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threatening disease but is often be overlooked in our uh clinical practice.

Uh so this is the road map of what we will be covering today. First of all, so first of all what is tubicolysis uvitis? TBU is an intraocalate

uvitis? TBU is an intraocalate inflammation that caused by mcoacterium tuberculosis and because of the pulary nature of MTB in alkal tissues the

diagnosis is predominantly presumptive.

So that built from four key pilers compatible phenotype imunological evidence radiological evidence and you have to exclude the alternatives

and one minute analyzis found out that the prevalence of TBU in all of the case uh uvitis cases worldwide is approximately 4% but this prevalence uh

can be varies from region to region especially in TB and demic region this percentage can be much larger ranging

from 11% to 25%. And I have to I have to remind you that uh Vietnam is still a TB endemic country. So US ofthmologist

endemic country. So US ofthmologist should have a higher suspicion for TBU when evaluating p uh patients with uvitis.

So these tables summarize the prevalence of uh tubicolysis uvitis in different continents and highlighting the burden

of uh TBU in especially in Asia and when talking about the management of uh tubicolysis ubiitis we have to mention about the coots1 study. So this

is the first large multinational cohort study that included uh more than 800 patients from four different continents

and um this study provided us with valuable insights on clinical management of TBU. So I will be referencing this

of TBU. So I will be referencing this study a lot in my presentation.

So this is also one of the most striking statistic that I want you to take away from this talk. uh from the cod study uh

more than 90% of patient had no systemic TB symptoms at presentation and 75% had no known prior history of TB. So alkal

disease may be the first and sometime the only manifestation of TVU of TB. So

if we don't think about it maybe no one else will.

And uh as we all know TVU is a very grace masquerader and I would like to quote from uh my colleague is TV can cause anything except pregnancy. It's

funny but it's true uh because you can see many manifestation of TVU. So from

the cod study uh posterior uvitis is the most common then compan uvitis and then intermediate uvitis and anterior uvitis

is the least common and crucially 60% of patient have b lateral involvement. So

this is another red flag for an underlying systemic process uh as the n the nature of uh tubicolysis.

So now I will introduce to you briefly about the clinical phenotypes of uh TVU.

So the first one is anterior uvitis is classically chronic and granolomedas with mutton fat kps iris nodules posterior synaki and in the Hong Kong

series around 50% of patient initially presented as uh anterior uvitis and many progressed to have posterior or

panuvitis later with intermediate uvitis we can see vitrusis with snowballs snow bankangs it may be isolated at first but

can involves into pen uh uvitis later.

Posterior uvitis is the most characteristic form of TDU and there are four different phenotypes to keep in mind. The first one is multif focal

mind. The first one is multif focal corditis with multiple discrete coroidal lesion of varying uh activity. The

second one is sepenas like coroditis. Uh

so this so there are geographic or plaoid lesions with active edges and heal center. It is multif focal and and

heal center. It is multif focal and and asymmetric and it have been said in many articles that cigenous licoroditis is highly suggestive of tubercular uvitis

until proven otherwise.

The third one is the occlusive retinovasculitis mostly affect peripheral veins causing capillary non-perusion and a strong drive to

neovascularization.

The last one is the coroidal to vocal.

So their vascularized subretin masses sometimes with absess or serrus detachment and panuvitis is the inflammation of all

three ocular components carries the worst prognosis and the combination that predicts the poorest outcome is vitrus haze with coroidal involvement. So when

you see those two together play uh pay very close attention to your patient and as I have said earlier there is no

uh definitive diagnostic test for TVU.

So the diagnosis is based on four principal components. The first one is

principal components. The first one is compatible alkal phenotype that I have just introduced to you. The the second one is imunological evidence. The third

one is uh supportive systemic evidence and the last one is the exclusion of the alternatives which should be syphilis and psychodosis. The two very great also

and psychodosis. The two very great also great masqueraders in the uvi uvitis world.

And here's a brief review on the on some of the diagnostic tools that you can use in diagnosing TVU with the skin test is in inexpensive widely available but it

interpretation is confounded by prior BCG vaccination and and also the uh uh exposure to non-tuberculus mcoacterial

and I have to remind you again that we are living in Vietnam so we are TB TB endemic region and also BCG vaccination

is compulsory. So this test is not so

is compulsory. So this test is not so the spec spec specificity of this is not re reliable. And the second one is IGA

re reliable. And the second one is IGA including quantifon TV gold or T-spot.

So they are not affected by BCG offer higher specificity. So this is a

higher specificity. So this is a preferred blood test for TB in the moment.

uh chest X-ray and chest CD can pick up findings uh that's [clears throat] suggestive of pulmonary TB with PCR of acrius or vitrius samples and his

hisystopathology they're highly specific but the sensitivity varies and also it's invasive to take the uh to take the

samples so we really perform this multimodal imaging is also play a central role in TVU So FA of course a traditional gold standard for vascular leakage, capillary

non-perusion neovascularization ICGA for coridal lesions, OCT of course for uh ED for macro edema and structural

retinal changes and uh recently we also have white field OCTA which is also good identifying uh eskeemic area and vascular abnormalities.

And when we have all the components in hand, there are three major classification system that can help to guide our next approach. So the first one here is the gapa criteria. So this

criteria is based on science, iminological evidence, radiological evidence and it's quite practical in our everyday

uh [clears throat] in our everyday clinic and we normally will refer the patient to an infectious disease

specialist when the diagnosis of probable IOTB is established.

The second one is the sun criteria. So

this criteria is actually made for research enro uh enrollment. So it's

very specific but almost too specific.

So I think the sun criteria is excellent for research but may misses many real world cases. And the last one I want to

world cases. And the last one I want to introduce to you is the uh coots calculator. So this is a consensus

calculator. So this is a consensus derived online tools that uh take five inputs and it outputs a score from one to five that indicate the probability of

TVU in the patient. So this is the end the interface of uh the the cost calculator from uh alkalatv.net net with

the percentage the probability of TVU with the calculated point and also there is a CS calculator uh validation cohort

uh that show that the CS of five uh a COD of five score have around 90% of sensitivity of specificity but only

26% of uh sensitivity. Meanwhile, the

clinical judgment have around nu 96% of sensitive but only 30% of specific.

So the clinical cl take away from here is that we should use our clinical judgment to screen for TB and then we consult the CS calculator to confirm the

diagnosis. The two are complimentary.

diagnosis. The two are complimentary.

And so the main state treatment of TBU is anti-tubercular therapy or AT. And

the decision to initiate or the duration of ATT is solely based on a respiratory or uh an infectious disease physician.

And we should monitor patient AC vision uh visual acuity, color vision and visual field monthly.

Cortical steroid is also a very essential adjunctive treatment in TVU.

But however there is a one principle that should be emphasized. So we should start systemic cortical steroid two to four weeks after the starting of

at uh the roots of administration of cortical steroids in TVU is the same as other uvitis disease and also it should

be individualized for each patient's clinical need for inflammation and vascular complication of TVU there are three modalities that should be considered so

the first one is antiv DVF for refractory edema and neovascularization.

Laser photocoagulation is the definitive treatment for eskeemic retina. um and

PPV sometime is indicated for non-clearing vitrus hemorrhage tractional RD and erm and the complications of TVU can occur

in around 60 to 80% of patient uh with vas with uh inflammatory and vascular complication of TVU CME CME is the leading cause of visual mobility retinal

vasculitis with occlusion is also common that can cause retinal vascularization and vitrus hemorrhage Second structural structural

complication of TBU include cataract, secondary gluccom, optic optic atrophy, uh ERM and treatment related should uh

related complications should also be recognized such as at hepotoxicity, atmpoptic neuropathy, high hypertension and we have to keep in mind that macular

eskemia remains the principal determinant of irreversible ible vision loss.

So there are five key messages that I want you to take away from this talk. So

first suspect TBU early. You have to think about TB in in order to diagnose it. And we diagnose T TV TBU on four

it. And we diagnose T TV TBU on four pilers not on one test. We use clinical judgment to screen and then use C's uh C's calculator to confirm at first and

steroids if needed and anticipate complications early.

Thank you for your attention.

Thank you for very interesting. Uh any

question from audience?

So I have a question. Um I think um TV is very very um no

even is my um polic um first uh for the diagnosis of TV even this is very hard.

So what kind of parclinical test you do you usually do to um

Because that you as you know mental test or IC is not available everywhere.

If it's not available what kind of do you do?

Well I well actually when when I read about TVU you can actually use the test but um Yeah, some yeah, you just you you you could

you the skin test, but the uh specific city is not good in Vietnam in general.

But if you have like if you have suspicion of TV, you you should do it at a at a first place and you should have a cut off a little bit higher a little bit

bigger than that you normally do. So the

cut t the threshold to diagnose to have the uh mental test positive is you have to have the uh lesion that bigger than 10 mm but in some research they say in

endemic region you you should use maybe bigger than 15 and sometime bigger than uh 20. Yeah, you can do that. And I

uh 20. Yeah, you can do that. And I

believe that if you if you suspecting TB, you can just give the patient uh you can refer the patient to an infectious disease physician and they will they

will have the test for you. I believe

so. If you don't have it, maybe some some other will.

Well, I work as um central hospital.

It's a very large host, right? But

mental test is not available. So, so

actually in my hospital we don't have that too. We don't have we have to send

that too. We don't have we have to send the patient outside. So actually I believe that the skin test is pretty rare right now but the uh IG it's quite

it's quite common. It's not that hard to to find in other like diagnostic center because we also send them to to those kind of center. We don't just keep the

patient in. So I I believe that because

patient in. So I I believe that because at a very aggressive treatment, very aggressive therapy, so we should have all the thing to get the to get the

result.

Yeah. Thank you.

So uh listening to your talk, I I have feeling like I'm sitting in a conference somewhere in US because your American English is so

impressive.

So just one question.

Thank you. You know uh a very common common scenario that you see the patient you see one patient and you you think

that it could be ocular TV and you uh send the patient for contra and it's positive and you after that you

send the patient to the physician for TB screening and they they cannot find

anything and they refused to start ATT.

So what would you do?

You already um exclude other in theology. So that is also a very uh good

theology. So that is also a very uh good question because we do face that in our hospital and recently in um in our hospital Hman Eye Hospital we have a

conference with the uh respiratory infectious disease doctors and we are coming up with more and more um agreement on when to start a treatment

but they still refuse to treat the patient if we we only have the uh ocular manifestation.

Um well so in that case I believe that I would just I will follow up the follow up with the patient and maybe start try

to start with uh topical steroid first and then or sometimes I've heard because I've known from uh like a a senior

doctor in um retinal um department that she will refer the patient they uh to one doctor once one specific doctor that

will initiate the at uh treatment for the patient if it's alkalo only TV. So

if if I'm so positive about the diagnosis, maybe I will just contact the directly to the that doctor and if he he takes it, I will just I will I will just

refer the patient to that doctor and or if they say that no, they think it's not u TV, then maybe I will just follow the patient and start cauteroid and watch

the uh the progress of the patient.

Okay. Excellent. Thank you. Thank you.

So thank you very much for your very comprehensive presentation. uh actually

comprehensive presentation. uh actually uh according to my knowledge uh so now the uh clinical diagnosis of oklo TV in

Vietnam is very challenges uh because that uh as you said that so many patient uh they have only the oklo manifestation

and otherwise they don't have any systemic uh symptom or evidence of TB so uh on clinical practice um actually when

we uh cannot find any evidence of a systemic disease. So we uh it's very

systemic disease. So we uh it's very difficult to convince the physician to treat the patient with at uh that is the the problem and also about the green go

test in Vietnam. So uh I don't know exactly uh how Chukin practice in the middle and in the south but in the north

uh now day we cannot find any center to perform the mangu test only uh the quantiferon and chic rate and sometime

the physics win uh you know the collect the sputum and do the culture but very challenges. So uh maybe in the future we

challenges. So uh maybe in the future we can find more about the intraocular fluid PCR. I think it's very useful in

fluid PCR. I think it's very useful in some center we can perform it. Yeah.

Um well as I as far as as I know so microacterium nature in the the outlet tissue is not

that much. So if you yeah you can you

that much. So if you yeah you can you can take the uh PCR of acquisit samples

but the sensitivity is pretty low around only 30% or so and because of of that I don't and also like a sampling I think

it's quite invasive so I believe that we should avoid uh being uh yeah

I I we should avoid like sampling alkaline tissues. Yeah.

alkaline tissues. Yeah.

No, actually I mean that we just uh do the biopsy the the uh aquous fluid biopsy for the patient.

Yeah, you can do you can do that. You

can do that but as I say uh the sensitivity is around uh 30%. So it's

not that high. You can do that of course but yeah it's very low quite low yield of the basillary in the ocular tissue.

So yeah but you can do that you can but the sensitivity is just low.

Yeah.

Yeah.

Okay. Thank you.

Thank you for very uh interesting topic.

We know that uh this uh UVID is always the challenge for the athologist in the world and also in

Vietnam. I think that's uh we not only

Vietnam. I think that's uh we not only based on the test we also combine with the uh other

um instrument like the uh cost calculator and also the clinical features we can combine because in my

experience most of the patients uh to be UV is always come from the medical

science so that's Why uh we get another choice it mean that we can treat uh it with the anti- tuberculosis and

it's work is it mean that we are right so sometime we can combine anything to overcome the challenge we cannot depend

on only one test or two test on the others but we uh always go forward with the uh technologies with the PC

something we can do for that. I think

that's is this always but the most important for the team is always the previous sign and always

think that everything not strangle or everything not strangely thank you what what Dr. as you before is exactly

what I intended to ask you but in my set. So uh uh yeah in in clinical

set. So uh uh yeah in in clinical practice we we always have patients who have uh who have uis

and quantum test positive but when we when we uh we refer them to the specialist they come back with [clears throat]

uh we answer that say I can I don't need I don't need to treat the typosis so in that in that case uh if I And in my

opinion, you should uh you should start with local treatment uh not topical because the topical doesn't affect with with

intermediate and seriitis you can use a local injection

for injections or or sub substant um that that way we can we can avoid the

the systemic uh complications for the patient and and it's in the same time we have we can we can also achieve the the

treatment effect. Thank you.

treatment effect. Thank you.

Okay. Thank you

for the next presentation we would invite Dr. A voting game from Vietnam is