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Purpose:
To systematically review the characteristics of patients with endogenous tuberculous (TB) endophthalmitis and panophthalmitis in an effort to help clinicians with diagnosis and treatment.
Patients and methods:
We conducted a systematic literature search in MEDLINE/PubMed, EMBASE and Web of Science from inception to August 2020. Referenc...
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Citations
... Uveitis is the most common form of ocular TB, and it may involve any part of the uveal tract. 2 Endophthalmitis is a severe manifestation with a rapid progression that can lead to intraocular tissue destruction and panophthalmitis. 3,4 Therapy is usually conservative with antitubercular antibiotics combined with corticosteroids. 3 In cases with endophthalmitis, in which the risk of imminent visual loss is very high, surgical options should be discussed, including pars plana vitrectomy (PPV). ...
Introduction: Ocular tuberculosis (TB) is an extrapulmonary mycobacterial disease with varied manifestations. Endophthalmitis is a severe manifestation with a rapid progression that may lead to intraocular tissue destruction and panophthalmitis. This study aimed to report a case of tuberculous endophthalmitis treated with pars plana vitrectomy (PPV). Case presentation: A 57-year-old male patient with TB endophthalmitis. The follow-up period was 6 months. The diagnosis was made on a clinical basis, and the specific etiology was confirmed by TST and IGRA tests. The diagnosis of ocular TB was delayed by one year. He had bilateral endophthalmitis with severe inflammation. The right eye (OD) was blind, and the left (OS) had best-corrected visual acuity (BCVA) of hand motion. Intraocular pressure (IOP) was elevated in both eyes. B-scan disclosed hyperreflective exudate, filling 1/3 of the vitreous cavity in OD, and vitritis and intravitreal hemorrhage in OS. We commenced triple antitubercular therapy. 23G PPV with silicone oil and phacoemulsification with IOL implantation were done. The intraocular inflammation in OS decreased postsurgically, and in one month, BCVA was 20/200 and IOP was within normal limits. Conclusion: Eendophthalmitis is an indication for therapeutic vitrectomy. The risks of surgery seem to be lower than the benefits, including a decent chance for visual improvement and avoidance of enucleation. In our case, 23G PPV with phacoemulsification seemed to be beneficial in decreasing the level of inflammation, improvement of visual acuity, reduction of IOP, and preservation of the eye.
... Poor prognosis in these cases is often due to initial misdiagnosis as sarcoidosis, syphilis, acute retinal necrosis, metastatic carcinoma, and so on. In most cases, the diagnosis is made on histopathology after enucleation of the affected eye 67 (Figure 1a-d). ...
Endogenous endophthalmitis (EE) is an uncommon but potentially devastating ocular infection involving the inner layers of the eye. The global incidence of EE is on the rise. Common ocular signs and symptoms associated with EE include conjunctival injection, ocular pain, and reduced visual acuity. On clinical examination, a history of prior or coexisting systemic infections, symptoms (e.g., fever, malaise), and localizing features may be noted. Clinical diagnosis is often challenging, resulting in critical delays that contribute to a poor prognosis. Blood cultures and ocular fluid samples can aid in conforming causative pathogen(s), after which empirical antibiotic therapy, both systemic and intravitreal, should be instated. The use of steroids to suppress inflammation remains controversial. Surgical options include pars plana vitrectomy. Overall prognosis varies depending on host and pathogen factors, and early diagnosis and initiation of appropriate treatment are crucial.
... Investigations. Haemoglobin was 7.8 g/dL (11)(12)(13)(14)(15), total leucocyte count 31.3 × 10 9 /L (5-14), 84% neutrophils and 13% lymphocytes with no atypical cells, and platelets 550 × 10 9 /L (1.5-4.0). ESR was 48 mm/1st hour (14)(15)(16)(17)(18)(19)(20), C-reactive protein 183 mg/L (<5), alanine transaminase 78 U/L (10-40) and aspartate transaminase 84 U/L (22-71). ...
... Haemoglobin was 7.8 g/dL (11)(12)(13)(14)(15), total leucocyte count 31.3 × 10 9 /L (5-14), 84% neutrophils and 13% lymphocytes with no atypical cells, and platelets 550 × 10 9 /L (1.5-4.0). ESR was 48 mm/1st hour (14)(15)(16)(17)(18)(19)(20), C-reactive protein 183 mg/L (<5), alanine transaminase 78 U/L (10-40) and aspartate transaminase 84 U/L (22-71). Cerebrospinal fluid (CSF) analysis was normal. ...
... It usually results from rupture of a sub-retinal abscess in a long-standing untreated or drug-resistant case of ocular tuberculosis. To date, only six cases of paediatric endogenous endophthalmitis and panophthalmitis have been reported [11][12][13], none of which was owing to CTB [14]. This case demonstrates a rare ocular manifestation, which is probably the only reported case of CTB complicated by secondary panophthalmitis in the literature to date. ...
Congenital tuberculosis (CTB) is the transmission of Mycobacterium tuberculosis infection from mother to infant during the intrauterine period or delivery. An 82-day-old infant presented to Nilratan Sircar Medical College and Hospital, Kolkata, with a history of persistent fever from Day 15 of age. Over the course of more than 2 months, there were pneumonia, hepatosplenome-galy and endophthalmitis which were unresponsive to a range of antibiotics, and there had been several admissions to local hospitals. On this admission, his chest radiograph and contrast-enhanced computed tomography (CECT) of the thorax demonstrated bilateral nodules and enlarged mediastinal lymph nodes. Ultrasound and CECT of the abdomen demonstrated hepatosplenomegaly with multiple hypodense enhancing lesions. GeneXpert of a gastric lavage on Day 2 of this admission detected M. tuberculosis without rifampicin resistance. The infant was diagnosed with tuberculosis (TB) complicated by caseating hepatic granulomas, which fulfilled Cantwell's diagnostic criteria for CTB. Magnetic resonance imaging of the orbit demonstrated focal heterogeneous lesions involving the anterior portion of the left ocular bulb and vitreous, suggesting panophthalmitis, which was unresponsive to intravitreal antibiotics. Following commencement of standard anti-TB therapy from Day 90 of life, there was clinical and radiological recovery of endophthalmitis. The mother had a cachectic appearance owing to weight loss, and she had attended only one antenatal appointment. She had a positive acid-fast bacilli sputum stain but was unwilling to allow a genital tract smear. In the spectrum of CTB, TB panophthalmitis is an extremely rare presentation, and, as far as we are aware, it has not been reported in a child.
... Next, Dr. Evereklioglu brought up a point about "uninjected white eye", and he proposed that this should be used to exclude an infectious etiology of ocular inflammation. We think this is partially correct, and we are not opposing that subtle conjunctival injection is a clue to diagnose ocular masquerade syndrome, but we also raise the point that some patients with infectious uveitis may also present with mild conjunctival injection [6][7][8]. In addition, we did not mention the prior treatment of our patient in the article. ...
Extranodal natural killer/T-cell lymphoma rarely presents as intraocular masquerade syndrome. We thank Dr. Evereklioglu for bringing up the importance of a thorough ocular examination, differential diagnosis, and consideration of the characteristics of ocular masquerade syndrome.
... The issue of EE is once again in focus as the incidence is reported during the COVID-19 pandemic [5,6]. Several articles have reviewed EE [7,[8][9][10]. However, the evidence on the magnitude and management outcomes of EE among diabetic patients in isolation are limited. ...
Although endogenous endophthalmitis (EE) among diabetic individuals (DEE) is uncommon, the prevalence of the condition has recently increased due to better intensive health care services available and an increased longevity of critically ill patients with systemic infections. The existing literature was critically reviewed on DEE and its present incidence, risk factors, causative organisms, management, outcomes and proposed measures to improve its public health approach. This review is of critical importance, as the COVID-19 pandemic has increased the risk of endogenous endophthalmitis (EE) for diabetic patients as a result of a systemic infection. Aggressive glycemic control is concurrent with patient care for DEE management, which requires lifelong maintenance. The early detection, standard management are crucial for patients' visual recovery. Still guarded prognosis is given to patients and relatives as outcomes are not always predictable. There is a need for teamwork of ophthalmologists with other health professionals and patients throughout the management. The causative organisms, early pharmacotherapy suitable for the identified organisms, pars plana vitrectomy, are predictors of visual outcomes. DEE patients need lifelong eye care.
... RB-PDAT is an emerging therapeutic modality for the management of infectious keratitis [142]. It was first introduced by Amescua et al. in 2017 for the management of a patient with multidrug-resistant Fusarium keratoplasticum keratitis [143]. ...
... In this therapeutic modality, rose bengal, a routinely used dye in ophthalmology, is excited with a green light at a wavelength of 500-550 nm to generate reactive oxygen species [144]. Rose bengal is a type II photosensitizer that, when activated, induces cellular apoptosis by converting triplet oxygen to singlet oxygen [142]. A pilot study performed by Naranjo et al. including Acanthamoeba keratitis (10 cases), Fusarium spp. ...
... In the case of intraocular TB, this may require a major intervention such as enucleation, which may be clinically undesirable [138][139][140]. Moreover, most patients with intraocular TB present without signs of systemic manifestation, and tuberculin skin test (TST) can be negative in patients with disseminated TB [141,142]. A recent review of endogenous TB endophthalmitis found that the majority of patients (63%) did not have a prior history of tuberculosis, and ocular manifestations were their presenting sign [141,142]. ...
Infectious eye disorders represent one of the most feared, sight-threatening, and challenging clinical ocular conditions. Visual loss due to eye infection significantly impacts patients’ productivity and quality of life. The development of accurate diagnostic tests and better treatment alternatives results from intensive and innovative medical research committed to improving the standard of care of patients suffering from these blinding diseases. This book focuses on the most recent advances in diagnostic techniques for common infectious disorders, including viral, fungal, and contact lens-related keratitis, infectious uveitis, endophthalmitis, and COVID-19-related eye infection. It also describes the current therapeutic strategies that significantly reduce the rate of ocular complications and improve the visual outcome of patients suffering from such devastating disorders.
... In the case of intraocular TB, this may require a major intervention such as enucleation, which may be clinically undesirable [138][139][140]. Moreover, most patients with intraocular TB present without signs of systemic manifestation, and tuberculin skin test (TST) can be negative in patients with disseminated TB [141,142]. A recent review of endogenous TB endophthalmitis found that the majority of patients (63%) did not have a prior history of tuberculosis, and ocular manifestations were their presenting sign [141,142]. ...
... Moreover, most patients with intraocular TB present without signs of systemic manifestation, and tuberculin skin test (TST) can be negative in patients with disseminated TB [141,142]. A recent review of endogenous TB endophthalmitis found that the majority of patients (63%) did not have a prior history of tuberculosis, and ocular manifestations were their presenting sign [141,142]. Furthermore, half of the presenting patients denied any systemic symptoms such as fever, chills or hemoptysis prior to presentation at the eye clinic. The most common presenting symptom was decreased vision (90%), followed by pain (58%), eye redness (32%), and proptosis (6.5%), all of which are nonspecific signs [141,142]. ...
... Furthermore, half of the presenting patients denied any systemic symptoms such as fever, chills or hemoptysis prior to presentation at the eye clinic. The most common presenting symptom was decreased vision (90%), followed by pain (58%), eye redness (32%), and proptosis (6.5%), all of which are nonspecific signs [141,142]. ...
This chapter comprehensively covers all aspects of endogenous endophthalmitis from systemic infectious agents, with an emphasis on reported and newer etiologies to broaden the diagnostic and investigative acumen of treating ophthalmic providers. The discussion includes the etiology of metastatic endophthalmitis and diagnostic investigations, including polymerase chain reaction (PCR), for identification of bacterial and viral infections involving the eye in both immunosuppressed in non-immunosuppressed patients. Additionally, we present clinical and diagnostic findings of fungal infections, protozoal infections, and helminthic infections. Pediatric cases are also reported and etiologies described. We discuss both etiology and diagnostic challenges. Current therapeutic modalities and outcomes are reviewed. While no two cases of metastatic endophthalmitis are the same, some similarities may exist that allow us to generalize how to approach and treat this potentially sight- and life-threatening spectrum of diseases and find the underlying systemic cause.
A female in her early 40s presented to the outpatient clinic for weight loss, fatigue, cough, followed by a gradual painful loss of vision in the right eye associated with redness over the past 3 months. Physical examination revealed bilateral axillary lymphadenopathy and non-healing skin ulcers on the left forearm and the left gluteal region. The patient had no light perception in the right eye and grade 4+ cells in the anterior chamber. A chest X-ray showed a cavitary lesion in the left upper lobe. Histopathological tests from the skin and lymph nodes revealed caseating granulomas, raising the suspicion of tuberculosis. A sputum nucleic acid amplification test was performed, which returned positive for Mycobacterium tuberculosis . The patient was treated with antitubercular chemotherapy and showed encouraging signs of progress after the treatment.
Clinical case
A 24-year-old Nepalese male, ex-smoker, with past medical history of post-natal prolonged hospital stay and recurrent pneumonia as an infant, presented with a 2-week history of progressive visual impairment. He denied fever, chest pain, shortness of breath or unintentional weight loss. He recalled a 2-week dry cough episode that occurred 3 months before admission.
Physical examination revealed a painless lump on the vertex of the skull and tenderness on lumbar and sacral spine. White blood cell count was 12 × 10³ cells/l and CRP 15 mg/l. HIV antigen/antibody test and syphilis serology were negative. MRI of the brain showed bilateral optic nerve oedema (Figure 1A) and a skull soft tissue lesion with focal bone destruction displacing the dura (Figure 1C). Ophthalmologists confirmed bilateral neuro-retinitis associated with severe bilateral visual loss and severe papillitis observed on fundoscopy (Figure 1B). MRI of the spine showed a large inflammatory posterior sacral mass associated with areas of sacral osteomyelitis and a presacral collection. CT of the thorax showed mediastinal lymphadenopathies. An electrocardiogram showed sinus rhythm with diffuse saddle-shaped ST segment elevation. Echocardiography revealed acoustic enhancement of the posterior aspect of the pericardium consistent with pericarditis. Necrotizing granulomas (Figure 1D) were observed on haematoxylin-eosin staining of a sacral biopsy and Ziehl-Nielsen stain was positive (Figure 1D, inset). Polymerase chain reaction for Mycobacterium tuberculosis resulted negative on sputum samples and sacral tissue. However, sensitive M. tuberculosis was isolated from the sacral and scalp tissue culture.
