Tubercular Uveitis: Multimodal Imaging, Immunologic Stratification, and a Practical Framework for Diagnosis and Management

Abstract: Tubercular uveitis (TBU) remains difficult to diagnose and monitor because microbiologic confirmation is uncommon and clinical phenotypes overlap with other inflammatory chorioretinal disorders. This narrative review integrates evidence from multimodal imaging, immune testing, systemic tuberculosis evaluation, molecular diagnostics, biomarkers, treatment response, and monitoring to support a practical probability-based approach to suspected TBU. A targeted search of PubMed, Embase, Web of Science, the Cochrane Library, and Google Scholar was conducted for English-language literature through May 10, 2026, prioritizing consensus statements, systematic reviews, multicenter studies, and clinically relevant imaging, biomarker, and treatment reports. Enhanced-depth and swept-source optical coherence tomography, optical coherence tomography angiography, fundus autofluorescence, indocyanine green angiography, and ultra-widefield fluorescein angiography provide complementary information on choroidal granulomas, serpiginous-like choroiditis, retinal vasculitis, ischemia, and paradoxical worsening. Tuberculin skin testing and interferon-gamma release assays support tuberculosis attribution but do not prove ocular causality, while polymerase chain reaction and emerging molecular assays increase specificity when positive. Cytokine profiles, type I interferon signatures, complement C1q, and cell-free DNA remain investigational. TBU should be managed as a clinicoradiologic and immunologic probability diagnosis that links phenotype, imaging, tuberculosis exposure evidence, mimic exclusion, antitubercular therapy decisions, anti-inflammatory timing, and longitudinal monitoring to reduce both missed TBU and unnecessary treatment. Keywords: tubercular uveitis, ocular tuberculosis, multimodal imaging, OCTA, IGRA, antitubercular therapy