Rubella Virus- and Cytomegalovirus-Associated Anterior Uveitis: Clinical Findings and How They Relate to the Current Fuchs Uveitis Syndrome Classification.

Rubella virus (RV) and cytomegalovirus (CMV) have both been implicated in anterior uveitis (AU). Clinical phenotypes can vary widely among both etiologies, including Fuchs uveitis syndrome (FUS) as a very distinct phenotype that has been associated with both RV and CMV. The Standardization of Uveitis Nomenclature (SUN) Working Group recently updated the classification criteria for FUS as unilateral AU, including either heterochromia or diffuse iris atrophy combined with stellate keratic precipitates as key findings. The aim of this study was to determine whether our patients adhere to the classification criteria of FUS as previously reported and whether RV- or CMV-associated uveitis can be differentiated by clinical findings. Therefore, this study investigated the clinical characteristics of patients with AU and intraocular presence of either RV or CMV determined by the Goldmann-Witmer coefficient (GWC). Our study included 100 patients (107 eyes) with AU and positive GWC for RV (86) and CMV (21). Clinical findings of RV-positive eyes were as follows: keratic precipitates (91.9%) with a predominantly diffuse distribution (81.4%), unilateral cataract (80.2%), pseudophakia (73.5%), and vitreous cells (59.7%), whereas heterochromia was present in only 39.5% of eyes and iris atrophy in 12.9% of eyes. In CMV-positive eyes, conversely, a higher incidence of ocular hypertension with markedly increased intraocular pressures above 30 mmHg (66.7%), keratic precipitates (81.0%), which were most commonly distributed in the center of the cornea (63.6%), an unaffected lens (55.0%), absent iris atrophy (100%), and absent posterior synechiae (90.5%) could be detected. This indicates a clinical presentation that was mainly compatible with Posner-Schlossman syndrome. In our cohort of RV-positive FUS patients, we saw a different cluster of clinical findings compared to the classification criteria suggested by the SUN Working Group. The main criteria, such as unilaterality, were mostly fulfilled. When applying all classification criteria, only 8.4% of 107 eyes and 10.5% of all 86 RV-positive eyes would qualify for the diagnosis of FUS. In addition, in our cohort of predominantly Caucasian patients, the clinical findings in patients with proven CMV infection differed from the clinical presentation typically associated with FUS.

Virus-associated anterior uveitis and secondary glaucoma: Diagnostics, clinical characteristics, and surgical options.

In this retrospective, single-center, observational study, we compared the clinical characteristics, analyzed the glaucoma development, and the glaucoma surgery requirement mediators in patients with different virus-associated anterior uveitis (VAU). In total, 270 patients (= eyes) with VAU confirmed by positive Goldmann-Witmer coefficients (GWC) for cytomegalovirus (CMV), herpes simplex virus (HSV), varicella-zoster virus (VZV), rubella virus (RV), and multiple virus (MV) were included. Clinical records of these patients were analyzed. Demographic constitution, clinical findings, glaucoma development, and surgeries were recorded. The concentrations of 27 immune mediators were measured in 150 samples of aqueous humor. The GWC analysis demonstrated positive results for CMV in 57 (21%), HSV in 77 (29%), VZV in 45 (17%), RV in 77 (29%), and MV in 14 (5%) patients. CMV and RV AU occurred predominantly in younger and male patients, while VZV and HSV AU appeared mainly with the elderly and females (P<0.0001). The clinical features of all viruses revealed many similarities. In total, 52 patients (19%) showed glaucomatous damage and of these, 27 patients (10%) needed a glaucoma surgery. Minimal-invasive glaucoma surgery (MIGS) showed a reliable IOP reduction in the short-term period. In 10 patients (37%), the first surgical intervention failed and a follow-up surgery was required. We conclude that different virus entities in anterior uveitis present specific risks for the development of glaucoma as well as necessary surgery. MIGS can be suggested as first-line-treatment in individual cases, however, the device needs to be carefully chosen by experienced specialists based on the individual needs of the patient. Filtrating glaucoma surgery can be recommended in VAU as an effective therapy to reduce the IOP over a longer period of time.

Immune Mediator Profile in Aqueous Humor Differs in Patients with Primary Acquired Ocular Toxoplasmosis and Recurrent Acute Ocular Toxoplasmosis.

PURPOSE: To compare the intraocular cytokine and chemokine profiles in patients with acute primary acquired ocular toxoplasmosis (pOT) or recurrent ocular toxoplasmosis (rOT) and to correlate them with their clinical characteristics. METHODS: Aqueous humor samples were collected from 62 consecutive patients (21 pOT, 30 rOT, and 11 noninfected controls) and analyzed by multiplex assay. Correlations were assessed between cytokine/chemokine levels, type of inflammatory response (Th1, Th2, and Th17), and clinical characteristics. In all OT patients, the clinical diagnosis of either pOT or rOT was confirmed by positive intraocular Goldmann/Witmer-Desmonts coefficient. Correlations were assessed between a preselected panel of immune mediators and the clinical characteristics of OT. RESULTS: In pOT patients, increased levels of IL-2, IFN-γ, TNF-α, IL-15, IL-4, IL-5, IL-9, IL-13, IL-17, IL-1Rα, IL-6, IL-1ß, and chemokines MIP-1α, MIP-1ß, IP-10, Eotaxin, IL-8, RANTES, PDGF-bb, GM-CSF, G-CSF, and MCP-1 were found in comparison to those in controls (p < 0.05). Patients with rOT showed elevated levels of IL-2, IFN-γ, TNF-α, IL-15, IL-4, IL-5, IL-9, IL-17, IL-1Rα, IL-6, IL-1ß, and chemokines MIP-1α, IP-10, Eotaxin, IL-8, RANTES, PDGF-bb, G-CSF, and MCP-1 compared to controls (p < 0.05). In addition, IL-7 (p = 0.028) differed between pOT and rOT; IL-9 (p = 0.054) and IL-13 (p = 0.051) showed a tendency of higher concentration in pOT than in rOT. A negative correlation was found between IL-7 (p = 0.017) as well as IL-9 (p = 0.008) and the number of recurrences. Cytokine ratios showed no difference between pOT and rOT, indicating a dominant Th1-type response in both infectious groups. Moreover, a positive correlation was detected between IL-7, VEGF, IL-13 and age at aqueous humor sampling (p < 0.05). CONCLUSIONS: This study for the first time shows subtle differences between the intraocular cytokine profiles in patients with either acute pOT or rOT.

Different composition of intraocular immune mediators in Posner-Schlossman-Syndrome and Fuchs' Uveitis.

Posner-Schlossman-Syndrome (PSS) is clinically characterized by acute, recurrent, mild, unilateral uveitis anterior accompanied by elevated intraocular pressure (IOP). Fuchs´ Uveitis (FU) is a chronic, low-grade-inflammatory disorder, involving anterior uvea and vitreous. The clinical findings show remarkable similarities as well as differences. In our study, we determine the composition of immune mediators in aqueous humor of patients with PSS and FU and evaluate if immune mediators play a crucial role in specific viral intraocular inflammation and IOP rises. Aqueous humor samples from 81 uveitis patients (= eyes) presenting with either PSS or FU were collected at one time point. Local intraocular antibody synthesis to rubella virus was confirmed in 65 patients, whereas 16 were tested positively for human cytomegalovirus. Thirteen patients with PSS and 10 patients with FU were treated with glaucoma medications. Additionally, 11 cataract patients acted as control group. Immune mediator concentrations were measured by Bio-Plex Pro assay. We observed in both PSS (IFN-γ: 174.9 pg/mL; TNF-α: 25.1 pg/mL) and FU (IFN-γ: 25.4 pg/mL; TNF-α: 27.2 pg/mL) groups a significantly increased level of T-helper 1 immune mediators compared to controls (IFN-γ, TNF-α: 0 pg/mL) [median]. Notably, PSS patients (IL-1RA: 73.4 pg/mL; IL-8: 199.4 pg/mL; IL-10: 33.4 pg/mL; IP-10: 126350 pg/mL) showed a stronger and more active ocular inflammatory response, than FU patients (IL-1RA: 4.3 pg/mL; IL-8: 72.4 pg/mL; IL-10: 1.6 pg/mL; IP-10: 57400 pg/mL). Furthermore, a negative correlation between mediators and IOP was seen in the PSS group, potentially caused by acetazolamide-treatment. Our findings show that immune mediators play a crucial role in specific viral intraocular inflammation and influence IOP levels. Remarkable similarities but also significant differences of immune mediator concentrations are apparent in PSS compared to FU. High concentrations of IL-1RA, IL-8, IL-10, and IP-10 correlate with active inflammation in PSS, while FU may trigger chronic inflammation. Our data also substantiated a very similar composition of cytokines in those patients from the PSS group suffering from ocular hypertension and thus offers a potential explanation model for a negative correlation between mediators and IOP.

Toxoplasma serotype is associated with development of ocular toxoplasmosis.

BACKGROUND: Worldwide, ocular toxoplasmosis (OT) is the principal cause of posterior uveitis, a severe, life-altering disease. A Toxoplasma gondii enzyme-linked immunoassay that detects strain-specific antibodies present in serum was used to correlate serotype with disease. METHODS: Toxoplasma serotypes in consecutive serum samples from German uveitis patients with OT were compared with non-OT seropositive patients with noninfectious autoimmune posterior uveitis. OT patients were tested for association of parasite serotype with age, gender, location, clinical onset, size, visual acuity, or number of lesions (mean follow-up, 3.8 years) to determine association with recurrences. RESULTS: A novel, nonreactive (NR) serotype was detected more frequently in serum samples of OT patients (50/114, 44%) than in non-OT patients (4/56, 7%) (odds ratio, 10.0; 95% confidence interval 3.4-40.8; P < .0001). Non-OT patients were predominantly infected with Type II strains (39/56; 70%), consistent with expected frequencies in Central Europe. Among OT patients, those with NR serotypes experienced more frequent recurrences (P = .037). Polymerase chain reaction detected parasite DNA in 8/60 OT aqueous humor specimens but failed to identify Type II strain alleles. CONCLUSIONS: Toxoplasma NR and Type II serotypes predominate in German OT patients. The NR serotype is associated with OT recurrences, underscoring the value of screening for management of disease.

Intraocular antibody synthesis against rubella virus and other microorganisms in Fuchs' heterochromic cyclitis.

INTRODUCTION: Fuchs' heterochromic cyclitis (FHC) is a common intraocular disease of uncertain etiology that has recently been related to rubella virus (RV) infection. METHODS: We investigated the synthesis of RV-specific IgG using aqueous humor and serum samples from 63 consecutive patients with FHC. In addition, intraocular immunoglobulin G production against herpes simplex virus (HSV), varicella zoster virus (VZV), cytomegalovirus (CMV) and toxoplasma gondii was determined. In 20 patients, the detection of RV RNA was additionally performed by RT-PCR on the E1 gene. Forty-six patients with HSV- and VZV-associated uveitis, HLA B-27 positive anterior uveitis, and Posner-Schlossman syndrome served as controls. RESULTS: Specific intraocular antibody synthesis against RV was confirmed in all 63 FHC patients, whereas none of the 46 controls was positive for RV IgG. Interestingly, in 11 patients with positive RV IgG synthesis, additional HSV (eight), VZV (one) and CMV (two) specific antibodies could be detected. Only twice was viral RNA detectable by PCR in a patient with FHC. CONCLUSIONS: In this largest reported series of FHC patients, we detected a strong association between FHC and intraocular antibody synthesis against rubella virus. Furthermore, in 11 patients, it was possible to confirm an additional intraocular antibody synthesis, in particular HSV. PCR-positive results in the aqueous humor were exclusively obtained for RV. In contrast to other studies, the RV genome could only be identified in two patients (10%).

Gene transfer of cyto-protective molecules in corneal endothelial cells and cultured corneas: analysis of protective effects in vitro and in vivo.

The loss of corneal endothelial cells plays a critical role in many corneal diseases and is a common phenomenon following cornea transplantation. In addition, the non-regenerative capacity of human corneal endothelial cells (HCEC) ultimately requires appropriate protection of corneal tissues during ex vivo storage to ensure vitality of the cells. However, only 70% of donor corneas can be used for grafting because of endothelial deficiencies. Corneal endothelial cell loss during storage is mainly induced by apoptotic cell death. This study was undertaken, for proof of principle, to investigate whether over-expression of cyto-protective molecules Bcl-x(L), Bag-1, and HO-1 prevents the loss of corneal endothelial cells both in vitro and in vivo. We demonstrate that gene transfer of both Bcl-x(L) and HO-1 has cyto-protective effects on HCEC in vitro. However, gene transfer of a single cyto-protective molecule does not prevent its rejection upon transplantation in a MHC class I/II disparate rat model.

Specific antibody production in herpes keratitis: intraocular inflammation and corneal neovascularisation as predicting factors.

PURPOSE: The purpose of the study is to investigate whether analysis of specific antibody synthesis can aid the diagnosis of herpes keratitis. METHODS: Aqueous humor was collected from 39 patients with presumed recurrent herpes keratitis, including 23 consulting for keratitis and 16 patients scheduled for penetrating keratoplasty. Local antibody production was ascertained by analysis of paired aqueous humor/serum samples, using a modified micro-ELISA technique. RESULTS: Local production of antibodies was found in 32 patients (82%): anti-herpes simplex virus (HSV) antibodies in 26 (67%) and anti-varicella zoster virus (VZV) antibodies in 11 (28%). Twenty of 23 patients with active keratitis (87%), and 12 of 16 undergoing keratoplasty (75%), tested positive. Five patients had local production of both anti-HSV and anti-VZV antibodies, whereas seven patients tested negative. Local antibody production was significantly associated with intraocular inflammation (P<0.05), corneal neovascularisation (P<0.05), and positive response to anti-viral treatment (P<0.05). No complications were encountered in sampling aqueous humor. CONCLUSIONS: Assessment of local anti-HSV and -VZV antibody production is a safe and reliable diagnostic procedure for recurrent herpes keratitis. It might be particularly helpful in patients presenting with intraocular inflammation and neovascularisation since it discriminates between herpes and non-herpes pathologies and may therefore be useful for preventive and therapeutic strategies.

Fibroblast growth factor-2 protects endothelial cells from damage after corneal storage at 4 degrees C.

BACKGROUND: Since the introduction of cold corneoscleral segment storage prior to keratoplasty there have been continuous efforts to ameliorate the preservation media in order to better maintain the quality of the corneal epi- and endothelium. Recent studies have shown that basic fibroblast growth factor (FGF-2) preserves the viability of, for example, retinal ganglion cells and pigment epithelium cells. Therefore, we investigated the effect of different concentrations of FGF-2 added to a modified Optisol storage medium on endothelial damage after corneal storage at 4 degrees C. METHODS: . Bovine corneas were stored at 4 degrees C for 14 days and for another 24 h at 34 degrees C. Various FGF-2 concentrations (4, 20 and 40 ng/ml) were added to the medium either at day (D) 1, D14, or both D1 and D14. Quantitative evaluation of corneal damage after 14+1 days of storage was conducted by means of the Janus green photometry assay. Histological and ultrastructural investigations of the preserved endothelium were also performed. Bovine cell culture experiments using the TUNEL assay aimed to elucidate the role of FGF-2 on prevention of endothelial apoptosis. RESULTS: The mean endothelial damage in control corneas increased from 4.9 +/- 1.8% (fresh corneas) to 13.4 +/- 2.4% after 14+1 days of storage. FGF-2 at 20 ng/ml or 40 ng/ml added at any of the indicated time points significantly reduced the overall endothelial damage by 5.1-7.3%, corresponding to 38-54% less endothelial damage than in control corneas (P<0.001). Light- and electron microscopic investigations confirmed this protective effect of FGF-2 on corneal endothelial cells. The TUNEL assay revealed a true anti-apoptotic effect of FGF-2 on endothelial cells in culture. CONCLUSION: Our study clearly demonstrates the effectiveness of FGF-2 to enhance cell survival of the corneal endothelium after storage at 4 degrees C. A clinical interest could be seen in the potential future application of FGF-2 as an adjuvant to corneal preservation media in order to better maintain endothelial viability during corneal storage.