India Prof. Dr. Jyotirmay Biswas MS. FMRF, FNAMS, FIC Path., FAICO Director of Uveitis and Ocular Pathology department Sankara Nethralaya, 18, College Road, Nungambakkam Chennai – 600 006, India. E-mail: drjb@snmail.org

Top 5 things in Tubercular uveitis

1

When do you suspect tubercular uveitis ? Granulomatous anterior or intermediate uveitis Broad posterior synechiae Retinal vasculitis with choroiditis Multifocal serpiginoid choroiditis Sub-retinal abscess Choroidal nodule

Am J Ophthalmol 2010;149: 562-570 Broad –based posterior synechiae Retinal vasculitis with or without choroiditis Serpiginous like choroiditis

When do you suspect tubercular uveitis ? It can have protean manifestations

17 yr old girl biopsy proven abdominal TB OD Frosted branch angiitis due to Tuberculosis

Pre treatment Post treatment with ATT

2

Tubercular Uveitis- what are the tests ? Mantoux and QuantiFERON TB gold test is supportive only Exposure does not mean active infection Do anterior chamber tap, vitreous aspiration, FNAB Subject to polymerase chain reaction for MTB genome

40% positive cases were Mantoux negative Ophthalmology 2011;118: 772-777 40% positive cases were Mantoux negative

QuantiFERON TB gold test alone may not be specific for intraocular TB. Ind J Ophthalmol 2009,57 (6) 427-430 QuantiFERON TB gold test alone may not be specific for intraocular TB. The significance of this test in a case scenario needs to be interpreted with clinical presentation and other evidences for intraocular TB

3

Tubercular Uveitis X ray Chest is not enough Do high resolution CT chest

Ocular Immunology and Inflammation, 19(1),51-57,2011 81% TB, 8.3% sarcoidosis

Chest HRCT showing tree in bud appearance Subretinal abscess. Chest HRCT showing tree in bud appearance

4

Intraocular Fluid study often gives the diagnosis Polymerase chain reaction is often diagnostic Sensitivity around 80% Specificity 100%

21 year old female with gran 21 year old female with gran. Anterior uveitis with mutton fat KPs and broad post and peripheral anterior synechiae AC tap done

Agarose gel electrophoretogram representing the results of Mycobacterium tuberculosis PCR targeting MP64 gene and IS6110 region 200 bp MPB 64 IS6110 MPB64 gene IS6110 NC2 : Negative control second round NC2 : Negative control second round NC1 : Negative control first round NC1 : Negative control first round VRF 4948/12 AC tap : Positive VRF 4948/12 AC tap : Positive PC : Positive Control H37RV DNA PC : Positive Control H37RV DNA 100 bp : Molecular weight marker 100 bp ladder

FNAB specimen PCR for MTB + SUBRETINAL ABSCESS FNAB Blood Before treatment FNAB specimen PCR for MTB +

5

How do you treat tubercular uveitis? Start with four drug anititubercular therapy Always combine with steroid

Tubercular Uveitis- what is the duration of treatment ? Don’t treat as pulmonary TB for 6months Treat as extra pulmonary TB and give ATT at least for 9 months

British Journal Of Ophthalmology November 2012 What is the correct duration of anti tubercular therapy? British Journal Of Ophthalmology November 2012

A SANKARA NETHRALAYA PRESENTATION THANK YOU A SANKARA NETHRALAYA PRESENTATION