Multiple Anterior Chamber Paracenteses May Be Needed to Identify Cytomegalovirus Anterior Uveitis

PURPOSE

To demonstrate cases of anterior uveitis requiring more than one anterior chamber paracenesis to elucidate CMV as the causative etiology.

DESIGN

Retrospective chart review.

METHODS

Patients were seen at the Francis I. Proctor Foundation at the University of California, San Francisco between 2013 to 2024. Patients who required more than one anterior chamber paracentesis to detect CMV as the etiologic agent of their anterior uveitis were included. Number of anterior chamber paracenteses required to detect CMV, demographic and clinical features, viral load at time of positive anterior chamber paracentesis and association between topical corticosteroid use and viral load at time of positive anterior chamber paracentesis.

RESULTS

Fourteen patients required a median of 2 (range 2-4) anterior chamber paracenteses to detect CMV. Mean age was 48.2 years, and 57.1% were male. Most patients (64.3%) were born in East and Southeast Asia. All affected eyes featured ocular hypertension. Five patients (35.7%) were initially treated with systemic immunosuppression before CMV was detected. Increasing frequency of topical corticosteroid use was significantly associated with higher CMV viral loads (p<0.001). Five patients (35.7%) required glaucoma surgery. In 13 patients with available data, uveitis was present for an average of 2776 days (range 23-7889 days) prior to CMV detection. Once diagnosed, most patients were treated with oral valganciclovir, with one patient transitioning to letermovir due to side effects.

CONCLUSIONS

CMV anterior uveitis may be more prevalent than previously recognized and often requires multiple anterior chamber paracenteses for diagnosis. Reliance on a signle negative test may lead to misdiagnosis and inappropriate treatment. Clinicians should maintain a high index of suspicion for CMV in cases of recurrent anterior uveitis, particularly in patients of East and Southeast Asian descent. This study highlights the importance of repeated testing and appropriate antiviral treatment to prevent complications such as glaucoma.

Clinical characteristics and treatment outcomes of Cytomegalovirus anterior uveitis and endotheliitis: a systematic review and meta-analysis

Cytomegalovirus (CMV) anterior uveitis is the most common form of ocular manifestation of CMV in immunocompetent individuals. The difficulty in diagnosing CMV anterior uveitis may delay adequate treatment and affect outcomes. We sought to review systemically the overall clinical characteristics and compare treatment outcomes in CMV anterior uveitis and endotheliitis. A literature search was performed, and studies describing clinical characteristics, treatment regimens, and outcomes that included more than five treated eyes were included. In these 23 studies, acute CMV anterior uveitis commonly presented with high intraocular pressure (IOP; 95.31%, 95% CI 90.45 - 98.60) and mild anterior chamber inflammation (cells >2+ = 3.18%, 95% CI 0.21- 8.54). About two-thirds of CMV endotheliitis cases presented with high IOP and coin-shaped corneal lesions. Acute CMV anterior uveitis showed good clinical response to topical 0.15% ganciclovir (GCV) gel or oral valganciclovir (VGCV) (90%, 95% CI: 74-100% and 95%, 95% CI: 88-100%, respectively). For chronic CMV anterior uveitis, both topical GCV and oral VGCV yielded comparable results. Topical 0.5-2% GCV or a combination of topical and oral VGCV for CMV endotheliitis both resulted in good clinical response. Recurrence of inflammation was common after cessation of maintenance therapy. Overall, topical GCV resulted in an optimal outcome for CMV anterior uveitis. Escalated concentration and frequency of usage are needed for chronic CMV anterior uveitis and endotheliitis. Adequate induction and maintenance phases of anti-CMV treatment seem necessary to prevent recurrences.

Lassa Virus Targeting of Anterior Uvea and Endothelium of Cornea and Conjunctiva in Eye of Guinea Pig Model

Lassa virus (LASV), a hemorrhagic fever virus endemic to West Africa, causes conjunctivitis in patients with acute disease. To examine ocular manifestations of LASV, we histologically examined eyes from infected guinea pigs. In fatal disease, LASV immunostaining was most prominent in the anterior uvea, especially in the filtration angle, ciliary body, and iris and in and around vessels in the bulbar conjunctiva and peripheral cornea, where it co-localized with an endothelial marker (platelet endothelial cell adhesion molecule). Antigen was primarily associated with infiltration of T-lymphocytes around vessels in the anterior uvea and with new vessel formation at the peripheral cornea. In animals that exhibited clinical signs but survived infection, eyes had little to no inflammation and no LASV immunostaining 6 weeks after infection. Overall, in this model, LASV antigen was restricted to the anterior uvea and was associated with mild chronic inflammation in animals with severe disease but was not detected in survivors.

The diagnostic utility of anterior chamber paracentesis with polymerase chain reaction in anterior uveitis

PURPOSE

To determine the value of anterior chamber paracentesis with polymerase chain reaction (PCR) in patients with anterior uveitis.

DESIGN

Retrospective observational case series.

METHODS

SETTING

Bascom Palmer Eye Institute.

PATIENT POPULATION

Fifty-three patients with a diagnosis of anterior uveitis who underwent anterior chamber paracentesis with PCR.

OBSERVATION PROCEDURES

Anterior chamber paracentesis with PCR of aqueous fluid.

MAIN OUTCOME MEASURE

Diagnostic utility and frequency of management change based on anterior chamber paracentesis and PCR.

RESULTS

There were 15 of 53 (28%) acute and 35 of 53 (65%) chronic anterior uveitis patients. PCR positivity of herpes simplex virus, cytomegalovirus, varicella zoster virus, and Epstein-Barr virus in our population were 4 of 53 (8%), 1 of 47 (2%), 1 of 35 (3%), and 1 of 18 (6%). Overall, 7 of 53 patients (13%) had a change in management because of PCR results from anterior chamber paracentesis. Four patients encountered paracentesis complications (4/53, 7.5%), 1 with long-term sequelae.

CONCLUSIONS

Anterior chamber paracentesis with PCR had a relatively low diagnostic utility and resulted in few management changes in patients with suspected infectious anterior uveitis.