1 / 19

A case of spikes and specks

A case of spikes and specks. Grand Ward Round 18 October 2007. 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.

emily
Download Presentation

A case of spikes and specks

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. 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

  4. 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

  5. Thoughts?

  6. 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 • Fuch’s heterochromic iridocyclitis

  7. Progress • Another episode of high IOP (40mmHg) in Sept 2007 • L AC tap performed • Tetraplex PCR • Positive for CMV. CMV DNA 1.4E+06 copies/mL • HSV, VZV, Toxoplasma neg

  8. 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

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

  10. 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

  11. 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

  12. 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 2006;90: 852-5.

  13. 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

  14. 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

  15. 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 2006;90: 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.

  16. Stellate KPs • Seen in AC inflammation due to • Fuch’s 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 1996;232: 391-396 Pillai CT et al. Evaluation of corneal endotheluim and kertic precipitates by specular microscopy in anterior uveitis. Br J Ophthalmol 2000; 84:1367-1371

More Related