Consensus on Managing Tubercular Uveitis

Download PDF

Antitubercular therapy (ATT) has been shown to be effective in reducing recurrences of tubercular uveitis in nearly 86% of patients.¹ Yet some physicians remain reluctant to initiate treatment.

“Ocular tuberculosis remains a challenge all over the world, as the diagnosis is largely presumptive due to lack of positive histopathologic confir­mation,” said Vishali Gupta, MD, at the Advanced Eye Centre in Chandigarh, India. “In several countries, ophthal­mologists have to refer these patients to infectious disease experts or physi­cians who refuse to start ATT for lack of confirmed diagnosis. This can lead to multiple recurrences [of disease], resulting in increased ocular morbidity and visual loss,” said Dr. Gupta.

TUBERCULAR CHOROIDITIS. The spectrum of choroidal involvement ranges from (1) tubercular serpiginous-like choroiditis to (2) tubercular multifocal choroiditis, (3) tuberculoma, and (4) tubercular unifocal choroiditis.

Enter consensus guidelines on initiating ATT. To limit confusion, a team of international experts from the Collaborative Ocular Tuberculosis Study (COTS) has issued consensus guidelines on initiating ATT in several clinical scenarios.² The guidelines sug­gest that clinicians take the following steps:

• First, ascertain whether the clinical presentation in the eye is suggestive of TB.
• Second, consider whether the patient lives in a TB-endemic region (defined as having an incidence of more than 100 cases per 100,000 persons). Consensus was more robust for endemic regions. 

“It is also important to rule out other possi­ble etiologies in the differential diagnosis, as TB can mimic several other varieties of uveitis,” both infec­tious and noninfectious, Dr. Gupta said.

• Once ocular TB is suspected, order an immunologic test—a tuberculin skin test and/or an interferon-gamma release assay.
• In the three subtypes of tubercular choroiditis—tubercular serpiginous-like choroiditis, tuberculoma, and tubercular focal or multifocal choroid­itis—any positive immunologic test plus radiologic signs of active or healed pulmonary tuberculosis justifies initia­tion of ATT.
• In endemic regions, a positive result from a single immunologic test is suffi­cient to initiate treatment of tubercular serpiginous-like choroiditis or tubercu­loma, even without radiologic features suggestive of tuberculosis.

When to use adjunctive therapy for inflammation. There is strong agreement to start oral corticosteroids with, or soon after, initiation of ATT in patients who have tubercular serpigi­nous-like choroiditis or tuberculoma (with no associated systemic infectious disease). But opinion is mixed regard­ing the timing of initiating oral corti­costeroids in patients with tubercular multifocal or unifocal choroiditis.

And a caveat. Beware of potential drug interactions when combining ATT with various immunosuppressive drugs. When in doubt, consult the patient’s internist.

Impact on practice. Dr. Gupta now has more confidence in making deci­sions about initiating ATT, particularly in borderline situations. “Earlier, I was not sure whether or not I should start ATT. But after this consensus, I have started treating these patients, even though only one test is positive,” she said. “The guidelines have made a dif­ference in my practice patterns.”

—Miriam Karmel

___________________________

1 Agrawal R et al. JAMA Ophthalmol. 2017;135(12):1318-1327.

2 Agrawal R et al. Ophthalmology. Published online Jan. 10, 2020.

___________________________

Relevant financial disclosures—Dr. Gupta: None.

For full disclosures and the disclosure key, see below.

• Endophthalmitis: Which Sampling Method Is Best?

• Why Screen Multifocal IOL Patients With OCT?

• DRCR.net Five-Year Outcomes for Protocol T

• Automated Test for Strabismus Proves Accurate