Zoster sine herpete with bilateral ocular involvement

Clinical characteristics of virus-related uveitic secondary glaucoma: focus on cytomegalovirus and varicella zoster virus

Background

We aimed to analyze the clinical characteristics of secondary glaucoma related to cytomegalovirus (CMV)- and varicella zoster virus (VZV)-positive uveitis.

Methods

In this retrospective study, we enrolled patients with anterior uveitic secondary glaucoma. All the patients underwent aqueous and serum analyses for viral antibody through enzyme-linked immunosorbent assay. Among the 60 included patients, 22 had CMV-negative Posner-Schlossman syndrome (CMV-negative PSS), 25 had CMV-positive PSS, and 13 had VZV-positive anterior uveitis secondary glaucoma (VZV-AUSG). We evaluated the following main indicators: age, disease duration, intraocular pressure (IOP), cup-to-disc ratio, best corrected visual acuity (BCVA), corneal endothelial cell (CEC) count, ocular morphological changes, and medical treatments.

Results

We found that 53.2% (25/47) patients with PSS were CMV-positive. Patients with CMV-positive PSS had a larger cup-to-disc ratio (p = .043), lower CEC density (p = .017), more severe CEC loss (p < .001), and more iris depigmentation (p = .006) than CMV-negative PSS patients. Compared with patients with CMV-positive PSS, those with VZV-AUSG were older (p = .003), presented a higher IOP (p = .015), and had poorer BCVA (p < .001). Patients with CMV-positive PSS and VZV-AUSG all accepted ganciclovir treatment, and those with CMV-positive PSS used fewer antiglaucoma agents simultaneously compared with CMV-negative PSS (p = .005) and VZV-AUSG (p < .001). All three groups had a comparable proportion of patients requiring antiglaucoma surgery.

Conclusions

We observed some distinctive clinical features in CMV-positive PSS compared with CMV-negative PSS. Further, we found that patients with VZV-AUSG presented with a higher IOP and worse visual acuity, and required more antiglaucoma medication than those with CMV-positive PSS.

Identification of Herpes Zoster-Associated Temporal Arteritis Among Cases of Giant Cell Arteritis

PURPOSE

To examine whether herpes zoster antigen (also called varicellazoster virus antigen) was detectable in temporal artery biopsies taken from individuals with giant cell arteritis (GCA).

DESIGN

Retrospective comparative case series.

METHODS

Sections of formalin-fixed paraffin-embedded temporal arteries were examined first by hematoxylin-eosin (H&E) staining to establish the diagnosis of GCA. Adjacent sections of the same biopsy were then examined by immunohistochemistry, using 2 different monoclonal antibodies against a major antigen of varicella-zoster virus called gE. Pathologic specimens were obtained from patients cared for at the University of Iowa and Washington University in St. Louis ophthalmology clinics.

RESULTS

The study included biopsies from 25 patients with symptoms of GCA as well as positive H&E pathology and 25 patients with symptoms compatible with GCA but negative H&E pathology. Among the GCA-positive group, 3 patients had positive staining for herpes zoster antigen. Among the GCA-negative group, herpes zoster antigen was not detected in any biopsy. In both groups of patients, false-positive staining for herpes zoster antigen was detected in the presence of calcifications in the arteries. False-positive staining was also detected on some extra-arterial skeletal muscle and erythrocytes.

CONCLUSION

Herpes zoster antigen was detected in 3 of 25 temporal arteries from patients with biopsy-proven GCA. One of the 3 positive cases was noteworthy because the patient had had herpes zoster ophthalmicus diagnosed 3 weeks before the onset of GCA symptoms. False-positive staining for herpes zoster antigen was detected on several temporal artery biopsies.

A new era of uveitis: impact of polymerase chain reaction in intraocular inflammatory diseases

Uveitis is a sight-threatening intraocular inflammatory disorder which may occur from both infectious and non-infectious or autoimmune causes. The frequency of infectious uveitis and autoimmune uveitis varies depending on countries and regions. According to a nationwide survey conducted by the Japanese Ocular Inflammation Society, infectious and non-infectious uveitis accounted for 16.4 and 50.1% of new patients, respectively while the remaining 33.5% of new uveitis cases were not classified or were idiopathic uveitis. Infectious uveitis is particularly important because it causes tissue damage to the eye and may result in blindness unless treated. However, it can be treated if the pathogenic microorganisms are identified promptly and accurately. Remarkable advancements in molecular and immunological technologies have been made in the last decade, and the diagnosis of infectious uveitis has been greatly improved by the application of molecular and immunological investigations, particularly polymerase chain reaction (PCR). PCR performed on a small amount of ocular samples provides a prompt, sensitive, and specific molecular diagnosis of pathogenic microorganisms in the eye. This technology has opened a new era in the diagnosis and treatment of uveitis, enabling physicians to establish new clinical entities of uveitis caused by infectious microorganisms, identify pathogens in the eyes of many patients with uveitis, and determine prompt diagnosis and appropriate therapy. Here we review the PCR process, new PCR tests specialized for ocular diseases, microorganisms detected by the PCR tests, diseases in the eye caused by these microorganisms, and the clinical characteristics, diagnosis, and therapy of uveitis.

The significance of the determination of lymphocytes with clinical manifestation of ophthalmic zoster sine herpete

Objective:

To examine the significance of VZV-IgG (IgG) enzyme immunoassay (EIA) and the determination of peripheral blood lymphocyte counts in the diagnosis of ophthalmic zoster sine herpete (ophthalmic ZSH).

Method:

Clinical case-control study with a sample of 65 patients with ophthalmic ZSH (16 males and 49 females; mean age 56 ± 18 years) in whom pressure elicited pain in tender points of Valleix (tender points of sites at which the trigeminal nerve appears subcutaneously). A total of 41 healthy controls (17 males and 24 females, mean age 48 ± 21 years) were also recruited. In each group, IgG and lymphocyte count were determined upon receiving the consent of patients. Multiple logistic regression analysis was used to evaluate the factors associated with diagnosis of ophthalmic ZSH. Odds ratios and 95% confidence intervals (CI) were determined for each variable.

Results:

Lymphocyte count in the patients with ophthalmic ZSH was significantly low, though there were no significant differences in age, gender, and IgG between the two groups. Multiple logistic regression analysis revealed that lymphocytes pose a significant prognostic factor, and in case of 1,800 lymphocytes/μl or more, the odds ratio to less than1,800 lymphocytes/μl was 0.29 (95% CI: 0.12–0.72).

Conclusion:

Patients with orbital pain should be suspected as having ophthalmic ZSH as this allows for the determination of lymphocyte counts after tender points were confirmed. The swift diagnosis of ophthalmic ZSH and the administration of antiviral drugs from an early stage improve the subjective symptoms of the patient and is regarded as necessary to reduce the risk of severe complications.

Bilateral acute depigmentation of the iris: report of 26 new cases and four-year follow-up of two patients

PURPOSE

To report new cases of bilateral acute depigmentation of the iris (BADI), a recently described clinical entity, and to report the 4-year follow-up of 2 patients that was published previously.

DESIGN

A retrospective case series.

PARTICIPANTS

Twenty-six Turkish patients who were diagnosed with BADI between 2006 and 2008 and 2 patients who were reported previously.

METHODS

We reviewed the patients' charts and clinical photographs. Observation procedures included clinical examination, anterior segment color photography, laser flare photometry, and pupillometry. We performed an anterior chamber tap in 2 patients for polymerase chain reaction (PCR) to demonstrate the DNA of herpes simplex virus (HSV), varicella zoster virus (VZV), and cytomegalovirus (CMV) in the aqueous samples.

MAIN OUTCOME MEASURES

Demographic features, presenting symptoms, laboratory findings, changes in iris stromal pigment and architecture, and time to resolution of pigment dispersion in the anterior chamber.

RESULTS

Nineteen patients were female, and 7 patients were male. Mean age was 32.3+/-8.6 years. All had bilateral involvement. Twenty patients (76.9%) presented with photophobia and red eyes, and 4 patients (15.4%) presented with a recent change in eye color. Ten patients (38.5%) had flu-like symptoms preceding the onset of ocular symptoms. Diagnostic laboratory workup, viral serology, and PCR analysis of the aqueous humor were unrewarding. Diffuse depigmentation of the iris stroma from the collarette to the iris root was seen in 16 patients, and geographic areas of depigmentation were seen in 10 patients. There was heavy pigment deposition in the trabecular meshwork in all patients. Anterior chamber flare was elevated in eyes with circulating pigment. The pupil was not affected. Twenty patients received topical corticosteroids. Pigment dispersion resolved in 1 to 16 weeks (median, 9 weeks). The intraocular pressure was elevated in 8 steroid-treated eyes but was controlled with antiglaucomatous medications. In 2 patients reported previously, the depigmented iris stroma became repigmented after 4 years.

CONCLUSIONS

Patients with BADI present with bilateral, symmetrical, nontransilluminating depigmentation of the iris stroma and pigment discharge into the anterior chamber. Young female persons are more commonly affected. The cause remains unknown. After 4 years, the ocular findings in 2 patients normalized.

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.

Use of multiplex PCR and real-time PCR to detect human herpes virus genome in ocular fluids of patients with uveitis

AIM

To measure the genomic DNA of human herpes viruses (HHV) in the ocular fluids and to analyse the clinical relevance of HHV in uveitis.

METHODS

After informed consent was obtained, a total of 111 ocular fluid samples (68 aqueous humour and 43 vitreous fluid samples) were collected from 100 patients with uveitis. The samples were assayed for HHV-DNA (HHV1-8) by using two different polymerase chain reaction (PCR) assays, qualitative PCR (multiplex PCR) and quantitative PCR (real-time PCR).

RESULTS

In all of the patients with acute retinal necrosis (n = 16) that were tested, either the HSV1 (n = 2), HSV2 (n = 3), or VZV (n = 11) genome was detected. In all patients, high copy numbers of the viral DNA were also noted, indicating the presence of viral replication. In another 10 patients with anterior uveitis with iris atrophy, the VZV genome was detected. When using multiplex PCR, EBV-DNA was detected in 19 of 111 samples (17%). However, real-time PCR analysis of EBV-DNA indicated that there were only six of the 19 samples that had significantly high copy numbers. The cytomegalovirus (CMV) genome was detected in three patients with anterior uveitis of immunocompetent patients and in one immunocompromised CMV retinitis patient. In addition, one patient with severe unilateral panuveitis had a high copy number of HHV6-DNA. There was no HHV7- or HHV8-DNA detected in any of the samples.

CONCLUSIONS

A qualitative multiplex PCR is useful in the screening of viral infections. However, the clinical relevance of the virus infection needs to be evaluated by quantitative real-time PCR.

Bilateral acute depigmentation of the iris

PURPOSE

To report on five cases of unusual bilateral stromal depigmentation of the iris and pigment dispersion masquerading as uveitis.

METHODS

We describe the clinical features of five consecutive patients who presented with acute depigmentation of the iris stroma between June and October 2003.

RESULTS

Four patients were female, one was male. Age at presentation ranged from 15 to 25 years. Presenting symptoms were sudden-onset ocular discomfort and red eye in four patients and change of eye color in one patient. All patients had bilateral involvement, with a symmetrical diffuse depigmentation of the iris stroma in three cases and patchy areas of iris depigmentation in two. Other common features were mild ciliary injection (seven eyes), Krukenberg spindle (seven eyes), circulating pigment in the anterior chamber (eight eyes), and heavy pigment deposition in the angle (ten eyes). No eyes had iris transillumination defects, inflammatory keratic precipitates or inflammatory cells in the anterior chamber. Systemic laboratory work-up was unrewarding in all cases, and PCR analysis of the aqueous humor for HSV1 and 2 was negative in one patient. Four patients were treated with a short course of topical corticosteroids and three with oral acyclovir. One patient was lost to follow-up. The remaining four patients were followed up for 6-19 months with a stable clinical picture.

CONCLUSION

In contrast to pigment dispersion syndrome, pigment seemed to be released from iris stroma in the five cases described here. Although patchy depigmentation of the iris resembled the lesions seen in herpetic iridocyclitis in two of the patients, symmetrical bilateral involvement and lack of intraocular inflammation were the differentiating features. The patients described here could represent a new entity or an unusual presentation of herpetic eye disease.

Corneal epithelial keratitis in herpes zoster ophthalmicus: "delayed" and "sine herpete". A non-contact photomicrographic in vivo study in the human cornea

PURPOSE

To investigate the origin of corneal epithelial keratitis occurring without accompanying herpes zoster ophthalmicus (HZO) cutaneous rash.

METHODS

Corneal epithelial lesions in seven patients (four with a history of classical HZO with cutaneous rash, one of herpes zoster oticus, and two with no history of herpes zoster, were examined with the slit lamp and photographed by non-contact in vivo photomicrography. The findings were compared with lesions in classical acute HZO. Polymerase chain reaction (PCR) was done in three patients.

RESULTS

Slit lamp appearance, morphology at higher magnification, and kinetics of the lesions were indistinguishable from classical acute HZO. PCR was positive for varicella-zoster virus DNA in all three samples.

CONCLUSIONS

The findings strongly suggest that HZO typical corneal epithelial lesions occurring in the absence of cutaneous rash are in fact recurrent episodes of virus shedding.