Coincidence of Varicella-Zoster Virus Anterior Uveitis in a Patient with Chandler's Syndrome
A healthy, 40-year-old woman visited a private clinic with the complaint of hyperemia in her left eye and was referred to our hospital due to the presence of focal iris atrophy. At the initial examination, slit-lamp biomicroscopy of the left eye revealed localized iris atrophy with PAS at several sites, along with a hammered-silver appearance in the corneal endothelium. The corneal edema was absent and the IOP was 11 mm Hg (fig. ). The best corrected visual acuity was 20/20 in the affected eye. Anterior segment optical coherence tomography (OCT) documented the presence of PAS, with the corneal thickness being almost the same in both eyes (fig. ). Specular microscopy of the corneal endothelium in the left eye showed abnormal cells with a disrupted and irregular cellular border (fig. ). The corneal endothelium of the right eye was normal. Based upon these clinical findings, we diagnosed this patient as having Chandler's syndrome, and we decided to follow up without any treatment. However, PAS progressed rapidly at a somewhat unusual speed and, 3 months later, the IOP in the left eye was elevated to 32 mm Hg, while the anterior chamber was silent. Latanoprost (Xalatan®; P?zer Japan, Tokyo, Japan) and dorzolamide hydrochloride-timolol maleate ophthalmic solution (COSOPT®; Santen Pharmaceutical Co. Ltd., Osaka, Japan) were topically applied to control the IOP <20 mm Hg. Six months later, the patient started to complain of visual disturbance in the left eye. Slit-lamp biomicroscopy revealed the inflammatory cells in the anterior chamber to have white keratic precipitates (fig. ). There was no vitreous opacity or retinal exudate. Polymerase chain reaction (PCR) was performed on an aqueous humor sample in search of a panel of human herpes viruses (HHVs) including herpes simplex virus (HSV) type 1 or type 2, VZV, Epstein-Barr virus (EBV), cytomegalovirus and HHV-6, HHV-7 and HHV-8 [, ]. It was found to be positive only for VZV. At this stage, we strongly suspected that this patient had unilateral anterior uveitis due to zoster sine herpete, and so we started the treatment with 3% acyclovir eye ointment (Zovirax®; Santen Pharmaceutical Co., Ltd.) 5 times a day and 0.1% betamethasone eye drops (Rinderon®; Shionogi Pharmaceutical Co. Ltd., Osaka, Japan) 4 times a day, with oral administration of 20 mg/day of prednisolone and 1,500 mg/day of valacyclovir (Valtrex®; GlaxoSmithKline, Brentford, UK). The anterior chamber reaction subsided with this medication and was controlled with topical acyclovir and corticosteroids within 2 months. The iris atrophy and PAS further progressed with reduced corneal endothelial cell density (fig. ). As the IOP was elevated in spite of full medication with antiglaucoma agents, trabeculectomy was performed to control the IOP <15 mm Hg without medication.