SAoO-Kongress 28.2.2018

Herpetische Uveitis anterior

Prof. Dr. Matthias Becker

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SAoO-Kongress 28.2.2018

In Übergängen denken…

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SAoO-Kongress 28.2.2018

Herpesviridae

• Large family of DNA viruses (>130 herpesviruses) • Large double-stranded, linear DNA genomes• At least five species of Herpesviridae are extremely

widespread among humans• More than 90% of adults have been infected with at

least one of these• Latent form of the virus remains in most people

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Herpesvirus types

Herpesvirus types known to infect humans:1. Herpes simplex virus 1 (HSV-1)2. Herpes simplex virus 2 (HSV-2)3. Varicella-zoster virus (VZV)4. Epstein–Barr virus (EBV)5. Cytomegalovirus (CMV)6. Human herpesvirus 6A (HHV-6A)7. Human herpesvirus 6B (HHV-6B)8. Human herpesvirus 7 (HHV-7)9. Kaposi's sarcoma-associated herpesvirus (KSHV)

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Zoster ophthalmicus• Vesicles on the tip or

the side of the nose• Hutchinson sign• Precedes the

development ofuveitis

• Nasociliary branch ofN. V. innervatesboth: cornea, lateral dorsum of the nose

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Courtesy of D. Goldstein, BCSC

SAoO-Kongress 28.2.2018

Clinical signs (VZV, HSV)

• VZV-uveitis: history of ipsilateral zoster ophthalmicus• Varicella-zoster sine herpete: anterior uveitis without prior

cutaneous component• Variable corneal involvemet (keratouveitis) • Decreased corneal sensation (diffuse or localized)• Anterior, posterior synechiae• Hypopyon (hemorrhagic)

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Übersicht Endothel-Präzipitate

Granulomatös („speckig“)• Sarkoidose, Tuberkulose, MS (beidseitig)• Herpetische Uveitis (einseitig)

Nicht-granulomatös• Fein

• Ankylosierende Spondylitis, HLA-B27+ AAU• Sternförmig-diffus

• Fuchs Uveitis Syndrom

SAoO-Kongress 28.2.2018

DD: Präzipitate - granulomatös

SAoO-Kongress 28.2.2018

DD: Nicht-granulomatös / fein

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DD: Nicht-granulomatös/ sternförmig

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Keratic precipitates

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• Large, central greasy• Fine stellate, diffusely

distributed

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Iris atrophy

• Patchy or sectoral• Pupil dilated

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Atrophy of irispigment epitheliumnot just anteriorstroma

SAoO-Kongress 28.2.2018

Ocular hypertension

• Trabeculitis• Frequent complication (DD: toxoplasmosis)• Other uveitides: decreased IOP (ciliary body

hyposecretion)

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Clinical signs (CMV)

• Immunocompetent adults• Chronic or recurrent, unilateral, anterior uveitis, mild

AC activity• Ocular hypertension• Corneal edema• Variable degrees of sectoral iris atrophy• No corneal scars, no posterior synechiae, no flare or

fibrin and no posterior segment involvement

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CMV

• Fails to respond to corticosteroids and high doses ofacyclovir

• Can present as acute relapsing hypertensive anterioruveitis, also known as Posner-Schlossman syndrome(PSS); half of all presumed cases of PSS are CMV-positive

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Epstein-Barr Virus

• Associated with infectious mononucleosis (IM), Burkittlymphoma, nasopharyngeal carcinoma, Hodgkin disease, and Sjögren syndrome

• Primary infection in the context of IM: mild, self-limitingfollicular conjunctivitis

• Most ocular disease is self-limiting and does not require treatment

• Topical corticosteroids and cycloplegia

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Diagnostic options

• Aqueous tap• Real-time PCR analysis• Goldmann-Witmer coeffizient

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Therapeutic management: Topical

• Corticosteroids• Cycloplegics• Antiviral drugs (Zovirax) for keratouveitis (to prevent

dendritic keratitis as a complication of topicalcorticosteroid therapy)

• Prolonged topical antiviral therapy is associated with thedevelopment of keratopathy

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Therapeutic management: Systemic

HSV or VZV (higher doses) :• Acyclovir (Zovirax, 400– 800 mg, 5 times/day)• Valacyclovir (Valtrex, 500 mg to 1 g, 2 times/day)• Famciclovir (Famvir, 250–500 mg, 3 times/day)

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Prophylactic therapy

HSV: • Acyclovir, 400 mg 2 times/day• Valacyclovir, 500 mg/day

VZV • Acyclovir, 800 mg 2 times/day• Valacyclovir, 1 g/day

Immunization• VZV (Zostavax)

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Take home message

• Diagnosis often made clinically• Viable therapeutic options available• Role of corticosteroids• Sometimes long-term therapy necessary

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