Acute retinal necrosis.

Acute retinal necrosis (ARN) is a rare, progressive viral uveitis, with the majority of cases caused by herpesviruses. The diagnosis of ARN is often delayed, and most patients will have some degree of permanent visual loss. We report a case of ARN in a previously healthy 32-year-old patient.

Does ganciclovir exert retinal toxicity after multiple continuous intravitreal injections?

BACKGROUND: The objective of this study is to report a case of acute retinal necrosis in which abnormalities in visual function did not correspond to retinal anatomical outcomes. CASE PRESENTATION: A 39-year-old female diagnosed with acute retinal necrosis underwent repeated (nine rounds) intravitreal ganciclovir injection (3 mg/0.1 ml) into the left eye, one injection every 2 weeks. During the therapy, the patient noticed her visual acuity declining gradually. The best corrected visual acuity in the left eye was 20/33. The visual field showed massive visual damage. There was no posterior necrotizing involvement, no macular edema or exudation, and only slight abnormity of the interdigitation zone in the fovea area was visible on OCT. Angio-OCT revealed normal capillary density of three retinal capillary and choriocapillaris layers. The visually evoked potential was normal. The photopic single-flash response showed a declined amplitude of a-wave and b-wave. The amplitudes of photopic 30 Hz flicker were decreased. Multifocal electroretinography revealed macular dysfunction. CONCLUSION: Ganciclovir-associated photoreceptor damage may induce abnormalities in retinal function in response to multiple continuous intravitreal ganciclovir injections at a relatively high dosage (3 mg/0.1 ml).

Tick-borne encephalitis related uveitis: a case report.

BACKGROUND: Tick-borne encephalitis (TBE) is an infectious disease of the central nervous system caused by the TBE virus (TBEV), which is usually transmitted by a tick-bite, with increasing incidence in northeastern Europe and eastern Asia during the past decade. Ocular involvement has not been described in the literature to date. CASE PRESENTATION: A 58-year-old patient presented to the emergency department with occipital headaches and poor balance for 5 days. He reported a tick-bite 6 weeks before without erythema migrans followed by a flu-like syndrome. Serological testing was negative for Borreliosis and TBEV. At presentation, he was febrile with neck stiffness and signs of ataxia. Three days later, he presented unilateral visual loss in his right eye. Examination revealed non granulomatous anterior uveitis, vitreous inflammation, and retinal haemorrhages at the posterior pole without macular oedema or papillitis. Polymerase chain reaction (PCR) of the cerebrospinal fluid returned negative for all Herpes family viruses. No clinical evidence of other infection nor malignancy was identified. A seroconversion of the TBEV- immunoglobulin titres was observed 2 weeks later while the serum antibodies for Borrelia were still not detected. Magnetic resonance imaging was unremarkable. We concluded to the diagnosis of TBE-related uveitis. Under supportive treatment, there was complete resolution of the neurological symptoms and the intraocular inflammation without sequelae within the following weeks. CONCLUSIONS: We describe a new association of TBEV with uveitis. In view of the growing number of TBE cases and the potential severity of the disease we aim at heightening awareness to achieve prompt recognition, prevention, and treatment.

Cytokines Produced in Response to Varicella-Zoster Virus Infection of ARPE-19 Cells Stimulate Lymphocyte Chemotaxis.

Posterior uveitis is an ocular complication that can occur with reactivation of varicella-zoster virus (VZV). It may lead to loss of vision due to retinal detachment and chronic inflammation, which often causes more severe disease than the virus infection itself. To increase our understanding of the immune response, we infected the retinal pigment epithelial (RPE) cell line, ARPE-19, with cell-associated VZV and compared its response to that of the MeWo cell line using multiplex assays. We observed (1) a difference in the magnitude and kinetics of cytokine responses between the 2 cell types and (2) differential migration of CD4+ and CD8+ T cells towards these cytokines. Thus, our data provide information about the cytokine and lymphocytic responses to VZV infection of RPE cells, thereby providing a useful platform for future studies to address mechanisms underlying the immunopathology of VZV-associated posterior uveitis.

Unilateral Acute Retinal Necrosis with Contralateral Non-necrotizing Herpetic Uveitis.

PURPOSE: The objective of this study is to report a case of unilateral acute retinal necrosis (ARN) with contralateral eye presenting as non-necrotizing herpetic uveitis. CASE REPORTS: Case 1: A 48-year-old female presented at our clinic with blurred vision in the right eye for 7 days. She was diagnosed with ARN in the left eye 2 weeks ago. Ophthalmic examination revealed reduced visual acuity in the right eye (20/33) with the presence of optic disc swelling and macular exudation without peripheral necrotic lesions. With systemic antiviral therapy, optic disc swelling of the right eye vanished gradually, and the visual acuity improved to 20/20. Loss of retinal nerve fiber layer (RNFL) and decreased retinal thickness in the corresponding area occurred during follow-up. CONCLUSION: Non-necrotizing herpetic uveitis may occur in the contralateral eye of unilateral ARN under rare conditions. Structure abnormities, including loss of RNFL and focal decreased retinal thickness, are irretrievable.

Viral Anterior Uveitis: A Practical and Comprehensive Review of Diagnosis and Treatment.

Anterior uveitis is the most common type of uveitis worldwide. The etiologies of anterior uveitis can be divided into infectious and non-infectious (idiopathic, autoimmune, autoinflammatory, trauma, and others). The viral pathogens most commonly associated with infectious anterior uveitis include Herpes Simplex Virus, Varicella-Zoster Virus, Cytomegalovirus, and Rubella Virus. Other emerging causes of viral anterior uveitis are West Nile Virus, Human-Immunodeficiency Virus, Epstein-Barr Virus, Parechovirus, Dengue Virus, Chikungunya Virus, and Human Herpesvirus type 6,7, and 8. Early recognition allows prompt management and mitigates its potential ocular complications. This article provides an updated literature review of the epidemiology, clinical manifestations, diagnostic tools, and treatment options for viral anterior uveitis.

Systemic and Ophthalmic Manifestations of Chikungunya Fever.

PURPOSE: Chikungunya is a re-emerging viral infection across the globe. The purpose of this article is to review the systemic and ophthalmic manifestations associated with chikungunya fever. METHOD: A review of literature was conducted using online databases. RESULTS: In this report, we have reviewed the presently available literature on uveitis caused by chikungunya and highlighted the current knowledge of its clinical manifestations, imaging features, laboratory diagnostics, and the available therapeutic modalities from the systemic and ophthalmic standpoint. CONCLUSIONS: Ocular involvement in chikungunya infection may occur at the time of systemic manifestations or it may occur as a delayed presentation many weeks after the fever. Treatment relies on a supportive therapy for systemic illness. Treatment of ocular manifestation depends on the type of manifestations and usually includes a combination of topical and oral steroids.

Unusual pattern of herpetic optic neuropathy: a case report and literature review of the pathophysiology of herpetic uveitis.

Herpetic uveitis is a relatively common type of intraocular inflammation with a broad spectrum of manifestations ranging from mild anterior uveitis to rapidly progressing vision threatening necrotizing retinitis. Posterior herpetic uveitis presents with different clinical patterns within a spectrum depending presumably on the immune status of the patient. Systemic steroid use for viral uveitis without prior antiviral coverage is inappropriate and can lead to dramatic sequelae. Here, we report an unusual case of herpetic optic neuropathy in the contra lateral eye of a patient with acute retinal necrosis after improper use of oral steroids.

A case of non-necrotising herpetic retinitis.

In developed countries, the main etiology of posterior uveitis is of infectious origin, Herpes is the most common viral agent as it has a wide spectral of ocular manifestations. These manifestations could depend on the patient's immunologic state, ranging from a mild focal form of non-necrotizing herpetic renitis (NNHR) to a severe form of Acute retinal necrosis (ARN). We present a case of NNHR by VHS 2 and the different differential diagnostics previous to its diagnosis: atypical ocular toxoplasmosis, ocular tuberculosis and ARN. During its evolution, it presented a drastic drop in the visual acuity despite of the antiviral treatment, and with systemic corticoids and the injury's clinical improvement. This event led to reevaluate the suspected entities, establishing the NNHR as a definitive diagnostic by exclusion that constituted a challenging diagnostic.

Atypical associations of viral anterior uveitis with glaucoma-a series of challenging scenarios with review of literature.

PURPOSE: To report unusual associations, atypical clinical presentations, and outcomes of tailored treatment of viral uveitis and glaucoma. METHODS: Patients diagnosed with viral uveitis with associated glaucoma, seen at a tertiary eye care center between 2013 and 2020, were screened. Twenty-four patients with unclassified or atypical clinical presentations of viral uveitis, atypical clinical course, or with diagnostic challenges and associated glaucoma, were included. Patients with classical features of viral anterior or posterior uveitis, other forms of autoimmune/infectious/traumatic uveitis, were excluded. RESULTS: Viral re-activation causing recurrent choroidals after glaucoma filtering surgery responsive to systemic antiviral therapy, massive pigment dusting/plume as a presenting feature, multiple progressive focal anterior synechiae similar to iridocorneoendothelial (ICE) syndrome, were seen in this cohort of unusual viral uveitis in glaucoma. A high index of suspicion helped diagnose a viral etiology in cases with high intraocular pressure (IOP) after uneventful Ahmed glaucoma valve surgery (AGV) or post-YAG capsulotomy laser, presumed Posner-Schlossman syndrome with multiple recurrences or presumed steroid glaucoma. All patients responded well with anti-viral and tailored concomitant steroids, anti-glaucoma therapy with loss of visual acuity seen in one eye developing optic atrophy. CONCLUSIONS: Uncommon clinical presentations or associations of viral uveitis in glaucoma should be kept in mind. A high index of suspicion and tailored prompt treatment may ensure good outcomes preventing further visual morbidity in glaucoma.

Acute retinal necrosis: time to consider double dose of Foscarnet in the first 72 hours.

Purpose: To report a case of acute retinal necrosis (ARN) and to emphasize special aspects of the management. Factors that must be considered. Methods: We present the case of an 83-year-old woman examined for acute vision loss in her left eye (LE). Background: diabetes, pseudophakic in her LE; subluxated intraocular lens (IOL) and advanced pseudoexfoliative glaucoma in her right eye (RE). The visual acuity (VA) was hand movements in both eyes. Funduscopic examination revealed vitritis, temporal area of retinal necrosis with peripapillary choroiditis spots and macular haemorrhages in her LE and OCT showed a cystic macular edema. Results: A positive polymerase chain reaction (PCR) test for Varicella Zoster Virus (VZV) in aqueous humor of her LE was found. She underwent intravenous Acyclovir 10 mg per kg every 8 hours. She received two doses of adjunctive intravitreal Foscarnet (2.4 mg/ 0.1 mL) in the first 3 days of treatment (2 days between doses). After 3 days of treatment, she started with intravenous prednisone 60 mg per day. The VA of her LE was 0,8 and the retinal necrosis activity was stationary. In fundoscopic examination, vitritis and retinal hemorrhages have disappeared. At that moment there were no foci of chorioretinitis or macular edema although retinal ischemia persisted at the inferior nasal level. Conclusions: The role of adjunctive intravitreal antiviral therapy in combination with systemic treatment revealed promising results. Corticosteroids can be used topically and orally to decrease the severe inflammatory response associated with ARN. Early treatment is crucial to optimize visual and anatomic outcomes.

Peripapillary retinal nerve fiber layer and ganglion cell-inner plexiform layer changes on optical coherence tomography in patients with unilateral hypertensive cytomegalovirus anterior uveitis.

PURPOSE: To investigate whether peripapillary retinal nerve fiber layer (pRNFL) and macular ganglion cell-inner plexiform layer (GCIPL) thinning are present in patients with unilateral hypertensive Cytomegalovirus anterior uveitis (hCMV AU). METHODS: We included 19 eyes with unilateral hCMV AU and their unaffected fellow eyes as the control group in this study. Peripapillary RNFL and macular GCIPL changes were determined using spectral-domain (SD) - optical coherence tomography (OCT). RESULTS: The overall calculated mean pRNFL thickness was significantly lower in the effected eyes with hCMV AU than in the uneffected fellow eyes (p = 0.012). The mean macular GCIPL thickness in the affected eyes was also significantly lower than in the normal eyes (p < 0.001). CONCLUSION: Measurement of pRNFL and macular GCIPL thickness with OCT may detect signs of damage before the visual field changes in patients with hypertensive CMV AU. Early aggressive treatment in these patients may prevent further glaucomatous damage.

The role of antibody indexes in clinical virology.

BACKGROUND: Serological techniques are an essential part of the diagnostic tools used in clinical virology. Among these techniques, antibody indexes are not novel, but do require specific expertise. Their niche has expanded substantially in recent years due to increasing evidence of their performance to diagnose viral infections. OBJECTIVES: This narrative review describes the background and clinical applications of antibody indexes. The first objective is to provide an overview of the theoretical background, insights for implementation, limitations and pitfalls. The second objective is to review the available evidence for the diagnostic performance, with a specific focus on viral encephalitis and uveitis. SOURCES: A comprehensive literature search was performed in PubMed, including original studies and reviews, with no time limit on the studies included. The following search terms were used: antibody index, Goldmann-Witmer coefficient, Reibergram, viral encephalitis, viral uveitis, herpes simplex virus, varicella zoster virus, cytomegalovirus, Epstein-Barr virus, rubella virus, measles virus, enterovirus, influenza virus, flaviviruses. CONTENT: Antibody indexes can support the diagnosis of a spectrum of viral infections in immune privileged sites such as the central nervous system and the eye, through the demonstration of virus-specific intrathecal or intraocular antibody production. This is especially useful in situations where PCR has a lower positivity rate: infections with rapid viral clearance due to natural immunity or treatment and chronic stages of viral infections. IMPLICATIONS: Antibody indexes expand the clinical microbiologist's diagnostic toolbox. Careful interpretation of the results of these assays is crucial and further standardization of methods is required to improve interchangeability of results between laboratories.

A case of non-necrotising herpetic retinitis. / Un caso de retinitis herpética no necrosante.

In developed countries, the main origin of posterior uveitis is an infection. Herpes is the most common viral agent, as it has a wide spectrum of ocular manifestations. These manifestations may depend on the immunological state of the patient, and range from a mild focal form of non - necrotising herpetic retinitis (NNHR) to a severe form of acute retinal necrosis (ARN). A case of NNHR due to Herpes simplex virus type 2 (HSV-2) is reported, along with the different differential diagnostics prior to its diagnosis: atypical ocular toxoplasmosis, ocular tuberculosis, and ARN. During its course, despite the antiviral treatment, systemic corticoids and the clinical improvement of the injury, there was a drastic drop in the visual acuity. This event led to the re-evaluation of the suspected entities, establishing the NNHR as a definitive diagnostic by exclusion, which was a diagnostic challenge.

Clinical Profile of Herpes Zoster Ophthalmicus in a South Indian Patient Population.

PURPOSE: To analyze and compare the clinical profile of herpes zoster ophthalmicus (HZO) patients in a South Indian patient population aged <60 years and ≥60 years and determine the risk factors for recurrence of ocular inflammation. METHODS: Retrospective study of 249 cases between 2006 and 2016 from two tertiary referral eye centres in south india. RESULTS: Out of 249 cases, 189 cases were <60 years (Group 1) and 60 cases were aged ≥60 years (Group2). Presence of diabetes mellitus, increased intraocular pressure(IOP) at the time of active inflammation, use of topical steroids and recurrences were significantly more common in group 1. Significant risk factors for recurrences included corneal, uveal, scleral involvements and increase in IOP. Good vision at presentation was noted in 67.9% of the patients. CONCLUSIONS: Anterior uveitis with or without keratitis was the most common presentation observed in more than 50% cases. The overall visual outcome was good.

Diagnosis of Cytomegalovirus Anterior Uveitis in Two European Referral Centers.

PURPOSE: To evaluate diagnostic methods and clinical signs of CMV anterior uveitis (AU), a rarely described entity in Europe. METHODS: We included patients with clinical characteristics of CMV AU and positive PCR and/or Goldmann-Witmer coefficient (GWc) for CMV. RESULTS: We report 21 patients with unilateral uveitis (100%) and signs of Posner-Schlossman syndrome (PSS) (n = 20, 95.2%), Fuchs uveitis syndrome (FUS) (n = 1, 4.7%), and endotheliitis (n = 4, 19,04%). PCR was positive in 15/21 (71.4%) and GWc in 8/9 patients (88.9%) in aqueous for CMV. GWc was the only positive test in 6/9 patients (66,6%). When PCR alone was performed (without GWc) in the first tap, repeated aqueous taps were needed, twice in five cases and thrice in one case. CONCLUSION: Combining PCR and GWc were very helpful to confirm the clinical diagnosis of CMV AU. In case of very high clinical suspicion and negative results, repeated tap seems to be recommended.

Challenges of Diagnosing Viral Anterior Uveitis.

The viral causes of anterior uveitis (AU) emerged with the use of novel molecular diagnostic tests and serologic tests adapted for small volumes (Goldmann-Witmer Coefficient). The viral causes of AU may be underestimated, and some of the presumed idiopathic AU cases will probably be proven to be of viral origin in the coming years. So far, a viral origin of AU was suspected in patients who presented with unilateral hypertensive AU. It is not clear which clinical presentations should raise a suspicion of viral etiology. There is an overlap in the clinical manifestations of AU caused by viruses and other non-viral forms of AU. A viral cause of AU should be suspected in patients with unilateral AU, exhibiting small or medium sized KPs, some form of iris atrophy, high IOP and early development of a cataract and the definitive diagnosis can be proven by aqueous humor analysis.

Topical Ganciclovir in Cytomegalovirus Anterior Uveitis.

PURPOSE: To study the effects of topical ganciclovir 0.15% gel on cytomegalovirus (CMV) anterior uveitis in a tertiary uveitis referral center in Brussels, Belgium. METHODS: A retrospective study of patients with a clinical diagnosis of CMV anterior uveitis/endotheliitis demonstrated by a positive polymerase chain reaction and/or Goldmann-Witmer coefficient (GWc). RESULTS: We report a series of 15 patients presenting clinical characteristics of CMV anterior uveitis. Patients had a pretreatment follow-up of 13.00 ± 12.78 months and a posttreatment follow-up of 42.64 ± 31.23 months. The 14 non-Asian patients (93.3%) had clinical characteristics of Posner-Schlossman syndrome, and the only Asian patient (6.7%) had keratic precipitates like Fuchs heterochromic iridocyclitis. At presentation, uveitis was unilateral in all patients, visual acuity (VA) was 0.91 ± 0.25, and all patients had an increased intraocular pressure (IOP), with a mean IOP of 41.40 ± 10.35 mmHg. At the end of the follow-up, 5 patients (33.3%) had glaucoma, 2 needed glaucoma surgery (13.3%). The mean final VA was 0.93 ± 0.11; 13 patients (86.5%) reached a final VA of 0.7 to 1. Patients had a significantly lower number of recurrences/year posttreatment (0.76 ± 0.57) than in the pretreatment period (3.76 ± 2.44) (P = 0.001). The mean time to recurrence increased from 4.03 months before treatment to 12.58 months after treatment (P = 0.003). CONCLUSION: Our results suggest that patients treated with 0.15% topical ganciclovir have a decreased frequency of CMV anterior uveitis recurrences, most preserve a relatively good central vision over time. However, glaucoma is a frequent and severe complication.

Características clínicas y diagnóstico etiológico de las uveítis virales / Clinical characteristics and etiologic diagnosis of viral uveitis

Objetivo: determinar las características clínicas y epidemiológicas de las uveítis virales según su etiología. Métodos: se realizó un estudio observacional y descriptivo transversal, que determinó el diagnóstico clínico y etiológico, según la reacción en cadena de polimerasa (PCR) de 10 ojos de pacientes atendidos en la consulta de uveítis, en el Instituto Cubano de Oftalmología ®Ramón Pando Ferrer¼, de mayo a noviembre del 2010. Se utilizó una muestra de fluidos intraoculares tomada a los pacientes. Las variables analizadas fueron: edad, sexo, color de piel, antecedentes personales generales u oculares, clasificación anatómica y patológica de la uveítis, curso evolutivo, bilateralidad, agudeza visual y presión intraocular iniciales y finales respectivamente, hallazgos al fondo de ojo y resultados de la PCR. La información fue procesada y los resultados expuestos en tablas. Resultados: la edad promedio de los pacientes estudiados fue de 34,5 años, que presentaron en su mayoría episodios de uveítis anteriores unilaterales. La agudeza visual mejor corregida final mejoró con respecto a la inicial en el grupo de estudio, aunque la presión intraocular se mantuvo elevada sin lograr controlarla. El virus más hallado fue el Herpes simple. Conclusiones: los virus son responsables de producir inflamaciones oculares de presentación variada, lo que en ocasiones retrasa el diagnóstico, empeorando el pronóstico visual. En estos casos el método de PCR ha demostrado ser una herramienta útil para establecer el diagnóstico etiológico

Objective: to identify the clinical and epidemiological characteristics of viral uveitis according to their etiology. Methods: observational, cross-sectional and descriptive study to determine the clinical and etiological diagnosis, according to the plolymerase chain reaction results, of 10 eyes from patients seen at the uveitis consultation service at Ramon Pando Ferrer Cuban Institute of Ophthalmology from May to November 2010. The sample comprised intraocular fluids taken from the patients. The analyzed variables were age, sex and race, general or ocular personal background, anatomical and pathological classification of uveitis, progression, bilaterality, and initial and final visual acuity and intraocular pressure, respectively, funduscopy findings and PCR results. The collected information was processed and expressed in tables. Results: the average age of the studied patients was 34.5 years; most of them had had episodes of unilateral anterior uveitis. The final best corrected visual acuity improved when compared to the initial one of the study group, although the intraocular pressure remained high with no control. The most found virus was Herpes simplex. Conclusions: the viruses are responsible for causing ocular inflammation of varied presentations, which occasionally delays the diagnosis and worsens the visual prognosis. In these cases, the PCR method has proved to be useful tool to set the final etiological diagnosis