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ARTICLES
Year : 1954  |  Volume : 2  |  Issue : 1  |  Page : 15-18

Tuberculosis of the eye ball, with a case report of tuberculoma of the orbit


Department of Pathology & Bacteriology, Medical College, Nagpur, India

Correspondence Address:
J B Shrivastav
Department of Pathology & Bacteriology, Medical College, Nagpur
India
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How to cite this article:
Shrivastav J B, Sharma K D. Tuberculosis of the eye ball, with a case report of tuberculoma of the orbit. Indian J Ophthalmol 1954;2:15-8

How to cite this URL:
Shrivastav J B, Sharma K D. Tuberculosis of the eye ball, with a case report of tuberculoma of the orbit. Indian J Ophthalmol [serial online] 1954 [cited 2020 Apr 8];2:15-8. Available from: http://www.ijo.in/text.asp?1954/2/1/15/33589

Manifestations of tuberculosis in the eye-ball are varied. No part of the eye­ball is immune to a tuberculosis lesion except the lens. The usual parts affected however, are the conjunctiva, choroid, iris and rarely the optic nerve and the orbital tissue. Lesions in these places are always supposed to be secondary to a primary focus in some other part of the body, though very often it becomes difficult to demonstrate it.

The conjunctiva may be affected in three' different forms. One is the miliary form, where small yellowish grey transparent nodules, resembling trachoma granules can be seen. The other form is characterized by ulcer formation, more frequent over the palpebral conjunctiva and fornix. Sometimes, instead of the ulcerative form, hypertrophied papilla; are formed, indicating a more productive type of lesion.

The disease appears in three different forms in the iris also.

1. Miliary tuberculosis - characterized by small grey and transparent nodules.

2. Conglomerate form - large caseating areas, often having satellite tubercles around them.

3. Diffuse form - a chronic form of iridocylitis where tubercles are not seen over the surface, as they lie deep down.

In addition to this there is the nongranulomatous type of iritis, as described by Wood which is an anaphylactic condition due to hypersensitvity to the toxins of the tubercle bacilli, and is outside the scope of our present considerations.

The miliary, conglomerate and diffuse forms are also seen in tuberculosis of the choroid.

Wolff (1944) concludes that probably all, or nearly all, cases dying of general miliary 'tuberculosis get miliary tubercles of choroid before the end. The conglomerate form is a disease of children. It very soon invades the retina, the vitreous and may perforate the bulb leading to phthisis bulbi. The diffuse from converts a greater part of the eye-ball into tuberculous granulation tissue and leads to phthisis bulbi.

The affection of the optic nerve is a rarity. Recently a case of Tuberculoma of the optic nerve has been reported from this Hospital (Keshawachar-1953) It was a globular mass measuring 0.5 cms in diameter in the region of the optic nerve. Though clinically diagnosed as a tumour arising from the elements of the nerve, histology showed conglomeration of several typical tubercles which had practically involved the whole thickness of the optic nerve. Along the length of the sclera, in the cornea, choroid and iris multiple discrete tubercles were present. The retina and papilla were the only two parts of the eye-ball that had escaped involvement by the tubercular process.


  Tuberculoma of the Orbit Top


Hinterleitner (1944) has reported two cases of tuberculosis of orbital tissues. Chandy and Isaiah (1951) have described a growth in the orbit. It was difficult to decide on histologic study whether it was a tuberculoma or a sarcoid.

We are reporting this case primarily for the rarity of tuberculoma in the orbital tissues.


  Case Record Top


A Hindu female aged 40 years was admitted on 21-12-53 in the Ophthalmic Ward of the Medical College, Nagpur. She was complaining of a swelling over the upper lid of left eye, drooping of the lid and loss of vision in that eye because of ptosis. All the complaints were of a month's duration. The complaint started with a small boil on the upper lid of that eye. This was removed by a local doctor. Since then the swelling had gradually and steadily increased in size, On examination the upper lid was swollen and drooping. It was completely covering the cornea. The swelling was under the medial half of the upper lid. It was tender and the margins were distinctly felt. The consistency was mode­rately hard. The tumour was free from the supraorbital margin and was felt between the orbital margin and the eye-ball proper. The tumour was not movable and proof puncture did not reveal anything diagnostic. The preauricular and neck glands were not enlarged. The patient was quite healthy and had no other complaints. X-ray of the left orbit did not reveal anything abnormal. Examina­tion of the frontal sinus did not show any pathologic process.

The clinical diagnosis was "Fibroma of the Lid" which on the operation table was changed to "Fibroma of Orbit". She was operated under local anaesthesia. An incision all along the superior orbital margin was given. The tumour appeared to have coma from the nasal wall of the orbital cavity. It was adherent to the conjunctiva of the superior fornix which had to be snapped away along with the retrobulbar tumour. It was not possible to remove the mass completely, and so a small bit of the mass was left behind. In the post-operative period she was treated with penicillin and sulphadiazine. Pathologic report on the excised mass was - "Tuberculoma". On the basis of this report she was given streptomycin 0.5 gm. daily, Tibizide 50 mgm.t.d.s. and PAS 4 gm.t.d.s. She was given 6 gm, of Streptomycin, 144 gm. of PAS and 1800 mgm. of Tibizide in all. Under this treatment it was found that the small bit of mass left on the nasal wall, which could be felt through the skin, slowly became impalpable. The drooping of the upper lid also diminished considerably, the patient was able to open her left eye and the vision was restored.

GROSS & MICROSCOPIC APPEARANCES:­

The material sent measured 2.5 x 1.5 x 1 cms. External surface was rough, greyish brown and devoid of any capsule. The cut surface was uniformly grey with small areas of necrosis. Microscopy:- The tumour tissue was composed of a large number of round and discrete tubercles of varying sizes. They were separated by strands of hyaline, a vascular fibrous tissue. [Figure - 1]. There was no capsule surrounding the tumour mass and the follicles were extending upto the line of excision indicating incomplete removal of the tumour. The tubercles showed characteristic histology with a small area, stained homogeneously pink, of coagulative necrosis; a prominent zone composed of large, pale, irregular epitheloid cells with one or two giant cells; and a peripheral collection of lymphocytes [Figure - 2]. The larger follicles were conglomerations of several small follicles - each with characteristic histology; while the smaller pin point tubercles were foci of collections of epitheloid cells alone. Caseation though present microscopi­cally in most tubercles, was not extensive. Lack of caseation, together with well marked fibroblastic reaction in between the tubercles had given the tumour mass a firm consistency of a Fibroma.


  Discussion Top


Tuberculous involvement of the eye-ball and orbital tissue is no doubt always secondary to tubercular process in some other part of the body, e.g. in the lung, glands, bones and joints. However, it may be difficult or impossible to demon­strate this in most cases. In the case of tuberculoma of optic nerve reported from this hospital, no primary site could be demonstrated, though the wide extension of the process inside the eye-ball was in favour of dissemination from an unknown primary focus. Peculiarly enough in that case the miliary process was confined to the eye-ball only.

In the present case under discussion no tuberculosis lesion was detected in the lungs and lymph glands. The skiagram of the orbit did not reveal any bony changes. This rules out the possibility that the tuberculous process may have spread into the orbital tissue from neighbouring bones. For these reasons this lesion may be considered primary.


  Summary Top


(1) A case of tuberculoma of the orbital tissue is reported.

(2) There was involvement of orbital tissue without any obvious manifestation of the disease in any other part of the body.

(3) Pathology of tuberculosis of the eye-ball and the orbital tissue has been briefly reviewed.

We are grateful to Dr. G. L. Sharma, Dean, Medical College, for permission to publish the case-report, and to Dr. Keshvachar, Reader in Ophthalmology for the Clinical history of the case. We thank Shri Joshi Rao for the photo-micrographs and Shri Saha for the technical help.[4]

 
  References Top

1.
Chandy J. & Isaiah P. ( 1951) Ind. J. of Surg., 3, 251-258.  Back to cited text no. 1
    
2.
Hinterleitner, (1944) Ophthalmologica, 108, 210-216.  Back to cited text no. 2
    
3.
Keshvachar K., (1953) J. of All-India Ophth. Soc. 1, 64-65.  Back to cited text no. 3
    
4.
Wolff E., (1944) A Pathology of the Eye. pp. 35, 81, 82. 227 2nd Edition, H. K. Lewis & Co. Ltd., London.  Back to cited text no. 4
    


    Figures

  [Figure - 1], [Figure - 2]



 

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