Presumed Fuchs Heterochromic Iridocyclitis and Posner-Schlossman Syndrome: Comparison of Cytomegalovirus-Positive and -Negative Eyes

treatment. We entirely agree, but did not address the issue of classification in our article because we investigated a highly selected group of patients with classic nonarteritic CRAO with retinal ischemia and a cherry red spot and no evidence of temporal arteritis. As outlined in our article, arteritic CRAO was an exclusion criterion for thrombolytic therapy.1 Furthermore, we included only patients with nonarteritic CRAO without cilioretinal artery sparing. Because the study by Hayreh and Zimmerman involved CRAO patients with an interval between the onset of symptoms and the first visit ranging from less than 1 day to more than 6 months, it was possible to distinguish a category of eyes with transient nonarteritic CRAO that may last minutes to hours.2 However, only 13% of their patients sought treatment within the first 24 hours after symptom onset, whereas in our study, all subjects were treated within an extremely short interval ranging from 1.5 to 12 hours. We concur with Drs Falavarjani and Modarres that it would have been preferable to have performed fluorescein angiography before treatment. However, as discussed in our article and in the Editorial of the same issue of THE JOURNAL, the therapeutic window for rescuing ischemic tissue in CRAO is challengingly brief.3 Therefore, pretreatment evaluation should be limited to the minimum. Drs Falavarjani and Modarres express their concern that the visual outcome observed in our study simply may represent the natural course of CRAO. They refer to the aforementioned cohort study on the natural history of visual outcome in CRAO. The authors found that eyes with vision of counting fingers or worse improved in 67% of cases with nonarteritic CRAO with cilioretinal artery sparing and in 22% of eyes with nonarteritic CRAO. However, in our study, improvement in best-corrected visual acuity (VA) was defined as an increase of 3 or more Snellen lines, whereas in the study by Hayreh and Zimmerman, improvement in VA was defined as any gain in lines of vision. Therefore, it may be speculated that the proportion of eyes with significant spontaneous improvement was much smaller than suggested. Of 177 patients with nonarteritic CRAO who were included in their study, 122 underwent repeated visits after symptom onset. Of these, only 2 (1.64%) exhibited a final VA better than 20/200, whereas in our study, 41% of patients who received thrombolytic treatment within the first 6.5 hours achieved a final best-corrected VA of 20/50 or better. In contrast, none of our patients who had been treated after more than 6.5 hours showed any visual improvement after an average follow-up of 2.2 months. Drs Falavarjani and Modarres bring to our attention that the task of assessing treatment outcomes in CRAO is difficult. However, available data on the natural course of CRAO or visual outcome after conventional therapies4 support rather than contradict our conclusion that timely 1106

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intervention with intravenous thrombolysis provides a better chance for recovery of vision in CRAO. LARS-OLOF HATTENBACH

Ludwigshafen am Rhein, Germany CLAUDIA KUHLI-HATTENBACH INGE SCHARRER HOLGER BAATZ

Frankfurt am Main, Germany

REFERENCES

1. Hattenbach LO, Kuhli-Hattenbach C, Scharrer I, Baatz H. Intravenous thrombolysis with low-dose recombinant tissueplasminogen activator in central retinal artery occlusion. Am J Ophthalmol 2008;146:700 –706. 2. Hayreh SS, Zimmerman MB. Central retinal artery occlusion: visual outcome. Am J Ophthalmol 2005;140:376 –391. 3. Biousse V. Thrombolysis for acute central retinal artery occlusion: is it time? Am J Ophthalmol 2008;146:631– 634. 4. Mueller AJ, Neubauer AS, Schaller U, Kampik A, for the European Assessment Group for Lysis in the Eye. Evaluation of minimally invasive therapies and rationale for a prospective randomized trial to evaluate selective intra-arterial lysis for clinically complete central retinal artery occlusion. Arch Ophthalmol 2003;121:1377–1381.

Presumed Fuchs Heterochromic Iridocyclitis and Posner-Schlossman Syndrome: Comparison of Cytomegalovirus-Positive and -Negative Eyes EDITOR: WE READ WITH INTEREST THE ARTICLE BY CHEE AND JAP

on presumed Fuchs heterochromic iridocyclitis and Posner-Schlossman syndrome1 and commend the authors for their clinical description of nodular endothelial lesions in cytomegalovirus (CMV)-positive patients. As the authors point out, CMV is increasingly being recognized as a cause of anterior uveitis, and the addition of another clinical sign that suggests the diagnosis of CMV is a helpful addition to the literature. We caution the reader, however, that keratic precipitate (KP) associated with other conditions sometimes may have a similar nodular appearance, with central pigmentation and a halo. We present a slit-lamp photograph of a patient with history of chronic iridocyclitis secondary to syphilis, by serologic confirmation, whose keratic precipitates also appeared to be nodular with a surrounding halo and variable pigmentation (Figure). We have also seen similar KP in patients with biopsy-proven sarcoidosis. OF

OPHTHALMOLOGY

JUNE 2009

FIGURE. Slit-lamp photograph of the cornea showing keratic precipitates surrounded by haloes with pigmentation (arrows) from a patient with a history of chronic iridocyclitis secondary to syphilis by serologic confirmation.

We postulate that the halo represents hyalinized glassy changes in the Descemet membrane caused by endothelial damage from a previously larger granulomatous KP. We suggest that, although this type of KP may suggest the diagnosis of CMV, other causes of uveitis also be considered. MARGARET WONG DEBRA A. GOLDSTEIN HOWARD H. TESSLER

Chicago, Illinois

REFERENCE

1. Chee SP, Jap A. Presumed Fuchs heterochromic iridocyclitis and Posner-Schlossman syndrome: comparison of cytomegalovirus-positive and -negative eyes. Am J Ophthalmol 2008; 146:883– 889.

REPLY WE THANK DR WONG AND ASSOCIATES FOR THEIR INTER-

est in our article.1 We wish to emphasize that our study showed that the nodular endothelial lesions, when present in an eye with other features supportive of a diagnosis of Fuchs heterochromic cyclitis or Posner-Schlossman syndrome, are suggestive of cytomegalovirus (CMV) infection. We do agree with Dr Wong that nodular endothelial-like lesions also may be observed in other uveitic entities, such as chronic iridocyclitis associated with syphilis or sarcoidosis. In these cases, the halo certainly may represent hyalinized changes in the Descemet membrane caused by previously larger granulomatous keratic precipitates, as they had described in their cases. However, the anterior segment optical coherence VOL. 147, NO. 6

FIGURE. Eye of a patient with chronic recurrent VogtKoyanagi-Harada disease. (Top) Slit-lamp photograph showing nodular endothelial-like lesions. This eye had negative polymerase chain reaction results for cytomegalovirus. (Bottom) Optical coherence tomography image of the cornea of the same eye showing a flattened configuration of these lesions.

tomography (AS-OCT; Visante, Model 1000; Carl Zeiss Meditec, Dublin, California, USA) images of these lesions in non-CMV eyes may be different. One example is seen in this eye with chronic recurrent Vogt-Koyanagi-Harada disease with previous granulomatous keratic precipitates, which had negative polymerase chain reaction for CMV. The AS-OCT image of these nodular endothelial-like lesions show a flattened configuration (Figure), differing distinctly from that seen in CMV positive eyes that are nodular.1 Hence, although these lesions may look very similar on slit-lamp examination, the AS-OCT images are able to distinguish between the 2 types of lesions.

CORRESPONDENCE

SOON-PHAIK CHEE ALIZA JAP

Singapore, Republic of Singapore 1107