The human herpes viruses (HHV) are known to cause intraocular inï¬ammation with characteristic iris thinning, typically by herpes simplex viruses 1 (HSV-1 or HHV-1) and 2 (HSV-2 or HHV-2), as well as varicella zoster virus (VZV or HHV-3) and cytomegalovirus (CMV or HHV-5), and as discovered by recent technologic advances, are thought to underlie many cases of inï¬ammatory iris-involving conditions, such as Fuch’s heterochromic iridocyclitis.4
Prominent iris thinning in this case prompted obtaining herpetic serology that was not part of initial testing.
Given evidence of chronicity and structural damage, aqueous biopsy by anterior chamber paracentesis in the ofï¬ce was also elected with polymerase chain reaction (PCR) testing aimed at direct viral detection of HHV. Results demonstrated positive HHV-1 and HHV-2 serology tests, but negative PCR for DNA for these two viruses. PCR for HHV-5 DNA was also negative.
Meanwhile, HHV-3 DNA was detected by PCR, establishing the diagnosis of nodular anterior scleritis caused directly by varicella zoster virus. This ï¬nding highlights that even with focused serologic testing (in this case for two other herpes viruses), there can be misleading results, and that direct molecular evidence (when feasible) is preferable to indirect immunologic testing.5 Furthermore, HHV have been reported to cause as many as 7% of scleritis cases.6
Oral treatment with 1 gram of valacyclovir three times daily was then initiated. At 1 month follow-up, symptoms and scleral inï¬ammation had improved dramatically (Figure 4).