Herpes simplex uveitis.

BACKGROUND: Uveitis in herpes simplex virus (HSV) ocular disease is usually associated with corneal stromal disease. It has generally been believed that herpetic uveitis in the absence of corneal disease is very rare. When seen it is usually attributed to varicella zoster virus (VZV) infections. The diagnosis of uveitis caused by herpes simplex is often not diagnosed resulting in inadequate treatment and a poor visual result. METHODS: Seven patients from a large uveitis practice who presented with a clinical picture of: anterior uveitis and sectoral iris atrophy without keratitis, a syndrome highly suggestive of herpetic infection, are reported. Polymerase chain reaction (PCR) was done in the aqueous of four of them and was positive for HSV. One patient had bilateral disease. Most of the patients also had severe secondary glaucoma. RESULTS: Of the seven patients presented five had no history of any previous corneal disease. Two had a history of previous dendritic keratitis which was not active at the time of uveitis development. One patient with bilateral disease was immunosuppressed at the time when the uveitis developed. Six of the seven patients had elevated intraocular pressures at the time of uveitis and five required glaucoma surgery. Intractable glaucoma developed in two patients leading to rapid and severe visual loss despite aggressive management. CONCLUSION: Findings suggest that uveitis without corneal involvement may be a more frequent manifestation of ocular herpes simplex disease than previously thought. Absence of corneal involvement delays a correct diagnosis and may worsen visual outcome. Primary herpetic uveitis (when there is no history of previous corneal disease) seems to be more severe than the uveitis in patients with previous corneal recurrences. The associated glaucoma may be a devastating complication.

Herpes simplex uveitis

BACKGROUND: Uveitis in herpes simplex virus (HSV) ocular disease is usually associated with corneal stromal disease. It has generally been believed that herpetic uveitis in the absence of corneal disease is very rare. When seen it is usually attributed to varicella zoster virus (VZV) infections. The diagnosis of uveitis caused by herpes simplex is often not diagnosed resulting in inadequate treatment and a poor visual result. METHODS: Seven patients from a large uveitis practice who presented with a clinical picture of: anterior uveitis and sectoral iris atrophy without keratitis, a syndrome highly suggestive of herpetic infection, are reported. Polymerase chain reaction (PCR) was done in the aqueous of four of them and was positive for HSV. One patient had bilateral disease. Most of the patients also had severe secondary glaucoma. RESULTS: Of the seven patients presented five had no history of any previous corneal disease. Two had a history of previous dendritic keratitis which was not active at the time of uveitis development. One patient with bilateral disease was immunosuppressed at the time when the uveitis developed. Six of the seven patients had elevated intraocular pressures at the time of uveitis and five required glaucoma surgery. Intractable glaucoma developed in two patients leading to rapid and severe visual loss despite aggressive management. CONCLUSION: Findings suggest that uveitis without corneal involvement may be a more frequent manifestation of ocular herpes simplex disease than previously thought. Absence of corneal involvement delays a correct diagnosis and may worsen visual outcome. Primary herpetic uveitis (when there is no history of previous corneal disease) seems to be more severe than the uveitis in patients with previous corneal recurrences. The associated glaucoma may be a devastating complication

[Sudden blindness in an AIDS patient. Simultaneous infection with cytomegalovirus and herpes simplex viruses and development of malignant non-Hodgkin lymphoma]. / Plötzliche Erblindung bei einem AIDS-Patienten. Gleichzeitige Infektion mit Zytomegalie und Herpes simplex-Viren und Auftreten eines malignen Non-Hodgkin-Lymphoms.

A 50 year old patient with non-diagnosed HIV-infection at onset of his illness developed impairment of vision and temporary double vision combined with severe hemianopsia. With normal fundus and suspicious Herpes simplex iritis therapy with Acyclovir was started. Primarily the patient showed a good response to the therapy and loss of vision could be prevented. After 4 weeks CMV-retinitis developed. In spite of Gancyclovir therapy manifestation of total loss of vision after 6 weeks. Autopsy demonstrated signs of simultaneous a CMV-infection of the retina and a herpes simplex-infection of the optic nerve combined with a Non-Hodgkin-Lymphoma of the optic tract.

[Characteristics of the clinical course of epidemic keratoconjunctivitis]. / Osobennosti klinicheskogo techeniia épidemicheskogo keratokon"iunktivita.

Clinical picture of epidemic keratoconjunctivitis was studied in 232 patients. The patients were divided into 3 groups. Group I included 147 patients with a monoinfection: Group 2 consisted of 70 epidemic keratoconjunctivitis patients after surgery for cataracts and glaucoma; Group 3 included 15 patients with epidemic keratoconjunctivitis and ophthalmic herpes. Some differences in the relative incidence of clinical signs and in the course of the condition were detected in the patients after surgery. Clinical course of epidemic keratoconjunctivitis paralleled by ophthalmic herpes was not characterized by a clear-cut staged pattern. Adenoviral ophthalmic infection coursed less severely than usual.

Subconjunctival 5-fluorouracil and herpes simplex keratitis.

We present a case of herpes simplex keratitis that appeared during a period following filtering surgery in which subconjunctival 5-FU was being administered. Although the 5-FU treatment was not halted, 4 days later the keratitis healed. The typical practice of discontinuing 5-FU treatment when these kinds of inflammation occur following filtering surgery may be unwarranted.

Anterior segment ischemia in chronic herpes simplex keratouveitis.

Six patients with chronic herpes simplex keratouveitis developed a rapidly progressive ocular inflammation unresponsive to corticosteroid and antiviral therapy. Severe secondary glaucoma unresponsive to maximum medical therapy ensued and was treated by cyclocryotherapy in five patients. Ocular ischemia with secondary corneal and scleral calcification subsequently developed in all six patients. All had also received prolonged topical therapy with topical antiviral agents, corticosteroids, beta adrenergic blockers and epinephrine compounds. Three eyes eventually required enucleation for the relief of pain; one stabilized, and two others became phthisical. One of the phthisical eyes developed a secondary fungal endophthalmitis. Histopathologic examination of the three enucleated globes revealed extensive corneal, scleral and conjunctival calcification, secondary angle closure, iris and ciliary body necrosis, focal choroiditis, retinal necrosis and atrophy. The syndrome recognized in these patients appears to be a rare but devastating complication of herpes simplex keratouveitis, possibly exacerbated by the application of cyclocryotherapy and other factors.

[Retinal lymphoma, retinal necrosis: identification of retinal viral particles and anti-herpetic antibodies in the vitreous body]. / Lymphome rétinien, nécrose rétinienne: identification de particules virales rétiniennes et d'anticorps anti-herpétiques dans le vitré.

Clinical data and histopathologic report of the association of a retinal malignant lymphoma and acute retinal necrosis. Demonstration of virus particle and vitreous herpetic antibodies.

Concurrent adenoviral and herpetic ocular infections.

We report two cases of a previously unrecognized clinical entity: concurrent adenoviral and herpetic ocular infection. The first case was recognized clinically by the presence of herpetic keratitis and findings attributable to epidemic keratoconjunctivitis (EKC) including lid swelling, pseudomembranous and follicular conjunctivitis, subconjunctival hemorrhages, preauricular lymphadenopathy, and corneal infiltrates. Only Herpes simplex virus was recovered by culture. In the second case of apparent EKC (again initially only Herpes simplex was isolated) after maintaining virus cultures long enough to isolate adenovirus, the diagnosis of concurrent infection was established when the second virus was isolated.

The effect of cellular immune tolerance to HSV-1 antigens on the immunopathology of HSV-1 keratitis.

Previous studies have revealed that herpes simplex virus type 1 (HSV-1) corneal stromal lesions do not develop in the absence of a cell-mediated immune (CMI) response to HSV-1 antigens. HSV-1 glycoprotein C (gC) has been shown to play an important role in the induction of the cytotoxic T lymphocyte (CTL) response to HSV-1 infections at anatomical sites other than the eye. Here we report that a deletion mutant lacking gC (gC-39) when used to infect the corneas of A/J mice was a poor inducer of both CTL and delayed type hypersensitivity (DTH) responses. We have also followed histologically and immunohistochemically the course of HSV-1 stromal disease in A/J mice following topical corneal (TC) infection with wild type (WT) HSV-1, TC infection with gC-39 HSV-1, and simultaneous TC and anterior chamber (TC + AC) infection with WT HSV-1. The latter type of infection has been shown to induce a profound state of DTH and CTL tolerance of HSV-1 antigens. Following TC infection with WT HSV-1, stromal disease progressed to severe ulcerative keratitis with neovascularization by day 21. Histologic and immunohistochemical analysis revealed a predominantly mononuclear infiltrate consisting of numerous plasma cells as well as L3T4+ (T helper/inducer) and Lyt-2+ (T suppressor/cytotoxic) T lymphocytes. Following TC infection with gC-39, or simultaneous TC + AC infection with WT HSV-1, the severity of stromal disease did not progress beyond day 7. On day 21, there was at most a mild stromal cellular infiltrate consisting predominantly of polymorphonuclear neutrophils. These findings indicate that early stromal disease consists of a nonspecific inflammatory response, but severe stromal disease involves a CMI response to HSV-1. AC injection of HSV-1 inhibits the CMI response, thereby halting the progression of stromal disease. Similarly, gC-39, a poor inducer of CMI responses, is also a poor inducer of stromal disease.

Herpetic canalicular obstruction.

The viruses of primary herpes simplex, herpes zoster, chicken pox, and vaccinia may produce inflammatory changes in the epithelial lining of the lacrimal canaliculi, resulting in varying degrees of obstruction. Five cases are described and compared with previously reported cases. A review of the literature suggests that the association of ocular viral infections and canalicular complications may be more prevalent than previously suspected. The possible important role of antiviral agents is considered. Early recognition and intubation can often prevent permanent canalicular obstruction, but late cases may require the Jones tube procedure, conjunctivodacryocystorhinostomy.

Laser therapy of conjunctival papillomas.

Carbon dioxide (CO2) laser therapy was successfully used in the treatment of recurrent conjunctival papillomas in a 40-year-old man. Surgical excision, cryotherapy and immunotherapy with transfer factor and dinitrochlorobenzene had all been unsuccessful in eradicating the lesions. CO2 laser therapy should be considered as an alternative treatment for conjunctival papillomas refractory to other forms of therapy.

Adenosine deaminase in herpes simplex virus induced corneal stromal disease.

The development of herpes simplex virus (HSV)-induced disciform stromal disease produced by the intrastromal injection of the RE strain of HSV-1 is characterized by concurrent increases in adenosine deaminase (ADA) activity and corneal thickness. ADA activity increased from 8.6 units/cornea in normal corneas to about 14.1 units and 31.1 units in mock-infected controls and HSV-infected corneas respectively by 15 days postinjection. The molecular weight species of ADA in the corneas of HSV-infected rabbits appeared altered relative to that present in corneas which were not infected. A single topical dose with as low as 0.1% 2'-deoxycoformycin (dCF), an ADA inhibitor possessing immunosuppressive activity, was capable of totally inhibiting the corneal ADA activity. Titration of the free dCF in the cornea following a single topical dose of 0.25% dCF indicated that enough dCF remained in the cornea 24 hrs after instillation to totally inhibit all corneal ADA plus 66 units of additional enzyme. These data suggest that ADA may be a suitable target for immunosuppressive therapy during HSV-induced disciform stromal disease.

Histopathology of herpes simplex virus keratouveitis.

Twenty-four eyes removed for complications of HSV keratitis were studied histopathologically. There were 20 men and 4 women with an average age of 61 years. Severe keratitis was seen in 14, moderate in 7, and mild in 3 eyes. Common features associated with severe keratitis were: acute perforation, granulomatous keratitis with giant cells in the stroma and Descemet's region, stromal inflammatory cells, angle-closure, severe iridocyclitis with diffuse or focal infiltration of lymphocytes and plasma cells, low-grade vitritis, choroiditis, and/or retinal periphlebitis. Specimens with moderate to mild keratitis had a similar distribution of inflammation but a lower incidence of granulomatous keratitis.

Pseudomelanoma of the iris in herpes simplex keratoiritis.

A 37-year-old white man with a long history of recurrent herpetic keratitis presented with a rapidly enlarging pigmented iris lesion. The primary diagnostic concern was that the lesion might be a malignant melanoma. A biopsy of the mass was done and proved it to be a granuloma with granulomatous arteritis and infarction of the iris. In a patient with a history of recurrent ocular inflammation, such a hypersensitivity granuloma should be considered in the differential diagnosis of iris melanoma.

Local and regional immune function of vitamin A-deficient rats with ocular herpes simplex virus (HSV) infections.

Experimental ocular herpes virus (HSV) infections are more severe in vitamin A-deficient rats (-A) compared with normal pair-fed controls (+A). In an effort to determine whether alterations in specific or nonspecific immune responses were responsible for the increased susceptibility of -A rats, cell-mediated responses and natural killer cell (NK) activity were monitored during the course of ocular herpetic infections in -A and +A rats. Prior to infection the concanavalin A (Con A)-induced response of splenic lymphocytes from -A rats was significantly less than that of +A animals. Three days following topical application of HSV to abraded corneas, the Con A-induced splenic response decreased in both -A and +A animals and remained at low levels for 10 d following infection. The cervical lymph node (CLN) response to Con A was depressed 7 d following infection but was higher in the -A group than in the +A group at all time points. In vitro response to inactivated HSV antigen appeared on d 7 in the spleen and d 10 in the CLN. The responses were higher in -A animals compared with +A pair-fed controls and were related to the severity of the disease rather than to dietary treatment. Splenic NK cytotoxic responses were higher in +A than -A animals and decreased in both groups during the 10-d post-infection period. Cervical lymph node NK responses were unaffected by diet or ocular HSV infection.

Familial Richner-Hanhart syndrome: genetic, clinical, and metabolic studies.

The genetic, clinical, and metabolic studies of two familial cases of Richner-Hanhart syndrome (type II hypertyrosinemia are described and the findings compared with other familial cases of palmo-plantar keratoderma. The clinical pictures are identical except that in the latter there are not ocular symptoms and the tyrosine levels are not raised. One of the two patients examined was treated with a diet low in tyrosine and phenylalanine with immediate improvement in clinical symptomatology and complete disappearance of the dendritic keratitis.

Herpesvirus infection of cornea allografts.

This report describes three patients who have in common an occurrence of ocular epithelial herpes infection following a penetrating keratoplasty for a corneal opacity unrelated to herpesvirus infection. It may be that patients undergoing episodes of graft rejection are at increased risk for the reactivation of herpesvirus latent in the trigeminal ganglia, and corticosteroids should be used with this in mind. Because virtually all adults have been exposed to herpes and therefore harbor latent virus, a viral etiology should be considered for lesions in post-penetrating keratoplasty patients. Although the occurrence of this possibly rejection-related reactivation of herpes simplex virus is undoubtedly rare, management of potential cases of this nature should take this possibility into account.

Combined use of sodium hyaluronate and tissue adhesive in penetrating keratoplasty of corneal perforations.

A new technique which allows the use of a guarded trephine in penetrating keratoplasty for corneal perforation is described. It involves the combined use of cyanoacrylate adhesive and sodium hyaluronate and allows a normotensive eye to be obtained prior to trephination. Five cases in which this technique was used are described. A better tectonic result can be obtained and visual rehabilitation may be more readily achieved without performing a secondary procedure.