Distinguishing Features of Anterior Uveitis Caused by Herpes Simplex Virus, Varicella-Zoster Virus, and Cytomegalovirus

Am J Ophthalmol. 2021 Jul;227:191-200. doi: 10.1016/j.ajo.2021.03.020. Epub 2021 Mar 25.


Purpose: To determine distinguishing features of the clinical characteristics of anterior uveitis (AU) caused by herpes simplex virus (HSV), varicella-zoster virus (VZV), and cytomegalovirus (CMV).

Design: Retrospective, multicenter case series.

Methods: Consecutive patients with herpetic AU examined at 11 tertiary centers in Japan between January 2012 and December 2017 and who were followed for ≥3 months were evaluated. Diagnosis was made by polymerase chain reaction (PCR) for HSV, VZV, or CMV in the aqueous humor, or classical signs of herpes zoster ophthalmicus.

Results: This study enrolled 259 herpetic AU patients, including PCR-proven HSV-AU (30 patients), VZV-AU (50), and CMV-AU (147), and herpes zoster ophthalmicus (32). All HSV-AU and VZV-AU patients were unilateral, while 3% of CMV-AU patients were bilateral. Most HSV-AU and VZV-AU patients were sudden onset with an acute clinical course, while CMV-AU had a more insidious onset and chronic course. There were no significant differences for all surveyed symptoms, signs, and complications between HSV-AU and VZV-AU. However, significant differences were detected for many items between CMV-AU and the other two herpetic AU types. Ocular hyperemia and pain, blurring of vision, ciliary injection, medium-to-large keratic precipitates (KPs), cells and flare in the anterior chamber, and posterior synechia significantly more often occurred in HSV-AU and VZV-AU vs CMV-AU. In contrast, small KPs, coin-shaped KPs, diffuse iris atrophy, elevated intraocular pressure, and glaucoma surgery were significantly more frequent in CMV-AU vs HSV-AU and VZV-AU.

Conclusion: This multicenter, retrospective study identified distinguishing features of HSV-AU, VZV-AU, and CMV-AU.

Publication types

  • Multicenter Study

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Antiviral Agents / therapeutic use
  • Aqueous Humor / virology
  • Cytomegalovirus / genetics
  • Cytomegalovirus / isolation & purification
  • Cytomegalovirus Infections / diagnosis*
  • Cytomegalovirus Infections / drug therapy
  • Cytomegalovirus Infections / physiopathology
  • Cytomegalovirus Infections / virology
  • Eye Infections, Viral / diagnosis*
  • Eye Infections, Viral / drug therapy
  • Eye Infections, Viral / physiopathology
  • Eye Infections, Viral / virology
  • Female
  • Herpes Simplex / diagnosis*
  • Herpes Simplex / drug therapy
  • Herpes Simplex / physiopathology
  • Herpes Simplex / virology
  • Herpes Zoster Ophthalmicus / diagnosis*
  • Herpes Zoster Ophthalmicus / drug therapy
  • Herpes Zoster Ophthalmicus / physiopathology
  • Herpes Zoster Ophthalmicus / virology
  • Herpesvirus 3, Human / genetics
  • Herpesvirus 3, Human / isolation & purification
  • Humans
  • Intraocular Pressure / physiology
  • Male
  • Middle Aged
  • Polymerase Chain Reaction
  • Retrospective Studies
  • Simplexvirus / genetics
  • Simplexvirus / isolation & purification
  • Uveitis, Anterior / diagnosis*
  • Uveitis, Anterior / drug therapy
  • Uveitis, Anterior / physiopathology
  • Uveitis, Anterior / virology
  • Visual Acuity / physiology
  • Young Adult


  • Antiviral Agents