inflamation session - All India Ophthalmological Society

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INFLAMMATION SESSION307country like India, TB causing ocular and orbitaldisease has become increasingly rare. 2 Theincidence of ocular tuberculosis in a population isdifficult to estimate. The incidence of tubercularuveitis in India has varied from 2 to 30%. 3,4 Thislarge variation in incidence rate in differentreports possibly suggest the difference indiagnostic criteria.Ocular tuberculosis can be of two types –primary and secondary. The term primary oculartuberculosis has been used when tuberculouslesions are confined to eyes and no systemiclesions are clinically evident. The term has alsobeen used to describe the cases where the eye hasbeen the initial portal of entry. Secondary oculartuberculosis has been defined as ocular infectionresulting from contiguous spread from adjacentstructures or hematogenous spread from lungs.The various clinical presentations of oculartuberculosis are – Uveitis (Anterior andposterior), Episcleritis, Phlyctenular conjunctivitis,Eale’s disease, orbital tuberculosis etc.Definitive diagnosis of ocular tuberculosis can bemade only by demonstrating mycobacteriumtuberculosis in the ocular tissue. However,obtaining ocular tissue for diagnostic purposes isnot only difficult but also associated withsignificant ocular morbidity. Therefore, a highdegree of clinical suspicion is the key to earlydiagnosis.The clinical diagnosis of ocular tuberculosis maybe based on presence of atleast 3 of the following5 feature: (i) Suggestive clinical picture (ii)Exclusion of other aetiologies (iii) PositiveMantoux test (iv) Therapeutic response to antituberculartherapy and (v) Present or past historyof tuberculosis.The pathogenesis of ocular tuberculosis is basedon Rich’s Law which states that : Ocular lesion isdirectly proportional to Number and virulence oforganisms degree of hypersensitivity/Hostresistance.To focus on the diversity of clinical presentationof ocular tuberculosis and discuss the diagnosticapproach and an effective treatment.Materials and MethodsOur study enrolled 30 consecutive patientsduring a period of 1 year. All the cases fulfillingthe diagnostic criteria for ocular tuberculosiswere included in the study. All the casesunderwent detailed ophthalmic evaluationincluding a detailed history, visual assessment,slit lamp biomicroscopy, applanation tonometeryand Indirect ophthalmoscopy with scleralindentation.Systemic investigations included a completeblood count, erythrocyte sedimentation rate(ESR), Mantoux test, Chest X-Ray and detailedevaluation of immunosuppressive disorders forHIV by enzyme linked immunosorbent assay(ELISA). FFA was done wherever required.Diagnosed Pediatric patients of tubercularmeningitis already on ATT, referred to us forophthalmic examination – VEP was advised forchildren with non-reacting pupil and alteredsensorium .In our study, topical steroids, ATT and systemicsteroids wherever necessary gave good results.ResultsTuberculosis of eye were uniocular in 16 patientsand binocular in 14 patients. As per Table-3, thecondition was more in males than females. Themale:female ratio was found to be 1.3:1 . Table 1Table-1Clinical manifestation No.of PercentagePatients %B/L recurrent Chalazia 2 7%Phlyctenular Conjunctivitis 6 20%Episcleritis 5 17%Chr. Granulomatous uveitis 5 17%Choroiditis 4 13%Peripheral uveitis 1 2.5%Eale’s disease 2 7%Recurrent CSR 2 7%MR palsy 1 2.5%Toxic amblyopia sec to ATT 2 7%Table-230 100%Age in years No. of Patients Percentage%0-15 years 7 23%16 – 30 years 19 63%31 - 45 years 4 14%>45 years 30 100%Table-3: Sex incidenceSex No. of Patients Percentage %Male 17 57%Female 13 43%30 100%
308 AIOC 2009 PROCEEDINGSshows that in our study, Phlyctenularconjunctivitis was the commonest manifestation;it involved either the cornea or conjunctiva.However the commonest site of involvement wasthe limbal region. It usually appeared as a smallnodule surrounded by hyperemia. Most of thecases showed recurrent episodes of episcleritis.Patients with uveitis presented with eitherchoroid tubercles, chronic anteriorgranulomatous iridocyclitis, choroiditis orperipheral uveitis. Patients with Eale’s diseasepresented with painless, sudden visual loss inone eye due to vitreous hemorrhage. 2 cases hadh/o recurrent B/L chalazia. 2 cases were ofrecurrent CSR , 1 case presented with Medialrectus palsy. 2 children diagnosed as havingtubercular meningitis were already on ATT whenthey came for ophthalmic examination. Onexamination, they had toxic amblyopiasecondary to ATT, VEP was done for thesepatients and was noted as non-recordable.DiscussionThe diagnosis of ocular TB is frequentlypresumptive. Definitive diagnosis relies ondemonstration of tubercle bacilli in tissue but thisis fraught with the difficulty of obtaining oculartissue for biopsy in seeing eyes due to invasivenature of the procedure. 5 The other approach isto evaluate for systemic evidence of the diseasein a patient with suggestive ocular features, butthe absence of clinically evident systemic TB doesnot rule out ocular TB. In our study oculartuberculosis was suspected when 3 out of thefollowing five features were present. These are:1. Samson MC, Foster CS. Tuberculosis In : Foster CS,Vitale AT (eds). Diagnosis and Treatment of Uveitis.WB Saunders Company: Philadelphia 2002;264-72.2. American Thoracic Society : Diagnostic standardsand classification of tuberculosis of tuberculosis inadults and children: Am J. Rspir. Crit. Care Med 2000;161:1376-95.3. Sen DK. Tuberculosis of the orbit and lacrimalgland. J. Paed Ophthalmol 1980;17:232-8.4. Agarwal PK, Nath J, Jain BS. Orbital involvement intuberculosis. Indian J Ophthalmol 1977;25:12-6.5. Eye doi; 10.1038/sj.eye .6702093; Eye 2006;20:1068–73.References(i) Suggestive clinical picture (ii) Exclusion ofother aetiologies (iii) Positive Mantoux test (iv)Therapeutic response to anti-tubercular therapyand (v) Present or past history of tuberculosis. Inthe present study, the infection was seen mostcommonly in the age group 16-30 years and nonein the age group >45 years. This was unlike theprevious study by Holland published in Surveyof Ophthalmology in 1993 which showed that itcan occur in 1 to 75 years of age. Males wereinfected more than females(1.5:1) in this studywhich is in accordance with previous studies.Ocular TB presents a complex clinical problemdue to a wide spectrum of presentations anddifficulty in diagnosis. In most of the previousstudies done, Uveitis has been the most commonocular manifestation and can be present asanterior, posterior, or panuveitis. 1 In our studypatients with uveitis presented with chronicanterior granulomatous iridocyclitis , multifocalchoroiditis, choroidal tubercles and peripheraluveitis. The spectrum of ocular tuberculosis isstill evolving. Gupta et al (14) recently reported aseries of 7 cases with a serpiginous-likechoroiditis. All 7progressed inspite of steroidtreatment and subsequently responded to ATT. 5There is thus a wide spectrum of presentationsand thus a high index of suspicion is needed,especially in at-risk patients for timely diagnosisand treatment. Further, the dramatic response toATT in these cases justifies empirical treatmentbased on a high index of clinical suspicion andpositive tuberculin test.6. Rosen PH, Spalton DJ, Graham EM. Intraoculartuberculosis. Eye 1990;4:486-92.7. Inhihara M, Ohno S. [Ocular tuberculosis]. NipponRinsho 1998;56:3157-61.8. Biswas J, Madhavan HN, Gopal Badrinath SS.Intraocular tuberculosis. Clinicopathologic study offive cases. Retina 1995;15:461-8.9. Bodaghi B, LeHoang P. Ocular tuberculosis[review]. Curr Opin Ophthalmol 2000;11:443-8.10. Khosla PK, Garg SP : Role of tuberculosis inintraocular inflammation in India. In Shimigu K,Editors – Current aspects in ophthalmology place.1992;1981-2.Discussion comment by Dr Naresh Kumar Yadav : Number of cases very less. The title should havestated presumptive ocular tuberculosis, as no tests were done to isolate and identify the mycobacterium. Non invasivetests like Polymer chain reaction and quantiferon gold test could be done. Attributing Recurrent chalazion andreccurent CSR to tuberculosis is far fetched, at least specimen from chalaiion could have been sent for HP. Thereis no mention about the treatment and its duration given to the patients.
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