Viral Anterior Uveitis
Treating viral anterior uveitis requires an approach that differs from treating routine posterior uveitis cases. By gaining an understanding of the clinical manifestations and symptoms of the disease, uveitis specialists can prepare themselves to manage this chronic condition that, if left untreated, could result in long-term vision loss.
DIAGNOSING VIRAL ANTERIOR UVEITIS
Patients with viral anterior uveitis generally present with symptoms that include ocular pain, photophobia, and decreased vision. Unilateral disease is common. Upon examination, clinical signs can include elevated intraocular pressure, pigmented keratic precipitates, and iris atrophy.
In a recent installment of Retina Today’s Uveitis Resource Center, Anat Galor, MD, explained to Thomas Albini, MD, that close examination of iris atrophy may allow clinicians to identify the disease source. Viral anterior uveitis is generally caused by herpes simplex virus (HSV); varicella zoster virus (VZV) is another leading viral cause of the disease. HSV results in segmental iris atrophy, whereas VZV results in diffuse iris atrophy. However, as Dr. Galor explained, mixed atrophy patterns are common.
Diagnosing VZV-mediated uveitis is generally easier than diagnosing HSV-mediated uveitis because patients with VZV uveitis generally recall previous experience with shingles. Patients are less likely to recall a history of periocular vesicles, Dr. Galor said, which means that clinicians may not consider HSV at the top of their diagnosis.
THERAPY FOR HSV-RELATED DISEASE
Dr. Galor explains to patients with viral anterior uveitis that they can expect chronic inflammation, and that acyclovir (Zovirax, Valeant, and generic formulations) and valacyclovir (Valtrex, GlaxoSmithKline) are generally well tolerated, she told Dr. Albini. Patients with suspected HSV-related uveitis are prescribed 400 mg oral acyclovir five times daily in addition to steroid drops. For patients who respond to treatment after 14 days, Dr. Galor tapers the steroid regimen and reduces antiviral treatment to 400 mg twice daily.
Dr. Galor explained that differences between generic and brand name antivirals are important to understand. Although generic oral acyclovir costs less than a branded drug, more frequent dosing is required. Still, without a head-to-head trial evaluating the efficacy of generic and branded antivirals, it will be impossible to offer anything other than anecdotal evidence that one provides superior therapeutic benefit compared with the other, she said.
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