Anterior segment involvement in Epstein-Barr virus: a review

Clinical strategies to prevent recurrence of Herpes simplex and Herpes zoster following ocular surgery: A comprehensive review with practical guidelines

Recurrences of herpetic infections following intraocular surgeries pose a threat to optimal surgical outcomes. The high prevalence of herpetic diseases require ophthalmologists to be familiar with the special measures in the surgery of these patients. A thorough preoperative assessment and meticulous postoperative surveillance should be tailored for each patient, depending on the surgery and the risk of virus reactivation. We compile the relevant evidence in the literature and provide a comprehensive review of the preoperative assessment and postoperative diagnostic clues and management of the herpetic infections following different types of intraocular surgeries, including cataract surgery, keratoplasty, corneal crosslinking, glaucoma, and refractive surgeries.

Possible viral agents to consider in the differential diagnosis of blepharoconjunctivitis

BACKGROUND

Blepharoconjunctivitis poses a diagnostic challenge due to its diverse etiology, including viral infections. Blepharoconjunctivits can be acute or chronic, self-limiting, or needing medical therapy.

AIM

To review possible viral agents crucial for accurate differential diagnosis in cases of blepharoconjunctivitis.

METHODS

The PubMed database was searched for records relating to viral blepharoconjunctivitis. The search string generated was "("virally"[All Fields] OR "virals"[All Fields] OR "virology"[MeSH Terms] OR "virology"[All Fields] OR "viral"[All Fields]) AND "Blepharoconjunctivitis"[All Fields]".

RESULTS

A total of 24 publications were generated from the search string. Reference lists from each relevant article were also searched for more information and included in this review. Viral etiologies such as adenovirus, herpes simplex virus (HSV), varicella-zoster virus (VZV), and Epstein-Barr virus (EBV) are frequently implicated. Adenoviral infections manifest with follicular conjunctivitis and preauricular lymphadenopathy, often presenting as epidemic keratoconjunctivitis. HSV and VZV infections can result in herpetic keratitis and may exhibit characteristic dendritic corneal ulcers. EBV, although less common, can cause unilateral or bilateral follicular conjunctivitis, particularly in immunocompromised individuals. Other potential viral agents, such as enteroviruses and molluscum contagiosum virus, should also be considered, especially in pediatric cases.

CONCLUSION

Prompt recognition of these viral etiologies is essential for appropriate management and prevention of complications. Thus, a thorough understanding of the clinical presentation, epidemiology, and diagnostic modalities is crucial for accurate identification and management of viral blepharoconjunctivitis.

Etiological analysis of ocular herpes virus infection

OBJECTIVE

To do the etiological analysis of ocular herps virus infection, revealing the pathogen species and the distribution of different virus types within the eye.

METHODS

Samples were collected from 2017 to 2021 at the Department of Ophthalmology, Peking University Third Hospital and tested using real-time PCR for common ocular viruses: herpes simplex virus 1 (HSV-1), cytomegalovirus (CMV), varicella-zoster virus (VZV) and Epstein-Barr virus (EBV). The pathogenesis of the different viruses was classified and analyzed according to the site of infection.

RESULTS

Viral PCR detections were performed on 3627 samples collected over the 5-years and 649 (17.89%) samples contained one or more of the viruses tested. The overall detection rate of CMV was highest at 9.93%. Of all sample types, aqueous humor was the most common (1752 cases), of which 340 were positive (19.41% positive rate). Corneal samples were the next most common, with 1481 cases and 250 positive results (16.88% positive rate). CMV positivity was higher in aqueous humor and corneal samples than other viruses; vitreous body had the highest positive rate at 36.36% (20/55), among which 18 cases were VZV positive.

CONCLUSIONS

Distribution of virus types differed among infection sites, with CMV the most common virus type detected in the cornea and aqueous humor, while VZV was the most common virus detected in the vitreous body.

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.

Panuveitis by Coinfection with Toxoplasma gondii and Epstein Barr Virus. Should We Use Antiviral Therapy? - A Case Report

BACKGROUND

To report the atypical presentation and treatment in a case of Toxoplasma gondii (Tg) and Epstein Barr Virus (EBV) intraocular coinfection.

CASE PRESENTATION

A 60-year-old male patient who presented anterior hypertensive uveitis followed by a new finding of a yellowish-white fluffy retinochoroidal lesion in the superior-temporal quadrant. He was initially treated with antiviral therapy without improvement. Next, due to the Tg infection suspicion, anti-toxoplasmic treatment was added, and therapeutic and diagnostic vitrectomy was performed along with intravitreal clindamycin. Polymerase chain reaction (PCR) analysis in intraocular fluids confirmed Tg and EBV coinfection. Then, anti-Toxoplasma oral treatment and antiviral and oral corticosteroids were administrated, achieving improvement.

CONCLUSIONS

In a patient with atypical retinochoroidal lesions, an intraocular fluids PCR should be performed, in addition to the serological laboratories to rule out coinfection, confirm the diagnosis, and establish an appropriate treatment. Coinfection could impact the pathogenesis and prognosis of the disease.Abbreviations: OT: Ocular toxoplasmosis; Tg: Toxoplasma gondii; EBV: Epstein Barr Virus; CMV: Cytomegalovirus; HIV: Human Immunodeficiency Virus; HSV: Herpes Simplex Virus; VZV: Varicella Zoster Virus; PCR: Polymerase chain reaction; OD: Right eye; OS: Left eye; BCVA: best-corrected visual acuity.

Causes of infectious pediatric uveitis: A review

Infectious pediatric uveitis is a rare disease that can cause severe ocular damage if not detected rapidly and treated properly. Additionally, early identification of an infection can protect the child from life-threatening systemic infection. Infectious uveitis can be congenital or acquired and may manifest as a primary ocular infection or as a reactivation. Nevertheless, publications on infectious paediatric uveitis are usually limited to a small number of patients or a case report. So far, most studies on uveitis in children have focused primarily on noninfectious uveitis, and a systematic study on infectious uveitis is lacking. In this review, we summarize the literature on infectious uveitis in pediatric populations and report on the epidemiology, pathophysiology, clinical signs, diagnostic tests, and treatment. We will describe the different possible pathogens causing uveitis in childhood by microbiological group (i.e. parasites, viruses, bacteria, and fungi). We aim to contribute to early diagnosis and management of infectious pediatric uveitis, which in turn might improve not only visual outcome, but also the general health outcome.

Epstein-Barr virus-positive iris diffuse large B-cell lymphoma detected by metagenomic next-generation sequencing

PURPOSE

Epstein-Barr virus (EBV)-positive diffuse large B-cell lymphoma (DLBCL) is a relatively rare subtype of DLBCL. Herein, we report a case of a patient with EBV-positive iris DLBCL after undergoing penetrating keratoplasty and discuss its possible pathogenesis.

METHODS

A 72-year-old male patient presented to our hospital with progressive blurring of vision in the left eye for the past 4 months. Small white nodular lesions were observed on the iris and retinal surface of the left eye, with a white cloud-like opacity in the vitreous cavity.

RESULTS

The patient was eventually diagnosed with EBV-positive iris DLBCL after undergoing pathological and metagenomic tests. After injecting methotrexate in the left vitreous cavity and administering systemic and local antiviral treatments, the ocular lesions disappeared.

CONCLUSION

EBV infection, drug immunosuppression, and aging-related immune deterioration may play significant roles in the pathogenesis of EBV-positive iris DLBCL.

SYNOPSIS

Epstein-Barr virus (EBV)-positive diffuse large B-cell lymphoma (DLBCL) is a new subtype of DLBCL, which rarely occurs. Herein, we report a case of a patient with EBV-positive iris DLBCL after undergoing penetrating keratoplasty and discuss its possible pathogenesis.

PCR testing for herpesviruses in aqueous humor samples from patients with and without clinical corneal endothelial graft rejection

To compare prevalence of positive PCR tests for herpesviruses between patients with and without a history of clinical corneal endothelial allograft rejection (AGR). Retrospective cross-sectional study with two-group comparison. A total of 307 aqueous humor (AH) samples from 235 Patients and 244 eyes who underwent penetrating keratoplasty or Descemet membrane endothelial keratoplasty or had a diagnostic AH aspiration due to clinical AGR between 2019 and 2023 were tested for DNA of herpes simplex virus (HSV), varicella-zoster virus (VZV), cytomegalovirus (CMV), and Epstein-Barr virus (EBV). PCR test results were compared between the two groups (with/without AGR). Another sub-analysis examined the results of patients without a history of herpetic keratitis. A total of 8% of eyes with clinical AGR (9/108) had a positive PCR result for one of the herpesviruses (HSV:3, CMV:3, EBV:2, VZV:1). All patients in the group without AGR had negative PCR results for all previous viruses (0/136). The difference was statistically significant (p < 0.001). The sub-analysis of eyes without a history of herpetic keratitis also revealed significantly more positive herpes PCR results (7/87) in eyes with AGR than in eyes without AGR (0/42, p = 0.005). Clinical AGR after keratoplasty shows a significant correlation to viral replication. Herpetic infection and AGR could occur simultaneously and act synergistically. Timely differentiation between active herpetic infection and/or AGR is pivotal for proper treatment and graft preservation.

A Case of Epstein-Barr Virus Encephalitis and Orbital-Face Inflammation

Epstein-Barr virus (EBV) can cause follicular conjunctivitis, keratitis, oculoglandular syndrome, meningitis, and encephalitis. We report a 54-year-old Hispanic male who presented with right pupil-involved complete ophthalmoplegia, orbital and masticatory muscle inflammation, trigeminal enhancement, and new corneal infiltrate highly suggestive of EBV. Labwork was negative except for positive EBV polymerase chain reaction (PCR) in serum. Magnetic resonance imaging (MRI) of his brain and orbits with contrast showed enhancement of the right ganglion of the trigeminal nerve, oculomotor nerve, all extraocular muscles in the right orbit, and right masticatory and temporalis muscles and a right subacute lacunar infarct. The patient was diagnosed with encephalitis and orbital-face inflammation secondary to EBV infection. The patient improved with systemic steroids.

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.

Steroids in the Management of Infectious Keratitis

PURPOSE

To summarize the evidence base on the use of topical corticosteroids for infectious keratitis.

METHODS

Narrative review.

RESULTS

Infectious keratitis is a painful condition that often results in visually significant corneal stromal scarring, even when antimicrobial therapy is successful. Corticosteroids may reduce inflammation and subsequent scar formation and while relieving the acute ocular pain associated with a corneal ulcer. However, corticosteroids also reduce the host immune response, which could hinder the ability to clear infection. The safety and effectiveness of corticosteroids depends to a large part on the efficacy of the antimicrobials being used to treat the underlying infection. Randomized trials have found that corticosteroids are safe and effective for herpetic keratitis when used with appropriate antiviral therapy, and are safe for bacterial keratitis when used with broad spectrum topical antibiotics. The effectiveness of corticosteroids for bacterial keratitis has not been shown conclusively, although more advanced bacterial corneal ulcers may do better with corticosteroids. No randomized trials have assessed the safety and effectiveness of steroids for fungal or acanthamoeba keratitis. Animal studies suggest corticosteroids may be harmful in fungal keratitis, and observational human studies have found that steroids are harmful for fungal and acanthamoeba keratitis when started prior to anti-amoebics.

CONCLUSIONS

Topical corticosteroids, when used as an adjunct to antimicrobial therapy, may be beneficial if the antimicrobial being used can effectively clear or suppress the infection, such as in bacterial and herpetic keratitis. Randomized trials would be helpful to further delineate the role of corticosteroids for infectious keratitis.

Eyelid Edema May Be as a Sign of Dacryoadenitis in the Course of Epstein-Barr Virus Infectious Mononucleosis

Epstein-Barr virus (EBV) is a widespread virus that causes frequent, in many cases asymptomatic, infections. Mononucleosis is the most frequent clinical syndrome encountered during EBV infection. In rare cases, the disease can present at the onset with atypical signs that make an immediate diagnostic classification difficult. An example in this sense is the onset of dacryoadenitis with consequent eyelid edema. In these cases, it is difficult to immediately recognize this sign as referable to mononucleosis and it appears necessary to carry out a series of analyses aimed at excluding any other edematous causes. We describe below a clinical case of dacryoadenitis in the course of infectious mononucleosis and a review of similar cases described in the literature starting from 1952 (the year in which this sign was described for the first time). We counted 28 cases before ours, thus confirming the exceptional nature of this event.