Tuberculosis of the eye

The frequency of tuberculosis lesions among all eye diseases, according to different authors, fluctuates from 1.3 to 5%. The proportion of eye tuberculosis increases significantly in the group of inflammatory diseases of the vascular membrane (uveitis), although the fluctuations are also significant: from 6.8 to 63%.

Between 1975 and 1984, the incidence of ocular tuberculosis decreased by more than 50%. In the structure of extrapulmonary tuberculosis, tuberculous eye lesions occupied 2nd-3rd place. In the last decade, the rate of decline in the incidence of visual tuberculosis, as well as extrapulmonary tuberculosis in general, has stopped, and in some regions of Russia, starting in 1989, an increase in this indicator has been noted. An analysis of the results of a study of people newly diagnosed with ocular tuberculosis in 23 territories of Russia showed that the traditional idea of the medical and social status of a patient with respiratory tuberculosis, usually associated with asocial strata of the population, does not correspond to that in cases of ocular tuberculosis. Tuberculous lesions of the visual organ occur in most cases in young and middle-aged people, more often in women, city dwellers or residents of a large town, with satisfactory housing and living conditions, with an average income, from among employees or skilled workers, without bad habits, suffering from concomitant diseases. The overwhelming majority of patients with eye tuberculosis (97.4%) are identified by seeking help. At the same time, a high proportion of specific processes diagnosed at late stages of development is noted - 43.7%. This fact indirectly indicates that at the beginning of manifestations of general tuberculosis infection, specific eye lesions were missed. It should also be noted that at a young age, tuberculous chorioretinitis is detected significantly more often (more than 2.5 times) - as a rule, in the early stage of the disease, and after 50 years - anterior uveitis, and among them, advanced processes are more often noted. This is due to the peculiarities of detection of eye tuberculosis in different age categories depending on the predominant localization of inflammation and, from our point of view, indicates the need to direct maximum efforts to detect tuberculosis lesions in children, adolescents and young people.

Tuberculosis of the choroid of the eyeball (tuberculous uveitis)

The onset of the disease is usually subtle and often asymptomatic. The inflammatory process is sluggish, torpid, without pronounced pain syndrome, but can become more acute in cases of an allergic component (which is more often observed in adolescents and young people) and/or secondary infection. The clinical picture of hematogenous tuberculous uveitis is characterized by pronounced polymorphism, so it is difficult to identify strictly pathognomonic signs of the disease.

Based on the predominant localization, tuberculous uveitis can be divided into 4 groups:

• anterior uveitis;
• peripheral uveitis (posterior cyclitis, pars planitis, intermediate uveitis);
• chorioretinitis;
• generalized uveitis (panuveitis).

Lesions of other membranes of the eye in hematogenous tuberculosis of the eyes occur secondary to one or another localization of specific inflammation in the vascular membrane, therefore it is hardly advisable to distinguish them into separate, independent forms.

When studying the clinical picture of any intraocular disease, one should begin with a search for the original, so-called “primary” focus in the choroid.

In most cases, the uveal process is clearly expressed and easily detected during an ophthalmological examination of the diseased eye.

Tuberculous lesions of the accessory organs of the eye and the bone orbit Tuberculous diseases of the skin of the eyelids are rare nowadays, the diagnosis is established by a dermatologist on the basis of histological or bacteriological studies. The process can occur in the following forms: tuberculous lupus, tuberculous ulcer of the skin of the eyelid, scrofuloderma of the eyelid, miliary tuberculosis of the skin of the face. Tuberculosis of the conjunctiva. The disease is unilateral, does not cause subjective sensations, unless a secondary infection joins. In the conjunctiva of the cartilage of the upper eyelid or the transitional fold of the lower eyelid, a group of grayish nodules appears, which can merge. After 3-4 weeks, they can ulcerate and form a deep ulcer with a bumpy bottom covered with a greasy coating. The ulcerated surface granulates slowly, persists for months. In some cases, a dense fibrous capsule forms around the nodules, perifocal inflammation is weakly expressed, the formation resembles a chalazion or a neoplasm. In this case, the diagnosis is established based on histological examination. Tuberculous dacryoadenitis is characterized by an enlarged and dense gland without pain and obvious signs of inflammation. This circumstance can lead to an erroneous diagnosis of a neoplasm of the lacrimal gland. The disease, as a rule, occurs against the background of tuberculosis of the peripheral lymph nodes, which can help in differential diagnosis.

Tuberculous dacryocystitis occurs more often in children and the elderly and can develop independently (with primary tuberculous infection) or as a result of the spread of specific inflammation from the skin of the eyelids or conjunctiva. In the area of the lacrimal sac, hyperemia of the skin, swelling of a doughy consistency of cotton wool are determined; the discharge is scanty; the washing fluid passes into the nose. since the disintegrating granulations do not completely block the lumen of the lacrimal sac. Sometimes a fistula is formed, which makes it possible to conduct bacteriological studies. Contrast radiography of the lacrimal ducts reveals filling defects due to the presence of tuberculous tubercles and granulations and niches due to their disintegration. Tuberculous osteomyelitis of the orbit is almost always localized in its outer or lower half, in the area of the lower-outer edge. Inflammation is usually preceded by blunt trauma to the orbital region. After the contusion symptoms subside, hyperemia of the skin and pain when touched appear due to the development of specific osteomyelitis with caseous decay, which is accompanied by abscess formation and fistula formation. Fistulas subsequently heal with a rough scar fused with the bone, deforming the eyelid.

Tuberculous-allergic eye diseases

The inflammatory process that occurs with tuberculosis-allergic lesions is not bacterial and does not have the characteristic features of a specific granuloma. However, by its origin, it is closely related to tuberculosis infection. A sharp increase in the specific sensitivity of eye tissues and intoxication create conditions in which any irritant effect, including specific toxins themselves, can become a source of hyperergic inflammation. In this case, tuberculosis-allergic disease can occur in any part of the eyeball, usually in children and adolescents.

Among the diseases of the anterior segment of the eye in recent years, the following have been encountered:

• phlyctenular keratoconjunctivitis, characterized by the appearance of phlyctenular nodules in the conjunctiva of the eyeball, in the limbus area or on the cornea, which are lymphocytic infiltrates;
• keratitis, the clinical picture of which is characterized by the superficial location of infiltrates with a dense network of newly formed vessels;
• serous iridocyclitis.

All of the listed forms are characterized by a more acute onset, severity of the inflammatory process, rapid subsidence with the use of glucocorticoids and a tendency to relapse.

Among tuberculous-allergic diseases of the posterior segment of the eye, retinovasculitis is most common, which is a pathological change in the retinal vessels, localized, as a rule, on the periphery of the fundus. Along the vessels, there are exudate stripes, pinpoint retinal foci and areas of dyspigmentation, and accompanying stripes. The severity of these changes may vary and depends on the manifestation of the general tuberculous infection and the immunological status of the patient (in most patients in this group, violations of the humoral link of immunity are determined). The most severe course of retinovasculitis is accompanied by infiltration of the vitreous body, and damage to the vessels of the ciliary body leads to the development of tuberculous-allergic peripheral uveitis.

Miliary choroiditis, by its morphology, should rather be attributed to tuberculosis-allergic manifestations of general tuberculosis infection, since in its structure it does not have a specific granuloma, does not contain tuberculosis mycobacteria and occurs with generalized tuberculosis in the overwhelming majority of cases in children. It is characterized by the appearance of yellowish, moderately protruding foci, more often in the peripapillary or paramacular zones, ranging in size from pinpoint to 0.5-1.0 mm in diameter. Their number varies from 3 to 15, sometimes there are many of them, in rare cases their fusion is observed.

Lesions of the visual organ in tuberculosis of the central nervous system

Tuberculous meningitis is accompanied by dysfunction of the cranial nerves, which is manifested by ptosis of the upper eyelid, dilation of the pupil, divergent strabismus (III pair). The second most common lesion is the abducens nerve (VI pair) - convergent strabismus, inability to turn the eyeball outward. Congestive discs of the optic nerve are observed with blockade of the ventricular cisterns with their secondary expansion and with cerebral edema.

In cerebral tuberculomas, congestion of the optic nerve discs, neuritis, and secondary atrophy of the optic nerves are most often detected. A combination with chiasmal changes in the visual field and tractus homonymous hemianopsia due to compression of the chiasm and brainstem is possible.

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