Ethambutol optic neuropathy incidence 1.54 percent with renal impairment and hypertension as key risk factorsKidney disease and high blood pressure raise risk of vision loss from TB drug

Frontiers in Medicine Published May 29, 2026 DOI ↗ Editorial oversight: Dr. Lars van Dijk, PhD · Surgical, Procedural & Diagnostic

AI-generated summary of the cited source, checked by automated accuracy review. How we work

Key Takeaway

Consider screening high-risk patients for ethambutol optic neuropathy given the 1.54 percent incidence and identified risk factors.

This is a systematic review and meta-analysis examining the incidence and risk factors of ethambutol optic neuropathy (EON), neuro-ophthalmic manifestations of tuberculous meningitis (TBM), and prognostic biomarkers for visual outcomes. The analysis included a total sample size of 260,430. The pooled incidence of EON was 1.54 percent (95% CI: 0.81-2.49 percent, I²=98.2 percent). Renal impairment was associated with an increased risk of EON (OR 3.73, 95% CI: 1.78-7.83), as was hypertension (OR 2.37, 95% CI: 1.46-3.84). In TBM, cranial nerve III palsy occurred in 17.4 percent of cases, papilledema in 12.5 percent, and optic atrophy in 16.7 percent. Hydrocephalus rates were higher in pediatric patients (72.5 percent) versus non-pediatric patients (13.0 percent), with a relative risk of 5.56. For subclinical changes, VEP demonstrated better detection than OCT (Hedges’ g difference: 0.686, P-value = 0.001). Visual recovery in clinical EON cases was 52.4 percent, with younger age and earlier ethambutol discontinuation associated with improved recovery. The authors note the high heterogeneity (I²=98.2 percent) as a limitation. Screening protocols targeting high-risk populations are recommended.

Ethambutol is a common medicine used to treat tuberculosis. But it can sometimes damage the optic nerve, leading to vision loss. A new analysis looked at data from over 260,000 people to understand who is at risk. The goal was to protect patients from losing their sight while they fight this serious infection.

The study found that people with kidney issues or high blood pressure face a much higher chance of this side effect. Those with kidney problems had nearly four times the risk. People with high blood pressure had more than double the risk. These conditions make the eyes more vulnerable to the drug.

For those who develop vision problems, the outlook depends on age and timing. Younger patients had a better chance of recovering their sight. Stopping the medicine early also helped improve visual outcomes. The researchers noted that detecting early changes in the eye nerves was harder with some tests than others. This means doctors need to watch patients closely, especially those with high blood pressure or kidney disease.

What this means for you:

Kidney disease and high blood pressure significantly increase the risk of vision loss from the TB drug ethambutol.

Study Details

Study typeMeta analysis

EvidenceLevel 1

PublishedMay 2026

View Original Abstract ↓

IntroductionTuberculosis (TB) and its treatment have been associated with significant neuro-ophthalmic morbidity; however, the magnitude and determinants of these complications remain incompletely characterized. This systematic review and meta-analysis aimed to evaluate the incidence and risk factors of ethambutol optic neuropathy (EON), neuro-ophthalmic manifestations of tuberculous meningitis (TBM), and prognostic biomarkers for visual outcomes.MethodsFollowing PRISMA 2020 guidelines, we searched PubMed, Scopus, Embase, Web of Science, Cochrane Library, and Google Scholar up to the 30th of September 2025. Studies reporting EON incidence, TBM neuro-ophthalmic complications, or subclinical neurotoxicity biomarkers were included. Random-effects meta-analysis with generalized linear mixed models was performed.ResultsTwenty-two studies (N = 260,430) were included. Pooled EON incidence was 1.54% (95% CI: 0.81-2.49%, I²=98.2%). Renal impairment (OR 3.73, 95% CI: 1.78-7.83) and hypertension (OR 2.37, 95% CI: 1.46-3.84) were significant risk factors. TBM neuro-ophthalmic manifestations included cranial nerve III palsy (17.4%), papilledema (12.5%), and optic atrophy (16.7%), with pediatric patients demonstrated significantly higher hydrocephalus rates (72.5% vs 13.0%, RR 5.56). Visual evoked potential (VEP) demonstrated better detection of subclinical changes over optical coherence tomography (OCT) (Hedges’ g difference: 0.686, P-value = 0.001). Visual recovery occurred in 52.4% of clinical EON cases. Factors associated with improved recovery included younger age (MD= -3.8 years, P-value= 0.095) and earlier ethambutol discontinuation.ConclusionsTB-related neuro-ophthalmic complications represent significant morbidity with identifiable risk factors. Visual evoked potentials offer superior subclinical detection and early intervention improves visual outcomes. Screening protocols targeting high-risk populations are recommended.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/, identifier CRD420251141453.

Ethambutol optic neuropathy incidence 1.54 percent with renal impairment and hypertension as key risk factorsKidney disease and high blood pressure raise risk of vision loss from TB drug

Study Details

Systematic review of extensive macular atrophy with pseudodrusen reports visual acuity decline and atrophy progression

Eye disease linked to vision loss and thicker eye layers in study

Clinical research that matters. Delivered to your inbox.

Ethambutol optic neuropathy incidence 1.54 percent with renal impairment and hypertension as key risk factorsKidney disease and high blood pressure raise risk of vision loss from TB drug

More on Tuberculosis

Study Details

Systematic review of extensive macular atrophy with pseudodrusen reports visual acuity decline and atrophy progression

Eye disease linked to vision loss and thicker eye layers in study

Clinical research that matters. Delivered to your inbox.

Related in Ophthalmology

From Other Specialties