Granulomatous Uveitis: TB, Sarcoidosis and Syphilis

Last updated: November 2026

Mutton-fat KPs and iris nodules point to granulomatous uveitis. In India the three causes you must always consider are tuberculosis, sarcoidosis and syphilis, because each needs specific treatment and steroids alone can make TB and syphilis worse.

Clues to each cause

Cause	Ocular clues	Systemic clues and tests
Tuberculosis	Broad posterior synechiae, choroidal granulomas, serpiginous-like choroiditis (multifocal, progressive, often bilateral), occlusive retinal vasculitis	Positive IGRA or Mantoux, chest CT (healed or active lesions), history of TB contact
Sarcoidosis	Koeppe and Busacca nodules, tent-shaped synechiae, snowballs, candle-wax drippings (periphlebitis), multifocal choroidal lesions, lacrimal gland enlargement	Raised ACE and lysozyme, chest X-ray or CT (hilar lymphadenopathy), biopsy of skin or nodes
Syphilis	Any pattern ("the great mimic"): granulomatous anterior uveitis, placoid chorioretinitis (ASPPC), retinitis, optic neuritis, interstitial keratitis	Treponemal (TPHA, FTA-ABS) and non-treponemal (VDRL, RPR) tests; test for HIV

Treatment principles

Tuberculosis: anti-tubercular therapy (four drugs, for 6–12 months with the physician) plus steroids to control inflammation; steroids alone risk worsening. The COAT studies help decide when to start ATT.
Sarcoidosis: steroids (topical, local or systemic), then steroid-sparing drugs.
Syphilis: treat as neurosyphilis with IV penicillin for 10–14 days; topical steroids for anterior inflammation.

Rules

Test every uveitis patient for syphilis.
Exclude TB before systemic steroids or biologics, especially in endemic regions.
Serpiginous choroiditis in India is often TB-related: look for TB before treating it as autoimmune.

Where residents slip

Giving high-dose steroids for serpiginous-like choroiditis without considering TB.
Forgetting syphilis because the picture "looks like" something else.
Not testing for HIV in syphilitic uveitis.

Test yourself: flip cards

Key sources

Agrawal R, et al. Collaborative Ocular Tuberculosis Study (COTS) consensus guidelines on the management of tubercular uveitis. Ophthalmology. 2021;128:266-276
Mochizuki M, et al. International Workshop on Ocular Sarcoidosis criteria. Br J Ophthalmol. 2019;103:1418-1422
Centers for Disease Control and Prevention. Ocular syphilis clinical guidance (current)

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Written by Dr. Dhaval Patel, MD (Ophthalmology, AIIMS New Delhi)

Consultant, Cataract & Refractive Surgery — among a small number of AIIMS-trained ophthalmologists practicing in Gujarat. Read full credentials & experience or view his 28 publications on ResearchGate.

📚 Also the author of OKAT Decoded and other high-yield ophthalmology exam-prep books used by residents and PG aspirants.

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