Vishali Gupta

Presumed tubercular serpiginouslike choroiditis: clinical presentations and management.

PURPOSE Choroiditis, choroidal tubercles, and tuberculomas are well known ocular manifestations of systemic tuberculosis. The present series aimed to report the occurrence of serpiginouslike choroiditis of presumed tubercular origin. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS Eleven eyes in seven consecutive patients with a diagnosis of choroidal tuberculosis simulating serpiginous choroiditis were studied between 1997 and 2000. TESTING AND INTERVENTION: All patients had their fundus photographs taken at the time of initial presentation as well as during follow-up. All patients underwent a Mantoux skin test and chest radiography. In addition, five patients had their aqueous or vitreous humor subjected to polymerase chain reaction (PCR) for Mycobacterium tuberculosis. Sputum examination, biopsy, or both were carried out whenever recommended by the pulmonologist. Systemic antituberculosis chemotherapy was instituted in combination with treatment for ocular inflammation. MAIN OUTCOME MEASURE Therapeutic response and visual improvement. RESULTS There were five men and two women ranging in age from 17 to 32 years. Clinical presentations included three morphologic variants; multifocal progressive choroiditis showing wavelike progression to confluent, diffuse lesions resembling serpiginous choroiditis (three eyes); diffuse choroiditis characterized by diffuse plaquelike choroiditis with an amoeboid pattern suggestive of serpiginous choroiditis at initial presentation (four eyes); and mixed variety where opposite eyes had mixed features (four eyes). All patients had strongly positive Mantoux skin test results and positive chest radiograph results. The PCR results from aqueous and vitreous humor in four samples was positive for Mycobacterium tuberculosis; one had sputum positive for acid-fast bacilli, whereas two had histopathologic evidence of tuberculosis from cervical or parahilar lymph nodes. Treatment was associated with resolution of choroidal lesions and visual improvement. Final visual acuity of 20/30 or better was achieved in five eyes. CONCLUSIONS Choroidal tuberculosis may present as multifocal progressive or diffuse choroiditis resembling serpiginous choroiditis. It is important to recognize these presentations because these eyes show good response to systemic antituberculosis chemotherapy.

Ocular Signs Predictive of Tubercular Uveitis

PURPOSE To determine ocular signs predictive of tubercular uveitis. DESIGN Retrospective, nonrandomized, comparative interventional case study. METHODS Three hundred eighty-six patients with active uveitis were treated at a tertiary care single-center uveitis practice. Uveitis was presumed to be tubercular in patients who showed evidence of latent or manifest tuberculosis without any other known cause and who did not show recurrence of uveitis after 12 months of antitubercular therapy. One hundred eighty-two patients who thus obtained clinical diagnoses of presumed tubercular uveitis were enrolled in group A. Two hundred four patients with uveitis resulting from a nontubercular cause were enrolled in group B. Patients were monitored for the presence of types of keratic precipitates (mutton fat or fine), posterior synechiae (broad based or filiform), iris nodules, snowballs, snow banking, vasculitis (with or without choroiditis), serpiginous-like choroiditis, and other types of posterior uveitis (choroidal abscess, retinochoroiditis, or exudative retinal detachment) which were compared between the 2 groups. Statistical analysis was carried out at a 5% level of significance. The main outcome measures were clinical signs significantly associated with tubercular uveitis. RESULTS Broad-based posterior synechiae, retinal vasculitis with or without choroiditis, and serpiginous-like choroiditis were seen significantly more commonly in patients with tubercular uveitis. Filiform posterior synechiae were more frequent in eyes with nontubercular uveitis. CONCLUSIONS Broad-based posterior synechiae, retinal vasculitis with or without choroiditis, and serpiginous-like choroiditis in patients with latent or manifest tuberculosis in tuberculosis-endemic areas are suggestive of a tubercular cause of uveitis and merit specific treatment.

Role of Anti-Tubercular Therapy in Uveitis With Latent/Manifest Tuberculosis

PURPOSE To assess the role of anti-tubercular therapy in uveitis with latent/manifest tuberculosis (TB). DESIGN Retrospective, interventional case series. METHODS A total of 360 patients from uveitis clinic with following inclusion criteria were studied: 1) complete clinical records of visual acuity, slit-lamp biomicroscopic examination, intraocular pressure, complications if any, and treatment records at the baseline and at all follow-up visits; 2) a documented positive tuberculin skin test (10 mm of induration or more) at 48 to 72 hours; 3) evidence of active uveitis, i.e., cellular reaction in the anterior chamber with or without keratic precipitates, and/or active vitreous inflammation, retinal vasculitis, choroiditis, or neuroretinitis; 4) all known causes of infectious uveitis except TB and known noninfectious uveitic syndromes ruled out; and 5) a minimum one year of follow-up from the initiation of treatment. Of these, 216 patients (Group A) received four-drug anti-tubercular therapy and corticosteroids, and 144 patients (Group B) received corticosteroids alone. The main outcome measure was recurrence of inflammation after minimum six months of initiating treatment in each group. RESULTS Recurrences reduced significantly (P < .001) in Group A (15.74%) as compared to Group B (46.53%) over a median follow-up of 24 and 31 months, respectively. The patients treated with anti-tubercular therapy with corticosteroids had decreased risk of developing recurrence of uveitis by approximately two-thirds as compared to those treated with corticosteroids alone. CONCLUSION Addition of anti-tubercular therapy to corticosteroids in uveitis patients with latent/manifest TB led to significant reduction in recurrences of uveitis.

Fungal endophthalmitis following cataract surgery: clinical presentation, microbiological spectrum, and outcome.

PURPOSE To determine the clinical presentation, microbiological spectrum, and outcome in cases of fungal endophthalmitis following cataract surgery. DESIGN Observational case series. METHODS SETTING Tertiary referral hospital. PATIENTS Retrospective analysis of 27 cases of smear- and culture-proven fungal endophthalmitis. INTERVENTION Pars plana vitrectomy in 18 eyes, where the corneal condition did not preclude the same. All eyes received intravitreal amphotericin B and dexamethasone along with systemic antifungal agents. MAIN OUTCOME MEASURES Functional success: Final visual acuity of 3/60 or better with attached retina. Anatomical success: Final visual acuity of better than light perception with preserved anatomy of globe. RESULTS The majority of the eyes (22 of the 27) had early onset and diffuse presentation (that is, anterior segment as well as posterior vitreous exudates). Substantial corneal involvement was seen in 14 eyes (51.85%). Aspergillus sp. was the most common isolate. Multivariate analysis using forward stepwise logistic regression showed corneal involvement as the single most important risk factor in determining final visual outcome (P =.0429). CONCLUSIONS Early onset and diffuse presentation, which mimics bacterial endophthalmitis, stresses the importance of both bacterial and fungal cultures from intraocular fluids to reach a diagnosis apart from the clinical judgment. Corneal involvement was the most important predictor of outcome in cases of fungal endophthalmitis.

Tubercular posterior uveitis.

Tuberculosis is defined by the Centers for Disease Control (CDC) as a chronic bacterial infection caused by Mycobacterium tuberculosis, characterized pathologically by the formation of granulomas. Themost common site of infection is the lung, but other organs may be involved. The M. tuberculosis spreads by droplet infection from coughing or sneezing. Nearly one third of the world’s population is infected, with an annual incidence approaching 8.7 million patients. There are remarkable geographic variations in the distribution of tuberculosis and 22 countries, including India, China, Indonesia, Bangladesh, Pakistan, Nigeria, Philippines and South Africa, among others, have been identified that contribute 80% of the world’s total burden of tuberculosis. Although mortality from tuberculosis has been known from the prehistoric times, it peaked during the industrial revolution in the west in the mid 19th century aided by poor housing, unsanitary conditions, poverty, and poor personal hygiene, many of which prevail even today in most of the developing countries. Since 1953, when the CDC began its public health surveillance program for tuberculosis in the United States, there has been a 10-fold decrease in the annual incidence of tuberculosis from 53/100,000 in 1953 to 5.2/100,000 in 2002. It, however, remains still very high in several regions of the world. Recent data from India suggest that the case rate may be nearly 187/100,000. Besides, in the last several years, new challenges have emerged in the form of close association of tuberculosis in patients with human immunodeficiency virus (HIV) infection. The association has been so striking that

Spectral-domain Cirrus high-definition optical coherence tomography is better than time-domain Stratus optical coherence tomography for evaluation of macular pathologic features in uveitis.

PURPOSE To compare high-definition (HD) spectral-domain optical coherence tomography [SD-OCT] (Cirrus HD-OCT; Carl Zeiss, Dublin, California, USA) with time-domain optical coherence tomography [TD-OCT] (Stratus version 4; Carl Zeiss) for imaging macula in patients of uveitis. DESIGN Interventional case series. METHODS Thirty consecutive patients (51 eyes) with uveitis of various causes with vitreous haze of 1+ or worse were treated in an institutional setting. All patients had their vitreous haze graded and OCT scans both on TD-OCT (Stratus) and SD-OCT (Cirrus). Information obtained from Cirrus OCT scans was compared with that obtained from Stratus OCT scans. RESULTS Overall, for all grades of media clarity, the macula was interpreted as normal in 30 eyes (58.8%) on Stratus OCT and 26 eyes (50.9%) on Cirrus OCT and abnormal in 15 eyes (29.4%) on Stratus OCT and 24 eyes (47.0%) on Cirrus OCT, whereas poor scan quality deterred any interpretation in six eyes (10.0%) on Stratus OCT and only in one eye (1.8%) on Cirrus OCT. Additional information on Cirrus OCT could be obtained in nine (21.9%) of 41 eyes with grade 1+ vitreous haze, six (75%) of eight eyes with grade 2+ vitreous haze, and one eye (50%) with vitreous haze of 3+. CONCLUSIONS Our preliminary results suggest that SD Cirrus HD-OCT has an advantage over TD Stratus OCT in uveitic eyes by providing better identification of normal and pathologic structure in patients with poor media clarity.

Tubercular serpiginous-like choroiditis presenting as multifocal serpiginoid choroiditis.

PURPOSE To describe the clinical features, course, and outcome in tubercular serpiginous-like choroiditis. DESIGN Retrospective cohort study. PARTICIPANTS A total of 105 patients (141 eyes) between May 2002 and July 2010. METHODS Patients had the following inclusion criteria: (1) complete clinical records and digital fundus images at baseline and follow-up visits, (2) positive tuberculin skin test or QuantiFERON-TB Gold (Cellestis International Pty Ltd. Chadstone, Victoria, Australia) test result, (3) active serpiginous-like choroiditis in at least 1 eye, (4) all known causes of infectious (except tuberculosis) and noninfectious uveitis ruled out, and (5) a minimum of 9 months of follow-up from initiation of treatment that included antitubercular therapy (ATT) with oral corticosteroids (93 patients) or corticosteroids alone (12 patients). MAIN OUTCOME MEASURES Clinical characteristics and evolution of choroiditis lesions from the acute to healed stage, recurrence, visual outcome, and complications. RESULTS Mean age was 33 ± 9.3 years (range, 12-54 years; 75 male and 30 female patients). Serpiginous-like choroiditis was bilateral (at least 1 eye active) in 66 patients (62.9%). Of 171 affected eyes, 141 (82.45%) had active lesions at presentation. Of 141 eyes, 115 (81.56%) showed vitreous inflammation. Lesions were multifocal in 133 eyes (94.3%), were noncontiguous to optic disc in 122 eyes (86.52%), and involved the macula in 125 eyes (88.65%). Of patients receiving ATT, all showed resolution of lesions and 9 (9.7%) developed recurrences (median follow-up, 21 months). In addition, 12 patients (12.9%) showed continued progression over a median 3.5 weeks after initiation of therapy. Of 12 patients treated with corticosteroids alone, none showed progression but 9 (75%) developed recurrence (median, 26.5 months). Final visual acuity of ≥ 6/12 was achieved in 108 eyes (76.60%) versus 72 eyes (51.06%) before treatment. Fovea was spared in 95 of 125 eyes (76%) with macular involvement. Five eyes (3.5%) developed choroidal neovascular membrane. CONCLUSIONS Tubercular serpiginous-like choroiditis presented as multifocal serpiginoid choroiditis affecting predominantly young to middle-aged men. It was frequently bilateral with vitreous inflammation and characterized by multifocal lesions that were noncontiguous to the optic disc and showed serpiginoid spread. Antitubercular therapy significantly reduced recurrences. Lesions responded to combined antitubercular and steroid therapy, usually spared fovea, and had a good final visual acuity.

Novel multi-targeted polymerase chain reaction for diagnosis of presumed tubercular uveitis.

BackgroundThe objective of this study was to report the use of multi-targeted polymerase chain reaction (PCR) in the diagnosis of presumed tubercular uveitis. Multi-targeted PCR using three targets specific for Mycobacterium tuberculosis, i.e., IS6110, MPB64, and protein b, was performed on intraocular fluid samples of 25 subjects. Nine had presumed tubercular uveitis, six had intraocular inflammation secondary to a nontubercular etiology (disease controls), and ten had no evidence of intraocular inflammation (normal controls). As described previously, response to antitubercular therapy was considered as the gold standard.ResultsMulti-targeted PCR was positive in seven out of nine patients with presumed tubercular uveitis and negative in all normal and disease controls. The sensitivity and specificity were 77.77% and 100%, respectively. For the diagnosis of presumed tubercular uveitis, multi-targeted PCR had a positive predictive value of 100% and a negative predictive value of 88.88%.ConclusionMulti-targeted PCR can be a valuable tool for diagnosing presumed tubercular uveitis.

Clinics of Ocular Tuberculosis

Abstract Purpose: Ocular tuberculosis is an extrapulmonary tuberculous condition and has variable manifestations. The purpose of this review is to describe the clinical manifestations of ocular tuberculosis affecting the anterior and posterior segments of the eye in both immunocompetent and immunocompromised patients. Methods: Review of literature using Pubmed database. Results: Mycobacterium tuberculosis may lead to formation of conjunctival granuloma, nodular scleritis, and interstitial keratitis. Lacrimal gland and orbital caseating granulomas are rare but may occur. The intraocular structures are also a target of insult by M. tuberculosis and may cause anterior granulomatous uveitis, anterior and posterior synechiae, secondary glaucoma, and cataract. The bacillus may involve the ciliary body, resulting in the formation of a localized caseating granuloma. Posterior segment manifestations include vitritis, retinal vasculitis, optic neuritis, serpiginous-like choroiditis, choroidal tubercules, subretinal neovascularization, and, rarely, endophthalmitis. Conclusions: The recognition of clinical signs of ocular tuberculosis is of utmost importance as it can provide clinical pathway toward tailored investigations and decision making for initiating anti-tuberculosis therapy.

Spectral-Domain Cirrus Optical Coherence Tomography of Choroidal Striations Seen in the Acute Stage of Vogt-Koyanagi-Harada Disease

PURPOSE To describe changes in the retinal pigment epithelium (RPE) corresponding to the choroidal striations in acute-stage Vogt-Koyanagi-Harada (VKH) disease. DESIGN Prospective, consecutive case series. METHODS Four patients (eight eyes) with acute-stage VKH disease were studied. All underwent fundus fluorescein angiography (FFA), ultrasonography, and spectral-domain optical coherence tomography (SD OCT). The main outcome measure was the correlation of the findings seen on a 3-dimensional (3D) single-layer RPE map constructed on SD OCT with the serous retinal detachment (RD) and choroidal striations. RESULTS The retina inner to external limiting membrane did not show any structural alteration in any of the eyes. The 3D single-layer RPE map showed undulations and bumps on the RPE surface in all the eyes. The troughs of the undulations were noted to correspond to the choroidal striations seen as hypofluorescent lines in the early phase of FFA. The bumps over the undulations corresponded to the pinpoint hyperfluorescent dots on FFA, resulting in the development of serous RDs over the troughs, thus obscuring the hypofluorescent lines in the late phase of fluorescein angiograms. CONCLUSIONS The troughs of the RPE undulations were seen clinically as choroidal striations in the acute uveitic stage of VKH disease.