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   Table of Contents      
ARTICLE
Year : 1967  |  Volume : 15  |  Issue : 5  |  Page : 175-180

Active systemic lesions in cases of suspected ocular tuberculosis


1 Department of Ophthalmology, Kasturba Medical College, Manipal, India
2 Department of General Medicine, Kasturba Medical College, Manipal, India

Date of Web Publication21-Jan-2008

Correspondence Address:
P N Srinivasa Rao
Department of Ophthalmology, Kasturba Medical College, Manipal
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Srinivasa Rao P N, Bhat K S. Active systemic lesions in cases of suspected ocular tuberculosis. Indian J Ophthalmol 1967;15:175-80

How to cite this URL:
Srinivasa Rao P N, Bhat K S. Active systemic lesions in cases of suspected ocular tuberculosis. Indian J Ophthalmol [serial online] 1967 [cited 2020 Dec 3];15:175-80. Available from: https://www.ijo.in/text.asp?1967/15/5/175/38803

Table 1

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Table 1

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Tuberculosis can affect the eye in two ways:-(1) actual infection of the ocular tissue by the organism, (2) an allergy to tuberculous proteins. While it is conceded, that tuberculosis is an important and frequent cause of ocular diseases such as uveitis, the importance and frequency ascribed to it vary from clinic to clinic, according to va­rious diagnostic criteria employed, the nutritional status of the region and the success of anti-tubercular measures. The problem is complicated due to several factors: (1) Inability to demon­strate bacilli in the available aqueous. (2) Lack of tissue for biopsy or culture. (3) The pleomorphic clinical sympto­matology which may be simulated by a great variety of other infections. (4) Immunological tests such as Man­toux test have got little diagnostic value in an area where the test seems to be universally positive in the general public. Under the circumstances, the problem is reviewed here in reverse. Cases suspected of ocular tuberculous lesions were subjected to general medical survey by one of us (K.S.B.) to find out systemic active lesions if any.


  Review of Literature Top


European investigators report a high incidence of systemic tuberculosis in patients with ocular tuberculosis. WERDENBERG (1938) reported that 60% of the ocular tuberculous patients at Davos showed calcified hylar nodes, 30% showed X-Ray evidences of old inactive infection in the lung fields, and the remaining 10% showed evidence of active systemic tuberculo­sis. WEGNER and ZINTZ (1951) re­ported severe pulmonary changes in 10% of 300 cases of frank ocular tuberculosis, and unmistakable tuber­culous foci elsewhere in the body in 60%.

In an analysis of 306 patients with ocular tuberculosis LASCU GROSSU and NICULESCU (1956) found "an­tagonism" (severe ocular symptoms and slight or inactive pulmonary involve­ment) in 67% of the cases, parallism (severe ocular symptoms and severe active, pulmonary or systemic le­sions) in 21 % and what they termed slight parallism in the remaining 12%.

For many years phlyctenular kerato­conjunctivitis has been associated with tuberculosis. The positive dermal re­action is found in a percentage of cases varying from 60 to 100 with an ave­rage of 80%. The frequency with which clinical evidence of the pre­sence of active tuberculosis, whether pulmonary or lymphatic can be ob­tained in phlyctenular subjects has va­ried widely with different observers. Thus Stalder (1926) as quoted by Duke Elder (1965) found lung lesions in 83% of the patients with phlyctenes in con­trast to 6% in controls. SIWE (1935) diagnosed active pulmonary lesions in a considerable proportion of patients with phlyctenes depending on the age, varying from 75% in children under 4 years to 26°% o between 7 and 13. SORSBY (1942) and THYGESON (1951) found a relatively small per­centage of active tuberculosis either in the lungs, lymphnodes, bones or joints (6%). But all observers are agreed that radiological evidence of past disease is very high. (72.2%, SORSBY-1942).

KONTAS K. A. (1958) found ab­normalities of the fundus in 43 out of 318 patients (13%) with pulmonary tuberculosis.

PACYNSKA (1957) studied 500 pa­tients with pulmonary tuberculosis and found only 2 cases of choroidal foci which can be considered definitely tuberculous.

The dominant role ascribed to tuber­culosis in the etiology of uveitis has undergone considerable de-emphasis. In 1941, a report from the Wilmer In­stitute indicated tuberculosis to be the cause of 79% of all instances of uveitis. In 1944, this figure dropped to 52% and in 1953 to 22%. The pre­sent day concepts of the importance of tuberculous uveitis varies from a maximum of 75% to a minimum of only 10% (THEODORE and SCHLOSSMAN 1958).

THEODORE and SCHLOSSMAN (1958) concluded that the incidence of ocular tuberculosis is not proportional to the incidence of systemic disease. Ocular involvement rarely occurs in systemic tuberculosis unless there is miliary dissemination. In a study of 2000 Alaskan children, all of whom were affected with pulmonary or extra pulmonary tuberculosis, FRITZ, THYGESON and DURHAM (1951) failed to uncover a single instance of uveitis, tuberculous or otherwise.

The rarity of active ocular tuber­culosis in sanatorium patients with active pulmonary tuberculosis is well ­known. AMSLER (1957) places this figure at less than 1%. In the Wilmer Institute series, active pulmonary lesions were only occasionally found in patients with ocular tuberculosis and in only approximately 507, were there inactive lesions in the lung fields or abnormal mediastinal changes attri­butable to tuberculosis.

THEODORE AND SCHLOSSMAN (1958) suggest that the lack of corre­lation of the eye complaints with systemic tuberculosis might indicate (1) that a long latent period occurs before the tubercle bacilli travel from the lung or any extra pulmonary source to the eye, (2) that the uvea is not an especially receptive site for, the tuber­cle bacilli and (3) that some other mechanism possibly allergic is respon­sible for uveal tuberculosis.


  Clinical Considerations Top


The clinical manifestations of ocular tuberculosis are protean and are too familiar for detailed descriptions. Any and every part of the eye can be in­volved in either or both the two ways mentioned above, viz. infection and allergy to tuberculous proteins.

The methods available for the diag­nosis of ocular tuberculosis are un­satisfactory. When all avenues have been explored, the final diagnosis is too often tentative and presumptive. The development of what is almost a specific therapy for localized tubercu­losis has added the therapeutic trial test to the diagnostic armamentorium and usually makes it possible to con­firm or reject a shaky presumptive diagnosis. The various approaches to the diagnosis are (1) clinical picture. (2) elimination of other probable etiological factors, (3) evidence of col­lateral tuberculous infection, (4) immu­nological evidence of a tuberculous in­fection and (5) the therapeutic trial test.

It is with the physical evidence of a collateral tuberculous infection that we are interested.


  Materials and Methods Top


150 cases of suspected ocular mani­festations of tuberculosis were collected from the records of Kasturba General Hospital which maintains the Inter­national System of record keeping. These cases were collected over a pe­riod of 4 years (May 1961 to Decem­ber 1965). Only those cases that were regularly under observation and fully investigated and followed up have been taken for this study. The cases were of (1) phlyctenulosis, mostly recur­rent (2) granuloma conjunctiva, (3) scleritis, (4) episcleritis, (5) sclerosing, keratitis, (6) deep interstitial keratitis, (7) granulomatous and non-granulo­matous iridocyclitis, (8) generalised uveitis, (9) choroiditis, (10) optic neu­ritis, (11) recurrent vitreous haemorr­hage, (12) extra ocular palsies.

The following investigations were done (1) Total W.B.C. count, (2) Dif­rential count, (3) E.S.R., (4) V.D.R.L. and Kahn's floculation test. (5) Urine for albumin, sugar and deposits, (6) Mantoux test. After these tests, if the tuberculous etiology was considered as a distinct possibility, they were further investigated as mentioned below. In this investigation if V.D.R.L. and Kahn's tests were positive, and a history of exposure was acknowledged, the cases were rejected. Similarly, if Mantous test were negative, the cases were rejected, since low degree cutane­ous reactions are of neither positive nor negative value.-WOODS (1961).

The cases thus selected were sub­jected to a medical survey by a con­sulting physician. This included ex­amination of all systems especially respiratory and glandular. Particular note was taken of cervical and axillary lymphnodes. In the history, a family history of close and constant contact with a tuberculous patient was en­quired. A history of evening rise of temperature, sweating, loss of weight and loss of appetite were particularly noted. A chest X-Ray (postero ante­rior view) was taken as a routine and in many cases biopsy of the glands was done.

Finally if a systemic active focus was found, the patient was subjected to a therapeutic trial test consisting of streptomycin injection daily and isonia­zid 100 mg three times a day for atleast one month. If both ocular and systemic clinical picture showed defi­nite improvement, the case was taken as ocular tuberculosis associated with active systemic focus.

The following 3 cases emphasize the "benign" nature of the systemic tuber­culosis.


  Case Reports Top


1. Mrs. U.D., 30 years old, female came to the Hospital with a history of joint pain in multiple joints and high fever for 6 days. The case was investi­gated by a responsible physician. Chest X-ray was taken and E.S.R, was done. The disease was diagnosed as rheu­matic fever. During the course of treatment, the patient developed scle­rosing keratitis which was attributed to the rheumatic fever. When the ocular lesion tended to recur in spite of treat­ment for rheumatic fever, a second thought was given. A second "head to foot" examination was made with spe­cial attention to the possibility of sys­temic tuberculosis. That revealed mat­ted glands in the left axilla. The biopsy showed tubercular adenitis. Anti-tuber­culous treatment was given resulting in amelioration of her joint pains, fever, and ocular symptoms.

2. Shree K.V.A.-25 year old, Male, came to the Eye O.P.D. with pain in the right eye of 7 days duration. Sud­den loss of vision, right eye-7 days. Headache-2 weeks. On examination, the right eye had only perception of light, right pupil showed ill-sustained reaction; fundus was normal. A diag­nosis of retrobulbar neuritis was made. A lumbar puncture revealed C.S.F. un­der pressure, WBC 290/cmm, mostly lymphocytes, (Polymorphs 9%, lym­phocytes 91%), total proteins 120 mg%, sugar 65 mg chlorides 750 mg%, Pandy's test positive and VDRL-negative. A diagnosis of tuber­culosis was made, and antituberculous treatment improved the clinical picture fully. Later, the family physician of the patient revealed to us that the patient had loss of appetite, loss of weight, in­creased sweating, irregular fever for the last 6 months, and it was attri­buted to "Neurosis". Six months later, the mother of the patient (with whom he was living) submitted to the hospital for the treatment of glandular tuber­culosis and tuberculosis of the spine.

3. K.M., 17 years old male, had a deep corneal opacity of 8 years dura­tion. Its vascularity in the form of a loop and arborization interested the house-surgeon, who made a head to foot clinical examination of the pa­tient. A hypopigmented patch was found over the back which was proved to be tuberculous in nature by biopsy. Both the corneal opacity and the hypo­pigmented patch over the back improv­ed with anti-tuberculous line of treat­ment. (SRINIVAS RAO and SHAN­KAR BHATT-1962).


  Observations Top


The observations are recorded in [Table - 1], some of which are illus­trated in Plates 1-4.


  Discussion Top


The incidence of systemic active le­sion in cases of suspected ocular tuber­culosis was 34 out of 150 (22.6%) and in 3 (2%), healed but gross lesions were found. Out of the 34, 21 proved to be glandular, 4 pulmonary, 4 pro­gressive primary complex and 5 in other sites.

There would have been a higher percentage of incidence, if the ex­amination had included more thorough investigations such as both antero­posterior and lateral views of the chest culture and animal inoculations of the gastric washings in suspicious cases. In addition, repeated clinical review of the remaining 116 cases with periodic X-Rays and ESR test would have probably revealed some more active lesions.

The incidence of glandular tubercu­losis would also have been higher, had routine biopsy been done in all cases where glands were palpable.

In almost all cases the systemic lesion tended to be "benign" in the sense, we could have easily missed it, had we not looked for it.

The Kasturba General Hospital has about 640 patients of systemic tuber­culosis in the list of regular treatment, yet none (except one) had any ocular symptoms attributable to tuberculosis. However, it has to be admitted that they were not regularly checked by ophthalmologists. Only in one case, the patient who had come for pul­monary, tuberculosis had an eye com­plaint (phlyctenule) attributed to tuber­culosis.

The type of ocular lesions that were associated with systemic tuberculosis mostly were of phlyctenulosis. Thus, out of 42 cases of phlyctenulosis, 15 had systemic lesions, out of 17 of sclerosing keratitis, 11 had tuberculo­sis and out of 7 of recurrent vitreous haemorrhage, systemic lesions were found in 3. [Table - 1]. At least in these types of cases, it is a good plan to exclude the possibility of an active systemic focus. It is of interest to note that all the 4 progressive primary com­plex cases were associated with phly­ctenulosis, and 3 out of the 4 were of an age less than 5 years. In spite of all the talk about granulomatous and non-granulomatous iridocyclitis, we were able to demonstrate systemic ac­tive focus in only one case out of 31 of iridocyclitis.

Another feature of this work is the eye findings have led to the detection of 4 insufficiently and irregularly treated cases of systemic tuberculosis.

Lastly the choroidal tubercles which are supposed to have some diagnostic significance were not recorded in this series, showing thereby that its value as a diagnostic aid in systemic tuber­culosis is insignificant.[14]

 
  References Top

1.
AMSLER M. (1955). In A. SORBY'S "Modern Trends in Ophthalmology", third serial, Butterworth, London, p. 137.  Back to cited text no. 1
    
2.
AMSLER M. (1957), Acta Tuberc. Beig. 48, 89.  Back to cited text no. 2
    
3.
DUKE-ELDER S. W. (1965). System of Ophthalmology, Vol. VIII, part 2. Henry Kinpton, London, pp. 833, 1028.  Back to cited text no. 3
    
4.
FRITZ M. H., THYGESON P. and DURHAM D. G., (1951). Amer. J. Ophth. 34, 177.  Back to cited text no. 4
    
5.
KONTAS K. A. (1958). Ophthalmolo­gica, 135, 187.  Back to cited text no. 5
    
6.
LASCU F., GROSSU E. and NICU­LESCUM. (1956). Oftamologia (Buch­arest), 1, 31.  Back to cited text no. 6
    
7.
PACYNSKA JULIA (1957). Klinika Oczna 27, 259.  Back to cited text no. 7
    
8.
SIWE S. A. (1935) Acta Tubers. Scand. 8, 225.  Back to cited text no. 8
    
9.
SORSBY A. P. (1942). Brit. J. Ophthal. 26, 159 & 189.  Back to cited text no. 9
    
10.
SRINIVASA RAO R. N. and SHAN­KAR BRAT (1967) J. Indian Medical Assn. 48, 502.  Back to cited text no. 10
    
11.
THEODORE F. H. and SCHLOSS­MAN A. (1958). Ocular allergy. Wil­liams and Wilkins Co. Baltimore 281, 314, 340.  Back to cited text no. 11
    
12.
WEGNER W. and ZINTZ R. (1951). Klin, Mbl, Augenheilk 119, 350.  Back to cited text no. 12
    
13.
WERDENBERG E. (1938), Klin Mbl. Augenheilk 101, 641.  Back to cited text no. 13
    
14.
WOODS A. C. (1956), Endogenous Inflammations of Uveal Tract. Wil­liams & Wilkins, BALTIMORE, p. 340­-418.  Back to cited text no. 14
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
 
 
    Tables

  [Table - 1]



 

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