Comparison of visual field defect progression in secondary Glaucoma due to anterior uveitis caused by three types of herpes viruses

CMV-Related Anterior Uveitis in a Mediterranean European Population: Clinical Features, Prognosis, and Long-Term Treatment Outcomes

PURPOSE

To describe the spectrum of clinical features of cytomegalovirus-related anterior uveitis (CMV-AU) along with potential comorbidities, to calculate complication rates, and to determine risk factors and biomarkers affecting prognosis in a cohort of a Southern European Mediterranean population.

MATERIALS AND METHODS

It is a retrospective, multicenter case series of consecutive patients with persisting hypertensive AU, unresponsive to topical steroids therapy, and CMV-positive essays from two uveitis referral centers were collected and analyzed.

RESULTS

Fifty-seven eyes of 53 patients with polymerase chain reaction-verified CMV-AU over a period of 8 years were included with a mean age of 48 ± 18. Four presentation patterns were identified: 26.3% as Posner-Schlossman-like, 31.6% as chronic AU, 19.3% as presumed herpetic uveitis, 12.3% as Fuchs uveitis syndrome-like, and 10.5% without specific initial classification. About 15.8% received oral valganciclovir, 22.8% received topical valganciclovir, and 61.4% received both, for a mean duration of treatment of 44 months. AU recurrences were observed in 23 eyes with a mean of 1.5 (±1.5) recurrences per year. The only finding significantly associated with recurrence was the presence of posterior synechiae (PS) (p = 0.034). Fewer keratic precipitates (KPs) were indicative for the need of longer treatment, and endotheliitis was strongly associated with the need for filtration surgery.

CONCLUSION

In this immunocompetent southern European population, four distinct clinical presentation patterns were further confirmed, and possible biomarkers such as PS, KPs, and endotheliitis were newly reported to influence treatment outcomes. Large-scale studies could provide a more effective customized treatment protocol.

Viral infections and pathogenesis of glaucoma: a comprehensive review

Glaucoma is a leading cause of irreversible blindness worldwide, caused by the gradual degeneration of retinal ganglion cells and their axons. While glaucoma is primarily considered a genetic and age-related disease, some inflammatory conditions, such as uveitis and viral-induced anterior segment inflammation, cause secondary or uveitic glaucoma. Viruses are predominant ocular pathogens and can impose both acute and chronic pathological insults to the human eye. Many viruses, including herpes simplex virus, varicella-zoster virus, cytomegalovirus, rubella virus, dengue virus, chikungunya virus, Ebola virus, and, more recently, Zika virus (ZIKV) and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), have been associated with sequela of either primary or secondary glaucoma. Epidemiological and clinical studies suggest the association between these viruses and subsequent glaucoma development. Despite this, the ocular manifestation and sequela of viral infections are not well understood. In fact, the association of viruses with glaucoma is considered relatively uncommon in part due to underreporting and/or lack of long-term follow-up studies. In recent years, literature on the pathological spectrum of emerging viral infections, such as ZIKV and SARS-CoV-2, has strengthened this proposition and renewed research activity in this area. Clinical studies from endemic regions as well as laboratory and preclinical investigations demonstrate a strong link between an infectious trigger and development of glaucomatous pathology. In this article, we review the current understanding of the field with a particular focus on viruses and their association with the pathogenesis of glaucoma.

Herpetic Anterior Uveitis Multicentre Longitudinal Study (The UVHER Project). Baseline Characteristics

PURPOSE

The aim of the UVHER project is to evaluate the risk of development of optic nerve damage in patients with herpetic anterior uveitis (AU) prospectively followed over 2 years. Herein, we described the baseline characteristics.

METHODS

This is a multicentre, prospective study. An aqueous humour tap was performed. Only patients with a positive PCR were included. Clinical characteristics, optical coherence tomography (OCT) parameters and visual field (VF) abnormalities were registered.

RESULTS

27 patients were included: 18 Herpes Simplex (HSV), one Varicella Zoster (VVZ), and 8Cytomegalovirus (CMV). Patients with HSV-AU had severe inflammation, iris atrophy and corneal involvement. In patients with CMV-AU, less inflammation and medium-to-large keratic precipitates were observed. OCT showed a thinner RNFL and GCL in CMV-AU patients in comparison to HSV patients. VF showed abnormalities in six cases.

CONCLUSIONS

Patients in the UVHER cohort showed the typical clinical manifestations of herpetic AU. In CMV patients, optic nerve damage was observed at baseline, and in HSV patients, inflammation was more severe.

Anterior Uveitis Associated with Human Herpesvirus 7 Infection Diagnosed by Multiplex Polymerase Chain Reaction Assay: A Case Report

BACKGROUND

Herpetic anterior uveitis (AU) is usually caused by the herpes simplex virus, varicella-zoster virus, and cytomegalovirus. Herein, we report a case of herpetic AU associated with human herpesvirus 7 (HHV-7) infection.

STUDY DESIGN

A case report.

CASE PRESENTATION

A 49-year-old female patient presented with complaints of blurred vision and hyperemia in the right eye. Slit-lamp examination revealed bilateral fine and a few small white keratic precipitates (KPs), Descemet membrane folds in the right eye, and severe and mild cellular infiltration in the anterior chamber of the right and left eye, respectively. HHV-7 viral DNA was detected by a polymerase chain reaction assay of an aqueous humor sample. The AU improved significantly with topical steroids.

CONCLUSION

We report a rare case of herpetic AU characterized by fine and small white KPs in which only HHV-7 DNA was detected in the aqueous humor.

Glaucoma control after phacoemulsification in eyes with functioning glaucoma filtration surgeries: trabeculectomies versus glaucoma drainage devices

PURPOSE

Several studies have demonstrated decompensation of intraocular pressure (IOP) control following phacoemulsification in eyes with a functioning trabeculectomy. Limited evidence base suggests that this effect is minimal in eyes with functioning glaucoma drainage devices (GDD). The aim of this study was to report on glaucoma control after phacoemulsification in eyes with a functioning GDD compared to eyes with a functioning trabeculectomy.

METHODS

Single-centre retrospective comparative study of patients with a functioning non-valved GDD (Baerveldt 350; Johnson & Johnson Surgical Vision) or trabeculectomy undergoing phacoemulsification. Glaucoma outcomes including IOP, cup:disc ratio (CDR), global retinal nerve fibre layer (RNFL) thickness and visual field mean deviation (MD) are reported. Failure was defined as IOP rise > 20% from baseline.

RESULTS

Fifteen eyes with a functioning trabeculectomy and twenty-three eyes with a functioning GDD with 24-month post-phacoemulsification data were identified. Mean IOPs were significantly lower in the trabeculectomy group at month 24 compared to the GDD group, 9.5 and 15.9 mmHg (p = 0.001) respectively. At month 12, there was significant worsening on MD in GDD group compared to trabeculectomy group, - 20.0 dB and - 11.3 dB respectively (p = 0.03). A greater proportion of eyes failed in the GDD group compared to the trabeculectomy group, N = 15 (65%) and n = 7 (47%), p = 0.26.

CONCLUSION

As with functioning trabeculectomies, phacoemulsification should be approached with similar caution in eyes with functioning GDD. An existing GDD is at least as likely to fail following clear corneal phacoemulsification as an existing trabeculectomy and non-augmented GDDs may be at greater risk.

The beneficial impact of filtration surgery on antiviral therapy cessation in patients with cytomegalovirus-related secondary glaucoma

Purpose

Cytomegalovirus (CMV)-related keratouveitis elevates intraocular pressure (IOP). Antiviral therapy does not always control IOP and some patients do not tolerate systemic antiviral therapy because of the side effects. The purpose of this study is to evaluate the clinical characteristics of patients with CMV-related keratouveitis and determine the impact of glaucoma surgeries on the postoperative antiviral therapy regimen.

Methods

We enrolled twenty-two patients with CMV-DNA-positive keratouveitis between June 2012 and July 2019 in Kobe University Hospital. The following clinical parameters were collected: gender, age, history of previous intraocular surgery, antiviral medications, visual acuity, IOP, glaucoma drug score, corneal endothelial cells density, and the mean deviation of a Humphrey visual field test at the first visit and before and 1 year after glaucoma surgery.

Results

All twenty-two patients started on oral and/or topical antiviral therapy. Eighteen patients needed glaucoma surgery despite their antiviral medications. Nine patients underwent trabeculotomy (TLO) and nine underwent trabeculectomy (TLE) as the first surgical intervention. Six of patients who initially underwent TLO and two of the patients who initially underwent TLE required additional TLE within 1 year. Each of the 15 patients who underwent at least 1 TLE showed a reduction in the magnitude and variation of IOP and glaucoma drug scores and 13 patients were able to discontinue antiviral therapy. For the remaining 4 patients, IOP and inflammation were controlled but with antiviral medications.

Conclusions

In patients with CMV-related keratouveitis, TLE decreases and stabilizes IOP and contributes to withdrawal from antiviral medications.

Clinical features of uveitis in elderly patients in central Tokyo (2013-2018)

PURPOSE

To clarify the clinical features of uveitis in elderly patients in central Tokyo.

METHODS

We retrospectively identified 1424 patients with uveitis who visited the Uveitis Clinic of the University of Tokyo Hospital between January 2013 and December 2018. The patients were categorized into two groups based on their ages at the time of disease onset: patients aged 65 years or older were included in Group A, whereas those younger than 65 years were included in Group B. The etiological classification of uveitis and its causes were investigated for each group.

RESULTS

Group A presented significantly higher rates of infectious uveitis (35.5% vs. 17.8%, p < 0.0001) and masquerade syndromes (17.9% vs. 5.0%, p < 0.0001) than Group B. Furthermore, Group A had significantly higher rates of sarcoidosis (23.1% vs. 9.3%, p < 0.0001), intraocular lymphoma (16.6% vs. 4.6%, p < 0.0001), cytomegalovirus iritis (11.0% vs. 5.6%, p = 0.0043), and cytomegalovirus retinitis (5.2% vs. 1.5%, p = 0.0020) than Group B.

CONCLUSION

Our results demonstrate a clear difference in the causative diseases of uveitis between elderly and non-elderly patients. These findings may support ophthalmologists in their diagnostic process for elderly patients with uveitis.