An 89-year-old woman with systemic hypertension presented with a history of multiple episodes of hypertensive anterior uveitis in the RE after uneventful cataract surgery two years before. Extensive systemic investigations had been unrevealing, ruling out tuberculosis, syphilis and sarcoidosis, among other infections/noninfectious conditions. The ultrasound biomicroscopy showed a well-placed intracapsular intraocular lens with no ciliary touch. Empiric treatment with topical and systemic corticosteroids led to the initial improvement, followed by recurrence of intraocular inflammation in the RE. Continuous use of timolol, dorzolamide and brimonidine drops in the RE was then necessary. At presentation, BCVA was 20/40 in the RE and 20/20 in the LE. Slit-lamp examination of the RE showed white medium-sized coin-shaped central/paracentral keratic precipitates, connected by a fibrin network adhered to the corneal endothelium. The anterior chamber of the RE had 3+ cells and 1+ flare and the iris displayed focal atrophy inferonasally (Figure 3). A topic (in-the-bag) single-piece-intraocular lens (IOL) was also seen in both eyes. The anterior segment of the LE and the fundus examination of both eyes were otherwise unremarkable.
In face of the suspicion of an herpes virus etiology, an AC tap for PCR of aqueous humor, as well as serological tests for herpesviruses were performed. Results were positive for CMV DNA in aqueous humor, and for specific IgG anti-HSV, VZV and CMV in the serum. The specular microscopy revealed an endothelial cell count of 1,035 and 1,720 cells/mm2 in the RE and the LE, respectively.
Topical 2% ganciclovir eye drops 5x/day and topical 0.15% ganciclovir gel at bedtime were then started, in addition to 1% prednisolone drops in a tapering regimen. The intraocular inflammation progressively improved, with no further crises of intraocular inflammation after six months of follow-up.