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

Clinical characteristics of viral-associated Fuchs uveitis syndrome and Posner-Schlossman syndrome in a Chinese population

PURPOSE

To identify the types of viral infection in aqueous humor (AqH) among patients diagnosed as Fuchs uveitis syndrome (FUS) or Posner-Schlossman syndrome (PSS) and investigate their relevance to clinical manifestations and visual outcome.

METHODS

A total of 375 patients and 171 patients were diagnosed as FUS or PSS in our department. AqH and serum samples from 68 FUS patients and 16 PSS patients were obtained during eye surgery. The viral etiologies, clinical features, auxiliary tests and visual prognosis of patients with FUS or PSS who underwent AqH analysis were analysed and compared.

RESULTS

Among 68 FUS patients, rubella virus (RV), cytomegalovirus (CMV), herpes simplex virus (HSV) and varicella-zoster virus were identified in 17, 11, 1 and 1 patients, respectively. Seven patients with CMV and 1 with HSV were identified in 16 PSS patients. In both FUS and PSS groups, virus-associated eyes had higher proportion of secondary glaucoma and worse visual prognosis as compared with non-virus-associated eyes (all P < 0.05). In FUS group, specifically, CMV infection manifested as more obvious anterior segment inflammation and lower corneal endothelial cell density (CECD). RV infection showed a higher percentage of vitritis. In PSS group, CMV-associated PSS had a lower retinal nerve fiber layer thickness and CECD, worse visual prognosis as compared with non-virus-associated PSS (all P < 0.05).

CONCLUSION

Our study identified 4 types of viral infection in FUS and 2 types of viral infection in PSS. Virus-associated patients are usually associated with more obvious clinical signs and poor visual prognosis.

2% Ganciclovir Controlled Posner-Schlossman Syndrome Relapse and Reduced the Chance of Corticosteroid Dependence: A Large Cohort in East China

PURPOSE

To present the process from acute Posner-Schlossman syndrome (PSS) relapse to remission under 2% ganciclovir (GCV), corticosteroids and anti-glaucoma agents on 323 patients.

METHODS

A retrospective study enrolling 323 PSS patients. Demographics and ophthalmic examination results were generated. Patients were treated with GCV, corticosteroids and anti-glaucoma agents andfollowed up every 2-6 weeks.

RESULTS

Patients were divided into the GCV monotherapy (N = 65, 20.12%), GCV and corticosteroids (G+C, N = 106) and GCV, corticosteroid and IOP-lowering drugs (G+C+L, N = 152) group. The G+C+L group had the highest intraocular pressure (IOP, 26.33 ± 10.26 mmHg, P < 0.001) and largest cup-to-disc ratio (0.58 ± 0.19, P < 0.05). After treatment, IOP of three groups dropped to similar level. Ninety-nine (30.65%) patients were corticosteroid-dependent whose daily corticosteroid consumption decreased after using GCV (from 2.23 ± 1.02 to 0.97 ± 0.98 drops/day).

CONCLUSION

2% GCV solutions worked effectively on PSS relapse with corticosteroids and anti-glaucoma agents. In patients suspected of CMV infection, proper GCV could reduce the chance of corticosteroid dependence.

Posner-Schlossman Syndrome European Study Group: study protocol and baseline patients characteristics of a multicentre study

BACKGROUND

The aim of the Posner-Schlossman Syndrome European Study Group (PSS-ESG) is to acquire a comprehensive dataset of European patients with PSS. Here, we present the first report on the study protocol and the clinical findings of the patients at baseline.

METHODS

The PSS-ESG is a retrospective, multicentre study designed to evaluate patients with PSS. The study, designed and driven by a European Expert Committee includes three datasets: (1) the baseline, (2) the follow-up and (3) the intraocular pressure (IOP)/glaucoma dataset.

RESULTS

A total of 11 centres adhered to the PSS-ESG and 107 patients were included (68 males, 39 females) mostly Caucasian (93.4%). At uveitis onset, the patient's age ranged between 11 and 76 years, (mean age: 42±15 years).Best-corrected visual acuity was >0.5 in 80.3% of the eyes, IOP was >40 mm Hg in 44% of the eyes. Keratic precipitates were found in 78.5% of the eyes. No flare or cells in anterior chamber were detected in 56% and 53% of the cases, respectively. PCR analysis on aqueous sample was positive for cytomegalovirus-DNA in 50.6% out of the 81 tested patients.

CONCLUSIONS

The PSS-ESG is the first multicentre study aimed to collect a comprehensive dataset of patients with PSS in non-Asian countries. A middlde-aged Caucasian male with a low-grade anterior chamber inflammation, keratic precipitates, preserved visual acuity and marked increased in IOP seemed to be the standard PSS patient across the 11 uveitis and glaucoma centres participating in the PSS-ESG.

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.

Cytomegalovirus-positive Posner-Schlossman syndrome: to compare differences in retinal vessel area density between the affected and non-affected eye using optical coherence tomography angiography

PURPOSE

To analyse differences in the retinal microvasculature in eyes with cytomegalovirus (CMV)-positive Posner-Schlossman syndrome (PSS) compared to the non-affected eyes using optical coherence tomography angiography (OCTA).

METHODS

In this monocentric, observational prospective case series, 25 patients with unilateral CMV-positive PSS were included. We compared the vessel area densities (VAD) in the macula, optic disc, and peripapillary region in PSS-affected and non-affected eyes using OCTA. We compared the visual fields (VF) of the affected and healthy eyes of each patient. The mean deviation (MD) of the VF was analysed together with the retinal nerve fibre layer (RNFL) thickness to evaluate the strength of correlation with the VAD parameters.

RESULTS

The VAD of the peripapillary superficial vascular complex (SVC) is significantly reduced in CMV-positive PSS-affected eyes (46.1 ± 9.3% versus 50.1 ± 6.3%, p = 0.008, adjusted p = 0.048). The VAD of the deeper macular, papillary, and peripapillary layers showed no differences between the affected and non-affected eyes. The mean deviation and the retinal nerve fibre layer thickness had correlations with the VAD of the macula (r = 0.451, p = 0.001, r = 0.553, p < 0.001), the peripapillary SCV (r = 0.430, p = 0.002, r = 0.723, p < 0.001), and the papillary region (r = 0.512, p < 0.001, r = 0.292, p = 0.039). Patients receiving systemic antiviral therapy (SAT) showed better VAD of the peripapillary choriocapillary layer (p = 0.001, no therapy: 31.4 ± 1.9%, SAT: 35.0 ± 1.6%), and choroidal layer (p = 0.009, no therapy: 34.2 ± 0.3%, SAT: 36.3 ± 1.8%) compared to those with no SAT.

CONCLUSION

A lower peripapillary VAD in the SVC might indicate vascular dysfunction as a sign of glaucomatous damage. SAT might have positive effects on the microcirculation in the deep retinal and choroidal layers.

TRIAL REGISTRATION

TRN: DRKS00028266, https://www.drks.de/drks_web/ .

Clinical Differences between Posner-Schlossman Syndrome Patients with Intermittent Intraocular Pressure Elevation and Glaucomatous Damage

INTRODUCTION

Although there is abundant evidence that Posner-Schlossman syndrome (PSS) can lead to secondary glaucoma, data on the clinical differences between PSS patients with secondary glaucoma and those with intermittent intraocular pressure (IOP) elevation are sparse.

METHODS

This retrospective observational study included 52 patients (52 eyes) diagnosed with PSS and admitted to Zhongnan Hospital of Wuhan University between January 2019 and February 2022. Demographic characteristics and clinical features were gathered from admission records. Patients were divided into two groups: 27 cases with intermittent IOP elevation (group A) and 25 cases with secondary glaucoma (group B and C). Of the secondary glaucoma cases, 18 were further divided into the topical IOP-lowering medications group (group B) and 7 into the glaucoma surgery group (group C). Clinical characteristics of different groups were compared.

RESULTS

Compared to the intermittent IOP elevation group, PSS patients with secondary glaucoma had a longer course of disease, a higher incidence of iris depigmentation, lower best corrected visual acuity, lower endothelial cell density, and higher interferon-γ (IFN-γ) concentration and cytomegalovirus (CMV) deoxyribonucleic acid (DNA) copy number in the aqueous humor (all p < 0.05). Group C presented a higher CMV DNA copy number in the aqueous humor than groups A and B (p < 0.05). Compound trabeculectomy proved effective in group C, with a functional filter bleb and well-controlled IOP without disease progression after 1 year of follow-up.

CONCLUSION

Distinctive characteristics existed between PSS patients with secondary glaucoma and those with intermittent IOP elevation. Compound trabeculectomy appears to be an effective treatment option when IOP cannot be controlled through topical medications.

Risk factors associated with corneal endothelial cell density in Posner-Schlossman syndrome

PURPOSE

To investigate the risk factors related to corneal endothelial cell density (ECD) in patients with Posner-Schlossman syndrome (PSS).

PATIENTS AND METHODS

It was an observational retrospective study. We reviewed the medical records of patients with PSS who attended the ophthalmology department at Wuhan University Zhongnan Hospital from January 2019 to December 2021. 42 eyes of 42 patients with PSS were included in the study. Demographic characteristics and clinical manifestations were recorded. The clinical characteristics of PSS patients with reduced ECD were compared with PSS patients with normal ECD. Simple and multiple linear regression analyses were carried out to identify the risk factors for ECD in PSS.

RESULTS

The ECD-lowered group had a longer disease duration (P = 0.000), higher rate of occurrence of corneal edema (P = 0.039), higher cytomegalovirus (CMV) deoxyribonucleic acid (DNA) copy number (P = 0.044), higher interleukin-10 (IL-10) level in the aqueous humor (P = 0.044), and thinner average retinal nerve fiber layer (RNFL) thickness (P = 0.016) than the control group. The results of multiple linear regression analysis indicated that disease duration (β =  - 0.287, P = 0.024) and level of IL-10 in the aqueous humor (β =  - 0.408, P = 0.001) were significantly negatively associated with ECD, while average RNFL thickness (β = 0.330, P =  0.007) was significantly positively related to ECD in PSS.

CONCLUSION

A longer disease duration, higher degree of glaucomatous damage and elevated level of IL-10 in the aqueous humor were associated with reduced ECD in PSS.

Iris abnormalities may influence the efficacy and filtration strategies of Posner-Schlossman syndrome: a retrospective study involving trabeculectomy, ExPRESS and Ahmed valve implants

PURPOSE

To evaluate and compare the one-year efficacy and influencing factors of different filtration surgeries on Posner-Schlossman syndrome (PSS) patients.

METHODS

A retrospective study enrolling 91 PSS patients who underwent filtering surgeries and were followed for at least one year. Unilateral PSS was diagnosed as recurrent attacks of mild, unilateral, non-granulomatous anterior uveitis, elevated intraocular pressure (IOP), keratic precipitates (KPs) on the corneal endothelium, open angle, no posterior synechia, and no inflammatory lesions in the posterior segment; the IOP and anterior segment returned to normal between attacks. Medical histories and thorough ocular examination results were collected. Trabeculectomy and ExPRESS were chosen as the first line and AGV was considered for those under high risk of fibrosis. Follow-up data, mainly IOP, best-corrected visual acuity (BCVA), and anterior segment manifestations at the 1st week, 6th month, and 12th month were generated and analyzed. Iris abnormalities were determined by depigmentation or atrophic changes on the anterior segment photograph. Complete surgical success was defined as 5 mmHg < IOP ≤ 21 mmHg without IOP-lowering drug or needle revision; qualified surgical success was defined as 5 mmHg < IOP ≤ 21 mmHg with IOP-lowering drugs or needle revisions. Survival analysis was performed to obtain the success rates.

RESULTS

At the 12th month, the complete surgical success rate of trabeculectomy (N = 54), ExPRESS (N = 23), and AGV group (N = 14) was 58.97% (95%CI 46.91-77.09%), 84.21% (95%CI 68.33-100.87%), and 100%; the qualified success rate was 71.79% (95%CI 62.46-88.34%), 89.47% (95%CI 77.07-103.33%), and 100%, respectively. Patients undergoing trabeculectomy experienced the largest decline of BCVA (from 0.58±0.46 to 1.01±0.51, P < .05); the trabeculectomy group endured the highest IOP (20.84±9.92 mmHg) compared to ExPRESS (14.51±2.86 mmHg, P < .05) and AGV group (13.17±3.32 mmHg, P < .05). At the 12th month, in the ExPRESS group, patients with iris abnormalities had higher IOP than the normal ones (15.65±2.05 mmHg, 12.93±3.17 mmHg, P < .05). ExPRESS helped patients with iris abnormalities maintain lower IOP than trabeculectomy (15.65±2.05 mmHg, 22.52±10.67 mmHg, P < .05). Three patients developed hypotony at the 3rd month (1 in ExPRESS and 2 in trabeculectomy group).

CONCLUSION

AGV and ExPRESS performed better than trabeculectomy in PSS patients in terms of IOP and success rate. Iris abnormalities might influence the postoperative IOP and this may be valuable in guiding filtration strategies.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (No. ChiCTR1800017532, date: 2018/08/02).

Clinical Characteristics of Posner-Schlossman Syndrome Patients in China

Background

To explore the clinical characteristics of Posner-Schlossman syndrome (PSS) patients in China, especially the risk factors associated with the dynamic changes of corneal endothelial cell (CEC) density and retinal nerve fiber layer (RNFL) thickness during the course of the disease.

Methods

In this retrospective cohort study, patients consequently suffering from PSS were recruited. Patients data including gender, age of onset, frequency of attack, and disease duration. We performed detailed ophthalmology examinations including intraocular pressure (IOP), best-corrected visual acuity (BCVA), slit-lamp examination, optical coherence tomography (OCT), assessing RNFL thickness, and determined CEC density in the outpatient department. The unaffected eyes served as control.

Results

We recruited 121 patients (eyes, n = 125), including 69 (57.0%) males and 52 (43.0%) females with Posner-Schlossman syndrome. The age of first-onset was 33.81 ± 13.63 years old. The majority of these patients were aged 20-50 years (80.2%). The peak IOP was 47.67 ± 13.31 mmHg in the affected eyes. The frequency of PSS attack was 2.7 ± 3.7 times per year. The disease duration was 9.5 ± 10.4 years. Among all patients, there were 27 (22.31%) patients with a history of digestive disorders, 25 (20.66%) patients with a history of allergies, and 24 (19.83%) patients with a history of infectious disease. In the affected eyes, CEC density (2532.94 ± 490.83/mm² vs. 2777.13 ± 356.87/mm², p < 0.001), the RNFL thickness of four quadrants (superior 105.46 ± 29.86 μm vs. 121.33 ± 17.30 μm, p < 0.001; temporal 74.58 ± 22.21 μm vs. 81.94 ± 18.20 μm, p = 0.009; inferior 110.50 ± 33.42 μm vs. 128.29 ± 14.39 μm, p < 0.001; nasal 54.85 ± 14.48 μm vs. 63.49 ± 15.40 μm, p < 0.001) and central papillary (87.11 ± 21.18 μm vs. 99.18 ± 7.97 μm, p < 0.001) were significantly reduced compared to the fellow eyes. The disease duration and recurrent frequency were significantly associated with CEC density (p < 0.001 and p = 0.029) and the disease duration was significantly associated with RNFL thickness (p = 0.002).

Conclusions

In this study, CEC loss and RNFL thinning were present in the affected eyes. Our results indicated that disease duration and recurrent frequency played an important role in the progression of PSS.

Posner-Schlossman syndrome relapse following inactivated COVID-19 vaccination in China

Introduction

This retrospective study aims to present the characteristics of Posner-Schlossman syndrome (PSS) relapse following inactivated COVID-19 vaccination.

Methods

From 2020 to 2022, 12 out of 106 PSS patients undergoing relapses after any dose of inactivated COVID-19 vaccines were enrolled. Medical histories, information on the vaccination and systemic adverse events were collected. Patients were treated with corticosteroids, intraocular pressure (IOP)-lowering drugs and systemic immunosuppressive agents (if needed). Daily regimen and release course were noted.

Results

The recurrence rate after vaccination was 11.32% (12/106, 95% CI: 5.29%-17.35%) among 106 PSS patients we surveyed. All the 12 patients were inoculated with inactivated COVID-19 vaccines developed by Sinopharm, China. The mean time of relapse was 5.27 ± 3.72 days (range: 1-13 days, median: 4 days). Higher IOP and more keratic precipitates (KPs) were seen in the relapse following vaccination (33.55 ± 12.99 mmHg, 91.67% had KPs compared to 25.38 ± 3.80 mmHg, 33.33% had KPs in previous relapse, P = 0.009). The mean release course was 30.71 ± 34.74 days for the relapse following vaccination and 7.33 ± 6.51 days for previous relapses. The attack frequency before and after vaccination was 3.56 ± 2.07 and 9.11 ± 7.34 times per year (P = 0.044). Higher daily doses of corticosteroids, IOP-lowering drugs and ganciclovir were needed to maintain stable course, though the difference did not reach statistical significance.

Discussion

More frequent relapses and harder control of IOP were found in PSS relapse following COVID-19 vaccination. Ophthalmologists need to be aware of the group vulnerability and take precautions, though the pathogenesis is still under investigation.

Rubella Virus- and Cytomegalovirus-Associated Anterior Uveitis: Clinical Findings and How They Relate to the Current Fuchs Uveitis Syndrome Classification

Rubella virus (RV) and cytomegalovirus (CMV) have both been implicated in anterior uveitis (AU). Clinical phenotypes can vary widely among both etiologies, including Fuchs uveitis syndrome (FUS) as a very distinct phenotype that has been associated with both RV and CMV. The Standardization of Uveitis Nomenclature (SUN) Working Group recently updated the classification criteria for FUS as unilateral AU, including either heterochromia or diffuse iris atrophy combined with stellate keratic precipitates as key findings. The aim of this study was to determine whether our patients adhere to the classification criteria of FUS as previously reported and whether RV- or CMV-associated uveitis can be differentiated by clinical findings. Therefore, this study investigated the clinical characteristics of patients with AU and intraocular presence of either RV or CMV determined by the Goldmann-Witmer coefficient (GWC). Our study included 100 patients (107 eyes) with AU and positive GWC for RV (86) and CMV (21). Clinical findings of RV-positive eyes were as follows: keratic precipitates (91.9%) with a predominantly diffuse distribution (81.4%), unilateral cataract (80.2%), pseudophakia (73.5%), and vitreous cells (59.7%), whereas heterochromia was present in only 39.5% of eyes and iris atrophy in 12.9% of eyes. In CMV-positive eyes, conversely, a higher incidence of ocular hypertension with markedly increased intraocular pressures above 30 mmHg (66.7%), keratic precipitates (81.0%), which were most commonly distributed in the center of the cornea (63.6%), an unaffected lens (55.0%), absent iris atrophy (100%), and absent posterior synechiae (90.5%) could be detected. This indicates a clinical presentation that was mainly compatible with Posner-Schlossman syndrome. In our cohort of RV-positive FUS patients, we saw a different cluster of clinical findings compared to the classification criteria suggested by the SUN Working Group. The main criteria, such as unilaterality, were mostly fulfilled. When applying all classification criteria, only 8.4% of 107 eyes and 10.5% of all 86 RV-positive eyes would qualify for the diagnosis of FUS. In addition, in our cohort of predominantly Caucasian patients, the clinical findings in patients with proven CMV infection differed from the clinical presentation typically associated with FUS.