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ARTICLES
Year : 1977  |  Volume : 25  |  Issue : 3  |  Page : 12-16

Orbital involvement in tuberculosis


King George's Medical College, Lucknow, India

Correspondence Address:
P K Agrawal
King George's Medical College, Lucknow
India
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Source of Support: None, Conflict of Interest: None


PMID: 614266

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How to cite this article:
Agrawal P K, Nath J, Jain B S. Orbital involvement in tuberculosis. Indian J Ophthalmol 1977;25:12-6

How to cite this URL:
Agrawal P K, Nath J, Jain B S. Orbital involvement in tuberculosis. Indian J Ophthalmol [serial online] 1977 [cited 2020 Aug 4];25:12-6. Available from: http://www.ijo.in/text.asp?1977/25/3/12/31262

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Table 1

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Orbital involvement in turberculosis is a rare manifestation[5],[1]. As reported earlier[2] the incidence of ocular involvement is higher in tubercular meningitis in this part of the country. We have also till now recorded 25 cases of tubercular involvement of orbit from 1969 to 1974, but only 14 cases are reported here as in rest 11 cases the follow up was not satisfactory and hence, excluded from this study. All the 14 cases are being presented here through tables and 3 of them being interesting cases are reported in detail.

Case No. 6

S, 18 years, male, presented with discharging sinus in left upper lid with ectropion [Figure - 1] and involvement of eye with exposure keratitis and tubercular cervical lymph adenopathy (biopsy proved). Chest X-ray showed healed primary complex. Skull X-ray showed rarification and irregular thickening of frontal bone. He was put on anti-tubercular treatment and sinus was scraped. Sinus healed and lymph adenopathy diminised within few months time.

Cases No, 11

S.P.,
43 years, male, came to us with proptosis left eye of 2 years duration. He gave history of some opera­tion 5 years back for proptosis. Examination revealed axial proptosis with up and slightly out displacement, irreduceable and limited movements all round. A firm mass was palpable at outer and upper orbital margin with marked conjunctival congestion. Mantoux test was strongly positive. X-ray chest showed a parenchymal tubercular lesion. X-ray paranasal sinuses showed left maxillary sinus hazy. Anterior orbitotomy was done and an irregular mass with varied consistency was removed. This mass was infilterating the nearby orbital muscles and also showed areas of necrosis and increased vascularity.

Histopathology showed tubercular granulation tissue with caseation. Patient was put on anti-tubercular treatment for one year. Proptosis regressed, but vision did not improve due to optic atrophy. The patient had recurrence after 2 years of regression of the lesion. This time he had a discharging sinus with marked proptosis. Excision was again done under cover of anti-tubercular treatment. The lesion suppressed but not completely eliminated and patient is still under observation.

Case No. 12

M.L.,
24 year old, male presented with gradual protru­sion of the left eye ball of one month duration, resulting in complete ophthalmoplegia [Figure - 2]. He gave history of recurrent attacks of fever accompanied with obvious protrusion of the left eye and swelling of the lid during the last two months. This used to regress with disap­pearance of fever. For last one month rapid protrusion of the left eye with gross diminution of the vision was noticed.

On examination the left eye ball was displaced for­wards and downwards. There was proptosis of 10 mm LE (Hertel's exophthalmometery), which was non­reducible, and tender. No mass was palpable on deep palpation. The lid veins were engorged and oedematous with marked conjunctival chemosis.

Ocular Tension-R.E. 22 mm Hg., L.E. 50 mm Hg., vision: R.E. 6/6, L.E.-No P.L., Fundus:-R.E-Normal, L.E.-showed retinal oedema with slight pallor of the optic disc. Hb-9.4 gm%, TLC-9800/ cumm, DLC-P70, L30, sleeping pulse-64/min. X-rays of chest, orbit, paranasal sinuses and optic foramen were normal. X-ray of skull showed both osteolytic and oeteosclerotic changes of greater wing of sphenoid on left side and widening of superior orbital fissure.

Left carotid angiography revealed that right anterior cerebral artery was displaced upwards and backwards and right middle cerebral artery was normal in position.

In venous phase tumour circulation was seen in the region of sphenoidal ridge with displacement of carotid vein coming down from upwards. Left temporal craniotomy was done. The histology of the mass showed tuberculoma [Figure - 3]. Patient was put on anti-tubercular treatment. Proptosis subsided but vision did not recover due to optic atrophy.


  Discussion Top


Tubercular foci maybe found indifferent tissues because of haematogenous spread of bacilli. Tubercle bacilli may remain dormant in such foci, but under suitable conditions they become active and produce tuberculosis of different organs. Trauma is one of the predisposing factors. The lymph nodes may become involved by lymphatic spread both up­wards and downwards.

In this part of our country the incidence of pulmonary tuberculosis is quite high. This may explain the high incidence of ocular tuberculosis as well, among younger age group in this series. The review of the cases reveals that the age ranges from less than one year to 48 years. 8 patients were below ten years, 4 patients within 10 to 25 years and only 2 cases within 40 to 48 years. Exceptionally, therefore, the disease may occur at any age[7].

Tubercular involvement of the orbit is uncommon. The infection may be evident in either of the two forms (1) Tubercle bacilli may settle down in orbital region by haematogenous spread from the site of pri­mary complex. This may lead to (a) periostitis of orbital margin or, (b) tuberculoma of orbital tissue. (ii) Direct extension from neighbouring structures, such as parana­sal sinuses, lacrimal gland or sac. Orbital periostitis is more common manifestation and usually associated with local or general signs and symptoms of tuberculosis mostly occuring in children or young adults.

No bone seems to be exempted from this lesion. In this series we had all the orbital margin bones involvement including frontal, zygomatic and maxillary. Our findings (zygo­matic 3 cases) are contrary to the belief that zygomatic bone is not commonly involved. The clinical course of disease is slow for weeks and sometimes for months, the region may remain red, swollen and oedematous, the oedema spreading slowly to the lid and conjunctiva and eventually a cold abscess is formed. Without realising the situation many a times these cold abscesses are incised as ordinary inflammatory abscess giving rise to a non healing sinus; or sometimes they burst by themselves resulting in cicatricial contraction and ectropion.

The clinical picture is quite evident at a stage when a sinus is formed. However, to establish these cases of tubercular in origin, we have to consider the direct or indirect evidences. Since we consider that orbital turberculosis is secondary to a primary in­fection commonly in lungs or intestine, one may find evidences of systemic active or in­active tuberculosis. It may not always be possible to demonstrate primary complex on radiological examination. Besides for a search of systemic tubercular infection in active or healed form, the radiological picture, a sterile culture (unless secondarily infected) may give evidences of tubercular origin. The Mantoux test is also an important guide line in such cases.

Lastly a tubercular lesion on histological examination of the tissue and culture positive for tubercle bacilli are the direct undisputed evidences.

The treatment of turbercular periostitis is an important part of the whole story. The trauma seems to be an important precipitating cause of osteomyelitis in many cases. An irregular and half hearted treatment and secondary infection may lead to a refractory type of lesion and may spread to involve the orbital contents, sinus formation and some­time spread to brain as was seen in case No. 10.

While treating such cases certain principles should be observed : a) The antitubercular drugs should be prescribed in combination of two or more drugs. b) The treatment should be regular and at least for a period of one year or more. c) Drugs should be prescribed in adequate dosages.

Our cases had been kept on either of the following regimens

(i) Streptomycine sulphate +PAS + INH.

(ii) Streptomycine sulphate + thioaceta­-

zone +INH.

The dosage schedule was as follows

Streptomycin sulphate-15-20 mg/kg body weight (not more than 1 gm), I.M.I. daily for two to three months. Patients above the age of 40 years were kept on 0.75 gm.

PAS-200 mg/kg body weight orally in two equally divided dosages after meals, for one year.

INH (Isoniazid)-5-8 mg/kg body weight (not more than 300 mg), daily orally in single dose for one year.

Thioacetazone-2.5 mg/kg body weight (not more than 150 mg) daily orally in single dose after dinner for one year.

A surgical treatment under the umbrella of chemotherapy is also very important. This may be in the form of drainage of cold abscess, scraping of granulation and unhealthy tissue, and removal of dead bone. An ultimate repair of deformities by plastic procedures may be done.


  Tuberculoma of the orbit Top


It is a much less common manifestation[3],[4] and in this series we had only 5 cases presen­ting with proptosis. The clinical presentation of such cases was that of an orbital space occupying lesion. The diagnosis in three cases was not evident till an orbitotomy was done and the mass removed showing typical histo­logical features of a tubercular granuloma. In retrospect, when these cases were again revie­wed and specially investigated for tuberculosis, we found healed lesions in lungs and a strongly positive Mantoux test. Out of these 3 cases so presented, in one case (No.12) the granuloma was in relation to the sphenoidal ridge giving rise to apex syndrome, in the 2nd case an infiltrating mass was removed from the central space, the origin of this could not be ascertained. In the third case the granuloma involving the lacrimal gland was removed. If diagnosed earlier these cases should respond to medical therapy and an orbitotomy may be avoided. We have made a dictum that cases of unilateral proptosis with evidence of tuber­culosis elsewhere and no evidence of any other space occupying lesion in the orbit should be put on anti-tubercular treatment (therapeutic trial) before contemplating to do an explora­tory orbitotomy.

The other two cases presented with prop­tosis and well established tubercular cervical lymphadenopathy and radiological evidence of primary complex in lung. These cases res­ponded well to anti-tubercular treatment. We further feel that if a person specially a child with such orbital lesion presents with evidences of active or inactive tubercular focus elsewhere in the body should be given a fair therapeutic trial with anti-tubercular drugs.


  Summary Top


This paper presents 14 cases of orbital in­volvement in tuberculosis. The lesions were present in two form e.g. tubercular periostitis and orbital space occupying lesions. The clinical presentation, diagnosis and manage­ment of these cases have been discussed.

 
  References Top

1.
Duke-Eider, S. 1952, "Text Book of Ophthal­mology", 5, p. 5459, Kimpton, London.  Back to cited text no. 1
    
2.
Gupta, S.P., Agrawal, P.K., Pratap, V.B., Das, V.K., 1970, Pro. A.I. Ophthal: Soc., 31; 291.  Back to cited text no. 2
    
3.
Mortada, A., 1961, Brit. J. Ophthal., 45, 662.  Back to cited text no. 3
    
4.
Mortada, A., 1971, Brit. J. Ophthal., 55, 565.  Back to cited text no. 4
    
5.
Offret, G., 1939, Les myosites orbitaires, Doin, Paris.  Back to cited text no. 5
    
6.
Pagel, W., Simmonds, F.A.H., Macdonald, N. and Nassau, E., Pulmonary Tuberculosis, IV Edition, Oxford University Press, London, 1964,. p. 102 and 134.  Back to cited text no. 6
    
7.
Schindler, 1950, Quoted Duke-Elder (1952).  Back to cited text no. 7
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]
 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3]


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