Intraocular Tuberculosis Mamta Agarwal Senior Consultant Uveitis & Cornea Services Sankara Nethralaya Chennai

Ocular history 32 yr/ M OD - C/O blurred vision x 4 months

General History H/O fever, loss of hearing, weight & appetite since 2 months Diagnosed as Tubercular Meningitis Current Treatment Oral antitubercular therapy

Clinical Presentation BCVA OD – CF1m OS – 6/6 SLE OD – AC quiet, vit cells+ OS - normal

First Examination - Fundus OD OS Choroidal granuloma with exudative retinal detachment Healed choroidal granuloma

HRCT chest MRI brain Miliary tuberculosis

Management Investigations ESR – 60 mm I hr HRCT chest – S/O miliary Tuberculosis MRI brain –Multiple tuberculoma in brain parenchyma U/S Retinochoroidal elevation with exudative RD Treatment Oral steroid & Antitubercular therapy

Follow up 2 months BCVA OD – CF1m OS – 6/6

Tubercular Choroidal granuloma Final Diagnosis Tubercular Choroidal granuloma

Ocular Tuberculosis Extra pulmonary tuberculosis – Pleura, lymphnodes, liver, kidney, CNS, eyes. Mechanism of disease Hematogenous spread Hypersensitivity reaction with distant focus of infection Most common clinical manifestations Choroidal mass 34% Choroiditis/ chorioretinitis 27% Vitritis 24% Iridocyclitis 13% Panuveitis 11% Others – conjunctivitis, interstitial keratitis, scleritis, ocular adnexa & orbit involvement

Discussion Diagnosis of ocular TB is a diagnostic challenge. Definite diagnosis – PCR/ Culture Presumed Ocular Tuberculosis Clinical history & findings Ancillary tests Therapeutic trial of anti tuberculosis treatment No single, safe, sensitive, specific test exists. Diagnostic tests like aqueous paracentesis or vitreous tap have lower sensitivities & risk of complications.

Conclusion HRCT chest is more sensitive & specific than X rays. Mantoux test has limited sensitivity. False positive in patients with non tuberculous mycobacterial infection & post BCG vaccination. False negative in immunocompromised states. Quantiferon tests fails to distinguish between active & latent infection. Useful in immunocompromised states, smear negative pulmonary TB. PCR tests – Highly specific, low sensitive, invasive procedure.