The Collaborative Ocular Tuberculosis Study (COTS) Consensus (CON) Group Meeting Proceedings

Abstract

An international, expert led consensus initiative was set up by the Collaborative Ocular Tuberculosis Study (COTS) group to develop systematic, evidence and experience-based recommendations for the treatment of ocular TB using a modified Delphi technique process. In the first round of Delphi, the group identified clinical scenarios pertinent to ocular TB based on five clinical phenotypes (anterior uveitis, intermediate uveitis, choroiditis, retinal vasculitis and panuveitis). Using an interactive online questionnaires, guided by background knowledge from published literature, 486 consensus statements for initiating ATT were generated and deliberated amongst 81 global uveitis experts. The median score of five was considered reaching consensus for initiating ATT. The median score of four was tabled for deliberation through Delphi round 2 in a face-to-face meeting. This report describes the methodology adopted and followed through the consensus process, which help elucidate the guidelines for initiating ATT in patients with choroidal TB.

Reply

“…3 With regard to the concerns of Venkatesh et al regarding the past treatment history and other clinical history, the survey participants were asked to assume that the scenarios considered did not involve patients with "active" systemic TB, or past history of ATT intake. 1,2 Although our colleagues state that "first attack" of choroiditis, bilaterality, and visual acuity should be considered before the initiation of ATT, this seems to be their personal opinion, because this is not universally agreed upon. 1,2 The authors also raised concerns regarding the use of the interferon-gamma release assay (IGRA) in diagnosing TBU.…”

“…1,2 Although our colleagues state that "first attack" of choroiditis, bilaterality, and visual acuity should be considered before the initiation of ATT, this seems to be their personal opinion, because this is not universally agreed upon. 1,2 The authors also raised concerns regarding the use of the interferon-gamma release assay (IGRA) in diagnosing TBU. Venkatesh et al may be aware that IGRA has been discouraged by the World Health Organization for "active" pulmonary TB (not TBU) because it is unable to distinguish it from latent TB.…”

“…1 The Collaborative Ocular Tuberculosis Study (COTS) consensus underlines that if a treating uveitis expert does not believe that the diagnosis is consistent with tubercular uveitis (TBU), there is no mandate that the expert must treat with ATT. 1,2 Our esteemed colleagues state that the participants in the study have a strong bias toward the diagnosis of TB choroiditis and argued that the clinical photographs may have several differential diagnoses aside from TBU. We would like to highlight the statement in our results where we mention that the clinical scenarios discussed assumes the exclusion of other possible forms of uveitis masquerading as TBU and that the clinical photographs in Figure 2 are intended to illustrate the clinical phenotypes of TBU discussed for the benefit of the reader.…”

“…We would like to highlight the statement in our results where we mention that the clinical scenarios discussed assumes the exclusion of other possible forms of uveitis masquerading as TBU and that the clinical photographs in Figure 2 are intended to illustrate the clinical phenotypes of TBU discussed for the benefit of the reader. 1,2 We would also like to refer Venkatesh et al to publications on choroidal involvement in TBU which have described acute posterior multifocal placoid pigment epitheliopathy as a rare phenotype associated with TB choroiditis. 3 With regard to the concerns of Venkatesh et al regarding the past treatment history and other clinical history, the survey participants were asked to assume that the scenarios considered did not involve patients with "active" systemic TB, or past history of ATT intake.…”

“…For countries such as India that have banned IGRA, the survey specifically allowed an option "test not done/not available" (Appendix 2 in the original article). 1,2 We would also like to emphasize that in several countries, the tuberculin skin test is not permitted/available. The survey has considered these factors and was therefore designed to reflect a global scenario when evaluating the various permutations of investigations available in the clinical scenarios discussed.…”