## Herpes simplex keratitis (usually HSV1)

- Causes anterior uveitis, usually associated with keratitis
- Unilateral AAU with KPs
- Patchy iris atrophy with transillumination defects
- Glaucoma secondary to trabeculitis or inflammatory debris
- Posterior uveitis: acute retinal necrosis, occlusive vasculitis, retinal detachment
- Requires a very slow taper of topical steroid
- Consider long-term oral antiviral prophylaxis

## Varicella zoster

- Vesicular rash
- Associated keratitis (superficial, disciform, stromal)
- Mild anterior uveitis
- Rarely necrotizing retinitis (ARN or PORN)
- Increased risk of uveitis if Hutchinson's sign positive
- Requires slow taper of topical steroid

## Cytomegalovirus

- CMV hypertensive uveitis occurs in immunocompetent patients
- Also a leading cause of visual loss in AIDS patients (and other immunocompromised individuals)
- Anterior uveitis associated with raised IOP
    - Less likely to have iris atrophy cp. HSV and VZV
    - Treatment can be challenging: consider **oral valganciclovir**
        - Valganciclovir is a prodrug of ganciclovir which is available orally
        - Excellent bioavailability
        - Has superceded ganciclovir for induction and maintenance therapy

- Corneal endotheliitis
- CMV retinitis

## Acute retinal necrosis

- Rare necrotizing retinitis caused by HSV1 or 2 and VZV

### Clinical features
- Unilateral reduced vision, floaters
- Occlusive arteritis
- Well-demarcated, circumferential areas of full-thickness necrotizing retinitis
- Vitritis and AC activity
- Retinal detachment
- Ischaemic optic neuropathy

###  Tests
- AC and/or vitreous tap with PCR

### Management

- Intravenous aciclovir
- Systemic corticosteroids
- Aspirin
- Barrier PRP
- Vitrectomy for RD
- Valaciclovir can be consider but carries risk of nephrotoxicity
- Intravitreal foscarnet

## Progressive outer retinal necrosis

- Devastating necrotizing retinitis caused by VZV in **immunocompromised** patients
- Painless loss of vision
- Rapidly progressive white areas of outer retinal necrosis with **minimal** vasculitis, retinitis or vitritis
- Management: consider IV ganciclovir, foscarnet
- Poor prognosis (high rate of RD)

## West Nile virus infection

- Single stranded RNA flavivirus causing zoonotic disease
- Transmitted via infected mosquito vector
- Diabetes is a risk factor: increases mortality
- 80% are asymptomatic
- Mild reduction in vision
- Bilateral > unilateral **multifocal chorioretinitis**
- Tests: WNV-specific IgM antibody
- No proven treatment, generally self-limiting

## Chikungunya virus infection

- Epidemics caused by human-mosquito transmission
- Self-limiting febrile illness with arthralgia, rash, low back pain
- Anterior uveitis
- Fine KPs
- Raised IOP
- Posterior uveitis: retinitis with haemorrhages, vasculitis, optic neuritis
- Tests: raised ESR/CRP, PCR to identify virus, and serum chikungunya specific IgM
- Management: symptomatic control. NSAIDs, topical corticosteroids for uveitis

## Measles, mumps, rubella, dengue, Ebola and HTLV-1 can cause uveitis

- Measles associated with subacute sclerosing panencephalitis
- HTLV-1 causes leukaemia

## HIV-associated disease (see viral infections sections under Microbiology)

- HIV-1 and HIV-2: retroviruses that infect CD4 T cells

### Risk factors

- Sexual intercourse
- IVDU
- Blood transfusion
- Maternal (vertical) infection

### Markers of disease

- CD4 count: indicator of immunocompromise
- Viral load: indicator of risk of progression

- Histology: large eosinophilic intranuclear/intracytoplasmic inclusion bodies (‘Owl’s eye’)

### Antiretroviral therapy

- Comprises at least 3 antiretroviral drugs
    - Nucleoside reverse transcriptase inhibitors
    - Protease inhibitors
    - Non-nucleoside reverse transcriptase inhibitors

### Ocular disease

- Conjunctival microvasculopathy: irregular calibre vessels with corkscrew pattern
- Keratouveitis:
    - VZV keratouveitis is common (AAU, raised IOP, iris atrophy)
    - HSV keratouveitis: similar risk to general population, but more severe
    - Microsporidial keratouveitis: punctate keratopathy with follicular conjunctivitis and anterior uveitis

- Anterior uveitis: affects over half of HIV patients
    - Can be caused by therapy eg. rifabutin (anti-atypical mycobacterial) and cidofovir (anti-CMV)

- CMV retinitis
    - Associated with very low CD4 counts (&lt;50/mm3)
    - Floaters, reduced vision, field loss
    - AC inflammation
    - Vitritis
    - Patterns of retinitis
         - Haemorrhagic retinitis with necrosis: large areas of hemorrhage against a background of whitened necrotic retina, typically along the vascular arcades
        - Granular retinitis (especially if peripheral): relatively indolent
        - **Perivascular, frosted branch angiitis**

  - RD
  - Optic neuropathy

### Management of CMV retinitis in HIV-patients

- ART to achieve a CD4 count of above 200
- Systemic antiviral: eg. (val)ganciclovir (risk of neutropenia), foscarnet, cidofovir (risk of renal toxicity)
    - Intravitreal antivirals

### Other ocular manifestations of HIV

- Toxoplasma retinochoroiditis
    - Therapy to combat pneumocystis is also toxoplasmacidal so the frequency has greatly reduced
    - More severe in HIV patients

- **HIV microvasculopathy**: tortuosity of retinal vessels with cotton wool spots, telangiectasia, intraretinal hemorrhages and occlusive disease
- Neuro-ophthalmic: cerebral toxoplasma, cryptococcal meningitis, neurosyphilis
- Molluscum contagiosum


Herpes simplex keratitis (usually HSV1) Causes anterior uveitis, usually associated with keratitis Unilateral AAU with KPs Patchy iris atrophy with…

Uveitis

Viral uveitis

Intro

FRCOphth Part 2 Study Notes

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