Tuberculosis of the eye

The incidence of tubercular lesions among all eye diseases, according to different authors, ranges from 1.3 to 5%. The share of eye tuberculosis increases significantly in the group of inflammatory diseases of the choroid (uveitis), although the fluctuations are also significant: from 6.8 to 63%.

Between 1975 and 1984, the incidence of eye tuberculosis declined by more than 50%. While in the structure of extrapulmonary tuberculosis, tuberculosis of the eyes took 2-3 place. In the last decade, the rate of decline in the incidence of tuberculosis in the organ of vision, as well as extrapulmonary tuberculosis in general, has halted, and in some regions of Russia since 1989, this indicator has been growing. Analysis of the results of the study of the first time ill with eye tuberculosis in 23 Russian territories showed that the traditional idea of the medical and social status of a patient with respiratory tuberculosis, usually associated with antisocial layers of the population, does not correspond to that in cases of eye tuberculosis. Tubercular lesions of the organ of vision occur in most cases in young and middle-aged people, more often in women, in towns or in a large village, with satisfactory living conditions, with moderate income, from employees or skilled workers, without bad habits, with concomitant diseases. The overwhelming majority of patients with eye tuberculosis (97.4%) identify by treatment. In this case, a high proportion of specific processes diagnosed in the late stages of development - 43.7%. This fact indirectly indicates that. That at the beginning of manifestations of a common tuberculosis infection, specific eye lesions were missed. Also, it should be noted that at a young age, tubercular chorioretinitis is detected more often (more than 2.5 times) - in this case, as a rule, in the early stage of the disease, and after 50 years - the anterior uveitis, and among them more often noted far-gone processes. This is due to the peculiarities of the 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 identify tuberculosis lesions in children, adolescents and young people.

Tuberculosis of the choroid of the eyeball (tuberculous uveitis)

The onset of the disease, as a rule, is rarely noticeable without symptom. The inflammatory process proceeds sluggishly, torpidly, without severe pain syndrome, but may acquire a more acute course in cases of accession of the allergic component (which is more often observed in adolescents and young people) and / or secondary infection. The clinical picture of hematogenic tuberculosis uveitis is characterized by pronounced polymorphism, so it is difficult to single out strictly pathognomonic signs of the disease.

By primary localization, tubercular uveitis can be divided into 4 groups:

• anterior uveitis;
• peripheral uveitis (posterior cyclites, pars planitis interim uveitis);
• chorioretinitis;
• generalized uveitis (panoveitis).

Lesions of other membranes of the eye in hematogenous eye tuberculosis occur secondary to a particular localization of a specific inflammation in the choroid, so it is hardly advisable to separate them into separate, independent forms.

When studying the clinical picture of any intraocular disease, one should start with the search for the initial, so-called "primary" focus in the choroid.

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

Tuberculous lesions of the auxiliary organs of the eyes and bone orbit Tuberculosis skin diseases of the eyelids are rarely present today, the diagnosis is established by a dermatologist on the basis of histological or bacteriological studies. The process can proceed in the following forms: tuberculosis, lupus erythematosus, eyelid scrofuloderma, miliary tuberculosis of the facial skin. Tuberculosis of the conjunctiva. The disease is unilateral, does not cause subjective sensations, unless secondary infection is attached. In the conjunctiva of the cartilage of the upper eyelid or the transitional fold of the lower eyelid, a group of nodules of grayish color appear that can merge. After 3-4 weeks they can ulcerate and form a deep ulcer with a tuberous bottom covered with greasy plaque. The ulcerous surface is granulated slowly, remaining for months. In some cases around the nodules formed a dense fibrous capsule, perifocal inflammation is poorly expressed, the formation resembles a halal or neoplasm. The diagnosis in this case is established on the basis of histological examination. Tuberculous dacryoadenitis is characterized by an enlarged and dense to the touch gland without pain syndrome and obvious signs of inflammation. This circumstance can lead to an erroneous diagnosis of the tumor of the lacrimal gland. Disease, as a rule, proceeds against a background of tuberculosis of peripheral lymph nodes, which can help in differential diagnosis.

Tuberculous dacryocystitis occurs more often in children and people of advanced age and can develop independently (with primary tuberculosis infection) or as a result of the spread of a specific inflammation from the skin of the eyelids or conjunctiva. In the area of the lacrimal sac, skin flushing is determined, swelling of the dough with a cotton paste; separated scant; the washing liquid passes into the nose. Since the disintegrating granulations do not completely block the lumen of the lacrimal sac. Sometimes fistula is formed, which makes it possible for bacteriological studies. With contrast radiography of the tear ducts, filling defects due to the presence of tubercle tubercles and granulations and niches are revealed - due to their disintegration. Tuberculous osteomyelitis of the orbit is almost always localized in its outer or lower half, in the region of the lower-external margin. Inflammation is usually preceded by a blunt trauma to the area of the orbit. After the subsidence of the contusion symptoms, there is skin hyperemia and tenderness when touching due to the development of specific osteomyelitis with caseous decay, which is accompanied by abscess formation and fistula formation. Fistulas later heal with a coarse, bone-jointed scar, a deforming eyelid.

Tuberculosis-allergic eye diseases

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

Among the diseases of the anterior part of the eye in recent years are met:

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

For all these forms is characterized by a more acute onset, the severity of the inflammatory process, rapid subsidence with the use of glucocorticoids and the tendency to recur.

Among tuberculosis-allergic diseases of the posterior eye, retinovuculites are more common, representing pathological changes in the retinal vessels, localized, as a rule, on the periphery of the fundus. Along the vessels appear strips of exudate, dotted retinal foci and areas of dyspigmentation, lane maintenance. The severity of these changes can be different and depends on the manifestation of the general tuberculosis infection and the immunological status of the patient (in most patients of this group, violations of the humoral immunity level are determined). The most severe course of retinovasculitis is accompanied by infiltration of the vitreous, and the damage to the vessels of the ciliary body leads to the development of tuberculosis-allergic peripheral uveitis.

Miliary choroiditis in its morphology, rather, should be attributed to tuberculosis-allergic manifestations of the common tuberculosis infection, because in its structure it does not have a specific granuloma, does not contain mycobacterium tuberculosis, and occurs in the generalized tuberculosis in the overwhelming majority of cases in children. It is characterized by the appearance of yellowish, moderately piercing foci, more often in the peripapillary or paramacular zones, ranging from point to 0.5-1.0 mm in diameter. The number of them varies from 3 to 15, sometimes they are numerous, in rare cases they observe their merging.

Disorders of the visual organ in central nervous system tuberculosis

Tuberculous meningitis is accompanied by a violation of the function of the cranial nerves, which is manifested by the ptosis of the upper eyelid, the dilatation of the pupil, the divergent strabismus (III pair). The second place in the frequency of the lesion is occupied by the abducent nerve (VI pair) - convergent strabismus, impossibility of turning the eyeball outwards. Stagnant discs of the optic nerve are observed during blockade of ventricular cisterns with their secondary expansion and with edema of the brain.

With the tuberculosis of the brain, stagnant discs of the optic nerves, neuritis and secondary atrophy of the optic nerves are most often detected. It is possible to combine with chiasmatic changes in the field of vision and the censored homonymous hemianopsia due to compression of the chiasm and the brainstem.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]