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CLINICAL STUDY
N Jones1
tuberculous
uveitis: diagnosis,
management,
and outcome
antigens (either as a tuberculin skin test or therapy).6 Four patients did not require tuberculin
g-interferon test) and if no other cause of uveitis was skin testing (they had active TB already diagnosed or
identified. Patients were included in the study only if a known past TB). Gamma-interferon testing for latent
full 6-month course of standard ATT was administered TB became available in our unit in the later stages of this
(usually 2 months of rifampicin, isoniazid, pyrizinamide, study period. All four patients tested were positive
and ethambutol followed by 4 months of rifampicin and these were also positive on tuberculin skin testing
and isoniazid).5 (Table 1).
Data was extracted from clinical records, including Three patients had evidence of active TB in a
age, sex, ethnic origin, country of birth, history of non-ocular site; two had pulmonary disease (one with
previous TB or contact, tuberculin skin testing and/or retinal vasculitis, one with intermediate uveitis) and
g-interferon testing and treatment details. Ocular status both had complete remission of uveitis 6 months after
including visual acuity (VA) and degree of inflammation completion of ATT. The third patient had spinal
were assessed at the commencement of ATT (baseline), TB and developed relapsing anterior uveitis at
after the completion of treatment (6 months), and presentation, which became quiescent for several
6 months later (12 months). Anterior uveitis was months during ATT, followed by a single recurrence
recorded as granulomatous or non-granulomatous at 6 months.
based on the appearance of keratic precipitates or iris The uveitis became quiescent during ATT and
nodules at presentation. Behaviour of chronic uveitis remained so 6 months later in 16 (67%), of those patients
was classified as fluctuating or unremitting. Details of who demonstrated an immune response to TB antigens
concurrent oral steroid treatment were noted. without evidence of active disease at another site.
In five patients (of whom three also received oral steroid
treatment), inflammation was controlled during ATT
Results
but recurrent anterior uveitis developed at a mean
TB-associated uveitis was considered in 45 patients over 0.2 months after discontinuing ATT, requiring topical
the study period. This group comprises 1.9% of the total steroids in four and a short course of systemic steroids
2368 patients referred to the Manchester Uveitis Clinic in one. In the other three patients (all with positive
during this period. Medical records were no longer Mantoux test), ATT had no beneficial effect on
available in 5 patients; of the remaining 40, 6 failed to inflammation. Of these, one had serpiginous choroiditis
complete a full 6-month course of ATT and 7 had and required oral immunosuppression and in the
defaulted from follow-up. The remaining 27 patients remaining two, a reappraisal changed the diagnosis
were therefore included in the study. Of these, to sarcoidosis.
11 (41%) were male and 16 (59%) female with a mean Nineteen patients required oral prednisolone at a
age of 36.1 years at presentation. mean starting dose of 57.2 mg/day, tapering for a mean
All 27 patients were UK residents, of whom 7 were of 9.6 months, owing to the severity of intraocular
born in UK, 10 in India, 5 in Pakistan, 4 in Africa, inflammation. The starting dosage was chosen according
and 1 in Bangladesh. In all, 19 (70%) were of Asian to patient weight, severity of inflammation, and the
ethnicity, 4 were Caucasian and 4 were Afro-Caribbean. concurrent use of rifampicin (which necessitates higher
Bilateral ocular inflammation was present in 21 patients doses). At the final assessment 6 months after completion
(78%). At presentation, 13 had chronic panuveitis, of ATT, 13 patients had 2 or more lines improvement
4 intermediate uveitis, 4 retinal vasculitis, 3 chronic in VA compared with presentation, 5 had deteriorated
anterior uveitis, 2 multifocal choroiditis, and 1 classical (3 because of cataract, 1 because of macular scarring,
serpiginous choroiditis (Table 1). Seven patients (26%) and 1 because of corneal scarring) and in 9 there was
had granulomatous keratic precipitates and 4 had no change. The visual results of ATT and the final
macular oedema. diagnosis are summarised in Table 1.
Fourteen patients (52%) had at some stage been in
close contact with a family member treated for TB,
Discussion
but none had received TB prophylaxis. Chest X-ray
was normal in 19, 6 showed signs indicative of old The diagnosis of extra-pulmonary TB is often difficult,
TB infection and 2 showed features consistent with nowhere more so than for intraocular disease3 and this is
active pulmonary TB. Twenty-three patients underwent reflected in the absence of information on ocular TB
Mantoux skin testing. All showed 10 mm or more of management in any of the TB guidelines of the UK, USA
induration (with the exception of one patient who was or Canada. Uncommonly, live mycobacteria or their
considered positive despite only 6 mm induration, DNA may be accessible from intraocular samples.7
because of concurrent high-dose oral corticosteroid More commonly, intraocular inflammation is either
Eye
Table 1 Clinical features and outcomes of anti-tuberculous treatment in study group.
Pt. no. Age at Sex Country Description Type Eye ? TB TB CXR TST G-IFN Start dose Steroid Rx R VA at L VA at R VA L VA Final
diagnosis of birth of uveitis contact of steroid duration presentation presentation at 12 m at 12 m diagnosis
1 26 M India REV NGR B Smear þ ve N Active Not Not done 60 24 6/5 6/5 6/36 6/5 TB uveitis
pulm TB done
2 45 F India CAU GRA B N N Clear þ þ Not done 6/6 6/6 6/6 6/6 TB uveitis
3 53 M Pakistan CPU NGR B N N Clear þ þ Positive 60 8 6/12 2/36 6/60 2/36 TB uveitis
4 42 F UK GEO NGR B N Y Old þþ Not done 3/60 6/9 3/60 6/6 Non TB-
focus serpiginous
5 33 F Pakistan EAL NGR B N N Clear þ þ Not done 40 6 6/12 CF 6/6 CF TB uveitis
6 18 F UK CPU NGR B N Y Clear þ Positive 40 12 6/9 6/9 6/12 6/6 Unknown
7 45 F India INT NGR R N Y Clear þ þ Not done 3/60 6/9 6/36 6/6 Unknown
8 3 F UK CPU NGR B N Y Hilar þ þ Not done 6/9 6/6 6/9 6/9 Unknown
nodes
9 38 M India MCH NGR B N N Clear þ þ Not done 60 7 6/6 6/24 6/5 6/5 TB uveitis
10 35 F Senegal FCH GRA B Old lung N Old Not Not done 30 7 6/4 6/9 6/5 6/9 TB uveitis
focus done
11 28 M UK INT NGR B N Y Clear þ þ Not done 80 8 6/9 6/9 6/9 6/9 Sarcoidosis
12 50 F India CPU NGR B N Y Clear þ þ Not done 60 12 6/24 6/18 6/18 6/18 TB uveitis
13 75 F UK CPU NGR B Old lung N Old Not Not done 80 13 6/36 6/36 6/9 6/12 TB uveitis
focus done
14 35 F India CPU GRA B N Y Clear þ þ Not done 60 8 6/18 6/60 6/9 6/60 TB uveitis
15 46 M India INT NGR R Smear þ N Active þ þ Not done 80 10 6/18 6/4 6/6 6/4 TB uveitis
pulm TB
16 60 F Pakistan CAU NGR B N Y Clear þ þ Not done 40 12 6/18 6/18 6/9 6/9 TB uveitis
C Sanghvi et al
22 46 F Bangladesh INT NGR L N N Old þ þ Not done 6/4 6/9 6/6 6/6 TB uveitis
focus
23 19 F India APU GRA B N N Clear þþ Not done 40 6 6/12 6/12 6/6 6/9 TB uveitis
24 27 M UK CPU NGR B N N Clear þþ Not done 6/60 6/24 1/60 6/6 TB uveitis
25 32 M India AAU NGR B Spine N Clear Not Not done 6/6 6/36 6/6 6/18 Unknown
done
26 23 M India EAL NGR B N Y Clear þþ Not done 60 5 6/6 6/9 6/6 6/6 TB uveitis
27 34 F Gambia INT NGR B N Y Hilar þþ Not done 60 7 6/9 6/9 6/6 6/6 Sarcoidosis
nodes
Abbreviations: APU, acute panuveitis; AAU, acute anterior uveitis; B, bilateral; CAU, chronic anterior uveitis; CPU, chronic panuveitis; CXR, chest X-ray; FCH, focal choroiditis; GEO, geographic choroiditis;
G-IFN, gamma-interferon testing GRA, granulomatous; INT, intermediate uveitis; L, left; MCH, multifocal choroiditis; N, no; NGR, nongranulomatous; R, right; REV, retinal vasculitis; TST, tuberculin skin test
þ , positive; þ þ , strongly positive; Y, yes.
477
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C Sanghvi et al
478
presumed to be a hypersensitivity response rather than has been used to characterise the state of ‘latent’ TB.
direct infection, or possibly mycobacteria are sequestered This term becomes confusing in the presence of active
within the retinal pigment epithelium as has been uveitis; this may be unrelated to the TB immune
anecdotally reported.8 In most circumstances, where response, which therefore is truly latent. However, the
cultured mycobacteria are unavailable, an accumulation uveitis may be an ophthalmic manifestation of TB, either
of supportive circumstantial evidence, together with directly or via a hypersensitivity mechanism. Despite the
an absence of evidence of other diseases within the absence of other sites of active TB it has been our practice
differential diagnosis, must be used. The strength of such to treat such cases as active TB and as such they are
supportive evidence will be judged via an informal notified.
Bayesian analysis by the doctor, in the knowledge of Tuberculin skin testing may thus be helpful and should
local risk factors, which differ markedly throughout be performed, but its predictive value is hampered by
the world. variable responsiveness, previous BCG vaccination,
A primary factor is the population risk for TB. The the effects of environmental mycobacterial exposure or
United Kingdom has in the past 50 years been a very possible sarcoidosis, and agreements on the relevant
low-risk area for TB acquisition among its indigenous diameter of induration, although necessary, are by
population, which has been partially protected by mass nature somewhat arbitrary. The predictive value varies
BCG vaccination, a policy that has now been replaced by depending on the population TB incidence and local
targeted BCG vaccination in high prevalence areas. BCG vaccination policy; in the United States, the routine
In contrast, some countries have a high prevalence of use of TB skin testing in patients with uveitis is
TB and the approach to diagnosis will differ.9 However, considered unhelpful13 whereas in India it is considered
increasing immigration to the United Kingdom from mandatory.8 In our study, excluding those with active TB
high prevalence countries, commencing with those from all of our patients were Mantoux test positive 410 mm
the Indian sub-continent in the 1960s and followed by and in the context of any active uveitis without
many from high-risk areas including Africa and Eastern another defined aetiology, this should be considered
Europe, have altered the population risk profile.2 important guidance. In our clinic, TB skin testing and/or
The type of uveitis exhibited may suggest TB to the g-interferon testing is not routinely undertaken for all
ophthalmologist, although the reasons for this may be patients. It is requested for patients with uveitis with
unreliable; observations made especially in the early a history of contact with TB, of emanating from a
twentieth century (when TB was endemic in the Western TB-endemic area, or where a suggestive uveitis is
world) have taught generations of ophthalmologists to seen and no other cause is identified.
consider certain types of uveitis (particularly The confounding issue of previous BCG vaccination
granulomatous anterior uveitis, choroiditis, and certain is currently the most important reason to consider
types of retinal vasculitis) more suggestive of TB than g-interferon testing; BCG was derived from M. bovis,
other forms of uveitis, an approach used for diagnosis in which is different antigenically from M. tuberculosis;
a recent study.9 However, in the absence of definitive g-interferon testing is more specific to M. tuberculosis.
intraocular evidence of aetiology, responsiveness to ATT In comparing sensitivity and predictive value g-interferon
may indicate the correct diagnosis; our series provides testing is currently not considered a replacement for
little support for a narrow diagnostic approach; recovery tuberculin skin testing as its value for the prediction of
of ‘atypical’ uveitis including non-granulomatous development of active TB in the future is as yet not
anterior uveitis was also seen, suggesting that the known,14 although interpretation will vary depending on
ophthalmologist should not exclude the possibility of the BCG vaccination policy of the country under study.
TB-associated uveitis from the differential diagnosis In this context, we have evaluated our own clinic’s
merely on the basis of clinical appearance. The recent approach to TB diagnosis and management, using a
description of ‘atypical serpiginous choroiditis’ positive response to ATT as a marker for correct
secondary to TB10 has been both reinforced by further diagnosis, and have examined retrospectively the clinical
studies11 and widened to include more varied and diagnostic markers leading to the initiation of
presentations including placoid-like retinitis12 and treatment. The period under study (1992–2007) has seen
this reminds us that our diagnostic net should be cast markedly increasing immigration, the introduction of
fairly widely. g-interferon testing and polymerase chain reaction (PCR)
A certain reliance on non-ocular diagnostic methods is for bacterial DNA.15
therefore necessary. The great majority of patients will Our study shows that in 19 patients (70.3%) uveitis
not have evidence of active TB at another extraocular site. disappeared and did not recur 6 months after stopping
Demonstration of the presence of an immune response ATT. The use of oral steroid in the majority of patients
to TB antigens in the absence of evidence of active TB is clearly a confounding issue, but the continued absence
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Presumed tuberculous uveitis
C Sanghvi et al
479
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C Sanghvi et al
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11 Mackensen F, Becker MD, Wiehler U, Max R, Dalpke A, 16 Varma D, Anand S, Reddy AR, Das A, Watson JP, Currie DC
Zimmerman S. Quantiferon TB-GOLDFa new test et al. Tuberculosis: an under-diagnosed aetiological agent
strengthening long-suspected tuberculous involvement in uveitis with an effective treatment. Eye 2006; 20:
in serpiginous-like choroiditis. Am J Ophthalmol 2008; 1068–1073.
146: 761–766. 17 Comer M, Young S, Lightman S. Anterior uveitis after
12 Teyssot N, Bodaghi B, Cassoux N, Fardeau C, Le Mer Y, healed acute retinal necrosis. Arch Ophthalmol 2002; 120:
Ullern M et al. Acute posterior multifocal placoid pigment 88–90.
epitheliopathy, serpiginous and multifocal choroiditis: 18 Kotake S, Kimura K, Yoshikawa K, Sasamoto Y, Matsuda A,
etiological and therapeutic management. J Fr Ophtalmol Nishikawa T et al. Polymerase chain reaction for the
2006; 29: 510–518. detection of mycobacterium tuberculosis in ocular
13 Rosenbaum JT, Wernick R. The utility of routine screening tuberculosis. Am J Ophthalmol 1994; 117: 805–806.
of patients with uveitis for systemic lupus erythematosus 19 Gupta V, Arora S, Gupta A, Ram J, Bambery P, Sehgal S.
or tuberculosis: a Bayesian analysis. Arch Ophthalmol 1990; Management of presumed intraocular tuberculosis: possible
108: 1291–1293. role of the polymerase chain reaction. Acta Ophthalmol Scand
14 Albini TA, Karakousis PC, Rao NA. Interferon-g release 1998; 76: 679–682.
assays in the diagnosis of tuberculous uveitis. Am J 20 Therese KL, Jayanthi U, Madhavan HN. Application of
Ophthalmol 2008; 146: 486–488. nested polymerase chain reaction (nPCR) using MPB 64
15 Centers for Disease Control Prevention. Targeted tuberculin gene primers to detect Mycobacterium tuberculosis DNA
testing and treatment of latent tuberculosis infection American in clinical specimens from extrapulmonary tuberculosis
Thoracic Society. MMWR Recomm Rep 2000; 49: 1–51. patients. Indian J Med Res 2005; 122: 165–170.
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