Download Herpes Simplex Virus Iridocyclitis

Herpes Simplex Virus Iridocyclitis
Abstract:
Iridocyclitis occurs in 4% of ocular herpes simplex infections usually between the ages of 41-46. 9-10
This case highlights successful management of this rare occurrence in a 77 year old Caucasian male.
I.
Case History
a. Patient demographics
i. 77 year old white male
b. Chief Complaint
i. Presented with eye pain
c. History of Present Illness (HPI)
i. Location: left eye
ii. Onset: the morning prior
iii. Relief: no help with Tylenol
iv. Duration: 1 day
v. Frequency: constant
vi. Severity: moderate
vii. Associated symptoms: photophobia, redness, tearing, pressure
d. Ocular history: established patient
i. Uveitis in the left eye 3 years prior (likely related to colitis)
ii. Glaucoma suspect based on asymmetric cupping and intraocular pressure greater
in the right eye
iii. Dry eye syndrome
iv. Pseudophakia both eyes
e. Medical history/Medications
i. Hypertension x 4 years, diverticulosis x 2 years, ulcerative colitis x 10 years,
anemia x 9 years and gout x 1 year
ii. Dextran, dicyclomine HCL, lisinopril, sulfalsalazine
f. Other: nonsmoker, blood pressure: 132/66
II. Pertinent findings
a. Clinical
i. Best corrected visual acuities: 20/20 OD, OS
ii. Pupils: equal, reactive to light OD, OS, negative APD
iii. VF: FTFC, OD, OS
iv. Motility: FROM OU, no diplopia
v. IOP: 18 mmHg OD, 10mmHg OS at 1:31pm
vi. SLE
1. Right eye findings unremarkable
2. Left eye findings:
a. Conjunctiva: 2+ injection with prominent leading vessels
towards the limbus
b. Cornea: 2+ inferior punctate epithelial keratopathy and fine
keratic precipitates in the lower half (consistent with von
Arlt’s triangle) seen on reexamination
c. Anterior chamber: deep with 3+ cell and flare
d. Iris: prominent, engorged iris vasculature with areas of
hemorrhage at 3, 9 and 12 o’clock
vii. Gonioscopy left eye only
1. Regular, open to ciliary body in all quadrants (40 RD) with temporal
peripheral anterior synechiae
viii. DFE
1. Lens: PCIOL, centered OU
2. Vitreous: clear OU
3. C/D: 0.5 OD, 0.25 OS with pink distinct borders OU
4. A/V: 2/3 OU
5. Macula: flat/intact OU
6. Periphery: no holes, tears, or detachments OU
7. Posterior pole: unremarkable OU
b. Laboratory Studies:
i. Negative: ANA, RPR, HLA-B27, ACE
ii. Positive: HSV IgG type 1 and 2
c. Others:
i. No carotid bruit
ii. Small oral ulcer on left side mouth (noticed at the end of the initial examination)
III. Differential diagnosis (beginning with the initial leading diagnosis)
a. Primary
i. Vascular
1. Ocular ischemic syndrome unilateral, 77 yrs old decreased vision,
ocular pain, iris vasculitis, but no mid-peripheral hemorrhages, no after
images or history of amarosis fugax 4-6
a. Possible etiologies
i. Carotid diseaseno carotid bruit, need carotid
doppler
ii. Ophthalmic artery diseaseless common
b. Other
i. Infectious Anterior Uveitis4-6
1. Herpes simplex and herpes zoster ophthalmicus patient exhibited
fine keratic precipitates, iris hemorrhaging, cell/flare, no corneal
involvement
2. Syphilis patient has no previous history
3. Lyme Diseaseno tick bite or skin rash, negative RPR
4. Tuberculosisno phlyctenular keratitis, no post. uveitis, PPD not
tested
5. Multiple Sclerosisno clinical signs or symptoms of MS
6. Sarcoidosis- negative ACE, mostly in AA, women, between 20-40 yrs
7. Vogt-Koyanagi-Haradapatient denied symptoms such as tinnitus,
hearing loss or dysacusia
IV. Diagnosis and Discussion
a. Unique features of case engorged iris vasculature with iris hemorrhaging, leading
conjunctival vessels, lack of epithelial defect, normal intraocular pressure and 20/20
vision and von Arlt’s triangle
i. Leading to initial diagnosis OIS (prior to dilated fundus examination)
ii. No retinal findings on DFE led to reevaluation of signs/symptoms, case
history review and consultation with ophthalmology
iii. Small cold sore on left side of mouth noted at this point  reexamination of
ocular findingsvon Arlt’s triangle noted
b. Final Diagnosis
i. Herpes simplex virus iridocyclitis based on patients case history, clinical
findings, small oral cold sore (seen at the end of the exam), and inconclusive
signs and symptoms of ocular ischemic syndrome
c. Criteria for diagnosis
i. Case history review and examination of patient as a whole
ii. Symptomsphotophobia, reduced visual acuity, ocular pain, redness
1. Mostly unilateral, only 8-19% bilateral 13, 17
iii. Signs keratic precipitates (von Arlt’s triangle), iris atrophy, iris hemorrhage,
anterior/ vitreous cells, iris transillumination defects, posterior iris synechiae,
increased intraocular pressure, unexplained corneal scarring 3-6, 12, 14, 18
iv. Lab HSV IgG 1, 2; polymerase chain reaction (PCR) test of aqueous humor
may be tested3-6, 11, 14
d. General information on Herpes Virus Family
i. 8 recognized human herpes viruses: herpes simplex virus type (HSV) 1, HSV 2,
varicella-zoster virus, cytomegalovirus, Epstein–Barr virus, human herpes virus
6, 7, and 85,8
ii. 60-90% of people are affected by one of the viruses in the herpes family7, 13
iii. By the age of 5, 60% of a all children have been infected with HSV type 13
iv. Herpes simplex virus cuboidal capsule surrounding linear double stranded
DNA virus genome that commonly affects humans7, 5
v. Primary HSV-1 infection most commonly in the mucocutaneous distribution
of the trigeminal nerve5, 14
vi. Primary infection of any of the 3 branches of cranial nerve V (ophthalmic,
maxillary, mandibular)  leads to latent infection in the trigeminal ganglion5
vii. Inter-neuronal spread of HSV patients develop subsequent ocular disease
without ever having had primary ocular HSV infection5
viii. Recurrent ocular HSV infection a reactivation of the virus in the trigeminal
ganglion, producing a lytic infection in ocular tissue5
ix. Increased recurrence in cold weather months with flu-like viral respiratory
infections, menstruation, sunlight and emotional stress7, 13
e. Epidemiology and pathogenesis of ocular HSV
i. Herpetic corneal disease500,000 cases of blindness in US 8-10
ii. One leading cause of anterior uveitis 9-17% 8, 11
iii. Average age41-46 years9-10
iv. Average diagnosis time 3.4 years10
v. No sexual predilection 1, 9
vi. Can effect every layer of ocular tissue blepharitis, conjunctivitis, scleritis,
episcleritis, keratitis, anterior uveitis, vitritis and retinitis 3, 5-9
vii. Statistical breakdown of ocular presence 9-10
1. lid or conjunctiva make up 54 %
2. superficial cornea 63%
3. deeper cornea 6%
4. uveitis in 4%
viii. Most common manifestion of herpetic uveitisiridocyclitis rather than posterior
uveitis, panuveitis or retinitis 3, 9
ix. Uveitis in herpetic disease  more commonly associated with keratitis 3, 8, 18
x. Anterior uveitis presenting in the elder populationmostly idiopathic (31.2%)
with herpes simplex/zoster and HLA-B27 positive as the next two most common
causes 2, 16
V. Treatment and Management
a. Initial treatment
i. Began use of Pred Forte every hour in the left eye and oral Valtrex 500 mg three
times a day1, 11
b. First follow-up: 7 days after initial visit
i. Vision: 20/20 OD, OS
ii. SLE: smaller KP’s than previous visit, 2-3 + cell and flare in anterior chamber,
engorged iris vasculature
iii. IOP: 22 mmHg OD, 12mmHg OS at 2:19 PM
iv. Continued same treatment but reduced Pred Forte to every 2 hours in the left
eye, added artificial tears 4 times a day both eyes, Alphagan P 2 times a day in
the right eye
c. Second follow-up: 14 days after initial visit
i. Vision: 20/20 OD, OS
ii. SLE: resolved KP’s, 1+ cell in anterior chamber, mildly irritated iris vasculature
between 4 and 7 o’clock on iris
iii. IOP: 19mm Hg OD, 9mm Hg OS at 2:05 PM
iv. Continued with same regimen but decreased Pred Forte to every 6 hours left eye
d. Third follow-up:1 month after initial presentation
i. Vision: 20/20 OD, OS
ii. SLE: clear cornea, quiet anterior chamber, no ciliary flush
iii. IOP: 13 mmHg OD, 12 mmHg at 1:31 PM
iv. Start slow taper of Pred Forte over 6 weeks; continue Valtrex 500mg three times
a day; continue artificial tears four times a day, other follow-ups scheduled
e. Possible complications microbial infections secondary to corneal compromise,
secondary glaucoma (one of the most significant causes of visual loss), cataracts and
other rare ocular complications (retinal detachment, epiretinal membrane,
endophthalmitis, corneal perforation 3, 5, 14
f. Recurrence rate
i. After one episode of ocular HSV rate of reoccurrence increases to 10% at 1
year, 23% at 2 years, and 50% at 10 years 11, 12
ii. Larger time intervals between previous episodeslinked to a larger time
interval in future ocular episodes 3
VI. Conclusion and clinical pearls
a. Things do not always seem as they appear, as illustrated in this ocular herpes simplex
iridocyclitis case.
b. When you think you know the diagnosis, it is easy to make the patient’s signs and
symptoms fit that particular ocular condition, while excluding other possibilities.
c. If the findings do not match the initial diagnosis, continue to reevaluate the signs,
symptoms and list of differentials.
d. It is important to remember to keep an objective mind when looking at all signs, look at
the patient as a whole and continue case history throughout the examination.
e. Before you know it, the answer may be staring right at you.
VII. References
1. Barron B. A Controlled Trial of Oral Accylovir for the Prevention of Stromal Keratitis or Iritis in
Patients with Herpes Simples Virus Epithelial Keratitis-The herpetic Eye Disease Study Group. Am Journal
of Ophthalmology 1997; 115:703-712.
2. Chatzistefaunou K, Markomichelakis N. Characteristics if Uveitis Presenting for the First Time in the
Elderly. Ophthalmology 1998; 105: 347-352.
3. Green, L. Herpes Simplex Ocular Inflammatory Disease. Int Ophthalmology Clinics 2006; 46:27-37.
4. Kaiser PK, Friedman NJ. The Massachusetts Eye and Ear Infirmary Illustrated Manual of
Ophthalmology. Saunders an imprint of Elsevier. 2nd ed 2004.
5. Kanski J. Clinical Ophthalmology: A Systematic Approach. Butterworth-Heinemann and. 6th ed 2007.
6. Kunimotoe DY, Friedberg MA. The Wills Eye Manual. Lippincott Williams and Wilkins. 4th ed 2004.
7. Khan B. Clinical Manifestations and Treatment Modalities in Herpes Simplex Virus of the Ocular
Anterior Segment. Int Ophthalmology 2004; 44:103-133.
8. Liesegang T. Classification of Herpes Simplex Virus Keratitis and Anterior Uveitis. Cornea 1999; 18(2):
127-143.
9. Liesegang T, Melton J. Epidemiology of Ocular Herpes Simplex: Incidence in Rochester, Minn, 1501982. Arch of Ophthalmology 1989; 107: 1155-1159.
10. Liesegang T. Herpes Simplex Virus Epidemiology and Ocular Importance. Cornea 2001; 20:1-13.
11. Miserocchi E, Modorati G. Efficacy of Valacyclovir vs. Acyclovir for the Prevention of Recurrent
Herpes Simplex Virus Eye Disease: A Pilot Study. Am Journal of Ophthalmology. 2007; 144; 547-551.
12. Microchip E, Wahid NK, Visual Outcome in Herpes Simplex Virus and Varicella Zoster Virus Uveitis.
Ophthalmology 2002; 109:1532-1537
13. Pepose J, Keadle T, Ocualar Herpes Simplex: Changing Epidemiology, Emerging Disease Patterns,
and the Potential of Vaccine Prevention and Therapy. Am. Journal of Ophthalmology 2006; 141:547-557.
14. Rapuano C, Luchs J, Kim T. Anterior Segment: The Requisites in Ophthalmology. Mosby. 1st ed 2000.
15. Santos, C. Herpes Simplex Uveitis. Boletin Medical Association of Puerto Rico 2004; 96: 71-83.
16. Suhler E, Lloyd M. Incidence and Prevalence of Uveitis in Veterans Affairs Medical Centers of the
Pacific Northwest. Am Journal of Ophthalmology 2008; 146: 890-890
17. Souza PM, Holland EJ, Huang AJ, Bilateral Herpetic Keratoconjunctivitis. American Academy of
Ophthalmology 2003; 110:493-496
18. Van der Lelij A, Ooijman F. Anterior Uveitis with Sectoral Iris Atrophy in the Absence of Keratitis.
Ophthalmology 2000; 107:1164-1170
19. Wilhelmus, KR, Falcon, MG, Jones, B.R. Herpes Iridocyclitis. Int Ophthalmology 1981; 4: 143-150.
20. Whitley RJ, Roizman B. Herpes Simplex virus infections. Lancet 2001: 357:1513-1518.