Infectious Uveitis

Abstract

Infectious uveitis is one of the most common and visually devastating causes of uveitis in the US and worldwide. This review provides a summary of the identification, treatment, and complications associated with certain forms of viral, bacterial, fungal, helminthic, and parasitic uveitis. In particular, this article reviews the literature on identification and treatment of acute retinal necrosis due to herpes simplex virus, varicella virus, and cytomegalovirus. While no agreed-upon treatment has been identified, the characteristics of Ebola virus panuveitis is also reviewed. In addition, forms of parasitic infection such as Toxoplasmosis and Toxocariasis are summarized, as well as spirochetal uveitis. Syphilitic retinitis is reviewed given its increase in prevalence over the last decade. The importance of early identification and treatment of infectious uveitis is emphasized. Early identification can be achieved with a combination of maintaining a high suspicion, recognizing certain clinical features, utilizing multi-modal imaging, and obtaining specimens for molecular diagnostic testing.

Keywords: infectious uveitis; molecular diagnostics; multi-modal ophthalmic imaging.

Figure 1

A 39 year-old pregnant woman at 34 weeks presented with peripheral retinal whitening suggestive of acute retinal necrosis with optic nerve involvement and visual acuity of 20/300 (A). Vitreous paracentesis revealed 800,000,000 copies/mL of VZV DNA by PCR. After 2 weeks of intravitreal foscarnet every 3 days and 2 months of oral valacyclovir 2 g PO TID, the retina remained attached, with resolution of retinitis, and improvement of vision to 20/200, limited by optic atrophy (B).

Figure 2

A 76 year-old man with a history of prostate cancer and follicular lymphoma s/p chemotherapy presented with a panuveitis and granular necrotoizing retinitis OU, left eye shown in (A); visual acuity was 20/50 OS. Vitreous paracentesis revealed 640,000,000 copies/mL of CMV DNA by PCR. After two weeks of intravitreal foscarnet every 3 days and 1 month of oral valganciclovir 900 mg PO BID, retinitis improved, and vision improved to 20/25 OS, without any retinal detachment (B).

Figure 3

A 46 year-old previously healthy man presented with counting fingers vision OS, an outer retinitis in the macula and inferonasal retina, and panuveitis (A). Arrows delineate AZOOR-like outer retinopathy in macula. RPR was 1:64 and FTA-ABS was positive. The patient was treated with 21 days of IV penicillin G with resolution of outer retinitis and improvement of visual acuity to 20/30 OS (B).

Figure 4

A 27 year-old healthy woman presented with a focal area of full-thickness retinitis adjacent to the optic nerve and an old pigmented chorioretinal scar, with overlying vitreous cells (A). Initial visual acuity was 20/30. She was treated with Atovaquone 750 mg PO QID for 3 months, as well as a tapering course of oral prednisone starting 3 days after initiating Atovaquone. The retinal lesion consolidated and vitreous cell resolved (B), with return to 20/20 vision OS.