Presumed tuberculous sclerokeratouveitis in immunocompetent South African patients

Background/objectives: Ocular tuberculosis remains a diagnostic challenge since its clinical presentation is so variable. We describe the clinical characteristics of patients presenting with sclerokeratouveitis secondary to presumed Mycobacterium tuberculosis infection.

Method: Retrospective analysis of 14 patients presenting with sclerokeratouveitis to Tygerberg Hospital. All patients underwent: (1) detailed ophthalmological evaluation, (2) tuberculin skin test (TST), (3) chest X-ray to assess for systemic disease, and (4) laboratory investigations to exclude other causes of ocular inflammation. Tuberculous sclerokeratouveitis was diagnosed if: (1) clinical findings showed scleritis with adjacent peripheral keratitis and anterior uveitis, (2) TST was positive, (3) other causes of sclerokeratouveitis were excluded, and (4) positive response to tuberculosis treatment without adjunctive anti-inflammatory agents was noted.

Results: Seventeen eyes were included. Mean age was 29.1 ± 12.1 years. All patients were females with no history of previous/current pulmonary tuberculosis. Only one patient was HIV positive, but virologically suppressed. All patients had a strongly positive TST result. Scleral involvement was nodular in four patients and diffuse in ten. Corneal involvement manifested as ill-defined peripheral stromal opacities adjacent to the area of scleritis with deep corneal stromal vessels. Corneal sensation was decreased in all involved eyes. All patients responded to tuberculosis treatment with complete resolution of the sclerokeratouveitis.

Conclusions: In our highly endemic area, tuberculous sclerokeratouveitis is seen in young, immunocompetent patients, and responds well to tuberculosis treatment without concurrent immunosuppression. Decreased corneal sensation may lead to an incorrect diagnosis of herpetic infection if a high index of suspicion is not maintained for ocular tuberculosis.