Fall 2017 Newsletter

Follow our latest updates in our Summer 2019 Newsletter

Fall 2017 Newsletter
7th Residency Announcement

Exciting Residency Announcement!

ACGME approves seventh resident complement; first increase in over 30 years!

Grand Rounds

Grand Rounds and Case Studies

Check out our weekly presentations

OTEP

OTEP

Ophthalmic Technician Education Program

LARGEST STUDY ON CHINESE AMERICANS PUBLISHED

LARGEST STUDY ON CHINESE
AMERICANS PUBLISHED

USC Ophthalmology Researchers Find More
Effective Treatments For Blinding Eye Diseases

EDUCATION

Case Study: Needle in a Haystack

Presenter: Andrew Clark, MD, PhD Discussant: Brian Toy, MD
 

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
CXR
CXR

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

Green

B/W

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

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