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.