ORIGINAL ARTICLE
OCULAR MANIFESTATION OF TUBERCULOSIS IN PULMONARY TUBERCULOSIS PATIENTS ATTENDING A TERTIARY CENTRE
Manoj Kumar Meghwani 1, R.P.Singh2, Nutan Saxena3, A. M. Jain4, Ruchika Agarwal5, C.M. Sharma6, Bijay Kumar7.
1. Associate Professor Department of Tuberculosis and Chest Diseases, Rama Medical College, Hospital & Research Center (RMCH & RC) Mandhana, Kanpur.
2. Professor Department of Tuberculosis and Chest Diseases, Rama Medical College, Hospital & Research Center (RMCH & RC) Mandhana, Kanpur.
3. Assistant Professor Department of Ophthalmology, Rama Medical College, Hospital & Research Center (RMCH & RC) Mandhana, Kanpur.
4. Professor, Department of Ophthalmology, Rama Medical College, Hospital & Research Center (RMCH & RC) Mandhana, Kanpur.
5. Assistant Professor Department of Ophthalmology, Rama Medical College, Hospital & Research Center (RMCH & RC) Mandhana, Kanpur.
6. Assistant Professor Department of Pediatrics, Rama Medical College, Hospital & Research Center (RMCH & RC) Mandhana, Kanpur.
7. Associate Professor Department of Pharmacology, Rama Medical College, Hospital & Research Center (RMCH & RC) Mandhana, Kanpur.
CORRESPONDING AUTHOR
Dr Manoj Kumar Meghwani
Department of Tuberculosis and Chest Diseaese
Rama Medical College, Hospital & Research Center (RMCH & RC)
G.T. Road, Mandhana, KANPUR UP-209217
Email :
HOW TO CITE THIS ARTICLE:
Manoj Kumar Meghwani , R.P.Singh, Nutan Saxena, A. M. Jain, Ruchika Agarwal, C.M. Sharma, Bijay Kumar. “Ocular Manifestation of Tuberculosis in Pulmonary Tuberculosis Patients attending a Tertiary Centre”. Journal of Evolution of Medical and Dental Sciences 2013; Vol2, Issue 24, June 17; Page: 4425-4428.
ABSTRACT: This Prospective study was conducted at department of Tuberculosis and Chest Diseases and department of Ophthalmology of RMCH & RC Kanpur from October 2012 to April 2013 to study the ocular manifestation of tuberculosis in diagnosed pulmonary tuberculosis patients. Diagnosed patients of pulmonary tuberculosis of both the sexes of various age groups were included in the study. Complete ocular examination including best corrected visual acuity (BCVA), anterior segment examination and dilated posterior segment examination was carried out in all the patients. We found that there was involvement of anterior segment in 5.68% of patients whereas in 9.09% cases posterior segment was involved. Thus in present study we found that there is high frequency of patients with Pulmonary Tuberculosis, have ocular signs that could be attributed to Tuberculosis infection.
KEY WORDS: Tuberculosis, Mycobacterium tuberculosis, phlyctenular conjunctivitis, Uveitis, Choroidal tubercles, Eales' disease.
INTRODUCTION: Tuberculosis (TB) is one of the oldest diseases known to mankind. Despite availability of specific and potent anti tubercular drugs, it continues to be one of the most prevalent infections in the world. According to the WHO and IUATLD every year 8 million new cases occur with 3 million of them being contagious and about one third of the world’s population is infected with Mycobacterium tuberculosis.2 It has been estimated that in India every year 1.8 million person develop the disease, of which about 0.8 million are infectious and, until recently 0.4 million died of it, approximately 1000 everyday.1
There is a lack of definite criteria for establishing a diagnosis of ocular tuberculosis therefore, the epidemiology of ocular tuberculosis is less certain. Variable rates of uveitis attributable to tuberculosis have been reported in various ophthalmology centres of India. A uveitis clinic in India reported 0.39% of uveitis cases were caused by tuberculosis.3As per a study conducted in referral center in Northern India 9.8% of uveitis cases were caused by tuberculosis.4 According to a study conducted at Aravind Eye Hospital in Madurai, Tamilnadu, India 5.6% of cases of uveitis were caused by tuberculosis.5 As there is no pathognomonic ophthalmic finding for ocular tuberculosis therefore clinical suspicion is an imperative first step towards the definitive diagnosis.
TB may affect the eye by direct invasion of tubercle bacillus following hematogenous dissemination with local destruction and inflammation or through a hypersensitivity reaction to the bacillus located elsewhere in the body. Tuberculosis can have a variety of ocular manifestations, and consequently may mimic a number of ocular inflammatory diseases7.Most commonly, tuberculosis presents as a posterior uveitis.6A study of 158 clinic patients with intraocular tuberculosis in India over a 10-year period revealed that 42 percent showed posterior uveitis, 36 percent had anterior uveitis, 11 percent had panuveitis and 11 percent had intermediate uveitis.6
Ocular tuberculosis has different manifestations it can appear on external eye as lid abscess or manifest as chronic blepheritis or atypical chalazia. It can present as mucopurulent conjunctivitis with regional lymphadenopathy. It can also present as phlyctenular conjunctivitis, infectious keratitis, interstitial keratitis or as a infectious scleritis. All of these presentations are easy to diagnose as material can be obtained for culture and biopsy. Rarely orbital disease can also occur.
The greater challenge is in the more common presentation but difficult to diagnose is tubercular uveitis. Uveitis from tuberculosis may involve ocular structures that are very difficult even impossible to biopsy or culture. It may present as iritis, which may be granulomatous (mutton fat keratotic precipitate, or Koeppe or Bussaca nodules) or as an intermediate uveitis in the form of pars planitis. Such findings of tubercular intermediate uveitis include vitritis, vitreous snowballs and snow banking, peripheral granulomas and vascular sheathing, all possibly complicated by cystoid macular edema.6,8 More commonly, intraocular tuberculosis may present with Choroidal tubercles which are small gray-white to yellow nodules smaller than a quarter disc diameter, which are not well circumscribed.Several such nodules can be present at a time, in one or both eyes.6,9 Posterior uveitis most often indicates choroidal involvement of tuberculosis. Choroiditis in tuberculosis can present in serpiginous-like fashion, and is hypothesized to occur due to a hypersensitivity reaction to present acid-fast bacilli.10The retina can indirectly be involved with ocular tuberculosis due to an associated choroiditis, but direct retinal involvement is rare.6In the event of primary retinal involvement, the presentation is either as a presumed tubercular retinal vasculitis or as Eales' disease, an associated vasculitis thought to represent a hypersensitivity reaction to tuberculosis.11
It can also present as an optic neuritis or papillitis.
This study was undertaken with the primary intention of evaluating frequency of various ocular signs associated with the pulmonary tuberculosis.
MATERIAL AND METHODS: A prospective study was conducted at department of Tuberculosis and Chest Diseases and department of Ophthalmology of RMCH & RC Kanpur. A total of 88 patients were included in the study. All the patients with confirmed diagnosis of pulmonary tuberculosis (Sputum positivity for AFB) were sent to the department of ophthalmology OPD of the institute. Ocular examination includes BCVA, anterior segment slit lamp examination and dilated fundus examination was carried out.
OBSERVATION
Anterior Segment Findings / Number of Patients / %Anterior Uveitis / 3 / 3.40
Phlyctenular Conjunctivitis / 1 / 1.13
Interstitial Keratitis / nil / nil
Scleritis / 1 / 1.13
Posterior Segment Findings / Number of Patients / %
Periphlebitis / 3 / 3.40
Choroiditis / 3 / 3.40
Vitritis / 1 / 1.13
Vitreous Hemorrhage / nil / nil
Retinal Neovascularisation / 1 / 1.13
Optic Atrophy / nil / nil
We found that there was involvement of anterior segment in 5.68% of patients whereas in 9.09% cases posterior segment was involved.
CONCLUSION: There is high frequency of patients with Pulmonary Tuberculosis have ocular signs especially in posterior chamber that could be attributed to Tuberculosis infection. Patients with diagnosed pulmonary tuberculosis should undergo complete ocular examination including dilated fundus examination.
REFERENCES
1. TB India, RNTCP Status Report 2006; http://www.tbcindia.org
2. WHO 1997.Report on tuberculosis epidemic, 1997, Geneva WHO: 1997.
3. Biswas J, Narain S, Das D, et al. Pattern of uveitis in a referral uveitis clinic in India. Int Ophthalmol.1996; 20:223-228.
4. Singh R, Gupta V, Gupta A.Pattern of uveitis in a referral eye clinic in north India. Indian J Ophthalmol. 2004; 52:121-125.
5. Rathinam SR, Namperumalsamy P. Global variation and pattern changes in epidemiology of uveitis. Indian J Ophthalmol. 2007; 55:173-183.
6. Gupta V, Gupta A, Rao NA. Intraocular tuberculosis—an update. Surv Ophthalmol 2007; 52(6):561-87.
7. Sheu SJ,Shyu JS,Chen LM,et al. Ocular manifestation of tuberculosis.Ophthalmology.2001; 108:1580-5.
8. Tabbara KF. Ocular tuberculosis: anterior segment. Int Ophthalmol Clin 2005; 45(2):57-69.
9. Gupta A, Gupta V. Tubercular posterior uveitis. Int Ophthalmol Clin 2005; 45(2):71-88.
10. Singh R, Gupta V, Gupta A. Pattern of uveitis in a referral eye clinic in north India. Indian J Ophthalmol 2004; 52(2):121-5.
11. J. Biswas, T. Sharma, L. Gopal, et al. Eales Disease—An Update. Survey of Ophthalmology 47(3):197-214.
FIG.1 Optic disc pallor with retinal hemorrhages with vitreous frond
FIG.2 Periphlebitis with retinal hemorrhages
Journal of Evolution of Medical and Dental Sciences/ Volume 2/ Issue 24/ June 17, 2013 Page 4425