Sir,

Primary tuberculous infection of the ocular surface was not uncommon in the 19th and early 20th centuries but is now very rare.1, 2, 3, 4, 5, 6 There have been few reports of primary tuberculous lesions affecting both cornea and conjunctiva.7

Case report

A 13-year-old South African female patient presented with a 3-month history of an inflamed epibulbar mass lesion in her right eye, not responding to topical chloramphenicol treatment. The lesion was gradually enlarging and mildly painful. She had no significant medical history and was otherwise healthy. She had two close contacts in the community with pulmonary tuberculosis.

On examination, her visual acuity was 6/6 bilaterally. A fleshy mass was situated at the superior limbus temporally, measuring 5 mm × 5 mm and involving both cornea and conjunctiva (Figure 1). The lesion was raised, mobile, and nontender and displayed several engorged conjunctival ‘feeder-vessels’. The anterior chamber showed no inflammatory activity and the posterior segment was normal. Her left eye was normal. She had no regional lymphadenopathy or skin lesions.

Figure 1
figure 1

Tuberculous keratoconjunctivitis.

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Clinically, the lesion resembled a juxtalimbal sessile conjunctival papilloma, with a differential diagnosis of conjunctival intraepithelial neoplasia and conjunctival squamous cell carcinoma with corneal invasion. A complete excision biopsy with localised lamellar keratectomy was therefore performed.

Histopathological analysis revealed granulomatous inflammation, areas of caseous necrosis (Figure 2), and positive staining for acid-fast bacilli.

Figure 2
figure 2

Granulomatous inflammation: giant cells and caseous necrosis.

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Subsequent systemic examination and chest X-ray revealed no signs of extraocular tuberculosis. She was diagnosed with primary mycobacterium tuberculosis keratoconjunctivitis and started on 6 months of standard systemic antituberculous treatment of oral rifampicin, isoniazid, and pyrizanimide.4, 7 The tuberculous lesion has shown no sign of recurrence.

Comment

Primary tuberculosis of the ocular surface occurs as a result of contamination from sputum droplets of patients with active respiratory tuberculosis causing an exogenous inoculation of bacilli.6, 8, 9 It has been found to be more common in the first two decades.10 Lesions are typically unilateral and involve conjunctiva alone, often the palpebral conjunctiva.1, 2 Conjunctival lesions can be described clinically as ulcerative, nodular, hypertrophic granulomatous, and pedunculated.10 Corneal lesions manifest as phlyctenulosis, infiltrates, ulcerations, and interstitial keratitis.11

Tuberculous keratoconjunctivitis is an uncommon presentation of ocular surface tuberculosis but should be considered in the differential diagnosis of atypical chronic ocular surface lesions, particularly in the developing world where the HIV pandemic has dramatically increased the incidence of pulmonary tuberculosis.