Zika May Lead to Bilateral Posterior Uveitis in Infected Adults

Although congenital chorioretinal lesions have frequently been reported in children of mothers infected with the Zika virus, there have been few reports of the ocular complications of Zika virus infection in adults. However, Shilpa Kodati, MD, and colleagues at the National Eye Institute (NEI) in Bethesda, Maryland, recently published what they believe is the first report of a case of bilateral posterior uveitis and acquired chorioretinal lesions associated with Zika virus disease.

The case was that of a healthy 26-year-old white man who had recently returned to Washington, District of Columbia, from a visit to Puerto Rico. On the day of his return, chills, arthralgia, myalgia, and a centrifugal skin rash developed. These symptoms led him to visit his physician, who diagnosed Zika virus infection. Real-time polymerase chain reaction (RT-PCR) assay confirmed the diagnosis.

A week after the patient’s return, redness developed in both eyes for 1 week and resolved without treatment. Nevertheless, a week later, the patient reported flashes of light in the left eye. Ophthalmic examination found visual acuities of 20/20 and a normal anterior segment in both eyes. However, 0.5+ cells were noted in the vitreous of the left eye during dilated fundus examination. Moreover, the left eye also had scattered, faint, yellow lesions. The left eye was treated with 0.5% loteprednol etabonate ophthalmic suspension (Lotemax/Bausch+Lomb), 3 times daily, and the patient was referred to a uveitis service.

A month after the patient returned from Puerto Rico, his condition had improved somewhat with treatment, but he was still mildly symptomatic and continued to have flashes of light. The mild vitreous inflammation noted in the left eye on initial examination had completely resolved, but fundus examination showed pigmented outer retinal and choroidal lesions in the nasal region of this eye.

Hyperautofluorescence found during fundus autofluorescence confirmed that the retinal pigment epithelium was also affected. Moreover, optical coherence tomography (OCT) imaging showed hyper-reflective nodular elevations in the outer retina near the pigmented lesions. In addition, the investigators found foci of hyperfluorescence consistent with active choroidal lesions in both eyes during indocyanine green dye angiography. However, RT-PCR testing of aqueous humor and samples from conjunctival swabs produced negative results for Zika virus.

Because of the peripheral location of the left chorioretinal lesions found during fundoscopy, the investigators stopped treating the patient with topical corticosteroids. During a follow-up examination 4 weeks later, visual acuities were still 20/20. Moreover, the chorioretinal lesions in the left eye were less prominent and showed less hyperautofluorescence, which suggested that they were resolving without treatment. In addition, repeated OCT imaging showed that the outer retinal changes had improved, so the patient was scheduled for routine follow-up.

The investigators noted that the chorioretinal lesions in the left eye and the numerous sites of leakage found during angiography suggested the presence of lesions at different stages of activity. However, whether the lesions were a direct effect of Zika virus infection or the result of an immune-mediated process was unclear.

According to the investigators, this case highlights the need to monitor Zika-exposed patients for visual symptoms and ocular findings because these may be the only indicators of Zika virus infection in some patients. In addition, they recommended quickly referring symptomatic patients with ocular findings for ophthalmic assessment.

They concluded by stressing the importance of making an accurate diagnosis of posterior uveitis in these patients because macular lesions threaten vision. They also stressed that long-term follow-up of patients with Zika virus-associated posterior uveitis is essential for monitoring the effects of inflammatory chorioretinal lesions.

The report of this case, “Bilateral posterior uveitis associated with Zika virus infection,” was published online in December by The Lancet.

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