Systemic viral infections and their retinal and choroidal manifestations

Cytomegalovirus as a Cause of Anterior Uveitis in Immunocompetent Patients

PURPOSE

To describe 7 cases of unilateral, chronic and/or recurrent anterior uveitis caused by cytomegalovirus (CMV) in immunocompetent patients; to identify specific ophthalmologic characteristics; and to evaluate the clinical effect of valganciclovir treatment.

DESIGN

Retrospective observational case series.

PARTICIPANTS

Immunocompetent patients (n = 7) with a history of chronic and/or recurrent unilateral anterior uveitis and a positive analysis for either CMV-DNA and/or antibodies against CMV in their aqueous humor (Goldmann-Witmer coefficient > 3).

METHODS

Full ophthalmologic examination, anterior chamber fluid analysis, serologic examination, and systemic evaluation. Treatment modalities included topical steroids, topical and/or systemic antiglaucoma medications, glaucoma surgery, and systemic valganciclovir.

MAIN OUTCOME MEASURES

Visual acuity, inflammation, and intraocular pressure (IOP).

RESULTS

Chronic unilateral anterior uveitis was seen in 6 patients, whereas recurrent uveitis was observed in 1. Additional findings consisted of slight iris atrophy and secondary glaucoma (n = 3), secondary glaucoma without iris abnormalities (n = 3), and a slightly elevated IOP without iris abnormalities (n = 1). Examinations of the aqueous humor by polymerase chain reaction demonstrated CMV-DNA in 6 patients and were negative for other herpes viruses in all. Goldmann-Witmer coefficients were strongly positive in 4 out of 5 patients. Other laboratory investigations were within normal limits. No other causes for uveitis were identified. Because of the insufficient effect of topical steroids and antiglaucoma medications, 5 patients were treated with additional oral valganciclovir with good clinical response in terms of uveitis activity and IOP. Discontinuation of valganciclovir in 1 patient resulted in a prompt recurrence of uveitis activity.

CONCLUSIONS

Cytomegalovirus may cause a chronic and/or recurrent anterior uveitis in otherwise healthy patients. Iris atrophy and glaucoma may accompany it, but an inflammatory reaction in the anterior chamber may be the only sign. Aqueous humor analysis is of the utmost importance in differentiating between CMV and other herpes viruses and in making a definite diagnosis in chronic anterior uveitis. Valganciclovir may be very effective in treating CMV anterior uveitis, but its exact role can only be determined in larger studies with a longer follow-up.

Kinetics of aqueous flare, intraocular pressure and virus-DNA copies in a patient with cytomegalovirus iridocyclitis without retinitis

BACKGROUND

A case report of recurrent unilateral granulomatous iridocyclitis with ocular hypertension without retinitis caused by cytomegalovirus (CMV) in an immunocompetent patient.

METHODS

Aqueous humor was analysed by multiplex PCR to detect viral DNA, and real-time PCR was used to evaluate virus copies before and after anti-virus treatments. Inflammation of the anterior chamber was evaluated by a laser flare photometry.

RESULTS

Genomic DNA of CMV - but not of other herpes viruses - was detected in the aqueous humor. Quantitative real-time PCR revealed 2.3 x 10(5) copies/ml of CMV DNA from the specimen. Oral valganciclovir was added to the ongoing treatment, which consisted of topical corticosteroid, timolol and latanoprost as well as systemic acetazolamide, resulting in the reduction of aqueous flare correlated with the reduction of virus copies in aqueous humor.

CONCLUSIONS

In this case of CMV-related iridocyclitis in an immunocompetent patient, specific additional anti-viral therapy was effective in controlling inflammation of anterior chamber but, as is so often the case, it was unable to control intraocular pressure. We show that inflammatory activity correlated well with the number of virus copies in the aqueous humor.

Ocular Manifestations After Primary Varicella Infection

PURPOSE

To report a case of ocular manifestations after a primary varicella infection.

METHODS

Review of the literature and a case report of a 10-year-old male patient with history of blurry vision and an enlarged pupil 2 months after a varicella infection. Examination revealed uveitis, interstitial keratitis, and internal ophthalmoplegia.

RESULTS

The uveitis resolved with topical steroids; the interstitial keratitis resolved with a faint scar, and the internal ophthalmoplegia persisted.

CONCLUSION

This case report describes a patient with uncommon ocular manifestations after primary varicella.

Diagnosis and treatment of cytomegalovirus iridocyclitis without retinal necrosis

AIM

To describe the diagnostic and therapeutic management of cytomegalovirus (CMV) anterior uveitis unassociated with retinal necrosis in immunocompetent patients.

METHODS

Patients referred between 2001 and 2003 for management of unilateral, chronic, recurrent uveitis associated with secondary glaucoma underwent extensive investigation including laboratory tests for herpes virus infections. Specific antiviral treatment was initiated in all cases and the level of ocular inflammation was evaluated during the follow up.

RESULTS

Five patients, three men and two women, were included. Median age was 50 years old (range 30-80 years). Anterior unilateral uveitis without iris atrophy was observed in all cases. Uveitis was chronic in three cases and recurrent in two cases. Glaucoma was observed in all patients with a median intraocular pressure of 30 mm Hg (range 22-43 mm Hg). Five patients responded initially to specific anti-CMV therapy. Even though glaucoma surgery was necessary in two cases, both ocular inflammation and glaucoma were controlled in all cases. Relapses occurred in three cases after cessation of therapy, requiring prolonged maintenance therapy with valganciclovir.

CONCLUSIONS

CMV infection and specific antiviral therapy should be considered in all cases of relapsing or chronic iridocyclitis and secondary glaucoma. Maintenance regimens of valganciclovir may be necessary to prevent further relapses.

Herpes zoster ophthalmicus: presenting as giant-cell arteritis

A 74-year-old woman was referred to the authors' clinic with a 1-week suspicion of giant-cell arteritis. Uncomplicated, bilateral temporal artery biopsies were performed 3 days after admission for therapy. Four hours after the procedure she developed vesicular lesions of the face compatible with herpes zoster ophthalmicus. The temporal artery biopsy revealed perineural lymphocytic aggregation. Both giant-cell arteritis and herpes zoster ophthalmicus form part of the differential diagnosis in elderly patients with headache. In such cases, clues from a temporal artery biopsy may aid in diagnosis of herpes zoster. In addition, the patient in this case developed the rash 10 days after onset of symptoms, which is rare as the average time from onset of symptoms to rash in zoster is 3-5 days.

Influenza retinitis: association with influenza encephalitis

PURPOSE

To report an unusual case of retinitis caused by influenza virus.

CASE

A 30-year-old male claimed partial color blindness after recovery from influenza encephalitis. Visual acuity was 0.3 in the right eye and 0.03 in the left. An ophthalmoscopic fundus examination looked normal, but fluorescein angiography revealed granular hyperfluorescence with multiple dark circular lesions at the posterior pole of both eyes. Serological testing revealed an influenza A virus infection. With corticosteroid pulse therapy (3 days) followed by oral methyl prednisolone for 1 month, visual acuity gradually recovered. Over the following 2-year period, visual acuity has recovered to 1.2 in both eyes, but color sensation still remains impaired.

CONCLUSIONS

Influenza encephalitis can cause visual loss due to retinitis at the posterior pole.

[Bilateral influenza-triggered panuveitis and subsequent therapy with amantadine and hyperimmunoglobulins]

BACKGROUND

Influenza A is one type of influenza virus that commonly causes acute respiratory illness. Outbreaks of influenza occur every year. Major antigenic variations preclude permanent immunity in the population. Often signs of conjunctivitis or photophobia are common during acute infection. Posterior uveitis is very rare.

PATIENT

A young lady with a diagnosed anterior uveitis was sent for further evaluation to the eye department with a known history of flu.

RESULTS

This patient had a severe ocular manifestation of influenza A infection. There was bilateral panuveitis with keratic precipitates, cells and flare, and an impressive retinopathy in both eyes. Serology was positive for influenza A.

CONCLUSION

The course of an influenza A infection is usually uncomplicated. Severe affection of the choriocapillaris results in a complicated post-influenza retinal pigmentary degeneration. Treatment with amantadine and therapy with hyperimmunoglobulins seem to be useful.

Optic neuropathy: puls/minus

A 26-year-old Asian woman presented with bilateral disk swelling, retinal exudates and infarcts. Evaluation found the underlying cause of the hypertensive optic neuropathy to be renal artery stenosis due to Takayasu's arteritis.

Photodynamic therapy for the treatment of choroidal neovascularization secondary to rubella retinopathy

PURPOSE

To describe a patient for whom photodynamic therapy was used to treat subfoveal choroidal neovascularization secondary to rubella retinopathy.

DESIGN

Interventional case report.

METHODS

A 36-year-old man with subfoveal choroidal neovascularization secondary to rubella retinopathy was treated with photodynamic therapy using verteporfin. Outcome was followed up with subsequent fundus examinations, fluorescein angiography, and evaluations of best-corrected visual acuity.

RESULTS

Two treatments of photodynamic therapy using verteporfin resulted in involution of the neovascular membrane, resolution of subretinal hemorrhage, and improvement in best-corrected visual acuity from 20/200 to 20/60 2 months after the second treatment. Owing to recurrence of active choroidal neovascularization, the patient required two more treatments of photodynamic therapy in the next 6 months, after which his best-corrected visual acuity was restored to 20/60.

CONCLUSION

Photodynamic therapy may be an effective treatment for subfoveal choroidal neovascularization secondary to rubella retinopathy.

Cytomegalovirus as a cause of anterior uveitis with sectoral iris atrophy

OBJECTIVE

To report two cases of recurrent anterior uveitis with sectoral iris atrophy and ocular hypertension during attacks caused by cytomegalovirus (CMV).

DESIGN

Two observational case reports.

PARTICIPANTS

Two immunocompetent patients with a history of recurrent unilateral hypertensive anterior uveitis with sectoral iris atrophy were referred to us with the presumptive diagnosis of herpetic uveitis.

MAIN OUTCOME MEASURES

Comprehensive ophthalmic examination, aqueous humor polymerase chain reaction (PCR), and peripheral blood serologic studies were performed on both patients.

RESULTS

Examination of aqueous humor by PCR was positive for CMV and negative for herpesvirus. Serum IgG/IgM titers disclosed past CMV infection. Both patients responded well to antiviral therapy with ganciclovir. The final visual acuity level was 20/20 in both eyes of both patients.

CONCLUSIONS

CMV infection can produce recurrent attacks of anterior uveitis with clinical characteristics indistinguishable from those previously considered highly suggestive or even pathognomonic for herpetic infection. This observation has implications for the therapeutic management of such patients.

Eales disease--an update

Eales disease, first described by Henry Eales in 1880, remains an enigma. The disease, observed more commonly in the Indian subcontinent than in the rest of the world, occurs in young healthy adult males, initially presenting as retinal periphlebitis and later as retinal ischemia that may lead to vascular alterations and neovascularization. Recurrent vitreous hemorrhage with or without retinal detachment is the common sequelae. In recent years, immunological, molecular biological, and biochemical studies have indicated the role of human leukocyte antigen, retinal autoimmunity, mycobacterium tuberculosis genome, and free radical mediated damage in the etiopathogenesis of this disease. However, its etiology appears to be multifactorial. The management depends on the stage of the disease and consists of medical treatment with oral corticosteroids in the active inflammatory stage and laser photocoagulation in the advanced retinal ischemia and neovascularization stages. The results of vitreoretinal surgery have been found to be satisfactory in case of vitreous hemorrhage with or without retinal detachment.

Treatment of cytomegalovirus retinitis with an intraocular sustained-release ganciclovir implant

The objective of this prospective study was to evaluate the efficacy and complications of the use of an intraocular sustained-release ganciclovir implant for the treatment of active cytomegalovirus (CMV) retinitis in AIDS patients. Thirty-nine eyes of 26 patients were submitted to ocular surgery. All patients underwent complete ocular examination before and after surgery. The surgical procedure was always done under local anesthesia using the same technique. The mean time for the surgical procedure was 20 min (range, 15 to 30 min). The average follow-up period was 3.7 months. Of all patient, only 4 presented recurrence of retinitis after 8, 8, 9 and 2 months, respectively. Three of them received a successful second implant. All 39 eyes of the 26 patients presented healing of retinitis as shown by clinical improvement evaluated by indirect binocular ophthalmoscopy and retinography. Retinitis healed within a period of 4 to 6 weeks in all patients, with clinical regression signs from the third week on. Six (15.4%) eyes developed retinal detachment. None of the patients developed CMV retinitis in the contralateral eye. The intraocular implant proved to be effective in controlling the progression of retinitis for a period of up to 8 months even in patients for whom systemic therapy with either ganciclovir or foscarnet or both had failed. The intraocular sustained-release ganciclovir implant proved to be a safe new procedure for the treatment of CMV retinitis, avoiding the systemic side effects caused by the intravenous medications and improving the quality of life of the patients.

Ocular, cerebral and systemic interrelationships of cytomegalovirus infection in a post-mortem study of AIDS patients

PURPOSE

Eighty-six post-mortems of AIDS patients were reviewed microscopically and the presence of cytomegalovirus (CMV) infection in the viscera, brain and eye was recorded.

METHODS

Immunohistochemical stains and in situ hybridisation with a CMV probe were performed.

RESULTS AND CONCLUSION

CMV infection was observed in 63% of the cases. Visceral, cerebral and ocular involvement were overall 49%, 33% and 29%, respectively. The visceral form with no concomitant ocular and/or cerebral infection was the main cause of death (31%) in the 54 CMV-infected patients. Although CMV retinitis occurred mostly (20%) as a component of systemic disease, in 13% of the CMV-infected patients the eyes only were involved, while there were no cases with CMV limited to the brain. In the absence of systemic involvement, 9% of the cases showed concomitant ocular and cerebral infection, but because we failed to observe CMV optic neuritis without ocular involvement, retrograde viral spread from the brain through the optic nerve appears to be an infrequent mechanism of CMV retinitis.

Ocular involvement and visual sequelae in hemophagocytic lymphohistiocytosis in association with congenital dyfsfibrinogenemia

We report a 7-year-old girl with hemophagocytic lymphohistiocytosis and an uncommon complication of vascular retinopathy and visual sequelae. She was also verified to be complicated with dysfibrinogenemia. The patient was treated with etoposide, dexamethasone, and cyclosporin A. During the fifth hospital week, a generalized tonic-clonic convulsion developed followed by deep coma. When she regained full consciousness, she complained of a visual disturbance. The ophthalmologic examination showed bilateral extensive retinal edema with numerous cotton-wool spots, indicative of vaso-occlusive retinopathy. This is inconsistent with the main finding of previous cases with ocular involvement, namely papilledema. Severely reduced visual acuity and visual field defects remained in both eyes even after systemic therapy. An awareness of this rare but serious complication is important because it may be preventable by early institution of chemotherapy. The pathogenesis of the retinopathy is also discussed.

Rapidly progressive herpetic retinal necrosis: a blinding disease characteristic of advanced AIDS

Eleven patients with rapidly progressive herpetic retinal necrosis (RPHRN) complicating AIDS were investigated retrospectively to study the disease spectrum, systemic involvement, and therapy. The mean CD4 cell count was 24/microL. There was a characteristic disease pattern with rapid progression, 82% bilaterality, relative resistance to intravenous antiviral therapy, and 70% retinal detachment. Varicella-zoster virus was the probable cause in 10 patients (detected by polymerase chain reaction in two eyes investigated), and herpes simplex virus was the probable cause in one. Cutaneous zoster occurred previously in 73% but was not concurrent. Seventy-three percent had central nervous system disease, possibly virus-related. RPHRN may be a local herpetic recrudescence in an immune-privileged site with transneural spread. Only four of 20 affected eyes retained useful vision. Poor ocular bioavailability, retinal ischemia, acquired drug resistance, and strain pathogenicity may underlie treatment failure. Acyclovir therapy appears relatively ineffective. Combined intravenous and intravitreal therapy with foscarnet and ganciclovir may be the best current management. Research advances are needed urgently.

Influence of viral infection on expression of cell surface antigens in human retinal pigment epithelial cells

BACKGROUND

Subacute viral infection is known to change the phenotype of infected cells, thereby causing immune-mediated tissue damage. The aim of this study was to investigate the expression of different cell surface molecules on human retinal pigment epithelial cells (RPEC) following viral infection, with special emphasis on those having immune-regulatory functions.

METHODS

Cultured RPEC were infected with cytomegalovirus (CMV), coxsackie-virus B3 (CVB) or herpes simplex virus type I (HSV). Double-staining fluorescence technique was used for visualization of virus infection and cell surface markers in the same cells by laser microscopy.

RESULTS

CMV downregulated MHC class I antigens on RPEC, whereas CVB and HSV did not alter MHC class I antigen expression. No induction of class II antigens was observed in RPEC infected with CVB, HSV or CMV. The intercellular adhesion molecule ICAM-1 (CD54) was strongly expressed in uninfected RPEC, and a slight increase was observed after virus infection. Vascular cell adhesion molecule 1 (VCAM-1) was expressed in low amounts in both uninfected and infected RPEC. No expression of intercellular adhesion molecule 2 (ICAM-2), E-selectin ELAM-1 or lymphocyte-function-associated antigen 1 (LFA-1) was observed on RPEC before or after virus infection.

CONCLUSION

Downmodulation of immune-regulating cell surface antigens has been suggested to provide a means of long-term survival of viruses in the infected cell, favoring establishment of persistent infection. Our observation in cultured human RPEC indicates that this mechanism might indeed contribute to the development of disease affecting retinal tissue.

Cytomegalovirus papillitis in patients with acquired immune deficiency syndrome. Visual prognosis of patients treated with ganciclovir and/or foscarnet

BACKGROUND

Of those patients with acquired immune deficiency syndrome in whom cytomegaloviral retinitis develops, cytomegaloviral papillitis reportedly develops in up to 4% as well. Although occasionally patients have a good visual outcome, the majority have a poor visual prognosis, with a visual acuity of 20/200 or worse, even with treatment.

METHODS

To evaluate the effects of prolonged induction with foscarnet or ganciclovir on the visual prognosis of cytomegalovirus (CMV) papillitis, the records of 22 patients seen between 1990 and 1995 at the Los Angeles County-University of Southern California Eye Clinic were reviewed. Papillitis was defined as greater than 270 degrees of disc edema/blurring of the disc margins as seen on direct examination and on color fundus photographs.

RESULTS

Eighteen patients with a mean initial visual acuity of 20/69 (range, 20/ 15-20/400) were treated with induction doses of intravenous ganciclovir (range, 5-7.5 mg/kg twice daily) or foscarnet (range, 60-90 mg/kg twice or 3 times daily) for a mean of 3.3 weeks. The mean follow-up period was 4.8 months (range, 1-13 months). These patients maintained a mean final visual acuity of 20/68 (range, 20/ 25-20/400) with greater than 90% resolution of the papillitis. The remaining four patients had poor outcomes (visual acuity < 20/400) because of progressive CMV papillitis or retinitis. The median survival time was 4.5 months from the diagnosis of papillitis, but 7 months from the onset of CMV ocular infection.

CONCLUSION

Patients with CMV papillitis have good visual prognosis when managed with high and prolonged doses of intravenous foscarnet and/or ganciclovir.

The ordered array of perivascular macrophages is disrupted by IL-1-induced inflammation in the rabbit retina

In this study we have shown that an antibody to CD18 identified a population of cells in the rabbit retina that resembled the perivascular macrophage found in other regions of the central nervous system. In the normal retina these cells possessed a ramified morphology and presented in an ordered array on the vitreal surface in association with the epiretinal vessels. Approximately 50% of the perivascular macrophages constitutively expressed MHC class II. In response to interleukin-1 beta (IL-1 beta)-induced inflammation, these cells became activated, as evidenced by a change from a ramified to an ameboid morphology and increased expression of MHC class II, and migrated away from the vessels. These changes were first detected around 3 h post-intraocular challenge coincident with the onset of inflammation. At the peak of the inflammatory response (approximately 24 h post-challenge), many activated perivascular macrophages were no longer associated with the vessels and formed long "cord" of MHC class II+ cells associated with underlying deposits of fibrin. In eyes challenged with heat-inactivated IL-1, no change in the morphology or distribution of the perivascular macrophage was noted. At 3 weeks post-challenge with IL-1, the number and distribution of the perivascular macrophages were restored to baseline values, although with a reduced cell size. Since these changes closely resemble those that occur in non-lymphoid dendritic cells in the skin, heart, and/or kidney following activation with cytokines or bacterial products, the results suggest that the perivascular macrophage represents the dendritic cell of the retina and may thus play an important role in immune surveillance in the eye and maintenance of the blood-retina barrier.

Serologic and polymerase chain reaction analysis of intraocular fluids in the diagnosis of infectious uveitis

PURPOSE

Infectious uveitis entities are usually rapidly progressive blinding diseases that can be prevented by prompt administration of specific antimicrobial therapy. With the aim of improving early diagnosis in patients with infectious uveitis, intraocular fluid samples from patients with sight-threatening posterior uveitis were investigated to determine the causative agent.

METHODS

Thirty-eight patients with acquired immunodeficiency syndrome (AIDS) and retinitis, eight immunosuppressed patients with retinitis, 16 immunocompetent patients with acute retinal necrosis, and 22 immunocompetent patients with toxoplasmic retinochoroiditis were analyzed by polymerase chain reaction for the presence of herpesviruses and Toxoplasma gondii DNA and for local antibody production against these microorganisms.

RESULTS

In patients with AIDS and retinitis, polymerase chain reaction was positive for cytomegalovirus DNA in 21 (91%) of the 23 ocular fluid samples obtained during active cytomegalovirus retinitis, whereas local antibody production analysis was negative in all cases. In acute retinal necrosis, varicella-zoster virus or herpes simplex virus could be established as the inciting agent in 81% of the cases, using the combination of both techniques. Polymerase chain reaction was positive in all samples obtained within two weeks after the onset of disease. Toxoplasma gondii DNA was detected in 4 of 13 samples (31%) from immuno-competent patients with active toxoplasmic retinochoroiditis; in each case, local antibody production was also detected. In contrast, no local antibody production was observed in two of three samples from transplant recipients that were positive for T. gondii DNA. All the control samples tested were negative for the above-mentioned tests.

CONCLUSIONS

In patients with AIDS, polymerase chain reaction analysis is preferable above local antibody production in detecting the inciting agent of retinitis. In other cases, the combination of both techniques can make a valuable contribution to the diagnosis.

Cytomegalovirus retinitis in an AIDS patient without severe depletion in CD4 cell count

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Detection of varicella-zoster virus DNA in ocular samples from patients with uveitis but no cutaneous eruption

Herpes zoster ophthalmicus is a well-recognised cause of intraocular inflammation, which may become recurrent or chronic after the acute phase has elapsed. Although it commonly presents with the typical rash, cases of ocular zoster with no cutaneous eruption have been well documented. We present two patients with unilateral anterior uveitis complicated by cataract, in whom molecular techniques based on the polymerase chain reaction detected varicella-zoster virus DNA in intraocular material obtained during cataract surgery. Neither patient gave a history of cutaneous eruption.