A Case of Hypertensive Uveitis

Case Study: Hypertensive Uveitis

Dr Janice Thean

A 74 year old man presented with a 3 week history of gradual blurring of his left vision. There was associated mild ocular redness and Chlorsig drops from his GP did not resolve it. VA on presentation was 6/36, IOP was 45 and the eye looked like this

What are the likely differential diagnoses?

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  1. Herpetic uveitis
  2. Posner-Schlossman syndromeFuch’s
  3. Heterochromic iridocyclitis

What other history would you need to get?

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  1. Previous similar episodes?

  2. Previous history of shingles?

  3. Previous history of cold sores?

  4. Previous history of HLA-B27 related conditions?

What other signs would you need to look for?

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  1. corneal sensation

  2. presence of dendrites

  3. dilated examination to rule out vitritis and retinitis

  4. is the other eye involved?

  5. any signs of iris atrophy?

  6. presence of peripheral anterior synechiae and posterior synechiae

What treatment would you start him on?

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Intensive topical steroids, cycloplegics and an IOP lowering agent.

At his review at 1 week, VA had improved to 6/12, IOP was 15. However, there was residual anterior chamber inflammation and the eye now looked like this:

 

What would you need to do now?

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It looks like a dendritic ulcer. So the most likely diagnosis is herpetic uveitis. Aciclovir eye ointment was added to the current regimen of treatment.

Discussion

The development of acute anterior uveitis is usually associated with a lowering of intraocular pressure, as inflammation of the ciliary body results in a decrease in aqueous production while aqueous outflow is enhanced by increased uveoscleral outflow. When faced with a case of acute anterior uveitis with increased intraocular pressure, one must consider an infective cause.

By far, the most common cause of hypertensive uveitis is herpetic in nature (HSV, VZV, CMV). All these are typically unilateral with HSV and VZV associated with iris stromal defects. The presence of a dendrite or disciform keratitis also helps with the diagnosis. Most of the time, a detailed history and careful examination is usually enough to achieve a correct diagnosis. CMV uveitis unfortunately, often requires an AC tap for PCR for correct diagnosis. Other infective causes could include Toxoplasmosis which often will have associated vitritis and retinal lesions.