Tubercular Scleritis: How common is it?

FP- 001736

Dr Santanu Mandal DO FRCS

Disha Eye Hospitals & research centre Barrackpore, West Bengal, India
dr_santanumandal@yahoo.com

Financial disclosure

I have no financial interests or relationships to disclose

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 tuberculosis reported 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;51:347349. 6. Watson PG, Hayreh SS. Scleritis and episcleritis. Br J Ophthalmol.1976;60:163-191.

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

Purpose of the study

To evaluate the incidence of

tubercular etiology
among recurrent scleritis cases in a tertiary eye care centre of Eastern India

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

Materials & Methods

Scleritis profile incomplete in all referred cases No. of recurrent attacks before presentation: 2- 5(range) Average time of presentation since first attack 5 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 ATT started , Day 1 Day 21 ATT started , Day 14

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 country simultaneous Mtx and QFT-G was advised

Results
Total no of rec. scleritis cases 32 (51 eyes) All were Immunocompetent 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.)

Day 1

2 wks after ATT

2 months after ATT

9 months after ATT

Results
3 cases - oral steroid in a tapering dose, with ATT (9ms.) 2 cases (uncontrolled DM) - oral NSAID with ATT (9ms.)

2 cases - topical NSAID with ATT (9ms.)

Day 0

Day 16 after ATT

2 ms. after ATT

9 ms. after ATT

24 ms.

No recurrence in 2 year follow up

Results
Different etiologies of recurrent scleritis
Type of scleritis Tubercular Rheumatoid Sero ve arthritis Wegeners Gout Viral No of cases/No of eyes

n = 32 cases (51 eyes)

M:F

Average age (Yrs)

7 (10eyes)
3 (6 eyes) 2 (2 eyes) 2 (4 eyes) 1 (1 eye) 1 (1 eye)

48.85
43 48.5 43.5 47 52

3:4
1:2 1:1 0:2 1:0 1:0

Idiopathic

16 (27 eyes)

43

11:5

Results
Different etiologies of recurrent scleritis n = 32 cases (51 eyes)

2 cases WG

1 case 1 case Gout Viral

Viral
7 cases Tuberculosis

Gout Sero-ve WG Female Male

2 cases
Sero ve arthritis

3 cases
RA
16 cases with etiological diagnosis

RA TB 0 2 4 6

16 cases = Idiopathic

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.

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 positive Mtx and QFT-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.

Discussion
QFT-G was advised in all cases with Mtx test - as oral steroid > 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.

Conclusion

Recurrent scleritis should be assessed with Mtx and QFT-G to rule out tubercular aetiology in an endemic country like India before starting any immunomodulatory drugs