Correlation between clinical suspicion and polymerase chain reaction verification of infectious vitritis

Triaging herpes zoster ophthalmicus patients in the emergency department: do all patients require referral?

OBJECTIVES

The objective was to assess the predictive value of clinical signs and symptoms of herpes zoster ophthalmicus (HZO) for development of moderate to severe eye disease.

METHODS

This was a prospective cohort multicenter study of 54 patients referred to the ophthalmology service after presenting to the emergency department (ED) or primary care clinic with a zosteriform rash of less than 10 days' duration. Upon referral to ophthalmology, easily assessable clinical signs and symptoms were documented. A complete ocular exam was then performed. Patients were followed for 2 months.

RESULTS

Twenty-three patients (43%) developed moderate to severe disease as defined by corneal or intraocular involvement. Eye redness and rash in the supratrochlear nerve distribution had a statistically significant association with clinically relevant eye disease. All 23 patients who developed moderate to severe eye disease presented with a red eye. Hutchinson's sign (nasociliary nerve involvement) was not predictive of clinically relevant eye disease.

CONCLUSIONS

Eye redness was 100% sensitive for predicting moderate to severe eye disease in this sample of patients and should necessitate immediate referral for ophthalmologic assessment. Patients lacking eye redness, even with a positive Hutchinson's sign, may not require immediate specialist consultation. All patients not being referred require careful instructions to seek further care should they develop any concerning eye symptoms such as redness, pain, photophobia, or visual disturbance.

Applications of the polymerase chain reaction in clinical ophthalmology

Molecular biology has become a valuable component in many areas of medicine, including ophthalmology. Polymerase chain reaction (PCR) is the most widely used tool. It has proven to be a powerful technique in diagnosis and quantification of microorganisms and antibiotic resistance screening. For a growing number of ophthalmic conditions PCR testing can be conducted. It is therefore important that clinicians be knowledgeable about the indications, strengths, and limitations of the technique. The purpose of this review is to explore the current role of PCR in the diagnosis and management of eye disease.

High prevalence of fastidious bacteria in 1520 cases of uveitis of unknown etiology

The etiologic evaluation of uveitis is frequently unsuccessful when noninvasive methods are used. We conducted a prospective study to evaluate systematic screening for pathogens of uveitis. All patients with uveitis referred to the participating tertiary ophthalmology departments from January 2001 to September 2007 underwent intraocular and serum specimen collection. The standardized protocol for laboratory investigations included universal polymerase chain reaction (PCR)-based detection of any bacteria and mycoses, specific PCR-based detection of fastidious (difficult-to-grow) bacteria and herpes viruses, and culture of vitreous fluid. Sera were tested for fastidious bacteria. Among the 1321 included patients (1520 specimens), infection was diagnosed in 147 (11.1%) patients: 78 (53%) were caused by fastidious bacteria that included spirochetes, Bartonella species, intracellular bacteria (Chlamydia species, Rickettsia species, Coxiella burnetii), and Tropheryma whipplei; 18 by herpes viruses; and 9 by fungi. Bartonella quintana, Coxiella burnetii, Paracoccus yeei, Aspergillus oryzae, and Cryptococcus albidus were found to be associated with uveitis for the first time, to our knowledge. We recommend applying a 1-step diagnostic procedure that incorporates intraocular, specific microbial PCR with serum analyses in tertiary centers to determine the etiology of uveitis.