Ocular Tuberculosis

Abstract

Ocular tuberculosis is an extrapulmonary mycobacterial infection with variable manifestations. The reported incidence of ocular involvement varies considerably, depending on the criteria used for diagnosis and the population sampled. However, tuberculosis is thought to affect the lungs in 80% of patients, with the remaining 20% being affected in other organs, such as the eye. It is imperative for physicians to consider this diagnosis in their differential, as ocular tuberculosis can present in a fashion similar to that of more common conditions causing ocular inflammation. In addition, prompt recognition of the clinical signs and symptoms leads to quicker initiation of antituberculosis therapy.

Figure 1

(A) Case 1. Shown is a bulbar conjunctival mass contiguous with a peripheral corneal ulcer with 80% stromal thinning. (B) Everted upper eyelid shows diffuse papillary reaction with tarsal necrosis laterally. (C) Case 2. Downgaze shows ulcerated bulbar conjunctiva. (D) Everted upper eyelid shows diffuse velvety appearance, with cheesy white areas of necrosis involving the upper tarsal border. Reprinted with permission from the Archives of Ophthalmology (27). Copyright 2003 American Medical Association. All rights reserved.

Figure 2

Case 1. A section from the bulbar conjunctiva shows an intact epithelium with discrete epithelioid cell granuloma in the deeper stroma, rimmed by lymphocytes (hematoxylin-eosin; original magnification, ×250). Reprinted with permission from the Archives of Ophthalmology (27). Copyright 2003 American Medical Association. All rights reserved.

Figure 3

(A) Case 1. At 1-year follow-up, the left eye shows a superior vascularized corneal scar with normal-appearing bulbar and tarsal conjunctiva. (B) Case 2. At 3-month follow-up, the everted right upper eyelid shows a residual area of necrosis (arrow) with mild persistent papillary reaction. Reprinted with permission from the Archives of Ophthalmology (27). Copyright 2003 American Medical Association. All rights reserved.

Figure 4

Acid-fast stain of a conjunctival biopsy specimen shows acid-fast positive rods (arrow) within epithelioid histiocytes.

Figure 5

Slit lamp picture of the left cornea showing a peripheral corneal ulcer and a heavily vascularized nodule. Reprinted with permission from the Archives of Ophthalmology (115). Copyright 2000 American Medical Association. All rights reserved.

Figure 6

Clinical appearance of a right eye shows mild conjunctival vasodilation and numerous confluent, temporal, tan iris nodules. Reprinted with permission from the Archives of Ophthalmology (116). Copyright 1998 American Medical Association. All rights reserved.

Figure 7

(Left) Gross appearance of the enucleated right eye. Note the scleral necrosis and the perilimbal scleral rupture (arrowhead) located interiorly. The limbal conjunctiva covers a dome-shaped, brown mass. (Right) Histopathological appearance of the enucleated right eye with a subconjunctival necrotic and inflammatory mass. There is necrosis of the iris, and the anterior chamber contains necrotic debris (arrowheads) (hematoxylineosin; original magnification, ×5). Reprinted with permission from the Archives of Ophthalmology (116). Copyright 1998 American Medical Association. All rights reserved.

Figure 8

Fundus photographs of the right (A) and left (B) eyes show bilateral, multifocal choroiditis (arrowheads). Serial FA photographs (C to F) show early blocking hypofluorescence and late-staining hyperfluorescence corresponding to areas of choroidal infiltrate, as well as mild, late leakage from the optic nerve heads in each eye. Reprinted with permission from the Archives of Ophthalmology (53). Copyright 1998 American Medical Association. All rights reserved.

Figure 9

B-scan ultrasonogram of the left eye showing an acoustically dense choroidal lesion with no choroidal excavation. Reprinted with permission from the Archives of Ophthalmology (117). Copyright 2000 American Medical Association. All rights reserved.

Figure 10

(A) Left eye fundus photograph showing discrete, multifocal active lesions (white arrows) of serpiginous-like choroiditis becoming confluent, along with old healing lesions (black arrows) that are noncontiguous to the optic disc and involve the posterior pole and peripheral fundus. (B) Right eye fundus photograph showing a solitary, placoid lesion of serpiginous-like choroiditis having an active edge with amoeboid spread and a healing center. Reprinted with permission from the American Academy of Ophthalmology (55). Copyright 2012 Elsevier. All rights reserved.

Figure 11

(A) Fundus fluorescein angiography of the same eye as in Fig. 10 showing active lesions (white arrows) that are hypofluorescent in the early phase. The inactive scars show transmission hyperfluorescence (red arrows). (B) Fundus FA of the same eye as in Fig. 10 showing hyperfluorescence of active lesions in the late phase (white arrows). The inactive scars show transmission hyperfluorescence (red arrows). Reprinted with permission from the American Academy of Ophthalmology (55). Copyright 2012 Elsevier. All rights reserved.

Figure 12

Fluorescein angiogram in the early venous phase showing early blockage at the edges of the lesion and early hyperfluorescence within the central aspect of the choroidal lesion; the overlying retinal vessels are normal and in focus. The other retinal vessels are not in focus secondary to the thickness of the lesion. Reprinted with permission from the Archives of Ophthalmology (117). Copyright 2000 American Medical Association. All rights reserved.

Figure 13

Fluorescein angiogram in the late phase revealing late staining of the choroidal lesion. Reprinted with permission from the Archives of Ophthalmology (117). Copyright 2000 American Medical Association. All rights reserved.

Figure 14

(A) Fundus photograph of right eye at presentation, showing a tuberculoma at the inferior macula with astrallike exudates. (B) Fundus photograph of the right eye at 9-month follow-up showing the tuberculoma totally disappeared. Reprinted with permission from Retina (42). Copyright 2012 Wolters Kluwer. All rights reserved.

Figure 15

Spectral domain optical coherence tomography image of the left eye prior to initiation of therapy shows subfoveal neurosensory detachment and proliferating retinal pigment epithelial cells (small white arrow) with serous retinal detachment superiorly and inferiorly (large white arrows) (A) and phagocytosed outer photoreceptor layer cells (small white arrow) (B). Reprinted with permission from the BMJ Case Reports. (118). Copyright 2013 BMJ Publishing Inc. All rights reserved.

Figure 16

Retinitis and retinal neovascularization obscuring a clear view of the optic disc in a fundus photograph. Reprinted with permission from the Archives of Ophthalmology (101). Copyright 1998 American Medical Association. All rights reserved.

Figure 17

Noncaseating granuloma from a transvitreal biopsy specimen. Reprinted with permission from the Archives of Ophthalmology (101). Copyright 1998 American Medical Association. All rights reserved.

Figure 18

Left fundus photograph illustrating optic disc new vessels with choroidal mass nasally. Reprinted with permission from the Archives of Ophthalmology (101). Copyright 1998 American Medical Association. All rights reserved.