Download - 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