Lack of Consensus in the Diagnosis and Treatment for Ocular Tuberculosis among Uveitis Specialists

Lou, Susan; Larkin, Kelly L.; Winthrop, Kevin; Rosenbaum, James T.

doi:10.3109/09273948.2014.926936

Cited by 38 publications

(25 citation statements)

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“…A prospectively derived clinical risk score will help to improve the diagnosis and management of TBU and potentially serve as a point-ofcare screening tool to identify asymptomatic pulmonary TB in carriers. This information will help to address current knowledge deficits [20][21][22][23][24]42 and support the global drive for active case-finding and early initiation of therapy in asymptomatic carriers of TB infection. 7,9 …”

Section: Looking Aheadmentioning

confidence: 99%

“…[32][33][34][35][36][37][38][39][40][41] This leads to delay in targeted therapy and poorer treatment outcomes 24,42 that are yet further compounded by a lack of consensus on the management approach for TBU. 20,21,24 This group of 25 ophthalmic centers performed an analysis of the largest cohort of TBU cases under the Collaborative Ocular Tuberculosis Study (COTS)-1 group. The first report from the COTS-1 group evaluated the clinical signs associated with TBU based on treatment outcomes in patients with TBU that were treated with ATT.…”

mentioning

confidence: 99%

“…[17][18][19] However, despite progress in coordinated efforts to address pulmonary TB, the approach to manage tubercular uveitis (TBU) remains controversial due to a lack of robust data. [20][21][22][23][24][25][26] In a recent review of index TB in India, a country endemic for TB, ocular TB was excluded due to lack of evidence. 27 This has resulted in barriers for physicians to initiate antitubercular therapy (ATT) in these patients.…”

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confidence: 99%

See 2 more Smart Citations

Global Variations and Challenges With Tubercular Uveitis in the Collaborative Ocular Tuberculosis Study

Agrawal

Gunasekeran

Raje³

et al. 2018

Invest. Ophthalmol. Vis. Sci.

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PURPOSE. The aim of this study was to examine regional variation management practices and outcomes for tubercular uveitis (TBU). METHODS.In this retrospective multinational cohort study, patients from 25 international eye care centers diagnosed with TBU with a minimum follow-up of 1 year were included. The geographic variation in treatment outcomes on survival analysis in patients with TBU were analyzed. Treatment failure is defined as a persistence or recurrence of inflammation within 6 months of completing antitubercular therapy, the inability to taper oral corticosteroids to less than 10 mg/d or topical corticosteroid drops to less than 2 drops daily, and/or recalcitrant inflammation necessitating corticosteroid-sparing immunosuppressive therapy. RESULTS.Records of 945 patients (1485 eyes) with TBU were analyzed. The mean age was 41.3 6 15.0 years (range, 4-90 years), with more males (52.9%, n ¼ 500/945) and predominant Asian ethnicity (74.4%, n ¼ 690/927). Most patients had no symptoms (92.0%, n ¼ 655/712) or history (76.7%, n ¼ 604/787) suggestive of pulmonary tuberculosis (TB). Some patients had evidence of inactive pulmonary TB on chest X-rays (26.9%, n ¼ 189/702) or chest computed tomography (68.6%, n ¼ 109/159). Patients with western geographic origin (logrank ¼ 6.47, P ¼ 0.010), African or Hispanic ethnicity (log-rank ¼ 19.9, P < 0.001), and positive immigrant status (log-rank ¼ 4.89, P ¼ 0.027) had poorer survival outcomes.CONCLUSIONS. This is a first-ever multinational analysis of TBU that highlights regional differences in treatment outcomes for this elusive form of extrapulmonary TB. Our findings will help in the design of future collaborative studies together with internists to develop best practice guidelines for this early opportunity to address TB infection and strategies to target at-risk groups such as immigrants.

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Section: Looking Aheadmentioning

confidence: 99%

mentioning

confidence: 99%

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confidence: 99%

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Global Variations and Challenges With Tubercular Uveitis in the Collaborative Ocular Tuberculosis Study

Agrawal

Gunasekeran

Raje³

et al. 2018

Invest. Ophthalmol. Vis. Sci.

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“…These varied presentations are thoroughly summarized by Dr Vishali Gupta et al in this issue of OII. 13 Five additional original articles, [14][15][16][17][18] one brief report 19 and four letters [20][21][22][23] in this issue of OII present important findings related to the diagnosis and treatment of tuberculous uveitis.…”

mentioning

confidence: 99%

“…Lou et al 14 report the results of two international surveys of the approach to diagnosis and treatment of IOTB -one completed by 87 members of the American Uveitis Society (AUS), most of whom were from either the US or Europe, and a second by an expanded group of 143 participants, nearly half of whom were from the developing world. 15 Both surveys highlight the lack of consensus regarding the approach to diagnosis and treatment -a common finding in surveys of this sort.…”

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confidence: 99%

Tuberculous Uveitis

Cunningham

Rathinam

Albini

et al. 2015

Ocular Immunology and Inflammation

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Uveitis—The Tortured Tale of the Tubercle

Gelder

2017

JAMA Ophthalmol

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Tuberculous uveitis has been recognized for a long time (Antoine Maitre-Jan described the first case of iritis associated with tuberculosis [TB] in 1707), and much is understood about its mechanisms. Numerous pathology studies have demonstrated ocular presence of Mycobacterium tuberculosis in cases of uveitis;animal studies have demonstrated that intraocular or miliary M tuberculosis infection will cause uveitic disease. The range of uveitis associated with TB is broad and includes anterior, intermediate, posterior, and panuveitis (including some interesting variants such as serpiginoid uveitis, retinal vasculitis, and choroidal tubercles). While most patients with biopsy-proven tubercular uveitis will have positive tuberculin test results (either the tuberculin skin test or the more recent interferon γ release assays [IGRA] such as QuantiFERON Gold), most patients with tubercular uveitis will have no evidence of pulmonary or other systemic disease. Multidrug treatment of true tubercular uveitis (often with concomitant corticosteroids) will often definitively resolve the uveitis. Conversely, many patients with uveitis will have positive tuberculin test results, particularly in endemic areas: do these patients actually have tubercular uveitis, or do they have 2 independent conditions? Despite near-consensus agreement among experts on these facts, tubercular uveitis remains very challenging to the practicing uveitis specialist. In 2015, the Uveitis Specialists Study Group surveyed the members of the American Uveitis Society, presenting 2 case scenarios and asking members for their estimation of the likelihood of tuberculous uveitis, their preferred workup, and recommended treatment. 1 The group found essentially no consensus among uveitis specialists with respect to any of these questions, with likelihood estimates for a single case ranging from 0% to 90%, and approximately equal numbers of respondents recommending treatment of 6, 9, and 12 months for TB in likely cases. Later, a second group of primarily non-US-based physicians was given the same set of scenarios. Their assessments, workup, and suggested treatments were also highly variable and in many cases significantly different from those of US-based specialists. 2 This difficulty arises from the lack of a gold standard diagnostic test for tubercular uveitis. It is believed that much of the uveitis associated with tuberculosis is caused by innate and adaptive immune responses to tubercular antigens as much as to the organism itself. As such, very small bacterial loads, perhaps as low as a single bacillus, 3 can induce substantial inflammation. While the polymerase chain reaction has been successfully used in many cases to diagnose tubercular uveitis, its false-negative rate is unknown; a negative result does not rule out tubercular disease. In the absence of a definitive laboratory test, the presence of a compatible form of uveitis and a positive skin or IGRA test result is taken as presumptive diagnosis for tubercular uveitis.

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Lack of Consensus in the Diagnosis and Treatment for Ocular Tuberculosis among Uveitis Specialists

Abstract: Consensus is lacking among uveitis specialists for the diagnosis or management of ocular TB.

Cited by 38 publications

References 10 publications

Global Variations and Challenges With Tubercular Uveitis in the Collaborative Ocular Tuberculosis Study

Global Variations and Challenges With Tubercular Uveitis in the Collaborative Ocular Tuberculosis Study

Tuberculous Uveitis

Uveitis—The Tortured Tale of the Tubercle

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