Herpetische Uveitis anterior - 2018.saoo.ch · SAoO-Kongress 28.2.2018 Herpesviridae •...
Transcript of Herpetische Uveitis anterior - 2018.saoo.ch · SAoO-Kongress 28.2.2018 Herpesviridae •...
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SAoO-Kongress 28.2.2018
Herpetische Uveitis anterior
Prof. Dr. Matthias Becker
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SAoO-Kongress 28.2.2018
In Übergängen denken…
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SAoO-Kongress 28.2.2018
Herpesviridae
• Large family of DNA viruses (>130 herpesviruses) • Large double-stranded, linear DNA genomes• At least five species of Herpesviridae are extremely
widespread among humans• More than 90% of adults have been infected with at
least one of these• Latent form of the virus remains in most people
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SAoO-Kongress 28.2.2018
Herpesvirus types
Herpesvirus types known to infect humans:1. Herpes simplex virus 1 (HSV-1)2. Herpes simplex virus 2 (HSV-2)3. Varicella-zoster virus (VZV)4. Epstein–Barr virus (EBV)5. Cytomegalovirus (CMV)6. Human herpesvirus 6A (HHV-6A)7. Human herpesvirus 6B (HHV-6B)8. Human herpesvirus 7 (HHV-7)9. Kaposi's sarcoma-associated herpesvirus (KSHV)
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SAoO-Kongress 28.2.2018
Zoster ophthalmicus• Vesicles on the tip or
the side of the nose• Hutchinson sign• Precedes the
development ofuveitis
• Nasociliary branch ofN. V. innervatesboth: cornea, lateral dorsum of the nose
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Courtesy of D. Goldstein, BCSC
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SAoO-Kongress 28.2.2018
Clinical signs (VZV, HSV)
• VZV-uveitis: history of ipsilateral zoster ophthalmicus• Varicella-zoster sine herpete: anterior uveitis without prior
cutaneous component• Variable corneal involvemet (keratouveitis) • Decreased corneal sensation (diffuse or localized)• Anterior, posterior synechiae• Hypopyon (hemorrhagic)
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SAoO-Kongress 28.2.2018
Übersicht Endothel-Präzipitate
Granulomatös („speckig“)• Sarkoidose, Tuberkulose, MS (beidseitig)• Herpetische Uveitis (einseitig)
Nicht-granulomatös• Fein
• Ankylosierende Spondylitis, HLA-B27+ AAU• Sternförmig-diffus
• Fuchs Uveitis Syndrom
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SAoO-Kongress 28.2.2018
DD: Präzipitate - granulomatös
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SAoO-Kongress 28.2.2018
DD: Nicht-granulomatös / fein
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SAoO-Kongress 28.2.2018
DD: Nicht-granulomatös/ sternförmig
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SAoO-Kongress 28.2.2018
Keratic precipitates
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• Large, central greasy• Fine stellate, diffusely
distributed
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SAoO-Kongress 28.2.2018
Iris atrophy
• Patchy or sectoral• Pupil dilated
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Atrophy of irispigment epitheliumnot just anteriorstroma
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SAoO-Kongress 28.2.2018
Ocular hypertension
• Trabeculitis• Frequent complication (DD: toxoplasmosis)• Other uveitides: decreased IOP (ciliary body
hyposecretion)
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SAoO-Kongress 28.2.2018
Clinical signs (CMV)
• Immunocompetent adults• Chronic or recurrent, unilateral, anterior uveitis, mild
AC activity• Ocular hypertension• Corneal edema• Variable degrees of sectoral iris atrophy• No corneal scars, no posterior synechiae, no flare or
fibrin and no posterior segment involvement
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SAoO-Kongress 28.2.2018
CMV
• Fails to respond to corticosteroids and high doses ofacyclovir
• Can present as acute relapsing hypertensive anterioruveitis, also known as Posner-Schlossman syndrome(PSS); half of all presumed cases of PSS are CMV-positive
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SAoO-Kongress 28.2.2018
Epstein-Barr Virus
• Associated with infectious mononucleosis (IM), Burkittlymphoma, nasopharyngeal carcinoma, Hodgkin disease, and Sjögren syndrome
• Primary infection in the context of IM: mild, self-limitingfollicular conjunctivitis
• Most ocular disease is self-limiting and does not require treatment
• Topical corticosteroids and cycloplegia
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SAoO-Kongress 28.2.2018
Diagnostic options
• Aqueous tap• Real-time PCR analysis• Goldmann-Witmer coeffizient
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SAoO-Kongress 28.2.2018
Therapeutic management: Topical
• Corticosteroids• Cycloplegics• Antiviral drugs (Zovirax) for keratouveitis (to prevent
dendritic keratitis as a complication of topicalcorticosteroid therapy)
• Prolonged topical antiviral therapy is associated with thedevelopment of keratopathy
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SAoO-Kongress 28.2.2018
Therapeutic management: Systemic
HSV or VZV (higher doses) :• Acyclovir (Zovirax, 400– 800 mg, 5 times/day)• Valacyclovir (Valtrex, 500 mg to 1 g, 2 times/day)• Famciclovir (Famvir, 250–500 mg, 3 times/day)
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SAoO-Kongress 28.2.2018
Prophylactic therapy
HSV: • Acyclovir, 400 mg 2 times/day• Valacyclovir, 500 mg/day
VZV • Acyclovir, 800 mg 2 times/day• Valacyclovir, 1 g/day
Immunization• VZV (Zostavax)
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SAoO-Kongress 28.2.2018
Take home message
• Diagnosis often made clinically• Viable therapeutic options available• Role of corticosteroids• Sometimes long-term therapy necessary
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