Ocular TB can affect any part of the eye, including the uvea, with the involvement of choroid being the most common one, the retina, the vitreous, the optic nerve and the sclera.
Among all causes of intraocular inflammation, clinical features of ocular TB are suggestive but not specific for the disease and that poses a significant challenge in the diagnosis, especially because in most cases the disease is confined to the eye in the absence of any findings throughout the body.
TB is an infection disease caused by Mycobacterium Tuberculosis, which is spread person-to-person by aerosolized particles when people sick with TB expel the microorganisms into the air by cough. In most cases healthy people infected with the mycobacterium have body’s natural defenses, namely the immune system, that contains the spread of the infection and leads to what is called latent infection. People with latent infection do not have active disease and don’t have any symptoms.
However, they are at risk of developing active disease during their lifetime (reactivation of latent infection), including ocular TB.
Ocular TB is due to the dissemination of the mycobacterium via the blood stream and its subsequent localization into the eye, where it is capable of inducing an inflammatory reaction, most commonly manifesting as uveitis. In most cases the active tubercular disease is confined to the eye and patients diagnosed with ocular TB have no active TB disease in their lungs, which means that they are not contagious.
Symptoms can affect one eye or both eyes, and include pain, redness, light sensitivity, blurred vision, floaters (dark floating spots in the vision), and decreased vision.
However, patients can be asymptomatic.
Ocular TB is usually suspected based on suggestive ocular signs, with the diagnosis being supported by laboratory investigations.
Different tests are performed to check for previous exposure to the mycobacterium, including tuberculin skin test and Quantiferon TB Gold.
In addition, chest imaging, including chest X-ray or chest computed tomography, is usually performed to detect any changes suggestive of TB in the lungs. All the tests can help achieve the diagnosis in selected patients manifesting a clinical picture suggestive of ocular TB.
The disease is curable and a prompt diagnosis with early treatment can address the disease at an early stage, avoiding damages to the eye and subsequent visual loss.
Treatment for ocular TB is the same as for pulmonary TB, consisting of a multi-drug regimen with 4 oral antimicrobial drugs (isoniazid, rifampicin, pyrazinamide and ethambutol), and is often managed with the help of a pulmonologist or an infectious disease specialist.
In addition to the anti-tubercular drugs, concomitant systemic steroids are frequently necessary to control the inflammation and prevent the damage to ocular tissues.
TB medicines have adverse effects, and patients should be closely monitored for the onset of ocular side effects, including optic neuritis, manifesting with loss of vision and associated with eye pain, loss of colour vision and visual field defects; and systemic side effects, including toxicity to the liver, manifesting with nausea, vomiting, dark urine, yellow skin or eyes, fever, persistent physical tiredness, abdominal tenderness; peripheral neuropathy (damage to the nerves of the peripheral nervous system), occurring most commonly in the lower extremities, with sensory disturbances (e.g., numbness, tingling, burning, pain, loss of temperature sensation), difficulty walking, weakness, decreased or absent deep tendon reflexes; gastrointestinal intolerance; skin rash and hypersensitivity reactions.
Ocular TB is curable and severe visual loss can be prevented when medications are taken properly.
If not well controlled, ocular TB can result in long term damage because of the chronic inflammation damaging the ocular tissues.
Common complications include cataract, glaucoma, abnormal vessels growing under the retina (choroidal neovascularization) and epiretinal membrane. All these complications can affect the quality of vision.
Tubercular anterior uveitis. Active granulomatous anterior uveitis with posterior synechiae.
Tubercular serpiginous-like choroiditis. Optos colour and autofluorescence images showing evolution of serpiginous-like choroiditis lesions from the acute to healed stage.
Tubercular multifocal choroiditis. Optos colour images showing choroiditis lesions at different stages of activity: active lesions appearing as yellowish lesions, while pigmented lesions indicating healed stage.
Multimodal imaging of tubercular choroidal granuloma.
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Ilaria Testi
The London Clinic Eye Centre
119 Harley Street
London W1G 6AU
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