Viral Anterior Uveitis

Abstract

Differential diagnosis of viral anterior uveitis (AU) based on the typical clinical findings (anterior chamber inflammation, morphology of the keratic precipitates, severity of IOP increase in relapse) is often straightforward. When differential diagnosis is difficult clinically, analysis of aqueous humour by PCR and/or antibody testing (Goldmann-Witmer coefficient) may be helpful. While both modalities are highly specific, they lack absolute sensitivity. Patients with HSV, VZV and CMV associated uveitis require both antiviral as well as antiinflammatory medication and often additional antiglaucomatous therapy, depending on IOP. In contrast, specific antiviral treatment is not possible in rubella associated AU and steroids should be administered with extreme caution due to their adverse effects. With all subtypes of virus associated AU, recurrent episodes put the patients at risk of developing secondary glaucoma, which often requires surgical treatment.

Key words

anterior uveitis - herpes simplex virus - varicella-zoster virus - cytomegalovirus - rubella virus

Publication History

Received: 01 November 2021

Accepted: 26 November 2021

Article published online:
23 March 2022

• References/Literatur

• 1 Radosavljevic A, Agarwal M, Chee SP. et al. Epidemiology of Viral Induced Anterior Uveitis. Ocul Immunol Inflamm 2021;
• 2 Pleyer U, Chee SP. Current aspects on the management of viral uveitis in immunocompetent individuals. Clin Ophthalmol 2015; 9: 1017-1028
• 3 Gaynor BD, Margolis TP, Cunningham jr. ET. Advances in diagnosis and management of herpetic uveitis. Int Ophthalmol Clin 2000; 40: 85-109
• 4 Pohlmann D, Schlickeiser S, Metzner S. et al. Different composition of intraocular immune mediators in Posner-Schlossman-Syndrome and Fuchsʼ Uveitis. PLoS One 2018; 13: e0199301
• 5 Jabs DA, Nussenblatt RB, Rosenbaum JT. et al. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol 2005; 140: 509-516
• 6 Standardization of Uveitis Nomenclature (SUN) Working Group. Classification Criteria for Herpes Simplex Virus Anterior Uveitis. Am J Ophthalmol 2021; 228: 231-236
• 7 Standardization of Uveitis Nomenclature (SUN) Working Group. Classification Criteria for Varicella Zoster Virus Anterior Uveitis. Am J Ophthalmol 2021; 228: 165-173
• 8 Standardization of Uveitis Nomenclature (SUN) Working Group. Classification Criteria for Cytomegalovirus Anterior Uveitis. Am J Ophthalmol 2021; 228: 89-95
• 9 Standardization of Uveitis Nomenclature (SUN) Working Group. Classification Criteria for Fuchs Uveitis Syndrome. Am J Ophthalmol 2021; 228: 262-267
• 10 Chan NS, Chee SP. Demystifying viral anterior uveitis: A review. Clin Exp Ophthalmol 2019; 47: 320-333
• 11 Relvas LJ, Caspers L, Chee SP. et al. Differential Diagnosis of Viral-Induced Anterior Uveitis. Ocul Immunol Inflamm 2018; 26: 726-731
• 12 Chee SP, Bacsal K, Jap A. et al. Clinical features of cytomegalovirus anterior uveitis in immunocompetent patients. Am J Ophthalmol 2008; 145: 834-840
• 13 Chan NS, Chee SP, Caspers L. et al. Clinical Features of CMV-Associated Anterior Uveitis. Ocul Immunol Inflamm 2018; 26: 107-115
• 14 Pohlmann D, Pahlitzsch M, Schlickeiser S. et al. Virus-associated anterior uveitis and secondary glaucoma: Diagnostics, clinical characteristics, and surgical options. PLoS One 2020; 15: e0229260
• 15 Lenglinger M, Pohlmann D, Pleyer U. [Anterior viral uveitis: Clinical aspects, diagnostic procedure and treatment options]. Ophthalmologe 2020; 117: 83-92
• 16 de Groot-Mijnes JD, de Visser L, Rothova A. et al. Rubella virus is associated with Fuchs heterochromic iridocyclitis. Am J Ophthalmol 2006; 141: 212-214
• 17 Ruokonen PC, Metzner S, Ucer A. et al. Intraocular antibody synthesis against rubella virus and other microorganisms in Fuchsʼ heterochromic cyclitis. Graefes Arch Clin Exp Ophthalmol 2010; 248: 565-571
• 18 Quentin CD, Reiber H. Fuchs heterochromic cyclitis: rubella virus antibodies and genome in aqueous humor. Am J Ophthalmol 2004; 138: 46-54
• 19 Relvas LJM, Antoun J, de Groot-Mijnes JDF. et al. Diagnosis of Cytomegalovirus Anterior Uveitis in Two European Referral Centers. Ocul Immunol Inflamm 2018; 26: 116-121
• 20 De Groot-Mijnes JD, Rothova A, Van Loon AM. et al. Polymerase chain reaction and Goldmann-Witmer coefficient analysis are complimentary for the diagnosis of infectious uveitis. Am J Ophthalmol 2006; 141: 313-318
• 21 Andrei G, Snoeck R. Advances and Perspectives in the Management of Varicella-Zoster Virus Infections. Molecules 2021; 26: 1132
• 22 van Velzen M, Missotten T, van Loenen FB. et al. Acyclovir-resistant herpes simplex virus type 1 in intra-ocular fluid samples of herpetic uveitis patients. J Clin Virol 2013; 57: 215-221
• 23 Su CC, Hu FR, Wang TH. et al. Clinical outcomes in cytomegalovirus-positive Posner-Schlossman syndrome patients treated with topical ganciclovir therapy. Am J Ophthalmol 2014; 158: 1024-1031.e2
• 24 Wong JX, Agrawal R, Wong EP. et al. Efficacy and safety of topical ganciclovir in the management of cytomegalovirus (CMV)-related anterior uveitis. J Ophthalmic Inflamm Infect 2016; 6: 10
• 25 Cheng YC, Kang EY, Hwang YS. et al. Treatment of cytomegalovirus anterior segment infection with intravitreal injection of ganciclovir in adjunction with or without oral valganciclovir: a long-term results. Sci Rep 2021; 11: 3105
• 26 Hwang YS, Lin KK, Lee JS. et al. Intravitreal loading injection of ganciclovir with or without adjunctive oral valganciclovir for cytomegalovirus anterior uveitis. Graefes Arch Clin Exp Ophthalmol 2010; 248: 263-269
• 27 Lu A, Sun Y, Porco TC. et al. Effectiveness of the Recombinant Zoster Vaccine for Herpes Zoster Ophthalmicus in the United States. Ophthalmology 2021;
• 28 Birnbaum AD, Tessler HH, Schultz KL. et al. Epidemiologic relationship between Fuchs heterochromic iridocyclitis and the United States rubella vaccination program. Am J Ophthalmol 2007; 144: 424-428