Virus-associated anterior uveitis and secondary glaucoma: Diagnostics, clinical characteristics, and surgical options

Viral Anterior Uveitis: Differences in Retinal Vessel Area Density between the Affected and Non-Affected Eye Using Optical Coherence Tomography Angiography

PURPOSE

To investigate differences in the retinal vessel area density (VAD) on optical coherence tomography angiography (OCTA) between eyes with unilateral herpetic viral anterior uveitis (VAU) (herpes-simplex virus (HSV) and varicella-zoster virus (VZV)) and the non-affected fellow eye.

METHODS

In this monocentric, observational, prospective case series we analyzed the VAD of the macula, optic disc, and peripapillary region in affected and non-affected eyes of 22 patients with HSV-positive and 22 patients with VZV-positive VAU using OCTA. We analyzed also the visual field mean deviation (MD), the retinal nerve fiber layer (RNFL) thickness, Bruch's Membrane Opening-Minimum Rim Width (BMO-MRW), and ganglion cell layer (GCL) thickness on OCT and correlated the results with the different VADs.

RESULTS

The macular VAD in the superficial vascular plexus (SVC) was significant lower in the affected compared to the non-affected eye for both viruses (HSV: 33.0% ± 3.3% vs. 34.7% ± 2.6%, p = 0.011; adjusted p = 0.040; VZV: 33.1% ± 3.2% vs. 34.3% ± 2.8%, p = 0.012; adjusted p = 0.050). Additionally, the VAD of the peripapillary SVC differed between the affected and non-affected eye for VZV-positive VAU (47.1% ± 6.2% vs. 50.5% ± 6.3%, p = 0.048, adjusted p = 0.100). For both HSV-positive and VZV-positive VAU, there were correlations between macular or peripapillary SVC VAD and BMO-MRW, GCL thickness, RNFL thickness or MD of the affected eye.

CONCLUSION

We observed vascular dysfunction characterized by decreased macular and peripapillary VAD in the superficial plexus on OCTA in eyes with HSV- and VZV-positive VAU compared to non-affected fellow eyes. These changes might be an early sign of glaucomatous damage or may be a direct consequence of the herpes viruses themselves.

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.

Rubella virus-associated uveitis at a tertiary care hospital in Germany between 2013 and 2019

Uveitis is a process of intraocular inflammation that may involve different sections of the uveal tract. Apart from systemic or localized immune-mediated diseases, infections are key players in the etiology of uveitis and entail different treatment strategies. Rubella virus (RuV) is a recognized causative agent for the development of Fuchs uveitis, representing a major cause of virus-associated intraocular inflammation. A cohort of 159 patients diagnosed with different forms of uveitis between 2013 and 2019 was subjected to diagnostic antibody testing of the aqueous or vitreous humor. The diagnostic panel included RuV, cytomegalovirus, herpes simplex virus, varicella-zoster virus, and toxoplasmosis. Within this cohort, 38 RuV-associated uveitis (RAU) patients were identified based on a pathologic Goldman-Witmer coefficient indicative of an underlying RuV infection. With a mean age of 45.9 years, the RAU patients were younger than the non-RAU patients (56.3, p < 0.001). The evaluation of clinical parameters revealed a predominance of anterior uveitis and late sequalae such as cataract and glaucoma among the RAU patients. In 15 of the patients a history of prior RuV infections could be confirmed. The study underlines the importance of long-term surveillance of RuV associated diseases that originate from infections before the introduction of RuV vaccination programs.

Bleb Associated Xen Gel Stent Endophthalmitis: A Case Report and Review of Literature

PURPOSE

To report a case of a unique late complication of the Xen gel stent, stent-related endophthalmitis was preceded by flattening of the bleb.

CASE REPORT

A 63-year-old female was presented with late-onset endophthalmitis preceded by flattening of the bleb two years post-insertion of Xen gel stent. B-scan of the posterior chamber revealed vitritis and hyaloid condensation, with no viral, fungal, or bacterial pathologies identified on anterior chamber tap. The patient's eye responded to injections of intravitreal antibiotics.

CONCLUSION

Endophthalmitis can occur as late as 2 years after implantation of glaucoma drainage device implants (GDIs) like the Xen gel stent if bleb flattening or leaking leads to contact of the stent with the conjunctiva. Therefore, in case of blebs getting flat, ophthalmologists should watch them more often. Intravitreal antibiotics may also be effective rather than surgical removal in the case of a non-eroded stent complicated by endophthalmitis.

Two Year Outcomes of Trabeculectomy in Cytomegalovirus Anterior Uveitis with Uncontrolled Intraocular Pressure

PURPOSE

To describe the two-year outcome of trabeculectomy in cytomegalovirus(CMV) anterior uveitis(AU).

METHODS

Records of 29 eyes of 29 consecutive CMV AU patients undergoing MMC-augmented trabeculectomy for uncontrolled IOP despite maximal tolerated topical medications were retrospectively reviewed. Treatment success was defined as IOP≤21 mmHg with same or reduced number of IOP-lowering medications compared to baseline, without systemic acetazolamide or further interventions for uncontrolled IOP.

RESULTS

Treatment success was 79.3% (23/29) at 24 months. Both median IOP and number of IOP-lowering medications dropped significantly from baseline (p < .01 and p < .001, all time-points, Wilcoxon sign-rank test, respectively), with 63.2% and 19.0% reduction in AU relapse/year and steroid use(p = .001 and 0.03, respectively), without sight-threatening sequelae. At 24 months, AU frequency was not significantly different between successful cases with and without ≥12-month use of topical ganciclovir (p = .51, Mann-Whitney U test).

CONCLUSION

MMC-augmented trabeculectomy was efficacious for IOP control in nearly 80% of CMV AU cases over two years.

Overview and update on cytomegalovirus-associated anterior uveitis and glaucoma

Cytomegalovirus anterior uveitis is the most common ocular inflammatory disease caused by cytomegalovirus infection. It mainly occurs in middle-aged males with competent immunologic function, and the incidence is higher in Asia. The clinical manifestations vary from Posner-Schlossman syndrome and corneal endotheliitis to Fuchs uveitis syndrome, and are often accompanied by intraocular hypertension. Secondary glaucoma is a potentially blinding ocular complication with a pathogenesis that includes complicated immunological factors, intraocular inflammation, different types of angle abnormalities, and the administration of steroids, which may result in physical discomfort and visual impairment. Diagnostic tests, such as the polymerase chain reaction, optical coherence tomography, ocular microscopy, and confocal microscopy, might help in identifying anterior uveitis caused by other viruses. Combinations of antiviral medications and anti-inflammatory agents are effective treatments. If pharmacological therapy cannot reduce intraocular pressure or slow the progression of glaucomatous optic neuropathy, surgical intervention is required as a last resort.

Cytomegalovirus-Positive Posner-Schlossman Syndrome: Impact on Corneal Endothelial Cell Loss and Retinal Nerve Fiber Layer Thinning

PURPOSE

To report objective morphologic changes in cytomegalovirus (CMV)-positive Posner-Schlossman syndrome (PSS).

DESIGN

Retrospective, consecutive case series.

METHODS

We reviewed the charts of patients with unilateral PSS tested positive for CMV by Goldmann-Witmer coefficients between 2007 and 2018 at our tertiary eye clinic. We report data on corneal endothelial cell (CEC) count, peripapillary retinal nerve fiber layer (RNFL), choroidal thickness (CT) using optical coherence tomography (OCT) as well as clinical findings and management. The unaffected eye served as control.

RESULTS

Fifty-two eyes of 52 patients were included and followed for 32.8 ± 28.3 months. The peak intraocular pressure was 45 ± 11 mm Hg. The CEC (2241.7 ± 381.1 cells/mm² vs 2529.4 ± 351.9 cells/mm², P = .0004) and the global RNFL thickness (80.81 ± 21.01 µm vs 97.38 ± 9.75 µm, P = .0001) were significantly reduced, whereas CT was nonsignificantly higher (295.69 ± 45.46 µm vs 274.00 ± 67.85 µm, P = .156) in the affected eyes compared to the fellow eye. Forty (76.9%) patients were treated with oral valganciclovir (VGC), 2 (3.8%) with topical ganciclovir alone, and 10 (19.2%) received no antiviral therapy. Eight eyes (15.4%) underwent trabeculectomy with mitomycin C. After cessation of oral VGC, 23 patients (57.5%) had recurrences.

CONCLUSIONS

In our cohort, CMV-positive PSS was often associated with RNFL thinning and CEC loss. Highly elevated intraocular pressures usually present the most relevant challenge. In conjunction with aqueous humor sampling, monitoring by OCT scans and endothelial microscopy may help to guide therapy decisions.

Viral Anterior Uveitis

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.

Atypical associations of viral anterior uveitis with glaucoma-a series of challenging scenarios with review of literature

PURPOSE

To report unusual associations, atypical clinical presentations, and outcomes of tailored treatment of viral uveitis and glaucoma.

METHODS

Patients diagnosed with viral uveitis with associated glaucoma, seen at a tertiary eye care center between 2013 and 2020, were screened. Twenty-four patients with unclassified or atypical clinical presentations of viral uveitis, atypical clinical course, or with diagnostic challenges and associated glaucoma, were included. Patients with classical features of viral anterior or posterior uveitis, other forms of autoimmune/infectious/traumatic uveitis, were excluded.

RESULTS

Viral re-activation causing recurrent choroidals after glaucoma filtering surgery responsive to systemic antiviral therapy, massive pigment dusting/plume as a presenting feature, multiple progressive focal anterior synechiae similar to iridocorneoendothelial (ICE) syndrome, were seen in this cohort of unusual viral uveitis in glaucoma. A high index of suspicion helped diagnose a viral etiology in cases with high intraocular pressure (IOP) after uneventful Ahmed glaucoma valve surgery (AGV) or post-YAG capsulotomy laser, presumed Posner-Schlossman syndrome with multiple recurrences or presumed steroid glaucoma. All patients responded well with anti-viral and tailored concomitant steroids, anti-glaucoma therapy with loss of visual acuity seen in one eye developing optic atrophy.

CONCLUSIONS

Uncommon clinical presentations or associations of viral uveitis in glaucoma should be kept in mind. A high index of suspicion and tailored prompt treatment may ensure good outcomes preventing further visual morbidity in glaucoma.

Epidemiology of Viral Induced Anterior Uveitis

Purpose: Viral agents are the most common cause of infectious anterior uveitis worldwide. The purpose of this review is to analyze the frequency, gender and racial differences of viral anterior uveitis (VAU) in various populations.Methods: Systematized literature review of epidemiological reports of VAU cited in PubMed, EMBASE and the Cochrane Library database published until June 30th, 2020.Results: A total of 12 clinical studies on epidemiology of definite VAU and 36 clinical studies of presumed VAU were identified. Members of Herpesviridae family represent the most common causes of VAU. Other less frequently reported causes, such as rubella and endemic viruses (HTLV-1, Chikungunya, Dengue, Ebola, Zika virus) were also analyzed.Conclusion: HSV, VZV are prevalent worldwide. CMV is more frequent in Asia, and rubella in the West. However, due to globalization and air travel, HTLV-1, Chikungunya, Dengue and Ebola may become important causes of VAU across the world.

Peripapillary retinal nerve fiber layer and ganglion cell-inner plexiform layer changes on optical coherence tomography in patients with unilateral hypertensive cytomegalovirus anterior uveitis

PURPOSE

To investigate whether peripapillary retinal nerve fiber layer (pRNFL) and macular ganglion cell-inner plexiform layer (GCIPL) thinning are present in patients with unilateral hypertensive Cytomegalovirus anterior uveitis (hCMV AU).

METHODS

We included 19 eyes with unilateral hCMV AU and their unaffected fellow eyes as the control group in this study. Peripapillary RNFL and macular GCIPL changes were determined using spectral-domain (SD) - optical coherence tomography (OCT).

RESULTS

The overall calculated mean pRNFL thickness was significantly lower in the effected eyes with hCMV AU than in the uneffected fellow eyes (p = 0.012). The mean macular GCIPL thickness in the affected eyes was also significantly lower than in the normal eyes (p < 0.001).

CONCLUSION

Measurement of pRNFL and macular GCIPL thickness with OCT may detect signs of damage before the visual field changes in patients with hypertensive CMV AU. Early aggressive treatment in these patients may prevent further glaucomatous damage.