Ten Pearls for Treatment of TB Uveitis

Prof. Amod Gupta
Published Online: April 1st, 2021 | Read Time: 2 minutes, 45 seconds

1. In TB-endemic countries, think of TB as a probable/possible etiology of uveitis in

  1. Presence of one or a few large full-thickness choroidal granulomas that show enhanced vascularity/RAP on FFA
  2. Retinal periphlebitis with subvascular retinitis/choroiditis lesions/scars that show extensive peripheral retinal ischemia.
  3. Multifocal serpiginoid choroiditis/Serpiginous-like choroiditis lesions with vitreous cells.

2. In the presence of any of the above clinical phenotypes, collect evidence of MTB infection by way of tuberculin skin test/QuantiFERON-TB Gold; X-ray/CT chest. The 2-step testing (Bayesian probability) improves the likelihood of MTB as a probable/possible etiology of uveitis in TB-endemic regions.

3. Polymerase chain reaction to detect MTB DNA from ocular fluids has low sensitivity limiting its utility in clinical practice. If positive, it confirms the diagnosis of TBU but a negative test does not rule out MTB.

4. Start 4-drug anti-TB drug regimen in consultation with an internist. All four drugs INH (H); Rifampicin (R); Ethambutol (E) and Pyrazinamide (Z) for the first 2-3 months and H and R for the next 6-9 months.

5. Because of a predominantly paucibacillary immune response, TB uveitis frequently requires administration of corticosteroids by local/depot or systemic routes. In view of the enhanced VEGF expression by TB choroidal granulomas, adjunctive use of anti-VEGF agents accelerate response to treatment.

6. Look for clinical response in 4-6 weeks of initiating treatment.

7. Patients with multifocal serpiginoid choroiditis/ Serpiginous-like choroiditis phenotype need very close monitoring for paradoxical/adverse worsening. This may be seen in 40-50% of these patients on the initiation of anti-TB treatment. Widefield fundus imaging must be done to document regression/ worsening on each visit.

8. Complete remission is seen in nearly 80% of patients with TB uveitis.

9. Recurrence of uveitis may be seen if uveitis is caused by MDR (~10%), incomplete or non-compliance treatment or is due to an etiology other than TB.

10. Healed TB posterior uveitis may be complicated by the development of CNVM that becomes a diagnostic challenge due to extensive scarring. Do not ignore any fresh visual complaints.

Prof. Amod Gupta
Emeritus Professor. Post Graduate institute of Medical Education and Research, Chandigarh
Prof. Amod Gupta graduated from medical school in 1973 and received his MS in ophthalmology in 1976. He has held prestigious posts as the Dean of medical faculty, head of the department of ophthalmology, professor of ophthalmology at the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh. He has raised the advanced eye centre at PGIMER in 2006 which is now one of the most advanced eye care centres in India. He was the founder President of the Uveitis society of India and ex-President of the Vitreoretinal society of India. Professor Amod Gupta has won many accolades including the prestigious Padma Shri award by the President of India in 2014. He was recognized among the Unsung Heroes of Ophthalmology in 2020 by the American Academy of Ophthalmology. Professor Amod Guptas contribution to research and innovation in ophthalmology is infinite and is one of the most cited ophthalmologists from India. He has mentored and taught many in the field of ophthalmology during his illustrious career spanning over four decades.
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