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The Collaborative Ocular Tuberculosis Study (COTS) calculator—a consensus-based decision tool for initiating antitubercular therapy in ocular tuberculosis

Eye volume 37, pages 1416–1423 (2023)Cite this article

Subjects

Abstract

Objective

To introduce the Collaborative Ocular Tuberculosis Study (COTS) Calculator, an online clinical scoring system for initiating antitubercular therapy (ATT) in patients with ocular tuberculosis (TB).

Method

The COTS Calculator was derived from COTS Consensus (COTS CON) data, which has previously published consensus guidelines. Using a two-step Delphi method, 81 experts evaluated 486 clinical scenario-based questions, ranking their likelihood of initiating ATT in each specific scenario. Each scenario was a permutation of the results and/or availability of five following components—clinical phenotype, endemicity, two immunological (tuberculin skin test, interferon-γ release assay) and one radiological (chest X-Ray) test results—and a sixth component further stratifying three of the clinical phenotypes. The median scores and interquartile ranges (IQR) of each scenario were tabulated, representing the expert consensus on whether to initiate ATT in that scenario. The consensus table was encoded to develop the COTS Calculator.

Results

The COTS Calculator can be accessed online at: https://www.oculartb.net/cots-calc. The attending physician can select the conditions present in the patient, which will generate a median score from 1 to 5. 114 out of 486 scenarios (24%) deliberated had a median score of 5 indicating expert consensus to initiate ATT.

Conclusion

The COTS Calculator is an efficient, low-cost, evidence and experience-based clinical tool to guide ATT initiation. While it holds substantial promise in improving standard-of-care for ocular-TB patients, future validation studies can help to as certain its clinical utility and reliability.

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Fig. 1: Flow chart depicting the number of clinical scenario-based questions reviewed in the Collaborative Ocular Tuberculosis Study Consensus (COTS CON) group Delphi Round 1 and 2, the clinical phenotypes reviewed in Delphi Round 2 phases 1 and 2, as well as the number of experts attending each discussion phase.
Fig. 2: Diagrammatic illustration of the ordinal score as entered by the experts and implication of median score and interquartile range (IQR).
Fig. 3: The patient details that can be entered include patient name, patient identity document (ID) number, patient’s age, patient’s gender (male or female), patient’s physician name, the patient’s affected eye (left, right, or both eyes).
Fig. 4: The clinical phenotype selected is “retinal vasculitis” out of five options (anterior uveitis, intermediate uveitis, panuveitis, retinal vasculitis, choroiditis), which prompted an additional stratification of “active” disease to be selected amongst two options (active, inactive).

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Data availability

The datasets generated during and/or analysed during the current study are not publicly available. Nevertheless, interested researchers are invited to direct data access requests to the corresponding author.

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Acknowledgements

All authors contributed to the intellectual development of this paper. RA and VG conceived and planned the study. ZL wrote the first draft of the paper. ZL and RA performed the literature review. RA, ZL, BB, IT, SM, AR, JHK, JRS, PM, QDN, CP and VG contributed to interpreting the results and provided critical feedback to the paper. The final version of the paper has been seen and approved by all authors.

Author information

Authors and Affiliations

  1. National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore

    Rupesh Agrawal

  2. Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore

    Rupesh Agrawal & Zhang Ludi

  3. Duke NUS Medical School, Singapore, Singapore

    Rupesh Agrawal

  4. Singapore Eye Research Institute, Singapore, Singapore

    Rupesh Agrawal

  5. National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital, London, UK

    Rupesh Agrawal, Ilaria Testi & Carlos Pavesio

  6. Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

    Bjorn K. Betzler

  7. St Joseph Mercy Hospital, Oakland, Pontiac, MI, USA

    Sarakshi Mahajan

  8. Ciudad Autónoma de Buenos Aires, Consultorios Oftalmológicos Benisek-Ascarza, Buenos Aires, Argentina

    Andres Rousellot

  9. Department of Ophthalmology, Schepens Eye Research Institute, Massachusetts Eye and Ear/Harvard Medical School, Boston, MA, USA

    John H. Kempen

  10. Sight for Souls, Fort Myers, FL, USA

    John H. Kempen

  11. Department of Ophthalmology, Addis Ababa University, Addis Ababa, Ethiopia

    John H. Kempen

  12. MyungSung Christian Medical Center (MCM) Eye Unit, MCM General Hospital, MyungSung Medical School, Addis Ababa, Ethiopia

    John H. Kempen

  13. Flinders University College of Medicine & Public Health, Adelaide, SA, Australia

    Justine R. Smith

  14. Queensland Eye Institute, Brisbane, QLD, Australia

    Justine R. Smith

  15. Save Sight Institute, Department of Ophthalmology, The University of Sydney, Sydney, NSW, Australia

    Peter McCluskey

  16. Byers Eye Institute, Stanford Medical School, Palo alto, CA, USA

    Quan Dong Nguyen

  17. Advanced Eye Centre, Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

    Vishali Gupta

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Correspondence to Rupesh Agrawal or Vishali Gupta.

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Competing interests

RA, ZL, BB, IT, SM, AR, JHK, JRS, PM, QDN, CP and VG report no competing interests, financial or propriety, in the subject matter or materials discussed in this paper. JHK is a consultant for Gilead Pharma, a company evaluating a treatment for non-infectious uveitis, and equity owner for Betaliq, a company developing an intraocular pressure-lowering treatment. RA is supported by a grant from the National Medical Research Council (NMRC) by Ministry of Health, Singapore, for the Clinician Scientist Award (CSA) from 2020 to 2023. He has not received funding for his work in this publication.

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Agrawal, R., Ludi, Z., Betzler, B.K. et al. The Collaborative Ocular Tuberculosis Study (COTS) calculator—a consensus-based decision tool for initiating antitubercular therapy in ocular tuberculosis. Eye 37, 1416–1423 (2023). https://doi.org/10.1038/s41433-022-02147-7

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