Role of An Ophthalmologist in Early Diagnosis and Management of by alicejenny


									370                                     AIOC 2009 PROCEEDINGS

Role of An Ophthalmologist in Early Diagnosis and Management
                   of Ocular Tuberculosis
       Dr. Sonal Vyas, Dr. A.K. Chandraker, Dr. Mangilal Garg, Dr. Nidhi Pandey,
                                 Dr. Santosh Singh Patel

                               (Presenting Author: Dr. Sonal Vyas)

    he term "Ocular tuberculosis" encompasses       Diagnosis of tuberculosis infection is difficult. A
    any infection by Mycobacterium tuberculosis     definitive diagnosis is possible when M.
or one of its three related mycobacterial species   tuberculosis can be visualized in, or cultured
(sp. bovis, africanum, and microti), in, on or      from, or its DNA amplified from the involved
around the eye. A tuberculous lesion, small and     tissue. In ocular tuberculosis sometimes it
                                                    becomes difficult. Hence the development of
sometimes even insignificant enough to have
                                                    enzyme linked immunosorbent assays (ELISA)
escaped our notice, elsewhere in the body,          has stimulated renewed interest in serological
produces not only diminution of vision but often    tests for diagnosis of tuberculosis. When indirect
irreparable damage to the eye leading to            evidence strongly suggest that tuberculosis is
permanent blindness.                                responsible for a patient’s clinical condition
                                     INFLAMMATION SESSION                                                          371

diagnosis is best termed presumed ocular                    Table-2: Treatment of Patients (N=75)
tuberculosis round the eye.                           Category           Treated          Response Side Effects
Materials and Methods                                 of ATT             Patients           Seen     Seen In
                                                                        No.        %      No.       %       No.    %
The present study was done from January 2007
to April 2009. This study included 75 cases of        CATEGORY I         11       14.67    9       81.82     1    9.10
ocular tuberculosis, who were diagnosed on the        CATEGORY II        2        2.67     1       50.00     1    50.00
basis of clinical ocular examination, presence of     CATEGORY III 62             82.67   58       93.50     6    9.68
systemic foci, various investigations like ESR,       TOTAL              75       100     68       90.67     8    10.67
montoux, sputum for AFB, Elisa for TB, TB PCR
and after excluding other etiological factors.
After confirmation of diagnosis, ATT was started      The WHO estimates that 9.27 million new cases
according to RNTCP criteria under the                 of TB occurred in 2007 (139 per
supervision of the physician. The entire patients     100000population), compared with 9.24 million
were followed regularly under RNTCP                   new cases (140 per 100 000 population) in 2006,
guideline.                                            95% in developing countries. Nearly 2 million
                                                      people die from TB each year. The exact burden
Results                                               of tuberculosis cannot be estimated as there is no
In our study patients were belonging from age of      clear diagnostic criterion and there is no
7 to 70 years but majority of them were from age      pathognomic ophthalmic finding for ocular TB.
group 21 to 30 years. Various clinical                Our study is compared with the study of
presentations seen in our study were shown in         ‘manifestation of ocular tuberculosis’ by G.N.
Table 1. History of contact with tubercular           Sahu et al 1998 and another study on ‘tubercular
patients was present in only 10 (13.33%) patients.    etiology in cases of retinal vasculitis’ by S. P. Rai
Out of 75, 54 (72%) patients were reactive to PPD     et al 2001 which showed the results in table 3.
(5 TU). ESR was found raised in 58 (77.33%), and
X- ray chest was showing tubercular infiltrations                    Table-3: Comparative Study
in 6 (8%) patients. Elisa for tuberculosis was        Findings          Sahu et al        Rai et al        Our Study
found positive in 47 (62.67%) and total 13                                1998             2001              2009
(17.33%) patients were having systemic                H/o contact        27.27 %           00 %             13.33 %
manifestations (pulmonary- 06, others- 07).           Raised ESR         50.90 %          11.40 %           77.33 %
Anti tubercular treatment (ATT) was started to        Positive PPD        100 %           61.00 %           72.00%
all 75 cases. 68 (90.67%) responded well to ATT.      X ray chest
Only 8 (10.67%) developed side effects which          involvement        49.09 %          29.50 %           08.00 %
were managed accordingly. (Shown in Table 2)          Elisa for TB
                                                      (IgM/IgG)               -           43.70 %           62.67 %
Table-1: Clinical Diagnosis of Patients (N=75)        Response
Diagnosis                 No. of Cases   Percentage   to ATT              100 %                -            90.67 %
Anterior uveitis              16          21.33%,
                                                        Table-4: Comparisons of Various Studies for
Nonhealing Corneal Ulcer      14          18.67%,
                                                        Systemic Involvement in Ocular Tuberculosis
Eales Disease                  9          12.00%                         Patients
Scleritis                      8          10.67%      Author                  Year          Ocular Tb Patients
Posterior uveitis              8          10.67%                                            With Systemic Tb
CSCR                           7           9.33%      Sahu et al              1998                  49.09 %
Sec. Optic Atrophy             3           4.00%      Morimura et al          2002                    10 %
Endophthalmitis                3           4.00%      Shome et al15           2006                      0%
B/L Papilloedema               2           2.67%      Babu et al              2006                    100 %
Phlyctenular Conjunctivitis    2           2.67%      Kurup et al             2006                  25.00 %
Orbital Cellulitis             2           2.67%      OUR STUDY               2009                  17.33 %
Conjunctival Mass              1           1.33%.     Ocular tuberculosis must be diagnosed early to
372                                        AIOC 2009 PROCEEDINGS

start treatment as delay may cause not only             definitive diagnosis can be daunting due to the
ocular but systemic complications too. Early            difficulty of getting ocular samples for
diagnosis is also important with respect to public      microbiologic or histologic evaluation, so high
health to prevent TB transmission to others.            awareness of ocular manifestations is must for an
But unfortunately Ocular tuberculosis can               ophthalmologist as he or she may be the first to
manifest a myriad of clinical presentation and the      diagnose tuberculosis.
1. Sahu GN, Mishra N, Bhutia RC, et al.                     tuberculosis control.
   Manifestations in ocular tuberculosis. Ahmedabad:    5. TB or not TB: treat to see, paul l a van daele, marleen
   National Conference on Tuberculosis and Chest           bakker, p martin van hagen, g seerp baarsma and
   Diseases. Ind J Tub. 1998;45:153–4.
                                                           robert w a m kuijpers, mja 2006;185(3):178-9.
2. S.P. Rai, B.N. Panda, V.S. Gurunath and P.K. Sahoo
                                                        6. Diagnosis of Ocular Tuberculosis: A Role for New
   Tubercular Etiology In Cases of Retinal Vasculitis
   Ind. J Tub, 2001;48:143.                                Testing Modalities? Bramante, Carolyn T. BA;
3.           Talbot, Elizabeth A. MD; Rathinam, Sivakumar R.
   ort/2009/en/index.html.                                 MNAMS; Stevens, Rosalind MD; Zegans, Michael
4. TBC India directorate of general health services        E. MD International Ophthalmology Clinics: 2007
   ministry of health and family welfare history of        ;47(3)45-62. doi: 10.1097/IIO.0b013

To top