A case of spikes and specks

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A case of spikes and specks

• Grand Ward Round
• 18 October 2007

2
History

• 65/Chinese/male
• First presented Jul 05 with LE pain, left-sided
  headache
• Examination
• VA 6/9
• Ac shallow, cells 2. Gonio closed angles
  bilaterally
• Mid dilated pupil. Moth-eaten appearance of
  iris noted.
• ( L RAPD documented later)
• NS 1
• IOP 62mmHg
• CDR 0.3 RE, 0.7LE

3
History

• Impression
• L Acute on chronic ACG
• R PAC
• Treated medically
• IOP subseq 35
• Underwent R/L PI next day

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Progress

• From Jul 05 to Aug 07
• Had 6 episodes of IOP spikes
• AC inflammation (cells 1-2), KPs noted during
  each spike
• Responded well to steroids and anti-glaucoma
  therapy
• Episodes usually occurred when off steroids or on
  tailing dose (BD)
• Maintained on
• Gutt Timolol 0.5 bd LE
• Gutt alphagan bd LE ? changed to Gutt Travatan
  May 06 (?reaction to alphagan)
• Increase in CDR, stable L nasal step on HVF. VA
  6/21 ? 6/15

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Thoughts?
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Differentials

• Uveitis and glaucoma
• While most uveitic conditions can lead to
  glaucoma
• Those a/w acute rise in IOP
• Herpetic uveitis
• HSV
• VZV
• CMV
• Posner-Schlossman Syndrome
• Fuchs heterochromic iridocyclitis

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Progress

• Another episode of high IOP (40mmHg) in Sept 2007
• L AC tap performed
• Tetraplex PCR
• Positive for CMV.
• CMV DNA 1.4E06 copies/mL
• HSV, VZV, Toxoplasma neg

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Progress

• L phaco/IOL/ Ahmed tube/MMC 10/10/07 with
  intravitreal ganciclovir
• IOP not controlled despite 3 anti-glaucoma meds,
  control of inflammation with steroids
• CDR 0.8 0.9
• Cataract with deteriorating VA (6/45)
• At last visit
• IOP 9mmHg
• VA 6/30 ? 6/21

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Discussion

• Differentials of hypertensive iridocyclitis
• When is investigation (AC paracentesis)
  indicated?
• How to treat CMV uveitis?

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• Features
• Described in 1948 by Posner and Schlossman
• Glaucomatocylitic crisis characterised by
  self-limited recurrent episodes of markedly
  elevated IOP with mild AC inflammation
• IOP elevation out of proportion to degree of AC
  inflammation
• Usually in adults 20-50 yrs
• Previously thought to be idiopathic, but
  postulated aetiologies include
• Abnormal vascular process
• Autonomic defect
• Infective HSV, CMV

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• Features
• Chronic unilateral (bilateral in 10)
  iridocyclitis
• Classic triad of
• Iris heterochromia
• KPs
• Cataract
• Low grade inflammation which does not usu req Rx
• Postulated aetiology
• Adrenergic dysfunction
• Infective cause link between ocular
  toxoplasmosis and FHI
• Immunologic theories

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CMV and the eye

• CMV retinitis in immunocompromised hosts
• HIV/AIDs, immunosuppressive drugs
• Increasing evidence for CMV as cause of
  hypertensive iritis in immunocompetent patients
• Local experience
• Case report by S Teoh Patient with PSS and incr
  IOP, aqueous PCR positivefor CMV
• Teoh SB, Thean L, Koay E. Cytomegalovirus in
  aetiology of Posner-Schlossman syndrome evidence
  from quantitative polymerase chain reaction. Eye
  2005 Dec 19 (12) 1338-40
• Case series by Chee SP 12 immunocompetent pt
  with corneal endothelitis and incr IOP. AC tap in
  11/12 ve for CMV DNA.
• Chee SP, Bascal K et al. Corneal endothelitis
  associated with evidence of cytomegalovirus
  infection. Ophthalmology 2007 Apr 114(4)
  798-803.
• Several other case reports and case series
• Van Boxtel LA et al. Cytomegalovirus as a cause
  of anterior uveitis in immunocompetent patients.
  Ophthalmology 2007 114(7) 1358-62
• De Shryer I et al. Diagnosis and treatment of
  cytomegalovirus iridocyclitis without retinal
  necrosis. Br J Ophthalmol 200690 852-5.

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CMV and the eye

• However, role of CMV in hypertensive iritis has
  been questioned
• Most of the cases reported received local
  immunosuppressive therapy (e.g. steroids) prior
  to AC tap
• CMV detected in aqueous may be a consequence of
  that
• CMV may not be the aetiologic agent
• Latent CMV is present in monocytes which transit
  through ocular tissues

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Investigation of hypertensive iritis

• When to tap?
• No consensus
• But probably reasonable to tap when high rate of
  recurrence, poor response to therapy, visual cx
  or deterioration
• To tap or not to tap?
• AC paracentesis is an intraocular procedure
• Risks cataract, endophthalmitis
• Evidence that AC paracentesis generally safe
• 361 patients underwent diagnostic tap
• No sight-threatening side effects e.g. cataract,
  endophthalmitis, keratitis
• 72 pt examined within 30min after tap 5 had
  small hyphaema
• Van der Lelik A, Rothova A. Diagnostic anterior
  chamber paracentesis in uveitis s safe
  procedure? Br J Ophthalmol 1997 81 (11) 976-9

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Treatment of CMV uveitis

• Treatment of infective component
• Intravitreal ganciclovir4
• Systemic ganciclovir 1,5
• Oral Valganciclovir 1-2
• Foscarnet 1
• Treatment of complications
• Glaucoma anti-glaucoma meds or surgery
• Treatment of inflammation
• Topical steroids

• De Shryer I et al. Diagnosis and treatment of
  cytomegalovirus iridocyclitis without retinal
  necrosis. Br J Ophthalmol 200690 852-5.
• Van Boxtel LA et al. Cytomegalovirus as a cause
  of anterior uveitis in immunocompetent patients.
  Ophthalmology 2007 114(7) 1358-62
• Mietz H et al. Ganciclovir for the treatment of
  anterior uveitis. Graefes Arch Clin Exp
  Ophthalmol 2000 Nov 238(11) 905-9.
• Chung RS, Chua CN. Intravitreal ganciclovir
  injections in aqueous cytomegalovirus DNA
  positive hypertensive iritis. Eye 2006 Sep
  20(9) 1080
• Chee SP, Bascal K et al. Corneal endothelitis
  associated with evidence of cytomegalovirus
  infection. Ophthalmology 2007 Apr 114(4)
  798-803.

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Stellate KPs

• Seen in AC inflammation due to
• Fuchs heterochromic iridocyclitis
• Herpetic uveitis
• Toxoplasmosis
• Not diagnostic, but useful for differential
  diagnoses
• What are they?
• Fibrin deposition around inflammatory cells
• Walter KA, Coulter VL, Palay DA et al. Corneal
  endothelial deposits in patients with
  cytomegalovirus retinitis. Am J Ophthalmol
  1996232 391-396
• Pillai CT et al. Evaluation of corneal
  endotheluim and kertic precipitates by specular
  microscopy in anterior uveitis. Br J Ophthalmol
  2000 841367-1371