Tuberculous orbital apex syndromes

MRI in intracranial tuberculosis: Have we seen it all?

Tuberculosis is emerging worldwide across diverse populations and geographies; unrestricted by the social divide and the geographical barriers in today's interconnected world. This rise in its prevalence can be linked to multiple factors including urbanisation, spurt in global travel, population explosion, migration and HIV infection. The varied and complex clinical presentation of intracranial tuberculosis tricks even the best of the clinicians. This along with the other facets associated with its management including drug resistance, paradoxical reaction, underlying HIV infection can make it particularly challenging. Imaging has a definitive role in the evaluation and follow-up of intracranial tuberculosis and MRI is the cornerstone in this regard. Typical features of intracranial tuberculosis are well-described. However, it is not infrequent to encounter atypical and bizarre presentations, both clinically and on imaging. A holistic clinical and imaging review of difficult cases, including newer MRI techniques, is necessary for the neuroradiologist, neurologist and the neurosurgeon to arrive at the right diagnosis in a timely fashion.

Neuro-Ophthalmic Manifestations of HIV Infection

Purpose: To review the broad spectrum of clinical neuro-ophthalmic presentations associated with human immunodeficiency virus (HIV) infection. Methods: Critical review of the literature regarding neuro-ophthalmic consequences of HIV infection and its sequelae. Results: Neuro-ophthalmological diseases are common in both asymptomatic HIV-positive patients and those who profound immunosuppression with acquired immune deficiency syndrome (AIDS). Neuro-ophthalmic manifestations of HIV infection can involve the afferent or efferent visual pathway. Common clinical presentations include headache, papilledema, chorioretinitis, optic nerve involvement, meningitis, and cranial nerve palsies. Other neuro-ophthalmic manifestations include involvement of the visual pathway in the brain producing visual field defects such as occur in progressive multifocal encephalopathy. Pupil abnormalities have also been reported. Discussion: Neuro-ophthalmic consequences of HIV are important to recognize as it is critical to identify underlying neoplastic or infectious diseases which could be amenable to treatment.

Orbital tuberculosis: perspectives from Victoria, Australia

PURPOSE

Orbital tuberculosis (TB) is a rare extra-pulmonary manifestation of tuberculosis and its clinical diagnosis poses unique challenges, with potential for destructive complications as well as social and public health implications. The aim of this study is to report our experience of patients presenting with orbital TB and to identify common aspects.

METHODS

A systematic search for mandatory notifications of orbital tuberculosis between January 01, 1994 and December 12, 2016 was undertaken in the Victorian Tuberculosis database. In addition, members of the Australian and New Zealand Society of Ophthalmic Plastic Surgeons (ANZSOPS) were surveyed to identify cases of orbital tuberculosis diagnosed on biopsy in the past 20 years. Medical case notes of identified cases were reviewed retrospectively.

RESULTS

Three cases were identified as having occurred in Victoria, aged 44-59 years old. All cases had emigrated from endemic countries with higher tuberculosis burden. Diagnosis of tuberculosis was often difficult due to few or non-viable acid fast bacilli and low yield of positive culture in paucicellular orbital specimens.

CONCLUSIONS

Orbital TB is rare but remains an important differential diagnosis of orbital mass lesions. The diagnosis of orbital TB requires a high index of clinical suspicion and targeted investigations in patients originating from endemic areas. Diagnosis and treatment rely on effective collaboration between ophthalmologists, infectious disease physicians, and pathologists.

Long-Term Outcomes of Oral Anti-Tubercular Therapy in Patient with Tubercular Dacryoadenitis: A Case Series

Purpose: To describe the clinico-radiological features and long-term outcomes in patients with tubercular dacryoadenitis (TbD) Methods: Retrospective, observational study of TbD patients who underwent a thorough clinical examination, orbital imaging study, and tailored ancillary investigations. Polymerase chain reaction (PCR) and microscopy were done in specific cases. A 4-drug anti-tubercular therapy (ATT) was started and clinical response was monitored in all. Patients with a minimum follow-up of 6 months "off-ATT" were included. Results: All patients were women and three presented with pain, blepharoptosis, and bilateral involvement. In all, ESR was raised, Mantoux test was positive and orbital imaging revealed enlarged lacrimal gland/s. Positive PCR and granulomatous inflammation on microscopy were seen in two patients. At a mean follow-up of 17.25 months, all women responded with no relapse or clinical recurrence. Conclusion: Bilateral lacrimal gland enlargement, positive Mantoux & PCR with early response to ATT may provide sufficient evidence for diagnosing TbD.

Infectious optic neuropathies: a clinical update

Different forms of optic neuropathy causing visual impairment of varying severity have been reported in association with a wide variety of infectious agents. Proper clinical diagnosis of any of these infectious conditions is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular findings. Diagnosis is confirmed by serologic testing and polymerase chain reaction in selected cases. Treatment of infectious optic neuropathies involves the use of specific anti-infectious drugs and corticosteroids to suppress the associated inflammatory reaction. The visual prognosis is generally good, but persistent severe vision loss with optic atrophy can occur. This review presents optic neuropathies caused by specific viral, bacterial, parasitic, and fungal diseases.

Tuberculous Orbital Apex Syndrome with Severe Irreversible Visual Loss

A 16-year-old girl presented with a unilateral red eye, progressive visual loss and diplopia. A detailed clinical assessment with appropriate investigations led to a diagnosis of Orbital Apex Syndrome (OAS) secondary to Tuberculosis (TB). We report this unusual case of TB OAS, which resulted in a poor visual outcome despite appropriate management.

Clinical spectrum of tuberculous optic neuropathy

PURPOSE

Tuberculous optic neuropathy may follow infection with Mycobacterium tuberculosis or administration of the bacille Calmette-Guerin. However, this condition is not well described in the ophthalmic literature.

METHODS

Ophthalmologists, identified through professional electronic networks or previous publications, collected standardized clinical data relating to 62 eyes of 49 patients who they had managed with tuberculous optic neuropathy.

RESULTS

Tuberculous optic neuropathy was most commonly manifested as papillitis (51.6 %), neuroretinitis (14.5 %), and optic nerve tubercle (11.3 %). Uveitis was an additional ocular morbidity in 88.7 % of eyes. In 36.7 % of patients, extraocular tuberculosis was present. The majority of patients (69.4 %) had resided in and/or traveled to an endemic area. Although initial visual acuity was 20/50 or worse in 62.9 % of 62 eyes, 76.7 % of 60 eyes followed for a median of 12 months achieved visual acuities of 20/40 or better. Visual field defects were reported for 46.8 % of eyes, but these defects recovered in 63.2 % of 19 eyes with follow-up.

CONCLUSION

Visual recovery from tuberculous optic neuropathy is common, if the diagnosis is recognized and appropriate treatment is instituted. A tuberculous etiology should be considered when evaluating optic neuropathy in persons from endemic areas.

The optic chiasm

In the first part of this chapter the anatomy and vascular supply of the chiasm are recounted, and the visual symptoms that may arise in chiasmal disease are noted. The neuro-ophthalmic signs, including the pattern of visual field defects, appearance of the optic disc, and various uncommon clinical accompaniments, are described. The second part deals with a comprehensive list of disease processes that may directly or indirectly affect the chiasm. These are divided into inflammatory disorders, including sarcoidosis, multiple sclerosis, and idiopathic chiasmitis; infective disorders, including tuberculosis; and a large section on tumors, including pituitary adenomas, cysts, and choristomas, malignant disorders, including germ cell tumors and glioma, and meningioma; and finally vascular disorders and compression due to hydrocephalus. In each case the clinical features and management of the disorder are noted, as well as the prognosis for visual improvement following treatment.