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Chapter 17 : Ocular Tuberculosis

Authors: Daniel M. Albert1, Matthew J. Thompson,2, Robert J. Peralta3
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Affiliations: 1: Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792; 2: Tower Clock Eye Center, 1087 West Mason Street, Green Bay, WI 54303; 3: Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792
Content Type: Monograph
Publication Year: 2011

Category: Clinical Microbiology; Bacterial Pathogenesis

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Abstract:

This chapter describes several different mechanisms through which eye can become infected with tuberculosis. Tuberculosis can involve the lid, conjunctiva, cornea, and sclera. In parts of the world where the prevalence of tuberculosis infection is higher in the general population, uveitis is still more likely to be attributed to tuberculosis. Uveitis can also manifest as simple iritis, the clinical signs of which are limited to cells and flare in the anterior chamber, or as iridocyclitis with involvement of the ciliary body. Iridocyclitis occurs clinically with inflammatory cells in the ciliary body and anterior vitreous and is associated with ciliary body pain and ciliary vasodilation. Alternatively, the inflammation may involve primarily the posterior part of the uvea (choroids), leading to choroiditis, the most common manifestation of ocular tuberculosis. Choroidal tubercles should always be looked for on funduscopic examination when a patient is suspected to have tuberculosis or has a fever of unknown origin. The chapter also talks about choroidal tuberculomas, ciliary body tuberculoma, tuberculous retinitis, tuberculous panophthalmitis, and orbital tuberculosis. Before the introduction of PCR technology, a definitive diagnosis of ocular tuberculosis was often elusive because it required the demonstration of the bacilli in ocular tissues or secretions by microscopy or culture. Once the diagnosis of ocular tuberculosis is made, systemic antituberculous therapy should be initiated at once. Any patient with a clinical picture highly suspicious for ocular tuberculosis should be treated with a multidrug regimen of proven efficacy.

Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
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Ocular Tuberculosis
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Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
/content/10.1128/9781555817138.ch17.ch17fig01
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 ( ). Copyright 2003 American Medical Association. All rights reserved.
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Image of Figure 1.
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 ( ). Copyright 2003 American Medical Association. All rights reserved.

Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
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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 ( ). Copyright 2003 American Medical Association. All rights reserved.
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Image of Figure 2.
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 ( ). Copyright 2003 American Medical Association. All rights reserved.

Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
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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 ( ). Copyright 2003 American Medical Association. All rights reserved.
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Image of Figure 3.
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 ( ). Copyright 2003 American Medical Association. All rights reserved.

Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
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Figure 4.
Slit lamp picture of the left cornea showing a peripheral corneal ulcer and a heavily vascularized nodule. Reprinted with permission from the ( ). Copyright 2000 American Medical Association. All rights reserved.
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Image of Figure 4.
Figure 4.

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

Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
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Figure 5.
Clinical appearance of a right eye shows mild conjunctival vasodilation and numerous confluent, temporal, tan iris nodules. Reprinted with permission from the ( ). Copyright 1998 American Medical Association. All rights reserved.
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Image of Figure 5.
Figure 5.

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

Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
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Figure 6.
(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) (hematoxylin-eosin; original magnification, ×5). Reprinted with permission from the ( ). Copyright 1998 American Medical Association. All rights reserved.
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Image of Figure 6.
Figure 6.

(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) (hematoxylin-eosin; original magnification, ×5). Reprinted with permission from the ( ). Copyright 1998 American Medical Association. All rights reserved.

Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
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Figure 7.
Fundus photographs of the right (A) and left (B) eyes show bilateral, multifocal choroiditis (arrowheads). Serial fluorescein angiographic 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 ( ). Copyright 1998 American Medical Association. All rights reserved.
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Image of Figure 7.
Figure 7.

Fundus photographs of the right (A) and left (B) eyes show bilateral, multifocal choroiditis (arrowheads). Serial fluorescein angiographic 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 ( ). Copyright 1998 American Medical Association. All rights reserved.

Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
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Figure 8.
B-scan ultrasonogram of the left eye showing an acoustically dense choroidal lesion with no choroidal excavation. Reprinted with permission from the ( ). Copyright 2000 American Medical Association. All rights reserved.
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Image of Figure 8.
Figure 8.

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

Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
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Figure 9.
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 ( ). Copyright 2000 American Medical Association. All rights reserved.
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Image of Figure 9.
Figure 9.

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 ( ). Copyright 2000 American Medical Association. All rights reserved.

Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
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Figure 10.
Fluorescein angiogram in the late phase revealing late staining of the choroidal lesion. Reprinted with permission from the ( ). Copyright 2000 American Medical Association. All rights reserved.
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Image of Figure 10.
Figure 10.

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

Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
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Figure 11.
Fundus photograph showing a white choroidal lesion causing the fovea to be ectopic. Reprinted with permission from the ( ). Copyright 2000 American Medical Association. All rights reserved.
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Image of Figure 11.
Figure 11.

Fundus photograph showing a white choroidal lesion causing the fovea to be ectopic. Reprinted with permission from the ( ). Copyright 2000 American Medical Association. All rights reserved.

Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
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Figure 12.
Fundus photograph of the left eye showing resolution of the choroidal tubercle with retinal pigment epithelium stippling within the resolving choroidal tubercle. Reprinted with permission from the ( ). Copyright 2000 American Medical Association. All rights reserved.
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Image of Figure 12.
Figure 12.

Fundus photograph of the left eye showing resolution of the choroidal tubercle with retinal pigment epithelium stippling within the resolving choroidal tubercle. Reprinted with permission from the ( ). Copyright 2000 American Medical Association. All rights reserved.

Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
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Figure 13.
Retinitis and retinal neovascularization obscuring a clear view of the optic disc in a fundus photograph. Reprinted with permission from the ( ). Copyright 1998 American Medical Association. All rights reserved.
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Image of Figure 13.
Figure 13.

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

Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
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Figure 14.
Noncaseating granuloma from a transvitreal biopsy specimen. Reprinted with permission from the ( ). Copyright 1998 American Medical Association. All rights reserved.
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Image of Figure 14.
Figure 14.

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

Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
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Figure 15.
Left fundus photograph illustrating optic disc new vessels with choroidal mass nasally. Reprinted with permission from the ( ). Copyright 1998 American Medical Association. All rights reserved.
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Image of Figure 15.
Figure 15.

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

Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
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Figure 16.
Acid-fast stain of a conjunctival biopsy specimen shows acid-fast positive rods (arrow) within epithelioid histiocytes.
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Image of Figure 16.
Figure 16.

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

Citation: Albert D, Thompson, M, Peralta R. 2011. Ocular Tuberculosis, p 269-282. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch17
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References

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