TB Scleritis. How Common It is AIOS 13 Final

7/28/2019 TB Scleritis. How Common It is AIOS 13 Final

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Tubercular Scleritis: How common is it?

Dr Santanu Mandal DO FRCSDisha Eye Hospitals & research centre

Barrackpore, West Bengal, [email protected]

FP- 001736


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Financial disclosure

I have no financial interests or relationships to disclose


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Introduction

Tuberculosis (TB) as a cause of scleritis very rare

Focal necrotizing scleritis - most common type of TB

scleritis1-4

A case of posterior scleritis with systemic tuberculosisreported by Gupta et al5

A series of scleritis from USA (1974) 4 out of 301 cases

had active tuberculosis6

1. Bloomfield SE, Mondino B, Gray GF. Scleral tuberculosis. Arch Ophthalmol. 1976;94:954-56.

2. Hermady R, Sainz de la Maza M, Raizman MB, Foster CS. Six cases of scleritis associated with systemic infection.Am J Ophthalmol.

1992;114:55-62.

3. Nanda M, Pflugfelder SC, Holland S. Mycobacterium tuberculosis scleritis.Am J Ophthalmol. 1989; 108:736-737.

4. Saini JS, Sharma A, Pillai P. Scleral tuberculosis. Trop Geogr Med. 1988;40:350-352.

5. Gupta A, Gupta V, Pandav SS, Gupta A. Posterior scleritis associated with systemic tuberculosis. Indian J Ophthalmol. 2003;51:347-

349.

6. Watson PG, Hayreh SS. Scleritis and episcleritis. Br J Ophthalmol.1976;60:163-191.


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Introduction

Scleritis may be a manifestation of multisystem disease

India is an endemic country for tuberculosis with an

incidence rate of 2 million7

7. WHO/INDIA: WHO regional office for South-East Asia 2010. Last update:17-july-2012


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Purpose of the study

To evaluate the incidence of

tubercular etiology

among recurrent scleritis cases

in a tertiary eye care centre ofEastern India


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Materials & Methods

Retrospective noncomparative case series

Recurrent scleritis cases initially treated elsewhere,

were included

Presented between April 08 and March 11

Total no. of cases - 32 (51 eyes)

Mean age - 45.06 7.15 years; Male: Female :: 18:14


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Materials & Methods

Scleritis profileincomplete in all referred cases

No. of recurrent attacks before presentation: 2- 5(range)

Average time of presentation since first attack5 ms.

None had any investigation to rule out TB Immune status was unknown at the time of referral

All past records & history were evaluated

Day 1 Day 14 Day 21ATT started , Day 1 ATT started , Day 14


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Materials & Methods

Complete investigation profile for scleritis was advised

Rheumatoid factor (RA factor)

Anti Nuclear Antibody (ANA)

Anti doublestranded DNA (Anti ds-DNA) c-ANCA, p- ANCA

Uric acid

Mantoux test (Mtx) & QuantiFERON TB Gold test (QFT-G)

Chest x-ray (PA)/X-ray PNS HRCT-few cases

USG B scan

India is a BCG vaccinated countrysimultaneous Mtx and QFT-G was advised


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Results

Mtx and QFT-G, both were + ve 7 cases (21.87%)

Out of 7, 4 had H/O exposure to open tuberculosis

M : F :: 3 : 4; Average age 48.85 yrs.

Treated with Anti tubercular drugs (ATT) for 9 ms.

(4 drugs 2 ms. & 2 drugs 7 ms.)

Total no of rec. scleritis cases32 (51 eyes)

All were Immunocompetent

Day 1 2 wks after ATT 2 months after ATT 9 months after ATT


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Results

3 cases - oral steroidin a tapering dose, with ATT (9ms.)

2 cases (uncontrolled DM) - oral NSAID with ATT (9ms.)

2 cases - topical NSAID with ATT (9ms.)

No recurrence in 2 year follow up

Day 0 Day 16 after ATT 2 ms. after ATT

9 ms. after ATT 24 ms.


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Results

n = 32 cases (51 eyes)

Type of scleritis No of cases/No of eyes Average age (Yrs) M:F

Tubercular 7 (10eyes) 48.85 3:4

Rheumatoid 3 (6 eyes) 43 1:2

Sero ve arthritis 2 (2 eyes) 48.5 1:1

Wegeners 2 (4 eyes) 43.5 0:2

Gout 1 (1 eye) 47 1:0

Viral 1 (1 eye) 52 1:0

Idiopathic 16 (27 eyes) 43 11:5

Different etiologies of recurrent scleritis


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Results

n = 32 cases (51 eyes)Different etiologies of recurrent scleritis

7 cases

Tuberculosis

RA

Sero ve arthritis

WG

Gout Viral

16 cases = Idiopathic

16 cases with etiological diagnosis

3 cases

2 cases

2 cases

1 case1 case

0 2 4 6

TB

RA

WG

Sero-ve

Gout

Viral

Female

Male


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Discussion

Scleritis is a painful, potentially destructive recurrent

ocular inflammation infectious or non infectious

(immune reaction)

TB - one of the presumed infectious causes of scleritis8

7 recurrent scleritis pts. refractory to

immunomodulators previously responded well to ATT

No recurrence in these pts. at 2 years follow up

8. W Taki, H Keino, T Watanabe, C Nakashima, A A Okada. Interferon- release assay in tubercular scleritis.

Arch Ophthalmol.2011; 129(3): 368-371.


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Discussion

Swab taken in suspected infectious scleritis cases -bacterial yield was nil

Ocular TB - a paucibacillary disease & immunogenic

reaction might be the probable cause of scleritis There are no classical reproducible signs for tubercular

scleritis - difficult to diagnose them clinically

Negative systemic investigations with positiveMtx andQFT-G - only way to interpret TB as the cause of

scleritis9

9. Ang M, Htoon HM, Chee SP. Diagnosis of Tuberculous uveitis: clinical application of an interferon

gamma release assay. Ophthalmology. 2009;116(7):1391-96.


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Discussion

QFT-G was advised in all cases with Mtx test - as oralsteroid > 15 mg/day affects Mtx result8

Combination of+ve Mtx and +ve QFT-G increase the

accuracy of diagnosing tubercular uveitis 9

Similar test results can also increase accuracy in

diagnosis of tubercular scleritis8

The current study corroborates with the study done by

W Taki et al8

8. W Taki, H Keino, T Watanabe, C Nakashima, A A Okada. Interferon- release assay in tubercular scleritis.Arch

Ophthalmol.2011; 129: 368-71.

9.Ang M, Htoon HM, Chee SP. Diagnosis of Tuberculous uveitis: clinical application of an interferon gamma

release assay. Ophthalmology. 2009;116:1391-96.


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Conclusion

Recurrent scleritis should be assessed with Mtx

and QFT-G to rule out tubercular aetiology inan endemic country like India before starting

anyimmunomodulatory drugs

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TB Scleritis. How Common It is AIOS 13 Final