Inflammatory Ischaemic Vasculitis With Vitritis Associated With Previous Exposure to Tuberculin Protein (TB Hypersensitivity)

Abstract

Purpose:: Ocular inflammation in the presence of retinal capillary closure has previously been reported as a sub group of ‘Idiopathic retinal vasculitis’. Hypersensitivity to tuberculin protein has been suggested as a causative agent for this type of presentation, in patients who have been exposed to TB (but in whom no focus of active infection can be identified) Few publications report the treatment options and long term outcomes in these patients. Here we outline the presentation, investigations, treatment regimens (including anti-TB medication, steroid use, retinal laser), response to treatment, visual outcome of 10 cases.

Methods:: Analysis of retrospective case series of 10 patients who presented to Moorfields Eye Hospital over the last six years with an inflammatory vitritis and vasculitis associated with peripheral +/- central capillary closure at presentation and a positive Haef test and with no evidence of TB chorioretinitis or granulomas.

Results:: In all bar one patient the disease presented bilaterally with median Snellen visual acuity 6/12 (range 6/4 to Hand movements). All patients had closure of the retinal vessels at presentation and 8 out of 10 (80%) required unilateral (4) or bilateral (4) laser panretinal photocoagulation during follow up for treatment of neovascularisation at the disc (NVD) or elsewhere (NVE). 7 out of 10 (70%) patients had evidence of active vasculitis on presentation, and 4 had branch retinal vein occlusions on presentation (1 bilateral). 8 out of 10 (80%) and 10 out of 10 (100%) patients presented with evidence of anterior chamber activity and vitiritis respectively. All patients had a positive (Grade 3 or more) Mantoux test. All received anti-tuberculous treatment as cover for Prednisolone therapy. Follow up varied from 6 months to 6 years. All made a good recovery with 17 out of 20 eyes (85%) resulting in a final BCVA of 6/6 or better and all eyes being 6/12 or better. No patients had recurrence of uveitis or neovascularisation.

Conclusions:: TB hypersensitivity should be considered in the differential diagnosis of retinal vasculitis in inflamed eyes when in the presence of retinal ischaemia +/- branch retinal vein occlusions. Prompt laser and immunosuppressive therapy with anti-tuberculous cover may be required to slow progression and prevent visual loss.

Keywords: uveitis-clinical/animal model • ischemia • inflammation