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

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.

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.

Presumed Herpetic Anterior Uveitis: A Study with Retrospective Analysis of 79 Cases

Purpose

To describe the clinical features, visual outcome, medical treatment, and complications of presumed herpetic anterior uveitis.

Methods

We retrospectively analyzed the clinical data related to 79 eyes of 77 patients with presumed herpetic anterior uveitis seen at the Uveitis Unit of the Ulucanlar Eye Training and Research Hospital from 1996 to 2011. Age at onset of disease, sex, follow-up duration, existence of corneal involvement, posterior synechiae, distorted pupil, iris atrophy, characteristic of keratic precipitates, elevated intraocular pressure (IOP), medical treatment, recurrence rate, complications, visual acuities (VA), and surgery for complications were recorded. The complication rates in patients with and without corneal involvement were compared.

Results

There were 38 (49.4%) female and 39 (50.6%) male patients. The mean age at presentation was 48.5 ± 14.8 (20–82) years. The follow-up period was 26.5 (2–127) months. Two patients had bilateral involvement. Ocular findings were a corneal scar or active keratitis in 37 (46.8%) eyes, secondary glaucoma in 14 (17.7%), iris atrophy in 39 (49.4%), distorted pupil in 16 (20.3%), posterior synechiae in 23 (29.1%), and granulomatous anterior uveitis in 30 (40%) eyes. Eight (10.1%) eyes had a posterior subcapsular cataract. Glaucoma surgery was required for uncontrolled IOP with maximum medical treatment in 2 (2.4%) eyes. Long-term oral acyclovir was used in 9 (11.3%) patients. Final VA was ≤ 0.1 in 8 (10.1%) eyes; of these, 6 had either corneal scarring or cataract and 2 preexisting amblyopia.

Conclusions

Presumed herpetic anterior uveitis with or without keratitis has characteristic clinical findings that enable the diagnosis. Long-term prophylactic antiviral therapy should be considered especially in patients <50 years old.

Topical glucocorticoid therapy directly induces up-regulation of functional CXCR4 on primed T lymphocytes in the aqueous humor of patients with uveitis

Overexpression of the constitutive chemokine receptor CXCR4 has been shown to contribute to the accumulation of leukocytes at sites of chronic inflammation. Glucocorticoids are widely used to treat inflammatory disorders such as uveitis to considerable effect, yet paradoxically have been reported to increase CXCR4 expression in vitro. We show here that ocular lymphocytes isolated from patients with uveitis who had been treated with topical glucocorticoids expressed highly elevated levels of CXCR4. The up-regulation of CXCR4 could be reproduced in vitro by culture of CD4(+) T cells with aqueous humor (AqH), indicating a role for the ocular microenvironment rather than preferential recruitment of CXCR4(+) cells. Untreated uveitis and noninflammatory AqH up-regulated CXCR4 to a limited extent; this was dependent on TGF-beta2. However, the highest levels of CXCR4 both in vivo and in vitro were found in the glucocorticoid-treated patients. Glucocorticoids appeared to be directly responsible for the induction of CXCR4 in treated patients, as the glucocorticoid receptor antagonist RU38486 inhibited the in vitro up-regulation by AqH from these patients. Dexamethasone selectively up-regulated CXCR4 in vitro, but not any of a wide range of other chemokine receptors. CXCL12, the ligand for CXCR4, was present in AqH under noninflammatory conditions, but the levels were low in untreated uveitis and undetectable in treated uveitis AqH. The importance of these results for the treatment of HIV patients with glucocorticoids is discussed as well as a role for glucocorticoid-induced CXCR4 up-regulation and CXCL12 down-regulation in controlling the migration of lymphocyte populations, resulting in resolution of inflammation.

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.

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.

Advances in diagnosis and management of herpetic uveitis

Herpetic eye disease is common and is frequently associated with intraocular inflammation or uveitis. Despite recent advances in measuring anti-herpes virus antibodies and viral DNA in ocular fluids, diagnosis remains largely clinical. The two more common syndromes include anterior uveitis, often associated with keratitis, and the acute retinal necrosis (ARN) syndrome. Treatment is complex and requires careful monitoring to provide the appropriate balance of antiviral medication and corticosteroids. Long-term prophylaxis with oral antiviral agents may be required in selected patients to help prevent the vision-compromising complications associated with recurrences.

Zoster sine herpete with bilateral ocular involvement

PURPOSE

To report a case of zoster sine herpete with bilateral ocular involvement.

METHOD

Case report.

RESULTS

A 65-year-old man showed bilateral iridocyclitis with sectoral iris atrophy and elevated intraocular pressure unresponsive to steroid treatment. No cutaneous eruption was manifest on the forehead. A target region of varicella-zoster virus DNA sequence was amplified from the aqueous sample from the left eye by polymerase chain reaction. Bilateral iridocyclitis resolved promptly after initiation of systemic and topical acyclovir treatment. Secondary glaucoma was well controlled by bilateral trabeculectomy.

CONCLUSIONS

Zoster sine herpete should be considered and polymerase chain reaction performed on an aqueous sample to detect varicella-zoster virus DNA for rapid diagnosis whenever anterior uveitis accompanies the characteristic iris atrophy, even in the case of bilateral involvement.

Anterior uveitis with sectoral iris atrophy in the absence of keratitis: a distinct clinical entity among herpetic eye diseases

OBJECTIVE

To determine the cause and describe the clinical features of unilateral anterior uveitis with sectoral atrophy of the iris in the absence of associated keratitis.

DESIGN

Retrospective, observational case series.

PARTICIPANTS

Thirty-one patients with unilateral anterior uveitis with sectoral iris atrophy and without (previous) keratitis.

METHODS

The patients were selected from our database of 592 patients with anterior uveitis.

MAIN OUTCOME MEASURES

We reviewed the clinical data on the 31 patients and the results of diagnostic anterior chamber fluid analysis for 24 of the 31 patients. Specifically, production of local antibodies against herpes simplex virus (HSV) and varicella zoster virus (VZV) was determined and the polymerase chain reaction was performed to demonstrate the DNA of HSV, VZV, and cytomegalovirus (CMV) in the aqueous samples.

RESULTS

Main clinical characteristics of anterior uveitis with iris atrophy included unilateral involvement with a prolonged course and recurrent exacerbations in all cases. Elevated intraocular pressure during intraocular inflammation occurred in 90% of patients (28 of 31). Visual outcome was favorable because 29 of 31 patients (94%) retained a visual acuity of 20/32 or more. The causal agent was identified as HSV in 83% (20 of 24) and VZV in 13% (3 of 24) and was inconclusive in one case. The patients with HSV uveitis were younger than those with VZV uveitis (mean age at onset 34 and 65 years, respectively; P = 0.0056).

CONCLUSIONS

Unilateral anterior uveitis with sectoral atrophy of the iris without associated (previous) keratitis is a distinct entity among herpetic eye diseases. Recurrent unilateral anterior uveitis with iris atrophy and/or elevated intraocular pressure has most likely been caused by HSV.

Varicella zoster viral disease

Herpes zoster is cause of considerable morbidity, especially among elderly patients, with a suggestion of a slight increase in incidence among female patients. Substantial research on the biology of the varicella zoster virus has led to advances in our knowledge of the pathophysiology of the disease along with more successful therapy for the acute episodes of herpes zoster. Ophthalmic zoster is more common than zoster in other cranial nerves and is associated with pronounced suffering. This article reviews the epidemiology, biology, and latency of herpes zoster, discusses the pathophysiology of the disease, and describes treatment options with antivirals and corticosteroids. The pathophysiology and treatment options for postherpetic neuralgia are also addressed. The varicella vaccine is now available, and initial results suggest that this may lessen the effect of herpes zoster in the future.

Symptomatic anterior uveitis in HIV-positive patients

Symptomatic anterior uveitis is rare in HIV-positive patients. The uveitis associated with cytomegalovirus retinitis (CMVR), the commonest ocular manifestation in AIDS patients, is rarely symptomatic and patients do not typically present with a red painful eye in conjunction with blurred vision. In this article we report 12 cases of symptomatic anterior uveitis in HIV-positive patients and discuss the aetiology. The case notes of all HIV-positive patients presenting to the eye department with symptoms of uveitis over a 4-year period were studied retrospectively. The notes were analysed for age, sex, race, risk factors of HIV, features of the uveitis, concurrent disease and CD4 counts. Only 12 patients were identified to have symptomatic uveitis out of a total 172 patients. There were 9 males and 3 females with an average age of 35 years. None of these patients were taking either rifabutin, protease inhibitors or cidofovir. Seven out of the 12 patients had granulomatous uveitis. Of these 7 patients, 4 had CD4 counts over 200 and no other concurrent illness whilst 3 patients, with CD4 counts between 130-200, were subsequently found to have an underlying aetiology namely lymphoma, tuberculosis and candida. The remaining 5 patients, all with CD4 counts below 40, had a history of systemic illness with herpes zoster preceding the onset of the uveitis. HIV-positive patients with symptoms of uveitis do not have active CMVR and the ophthalmologist must search for other causes such as tuberculosis or lymphoma in those with granulomatous uveitis or herpes zoster in those with non-granulomatous uveitis. The CD4 count may be helpful.

Herpes zoster sine herpete. A potential cause of iridoplegic granulomatous iridocyclitis

OBJECTIVE

Herpes zoster ophthalmicus (HZO) is a recurrence of varicella zoster virus involving cranial nerve V-1, but does not always have skin manifestations. The objective of this work is to study iridoplegic granulomatous iridocyclitis as an acute, fulminant iridocyclitis that probably is caused by the recurrence of varicella zoster virus without skin eruptions.

PARTICIPANTS

The author reports 15 cases of iridoplegia granulomatous iridocyclitis with involvement of the anterior uveal tract without known skin eruptions.

RESULTS

All patients have had a clinical course of iridocyclitis closely resembling those cases of herpes zoster with skin eruptions. Nine of the 15 are documented to have had a recurrence of varicella zoster virus with an appropriate rise and fall of systemic titers. The remaining six patients had clinical findings, including loss of accommodation, iridoplegia, and sectoral iris atrophy that were more typical for HZO than other infectious agents.

CONCLUSIONS

Iridoplegic granulomatous iridocyclitis is a newly described, acute, fulminant uveitis probably caused by a herpes virus and most probably by varicella zoster virus. Herpes zoster sine herpete (erupticum) should be suspected as a potential diagnosis in patients with appropriate anterior segment manifestations. Further study is necessary to discern if any of such cases could be caused by herpes simplex.

A polymerase chain reaction-based assay for diagnosing varicella-zoster virus retinitis in patients with acquired immunodeficiency syndrome

PURPOSE

To develop a rapid, sensitive, and specific laboratory assay based on the polymerase chain reaction for the diagnosis of varicella-zoster virus retinitis in patients with acquired immunodeficiency syndrome (AIDS).

METHODS

We developed and tested a polymerase chain reaction-based assay for the detection of varicella-zoster virus DNA in vitreous samples. We attempted to detect varicella-zoster virus DNA in 14 vitreous samples from patients with AIDS and a clinical diagnosis of progressive outer retinal necrosis syndrome. For controls, we also attempted to detect varicella-zoster virus DNA in vitreous samples from 75 immunocompetent patients with vitreoretinal disease and 88 patients with AIDS and vitreoretinal inflammatory disease not related to progressive outer retinal necrosis syndrome.

RESULTS

Varicella-zoster virus DNA was detected in 11 of 14 vitreous samples from AIDS patients with progressive outer retinal necrosis syndrome. All three samples that scored negative for varicella-zoster virus DNA came from eyes that had been treated aggressively with antiviral drugs and had clinically inactive disease at the time of vitreous biopsy. Varicella-zoster virus DNA was detected in only two of 75 control vitreous samples from immunocompetent patients with vitreoretinal disease and two of 88 control vitreous samples from patients with AIDS and vitreoretinal inflammatory disease not related to progressive outer retinal necrosis syndrome.

CONCLUSION

We have developed a rapid, sensitive, and specific polymerase chain reaction-based diagnostic assay for varicella-zoster virus DNA that will assist in the diagnosis of varicella-zoster virus retinitis in patients with AIDS.

Disciform keratitis: a case of herpes zoster sine herpete

PURPOSE

To describe a case of disciform keratitis in a patient with acquired immunodeficiency syndrome (AIDS) in which varicella-zoster virus was the causative agent.

METHOD

Case report, Polymerase chain reaction-based assays for varicella-zoster virus, cytomegalovirus, and herpes simplex virus were used to analyze an aqueous aspirate.

RESULTS

We examined a 41-year-old man with AIDS but without a history of varicella-zoster virus dermatitis who had disciform corneal edema in his left eye. Varicella-zoster virus was detected by a polymerase chain reaction-based assay in the aqueous of the left eye; however, neither cytomegalovirus nor herpes simplex virus DNA were detected by polymerase chain reaction-based assays. The corneal edema slowly resolved while the patient was treated with famciclovir.

CONCLUSION

Varicella-zoster virus may cause disciform keratitis without a preceding skin eruption.