Dr. Michael Indra Lesmana, Sp.M PID-FK.

UKRIDA

Manifestation of TB-Eye
Phlyctenulosis

unilateral - typically affects children photophobia, lacrimation blepharospasm delayed hypersensitivity to tuberculin protein topical steroids /steroidab

Intraocular Tuberculosis
Intraocular tuberculosis represents an extrapulmonary

form of the disease and they are seen in more than 50% of the patients who have both AIDS and tuberculosis
Jones et al: showed that the risk of extrapulmonary TB

was higher in patients with low CD4 +counts

great mimicker of various uveitis entities

Clinical Presentation in Intraocular Tuberculous

1. Anterior uveitis:

Granulomatous,nongranulomat ous, iris nodules and ciliary body tuberculoma

2. Intermediate uveitis : Granulomatous pars planitis/peripheral uvea 3. Posterior and panuveitis Choroidal tubercle Choroidal tuberculoma Subretinal abscess Serpiginous-like choroiditis

4. Retinitis and retinal vasculitis 5. Neuroretinitis and optic neuropathy 6. Endophthalmitis and panophthalmitis Eales disease is considered by some to reflect tuberculous infection or hypersensitivity

Case of patient with Anterior Uveitis (A) Anterior segment

photograph showing fibrinous inflammation in a 42-year-old man. His visual acutity was reduced to counting fingers (B)Ultrasound biomicroscopy shows exudates in pars plana

(C ) MRI shows cavitary lesion

(D) Sputum positive for acid-fast-bacilli.

Posterior and Panuveitis

In tuberculous posterior uveitis, the ocular changes

can be divided into four groups: 1.Choroidal tubercles 2.Choroidal tuberculoma 3.Subretinal abscess 4.Serpiginous-like choroiditis

Choroidal Tubercles
Right eye of a 24-yearold woman with tubercular meningitis showing optic disk edema, multiple small choroidal tubercles, and a healed choroidal tuberculoma temporal to the fovea with retinochoroidal anastamosis.

The most common intraocular manifestation of tubercular posterior uveitis

Choroidal Tuberculoma
(A) There are two granulomas in the upper temporal and lower nasal quadrant in the right eye In view of a strongly positive Mantoux test ( >20 mm induration) and positive chest x-ray, patient was given ATT with concomitant oral corticosteoids.

Fundus photofraph RE of a 45-year old man

Tubercular Retinal Vasculitis

Patient with systemic tuberculosis showing vasculitis Polymerase chain reaction from the vitreous humor was positive for M. tuberculosis.

Right eye of a 43-year-old man

Endophthalmitis - Panophthalmitis
Acute onset and shows rapid progression with

destruction of the intraocular tissues

The inflammation may be intense enough to produce

hypopyon, filling the anterior chamber with purulent material and involving the cornea
In panophthalmitis, the sclera is also involved, which

may result in globe perforation.

A case 22 yo,F, Protursion OD

Panophthalmitis ec TB . OD

UTZ

Post TB drugs treatment

Advised for evisceration

Diagnosis
Clinical indicators
Corroborative evidence

(Purified Protein Derivative, Chest Radiography and Computerized Tomography, Serodiagnosis or ELISA) Direct evidence (Acid-Fast, Culture of Intraocular Fluid/Tissue, Polymerase Chain Reaction)

Diagnosis
QuantiFERON is an approved, antigen specific test

that utilizes synthetic peptides representing Mycobacterium tuberculosis proteins

Including latent tuberculosis infection (LTBI) and

tuberculosis (TB) disease

This test was approved by the U.S. Food and

Drug Administration (FDA) in 2005.

QuantiFERON
Blood samples are mixed with antigens
The advantages:

> Is not subject to reader bias that can occur with Mantoux test > Is not affected by prior BCG (bacille CalmetteGurin) vaccination A positive result suggests that M. tuberculosis infection is likely; a negative result suggests that infection is unlikely

Diagnosis
Level I
Identification M.Tb in Ocular fluid/tissue

Staining, culture, PCR, histopath

Level II

Level evidence for diagnosis ocular TB

Identification M.Tb in Other fluid/tissue (eg.Lung)

Level III
Suggestive pattern of intraocular inflammation +

Suggestive clinical on systemic exam & Radiological

Treatment
MEDICAL MANAGEMENT 1. Drug Regimens for Treating Intraocular Tuberculosissimilar to those for pulmonary or extrapulmonary tuberculosis Comanagement with pulmonologist/internist
2. Duration of Treatment The initial regimen: RHZE. Pyrazinamide and ethambutol were stopped after 2 to 3 months and treatment with isoniazid and rifampin was continued for 9 to 12 months

3. Concomitant Use of Corticosteroids/ Immunosuppressive Agents

Low-dose systemic corticosteroids used for 4 to 6wks, along with multidrug ATT, may limit damage to ocular tissues caused from delayed type hypersensitivity

5. Ocular Side Effects of Anti-Tubercular Drugs The ethambutol toxicity is rare if the daily dose does not exceed 15mg/kg. Of the patients receiving daily dose of 25 mg/kg or more, 1--2% experience ocular toxicity

HIV-AIDS
Selected Anterior segment manifestation:

Molloscum contagiosum, HZO, Herpes simplex , Kaposi sarcoma

Most Common Posterior segment manifestation: HIV

Retinopathy, CMV retinitis

Molluscum contagiosum

HZO

Molluscum contagiosum, characterized by cutaneous nodules Painful, dermatoform, cluster vesicobullous

Herpes simplex

Kaposi Sarcoma (KS)

Painless, dendritic, decreased of corneal sensibility, recurrent

Nodul, reddish, painless, vascular, eyelid, conj- orbit

HIV Retinopathy
Ocular micro-angiopathic syndrome Non-infectious microvascular disorder characterised

by cotton wool spots, microaneurysms, retinal haemorrhages, Roth spots, telangiectatic vascular changes and areas of capillary non-perfusion

HIV Retinopathy

Cotton-wool spots (CWS) are the most common ocular micro-angiopathic manifestations of HIV/AIDS

CMV-Retinitis
CMV retinitis was a frequent opportunistic infection among patients with AIDS typically occurred in patients with CD4 T cells (helper T cells) 50 cells/L

CMV-Retinitis
Cytomegalovirus retinitis has been reported to affect up to 25% to 40% of HIV patients and is the most common cause of visual loss
Highly active antiretroviral therapy (HAART) effectively suppresses HIV replication, resulting in immune recovery, which, if sufficient, controls retinitis without anti-CMV therapy.

CMV-Retinitis Treatment
The induction regimen consisted of injection of 2

mg/0.04 ml of ganciclovir twice weekly for 4 weeks followed by a similar dose weekly for 4 weeks and then a weekly maintenance regimen of 1.0 mg/0.02 ml ganciclovir anti-CMV drugs are virostatic, and treatment has to be given in a continuous to prevent recurrence of the disease.

TOXOPLASMOSIS
This is a case of a 20 y.o F with blurring of vision 1 week

ptc. Associated with eye soreness, mild eye redness, seeing floaters and half of visual defect. Pt likes to consume street food satae No fever nor cough. (-) history of allergic Had prior consult but gain no relief

Ophthalmological Status
OD
VA : 2/60 (inferior side) Mild ciliary injection Clear cornea -f/-c +2 vitreous cell IOP 59 mmHg VA : 1.0 No injection Clear cornea -f/-c - vitreous cell IOP 12 mmHg

OS

Full EOM
+/+RC (-)RAPD

Full EOM
+/+RC (-)RAPD

Fundus Photo pre-treatment

Ancillary Test
Ro Thorax PA : Mild Infiltrate on left parahiler Aorta Calsification Ass: Bronchopneumonia DD/ Pulmonary TB

Hematologi
Hb 13.9 g/dl L 9.2 0/1/2/76/21/0 Ht 43 Tromb 285.000 Blood sugar 126mg/dl

Immunologi
Ig G Toxoplasma

(+) 100 IU/ml

Diagnosis and Treatment

Posterior Uveitis (Retinochoroiditis) ec Toxoplasmosis

OD with secondary glaucoma Meds: Ab-steroid topical 6x OD Timolol 0.5% 2x OD Cotrimoksazol forte 2x 1 tab Acetazolamide 250mg 3x 1 tab Methylprednisolone 1 x 48mg pc Kalium oral 2x1 tab

1 week post treatment

OD : VAD sc 0.5 ()

BCVA S-1.00 c -0.50 x 160 --- 0.8 (-) ciliary injection (-) vit cell IOP 10 mmHg () OS : VAD sc 1.0 IOP 12 mmHg

Fundus Photo 2nd wk post tx

Fundus Photo pre & 3rd wk post tx

THANK YOU