Clinical features of cytomegalovirus anterior uveitis in immunocompetent patients

PURPOSE: To describe the clinical presentation of cytomegalovirus (CMV) anterior uveitis in human immunodeficiency virus (HIV)-negative patients. DESIGN: Retrospective, interventional case series. METHODS: HIV-negative patients with anterior uveitis associated with elevated intraocular pressure (hypertensive anterior uveitis) seen at the Singapore National Eye Centre had their aqueous analyzed for viral deoxyribonucleic acid by polymerase chain reaction, and their records were reviewed for demographic data, ocular findings, laboratory results, and treatment. RESULTS: Aqueous was obtained from 105 of 106 eligible eyes. Twenty-four eyes demonstrated positive results for CMV (22.8%). Eighteen eyes had Posner-Schlossman syndrome (PSS; 75%) at presentation, five eyesba had Fuchs heterochromic iridocyclitis (FHI; 20.8%), and one eye had a presumed herpetic anterior uveitis. Twelve of the 24 eyes were treated with ganciclovir. Of the 12 who completed treatment, all responded clinically, and their aqueous demonstrated negative results for CMV on repeat testing. However, nine had recurrences within eight months of stopping treatment and required further courses of ganciclovir. The 81 CMV-negative eyes included 30 with PSS, 11 with FHI, 27 with uveitic glaucomas of unknown cause, and 13 with presumed herpetic anterior uveitis. CONCLUSIONS: CMV anterior uveitis is not uncommon in our immunocompetent patients and it may present as a recurrent acute or chronic inflammation, resembling PSS, herpetic anterior uveitis, or FHI.     

Cytomegalovirus retinitis in immunocompetent patients

BACKGROUND: Cytomegalovirus (CMV) retinitis usually affects severely immunosuppressed individuals. We report two immunocompetent patients who developed CMV retinitis. CASES: Case 1 was a 65-year-old man who was referred to us with blurred vision and floaters of 2 weeks duration in his left eye. Slit-lamp biomicroscopy showed keratic precipitates, aqueous cells, and vitreous opacity in his left eye. Funduscopic examination revealed yellow-white retinal lesions with arterial sheathing in the superotemporal midperiphery. Case 2 was a 63-year-old man who presented with a 2-week history of blurred vision in his left eye. Ophthalmologic examination of the left eye showed keratic precipitates, aqueous cells, vitreous opacity, and yellow-white lesions in the superotemporal peripheral retina. In both cases, CMV DNA was detected in the aqueous humor and therefore the diagnosis was CMV retinitis. CMV retinitis in both cases was indolent and was resolved in one month without treatment with antiviral drugs. Although both patients had diabetes mellitus, the results of their laboratory examinations were unremarkable and they were immunocompetent. CONCLUSIONS: Unlike CMV retinitis in immunocompromised patients, CMV retinitis in immunocompetent patients had significant anterior and vitreous inflammation but did not require antiviral treatment. A possible association between CMV retinitis and diabetes mellitus was suggested.     

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.     

Low-dose Cyclosporin a in uveitis a long-term follow-up

Seventy patients suffering from bilateral endogenous chronic uveitis or ocular Behcet's disease have been treated with 5 mg/kg/day Cyclosporin A. All patients were followed at regular intervals for up to eight years. In this group of patients, we observed that CsA is an effective drug for the treatment of intraocular inflammation. Patients have needed continuous treatment with CsA for an average period of 31 months. Exacerbations of the inflammatory processes have been observed in 95% of the patients on initial attempts to lower the CsA dosage. These exacerbations were controlled either by local treatment or a combination of low-dose systemic corticosteroids. Elevation of the serum creatinine was initially observed in all patients when under the higher doses of CsA. However, only 15 patients (21.4%) had levels which were higher than the upper normal limit. Elevation of the bilirubin level of 50% or more above baseline was observed in 45 patients (64.3%) but only 11 patients (15.7%) showed levels which were above the upper normal limit. During this period of follow-up, cure was achieved in 25 patients and no exacerbations were observed up to five years after discontinuation of treatment.     

Severe Cytomegalovirus anterior uveitis and corneal endotheliitis after use of topical tacrolimus

Dear Editor,Cytomegalovirus(CMV) uveitis is typically characterized by anterior segment inflammation with coin-shaped or linear keratic precipitates(KPs), mild cells and aqueous flare in the aqueous humor, corneal endothelial cell loss。     

Human leukocyte antigen-B27-associated uveitis: long-term follow-up and gender differences

PURPOSE: To evaluate clinical features and gender differences in human leukocyte antigen (HLA)-B27-associated acute anterior uveitis (AAU) in long-term follow-up. DESIGN: Retrospective cohort study. METHODS: The clinical records of 177 HLA-B27-positive patients (96 males [54%] and 81 females [46%]) who sought treatment for acute anterior uveitis (AAU) at the University Medical Center Utrecht between January 1995 and December 2005 were evaluated. All patients had a minimum follow-up of at least one year. The clinical data were analyzed at standardized intervals (one, five, and 10 years after the onset of uveitis). RESULTS: Average age at onset of AAU was 36 years, with no differences between males and females. HLA-B27-associated systemic disease developed earlier in males than in females (31 vs 37 years; P=.021). Consequently, at onset of AAU, HLA-B27-associated systemic disease were more frequent in males than in females (25/75 [33%] males vs nine/54 [17%] females; P=.030); however over time, males and females were at equal risk of developing a HLA-B27-associated systemic disease. Bilateral uveitis developed more frequently in females (6/45 [13%] of males vs 11/35, [31%] of females; P=.05). In none of the patients did bilateral visual acuity of less than 0.5 develop after the follow-up of 10 years. CONCLUSIONS: The long-term visual prognosis of HLA-B27-associated AAU was favorable, despite the frequent attacks of severe AAU. At the onset of AAU, the prevalence of HLA-B27-associated systemic disease was more frequent in males, but after the onset of uveitis, the risk of developing a HLA-B27-associated systemic disease is similar for both males and females.     

Clinical features of human T-lymphotropic virus type 1 uveitis: a long-term follow-up

To investigate the clinical manifestations of human T-lymphotropic virus type-1 uveitis (HU), 112 HU patients who were followed up periodically for more than one year were retrospectively analyzed with respect to their ophthalmological and systemic complications. The gender ratio (female/male ratio) of the HU patients was 2.0 and the initial complications were foggy vision in 34.5%, ocular floaters in 33.3%, and blurred vision in 15.5%. As for the ocular symptoms, the majority (78.6%) of patients were classified as intermediate uveitis with vitreous inflammation. Recurrence of uveitis episodes was seen in one half of the patients (51.8%); 12 patients had more than six uveitis episodes. The interval of uveitis episodes varied from two weeks to 10 years. Nearly one half of the patients (43.8%) had ocular complications: e.g., cataract in 22 patients, persistent vitreous opacities in 17 patients, and glaucoma in 16 patients. Although the visual prognosis was essentially good, 11 patients had poor visual prognosis (<0.1). The causes of poor vision in these patients were cataract, cystoid macular edema, epiretinal membrane, and optic nerve atrophy. Of the 112 HU patients, two developed HTLV-I-associated myelopathy (TSP/HAM) after the onset of HU, while none developed adult T-cell leukemia. Sixteen HU patients had a previous history of Graves' disease and a past history of methimazole therapy, while Graves' disease was found in another HU patient only after HU onset and methimazole was not administered before the onset of HU. The present data of long-term follow-up indicate that (1) HU causes various ocular complications and its visual prognosis can be poor, (2) TSP/HAM can be induced even after the onset of HU, and (3) methimazole is not a risk factor of HU after Graves' disease.     

Long-term follow-up of anterior uveitis after cataract extraction and intraocular lens implantation

PURPOSE: To assess whether cataract surgery and intraocular lens (IOL) implantation in patients with anterior uveitis interfere with the natural course of the ocular disease. SETTING: Tertiary care center at the University of Rome "La Sapienza", Rome, Italy. METHODS: Cataract extraction and IOL implantation were performed in 24 patients with uveitis-related cataract: 12 with Fuchs' heterochromic iridocyclitis (Group 1) and 12 with other types of anterior uveitis (Group 2). The mean follow-up in the 2 groups was 33.6 months and 24.8 months, respectively. The number and severity (inflammatory score) of uveitis relapses in all patients over the same period were recorded. RESULTS: After surgery, the mean number and severity of uveitis relapses decreased: Group 1, from 1.83 +/- 1.90 (SD) to 1.00 +/- 1.21 and from 1.08 +/- 0.90 to 0.92 +/- 0.67, respectively; Group 2, from 2.74 +/- 3.44 to 1.25 +/- 1.71 and from 1.83 +/- 1.10 to 1.25 +/- 0.75, respectively (P = .046). There were no statistically significant between-group differences. In Group 2, a trend toward worse visual rehabilitation was seen; this was significantly different from the result in Group 1 (P = .018) because of preoperative optic nerve damage, macula disease, or both. CONCLUSION: Cataract surgery and IOL implantation did not negatively influence the natural course of uveitis in patients with Fuchs' heterochromic iridocyclitis. Correct surgical timing, selection of cases, and adequate anti-inflammatory therapy may promote similar results in patients with other types of anterior uveitis.     

前葡萄膜炎156例病因分析

目的对156例(156眼)单眼前葡萄膜炎患者的临床资料进行分析,探讨其病因特点。方法根据病史、临床表现、合并全身疾病,采用实验室检查等辅助手段查找病因。结果 156例患者的主要病因为外伤和人工晶状体等手术各20例,分别占12·82%;单纯疱疹病毒性角膜炎并发前葡萄膜炎19例,占12·18%;其后依次是风湿性关节炎、糖尿病、Fuch综合征等;未找到病因者59例,占37.82%。结论前葡萄膜炎病因复杂,对此类患者应详细行眼部检查,并借助全身检查和辅助检查积极查找病因,及时诊治,避免严重并发症发生。     

650例前葡萄膜炎临床分析

目的探讨前葡萄膜炎的病因、类型、临床特点及预后。方法回顾性病例研究。分析2006年12月至2012年7月就诊于我院葡萄膜炎专科的650例前葡萄膜炎患者（856眼）的临床资料,根据病史、临床表现、合并全身性疾病、辅助检查及实验室检查等,对前葡萄膜炎的病因、临床特点、治疗效果及预后进行探讨。结果650例前葡萄膜炎患者（856眼）中单眼发病444例,双眼发病206例,男394例,女256例,男女比例为1．5：1;平均发病年龄（39．0±15．0）岁,20～50岁之间的青壮年患者占总病例的71．4％。急性期689眼,慢性期167眼。按病因主要分为特发性前葡萄膜炎（243例,37．4％）,不伴发全身关节病变的HLA—B27相关性前葡萄膜炎（123例,18．9％）,强直性脊柱炎（105例,16．2％）,Fuchs综合征（74例,11.4％）和病毒感染（44例,6．8％）。各种并发症发生率为39．5％,主要为并发性白内障（41．1％）和继发性青光眼（35．1％）。治疗后视力≥0．5者占75．4％,0．05～者占20．3％,〈0．05者占4-3％。结论前葡萄膜炎发病率高．病因复杂多样。易复发,如治疗不当将产生严重并发症。因此应对前葡萄膜炎患者进行详细、系统的检查,积极查因,从而指导临床治疗及预后。     

Immunologic profile in patients with acute anterior uveitis

The authors investigated 52 patients (22 men and 30 women) with acute anterior uveitis where they ruled out systemic autoimmune disease, metabolic disease and focal or chronic infection. At the time of the infection the patients had not been treated for several months by any immunosuppressive treatment. The authors investigated in these patients serum concentrations of immunoglobulins G, A and M, the concentration of the C3 component of complement and the concentration of circulating immune complexes. Before the onset of therapy they investigated the response to antigens of the Immunoskin test. They assessed also the ratio of transplantation antigens class I by the microlymphocytotoxic test. They compared furthermore immunological indicators in subjects with a first attack and relapse of the disease and in groups, classified by the severity of the inflammatory symptoms. The authors detected significantly more frequently (p = 0.0005) the incidence of HLA-B27 antigen. Those where it was present were more frequently affected with a severe inflammation, as compared with subjects who did not have this phenotype (p less than 0.04). The relapse of the disease was more frequent in women (p = 0.1). The immunological laboratory findings did not differ in the first attacks and relapses of the disease, differences were, however, found in groups which differed as to the severity of inflammatory symptoms. In these groups the response rate to tests of skin sensitivity differed also. Based on these findings the authors assume that the ratio of immune processes in the development of acute idiopathic anterior uveitis cannot be ruled out.     

Refractory anterior uveitis

Treatment of anterior uveitis should be etiological when a cause has been identified and provided for any symptomatic case, using topical corticosteroids and mydriatics/cycloplegics. Periocular and systemic agents are then used in certified cases that prove to be refractory to first-line therapy. If anterior uveitis is still rebellious to treatment, the physician should evaluate the accuracy of the present therapy in case of an unsuspected cause of uveitis, or a particularly severe or chronic intraocular inflammation.