Elsevier

Ophthalmology

Volume 114, Issue 7, July 2007, Pages 1358-1362
Ophthalmology

Original Article
Cytomegalovirus as a Cause of Anterior Uveitis in Immunocompetent Patients

https://doi.org/10.1016/j.ophtha.2006.09.035Get rights and content

Purpose

To describe 7 cases of unilateral, chronic and/or recurrent anterior uveitis caused by cytomegalovirus (CMV) in immunocompetent patients; to identify specific ophthalmologic characteristics; and to evaluate the clinical effect of valganciclovir treatment.

Design

Retrospective observational case series.

Participants

Immunocompetent patients (n = 7) with a history of chronic and/or recurrent unilateral anterior uveitis and a positive analysis for either CMV-DNA and/or antibodies against CMV in their aqueous humor (Goldmann-Witmer coefficient > 3).

Methods

Full ophthalmologic examination, anterior chamber fluid analysis, serologic examination, and systemic evaluation. Treatment modalities included topical steroids, topical and/or systemic antiglaucoma medications, glaucoma surgery, and systemic valganciclovir.

Main Outcome Measures

Visual acuity, inflammation, and intraocular pressure (IOP).

Results

Chronic unilateral anterior uveitis was seen in 6 patients, whereas recurrent uveitis was observed in 1. Additional findings consisted of slight iris atrophy and secondary glaucoma (n = 3), secondary glaucoma without iris abnormalities (n = 3), and a slightly elevated IOP without iris abnormalities (n = 1). Examinations of the aqueous humor by polymerase chain reaction demonstrated CMV-DNA in 6 patients and were negative for other herpes viruses in all. Goldmann-Witmer coefficients were strongly positive in 4 out of 5 patients. Other laboratory investigations were within normal limits. No other causes for uveitis were identified. Because of the insufficient effect of topical steroids and antiglaucoma medications, 5 patients were treated with additional oral valganciclovir with good clinical response in terms of uveitis activity and IOP. Discontinuation of valganciclovir in 1 patient resulted in a prompt recurrence of uveitis activity.

Conclusions

Cytomegalovirus may cause a chronic and/or recurrent anterior uveitis in otherwise healthy patients. Iris atrophy and glaucoma may accompany it, but an inflammatory reaction in the anterior chamber may be the only sign. Aqueous humor analysis is of the utmost importance in differentiating between CMV and other herpes viruses and in making a definite diagnosis in chronic anterior uveitis. Valganciclovir may be very effective in treating CMV anterior uveitis, but its exact role can only be determined in larger studies with a longer follow-up.

Section snippets

Patients and Methods

We included 7 patients with a chronic and/or recurrent unilateral anterior uveitis, persisting despite local steroid therapy, who had a positive anterior chamber fluid analysis for CMV. Chronic uveitis was defined as active intraocular inflammation for at least 3 months. Persistent unilateral anterior uveitis, sometimes complicated by severe increases in IOP, was the indication for an anterior chamber tap to determine whether an infectious cause could be identified. Anterior chamber

Results

The clinical features of our patients are summarized in Table 1, Table 2. Three patients (1, 4, and 5) are described in more detail.

We included 1 female and 6 male patients with unilateral chronic and/or recurrent anterior uveitis. The fellow eye did not have any abnormalities. The mean age of onset of uveitis was 43 years (range, 11–61 years). Patients were all healthy except for their uveitis. More specifically, laboratory workup and screening by an internist did not reveal any immunologic

Discussion

This series describes a somewhat variable clinical picture in 7 immunocompetent patients with CMV anterior uveitis. All patients were suffering from a mild, isolated, unilateral, chronic, and/or recurrent anterior uveitis. Corneal findings included diffuse keratic precipitates and focal corneal haze/edema (endotheliitis), sometimes related to surgical incision sites. On activation of the uveitis, IOP increases were noted in all patients, occasionally reaching values of 50 to 70 mmHg. Topical

References (16)

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    Citation Excerpt :

    However, recent reports have shown that CMV infection is a cause of hypertensive anterior uveitis and corneal endotheliitis that presents as acute or chronic inflammation in the immunocompetent individual. In immunocompetent patients, ocular manifestations are limited to the anterior segment [5–8]. CMV anterior uveitis accounts for as high as 22.8%–28.6% of cases of anterior uveitis associated with raised intraocular pressure (IOP). [2,5]

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Manuscript no. 2006-444.

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