Blogs

Diagnosis and treatment of intraocular tuberculosis challenges physicians

• April 2008
• R. B. Jain, MS, MRCOphth, DO, FRCS

There are roughly 8.7 million reported cases of tuberculosis worldwide, with nearly 3 million deaths attributed to the disease each year, according to the World Health Organization. Tuberculosis, which is seen more frequently in developing countries, generally affects the lungs, but it is capable of affecting extrapulmonary organs as well, including the eyes.

A lack of definitive diagnostic criteria presents the largest impediment to ophthalmologists looking to treat intraocular tuberculosis, R.B. Jain, MS, MRCOphth, DO, FRCS, said.

“The problem is that there is no clear-cut diagnosis. Many times, it is just presumptive. You have to presume that it is the diagnosis, based on clinical appearance, your experience,” Dr. Jain told Ocular Surgery News in a interview. “You cannot really prove in more than one-third of the cases that [the symptoms] are due to intraocular tuberculosis.”

A recent presentation at the All India Ophthalmological Society conference in Bangalore highlighted the ongoing battle against intraocular tuberculosis and sought to remind Indian ophthalmologists of the often subtle and confusing warning signs that accompany it. Dr. Jain noted the importance of considering tuberculosis when certain inflammatory diseases are present in the eye.

“Once you [have] seen multifocal choroiditis, especially if it is bilateral … in a country like India, where tuberculosis is so common, you have to start thinking of it as [a possible] diagnosis,” Dr. Jain said. “You also think of intraocular tuberculosis in recurrent, bilateral granulomatous iridocyclitis.”

He recounted a recent experience in which a patient was unhappy with the treatment of his symptoms with another ophthalmologist. Upon visiting Dr. Jain, the patient was diagnosed with multifocal choroiditis, which is when Dr. Jain inquired about tuberculosis. He found that for the past month the patient had been taking care of his brother, who was diagnosed with pulmonary tuberculosis.

The patient tested positive for the disease. According to Dr. Jain, even if the test was negative, he still would have gone forward with treatment for intraocular tuberculosis, using collaborative evidence to diagnose the disease.

Treatment efficacy

This treatment plan typically includes a combination of rifampicin, isoniazid, pyrazinamide and ethambutol. According to Dr. Jain, treatment will be the four drugs for 3 months and followed by rifampicin, isoniazid and pyrazinamide for an additional 6 months.

He has seen several cases in which tuberculosis was suspected clinically, but repeated tests by a physician came back negative, and tuberculosis treatment was not given. After 6 months to 1 year, these patients lost vision in the problematic eye and were developing symptoms in the other eye. Dr. Jain told these patients that if they wanted to save their other eye, they would have to begin treatment for tuberculosis.

“With [these] patients, I have been able to save the eyesight in the other eye on presumptive diagnosis only because there is no confirmative diagnosis,” he said.