<p class="first" id="d9652420e394">This international cohort study examines the clinical
features of tubercular uveitis
and the associations with response to antitubercular therapy.
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<h5 class="section-title" id="d9652420e400">Questions</h5>
<p id="d9652420e402">What are the suggestive clinical features and approach to diagnosis
of patients with
tubercular (TB) uveitis in a multinational retrospective review?
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<h5 class="section-title" id="d9652420e405">Findings</h5>
<p id="d9652420e407">In this cohort study, clinical features suggestive of TB uveitis
were identified through
survival analysis of time to treatment failure. Results suggested that accurate diagnosis
of TB uveitis required a multipronged approach considering clinical features and investigations
as a whole.
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<h5 class="section-title" id="d9652420e410">Meaning</h5>
<p id="d9652420e412">These results suggest a lack of comprehensive evidence for diagnostic
approaches for
TB uveitis, with regional inconsistencies in the workup of patients possibly affected.
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<h5 class="section-title" id="d9652420e416">Importance</h5>
<p id="d9652420e418">Eradication of systemic tuberculosis (TB) has been limited by
neglected populations
and the HIV pandemic. Whereas ocular TB often presents as uveitis without any prior
evidence of systemic TB, the existing uncertainty in the diagnosis of TB uveitis may
perpetuate missed opportunities to address systemic TB.
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<h5 class="section-title" id="d9652420e421">Objective</h5>
<p id="d9652420e423">To examine the clinical features of TB uveitis and the associations
with response
to antitubercular therapy (ATT).
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<h5 class="section-title" id="d9652420e426">Design, Setting, and Participants</h5>
<p id="d9652420e428">This retrospective multinational cohort study included patients
from 25 ophthalmology
referral centers diagnosed with TB uveitis and treated with ATT from January 1, 2004,
through December 31, 2014, with a minimum follow-up of 1 year.
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<h5 class="section-title" id="d9652420e431">Main Outcomes and Measures</h5>
<p id="d9652420e433">Treatment failure, defined as a persistence or recurrence of
inflammation within 6
months of completing ATT, inability to taper oral corticosteroids to less than 10
mg/d or topical corticosteroid drops to less than 2 drops daily, and/or recalcitrant
inflammation necessitating corticosteroid-sparing immunosuppressive therapy.
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<h5 class="section-title" id="d9652420e436">Results</h5>
<p id="d9652420e438">A total of 801 patients (1272 eyes) were studied (mean [SD] age,
40.5 [14.8] years;
413 [51.6%] male and 388 [48.4%] female; 577 [73.6%] Asian). Most patients had no
known history (498 of 661 [75.3%]) of systemic TB. Most patients had bilateral involvement
(471 of 801 [58.8%]). Common clinical signs reported include vitreous haze (523 of
1153 [45.4%]), retinal vasculitis (374 of 874 [42.8%]), and choroidal involvement
(419 of 651 [64.4%]). Treatment failure developed in 102 of the 801 patients (12.7%).
On univariate regression analysis, the hazard ratios (HRs) associated with intermediate
uveitis (HR, 2.21; 95% CI, 1.07-4.55;
<i>P</i> = .03), anterior uveitis (HR, 2.68; 95% CI, 1.32-2.35;
<i>P</i> = .006), and panuveitis (HR, 3.28; 95% CI, 1.89-5.67;
<i>P</i> < .001) were significantly higher compared with posterior distribution.
The presence
of vitreous haze had a statistically significant association (HR, 1.95; 95% CI, 1.26-3.02;
<i>P</i> = .003) compared with absence of vitreous haze. Bilaterality had an associated
HR
of 1.50 (95% CI, 0.96-2.35) compared with unilaterality (HR, 1 [reference]), although
this finding was not statistically significant (
<i>P</i> = .07). On multivariate Cox proportional hazards regression analysis, the
presence
of vitreous haze had an adjusted HR of 2.98 (95% CI, 1.50-5.94;
<i>P</i> = .002), presence of snow banking had an adjusted HR of 3.71 (95% CI, 1.18-11.62;
<i>P</i> = .02), and presence of choroidal involvement had an adjusted HR of 2.88
(95% CI,
1.22-6.78;
<i>P</i> = .02).
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<h5 class="section-title" id="d9652420e466">Conclusions and Relevance</h5>
<p id="d9652420e468">A low treatment failure rate occurred in patients with TB uveitis
treated with ATT.
Phenotypes and test results are studied whereby patients with panuveitis having vitreous
and choroidal involvement had a higher risk of treatment failure. These findings are
limited by retrospective methods. A prospectively derived composite clinical risk
score might address this diagnostic uncertainty through holistic and standardized
assessment of the combinations of clinical features and investigation results that
may warrant diagnosis of TB uveitis and treatment with ATT.
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