Tuberculosis and the Eye
Miles Stanford
Euretina Uveitis Course
Hamburg 2013
Epidemiology of TB
• One third of the world’s population has been
infected with TB: 1 new infection every
second
• 1:10 with latent TB will get active disease
• <5% are associated with HIV infection but this
rises to 100% in some areas
• Multidrug resistant disease is increasing
(approx 0.5 million)
• 58 countries have XDR TB cases
Prevalence of ocular disease in patients with TB
– reported case series
1% USA, 4% China, 6% Italy, 7% Japan,
Saudi Arabia
16%
Epidemiology of TB in the UK
• Current incidence 13.8/100,000
• Higher in patients from India (36%) and subSaharan Africa (24%)
• Current rate 11/100,000 in the North of
England
• 40/100,000 in Manchester
Pathophysiology: Hypotheses
• Direct infection with mycobacterium
• Delayed type hypersensitivity reaction
• Mycobacterium sequestered in RPE
Ocular TB – Anterior segment
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Eyelids
Conjunctiva
Phlyctenulosis
IK or sclerokeratitis
Lid granuloma and old necrotising scleritis
Diffuse scleritis in a 35 year old Nigerian
with a history of fever, night sweats,
weight loss and raised inflammatory
markers
Posterior segment manifestations of
TB
• Posterior uveitis in 42%; panuveitis in 11%
• Usually:
– Intermediate uveitis (11%)
– Retinal vasculitis +/- choroiditis
– Serpiginous-like choroiditis
Gupta A, Bansal R, Gupta V, Sharma A, Bambery P. Ocular signs predictive of tubercular
uveitis. Am J Ophthalmol. 2010 Apr;149(4):562-70
Acute presumed TB
retinal vasculitis (Eales
disease) in a 32 year
old Sri Lankan woman
Clear signs of old ocular disease in her other
eye
Kyrieleis periarteritis in a patient with
presumed TB
TB presenting as ampiginous choroiditis
Patient subsequently developed classical
Eales disease
Eales disease: inflammatory stage
24 year old caucasian with occlusive
vasculitis
Eales Disease: pre-proliferative stage
Presumed ocular TB presenting with
vitreous haemorrhage
Choroidal tubercles in a patient with
TBM
Massive tuberculous choroidal
granuloma
A 13 year old Somali girl with miliary TB – Optic
nerve head TB abscess
Serpiginous – like choroiditis
Ocular TB – differential diagnosis
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Sarcoidosis
Behcet’s disease
Idiopathic ischaemic retinal vasculitis
Choroidal infection – pneumocystis, etc
Choroidal tumour
Presumed ocular TB - diagnosis
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No pathognomic clinical features
Ask about TB contact, recent travel, etc
Check CXR
Mantoux skin test
γ interferon testing
Response to anti-TB treatment
CXR
Ghon complex/cavities
Mediastinal/hilar LAD
Calcified LNs
Mantoux test
• Specificity confounded by BCG vaccination
• Read at 48 - 72hrs: +ve if
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>5mm in HIV pt
>10mm in high-risk (from endemic area)
>15mm in all
US suggests cut off at 5mm and ignoring previous
BCG for screening
Gamma Interferon Tests
• Immunological test against antigens found in
mycobacterium TB
• Antigens NOT in BCG
• Quanti-feron TB Gold/in tube, T-SPOT,
ELISPOT
Current NICE guidance (2011)
• For Latent TB
- Offer Mantoux to household contacts of
patients with active TB and non- household
contacts (eg workplace)
- Consider IGRA for those with +ve Mantoux
and those who have had BCG
- Mantoux inconclusive, refer to TB specialist
- In immunocompromised offer both tests
M. TB from a vitreous smear
Ocular TB- Therapy
• Rifampicin, isoniazid, pyrizinamide,
ethambutol for 2 months
• Rifampicin and isoniazid for 4 months
• Will need longer if active TB detected
• Prednisolone as required but double the dose
when on rifampicin because of liver enzyme
induction
Treatment of TB - India
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Retrospective interventional case series
Inclusion criteria
Complete clinical records
Documented positive skin test (>10mm)
Evidence of active uveitis
All other infect/non-infect causes ruled out
Minimum 1 year follow up
Treatment of TB - India
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360 patients studied
216 received anti TB treatment and steroids
144 received steroids alone
Recurrences were reduced in the first goup
(15.7%) compared to the second (46%) –
p<.001 at median follow up of 24 and 31
months
AJO 2008 146;772-9
Presumed tuberculous uveitis:diagnosis
management and outcome
• Retrospective study of 27 patients
• 4/27 caucasian
• >1/2 had history of contact with a patient
treated for TB
• All received 6 months of anti-TB therapy
• 19/27 required systemic steroids as well
• Inflammation resolved after TB therapy in
70%
Eye 2011 25:475-80
Ocular TB – how long should we treat?
• Retrospective case series from Singapore
• 46 >6 months ATT, 18 <6 months
• Patients with > 9 months treatment were less
likely to relapse (OR 0.09, p=0.02)
• Patients with uveitis and latent TB treated for 9
months had an 11 fold reduction in the
likelihood of relapse
Br J Ophthalmol 2012 96:332-6
Ocular TB - Summary
• TB is on the increase as is the ocular disease
associated with it
• All patients with ampiginous/serpiginous
choroiditis should be screened for latent TB
• Consider the diagnosis especially in patients
presenting with occlusive retinal vasculitis
• If all else fails and clinical suspicion is still
high, try anti tuberculous therapy