Ocular Tuberculosis

Lecture for Medical students

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Tuberculosis (TB)
 Is a multisystem disease caused by a
pathogenic bacteria called Mycobaterium
Tuberculosis.
 TB is a very common cause of morbidity and

mortality throughout the world.

 The disease affect multiple organs and systems

of our body which includes our lungs, brain,

intestine, bones, skin, lymph nodes, and eyes.
 Patients with poor socioeconomic status and

those with compromised immunity such as

HIV/AIDS patients are mainly affected by the
disease. 2
Pathology/Pathogenesis
 Infection occurs after inhalation of the
bacteria from a patient with pulmonary TB.
 Some patients can have hematogenous

spread of the TB bacteria and develop TB in

multiple organs- Disseminated Tuberculosis
 Intraocular TB (eg Choroidal tubercle) occurs

due to hematogenous spread of the TB

bacteria.

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Pathology/Pathogenesis
 Surface ocular infection results from direct
inoculation (eg, conjunctival nodule) or
delayed hypersensitivity (eg,phlyctenule).

 Histopathologic examination feature of TB

infection reveals caseating granulomas with
Langerhans’ giant cells and acid-fast bacilli.

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Ocular Tuberculosis
 Ocular TB is rare
 Only 1%-2% of patients with active TB in other

parts of the body will have associated ocular

TB.
 Symptoms include:

◦ Blurred vision
◦ Floaters
◦ Occasionally redness, pain and photophobia

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Clinical features of ocular TB
 TB can involve both anterior and posterior
segment of the eye, ocular adnexa and orbit.
 The most common manifestations of Ocular
TB include:
◦ Phlyctenular keratoconjunctivitis
◦ Interstitial keratitis
◦ Granulomatous Iridocyclitis
◦ Scleritis
◦ Choroidal granuloma
◦ Posterior uveitis and
◦ Retinal vasculitis

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Anterior uveitis with hypoyon due to
TB

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Choroidal tubercle

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A patient with choroidal TB before and after treatment

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A patient with choroidal TB and
vitritis before and after treatment

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Tuberculous Retinal vasculitis

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A patient with brain TB with associated papiloedema and
multiple choroidal tubercles

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Choroidal tuberculoma before (A)and few
weeks after (B) treatment

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Ocular Investigations
 Gram stain and culture of ocular fluids
 Fluorescein angiography (FA) and ultrasonography
can be used to evaluate choroidal granulomas.
 On FA,the lesions may be hyper- or
hypofluorescent early; they stain late.
 B-scan ultrasonography typically shows an
elevated mass with an absent scleral echo.
 A-scan ultrasonography shows low internal
reflectivity.
 FA will show staining of vessels in cases of Retina
vasculitis.

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FA of a patient with tuberculouse multifocal choroiditis-
Lesions are hypofluorescent in early phase (B) and hyper in
late phase (C) of FA

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Systemic investigations
 Purified Protein Derivative (PPD) is skin test to determine
past exposure to M. tuberculosis organism.
 Positive PPD skin test without active systemic disease is

usually insufficient to make a presumptive diagnosis of

intraocular tuberculosis.
 Full systemic evaluation should follow. This evaluation

typically includes:
◦ chest x-ray;
◦ sputum analysis for acid fast bacilli
◦ Biopsy of liver, lymph nodes, or bone marrow;
◦ Stool for acid-fast smear;
◦ Cultures of blood, urine, cerebrospinal fluid, or pleural fluid.
 It is important to rule out concomitant HIV infection with
TB.
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Treatment
 All newly diagnosed patients must receive a
four-drug regimen of
◦ Isoniazid,
◦ Rifampin,
◦ Pyrazinamide,
◦ And either streptomycin or ethambutol for 6 to 9
months.
 Systemic corticosteroids should be used with
the anti-TB drugs for 4-5 weeks.
 Topical corticosteroids and cycloplegics may
be used adjunctively.

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Ocular side effects of Anti-TB drugs
 Ethambutol-
◦ At high dose it causes optic neuritis, and aquired
dyscromatopsia
◦ Its toxicity is dose related and occurs if the total
daily dose is above 15mg/kg
◦ Occurs 3-6 months after the start of treatment
◦ All patients taking ethambutol should have baseline
ocular evaluation and follow up every 2-3monthly.
 Isonizid rarely causes optic neuritis

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