Until the 2013 Zika virus (ZIKV) epidemic in Brazil, researchers believed the only ocular manifestation of the infection was nonpurulent conjunctivitis. Throughout the course of the outbreak, clinical features of ocular ZIKV were expanded to include both anterior and posterior uveitis.
A recent study — possibly the largest series evaluating patients with anterior uveitis associated with acute systemic symptoms of confirmed ZIKV infection — determined that ophthalmic evaluation should be performed in patients with red eye and acute ZIKV infection to potentially detect and manage hypertensive anterior uveitis.
The researchers sought to learn more about the clinical characteristics of anterior uveitis in a large cohort of adults with acute ZIKV infection by evaluating patients infected with ZIKV during a 2016 outbreak in Guadeloupe in the French West Indies.
Medical records of adult patients with red eye and virologic or serologic confirmation of acute ZIKV infection who were admitted to the Pointe-à-Pitre University Hospital from 2016 to 2017 for a systematic ophthalmologic examination were included in the study.
Also, all participants with anterior uveitis underwent a complete uveitis workup to rule out other causes of uveitis, such as HIV, cytomegalovirus, herpes simplex virus type 1 and type 2, and more. If patients had active uveitis and a history of uveitis or positive serology for other infectious diseases including dengue fever virus and chikungunya virus, they were excluded from this study.
The medical records show that, of 62 total patients with a red eye, 32 (51.6%) had no uveitis (mean age, 27.8 years; 26 female [81.3%]) and 30 (48.4%) had anterior uveitis (mean age, 27.5 years; 26 female [86.7%]), which was bilateral in all cases. Acute anterior uveitis was nongranulomatous and without synechiae, exhibiting mild anterior chamber reaction with small keratic precipitates. Ocular hypertension occurred in 25 patients (83.3%) with uveitis at presentation and persisted in 15 patients (50%) at 1 year despite anti-glaucoma therapy and control of uveitis. Uveitis responded to topical steroids in all cases. Intraocular pressure (IOP) was within normal limits for all patients without uveitis throughout the follow-up period.
The research shows that 48.4% of study participants had anterior uveitis. “The presence of a ciliary flush in an individual with acute ZIKV infection could lead to misdiagnosis with nonpurulent conjunctivitis,” they warn.
While acute anterior uveitis in ZIKV progresses gradually, even subtly, adequate attention and treatment is critical. The researchers note that “83.3% of patients with uveitis in this study also presented with ocular hypertension. The IOP in these cases remained elevated despite the use of anti-glaucoma eye drops in more than 50% of cases at 12 months.”
The findings do show that anterior uveitis responds well to corticosteroid eye drops, the disease is often associated with an elevated IOP, which can lead to vision loss if untreated.
Because global warming is progressing, the research team behind the study forecast that arboviruses, such as ZIKV, will become a global threat. That implies “an increased incidence of associated eye disease and potentially serious visual complications.”
The study suggests that practitioners offer a thorough clinical examination including slit lamp biomicroscopy and IOP measurement, of any patient infected with ZIKA who presents with red eye because the patient is at high risk of developing ocular hypertension.
Troumani Y, Touhami S, Jackson T, et al. Association of anterior uveitis with acute zika virus infection in adults., JAMA Ophthalmol. Published online November 25, 2020. doi: 10.1001/jamaophthalmol.2020.5131