Rupesh Agrawal1, Ilaria Testi2, Baharam Bodaghi3, Talin Barisani-Asenbauer4, Peter McCluskey5, Aniruddha Agarwal6, John H Kempen7, Amod Gupta6, Justine R Smith8, Marc D de Smet9, Yew Sen Yuen10, Sarakshi Mahajan11, Onn Min Kon12, Quan Dong Nguyen13, Carlos Pavesio2, Vishali Gupta14. 1. National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Republic of Singapore; Moorfields Eye Hospital and Biomedical Research Centre, Institute of Ophthalmology, University College London, London, United Kingdom; Singapore Eye Research Institute, Singapore, Republic of Singapore. 2. Moorfields Eye Hospital and Biomedical Research Centre, Institute of Ophthalmology, University College London, London, United Kingdom. 3. Department of Ophthalmology, Sorbonne University, Paris, France. 4. OCUVAC-Centre of Ocular Inflammation and Infection, Laura Bassi Centre of Expertise, Center of Pathophysiology, Infectiology & Immunology, Medical University of Vienna, Vienna, Austria. 5. Save Sight Institute, Department of Ophthalmology, University of Sydney, Sydney, Australia. 6. Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India. 7. Department of Ophthalmology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts; MyungSung Christian Medical Center (MCM) Eye Unit, MCM General Hospital and MyungSung Medical School, Addis Abeba, Ethiopia. 8. Flinders University College of Medicine and Public Health, Adelaide, Australia. 9. MIOS SA-Medical/Surgical Retina and Ocular Inflammation, Lausanne, Switzerland. 10. Department of Ophthalmology, National University Hospital, Singapore, Republic of Singapore. 11. St. Joseph Mercy Hospital, Oakland, Pontiac, Michigan. 12. Chest and Allergy Clinic, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom. 13. Byers Eye Institute, Stanford Medical School, Stanford, California. 14. Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Electronic address: vishalisara@gmail.com.
Abstract
TOPIC: The Collaborative Ocular Tuberculosis Study (COTS), supported by the International Ocular Inflammation Society, International Uveitis Study Group, and Foster Ocular Immunological Society, set up an international, expert-led consensus project to develop evidence- and experience-based guidelines for the management of tubercular uveitis (TBU). CLINICAL RELEVANCE: The absence of international agreement on the use of antitubercular therapy (ATT) in patients with TBU contributes to a significant heterogeneity in the approach to the management of this condition. METHODS: Consensus statements for the initiation of ATT in TBU were generated using a 2-step modified Delphi technique. In Delphi step 1, a smart web-based survey based on background evidence from published literature was prepared to collect the opinion of 81 international experts on the use of ATT in different clinical scenarios. The survey included 324 questions related to tubercular anterior uveitis (TAU), tubercular intermediate uveitis (TIU), tubercular panuveitis (TPU), and tubercular retinal vasculitis (TRV) administered by the experts, after which the COTS group met in November 2019 for a systematic and critical discussion of the statements in accordance with the second round of the modified Delphi process. RESULTS: Forty-four consensus statements on the initiation of ATT in TAU, TIU, TPU, and TRV were obtained, based on ocular phenotypes suggestive of TBU and corroborative evidence of tuberculosis, provided by several combinations of immunologic and radiologic test results. Experts agreed on initiating ATT in recurrent TAU, TIU, TPU, and active TRV depending on the TB endemicity. In the presence of positive results for any 1 of the immunologic tests along with radiologic features suggestive of past evidence of tuberculosis infection. In patients with a first episode of TAU, consensus to initiate ATT was reached only if both immunologic and radiologic test results were positive. DISCUSSION: The COTS consensus guidelines were generated based on the evidence from published literature, specialists' opinions, and logic construction to address the initiation of ATT in TBU. The guidelines also should inform public policy by adding specific types of TBU to the list of conditions that should be treated as tuberculosis.
TOPIC: The Collaborative Ocular Tuberculosis Study (COTS), supported by the International Ocular Inflammation Society, International Uveitis Study Group, and Foster Ocular Immunological Society, set up an international, expert-led consensus project to develop evidence- and experience-based guidelines for the management of tubercular uveitis (TBU). CLINICAL RELEVANCE: The absence of international agreement on the use of antitubercular therapy (ATT) in patients with TBU contributes to a significant heterogeneity in the approach to the management of this condition. METHODS: Consensus statements for the initiation of ATT in TBU were generated using a 2-step modified Delphi technique. In Delphi step 1, a smart web-based survey based on background evidence from published literature was prepared to collect the opinion of 81 international experts on the use of ATT in different clinical scenarios. The survey included 324 questions related to tubercular anterior uveitis (TAU), tubercular intermediate uveitis (TIU), tubercular panuveitis (TPU), and tubercular retinal vasculitis (TRV) administered by the experts, after which the COTS group met in November 2019 for a systematic and critical discussion of the statements in accordance with the second round of the modified Delphi process. RESULTS: Forty-four consensus statements on the initiation of ATT in TAU, TIU, TPU, and TRV were obtained, based on ocular phenotypes suggestive of TBU and corroborative evidence of tuberculosis, provided by several combinations of immunologic and radiologic test results. Experts agreed on initiating ATT in recurrent TAU, TIU, TPU, and active TRV depending on the TB endemicity. In the presence of positive results for any 1 of the immunologic tests along with radiologic features suggestive of past evidence of tuberculosis infection. In patients with a first episode of TAU, consensus to initiate ATT was reached only if both immunologic and radiologic test results were positive. DISCUSSION: The COTS consensus guidelines were generated based on the evidence from published literature, specialists' opinions, and logic construction to address the initiation of ATT in TBU. The guidelines also should inform public policy by adding specific types of TBU to the list of conditions that should be treated as tuberculosis.