History

• 64-year-old male with decreased/blurry vision OD x1wk
• Acute onset, slowly progressive
• Initially associated with eye pain and photophobia, which has resolved
• No proir episodes, no eye trauma
• Denies weight loss, fevers, rashes, oral/genital ulcers, MSK/joint pain, pet/animal exposures, new/recent sexual partners
• No chronic cough/breathing difficulties
• No sick contacts
• No known uncooked meat ingestion

Differential Diagnosis

• Acute, unilateral panuveitis OD with granulomatous anterior component
• Infectious
• Viral: HSV 1/2, VZV, CMV
• Bacterial: TB, syphilis, cat-scratch
• Parasitic: Toxoplasmosis
• Neoplastic
• Lymphoma
• Autoimmune
• VKH
• SLE
• Behcet
• Sarcodosis
• Sympathetic ophthalmoplegia

Pathophysiology

• Hypothesis 1
• Ocular seeding via hematogenous spread at time of infection prior to adaptive immune response
• Primary site uveal tract
• Latent then reactivation with clinical disease
• Hypothesis 2
• Inflammatory response to circulating bacterial antigens

Treatment

• Ocular TB is Active TB
• Initiate systemic antibacterial therapy with assistance of IM/ID
• Adjuvant topical and/or systemic steroids in most cases
• Initiation of steroids necessitates antibacterial therapy to reduce risk of worsening disease

Prognosis and Future Directions

• Started on Bactrim DS empirically and PF QID/atropine BID
• Returns 1wk VA 20/40: Continued vitreous haze but significantly improved
• Started on RIPE after discussion with ID Pending follow up after initiation of therapy

Summary

• Ocular TB can present in nearly any form with uveitis being the most common
• Accurate diagnosis remains a challenge and requires a combination of exam and diagnostic testing
• Clinical suspicion should remain high, especially in patients from endemic areas
• Patients frequently respond to a combination of antibacterial and corticosteroids
• International partnerships are actively working to better define and understand ocular TB

References

• World Health Organization. Global tuberculosis report 2013. Geneva, Switzerland: World Health Organization, 2013
• Zimmerman MR. Pulmonary and osseous tuberculosis in an Egyptian mummy. Bull N Y Acad Med. 1979 Jun; 55(6):604-8
• Ranjita, S., Loaye, A. S., & Khalil, M. (2011). Present Status of Nanoparticle Research for Treatment of Tuberculosis. Journal of Pharmacy and Pharmaceutical Sciences, 14(1), 100–116.
• Skeiky, Y. A. W., & Sadoff, J. C. (2006). Advances in tuberculosis vaccine strategies. Nature Reviews Microbiology, 4(6), 469–476.
• Barberis I et al (2017). The history of tuberculosis: from the first historical records to the isolation of Koch’s bacillus. J Prev Med Hyg. 58(1): E9–E12.
• Ernst JD (2012) The immunological life cycle of tuberculosis. Nature Reviews Immunology. 12, 581–591.
• Guirado E and Schlesinger LS (2013) Modeling the Mycobacterium tuberculosis granuloma – the critical battlefield in host immunity and disease. Front. Immunol. 4:98. doi: 10.3389/fimmu.2013.00098.
• MacNeil A et al (2019) Global Epidemiology of Tuberculosis and Progress Toward Achieving Global Targets — 2017. MMWR 68(11):263-266
• Albert DM and Raven ML (2016) Ocular tuberculosis. Microbiol Spectra. 4(6):doi:10.1128/microbiolspec.TNMI7-0001-2016
• Basu S et al (2015) Pathogenesis and Pathology of Intraocular Tuberculosis. Ocular Immuno & Inflam. 23(4): 353–357
• Biswas J et al (2016) Polymerase chain reaction for Mycobacterium tuberculosis DNA detection from ocular fluids in patients with various types of choroiditis in a referral eye center in India. Indian J Ophthalmol. Dec;64(12):904-907
• Agarwal A et al (2019) The Collaborative Ocular Tuberculosis Study (COTS)-1 Report 3: Polymerase Chain Reaction in the Diagnosis and Management of Tubercular Uveitis: Global Trends. Ocul Immunol Inflamm. 27(3):465-473
• Agarwal A et al (2019) Standardization of Nomenclature for Ocular Tuberculosis – Results of Collaborative Ocular Tuberculosis Study (COTS) Workshop. Ocul Immunol Inflamm. 00(00):1-11
• Testi I et al (2019) Tubercular Uveitis: Nuggets from Collaborative Ocular Tuberculosis Study (COTS)-1. Ocul Immunol Inflamm 25:1-9
• Agrawal R et al (2020) Collaborative Ocular Tuberculosis Study (COTS) Consensus Guidelines on the Management of Tubercular Uveitis – Report 1: Guidelines for Initiating Anti-Tubercular Therapy in Tubercular Choroiditis. Ophthalmology Accepted, pre-publication

Contact

• Brian Toy, MD, Assistant Professor of Clinical Ophthalmology, brian.toy@med.usc.edu
• Andrew Clark, MD, PhD, PGY-1 Ophthalmology resident, andrew.clark@med.usc.edu

Section Editors

• Charles Flowers, Jr., MD, Associate Professor of Clinical Ophthalmology, Program Director, charles.flowers@med.usc.edu
• Brandon Wong, MD, Assistant Professor of Clinical Ophthalmology, Associate Program Director, brandon.wong@med.usc.edu