Ocular tuberculosis can involve any part of the eye. The most common manifestations include choroiditis, anterior uveitis, and sclerokeratitis. Ocular tuberculosis has an incidence of 1.4-5.74% and may present as adnexal lesions like lupus vulgaris or eyelid tuberculous granuloma, anterior segment inflammation like conjunctivitis or phylyctenular keratoconjunctivitis, or posterior segment lesions like choroidal tubercles, tuberculoma, or serpiginous-like choroiditis. Consideration of an ocular tuberculosis diagnosis is important for patients presenting with occlusive retinal vasculitis or choroiditis. Screening for

1. OCULAR MANIFESTATIONS OF
TB
A G MALAVIKA
111601021

2. INTRODUCTION
• Tuberculosis is a chronic infection caused by Mycobacterium
tuberculosis that is characterized by the formation of necrotizing
granulomas.
• Tuberculosis is primarily involves the lung. Other organs
including the eye may be involved secondarily. Tuberculosis
may affect any part of the eye with variable clinical features.
• Ocular TB incidence ranges from 1.4 - 5.74%.

3. PATHOPHYSIOLOGY
• Tuberculosis is caused by M. tuberculosis which is an obligate
aerobic, slow growing, nonspore forming, nonmotile bacterium.
• M.tuberculosis tends to grow successfully in the choroid and
ciliary body where the oxygen tension is high compared with
other ocular structures.
• The hallmark of extra-pulmonary TB is caseating granuloma and
necrosis

4. CLINICAL PRESENTATION
A ) ADNEXAL MANIFESTATIONS
B) ANTERIOR SEGMENT MANIFESTATION
C) POSTERIOR SEGMENT MANIFESTATIONS
D) NEURO-OPHTHALMIC MANIFESTATIONS
E) DRUG-RELATED OCULAR TOXICITY IN TBINFECTED
PATIENTS

5. ADNEXAL MANIFESTATIONS
1) LUPUS VULGARIS
• Unilateral , insidious
• painless , soft , reddish-brown nodules which slowly enlarge to
form irregularly shaped red plaque and later ulceration and
scarring occurred (painful ).
• Often accompanied by lymphadenopathy.
• Complications - squamous cell carcinoma
• On diascopy, it shows characteristic "apple-jelly" colour.
• Biopsy will reveal tuberculoid granuloma with few AF bacilli.

7. 2) EYELID TUBERCULOUS GRANULOMA
• Unilateral , insidious
• Manifests with a violet-brown , non-tender, mobile nodule.
Often accompanied by lymphadenopathy.
• The nodule may ulcerate after some time and spread locally in
an irregular fashion and it is often accompanied by pain and
discharge.
• Complications include trichiasis and entropion formation.

9. ANTERIOR SEGMENT INVOLVEMENT
1) TUBERCULOUS CONJUNCTIVITIS
• Mucoid discharge, Edema of lids, chemosis
• Large follicles which ulcerate
• Small, painless, and indolent ulcer, nodule on the tarsal
conjunctiva and fornix.
• Parinaud oculoglandular syndrome.
• Preauricular lymphadenopathy is seen in these cases.

10. 2) CONJUNCTIVAL GRANULOMAS
• It is a Type IV Hypersensitivity reaction, presents as an
inflammatory mass on the conjunctiva.
• It is usually occurs due to tuberculosis but can be
associated with Staphylococcus aureus .
• Complications include keratitis ,scleritis, corneal ulcer
• Subsequent calcification of granulomas can impede
vision, and inflammation can cause irreversible damage
to ocular tissue.

12. 3) PHYLYCTENULAR KERATOCONJUNCTIVITIS
• Presents with photophobia, tearing and blepharospasm .
• slightly raised, small, pinkish white or yellow nodules surrounded
by dilated vessels located on conjunctiva near the limbus or on
peripheral cornea.
• Classically, there is no clear zone between the limbus and the
lesion.
• Delayed hypersensitivity reaction to mycobacterial antigens
• More commonly in children, bilateral.
• Responds promptly to topical application of corticosteroids.
• These ulcers are associated with neovascularization and can
go on to perforate.

13. 4) TUBERCULOUS SCLERITIS
• Mostly it presents as an anterior scleritis while posterior
scleritis is rare .
• Localized focal elevated nodules of the sclera.
• The sclera may be infected by direct spread from a local
conjunctival or choroidal lesion, or more commonly by
haematogenous spread.
• This may undergo necrosis and may lead to scleromalacia

15. 5) INTERSTITIAL KERATITIS
• an inflammation of the corneal stroma without primary
involvement of the epithelium or endothelium.
• In most cases, the inflammation is an immune-mediated
process triggered by an appropriate antigen.

16. 6) ANTERIOR UVEITIS
• unilateral or bilateral chronic granulomatous disease with
large, mutton fat keratic precipitates, posterior synechiae,
• In severe cases, hypopyon
• Iris nodules near the pupillary border (Koeppe) or on the
iris surface (Bussaca).
• complicated by the cataract and posterior synechiae
• INTERMEDIATE UVEITIS
• Chronic, low-grade, vitritis with snowball opacities, snow
banking, peripheral vascular sheathing, and peripheral
granuloma.

18. POSTERIOR SEGMENT
MANIFESTATIONS
1) CHOROIDAL TUBERCLES
• Unilateral or bilateral, grayish white to yellow in
color with indistinct borders, are located mostly in
the posterior pole
• On fluorescein angiography, they are
hypofluorescent during dye transit with late
hyperfluorescence.

19. 2) CHOROIDAL TUBERCULOMA
• Choroidal tubercle continues to grow, it forms a solitary
mass known as tuberculoma
• Present as a solitary, yellowish, subretinal mass with
surrounding exudative retinal detachment , mimicking a
choroidal tumor.
• May be located anywhere
• Measure from 4 to 14 mm

20. 3) SERPIGINOUS LIKE CHOROIDITIS
• It is a bilateral, chronic, progressive and recurrent inflammation
that primarily involves the choroid and choriocapillaris and
progresses to involve the retina .
• These lesions begin in the peri papillary area and spread
centrifugally.
4) SUBRETINAL ABSCESS

21. EALES’ DISEASE
• Bilateral, idiopathic, occlusive, peripheral
periphlebitis and neovascularization.
• Recurrent attacks of diminution of vision in young
males – recurrent vitreous hemorrhage
• The disease is characterized by three overlapping
stages: (a) periphlebitis, (b) occlusion and (c) retinal
neovascularization.
• Mild uveitis is common

22. • The treatment includes systemic
corticosteroids, antituberculosis treatment,
laser photocoagulation of the ischemic retina
NEURO-OPHTHALMIC MANIFESTATIONS:
papilledema, optic neuritis, retrobulbar neuritis,
neuroretinitis
COMPLICATIONS OF OCULAR TB
• Cataract
• Glaucoma
• Cystoid Macular edema
• Retinal detachment
• Corneal Scarring

23. DIFFERENTIAL DIAGNOSIS OF OCULAR TB
• Infectious Disorders
• Syphilis
• Toxoplasmosis
• Candidiasis
• Brucellosis
• Leprosy
• Nocardiasis
• Coccidiomycosis
• Leptospirosis
• Cat scratch disease
• Lyme disease

24. • DIAGNOSIS
I. Clinical signs
II. Ocular investigations
III. Systemic investigations
V. Exclusion of other uveitis
entities
V. Therapeutic test
VI. New diagnostic assays

25. SUMMARY
Incidence of ocular tuberculosis – 1.4%
• Involves all the ocular structures except lens
• Most common manifestation Chroiditis, Anterior
Uveitis, sclerokeratitis.
• Consider the diagnosis of TB especially in patients
presenting with occlusive retinal vasculitis & choroiditis.
• All patients on ATT should be screened for ocular
toxicity

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