Ocular involvement associated with chronic Epstein-Barr virus disease

Epstein-Barr Virus Keratouveitis-Induced Malignant Glaucoma After Penetrating Keratoplasty: A Case Report and Literature Review

PURPOSE

To report a case of Epstein-Barr virus (EBV) keratouveitis-induced malignant glaucoma after repeat penetrating keratoplasty (PK).

METHODS

Retrospective review of the patient's medical records and review of literature on EBV corneal endotheliitis and/or anterior uveitis.

RESULTS

A 78-year-old Thai female patient presented with a markedly edematous corneal graft, dense pigmented keratic precipitates, fibrinous anterior chamber reaction, uniformly flat anterior chamber, and ocular hypertension of 55 mmHg in the left eye on the first day after the third PK. An aqueous tap for polymerase chain reaction analysis was positive for EBV DNA but negative for other herpesviruses. The patient was diagnosed with EBV endotheliitis and anterior uveitis-induced malignant glaucoma; and successfully treated with oral valacyclovir and topical 2% ganciclovir eye drops.

CONCLUSIONS

EBV endotheliitis and anterior uveitis can induce malignant glaucoma following PK. A high index of suspicion is required when a patient has a history of unexplained multiple graft rejections.

Ocular Manifestations in Epstein Barr Virus Infection

The Epstein-Barr Virus (EBV), a member of the Herpesvirus family, occurs commonly and infects more than 90% of people worldwide. Most of systemic EBV infections throughout childhood and adulthood are typically asymptomatic or paucisymptomatic. Even though ocular involvements in EBV infections are infrequently reported, an increasing number of ocular manifestations have been previously reported . Ocular manifestation caused by EBV infection involved all segments of the eye, including oculoglandular syndrome, dry eye syndrome, dacryoadenitis, conjunctivitis, episcleritis, keratitis, uveitis, choroiditis, retinitis, retinal vasculitis, and papillitis. Previous reports found neurologic complications such as papilledema, optic neuritis, ophthalmoplegia, impaired accommodation, and facial nerve palsy. Any atypical ocular inflammatory process should be considered EBV infection in the differential diagnosis. The ocular manifestations of systemic EBV infection are varied and have not been emphasized. And the role of EBV infection in ocular manifestations should be fully described.

Anterior segment involvement in Epstein-Barr virus: a review

The aim of this study is to describe the involvement of Epstein-Barr Virus (EBV) in the diseases of the ocular anterior segment. This is a narrative review designed using the PUBMED, SCOPE and Web of Science databases, searching for reported literature on findings in the anterior ocular segment related to EBV between 1990 and 2020. Epstein-Barr Virus (EBV) is implicated in the development of salmon-coloured conjunctival masses in the context of acute mononucleosis and lymphoproliferative disorders. Moreover, EBV can cause haemorrhagic conjunctivitis and its corneal implications appear as different types of keratitis patterns. The involvement of EBV in the pathogenesis of anterior segment inflammation is not well-defined. Current evidence regarding anterior segment disease caused by EBV infection has been proved by positive viral detection through polymerase chain reaction test in eyes with lymphoproliferative disorders known to be caused by EBV, as B- and NK/T-cell lymphoid tumours. Antiviral treatment (oral Aciclovir or Valaciclovir) in anterior segment disease caused by EBV remains controversial.

Pathobiology and treatment of viral keratitis

Keratitis is one of the most prevalent ocular diseases manifested by partial or total loss of vision. Amongst infectious (viz., microbes including bacteria, fungi, amebae, and viruses) and non-infectious (viz., eye trauma, chemical exposure, and ultraviolet exposure, contact lens) risk factors, viral keratitis has been demonstrated as one of the leading causes of corneal opacity. While many viruses have been shown to cause keratitis (such as rhabdoviruses, coxsackieviruses, etc.), herpesviruses are the predominant etiologic agent of viral keratitis. This chapter will summarize current knowledge on the prevalence, diagnosis, and pathobiology of viral keratitis. Virus-mediated immunomodulation of host innate and adaptive immune components is critical for viral persistence, and dysfunctional immune responses may cause destruction of ocular tissues leading to keratitis. Immunosuppressed or immunocompromised individuals may display recurring disease with pronounced severity. Early diagnosis of viral keratitis is beneficial for disease management and response to treatment. Finally, we have discussed current and emerging therapies to treat viral keratitis.

Chronic active Epstein-Barr virus infection manifesting as coronary artery aneurysm and uveitis

Background

Chronic active Epstein–Barr virus (CAEBV) infection is a type of lymphoproliferative disorder characterized by chronic or recurrent infectious mononucleosis (IM)-like symptoms, which can have less-frequent clinical presentations. The prognosis of CAEBV is poor, and hematopoietic stem cell transplantation (HSCT) has been shown to be the only potentially effective treatment. In this article, we present a special CAEBV case of a patient who had no typical IM-like symptoms at the early stage, but manifested with severe and progressive coronary artery aneurysm (CAA), abdominal aortic lesions, and severe uveitis. These manifestations were uncommon features and could only be blocked by HSCT.

Case presentation

A 4-year-old girl with no special medical history complained of decreased vision for 10 months and cough after physical activities for three months. The blurred vision grew rapidly worse within one month, until only light perception remained. She was diagnosed with uveitis and cataract, and received prednisone and ciclosporin A treatment. However, her vision did not improve. Physical examination showed slight hepatosplenomegaly. Ultrasonic cardiogram showed bilateral CAA (5.0 mm and 5.7 mm for inner diameters), and abdominal CT scan revealed a thickened aortic wall, as well as stenosis and dilation of the segmental abdominal aorta. Other significant findings were increased EBV-DNA (3.29 × 10⁴ copies/mL) from peripheral blood, positive EBV antibodies (EBV-CA-IgG, EBV-EA-IgA, and EBV-NA-IgG), and positive EBV-encoded small RNAs found by bone marrow biopsy. Based on her clinical manifestations and evidence for EBV infection, we diagnosed CAEBV. She received allogeneic HSCT, and the cataract operation was performed after HSCT. EBV-DNA could not be detected in peripheral blood after HSCT. Her CAAs did not progress, and uveitis was well controlled. Her vision recovered gradually over the 3 years after HSCT.

Conclusions

We present a rare CAEBV case of a patient who suffered from uncommon and severe cardiovascular and ocular involvement that was relieved by HSCT. Therefore, early recognition and diagnosis of CAEBV are of vital importance to improve its prognosis. In summary, this atypical CAEBV case could help us recognize similar cases more easily, make the right diagnosis as early as possible, and deliver proper and timely treatment.

Successful Treatment of Necrotizing Retinitis with Epstein-Barr Virus-Positive Ocular Fluid by Intravitreal Methotrexate Injection

PURPOSE

To present a case of necrotizing retinitis with Epstein-Barr virus (EBV)-positive ocular fluid in a patient with sudden unilateral vision loss, which was successfully treated with intravitreal methotrexate (MTX) injections.

METHODS

Retrospective case report.

RESULTS

An 83-year-old female who had been on methylprednisolone for 20 years due to interstitial pneumonia developed vitreous opacity and extensive necrotizing retinitis with retinal hemorrhage sparing the posterior pole in the left eye. Multiplex polymerase chain reaction (PCR) for viral DNA using vitreous sample was positive for EBV but negative for herpes simplex virus, varicella-zoster virus, and cytomegalovirus. Real-time PCR detected EBV-DNA in aqueous humor but not in peripheral blood sample. Serologic testing was negative for Toxoplasma gondii, syphilis, and HIV. The patient did not respond to systemic ganciclovir or acyclovir. Subsequent treatment with intravitreal MTX resulted in immediate clinical improvement correlating with a decrease in copy number of EBV-DNA.

CONCLUSION

Intravitreal MTX may be an effective treatment option for patients with necrotizing retinitis and EBV-positive ocular fluid not responding to conventional antiviral therapy.

Bilateral granulomatous panuveitis in two patients with T-cell type of chronic active Epstein-Barr virus infection

Background

To report 2 cases of bilateral granulomatous panuveitis accompanied by chronic active Epstein-Barr virus infection (CAEBV).

Case presentation

Case 1 was a 38-year-old man who had a history of bilateral mild panuveitis who was diagnosed with CAEBV. Fifteen months later, a severe bilateral granulomatous panuveitis developed. White infiltrates covered the optic disc and all the retinal vessels of the right eye, and white nodules were seen along the retinal veins and arteries of the left eye. Case 2 was a 34-year-old man with bilateral panuveitis showing mutton-fat keratic precipitates and diffuse vitreous opacity in both eyes. A snow ball-like vitreous opacity was present in the right eye. Systemic investigations revealed the presence of CAEBV. In both cases, a comprehensive polymerase chain reaction (PCR) analyses of the aqueous humor detected significant copy numbers of EBV-DNA. The intraocular inflammation did not respond to steroid, methotrexate, and other immunosuppressive therapies, but was ameliorated after hematopoietic stem cell transplantation with preceding chemotherapy and low-dose total body irradiation in both cases.

Conclusion

Granulomatous panuveitis can develop in eyes with CAEBV as a primary symptom. Ophthalmologists should rule out CAEBV when EBV-DNA is positive in the intraocular fluids of steroid-resistant panuveitis.

RETINAL VASCULITIS ASSOCIATED WITH EPSTEIN-BARR VIRUS INFECTION, A CASE REPORT

PURPOSE

To report a case of retinal vasculitis associated with Epstein-Barr virus infection.

METHODS

Case report.

RESULTS

A 26-year-old woman came with blurry vision. Funduscopy illustrated vasculitis with frosted branch-like appearance. The patient was treated with systemic acyclovir and topical steroid. Circulating polymerase chain reaction was positive for Epstein-Barr virus antibodies. Two months of treatment resolved the clinical manifestations.

CONCLUSION

Epstein-Barr infection should be considered as the etiology of retinal vasculitis with similar clinical manifestations.

A case of primary extranodal natural killer/T-cell lymphoma in the orbit and intraocular tissues with cerebrospinal fluid involvement

Purpose

To report a rare case of primary orbital natural killer (NK)/T-cell lymphoma without nasal lesions but with cerebrospinal fluid involvement.

Observations

A 73-year-old woman was referred to the uveitis clinic with suspected unilateral acute uveitis in her right eye and a right orbital tumor. Epstein–Barr virus DNA was detected in the aqueous humor in her right eye, and orbital biopsy revealed the presence of extranodal NK/T-cell lymphoma (ENKTL), nasal type. Positron emission tomography showed significant ¹⁸F-fluorodeoxyglucose uptake in the right orbit, with no other signs of systemic involvement. Cerebrospinal fluid analysis demonstrated lymphoma cell infiltration. She was diagnosed with stage IV ENKTL and treated with orbital radiotherapy and systemic chemotherapy, with subsequent remission. However, the lymphoma relapsed in her left vitreous at 10 months after therapy, suggesting metastasis of lymphoma cells to the contralateral eye via the vitreous and cerebrospinal fluid.

Conclusions and importance

A few cases of ocular-tissue ENKTL have been reported, mostly involving invasion or dissemination of primary nasal lesions; in contrast, primary orbital and intraocular ENKTL has rarely been reported. To the best of our knowledge, this is the first report of a primary orbital ENKTL metastasizing to the vitreous of the contralateral eye. Although ENKTL is rare in the orbit and intraocular tissues, it should be considered as a possible differential diagnosis in patients with orbital tumors or intraocular inflammation resistant to steroid therapy because ENKTL has a very poor prognosis in the advanced stage.

A case report of Epstein-Barr virus-associated retinal vasculitis: successful treatment using only acyclovir therapy

The purpose of this study was to describe a presumed case of Epstein–Barr virus (EBV)-associated retinal vasculitis in a 42-year-old female with sudden unilateral vision loss and successful treatment with acyclovir therapy. Diagnostic vitreous biopsy of the right eye was performed to test for EBV and other known infectious causes of retinitis and evaluate vitreous cells and serological testing. Vitreous polymerase chain reaction viral DNA testing result was positive for EBV but negative for herpes simplex virus, varicella-zoster virus, and cytomegalovirus. Serologic testing was negative for toxoplasma gondii, syphilis, tuberculosis, and HIV. Histopathologic analysis of vitreous cells revealed atypical lymphocytes. Fluorescein angiography showed disk leakage, occluded retinal artery, peripheral vascular leakage, and ischemic area of the right eye. Intravenous acyclovir, 10 mg/kg/d, was prescribed for 14 days followed by oral acyclovir for 3 months. All lesions have become quiet. EBV may be a cause of retinal disease, and intravenous acyclovir is a successful treatment choice.

Acute Retinal Necrosis Associated with Epstein-Barr Virus in a Patient Undergoing Immunosuppressive Therapy

Acute retinal necrosis (ARN) is a rapidly progressive and severe retinitis resulting in a poor visual outcome. Infections caused by herpes viruses such as herpes simplex virus (HSV) types 1 and 2 or the varicella zoster virus (VZV) are known to be implicated in the development of ARN. In the present study, an 80-year-old female with ARN was examined. She had been affected with rheumatoid arthritis and had taken methotrexate for over 10 years. Her right eye showed clinical features of ARN, and her left eye showed mild retinitis. The genomic DNA in the aqueous humor and vitreous fluid from her right eye were analyzed by a comprehensive polymerase chain reaction (PCR) assay to screen infectious pathogens including viruses. The Epstein-Barr virus (EBV) was detected from both specimens, but neither HSV or VZV nor cytomegalovirus was detected. She underwent intraocular surgery following systemic corticosteroid and acyclovir applications. However, although the retinitis of her right eye was extinguished, the final visual outcome was blindness due to optic nerve atrophy. There are few reports indicating that EBV is associated with ARN development. The present findings suggest that EBV alone can be the causative agent of ARN.

A Therapeutic Trial of Valganciclovir in Patients with Uveitis and Positive Epstein-Barr virus Early Antigen D IgG Titers

Purpose

To evaluate the effectiveness of a therapeutic trial of valganciclovir in patients with uveitis with positive Epstein-Barr virus early antigen D immunoglobulin G titers (EBV EA-D).

Methods

We performed a retrospective chart review of 14 patients at the Massachusetts Eye Research and Surgery Institution who had uveitis with positive EBV EA-D but negative studies for all other causes of uveitis and were treated with valganciclovir 450 mg twice a day or valganciclovir 900 mg twice a day between January 2010 and August 2014.

Results

Nine of 14 patients, who had presumed EBV reactivation with associated intraocular inflammation, were successfully treated with valganciclovir: 3 of these were treated with valganciclovir 450 mg twice a day and 6 were treated with valganciclovir 900 mg twice a day. Five of 14 patients failed to respond to valganciclovir with persistent inflammation after at least 2 weeks of valganciclovir therapy, and were subsequently treated with immunomodulatory therapy to control inflammation.

Conclusions

Uveitis can be caused by EBV infection/reactivation. A therapeutic trial with valganciclovir 450 mg twice a day for 1 month in patients with uveitis with positive EBV EA antibody may be beneficial.

Epstein-barr infection of the retina: case report and review of the literature

PURPOSE

The purpose of this study is to describe a presumed case of Epstein-Barr virus (EBV) infection of the retina in a 65-year-old female with sudden bilateral vision loss.

METHODS

Diagnostic vitreous biopsy of the left eye was performed to test for EBV and other known infectious causes of retinitis and evaluate vitreous cells.

RESULTS

Serologic EBV testing was positive. Vitreous polymerase chain reaction viral DNA testing was positive for EBV, but negative for herpes-simplex virus, varicella-zoster virus, cytomegalovirus, and toxoplasma gondii. Histopathologic analysis of vitreous cells revealed atypical lymphocytes.

CONCLUSIONS

Epstein-Barr virus may be a cause of retinal disease. Awareness of this severe ocular complication may enable prompt diagnosis and treatment of future cases, and promote greater investigation into its disease prevalence.

Genotypic Detection of Epstein Barr Virus from Clinically Suspected Viral Retinitis Patients in a Tertiary Eye Care Centre, India

PURPOSE

To evaluate the diagnostic value of PCR on aqueous humour for detection and genotyping of Epstein Bar Virus in patients with viral retinitis.

METHODS

70 AH samples were collected from 20 HIV positive patients with clinically suspected viral retinitis and 25 patients with serpignous choroiditis and 25 AH from patients undergoing cataract surgery. PCR was performed to screen HHV-1 to HHV-5, Mtb and Toxoplasma gondii. Genotype prevalence was confirmed by phylogenetic analysis targetig EBV.

RESULTS

EBV was detected in 17 (37.7%) samples. Genotyping to subtype EBV, revealed the circulation of only one subtype (Type 1). PCR results for other infective agents were negative except for the presence of CMV in 5 (11.1%) AH.

CONCLUSION

The application of PCR to detect genotypes can be used as an epidemiological tool for clinical management. To our knowledge this is the first report on genotyping of EBV performed on intra ocular samples.

A case of unilateral optic disc swelling with chronic active Epstein-Barr virus infection

Ocular complications of chronic active Epstein-Barr virus (EBV) infection have rarely been reported and are usually associated with systemic symptoms. We described a 17-year-old boy with unilateral optic disc swelling without any systemic symptoms at the initial onset. Antibody titers to EBV were markedly elevated. Treatment with immunosuppressants and corticosteroids dramatically relieved all his symptoms, including unilateral optic swelling and visual field abnormalities.

Quantitative PCR for the detection of genomic DNA of Epstein-Barr virus in ocular fluids of patients with uveitis

PURPOSE

To measure the genomic DNA from Epstein-Barr virus (EBV) in ocular fluids and to analyze the clinical relevance of EBV in uveitis.

METHODS

Intraocular fluids (30 aqueous humor and 30 vitreous fluid samples) were taken from 55 patients with uveitis after informed consent was obtained. Samples were assayed for EBV DNA using qualitative multiplex polymerase chain reaction (PCR) and quantitative real-time PCR. Antibodies to EBV were examined using a complement fixation test.

RESULTS

EBV DNA was detected in 17 of 60 samples (28%) and 16 of 55 patients (29%) using multiplex PCR. However, only three of the 17 samples showed significantly high copy numbers of EBV DNA with real-time PCR. EBV DNA was not detected in the serum of all patients. EBV-specific antibodies were positive in the serum of all patients, but not in the vitreous fluid. Vitreous anti-EBV antibodies were positive only in patients displaying genomic DNA of EBV in the vitreous samples.

CONCLUSIONS

EBV DNA was detected by qualitative PCR in ocular fluids of many uveitis patients, but only a small proportion of patients showed high viral loads on quantitative real-time PCR, indicating that replication of the virus takes place only in a few patients.

The eye in systemic infection

Bacterial, fungal, viral, and parasitic pathogens all cause systemic infection and can spread to the eye. Dissemination of pathogens via the bloodstream can lead to direct involvement of the eye. Visual loss is common in bacterial or fungal endophthalmitis, and toxoplasmosis is a major cause of ocular morbidity and poor vision after congenital or acquired infection. Some infections cause intraocular damage by indirect mechanisms (eg, HIV-mediated immunosuppression), leading to opportunistic infections such as cytomegalovirus infection, periocular nerve involvement due to leprosy, and hypersensitivity reactions in tuberculosis. Eye symptoms might indicate the outcome of an underlying infection, such as development of retinal ischaemia in severe malaria, which is associated with a poor prognosis. Successful outcome for patients with ocular infection depends on close collaboration between clinicians identifying and treating underlying disease, specialist ophthalmic review, and ophthalmic interventional skills (when needed).

Virus infections of the eye

In reviewing the clinical features, diagnostic evaluations and therapies of the most common ocular viral infections we attempt to whet your appetite for attacking the numerous challenges in diagnosis and treatment of viral eye disease. The herpes viruses, HSV, VZV and CMV are the cause of significant ocular morbidity. HSV most commonly affects the cornea producing keratitis that can be recurrent and may lead to corneal clouding and neovascularisation. Manifestations can be purely infectious or immunological and treatment options must be tailored to the underlying pathophysiology. Herpes zoster ophthalmicus, caused by VZV infection of the first branch of the trigeminal nerve, produces a characteristic rash and can progress to keratitis and uveitis. HSV and VZV can cause retinitis in both immunocompetent and immunocompromised individuals. There has been a significant increase in the incidence of CMV retinitis since the beginning of the AIDS epidemic. We review the numerous new treatments, diagnostic tests and treatment strategies which have been developed in response to this potentially blinding retinal infection. Adenovirus produces an epidemic conjunctivitis and epidemic keratoconjunctivitis which are severe and extremely contagious conjunctival infections. HIV, molluscum contagiosum, EBV and rubeola also cause ocular diseases which are described.Copyright 1998 John Wiley & Sons, Ltd.

Increased presence of Epstein-Barr virus DNA in ocular fluid samples from HIV negative immunocompromised patients with uveitis

AIMS

To investigate whether routine testing for Epstein-Barr virus (EBV) is necessary in the examination of a patient with uveitis.

METHODS

Intraocular EBV DNA was determined in 183 ocular fluid samples taken from patients with AIDS and uveitis, HIV negative immunocompromised uveitis, acute retinal necrosis, toxoplasma chorioretinitis, intraocular lymphoma, anterior uveitis, and miscellaneous uveitis of unknown cause. In 82 samples from this group of patients paired serum/ocular fluid analysis was performed to detect local antibody production against EBV. Controls (n = 46) included ocular fluid samples taken during surgery for diabetic retinopathy, macular pucker, or cataract.

RESULTS

Serum antibody titres to EBV capsid antigen proved to be significantly increased in HIV negative immunocompromised patients with uveitis (p < 0.01) compared with controls. Local antibody production revealed only three positive cases out of 82 patients tested, two results were borderline positive and one patient had uveitis caused by VZV. EBV DNA was detected in three out of 46 control ocular fluid samples. In the different uveitis groups EBV DNA was noted, but was not significantly higher than in the controls, except in six out of 11 HIV negative immunocompromised patients (p = 0.0008). In four out of these six cases another infectious agent (VZV, HSV, CMV, or Toxoplasma gondii) had previously been identified as the cause of the uveitis.

CONCLUSIONS

When comparing various groups of uveitis patients, EBV DNA was found more often in HIV negative immunocompromised patients with uveitis. Testing for EBV does not have to be included in the routine management of patients with uveitis, since indications for an important role of this virus were not found in the pathogenesis of intraocular inflammation.

Detection of Epstein-Barr virus genome in ocular tissues

BACKGROUND

Epstein-Barr virus (EBV) is a ubiquitous mucosal pathogen with a propensity for lifelong, asymptomatic persistence. Because of reported association between EBV and ocular inflammatory disorders, we tested ocular tissues from normal eyes for presence of the EBV genome.

METHODS

Ten freshly harvested cadaveric human eyes were dissected into limbal cornea, central cornea, aqueous humor, iris, vitreous humor, and optic nerve. Total cellular DNA preparations were screened for DNA sequences specific to EBV's large internal repeat region. After Southern transfer, polymerase chain reaction products were detected by a 32P-labeled oligonucleotide probe specific to amplified sequences internal to the polymerase chain reaction primers.

RESULTS

Seven of ten eyes from deceased donors yielded a polymerase chain reaction product, indicating presence of EBV genome. In all, 12 (20%) of 60 cadaveric ocular samples contained EBV DNA. Only the optic nerve was consistently negative for EBV DNA.

CONCLUSIONS

Detection of EBV DNA in cadaveric ocular tissues indicates a broad anatomic distribution of this persistent mucosal pathogen. The frequency with which EBV was found at apparently normal ocular sites raises the possibility for viral involvement in disease states, but emphasizes the need for specific criteria to implicate EBV in ocular pathology.

Posterior subcapsular cataracts associated with megestrol acetate therapy

Megestrol acetate, used for eight weeks as an appetite stimulant in a man infected with human immunodeficiency virus, was associated with the development of bilateral posterior subcapsular cataracts. We propose that the glucocorticoid properties of megestrol were contributory. Complicating this association, the patient developed cytomegalovirus retinitis approximately six weeks after the cataracts were recognized.

Systemic antiviral drugs used in ophthalmology

Over the past two decades, the recognition of viral enzymes and proteins that can serve as molecular targets of drugs has revolutionized the treatment of viral infections. Beginning with acyclovir, a number of systemically administered agents which are both relatively safe and effective for the treatment of herpetic infections and human immunodeficiency virus (HIV) infections have become widely available. Because of increased numbers of herpes virus infections, as well as the rising epidemic of HIV infections, the ophthalmologist is, more likely than ever before to be involved in the treatment of severe and frequent ocular infections caused by herpes viruses. In addition, the acute retinal necrosis (ARN) syndrome has been demonstrated to be caused by herpes viruses and a once rare retinal infection caused by cytomegalovirus is common in patients with the acquired immunodeficiency syndrome (AIDS). In this article, four systemic antiviral drugs (Vidarabine, Acyclovir, Ganciclovir, and Foscarnet) that have demonstrated usefulness in the treatment of ophthalmic disease are reviewed in detail with regard to their mechanisms, applications, effectiveness, and side effects.

Conjunctival lymphocytic nodule associated with the Epstein-Barr virus

Infection with Epstein-Barr virus has been reported to have numerous systemic and ocular manifestations. In this study, a 38-year-old man with acute infectious mononucleosis was examined for a painless left red eye of three days' duration. The patient had a two-week history of fatigue, low-grade fever, sore throat, and lymphadenopathy. Serologic evaluation was indicative of an acute primary infection with Epstein-Barr virus. A large, salmon-colored, supranasal bulbar conjunctival mass was observed in the left eye. No associated conjunctivitis was present. Biopsy of the conjunctival lesion disclosed a dense leukocytic infiltrate, which consisted primarily of mature lymphocytes and plasma cells. Immunocytochemical evaluation of the tissue with monoclonal antisera disclosed Epstein-Barr latent membrane protein and nuclear protein 2 in a small fraction of the cells constituting the infiltrate. The conjunctival infiltrate resolved completely within one month, paralleling the regression of the patient's lymphadenopathy.

Three cases of EB virus-associated uveitis

We report our experience with three cases of Epstein-Barr virus (EBV)-associated uveitis. These patients had the following common clinical features: 1) a common cold-like prodrome, 2) bilateral involvement, 3) severe acute anterior uveitis with fibrinous exudate, 4) granulomatous anterior uveitis in the chronic stage, 5) little vitreous inflammation, 6) marked hyperemia and edema of the disc, 7) sunset glow fundus developed very early, 8) a good response to steroids but recurrence was common, 9) good final visual acuity, 10) no systemic changes in the course of the uveitis. High EBV IgG VCA antibody titers were found in the aqueous humor in all three cases (case 1, 1: 40; case 2, 1: 160; case 3, 1: 20). As controls, 37 cataract patients and 14 patients with various types of uveitis were examined for EBV antibodies in the aqueous humor. The result was negative in every case. On the basis of these data, the uveitis in these three patients appears to represent a new clinical entity: uveitis caused by EBV.

Ocular disease associated with Epstein-Barr virus infection

Epstein-Barr virus (EBV) is a ubiquitous DNA virus of the herpesvirus genus with a high prevalence rate for antibody (about 90%) in the adult population. It is the most common causative agent of infectious mononucleosis syndrome. During recent years an increasing number of ocular disease entities have been reported to be linked to EBV infection. These entities include oculoglandular syndrome, conjunctivitis, dry eye, keratitis, uveitis, choroiditis, retinitis, papillitis and ophthalmoplegia. While EBV-specific serologic tests can now document recent and past primary infection with EBV and also identify patients manifesting atypical immunologic reactions to EBV, the lack of an animal model, the absence of clear-cut response to therapy and the paucity of documentation by culture render the pathogenesis uncertain or the association questionable in many of these cases.

Detection of herpes viral genomes in normal and diseased corneal epithelium

Herpetic ocular disease is one of the major causes of corneal blindness. Clinical diagnosis of corneal disease is based principally on corneal appearance. However, abnormal morphology of the corneal epithelium (CE) is not an indicator for the presence of a herpes virus. Further, it has not been established if herpes viruses are present in normal corneal epithelial tissue. In these studies, the polymerase chain reaction was used to evaluate normal and diseased corneal epithelium for the presence of herpes simplex virus type 1 (HSV-1), Epstein-Barr virus (EBV) and cytomegalovirus (CMV) genomic sequences. Thirty-two normal corneal epithelium specimens obtained from cadavers shortly after death were analyzed for HSV-1, EBV and CMV genomic sequences. Three of the 32 normal CE specimens were positive for amplified EBV DNA, 1 was positive for HSV-1 DNA, and none was positive for CMV DNA. We also tested eight herpetic dendritic lesions of which 3 were HSV-1 culture and PCR positive. The remaining five dendritic lesions were HSV-1 culture and PCR negative. Since these lesions were not evaluated for other herpesviruses, the etiology of these dendritic lesions is unknown. Six corneal epithelium samples from HIV-infected donors were negative for EBV, CMV and HSV-1 amplified sequences. Positive EBV, CMV and HSV-1 serology on all normal donors and on donors with clinically apparent disease did not correlate with positive PCR results. The results of these studies suggest that EBV and HSV-1 DNA can be amplified from a small percentage of apparently normal corneal epithelium.

Detection of Epstein-Barr virus genomes in normal human lacrimal glands

Epstein-Barr virus (EBV) has been implicated in several ocular diseases; however, detection of the EBV genome in ocular tissues has not been documented. We report the detection of amplified EBV genomic sequences in 11 of 26 normal lacrimal gland DNA samples by using the polymerase chain reaction. Serum was available for 19 of the lacrimal gland donors. All 19 were EBV seropositive, although of the 19 lacrimal gland-seropositive patients, EBV sequences were detected in only 10 of the samples. Further, amplified EBV sequences were not detected in circulating lymphocyte DNA from normal seropositive volunteers, most likely because of the low frequency of circulating EBV-infected B cells. Amplification of EBV from cadaver lacrimal gland DNA was possible with minute quantities of DNA, whereas peripheral blood mononuclear cell DNA from normal volunteers did not amplify EBV sequences. Interestingly, the peripheral blood mononuclear cell polymerase chain reactions contained approximately 100 times more DNA than the lacrimal gland polymerase chain reactions. We conclude that the lacrimal gland may be a site for EBV persistence and that positive EBV serology is not an indicator of which individuals may have EBV harbored within their lacrimal glands.

Retinochoroiditis in acute Epstein-Barr virus infection

The case is reported of a 17-year-old male with secondary glaucoma and retinochoroiditis complicating acute clinical infectious mononucleosis. The diagnosis was confirmed by Epstein-Barr virus specific serology. Toxoplasmic infection was initially suspected. The differential diagnosis and relevant literature are discussed.

Acute multifocal hemorrhagic retinal vasculitis

The authors present a series of seven patients with acute visual loss associated with mild anterior uveitis, multifocal retinal vasculitis, retinal capillary nonperfusion, retinal hemorrhage, disc swelling, and vitreitis. Oral prednisone was of some benefit in these patients and oral acyclovir was generally ineffective. Neovascular complications including retinal, disc, choroidal, and iris new vessels were common, requiring photocoagulation in five patients. Horseshoe tears developed in two patients in zones of uninvolved retina but retinal detachment did not occur. The etiology remains unknown, although it may represent either a localized ocular form of Behçet's disease or other systemic syndrome, infection with a herpes group virus other than zoster varicella virus, or a manifestation of an undefined infectious agent.

Corneal subepithelial infiltrates associated with systemic Epstein-Barr viral infection

Corneal subepithelial infiltration resembling adenoviral keratitis developed in two patients with serologic evidence of systemic Epstein-Barr viral (EBV) infection and nondetectable antibody levels for adenovirus (ADV). These cases suggest that EBV is capable of mimicking more commonly recognized corneal infectious disease entities.