CLINICAL PREDICTORS OF TUBERCULAR RETINAL VASCULITIS IN A HIGH-ENDEMIC COUNTRY

Artificial Intelligence-Based Uveitis Diagnosis Through Retinal Vasculature Analysis: A Paradigm Shift in Ocular Tuberculosis

INTRODUCTION

Diagnosis of uveitis is complex and often requires a series of investigations. Here, we utilize artificial intelligence (AI) for the quantitative analysis of retinal vasculature parameters from fundus photographs to differentiate confirmed ocular tuberculosis (TB) from QuantiFERON (QFT)-positive uveitis without another identifiable cause and ocular toxoplasmosis.

METHODS

Medical records and stored fundus images of patients with uveitis from a cohort at the Department of Ophthalmology, University of Indonesia, were analyzed. Three groups of patients were included: confirmed ocular TB (group A), QFT-positive uveitis (group B), and ocular toxoplasmosis (group C). Fundus images were processed using the Retinalysis models package for segmentation and quantification of retinal vasculature parameters.

RESULTS

The study included nine patients (13 eyes) in group A, 38 patients (48 eyes) in group B, and 26 patients (39 eyes) in group C. Significant differences were found in vein tortuosity parameter, in the eyes within group A showing lower tortuosity score compared to eyes within group B (p = 0.030) and group C (p = 0.013). The area under the curve (AUC) of vein tortuosity for group A compared to group B was 0.749 (95% confidence interval (CI): 0.606-0.892), with a sensitivity of 67.3% and specificity of 76.9%. The AUC of vein tortuosity for group A against group C was 0.803 (95% CI: 0.658-0.948), with a sensitivity of 74.4% and a specificity of 84.6%. In group A, uveitis resolution and vein tortuosity tended to be normalized upon complete antitubercular treatment.

CONCLUSIONS

AI-based quantification of retinal vasculature parameters, particularly vein tortuosity, can differentiate confirmed ocular TB from QFT-positive uveitis and ocular toxoplasmosis. This approach shows promise for more precise diagnostic and therapeutic accuracy in ocular TB.

Management of Tubercular Retinal Vasculitis: A Case Report From an Endemic Region

India, being an endemic country for tuberculosis, has a very high prevalence of pulmonary and extrapulmonary tuberculosis. Various manifestations of ocular tuberculosis have been described, including granulomatous anterior uveitis, serpiginous choroiditis, and retinal vasculitis. We hereby describe the case of a 39-year-old male patient who presented to our clinic with complaints of diminished vision in the right eye for five months. His best-corrected visual acuity was 6/12 in the right eye with normal anterior segment examination. He was misdiagnosed as having central serous chorioretinopathy in the right eye at a primary center. The patient had typical fundus findings of perivascular infiltrates, focal vascular tortuosity, vitreous snowball infiltrates, and cystoid macular edema. Fluorescein angiography was done to evaluate the retinal findings and capillary non-perfusion areas. The patient was referred to a physician for the initiation of anti-tubercular treatment. Posterior sub-Tenon injection of triamcinolone acetonide was given for cystoid macular edema, and laser photocoagulation of capillary non-perfusion areas of the retina was done. The patient responded well to treatment with resolution of macular edema and healing of perivascular infiltrates. His visual acuity improved to 6/6 at the three-month follow-up. The patient was followed up for a period of two years with no reported complications or recurrences. This case highlights the diagnostic features of tubercular retinal vasculitis and its management.

Anti-tubercular therapy alone for treatment of isolated tubercular retinal vasculitis

PURPOSE

To compare the time to resolution of perivascular infiltrates in tubercular retinal vasculitis (TRV) between anti-tubercular therapy (ATT) alone, and in combination with systemic corticosteroids.

METHODS

Observational retrospective cohort study in a tertiary eye centre in eastern India. Patients with TRV who were treated with anti-tubercular therapy (ATT) alone (Group A), or in combination with systemic corticosteroids (Group B) were included in the study. Eyes with additional inflammatory signs (cystoid macular oedema, vitritis ≥2+, optic disc oedema) were excluded. Resolution was defined as complete disappearance of perivascular infiltrates on seven-field fundus photographs. Descriptive statistics were used for demographic data. A linear mixed effects model was applied to adjust for intereye correlations, in patients with bilateral disease. The primary outcome measure was time to resolution of perivascular infiltrates. Secondary outcome measure was need for laser or surgical intervention for management of complications of TRV.

RESULTS

Fifty eyes of 39 patients (Group A 21/18 and Group B 29/21) were included. Both groups had similar demographics and severity of vasculitis. All patients had complete resolution of TRV. On adjusting for intereye correlation, the mean difference in time to resolution between the two groups (Group A, 3.24 [95% CI 2.69-3.77] months, and Group B, 4.76 [95% CI 3.52-5.99] months) was not statistically significant (0.96 weeks [-0.52 to 2.45] p = 0.21). Vaso-occlusive complications and healing patterns were similar in both groups.

CONCLUSIONS

ATT alone, may be sufficient for resolution of perivascular infiltrates, in TRV without additional inflammatory signs.

Tubercular Retinal Vasculitis: Diagnostic Dilemma and Management Strategies

Ocular tuberculosis (OTB) is a rare, extrapulmonary manifestation of systemic TB, which has been a global etiology of uveitis for centuries, though concentrated in the developing world. OTB remains difficult to diagnose clinically despite a plethora of conventional and modern investigations. Tubercular retinal vasculitis (TRV) is a common and specific presentation of OTB but is variably defined in the literature in terms of clinical profile and the investigations essential for diagnosis and treatment. Ironically, the need and duration of antitubercular treatment is uncertain for this manifestation of ocular TB. The rationale and utility for corticosteroids is similarly equivocal for TRV. This review attempts to tease out a commonsense approach from the best available evidence and consensus in the literature to suspect, investigate and diagnose TRV with reasonable certainty, and institute appropriate treatment with due ethnic and geographic considerations.

Bilateral Ocular Tuberculosis in a Child with Negative Tuberculin Skin Test (TST): A Diagnostic Dilemma

Purpose: To report a case of bilateral ocular tuberculosis (OTB) in a child with negative Tuberculin skin test (TST).Methods: Case report.Observations: A 12-year-old malnourished systemically asymptomatic boy presented with sudden profound loss of vision in both eyes. Dense vitritis precluded fundus visualization in right eye (RE). In left eye, fundus findings of extensive vasculitis associated with multifocal retinochoroiditis were suggestive of OTB. However, negative TST, normal chest X-ray, and gram negative bacteriuria led to confusion between endogenous endophthalmitis and OTB. Based on strong clinical suspicion and high-resolution chest tomography (HRCT) of thorax which was suggestive of TB-pneumonitis, a diagnosis of presumed OTB was made. A good response to anti-tubercular-treatment and corticosteroids, with resolution of retinochoroiditis lesions, vasculitis, and vitritis, further supported our diagnosis.Conclusions: This case highlights the importance of keeping a high index of suspicion for TB-associated uveitis in children, based on clinical findings.