Ocular Tuberculosis

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Contents

1 Epidemiological Aspect of Ocular Tuberculosis........................ 1

May Zun Aung Win and Soon-Phaik Chee
2 Pathogenesis and Pathology of Ocular Tuberculosis................. 7
Seema Sen
3 Imaging Studies for Ocular Tuberculosis................................... 17
Atul Kumar, Rohan Chawla, and Ruchir Tewari
4 Laboratory and Radiological Investigations in the Diagnosis
of Ocular Tuberculosis.................................................................. 29
Randeep Guleria and Vijay Noel Nongpiur
5 Tuberculin Skin Test and Interferon-γ Release Assays
in the Diagnosis of Ocular Tuberculosis..................................... 35
Nicole Shu-Wen Chan and Soon-Phaik Chee
6 Management of Ocular Tuberculosis.......................................... 51
Nitin Kumar, Eliza Anthony, Parthopratim Dutta Majumder,
Ranju Kharel (Sitaula), and Jyotirmay Biswas
7 Tubercular Uveitis......................................................................... 61
Atul Kumar, Rohan Chawla, Raghav Ravani,
and Koushik Tripathy
8 Tubercular Multifocal Serpiginoid Choroiditis......................... 81
Sahil Jain, Aniruddha Agarwal, Kanika Aggarwal,
and Vishali Gupta
9 Tubercular Retinitis and Retinal Vasculitis................................ 89
Soumyava Basu and Taraprasad Das
10 Tuberculous Optic Neuropathy.................................................... 95
Rohit Saxena and Divya Singh
11 Ocular Tuberculosis in Immunocompromised
Patients........................................................................................... 101
Pukhraj Rishi, Ekta Rishi, Sridevi Nair, S. Sudharshan,
and Sharanya Abraham
12 Conjunctival and Corneal Tuberculosis...................................... 111
Namrata Sharma and Neelima Aron

vii
viii Contents

13 Tubercular Scleritis....................................................................... 117

Mi Fang Helen, Rupesh Agrawal, Vishali Gupta,
and Carlos Pavesio
14 Orbital and Periorbital Tuberculosis.......................................... 123
Neelam Pushker and Amar Pujari

Index....................................................................................................... 133
Contributors

Sharanya Abraham, MBBS, DO, DNB Uvea Department, Sankara

Nethralaya, Chennai, TN, India
Aniruddha Agarwal, MS Advanced Eye Center, Department of
Ophthalmology, Post Graduate Institute of Medical Education and Research
(PGIMER), Chandigarh, India
Kanika Aggarwal, MS Advanced Eye Center, Department of
Ophthalmology, Post Graduate Institute of Medical Education and Research
(PGIMER), Chandigarh, India
Rupesh Agrawal, FRCS, MD National Healthcare Group Eye Institute,
Moorfields Eye Hospital, NHS Foundation Trust, Tan Tock Seng Hospital,
Singapore, Singapore
Eliza Anthony, MBBS, DNB Ophthalmology Uvea Services, Medical
Research Foundation Sankara Nethralaya, Chennai, Tamil Nadu, India
Neelima Aron, MD Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi, India
Soumyava Basu, MS L V Prasad Eye Institute, Bhuabneswar, India
Jyotirmay Biswas, MBBS, MS, FMRF, FAICO Uveitis & Ocular
Pathology Department, Medical Research Foundation, Sankara Nethralaya,
Chennai, India
Nicole Shu-Wen Chan, MBBS Singapore National Eye Centre, Singapore
Rohan Chawla, MD, FRCS(Glasg) Dr. Rajendra Prasad Centre for
Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi,
India
Soon-Phaik Chee, FRCS(Ed), FRCS(G) Singapore National Eye Centre,
Singapore
Singapore Eye Research Institute, Singapore
Department of Ophthalmology, Yong Loo Lin School of Medicine, National
University of Singapore, Singapore
Duke-NUS Graduate Medical School Singapore, Singapore
Taraprasad Das, MD L V Prasad Eye Institute, Hyderabad, India

ix
x Contributors

Randeep Guleria, MD, DM Department of Pulmonary Medicine and Sleep

Disorders, All India Institute of Medical Sciences, New Delhi, India
Vishali Gupta, MS Advanced Eye Center, Department of Ophthalmology,
Post Graduate Institute of Medical Education and Research (PGIMER),
Chandigarh, Chandigarh, India
Mi Fang Helen, MBBS National Healthcare Group Eye Institute, Tan Tock
Seng Hospital, Singapore, Singapore
Sahil Jain, MS Advanced Eye Center, Department of Ophthalmology,
Post Graduate Institute of Medical Education and Research (PGIMER),
Chandigarh, India
Atul Kumar, MD, FAMS Dr. Rajendra Prasad Centre for Ophthalmic
Sciences, All India Institute of Medical Sciences, New Delhi, India
Nitin Kumar, MBBS, MS Uvea Services, Medical Research Foundation
Sankara Nethralaya, Chennai, Tamil Nadu, India
Parthopratim Dutta Majumder, MBBS, MS, FMRF Uvea Services,
Medical Research Foundation Sankara Nethralaya, Chennai, Tamil Nadu, India
Sridevi Nair, MD Sankara Nethralaya, Shri Bhagwan Mahavir Vitreoretinal
Services, Chennai, TN, India
Vijay Noel Nongpiur, MD Department of Pulmonary Medicine and Sleep
Disorders, All India Institute of Medical Sciences, New Delhi, India
Carlos Pavesio, MD, FRCOphth Moorfields Eye Hospital, London, UK
Amar Pujari, MD Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi, India
Neelam Pushker, MD Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi, India
Raghav Ravani, MBBS, MD Dr. Rajendra Prasad Centre for Ophthalmic
Sciences, All India Institute of Medical Science, New Delhi, India
Ekta Rishi, MS Sankara Nethralaya, Shri Bhagwan Mahavir Vitreoretinal
Services, Chennai, TN, India
Pukhraj Rishi, MS, FRCS Sankara Nethralaya, Shri Bhagwan Mahavir
Vitreoretinal Services, Chennai, TN, India
Rohit Saxena, MD, PhD Dr. Rajendra Prasad Centre for Ophthalmic
Sciences, All India Institute of Medical Sciences, Department of
Ophthalmology, New Delhi, India
Seema Sen, MD, Pathology Dr. Rajendra Prasad Centre for Ophthalmic
Sciences, All India Institute of Medical Sciences, Department of Ocular
Pathology, New Delhi, India
Namrata Sharma, MD, DNB Dr. Rajendra Prasad Centre for Ophthalmic
Sciences, All India Institute of Medical Sciences, New Delhi, India
Contributors xi

Divya Singh, MBBS, MD, DNB Dr. Rajendra Prasad Centre for
Ophthalmic Sciences, All India Institute of Medical Sciences, Department of
Ophthalmology, New Delhi, India
Ranju Kharel (Sitaula), MD, FAICO Department of Ophthalmology,
Maharajgunj Medical Campus, B. P. Koirala Lions Centre for Ophthalmic
Studies, Tribhuvan University, Institute of Medicine, Kathmandu, Nepal
S. Sudharshan, MS Uvea Department, Sankara Nethralaya, Chennai, TN,
India
Ruchir Tewari, MD, FICO Dr. Rajendra Prasad Centre for Ophthalmic
Sciences, All India Institute of Medical Sciences, New Delhi, India
Koushik Tripathy, MD, FRCS (GLASG) Dr. Rajendra Prasad Centre for
Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi,
India
May Zun Aung Win, MB, BS, MMedSc(Ophth) Ocular Inflammation
and Immunology Department, Singapore National Eye Centre, Singapore,
Singapore
 Epidemiological Aspect of Ocular
Tuberculosis 1
May Zun Aung Win and Soon-Phaik Chee

The incidence of TB in developed countries

Introduction decreased in the nineteenth century. This decline
was attributed to improved living conditions and
Tuberculosis (TB) is an airborne infection caused the discovery of effective antibiotics. In devel-
by Mycobacterium tuberculosis. While 10% of oped countries, such as the United States, the
individuals with infected TB become symptom- prevalence of ocular TB is estimated to be around
atic, in about 90% the infection remains latent 1–2%, while in Spain it is significantly higher at
without manifestation of the disease for the rest 18% (see Table 1.1). In contrast in developing
of their lives. In 1999, the World Health countries, there are approximately 8.4 million
Organization (WHO) declared tuberculosis a new cases of TB annually with a corresponding
global emergency causing nearly three million increased incidence of ocular TB [7].
deaths annually. In the same year, WHO reported Ocular TB was first diagnosed by Maitre-Jan
that there were 3.7 million cases of tuberculosis in 1711. The current prevalence of ocular TB var-
of which 20% of patients came from Africa, 38% ies from 0.5% to 1.4% [8]. Ocular TB is defined
from Southeast Asia, 22% from Western Pacific, as an infection by M. tuberculosis which can
6% from the United States, and 4% from the east- involve any part of the eye, superficial, intraocu-
ern Mediterranean [1]. lar, or the structures around the eye with or with-
out systemic involvement [9]. In primary ocular
M.Z.A. Win, MB, BS, MMedSc(Ophth) TB which is rare, the eye is the portal of entry
Ocular Inflammation and Immunology Department, which may be the conjunctiva, cornea, or sclera.
Singapore National Eye Centre, Singapore, Singapore
In secondary ocular TB, the ocular involvement
S.-P. Chee, FRCS(Ed), FRCS(G) (*) occurs by hematogenous spread of the organism,
Singapore National Eye Centre,
11 Third Hospital Avenue, Singapore, 168751 of which tuberculous uveitis is an example [10].
Due to the rich blood supply of the uveal tract,
Singapore Eye Research Institute,
11 Third Hospital Avenue, Singapore, 168751 the choroid is the most common site of ocular TB
manifestation [11, 12].
Department of Ophthalmology, Yong Loo Lin School
of Medicine, National University of Singapore, Ocular TB often presents without clinical evi-
1E Kent Ridge Road, Singapore, 119228 dence of active pulmonary TB and may be the
Duke-NUS Graduate Medical School Singapore, first and only manifestation of the infection [13].
8 College Road, Singapore, 169857 Among the various forms of ocular TB, posterior
e-mail: [email protected] uveitis is the most common [9].

© Springer International Publishing AG 2017 1

A. Kumar et al. (eds.), Ocular Tuberculosis, Essentials in Ophthalmology,
DOI 10.1007/978-3-319-57520-9_1
2 M.Z.A. Win and S.-P. Chee

Table 1.1 Studies in which rates of ocular tuberculosis Ocular TB in Developed Countries
were reported in patients with pulmonary tuberculosis
Percentage Currently, there is a lower prevalence of ocular
of ocular TB in
TB cases in developed countries compared to
pulmonary TB
Author Year Place patients developing countries (see Table 1.2). In Chile,
Bouza 1997 Spain 18 Israel, the Netherlands, Portugal, and Turkey, the
et al. [2] prevalence is very low, ranging from 0.7% to
Lara 2013 Philippines 6.8 2.7% [17–22]. In the United States, the percent-
et al. [3] age of ocular TB was 0.2% in 1987, reaching
Beare 2002 Africa 2.8 0.6% in 1996 and then declining to 0.38% in
et al. [4]
2014 [23–25]. Studies in the United Kingdom
Donahue [5] 1967 United States 1.46
show a notable rise in prevalence from 0.28% in
Biswas and 1995 South India 1.39
Badrinath [6] 1996 to 3.3% in 2015 [26, 27]. Japan is another
country in which the prevalence increased from
0.2% in 1997 to 6.9% in 2003 and then settled at
1.4% in 2016 [28–30].
A study from Denmark suggested that ocular
 pidemiology of Ocular TB
E TB is an important cause of ocular morbidity where
in Patients with Pulmonary TB cases presented as chronic iridocyclitis, peripheral
phlebitis, and disseminated choroiditis [47]. In
Epidemiological data for ocular TB are rare due Russia, ocular TB was on the increase especially
to the lack of standardized diagnostic criteria. with cases presenting as posterior uveitis [48].
Table 1.1 shows the rates of ocular TB among Studies in Argentina, France, Italy, and Saudi
pulmonary TB patients. Arabia reported high prevalence than other devel-
In 1960, Woods reported that 20% of patients oped countries with prevalence ranging from 6.2%
with pulmonary TB due to M. tuberculosis had in France to 10.5% in Saudi Arabia [32, 35–37, 42].
uveitis [14]. In contrast in 1967, Danahue found
that only 1.46% of pulmonary TB patients had
concomitant ocular TB in the United States [5]. Ocular TB in Developing Countries
Surprisingly in 1997, a prospective study from
Spain randomly examined 100 patients with pul- Infectious uveitis accounts for a significant pro-
monary TB and diagnosed 18 patients (18%) portion of uveitis cases seen in the developing
with ocular TB [2]. countries. Studies in Congo, Iraq, Lebanon, and
Among the developing countries, Biswas and Nepal found a high prevalence ranging from 4%
Badrinath in 1995 examined 1005 eyes of pulmo- to 11.4% [33, 43–45]. Myanmar has an alarm-
nary TB patients in south India and found that ingly high prevalence of 32.4% in a study con-
1.39% of patients concomitantly had ocular TB ducted in 2016 [46]. There is also a rising trend in
[6]. However, in another publication by Biswas India increasing from 5.6% in 2000 to 10.13% in
et al. in 1997, they found that culture-positive 2004 [34, 38]. Surprisingly in China there is an
ocular TB accounted for only 0.60% of the 1273 apparent decrease from 4% in 1986 to 0.7% in
uveitis patients seen in his uveitis referral clinic 2005 [31, 40]. Studies from Tunisia, Iran, and
[15]. In the Philippines, screening of 103 cases of Thailand reported almost similar percentage of
pulmonary TB found seven patients (6.8% preva- ocular TB with 1.1%, 1.5%, and 2.2%, respec-
lence) with ocular TB in 2013 [3]. tively [39, 41, 49].
Thus, reports of the prevalence of ocular TB The wide variability in the reported incidence
have been variable across time, patient popula- of ocular TB in the various studies in both the
tions, and geographical locations [16]. developed and developing countries mentioned
1 Epidemiological Aspect of Ocular Tuberculosis 3

Table 1.2 Prevalence of ocular tuberculosis in reported series from different countries by percentage
Author Year Country Percentage of ocular TB patients
Abrahams and Jians [31] 1986 China 4
Henderly et al. [23] 1987 United States 0.2
Palmares et al. [21] 1990 Portugal 2.2
Weiner and Ben Ezra [18] 1991 Israel 0.7
Rothova et al. [19] 1992 Netherlands 1.4
Couto and Merlo [32] 1993 Argentina 6.8
Smit et al. [20] 1993 Netherlands 2.7
Rodriguez et al. [24] 1996 United States 0.6
Thean et al. [26] 1996 United Kingdom 0.28
Kotake et al. [28] 1997 Japan 0.2
Kaimbo et al. [33] 1998 Congo 6
Rathinam and Namperumalsamy [34] 2000 India 5.6
Mercanti et al. [35] 2001 Italy 7.02
Bodaghi et al. [36] 2001 France 6.2
Islam and Tabbara [37] 2002 Saudi Arabia 10.5
Wakabayashi et al. [29] 2003 Japan 6.9
Singh et al. [38] 2004 India 10.13
Soheilian et al. [39] 2004 Iran 1.5
Yang et al. [40] 2005 China 0.7
Sengun et al. [22] 2005 Turkey 1.3
Pathanapitoon et al. [41] 2008 Thailand 2.2
Hanmade et al. [42] 2009 Saudi Arabia 7
Hong et al. [25] 2014 United States 0.38
Al-Shakarchi [43] 2014 Iraq 11.4
Abdulaal et al. [44] 2014 Lebanon 5.7
Liberman et al. [17] 2014 Chile 2.3
Jones [27] 2015 United Kingdom 3.3
Weiner and Ben Ezra [18] 2016 Israel 0.7
Nakahara [30] 2016 Japan 1.4
Manandhar [45] 2016 Nepal 4
Win et al. [46] 2016 Myanmar 32.4

above may reflect the difference in prevalence of eye leading to rapid destruction of the ocular
TB in these countries. However, these studies are structures. HIV is a contributing factor for the
also reported among different ethnic groups and reemergence of TB in recent years.
more importantly in different eras. The diagnosis CD4 cells play a major role in the immune
and detection techniques have also improved over response, and susceptibility to TB in HIV-­
time, with newer diagnostic tools being made infected patients increases markedly when CD4
available with the advancement of technology. T cells are depleted.
In patients with HIV infection, the initial cho-
roiditis may develop into a subretinal abscess,
 cular TB in the
O leading to a chorioretinitis involving the retina.
Immunocompromised The chorioretinitis can be extensive and involve
the ciliary body causing cyclitis with hypotony
Patients who are immunosuppressed or human and phthisis bulbi [50].
immunodeficiency virus (HIV) infected can A prospective study in Africa found a 2.8%
develop active mycobacterial disease in the prevalence of choroidal granulomas in HIV
4 M.Z.A. Win and S.-P. Chee

patients with pulmonary tuberculosis in 2002 Anatomical Location of Ocular TB

[4]. In 2006, Babu et al. reported an incidence
of 1.95% of ocular TB in 766 consecutive cases Tuberculous uveitis may present as anterior,
of HIV or acquired immune deficiency syn- intermediate, posterior, or panuveits [16]. The
drome (AIDS). Of these, more than a quarter most common presentation of ocular TB is ante-
had bilateral involvement. Their ocular pre- rior uveitis and sclerokeratitis in a study by
sentation included choroidal granulomas Demirci [55]. Retinal vasculitis, neuroretinitis,
(52.63%), subretinal abscess (36.84%), pan- and choroiditis are other common manifestations
ophthalmitis, conjunctival tuberculosis, and in a study by Shah et al. [52] While tuberculous
panophthalmitis [51]. choroidal granulomas are a result of hematoge-
Because of impaired cell-mediated immunity nous spread of the organism, the cause of TB vas-
in HIV-infected patients, there is increased sever- culitis with choroiditis patches is believed to be
ity and susceptibility of TB when compared to due to hypersensitivity reaction to bacterial pro-
patients with intact immune systems [5]. Therefore, tein. Posterior uveitis was the most common clin-
ocular TB in HIV-infected patients may present ical presentation in a study from India [57].
with severe sight-threatening complications. A study from Saudi Arabia reported that panu-
veitis was the most common form of ocular TB
[58]. In a study from Italian and Swiss centers,
Gender granulomatous uveitis was the most common pre-
sentation of ocular TB [59]. Torres and Calonge
In a study by Shah et al. in 2016, researchers reported that cystoid macular edema was the pre-
found 80% of TB uveitis patients to be male and dominant ocular presentation of TB [60]. In a
20% female [52]. Basu et al. in 2014 reported study from the Philippines, posterior uveitis was
that 67.5% of the TB population was male and the main finding in patients with ocular TB [3].
32.5% female [53]. In a study by Sanghvi et al. in In an evaluation of anatomical classification
2011, it was found that 59% of ocular patients of uveitis, Shah et al. found that 33% of cases had
were females and 41% male [54]. These studies anterior uveitis, 33.3% intermediate uveitis, and
represent a small sample of recent research pub- 26.6% posterior uveitis, and only 6.6% presented
lication with differing results, suggesting that as panuveitis [52]. In a study by Gupta et al., 43%
there is no clear gender variation for ocular of patients had panuveitis, while 36% had ante-
TB. These findings may reflect the social varia- rior uveitis, 11% had panuveitis, and another
tions in these different population studies as the 11% had intermediate uveitis [57]. However,
first two studies were from India and the last other reports found that disseminated choroiditis
from the United Kingdom. was the most common presentation [61–63].
Thus, ocular TB may present with different
clinical features in different countries. This may
Laterality be a result of various factors including the ethnic
group, immune status and response of the patient,
Ocular TB often presents as a unilateral and mycobacterial status (including drug-resistant
asymmetric disease [55]. In a prospective study strains), and size of inoculum.
done in the Philippines, all pulmonary patients
were diagnosed with unilateral ocular TB [3].
Both ocular and orbital TB are usually unilateral Conclusion
in presentation [56]. Most cases of military tuber-
culosis are bilateral. Thus, these variations may Tuberculosis (TB) has reemerged as a global
be related to the size of the inoculum during health problem in the recent years. Due to chal-
hematogenous spread. lenges faced in diagnosing ocular TB and the
1 Epidemiological Aspect of Ocular Tuberculosis 5

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 Pathogenesis and Pathology
of Ocular Tuberculosis 2
Seema Sen

Tuberculosis affects one-third of the world popu- nomenon of hypersensitivity to circulating

lation [1]. Extrapulmonary tuberculosis (TB) tuberculoproteins [6]. The bacilli tend to localize
involving the pleura, lymphatics, bone, genito- in tissues that have high regional oxygen tension
urinary system, meninges, or skin occurs in 15% which includes the apices of the lungs, kidneys,
of TB patients [2]. The incidence of ocular TB bones, meninges, eye, and choroid [3]. Within
ranges from 1.4% to 5.74% [3]; it may occur in the eye the preferred sites include the choroid and
association with either pulmonary tuberculosis or ciliary body where the oxygen tension is higher
in isolation, with no clinical or laboratory evidence in comparison to other ocular structures [7].
of pulmonary infection [4]. The number of extra- Ocular TB is often misdiagnosed as retino-
pulmonary tuberculosis cases has increased in blastoma, squamous cell carcinoma, xanthogran-
recent times in immunocompromised individuals uloma, or pseudotumor. Corneal or corneoscleral
with AIDS and tuberculosis (2.8–11.4%) [3, 5]. perforations may also occur. Its diagnosis is chal-
The organism M. tuberculosis (MTB) is an lenging in the absence of pulmonary disease [6].
obligate aerobic slow-growing, nonspore-­
forming, nonmotile bacteria. Humans are the only
natural host, and infection is usually by airborne Pathology of Ocular Tuberculosis
aerosol and enters into susceptible hosts through
the lung and results in a latent infection in indi- M. tuberculosis infection is usually chronic and
viduals with normal immune systems [3]. In 5% insidious when it affects the eye and adnexa. It is
of newly infected persons, the pulmonary process usually a hematogenous spread of the organism.
progresses. Rarely lymphohematogenous spread The three forms of disease include mycobacterial
of bacilli in large numbers may lead to miliary TB invasion of ocular tissues, hypersensitivity to anti-
or other extrapulmonary manifestations [4]. gen of MTB with viable mycobacteria, and hyper-
Spread to the eye and other extrapulmonary sensitivity in the absence of viable bacteria [1].
sites usually occurs from hematogenous or adja- Characteristic histopathological features in
cent spread of viable bacilli or as a local phe­ ocular tuberculosis include granulomatous
inflammation involving the sclera, cornea, con-
junctiva, iris, and ciliary body with central case-
S. Sen, MD, Pathology (*) ous necrosis and occasional or no acid-fast bacilli
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, (Fig. 2.1a, b). The granulomas are composed of
All India Institute of Medical Sciences, Department
of Ocular Pathology, New Delhi, India abundant epithelioid histiocytes, occasional giant
e-mail: [email protected] cells of Langerhans type, and lymphomononuclear

© Springer International Publishing AG 2017 7

A. Kumar et al. (eds.), Ocular Tuberculosis, Essentials in Ophthalmology,
DOI 10.1007/978-3-319-57520-9_2
8 S. Sen

Fig. 2.1 (a) Granulomatous inflammation with giant cell reaction (arrow) (H&E ×100). (b) Higher magnification to
show epithelioid cells (arrow) and lymphomononuclear surrounding the Langerhans giant cell (H&E ×200)

Fig. 2.2 (a) Subconjunctival necrotizing granuloma with giant cell reaction in a case of suspected eyelid tuberculosis
(H&E ×100). (b) High-power view to show necrosis (arrow) in the center of granuloma (H&E ×200)

cells. Since the granulomas in immunocompetent it may be nongranulomatous. The diagnosis of

individuals contain occasional bacteria, the stain- intraocular TB is difficult prior to enucleation.
ing may not reveal the presence of organisms. In The eyelid involvement is very rare and is usu-
such cases, the bacterial DNA may be detected ally secondary to orbital TB and may appear as a
by polymerase chain reaction (PCR). small nodule simulating a chalazion or as a drain-
Ocular tuberculosis is a unique form of extra- ing sinus (Fig. 2.2a, b). Rarely primary conjunc-
pulmonary tuberculosis which can present with tival and eyelid tuberculous granuloma may
several clinical manifestations based on the viru- occur [8–11].
lence of the organism and immune status of the Orbital or lacrimal gland (Fig. 2.3a, b) and
individual. Both ocular and orbital tuberculosis lacrimal sac granuloma may occur secondary to
are usually unilateral [8]. The most common clini- infection with M. tuberculosis [12, 13]. These
cal presentation is posterior uveitis followed by may be associated with preauricular lymphade-
anterior uveitis, pan uveitis, and intermediate uve- nopathy. Children can present as preseptal celluli-
itis. Although granulomatous uveitis is common, tis with a fistula or as abducens nerve palsy [14].
2 Pathogenesis and Pathology of Ocular Tuberculosis 9

Fig. 2.3 (a) Granulomatous inflammation (asterisk) in lacrimal gland (arrow shows lacrimal gland acini) (H&E ×100).
(b) Higher magnification shows epithelioid cell granuloma (arrow) and adjoining lacrimal gland (LG) (H&E ×200)

Fig. 2.4 (a) Tuberculous granuloma of the ciliary body fication to show granuloma with giant cell (arrow) and
with acute panophthalmitis. The vitreous shows necrotiz- destroyed ciliary processes (asterisk) (H&E ×200)
ing inflammatory reaction (H&E ×40). (b) Higher magni-

Interstitial keratitis and phlyctenular kerato- rarely confirmed by histopathology or PCR fol-
conjunctivitis represent a localized immunologic lowing enucleation.
(hypersensitivity) response to the antigens of Anterior uveitis presents with insidious granu-
mycobacteria. Tuberculous scleritis presents as lomatous uveitis which may be unilateral or bilat-
anterior scleritis mostly in the form of focal ele- eral. Iris lesions in tuberculosis appear as nodular
vated nodules which may undergo necrosis and areas at the pupillary margin, over the surface, or
result in scleromalacia. Many of the cases of in the angle and are made up of epithelioid cells,
anterior segment are not associated with systemic giant cells, and lymphocytes with extensive case-
manifestations of TB and appear localized to the ation. Cyclitis is seen frequently and may cause
eye [3, 10, 15]. caseating granulomas (Fig. 2.4a, b) [10, 17].
Scleritis, both necrotizing and non-­necrotizing, Posterior segment involvement is more com-
diffuse or nodular, may be associated with TB mon and may include features of endophthalmitis
[16]. The diagnosis is often presumptive and or panophthalmitis simulating intraocular tumors