In 2013, a 42-year-old woman presented for the first time to Phramongkutklao Hospital, Thailand. She had suffered from floaters for 4 weeks and sudden loss of vision for a week in the right eye. She had no ocular pain or photophobia. Her left eye was not affected. The visual acuity was finger count 3' in the right eye and was 20/25 in the left eye. Anterior segment examination revealed anterior chamber cell trace and fine keratic precipitates in the right eye and normal examination in the left eye. Intraocular pressure was 18 in both the eyes.
Fundus examination showed anterior vitreous cells' grade 3+ (Figure 1), vitreous haze grade 3, snow balls, and unclear optic disk in the right eye. The left eye's fundus was normal. Three days later, the inflammation increased; therefore, diagnostic vitrectomy was performed immediately.
Intraoperatively (Figure 2), we found dense vitritis, fibrous tissue on the superior disk with diffuse sclerotic vessels, and sheathing of both artery and vein. A vitreous sample was sent to the laboratory to perform polymerase chain reaction (PCR) for tuberculosis, herpesvirus family, and cytology for malignancy.
Serum CD3 was 2,327 cells/mL (67.5%), and CD4 was 1,138 cells/mL (33%). Serum Epstein-Barr virus (EBV) immunoglobulin (Ig) M was positive (borderline 0.8), and EBV IgG was also positive (9.50; normal: 0-0.8), while serum IgM and IgG for herpes simplex virus (HSV), varicella-zoster virus, and cytomegalovirus were negative. Serum tests for HIV, syphilis, toxoplasmosis, and tuberculosis were negative. Anergy skin test and chest scan for sarcoidosis were also negative.
Three days after vitrectomy, the right fundus showed mild vitreous haze, fibrous tissue, and optic disk edema with normal retinal vasculature at the posterior pole in the right eye. Fluorescein angiography (Figure 3) confirmed leakage at the optic disk and occluded retinal artery and retinal vein leakage at the periphery in all quadrants of the right eye. The ischemic area was also observed at the periphery. Vitreous PCR viral DNA testing result was positive for EBV but negative for HSV-1 and -2, varicella-zoster virus, and also cytomegalovirus.
After vitrectomy, her right visual acuity improved to 20/25, intraocular pressure was 30, anterior chamber cells' grade was 2+, and anterior vitreous cells' grade was 2+. She was treated with intravenous acyclovir 10 mg/kg for 2 weeks; antiglaucoma drugs, topical prednisolone acetate, and antibiotics were prescribed. Panretinal photocoagulation of the right eye at the ischemic area was performed (Figure 4).
After 14-day therapy (Figure 5) with intravenous acyclovir, her anterior chamber activity in the right eye was much improved, but intraocular pressure still rose to 32. The patient was continued on oral acyclovir (800 mg) five times daily and antiglaucoma drugs.
After 4 weeks of therapy (Figure 6), the fluorescein angiography showed that her right optic disk edema had decreased and retinal phlebitis had improved.
After 3 months of therapy (Figure 7), her right visual acuity increased up to 20/20, intraocular pressure was 17, and no anterior chamber cells were observed. Repeat fluorescein angiography showed neither retinal vascular nor optic disk leakage. She discontinued oral acyclovir; however, she remained on brimonidine/timolol ophthalmic solution and brinzolamide.
After 6 months of therapy (Figure 8), the visual acuity was 20/20 in both eyes, and intraocular pressure was controlled. Anterior chamber and vitreal cells were also quiet, and inactive retinal vasculitis was confirmed by fluorescein angiography. This case report was approved by The Institutional Review Board, Royal Thai Army Medical Department who have deemed that informed consent is not required when the patient cannot be identified, directly or through identifiers linked to the patient.