Thai J Ophthalmol Vol. 30 No. 2 July-December 2016 109

Intraocular Tuberculosis:The Great Mimic

Ocular tuberculosis (TB) À¡“¬∂÷ß°“√μ‘¥‡™◊ÈÕ«—≥‚√§

(Mycobacteria tuberculosis) ¿“¬„π≈Ÿ°μ“ (intraocular)

∫√‘‡«≥√Õ∫¥«ßμ“ (lids, orbit ·≈– lacrimal gland) À√◊Õ

∫πæ◊Èπº‘«¢Õߥ«ßμ“ (conjunctiva, sclera ·≈– cornea)

‚¥¬¡’≈—°…≥–∑“ߧ≈‘π‘°¢Õß°“√μ‘¥‡™◊ÈÕ«—≥‚√§∑’Ë·μ°μà“ß°—π

‰ª (μ“√“ß∑’Ë 1)1 „π∑’Ëπ’È®–‡πâπ‰ª∑’Ë°“√μ‘¥‡™◊ÈÕ«—≥‚√§¿“¬„π

≈Ÿ°μ“ (intraocular TB)

„πª√–‡∑»‰∑¬®“°°“√»÷°…“ºŸâªÉ«¬ uveitis „À¡à®”π«π

200 √“¬ æ∫«—≥‚√§‡ªì𠓇Àμÿ¢Õß uveitis √âÕ¬≈– 2.22

·≈–®“°°“√»÷°…“ºŸâªÉ«¬ uveitis „À¡à®”π«π 108 √“¬‡æ◊ËÕ

À“°“√μ‘¥‡™◊ÈÕ«—≥‚√§√–¬–·Ωß∑’ˬ—߉¡à· ¥ßÕ“°“√ (latent

tuberculosis) ‚¥¬°“√„™â QuantiFERON˙-TB Gold test

(QFT-G test; Cellestis, Australia) æ∫§«“¡™ÿ°¢Õß°“√

μ‘¥‡™◊ÈÕ«—≥‚√§√–¬–·Ωß∑’ˬ—߉¡à· ¥ßÕ“°“√„πºŸâªÉ«¬ uveitis

‡ªìπ√âÕ¬≈– 36 ®“°°“√∑’˺ŸâªÉ«¬¡’º≈ QFT-G test ‡ªìπ∫«°

„π¢≥–∑’˺≈ tuberculin skin test (TST) ‡ªìπ∫«°¡’‡æ’¬ß

√âÕ¬≈– 15 ‚¥¬‰¡à¡’ºŸâªÉ«¬ uveitis √“¬„¥∑’Ë¡’Õ“°“√À√◊ÕÕ“°“√

· ¥ß¢Õß°“√μ‘¥‡™◊ÈÕ«—≥‚√§√–¬– active ∑’˪եÀ√◊Õ∑’ËÕ◊Ëπ

√à«¡¥â«¬ ≈—°…≥–∑“ߧ≈‘π‘°¢ÕߺŸâªÉ«¬ uveitis ∑’Ë ‰¡à∑√“∫

 “‡Àμÿ·≈–¡’º≈ QFT-G test ‡ªìπ∫«°¡—°®–¡’≈—°…≥–

‡°…√“ æ—≤π摱Ÿ√¬å, æ.∫.

¿“§«‘™“®—°…ÿ«‘∑¬“ §≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à

Review Article/∫∑øóôπøŸ«‘™“°“√

‡ªìπÀ≈Õ¥‡≈◊Õ¥®Õμ“Õ—°‡ ∫ (√âÕ¬≈– 37) ·≈–«ÿâπμ“Õ—°‡ ∫

(√âÕ¬≈– 26)3

°“√«‘π‘®©—¬ ocular TB π—Èπ∑”‰¥â¬“°‡π◊ËÕß®“°‚√§¡’

≈—°…≥–∑“ߧ≈‘π‘°∑’ËÀ≈“°À≈“¬ “¡“√∂‡≈’¬π·∫∫ uveitis

∑’ˇ°‘¥®“° “‡ÀμÿÕ◊ËπÊ ‰¥â¡“°¡“¬ (the great mimic) ·≈–

¡—°‰¡àæ∫°“√μ‘¥‡™◊ÈÕ∑’˪ե√à«¡¥â«¬4 ¿“«– intraocular TB

‡°‘¥¢÷Èπ‰¥â∑—Èß®“°°“√μ‘¥‡™◊ÈÕ«—≥‚√§‚¥¬μ√ß·≈–®“°°“√μÕ∫

 πÕß∑“ß¿Ÿ¡‘§ÿâ¡°—πμàÕ‡™◊ÈÕ‚¥¬‰¡àæ∫°“√μ‘¥‡™◊ÈÕ∑“ß°“¬∑’Ë

™—¥‡®π (immune mediated) (μ“√“ß∑’Ë 2)5

≈—°…≥–∑“ߧ≈‘π‘°¢Õß intraocular TB ∑’Ëæ∫∫àÕ¬∑’Ë ÿ¥§◊Õ posterior uveitis √Õß¡“§◊Õ anterior uveitis,panuveitis ·≈– intermediate uveitis4

1. Anterior uveitis ®–¡’°“√Õ—°‡ ∫Õ¬à“ß™â“Ê ·≈–

‡√◊ÈÕ√—ß·∫∫ granulomatous Õ“®æ∫ iris nodules À√◊Õ

granuloma μ≈Õ¥®π posterior synchiae ·≈–μâÕ°√–®°

√à«¡¥â«¬6

2. Intermediate uveitis ¡—°‡ªìπ„πμ“∑—Èß Õߢâ“ß

≈—°…≥–§≈⓬ pars planitis °“√Õ—°‡ ∫®–‰¡à√ÿπ·√ß·≈–

‡√◊ÈÕ√—ß æ∫«ÿâπμ“Õ—°‡ ∫ À≈Õ¥‡≈◊Õ¥®Õμ“√Õ∫πÕ°Õ—°‡ ∫

110 ‡°…√“ æ—≤π摱Ÿ√¬å Vol. 30 No. 2 July-December 2016

√à«¡°—∫ snow ball opacities, snow banking, cystoid

macular edema Õ“®æ∫ peripheral retinochoroidal

granuloma

3. Posterior ·≈– panuveitis ‡ªìπÕ“°“√· ¥ß∑’Ë

æ∫‰¥â∫àÕ¬ ÿ¥ ‰¥â·°à choroidal tubercles, choroidal

tuberculoma (√Ÿª∑’Ë 1), subretinal abscess ·≈– serpi-

ginous-like choroiditis (√Ÿª∑’Ë 2)

4. Retinal vasculitis À≈Õ¥‡≈◊Õ¥®Õμ“Õ—°‡ ∫ à«π

„À≠à‡ªìπÀ≈Õ¥‡≈◊Õ¥¥” (periphlebitis) (√Ÿª∑’Ë 3)7 √à«¡°—∫

«ÿâπμ“Õ—°‡ ∫ Õ“®æ∫‡≈◊Õ¥ÕÕ°®Õμ“ ‡ âπ‡≈◊Õ¥ßÕ°„À¡à ·≈–

neuroretinitis

Eyelids Localized massConjunctivae Conjunctival granulomaSclera Focal necrotizing scleritis, nodular scleritis, sclerokeratitisCornea Interstitial keratitis, phlyctenulosisCiliary body Cyclitis caseating granulomaUvea Anterior granulomatous, uveitisVitreous VitritisChoroid Multifocal choroditis, chorioretinitis, peripapillary choroiditis, tuberclesRetina Retinitis retinochoroiditis, retinal vasculitisOptic nerve Papillitis, optic neuritis, retrobulbar neuritisOrbit Granuloma, localized massLacrimal gland Granuloma, localized mass

¥—¥·ª≈ß®“° Tabbara KF. Tuberculosis. Curr Opin Ophthalmol. 2007;18:493-501.

μ“√“ß∑’Ë 1 ≈—°…≥–∑“ߧ≈‘π‘°¢Õß°“√μ‘¥‡™◊ÈÕ«—≥‚√§∑’Ë¥«ßμ“·≈–∫√‘‡«≥√Õ∫¥«ßμ“

Õ“°“√· ¥ß 欓∏‘°”‡π‘¥∑’ˇªìπ‰ª‰¥â¢Õß«—≥‚√§∑’Ëμ“

Iris À√◊Õ angle granulomas °“√μ‘¥‡™◊ÈÕ‚¥¬μ√ßCiliary body tubercle °“√μ‘¥‡™◊ÈÕ‚¥¬μ√ßRetinal vasculitis °“√μÕ∫ πÕß∑“ß¿Ÿ¡‘§ÿâ¡°—πμàÕ‡™◊ÈÕChoroiditis °“√μÕ∫ πÕß∑“ß¿Ÿ¡‘§ÿâ¡°—πμàÕ‡™◊ÈÕChoroidal tubercle °“√μ‘¥‡™◊ÈÕ‚¥¬μ√ßSubretinal abscess °“√μ‘¥‡™◊ÈÕ‚¥¬μ√ßEndophthalmitis °“√μ‘¥‡™◊ÈÕ‚¥¬μ√ßPanophthalmitis °“√μ‘¥‡™◊ÈÕ‚¥¬μ√ß

¥—¥·ª≈ß®“° Abu El-Asrar AM, Abouammoh M, Al-Mezaine HS. Tuberculous uveitis. Int Ophthalmol Clin. 2010;50:19-39.

μ“√“ß∑’Ë 2 欓∏‘°”‡π‘¥∑’ˇªìπ‰ª‰¥â¢Õß intraocular tuberculosis

5. Neuroretinitis ·≈– optic neuropathy Õ“®æ∫

optic nerve tubercle, papillitis, papilledema, optic

neuritis, retrobulbar neuritis, neuroretinitis À√◊Õ optico-

chiasmatic arachnoiditis ‡ªìπμâπ

6. Endophthalmitis ·≈– panophthalmitis ¡—°

‡ªìπ·∫∫‡©’¬∫æ≈—π·≈–¥”‡π‘π‰ªÕ¬à“ß√«¥‡√Á« °“√Õ—°‡ ∫

Õ“®√ÿπ·√ß¡“°®π∑”„À⇰‘¥ hypopyon §Õ√Õ¬¥å∑’Ë¡’°“√

Õ—°‡ ∫√ÿπ·√ßÕ“®°≈“¬‡ªìπ subretinal abscess ¢π“¥„À≠à

∑–≈ÿ Bruchs membrane ‡¢â“ Ÿà®Õμ“·≈–«ÿâπμ“°≈“¬

‡ªìπ endophthalmitis ·≈–À“°‡ª≈◊Õ°≈Ÿ°μ“∑–≈ÿ∑”„Àâ

‡°‘¥ panophthalmitis

111Intraocular Tuberculosis: The Great Mimic

√Ÿª∑’Ë 1 ¿“æ∂à“¬®Õμ“¢â“ߢ«“· ¥ß choroidal granuloma „πºŸâªÉ«¬‡Õ¥ å∑’Ë¡’°“√μ‘¥‡™◊ÈÕ«—≥‚√§∑’˪ե (√Ÿª ’∑⓬‡≈à¡)

√Ÿª∑’Ë 2 ¿“æ∂à“¬®Õμ“¢â“ߢ«“· ¥ß serpiginous-like choroiditis °àÕπ·≈–À≈—ß°“√√—°…“¥â«¬¬“μâ“π«—≥‚√§ (√Ÿª ’∑⓬‡≈à¡)°. · ¥ß multifocal choroiditis ¡’≈—°…≥–‡ªìπ serpiginous-like choroiditis √à«¡°—∫«ÿâπμ“Õ—°‡ ∫ „πºŸâªÉ«¬™“¬Õ“¬ÿ

50 ªï∑’Ë¡’º≈∑¥ Õ∫ QuantiFERON˙-TB Gold ‡ªìπ∫«°∑’Ë√–¥—∫ 2.62 IU/mL ·≈– tuberculin skin test æ∫∫√‘‡«≥°√–¥â“ß (induration) ‡ âπºà“»Ÿπ¬å°≈“ß¢π“¥ 25 ¡‘≈≈‘‡¡μ√ ‚¥¬∑’Ë X-ray ªÕ¥‡ªìπª°μ‘

¢. · ¥ß multifocal choroidal atrophy ·≈– scar ¿“¬À≈—ß°“√√—°…“¥â«¬¬“μâ“π«—≥‚√§

°. ¢.

112 ‡°…√“ æ—≤π摱Ÿ√¬å Vol. 30 No. 2 July-December 2016

°“√«‘π‘®©—¬°“√«‘π‘®©—¬ ocular TB ∑”‰¥â¬“°‡π◊ËÕß®“°ºŸâªÉ«¬¡—°

‰¡à¡’ª√–«—μ‘°“√μ‘¥‡™◊ÈÕ∑’˪եÀ√◊Õ∑’ËÕ◊Ëπ√à«¡¥â«¬ °“√‡æ“–‡™◊ÈÕ

·≈–°“√μ√«®À“‡™◊ÈÕ‚¥¬‡∑§π‘§ polymerase chain re-

action ®“° intraocular fluid ¡—°‰¥âº≈≈∫  à«π°“√∑”

uveal biopsy ‡æ◊ËՇ擖‡™◊ÈÕπ—Èπ∑”‰¥â¬“° ¥—ßπ—Èπ°“√«‘π‘®©—¬

 à«π„À≠à®÷߇ªìπ°“√Õπÿ¡“π ‚¥¬Õ“»—¬‡°≥±å°“√«‘π‘®©—¬‚√§

¥—ßπ’È

1. ºŸâªÉ«¬¡“®“°/Õ“»—¬„π∂‘Ëπ√–∫“¥À√◊Õ¡’ª√–«—μ‘ —¡º— 

°—∫ºŸâªÉ«¬«—≥‚√§¡“°àÕπ

2. º≈°“√μ√«®∑“ßÕâÕ¡∑’Ë∫àß™’È«à“¡’°“√μ‘¥‡™◊ÈÕ«—≥‚√§

‰¥â·°à º≈ TST ‡ªìπ∫«° ‚¥¬æ∫∫√‘‡«≥°√–¥â“ß (indura-

tion) ‡ âπºà“»Ÿπ¬å°≈“ß¡“°°«à“ 10-15 ¡‘≈≈‘‡¡μ√¿“¬À≈—ß

°“√©’¥ 5 tuberculin units ¢Õß purified protein deriva-

tive ‡¢â“„μ⺑«Àπ—ß ¿“¬À≈—ß 48-72 ™—Ë«‚¡ß À√◊Õº≈∑¥ Õ∫

interferon-gamma release assays (IGRAs) ‡ªìπ∫«°

䴉ᡈ QuantiFERON-TB Gold In-Tube (QFT; Cellestis

Inc., Carnegie, VIC, Australia) ·≈– ELISpotPLUS (T-

SPOT.TB, Oxford Immunotec, Oxford, UK)3

3. ‰¡àæ∫ “‡ÀμÿÕ◊Ëπ∑’Ë∑”„À⇰‘¥ uveitis ‡™àπ syphilis

À√◊Õ toxoplasmosis ‡ªìπμâπ

4. ¡’°“√μÕ∫ πÕßμàÕ°“√√—°…“¥â«¬¬“μâ“π«—≥‚√§

‚¥¬„À⬓ 4 ™π‘¥ ‰¥â·°à isoniazid, rifampicin, ethambu-

tol ·≈– pyrazinamide ‡ªìπ‡«≈“ 4-6  —ª¥“Àå (therapeu-

tic test)

°“√√—°…“‡π◊ËÕß®“°°“√«‘π‘®©—¬‚√§ à«π„À≠à‡ªìπ°“√Õπÿ¡“π

·≈–≈—°…≥–∑“ߧ≈‘π‘°∑’Ëæ∫π—Èπ‡°‘¥¢÷Èπ‰¥â∑—Èß®“°°“√μ‘¥‡™◊ÈÕ

«—≥‚√§‚¥¬μ√ß·≈–®“°°“√μÕ∫ πÕß∑“ß¿Ÿ¡‘§ÿâ¡°—πμàÕ‡™◊ÈÕ

∑”„À⬗߉¡à‡ªìπ∑’Ë·πà™—¥«à“§«√„À⬓μâ“π«—≥‚√§À√◊Õ‰¡à·≈–

®–„À⇪ìπ√–¬–‡«≈“π“π‡∑à“‰√ ¥—ßπ—Èπ®÷ߧ«√æ‘®“√≥“ªí®®—¬

‡ ’ˬ߷≈–ª√–‚¬™πå∑’Ë®–‰¥â√—∫®“°°“√„À⬓μâ“π«—≥‚√§8

¬“μâ“π«—≥‚√§∑’Ë„™â„π°“√√—°…“ºŸâªÉ«¬ ocular TB §◊Õ

isoniazid 5 ¡‘≈≈‘°√—¡μàÕ°‘‚≈°√—¡μàÕ«—π rifampicin 450

¡‘≈≈‘°√—¡μàÕ«—π (∂â“πÈ”Àπ—°πâÕ¬°«à“ 50 °‘‚≈°√—¡) ·≈– 600

¡‘≈≈‘°√—¡ (∂â“πÈ”Àπ—°¡“°°«à“ 50 °‘‚≈°√—¡), ethambutol

15 ¡‘≈≈‘°√—¡μàÕ°‘‚≈°√—¡μàÕ«—π ·≈– pyrazinamide 25-30

¡‘≈≈‘°√—¡μàÕ°‘‚≈°√—¡μàÕ«—𠇪ìπ‡«≈“ 2 ‡¥◊Õπ μ“¡¥â«¬ rifam-

picin ·≈– isoniazid Õ’°Õ¬à“ßπâÕ¬ 4-7 ‡¥◊Õπ (√«¡‡ªìπ

√–¬–‡«≈“ 6-9 ‡¥◊Õπ) °“√„À⬓μâ“π«—≥‚√§πÕ°®“°®–™à«¬

√—°…“·≈⫬—ߪÑÕß°—π°“√°≈—∫‡ªìπ´È”‰¥â

√Ÿª∑’Ë 3 ¿“æ∂à“¬®Õμ“¢â“ߢ«“· ¥ß retinal periphlebitis „πºŸâªÉ«¬™“¬Õ“¬ÿ 34 ªï∑’Ë¡’º≈∑¥ Õ∫ QuantiFERON˙-TB Gold‡ªìπ∫«°∑’Ë√–¥—∫ 3.5 IU/mL ‚¥¬∑’Ë tuberculin skin test ·≈– X-ray ªÕ¥‡ªìπª°μ‘ (√Ÿª ’∑⓬‡≈à¡)

113Intraocular Tuberculosis: The Great Mimic

„π∫“ß√“¬Õ“®®”‡ªìπμâÕß„Àâ prednisone √—∫ª√–∑“π

¢π“¥ 0.5-1 ¡‘≈≈‘°√—¡μàÕ°‘‚≈°√—¡μàÕ«—π ·≈–À√◊Õ ¬“°¥¿Ÿ¡‘

μâ“π∑“π (immunosuppressive agents) √à«¡¥â«¬®π¡’

°“√μÕ∫ πÕß®“°π—Èπ§àÕ¬Ê ≈¥¢π“¥¬“≈ß °“√„Àâ·μଓ

°≈ÿà¡π’È ‚¥¬‰¡à„À⬓μâ“π«—≥‚√§®–∑”„Àâ‚√§·¬à≈ß·≈–°≈—∫

‡ªìπ´È”‰¥â

‡Õ° “√Õâ“ßÕ‘ß1. Tabbara KF. Tuberculosis. Curr Opin Ophthalmol. 2007;18:493-

501.

2. Pathanapitoon K, Kunavisarut P, Ausayakhun S, Sirirungsi W,Rothova A. Uveitis in a tertiary ophthalmology centre in Thai-land. Br J Ophthalmol. 2008;92:474-8.

3. Pathanapitoon K, Kunavisarut P, Sirirungsi W, Rothova A.Looking for ocular tuberculosis: Prevalence and clinical mani-festations of patients with uveitis and positive QuantiFERON(˙)-TB Gold test. Ocul Immunol Inflamm. 2016;16:1-8.

4. Gupta V, Gupta A, Rao NA. Intraocular tuberculosis-an up-date. Surv Ophthalmol. 2007;52:561-87.

5. Abu El-Asrar AM, Abouammoh M, Al-Mezaine HS. Tubercu-lous uveitis. Int Ophthalmol Clin. 2010;50:19-39.

6. Gupta A, Bansal R, Gupta V, Sharma A, Bambery P. Ocularsigns predictive of tubercular uveitis. Am J Ophthalmol. 2010;149:562›70.

7. Apinyawasisuk S, Rothova A, Kunavisarut P, PathanapitoonK. Clinical features and etiology of retinal vasculitis in NorthernThailand. Indian J Ophthalmol. 2013;61:739-42.

8. Ang M, Chee SP. Controversies in ocular tuberculosis. Br JOphthalmol. 2017;101:6-9.