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 Table of Contents    
CLINICAL IMAGE
Year : 2022  |  Volume : 15  |  Issue : 1  |  Page : 102-103  

Hypertensive anterior uveitis with papillitis: A diagnostic dilemma


Department of Uvea, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India

Date of Submission08-Apr-2021
Date of Decision28-May-2021
Date of Acceptance29-May-2021
Date of Web Publication02-Mar-2022

Correspondence Address:
Dr. Sudha K Ganesh
Department of Uvea, Medical Research Foundation, Sankara Nethralaya 18, College Road, Chennai - 600 006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ojo.ojo_109_21

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Keywords: Diffuse iris atrophy, polymerase chain reaction, viral anterior uveitis, viral papillitis


How to cite this article:
Nair N, Ganesh SK. Hypertensive anterior uveitis with papillitis: A diagnostic dilemma. Oman J Ophthalmol 2022;15:102-3

How to cite this URL:
Nair N, Ganesh SK. Hypertensive anterior uveitis with papillitis: A diagnostic dilemma. Oman J Ophthalmol [serial online] 2022 [cited 2022 May 28];15:102-3. Available from: https://www.ojoonline.org/text.asp?2022/15/1/102/338865



A 35-year-old male presented with acute onset of pain, redness, watering, and diminution of vision in the left eye (OS) for the last 20 days. His right eye was normal. He was already on multiple antiglaucoma medications in OS given by a local ophthalmologist.

On examination, visual acuity was hand movement in the OS. Slit lamp examination revealed that cornea was clear, severe fibrinous anterior uveitis (AU) with posterior synechiae with intraocular pressure (IOP) of 22 mmHg. Following therapy with hourly topical steroids and cycloplegics, vision improved to 20/50, AU subsided, and IOP was controlled. Fundus examination showed blurring of disc margins with retinal hemorrhage in the inferonasal quadrant [Figure 1]. Viral hypertensive AU with inflammatory disc edema of OS was considered as a possible diagnosis. A complete laboratory uveitis workup, including aqueous polymerase chain reaction (PCR) for herpes simplex virus (HSV), varicella zoster virus (VZV), and cytomegalovirus (CMV), were all negative.
Figure 1: Color fundus photograph of the left eye at presentation showing pallid disc edema and splinter haemorrhage inferonasally (white arrow). Macula was normal

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On review at 3 months, we noted new-onset diffuse iris atrophy arising at the pupillary border and extending 2 mm into the iris tissue, all around the pupillary margin with dense posterior synechiae [Figure 2]. The IOP with maximum medical therapy was 25 mmHg. Empirical oral antiviral therapy was started. The patient underwent trabeculectomy with mitomycin-C. Repeat nested PCR from aqueous, trabeculectomy, and iris tissues were negative for all viruses. On follow-up at 6 months, vision was 20/20, with no AU, controlled IOP and temporal disc pallor [Figure 3].
Figure 2: Slit lamp image on diffuse illumination of the left eye taken at 3 months from onset, showing diffuse iris atrophy arising at the pupillary border and extending roughly 2 mm into the iris tissues all around the pupillary margin (white arrows) with dense posterior synechiae and ectropion uvea nasally

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Figure 3: fundus photograph of the left eye at final review showing temporal pallor of disc. Macula was normal

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   Comment Top


Our patient had severe fibrinous AU, secondary glaucoma, and papillitis in OS at presentation. However, typical diffuse iris atrophic changes suggestive of viral uveitis occurred after 3 months. In patients with HSV iritis without keratitis and zoster sine herpete (ZSH), the diagnosis of herpetic uveitis is a challenge, especially in the absence of laboratory support.[1] In such scenario, the clinical signs can be a clue to diagnose the viral agent. Neuman et al.[2] have described keratic precipitates, corneal involvement, iris atrophy, and raised IOP as common clinical features of herpetic AU. Wensing et al. have described vasculitis and papillitis as a feature of nonnecrotizing viral uveitis.[3]

The pathology of iris atrophy, prevalence, and morphology are related to the routes of viral transmission and number of viral copies.[1] Round-shaped iris atrophy is seen in HSV, sectoral iris atrophy in VZV, ZSH and diffuse iris atrophy in CMV-AU. Sectoral iris atrophy in VZV is due to ischemia of iris tissue, while CMV-AU induced diffuse iris atrophy and associated pupillary distortion is most likely due to persistently high IOP.[1],[4] Our patient with high IOP and diffuse iris atrophy along the pupillary border was most likely due to CMV-AU though multiple PCR tests from ocular specimens were negative.

Reasons for initial negative PCR from aqueous could be low intraocular viral load or a false-negative PCR. The PCR samples obtained during trabeculectomy were negative, probably due to an already initiated antiviral therapy. Studies suggest that in CMV-AU, PCR samples taken during IOP spike and before antiviral treatment give better yield.[2],[4],[5]

Our case highlights an atypical presentation of presumed viral hypertensive fibrinous AU and papillitis with delayed appearance of iris atrophic changes and multiple negative viral PCRs.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Sakai JI, Usui Y, Suzuki J, Kezuka T, Goto H. Clinical features of anterior uveitis caused by three different herpes viruses. Int Ophthalmol 2019;39:2785-95.  Back to cited text no. 1
    
2.
Neumann R, Barequet D, Rosenblatt A, Amer R, Ben-Arie-Weintrob Y, Hareuveni-Blum T, et al. Herpetic anterior uveitis-Analysis of presumed and PCR proven cases. Ocul Immunol Inflamm 2019;27:211-8.  Back to cited text no. 2
    
3.
Wensing B, de Groot-Mijnes JD, Rothova A. Necrotizing and nonnecrotizing variants of herpetic uveitis with posterior segment involvement. Arch Ophthalmol 2011;129:403-8.  Back to cited text no. 3
    
4.
Chee SP, Bacsal K, Jap A, Se-Thoe SY, Cheng CL, Tan BH. Clinical features of cytomegalovirus anterior uveitis in immunocompetent patients. Am J Ophthalmol 2008;145:834-40.  Back to cited text no. 4
    
5.
Jap A, Chee SP. Emerging forms of viral uveitis in the developing world. Int Ophthalmol Clin 2010;50:155-71.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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