onset.35 Recovery was slightly longer in patients with neuroinvasive disease. Lack of comorbid conditions was associated with faster recovery of physical function.

Other viral infections

A number of other viral infections are associated with a transient mild anterior uveitis during the acute stages. These include measles (rubeola), mumps, influenza, Dengue fever, Epstein–Barr virus (EBV), and human T-lymphotropic virus type I (HTLV-1). The anterior uveitis rarely is accompanied by symptoms and is often undiagnosed because these patients do not undergo an ophthalmologic examination in the first week or two after the onset of disease. Retinitis and choroiditis caused by German measles (rubella) is rarely seen in the active stages of disease because rubella is a con­ genital infection. One other manifestation of measles virus infection is the rare, late presentation of subacute sclerosing panencephalitis. In addition to the progressive, fatal central nervous system disease characterized by dementia, ataxia, and myoclonus, an associated necrotizing retinitis involving the macula has developed in some patients.36 Lesions have occasionally been mistaken for Vogt–Koyanagi–Harada syn­ drome, toxoplasmosis, or juvenile macular degeneration. Uveitis of varying severity has been associated with EBV infection.37,38 One study reported positive antibody titers to early antigen (viral capsid antigen immunoglobulin M) in 10 patients with multifocal choroiditis;39 however, subse­ quent studies have not confirmed this association.40

Human T-lymphotropic virus type I

Human T-lymphotropic virus type I (HTLV-1) is the first human retrovirus to be associated with malignancy, an adult T-cell leukemia/lymphoma.41 HTLV-1 was initially associ­ ated with a chronic degenerative myelopathy also known as tropical spastic paraparesis.42 Uveitis has also been associ­ ated with HTLV-1 infection. Interestingly, HTLV-I infection appears to be endemic to specific geographical areas, includ­ ing Japan, central and equatorial regions of Africa, parts of Oceania, and South America.

HTLV-I associated uveitis is characterized by anterior uveitis, vitreous opacities, and retinal vasculitis.43,44 The initial diagnosis in many patients was an idiopathic inter­ mediate uveitis, and reduced visual acuity was often attri­ buted to cataract and cystoid macular edema. Retinal degeneration, retinal hemorrhages, epiretinal membranes, and optic nerve atrophy can occur, and corneal involvement

Figure 13-3.  A 12-year-old girl with herpes simplex virus keratitis complicated by anterior uveitis, disciform stromal keratitis, and formation of a Wesseley immune ring. (Courtesy of Roger George, MD.)

with corneal haze, scarring, and neovascularization have been reported.45 The uveitis can be treated with cortico­ steroids, but systemic immunosuppression is usually avoided, given the underlying viral infection.

As our ability to detect viral infection improves, and as new viral infections are described, a number of idiopathic forms of uveitis will very probably be attributed to a viral etiology. The section on West Nile virus uveitis was added to the fourth edition of this book, and as additional new viral causes of uveitis are identified, this chapter will undoubtedly become longer in future editions.

Case 13-1

Herpes simplex virus keratitis was diagnosed in a 12-year-old girl with dendritic keratitis. She was treated with topical trifluridine with resolution of the keratitis. Over the course of the next year she had several recurrences of the dendritic keratitis, but later developed a disciform stromal keratitis with an associated anterior uveitis. She was then treated with topical trifluridine and topical corticosteroids. On attempts to taper the topical corticosteroids there was an exacerbation of the stromal keratitis and anterior uveitis and the formation of a Wesseley immune ring (Fig. 13-3). Her clinical course was complicated by cataract and glaucoma, and she has required long-term therapy with topical trifluridine, corticosteroids, and betaxolol.

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