Uveitis associated with latent tuberculosis: A comparative study of the impact of antitubercular therapy combined or not with systemic corticosteroids

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.

Treatment in Latent Tuberculosis Uveitis-Is Immunosuppression Effective or Is Conventional 3- or 4-Drug Antituberculosis Therapy Mandatory?

Background/Aims: Controversy exists regarding 3- or 4 drug antituberculosis therapy (conventional ATT) in uveitis patients having latent tuberculosis (LTB), especially while initiating therapy with corticosteroids and/or other immunosuppressants. Methods: We performed a monocentral retrospective analysis of posterior uveitis patients with latent TB. Latent TB was diagnosed, in case of a positive QuantiFERON®-TB-Gold test and normal chest imaging, after ruling out other causes of infectious and noninfectious uveitis. Patients with active TB were excluded. From 2016 to 2020 we included 17 patients. Ophthalmological evaluation consisted of Best corrected visual acuity (BCVA), slit lamp examination, fundoscopy, OCT, and fluorescein- and indocyaningreen- angiography before and at months 3, 6, 12, 24, and the last follow-up after treatment. Results: Initially, all patients had active posterior uveitis with occlusive (n = 5 patients) and nonocclusive retinal vasculitis (n = 12 patients). Mean follow up was 28 ± 15 months. Therapy was started with systemic corticosteroids (mean prednisolone equivalent 71.3 mg/d) and already after 3 months it could be tapered to a mean maintenance dosage of 8.63 mg/d. Additional immunosuppressive treatment with cs- or bDMARDs was initiated in 14 patients (82%) due to recurrences of uveitis while tapering the corticosteroids <10 mg per/day or because of severe inflammation at the initial visit. While being on immunosuppression, best corrected visual acuity increased from 0.56 logMAR to 0.32 logMAR during follow-up and only three patients had one uveitis relapse, which was followed by switch of immunosuppressive treatment. As recommended, TB prophylaxis with 300 mg/d isoniazid was administered in 11 patients for at least 9 months while being on TNF-alpha-blocking agents. No patient developed active tuberculosis during immunosuppressive therapy. Conclusion: Mainly conventional ATT is strongly recommended—as monotherapy or in combination with immunosuppressives—for effective treatment in patients with uveitis due to latent TB. Although in our patient group no conventional ATT was initiated, immunosuppression alone occurred as an efficient treatment. Nevertheless, due to possible activation of TB, isoniazid prophylaxis is mandatory in latent TB patients while being on TNF-alpha blocking agents.

Presumed Latent Tuberculosis-related Intermediate Uveitis Manifesting as Recurrent Vitreous Hemorrhage

Purpose: We report a case of recurrent vitreous hemorrhage in a patient with presumed latent tuberculosis-related intermediate uveitis, and we review the literature.Case summary: A 58-year-old male visited our clinic complaining of ocular pain, conjunctival hyperemia, decreased vision, and uncontrolled intraocular pressure (IOP) in the left eye. The best-corrected visual acuity (BCVA) was 0.4 and the IOP of the left eye was 34 mmHg. Slit lamp examination revealed conjunctival hyperemia, corneal edema, and inflammatory cells in the anterior chamber and anterior vitreous; fundus examination revealed mild vitreous opacity attributable to vitritis. The high IOP and the intraocular inflammation were treated with antiglaucoma agents and corticosteroids under the impression of chronic anterior uveitis and uveitic glaucoma. Of the tests performed to identify the cause of the uveitis-related vitreous hemorrhage, the interferon-gamma release assay was positive. A presumptive diagnosis of latent tuberculosis-related uveitis was made after pulmonary tuberculosis was excluded by our respiratory internal medicine department. Isoniazid was administered for 9 months. The vitreous hemorrhage recurred 1 month after antituberculosis therapy commenced but, at 2 months, all of the hemorrhage was absorbed and the BCVA improved to 1.0 without further recurrence.Conclusions: Intraocular tuberculosis can present with various clinical manifestations. If tuberculosis-related uveitis is presumed, tests for latent and manifest tuberculosis should be scheduled to allow of early diagnosis and immediate antituberculosis therapy.

Anti-TB monotherapy for choroidal tuberculoma: an observational study

BACKGROUND

Choroidal tuberculoma is possibly the most unequivocal manifestation of ocular infection with Mycobacterium tuberculosis. Here, we investigate the need for adjunctive corticosteroids in the management of this infection. We have compared the efficacy of anti-tubercular therapy (ATT) with or without oral corticosteroids, in management of choroidal tuberculoma.

METHODS

We report a retrospective, observational study of patients treated with ATT for choroidal tuberculoma. Group A patients were treated with standard 6-month ATT alone, and Group B with ATT and oral corticosteroids, with/without intravitreal triamcinolone/ bevacizumab injections. Primary outcome measure was time to complete resolution of lesions. Secondary measures were time to first sign of resolution and change in best corrected visual acuity (BCVA) at final visit.

RESULTS

Fourteen patients were included in the study-seven in Group A and seven in Group B. Both groups had similar duration of symptoms and size of lesions but not baseline BCVA (p = 0.02). Perilesional fluid was noted in all eyes in each group. Mean time to complete resolution in group A was 1.89 ± 0.28 (range 1.25-2) months, significantly lesser than group B (5.17 ± 2.64 [range 2-9] months, p = 0.005, Mann-Whitney test). Mean time to first sign of resolution (range from 5 days to 10 weeks, p = 0.35) and mean change in BCVA between presentation and final follow up (p = 0.2) were comparable between both groups.

CONCLUSION

Anti-TB monotherapy alone, may be sufficient for resolution of at least, select cases of choroidal tuberculoma, without the need for adjunctive corticosteroids.