Rapidly blinding posterior tubercular uveitis
© Agarwal et al.; licensee Springer. 2014
Received: 15 January 2014
Accepted: 25 April 2014
Published: 9 June 2014
A 21-year-old female patient had chorioretinitis in the left eye which relapsed while being on anti-tubercular treatment and oral corticosteroids leading to blindness and the loss of the left eye.
Mycobacterium tuberculosis causing chorioretinitis showed a poor response, and the lung lesions showed a good response to the same anti-tubercular treatment.
Mycobacterium tubercle bacilli in the eye may show a poor response to the anti-tubercular drugs due to poor ocular penetration of the drugs secondary to early ocular hypoxia.
KeywordsOcular tuberculosis Blinding Posterior
Intraocular tuberculosis represents an extrapulmonary form of tuberculosis. Posterior uveitis is the most common manifestation of intraocular tuberculosis. The inflammation predominantly involves the choroid in the form of choroidal tubercles, tuberculoma, sub-retinal abscess, chorioretinitis, and serpiginous-like choroiditis. We report a case of pulmonary and intraocular tuberculosis which showed a good response to the anti-tubercular drugs in the lungs but not in the eye leading to a blinding posterior tubercular uveitis.
She was subsequently dispensed with a prosthetic shell for the left socket.
Tuberculosis is a clinical disease caused by infection with Mycobacterium tuberculosis and is characterized pathologically by the formation of granulomas. It is commonly described as a systemic disease of ‘protean manifestations’ that mainly involves the lungs. Extrapulmonary involvement, including lesions of the gastrointestinal tract, genito-urinary tract, cardiovascular system, skin, central nervous system, and eyes, may occur either in association with clinically apparent pulmonary tuberculosis or in isolation, with no clinical or laboratory evidence of pulmonary infection. In India, where pulmonary tuberculosis is endemic, the incidence of ocular involvement is variable.
In our patient, there was initially a response to the oral corticosteroids and four-drug ATT; however, this was 2 weeks later followed by a deterioration in the left eye and improvement in the lung lesions while being on treatment. We got different response in the lungs and in the eye even though it is presumed that the strain of mycobacterium tubercle bacilli causing infection in the lungs would also be the causative bacilli in the left eye. This excludes the fact that our case was of a multidrug-resistant tuberculosis as then neither lungs or the eye would have responded to the treatment. There was a resistance to start second line anti-tubercular drugs seeing to the resolution of the chest lesions; however, oral ofloxacin was added which failed to provide any additional benefit. We were unable to see the antibiotic sensitivity of the mycobacterium tubercle bacilli as the microbiology testing showed no growth though the polymerase chain reaction confirmed the same.
This case is reported to highlight the fact that it is not essential that pulmonary and extrapulmonary manifestation especially ocular involvement of tuberculosis may show the same response to the ATT. This maybe secondary to the fact that ocular hypoxia sets in very fast in eyes with inflammation of the choroid secondary to mycobacterium tuberculosis[4–6]. This causes decreased choroidal circulation, and this may reduce the penetration of the drugs of ATT into the eye. Early neovascular complications are seen in these eyes secondary to ocular hypoxia as in our case where we treated our patient with multiple intravitreal injections of bevacizumab (Avastin,Genentech) which is a nonselective vascular endothelial growth factor inhibitor providing relief from pain till the eye was enucleated. We need to be very careful and follow a case of intraocular tuberculosis at frequent intervals as there maybe a very fast progression of ocular tuberculosis leading to a complete loss of the eye.
Dr. Manisha Agarwal, M.S. (Ophthalmology), is the head of Vitreoretina Services, Dr.Shroff’s Charity Eye Hospital, New Delhi, India. Dr. Vivek Jha, M.D. (Medicine), is a physician and pulmonologist at Dr. Shroff’s Charity Eye Hospital, New Delhi, India. Dr. Jyotirmay Biswas, M.S. (Ophthalmology) is the head of Uvea and Ocular Pathology, Sankara Nethralaya, Chennai, India.
acid fast bacilli
best corrected visual acuity
erythrocyte sedimentation rate
high-resolution computed tomography
neovascularization of iris
optic nerve head
polymerase chain reaction.
The authors would like to acknowledge Ms. Renu Verma and Mr. Brajesh Kumar.
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