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Eye clinic - Herpetic uveitis

Opthalmologists Miss Claire Daniel and Miss Lucy Barker discuss the features and management of this extremely rare condition

Opthalmologists Miss Claire Daniel and Miss Lucy Barker discuss the features and management of this extremely rare condition

Case

A 40-year-old Caucasian woman presents with a two day history of a red right eye, photophobia and slightly blurred vision.  She has previously had four attacks of anterior uveitis in the same eye, but is otherwise well.

 

Examination reveals a best corrected visual acuity (BCVA ) of 6/5 in each eye.  She has a mildly injected right eye with cells in her anterior chamber and a few keratic precipitates on the corneal endothelium.  Intraocular pressure (IOP) is 25mmHg in the right eye and 18mmHg in the left.  Dilated fundal examination is unremarkable.

She is diagnosed with hypertensive anterior uveitis and treated with dexamethasone, cyclopentolate and timolol 0.25% eyedrops.

Returning a week later for review, her right BCVA is 6/6.  Examination reveals cells in the anterior chamber and more keratic precipitates than before, and transillumination shows mild iris atrophy.  Her IOP is 18mmHg and fundal examination is still unremarkable.  On further questioning, she has a history of cold sores.

The diagnosis is amended to herpetic hypertensive anterior uveitis and she is given Aciclovir 400mg, orally, five times per day alongside her steroid eyedrops.

 

The problem

Herpetic disease is the most common cause of hypertensive uveitis 1,2.  Herpes simplex and zoster are both associated with the condition, but herpes simplex is more common1. Herpetic uveitis can occur alone or with keratitis.  Ask patients about a history of cold sores - they do not have to occur simultaneously.

Herpetic infection is common – serological evidence of prior HSV-1 infection has been found in 24% children (1-15 years) and 46-54% young adults (25-30 years) [3].  HSV-2 is less common, with serum antibody detection in 3.3% adult men and 5.1% adult women3. Prevalence increases significantly in high-risk groups, such as those with HIV infection 4. But herpetic uveitis remains uncommon in the general population - incidence and prevalence of 0.3 and 0.5 per 100,0005.

 

Features

  • Throbbing or aching pain with photophobia
  • Red eye, especially around the limbus
  • Watery eye but no sticky discharge
  • Reduced corneal sensation
  • Normal or slightly blurred vision
  • Smaller and irregular pupil, on the affected side
  • A hypopyon -white fluid line of collected cells in the anterior chamber – in severe cases
  • Possible history of flare-ups (uveitis is recurrent)
  • History of herpetic infection.

 

Differential diagnosis

  • Conjunctivitis – usually bilateral, discharge and itchy eyes
  • Corneal abrasion –intense sharp, foreign body pain
  • Microbial keratitis – often associated with contact lenses, may see ulcer on the cornea
  • Episcleritis –diffuse or sectorial but rarely painful and no photophobia
  • Scleritis – classically a violet hue to the area of infection,  severe pain which may wake the patient
  • Acute angle-closure glaucoma – more painful, the patient may feel nauseous and vomit, the pupil is fixed and dilated and the cornea is cloudy

 

Examination

  • Check vision in each eye.
  • Check corneal sensation with a small piece of tissue paper.
  • Instil proxymetacaine 0.5% to anaesthetise any corneal surface problem and allow examination.  If the pain is significantly reduced, a diagnosis of anterior uveitis is less likely.
  • Instil fluorescein to identify corneal abrasions or ulcers.
  • Check pupils
  • Assess for photophobia with the ophthalmoscope.

 

Referral

  • Red eye and photophobia needs to be referred to eye casualty to exclude or confirm anterior uveitis. 
  • Severe pain or a hypopyon needs urgent referral.
  • Early referral (next day) is appropriate for less severe cases.
  • Include information on previous herpetic disease or treatment with Aciclovir in your referral.

 

Treatment

Consider prescribing cyclopentolate 1% TDS for pain relief, but only if angle-closure glaucoma is confidently excluded.

Patients with recurrent uveitis often self-diagnose, but please refer to allow a full examination, including IOP check. After referral, the patient will be treated with steroids and cycloplegic drugs.  If herpetic disease is suspected then oral Aciclovir will be added.

If the IOP is elevated, the patient will be treated with timolol 0.25%, unless it is contraindicated.  It is helpful to highlight any contraindication to ?-blockers in your referral.

 

Miss Claire Daniel is a consultant ophthalmic surgeon and Miss Lucy Barker is a specialist registrar at Moorfields Eye Hospital, London

 

References

1. Pogorzalek N, de Monchy I, Gendron G and Labetoulle M.  Hypertony and uveitis: 103 cases of uveitis.  J Fr Ophtalmol 2011; 34(3): 157-63

2. Saouli N and Brezin AP.  Ocular hypertension and uveitis.  Study of 374 cases of uveitis.  J Fr Ophtalmol 1999; 22(9): 943-9

3. Vyse AJ, Gay NJ, Slomka MJ et al., The burden of infection with HSV-1 and HSV-2 in England and Wales: implications for the changing epidemiology of genital herpes.  Sex Transm Inf 2000; 76: 183-187

4. Smith JS and Robinson NJ.  Age-specific prevalence of infection with Herpes Simplex virus types 2 and 1: A global review.  J Infect Dis 2002; 186(Suppl 1): S3-S28

5. Paivonsalo-Hietanen T, Tuominen J, Vaahtoranta-Lehtonen H and Matti Saari K.  Incidence and prevalence of different uveitis entities in Finland.  Acta Ophthalmol Scand 1997; 75(1): 76-81s

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