cases had
fundus features suggestive of this condition but
continued to progress in spite of adequate steroid
treatment and subsequently responded to ATT.
Our study showed 1 such presentation.
The diagnosis of tuberculosis is frequently
presumptive.
2
Definitive diagnosis is by
demonstration of tubercle bacilli in tissue
obtained by biopsy. In our study FNAC was
done in 1 patient which gave positive result. But
ocular manifestations may result from a delayed
hypersensitivity reaction in absence of any
infectious agent.
7
Thus evaluating presence of
systemic disease is of prime importance.
Mantoux skin test is the standard test for
diagnosis of systemic TB.
7
A positive skin test is
detectable 3 to 8 weeks after primary infection.
An intense skin reaction is an immunologic
response based on delayed hypersensitivity.
There is no specific size of induration that
confirms TB, nor does a negative test exclude
diagnosis of TB.
7
Thus the results of Mantoux test
need to be interpreted keeping in mind previous
BCG vaccination, exposure to nontuberculous
mycobacteria and systemic immunosuppression
or malnutrition. In cases of diagnostic dilemma
PCR for ocular fluid can be done. It is a rapid test
with a high sensitivity and specificity.
4
It is more
useful because only a small sample is needed and
viable cells are not required.
4
In our study PCR
testing of aqueous was done in 8 eyes of which 4
showed positive result. PCR testing of vitreous
sample was done in 4 eyes of which 2 showed
positive result. Newer tests such as Quantiferon
TB gold test are based on gamma interferon
production by T cells sensitized to specific
34 AIOC 2009 PROCEEDINGS
antigens, which are specific to M. tuberculosis
and therefore not influenced by BCG or most
nontuberculous bacteria. In our study 1 patient
was subjected to this test to confirm diagnosis of
TB.
Response to treatment is mainly monitored by
bacteriological evaluation. Patients with
pulmonary TB should get their sputum
examination done monthly till cultures turn
negative. In case of ocular TB the response to
treatment must be assessed clinically. Response
usually occurs within first 2 weeks. Patients on
ATT should also be educated and monitored for
drug toxicity. LFT should be done regularly and
medicines should be discontinued if there are
signs of drug induced hepatitis. Optic neuritis
may occur with ethambutol and eighth nerve
damage may occur with streptomycin.
Hypersensitivity reactions may also occur and
may need discontinuation of therapy. Acute
uveitis has been reported with rifampin.
11
1. Tubercular uveitis has protean
manifestations.
2. A high index of suspicion helps in early
diagnosis of TB uveitis.
3. Mantoux test remains a standard test to
diagnose ocular tuberculosis.
4. In case of diagnostic dilemma, PCR testing of
intraocular fluid can help in diagnosis.
5. Newer tests like quantiferon can be very
supportive and have increased the diagnostic
yield.
6. ATT in addition to topical/periocular/
systemic steroids remains as a mainstay of
treatment.
7. Improvement of ocular condition is based on
early recognition and appropriate
management of systemic condition.
35 BEST OF BEST PAPERS OF ALL SESSIONS
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