Kerala Journal of Ophthalmology

: 2022  |  Volume : 34  |  Issue : 2  |  Page : 157--160

Peripheral ulcerative keratitis with multiple punctate scleral abscess – A rare presentation of ocular tuberculosis

I Karthiga, Charmaine Bridgette Solomon, Sanaa Mohammed Konnakkodan, V Babitha, A Arun Kumar 
 Department of Ophthalmology, Government Medical College, Kozhikode, Kerala, India

Correspondence Address:
Dr. I Karthiga
The Kerala state housing board, working womens hostel, chevayur, Kozhikode 673017, Kerala


This case report represents an unusual presentation of ocular tuberculosis (TB). Ocular TB is rare, but it can be the first clinical manifestation of the disease. Here, we report a case of a 67-year-old male, a chronic smoker who presented with pain, redness, and photophobia (BE), and slit-lamp examination showed multiple corneal infiltrate along the limbus with multiple scleral abscesses not responding to routine treatment. Investigations revealed high erythrocyte sedimentation rate value, positive Mantoux reaction, and changes on contrast-enhanced computed tomography of the thorax. Sputum CBNAAT was negative, and pus aspirate revealed no growth with negative staining for acid-fast bacillus. With high suspicion of TB, we started on Anti tuberculosis therapy, and there was rapid healing of lesions. In endemic areas, even when microbiological studies are not positive, ocular TB should be kept in mind in atypical cases so that early treatment can be instituted to prevent serious complications.

How to cite this article:
Karthiga I, Solomon CB, Konnakkodan SM, Babitha V, Kumar A A. Peripheral ulcerative keratitis with multiple punctate scleral abscess – A rare presentation of ocular tuberculosis.Kerala J Ophthalmol 2022;34:157-160

How to cite this URL:
Karthiga I, Solomon CB, Konnakkodan SM, Babitha V, Kumar A A. Peripheral ulcerative keratitis with multiple punctate scleral abscess – A rare presentation of ocular tuberculosis. Kerala J Ophthalmol [serial online] 2022 [cited 2022 Dec 2 ];34:157-160
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India is the highest tuberculosis (TB) burden country in the world, having an estimated incidence of 26.9 lakh cases in 2019 (WHO). Pulmonary TB is responsible for 80% of the active systemic disease, the remaining 20% of the disease may affect other organs, including the eye.[1]

Ocular TB is rare, but it can be the first clinical manifestation of the disease.

Due to the rare occurrence of the disease, difficulty in detecting the bacillus, and the low suspicion index, diagnosis can be delayed leading to complications with high morbidity. Therefore, early diagnosis and treatment plays an important role.[2]

Here, we report a case of bilateral peripheral ulcerative keratitis (PUK) associated with multiple punctate scleral abscess with probable etiology of TB.

 Case Report

A 67-year-old male, a chronic smoker with no comorbidities, presented to the outpatient department with pain, redness, and photophobia for duration of 5 days in the right eye and 3 days in the left eye. He had no history of trauma with any vegetative matter.

General and systemic examinations were within normal limits.

On examination, BCVA was 6/12 (OD) and 6/9(OS).

Slit-lamp examination of the right eye showed lid edema with circumcorneal congestion, cornea showed multiple 2 mm × 1 mm epithelial defects with underlying infiltrate, well-circumscribed margins along the limbus from 4 to 7 o'clock position extending up to anterior stroma with surrounding stromal edema. AC showed cells 2+, flare 1+ [Figure 1]. The left eye also showed lid edema with circumcorneal congestion; cornea showed two 2 mm × 1 mm epithelial defects with underlying infiltrate, well-circumscribed margins at 7 and 8 o'clock position along the limbus extending up to anterior stroma with surrounding stromal edema. AC showed cells 1+, flare 1+ [Figure 2]. Indirect ophthalmoscopic examination of both eyes was normal.{Figure 1}{Figure 2}

Routine investigations revealed a high erythrocyte sedimentation rate of 116 mm/h; Mantoux was highly positive. Routine smear and culture of infiltrate were negative. Chest X-ray showed increased bronchovascular markings. Contrast-enhanced computed tomography of the thorax showed tree in bud appearance, which is a characteristic feature of TB [Figure 3]. However, sputum CBNAAT was negative.{Figure 3}

Meanwhile, during the course in the hospital, the patient developed multiple punctate scleral abscess and the corneal lesions remain unchanged in both eyes.

The patient was treated with systemic and topical antibiotics; scleral abscess aspirate sent for routine culture showed no growth. Acid-fast bacillus (AFB) staining was negative for bacilli, and polymerase chain reaction (PCR) could not be done due to an insufficient sample.

A high index of suspicion along with supporting investigations led us to a provisional diagnosis of PUK with scleral abscess – probable etiology of TB.

The patient was started on ATT after pulmonology evaluation. There was a symptomatic and clinical improvement with rapid healing of lesions vindicating our stand [Figure 4].{Figure 4}


TB is caused by Mycobacterium tuberculosis, one of the major causes of morbidity and mortality worldwide. Ocular TB is the infection by M. tuberculosis in the eye, around the eye, or its surface.

Ocular TB may not be usually associated with clinical evidence of pulmonary TB, as up to 60% of extrapulmonary TB patients do not have pulmonary TB.[3]

Incidence of ocular TB ranges from 1.4% to 5.74%; however, in an endemic region, it may reach up to 10%.[4]

Thirteen to fourteen thousand new cases are diagnosed per year, with 36% of these being diagnosed with extrapulmonary TB.[5]

Phlyctenulosis, conjunctival granulomas, and granulomatous anterior uveitis are the most common anterior segment presentations of ocular TB. The diagnosis of ocular TB can be made either by isolation of the organism on LJ medium or histopathologic staining methods of affected tissues or detection of the organism by PCR.

In general, corneal involvement is rare in TB. Kamal et al.[6] described bilateral interstitial keratitis as a presenting manifestation of ocular TB in a 17-year-old girl which responded to topical steroid and ATT. Probable tubercular antigen in aqueous humor causing delayed hypersensitivity reaction was attributed to be the cause.

Arora et al.[7] reported bilateral disciform keratitis as presenting feature of extrapulmonary TB in an 11-year-old girl which on further investigation revealed tubercular Pott's spine.

In our patient, it presented as PUK with multiple punctate scleral abscess. PUK is a potentially devastating disorder with crescent-shaped destructive inflammation at the margin of the corneal stroma. Adjacent conjunctival, episcleral, and scleral inflammation are also generally apparent.[8]

Bayraktutar et al.[9] reported a case of ocular TB with progressive unilateral corneal melting with subconjunctival nodules in a 47-year-old female. The diagnosis was confirmed by the detection of bacillus DNA with PCR in the biopsy specimen of subconjunctival nodule; however, Ziehl–Neelsen staining of the specimen was negative for AFB. It was suggested that though histopathology is negative for AFB, the biopsy specimen should be examined by PCR. In our patient, PCR could not be done due to insufficient samples.

Gupta et al.[10] isolated M. tuberculosis on histopathological examination of a case with Sweet's syndrome who presented with PUK and scleral nodules.

Deepali et al.[11] reported a case of multiple disc-shaped corneal stromal infiltrates with hypopyon, which showed no improvement with empirical therapy and later with supporting investigations started on ATT and showed a rapid response. Similar to this case, our patient was unresponsive to routine treatment for PUK. Clinical suspicion of TB along with supporting investigations prompted us to start ATT, to which the patient responded well.


Ocular TB, though rare, should be kept in mind in the differential diagnosis of patients with such presentation not responding to the standard antimicrobial therapy, especially in endemic regions such as India, as early diagnosis and treatment can prevent serious complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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