JAN 2014

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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44 EW CORNEA January 2014 Cornea editor's corner of the world Diagnosing and treating CMV anterior uveitis and endotheliitis by Ellen Stodola EyeWorld Staff Writer Knowing key features can help identify and treat patients C ommon viruses that we consider frequently that affect the anterior segment include the herpes simplex virus (HSV) and the herpes zoster virus (HZV). However, cytomegalovirus (CMV) infections should also be considered, especially in patients of Asian descent. When ophthalmologists think about CMV infections, they usually think of retinal complications in immunocompromised patients. However, CMV infections of the anterior segment can manifest in otherwise healthy patients. CMV anterior uveitis and endotheliitis are entities that a clinician should be aware of and the diagnosis may be missed without a high level of suspicion. Furthermore, they can masquerade as corneal graft rejection or failure. Aqueous fluid analysis via polymerase chain reaction (PCR) for CMV DNA can be done to confirm the diagnosis, and oral antivirals are effective. This month's "Cornea editor's corner of the world" has Soon-Phaik Chee, MD, and Donald T.H. Tan, MD, discussing their experience in the diagnosis, treatment, and sequelae of CMV anterior uveitis and endotheliitis.   Clara C. Chan, MD, cornea editor C MV acute anterior uveitis and endotheliitis can be identified by a number of features and patient characteristics. Diagnosing and preventing recurrence is extremely important to determine the best treatment option and reduce the risk of a worsening condition in these cases. Soon-Phaik Chee, MD, Singapore National Eye Centre, and associate professor, Department of Ophthalmology, National University of Singapore, and Donald T.H. Tan, MD, head and senior consultant, Singapore National Eye Centre, commented on some of the key features, diagnosis, and treatment. This slit lamp photograph shows a mixture of medium and small sized white keratic precipitates on the central and inferior aspect of the corneal endothelium. This is typical of CMV acute hypertensive anterior uveitis. Key ophthalmic features and patient characteristics Dr. Tan said that the spectrum of CMV infection in the anterior segment includes acute recurrent infection (similar to features of Posner-Schlossman Syndrome), sector iris atrophy with iritis, chronic infection (similar to Fuchs' heterochromic iridocyclitis) or corneal endotheliitis. "The key features of CMV endotheliitis are the presence of fine or medium-sized keratic precipitates (KPs), which characteristically (but may not always) adopt a ring or linear pattern, and may or may not be pigmented," he said. "One classic hallmark of CMV is the presence of white, opalescent nodular endothelial lesions, which may be confused with the nodules seen in posterior polymorphous corneal dystrophy." Dr. Tan said that patients are usually in the adult or elderly age group. "In patients with CMV infection post-transplant, endotheliitis may occur anytime after the PK or DSAEK. Oftentimes there is a preceding history of previous uveitis or uveitic glaucoma such as Fuchs' heterochromic cyclitis, and bilateral involvement can occur," he said. "Previous indications for the transplant may vary from post-surgical causes of corneal decompensation, such as pseudophakic bullous keratopathy or post-glaucoma or postlaser peripheral iridotomy cases; [patients may] have a previous This slit lamp photograph shows a swollen cornea with Descemet's folds and small keratic precipitates in an eye with CMV endotheliitis. Source (all): Soon-Phaik Chee, MD history of Fuchs' endothelial dystrophy." Dr. Chee detailed the spectrum of CMV infection. "CMV acute anterior uveitis tends to be unilateral, relapsing in nature and associated with a raised intraocular pressure of more than 40 mm Hg in many patients," she said. Patients between the ages of 20 and 40 may present with sudden blurring of vision, halos, and ipsilateral headaches, she said, indicating that about twothirds of patients who present with these problems are male. The eyes in these cases may be minimally red with small and medium sized KPs over the inferocentral cornea, which may form a ring pattern. "These KPs may be seen linearly arranged inferiorly," she said. CMV chronic anterior uveitis tends to be unilateral, like the acute condition, however, it also occurs bilaterally in 7% of patients. These patients are usually older, between the ages of 50 and 80, Dr. Chee said, and are predominantly male. Characteristics of patients include gradual blurring of vision due to the small KPs that are diffusely scattered over the endothelium or from cataract formation. These can sometimes be arranged in a ring pattern. In regard to CMV endotheliitis, Dr. Chee said this should be excluded in any case where there is unexplained corneal edema. The majority of these patients are male. It is bilateral in about one fifth of cases and may present at any age. Dr. Chee said that slit lamp exami-

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