The Diverse Spectrum of Presumed Ocular Tuberculosis Including Optic Neuropathy in a Tuberculosis-Endemic Region: A Case Series from India

Ocular tuberculosis (TB) presents with diverse clinical manifestations and remains a diagnostic and therapeutic challenge, particularly in TB-endemic regions. In addition, antitubercular therapy (ATT), especially ethambutol and linezolid, may contribute to treatment-related optic neuropathy and visual morbidity. This case series aimed to describe the clinical manifestations of presumed ocular TB and to assess the burden of ATT-induced optic neuropathy during the study duration. Diagnosis was based on clinical features, tuberculin skin test (Mantoux test) or interferon-gamma release assay (e.g., QuantiFERON-TB Gold), systemic evaluation, neuroimaging where indicated, and response to ATT. Anterior and posterior segment findings included: granulomatous uveitis (n = 2), panuveitis (n = 3), phlyctenular conjunctivitis (n = 1), serpiginous-like choroiditis (n = 3), multifocal choroiditis (n = 4), choroidal granuloma (n = 5), choroidal tubercle (n = 3), and Eales disease (n = 4). TB-associated optic neuropathy was observed in 13 patients secondary to intracranial TB. In 26 patients, ATT-induced optic neuropathy was observed. Retrobulbar optic neuritis was more frequently observed than papillitis in these cases. Favorable outcomes were observed in inflammatory ocular TB, whereas visual recovery was limited in patients with optic nerve involvement, particularly in those with intracranial disease. Treatment modification in cases of ATT-induced optic neuropathy was associated with partial visual recovery. To conclude, ocular TB demonstrates varied clinical manifestations, with significant risk of vision loss due to both disease and treatment-related toxicity. Early diagnosis, prompt initiation of ATT, and routine ophthalmic monitoring during therapy are essential to reduce visual morbidity in TB-endemic settings.