Tuberculous uveitis.pptx for educational purpose only

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1. Tuberculous posterior uveitis Dr Sandhya Somasundaran

2. CASE 1 45 year female with sudden onset of painless loss of vision associated with mild headache - 1 week back. Hypertensive,diabetic and having CAD for 3 yrs 2 Visual acuity-PL+ Grade 3 RAPD No evidence of anterior uveitis NS 2 BCVA 6/6 Pupil brisk No evidence of anterior uveitis NS 2

3. FUNDUS RIGHT EYE Media hazy due to fine vitreous floaters Optic nerve head granuloma noted with multifocal choroiditis patch.Scattered hemorrhages and white centered hemorrhages were also noticed. 3

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5. FUNDUS LEFT EYE Media clear.Disc margins blurred and disc appears pale . Multiple healed choroiditis patches seen in posterior pole and mid periphery.Few scattered hemorrhages also seen . Red Is the color of blood, and because of this it has historically been associated with sacrifice, danger and courage. 5

6. FUNDUS LEFT EYE 6

7. Multifocal choroiditis with optic nerve head granuloma

8. Investigations Hb-13.3gm% Tc -9100 RBS-250mg/dl FBS-210mg/dl PPBS- 260mg/dl 8 HbA1C-13.8 Blood urea-16 S.creatinine-1.1 Mantoux - 27mm S.ACE-5.8

9. MRI BRAIN PLAIN AND CONTRAST Right optic neuritis with chorioretinitis.No other involvement of brain structures 9

10. CECT THORAX Centrilobular nodules in adjacent lung parenchyma- possibly due to tuberculosis 10

11. Started on ATT Cat 1 along with systemic steroids

12. Two weeks later BCVA-2/60 Vitritis decreased Granuloma healed Choroiditis patches also healed 12

13. CASE 2 13

14. 60 yr old male patient with complaints of mild pain both eyes and defective vision left eye of one month duration. HT and CAD on treatment Family history of TB in elder brother 14

15. 15 BCVA 6/6 Pupil brisk NS grade 2 No evidence of anterior uveitis BCVA 3/60 Pupil brisk NS grade 2 No evidence of anterior uveitis Anterior segment examination

16. 16 FUNDUS RIGHT EYE Multiple irregular grey white coalescent lesions seen within temporal arcade and extending temporal to fovea also.Fovea appears spared.Few lesionswere having fuzzy borders suggestive of activity

17. FUNDUS LEFT EYE Multiple irregular grey white coalescent lesions seen within temporal arcade and extending temporal to fovea also..Few lesions were having fuzzy borders suggestive of activity.Fovea shows atrophic lesions. The lesions were less extensive than in right eye 17

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20. 20 OCT MACULA RIGHT EYE

21. 21 OCT MACULA LEFT EYE

22. 22 FUNDUS AUTOFLUORESCENCE RIGHT EYE

23. 23 FUNDUS AUTOFLUORESCENCE LEFT EYE

24. 24 FFA RIGHT EYE

25. 25 FFA LEFT EYE

26. 26 INVESTIGATIONS Complete blood count -WNL ESR-62mm Mantoux - 15mm Sputum AFB - negative Chest X ray- No evidence of active or healed pulmonary TB CECT thorax - No evidence of active or healed pulmonary TB

27. 27 Started on category 1 ATT Systemic steroids were also started

28. Follow up 28 After 6 wks of ATT and steroids BCVA in left eye improved to 6/36

29. QUERIES IN DIAGNOSIS AND TREATMENT OF OCULAR TUBERCULOSIS Guidelines for starting ATT Which are the ocular lesions strongly suspicious of ocular tuberculosis Should we start steroids along with ATT 29

30. 30 TESTS FOR TUBERCULOSIS Immunologic Tuberculin skin test (TST) Interferon gamma release assays (IGRA) Radiologic Chest X ray CECT chest PET scan Tissue Sample based tests Smear Culture Molecular nuclei acid amplification tests Histopathology

31. Correct technique of Mantoux 31 5TU of PPD 0.1ml is injected intradermally so that a pale wheal of skin 6-10mm is formed. Horizontal diameter of the induration should be read 48-72 hrs later Mantoux test should not be done in those Who had previous mantoux more than 15mm Who had tuberculosis previously

32. Endemic Non endemic TST/IGRA + Radiologic TST+IGRA+Radiologic TST+IGRA+Radiologic TST+IGRA+Radiologic Recurrent granulomatous anterior uveitis First episode of granulomatous uveitis with suggestive phenotypes like uveitis with iris nodules,keratic precipitates,posterior synechiae,insidious onset and chronicity Endemic Non endemic Anterior uveitis

33. 33 Intermediate ,panuveitis,Multifocal and unifocal choroiditis Intermediate,panuveitis,Multifocal and unifocal choroiditis Endemic Non endemic IGRA/TST+Radiologic IGRA+Radiologic

34. 34 Serpiginous like choroiditis,Choroidal granuloma,Active retinal vasculitis Serpiginous like choroiditis,Choroidal granuloma Active retinal vasculitis TST/IGRA +/- Radiologic TST + IGRA +/- Radiologic

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36. 36 1.Collaborative Ocular Tuberculosis Study (COTS) Consensus Guidelines on the Management of Tubercular Uveitis – Report 2: Guidelines for Initiating Anti-Tubercular Therapy in Anterior Uveitis, Intermediate Uveitis, Panuveitis and Retinal Vasculitis https://doi.org/10.1016/j.ophtha.2020.06.052 Rupesh Agrawal, Ilaria Testi, Baharam Bodaghi, Talin Barisani-Asenbauer, Peter McCluskey, Aniruddha Agarwal, John H. Kempen, Amod Gupta, Justine R. Smith, Marc D. de Smet, Yew Sen Yuen, Sarakshi Mahajan, Onn Min Kon, Quan Dong Nguyen, Carlos Pavesio, Vishali Gupta, for COTS CON group 2.Testi I, Agrawal R, Mehta S, Basu S, Nguyen Q, Pavesio C, et al. Ocular tuberculosis: Where are we today? Indian J Ophthalmol 2020;68:1808-17. 3. Shakarchi F. Ocular tuberculosis: current perspectives. Clin Ophthalmol . 2015;9:2223-2227 https://doi.org/10.2147/OPTH.S65254 References

37. Steroids along with ATT 37 Systemic corticosteroids could be initiated concomitantly with or soon after the administration of ATT in patients with TB SLC, tuberculoma with no active systemic infection, and TB Multifocal Choroiditis /TB Focal Choroiditis only if the threat to vision is high. In a meta-analysis by Aa ra kee et al there was no difference in the outcome between ATT alone and ATT + Steroids.

38. ATT monotherapy versus ATT + steroids in tuberculoma 38 Khalsa , A., Kelgaonkar , A. & Basu , S. Anti-TB monotherapy for choroidal tuberculoma : an observational study.  Eye  (2021). https://doi.org/10.1038/s41433-021-01505-1

39. TAKE HOME MESSAGE 39 Start ATT only with strong clinical suspicion and according to COTS guidelines Steroids only in sight threatening lesions

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