Posner-Schlossman Syndrome
Bianka Sobolewska, MD
Manfred Zierhut, MD
Centre of Ophthalmology
University of Tuebingen,
Germany
Ocular History
 49 year old healthy white women
 1999: OD
 recurrent anterior uveitis
 IOP up to 60 mmHg
 no response to oral aciclovir
April 2010: First Presentation
 VA: OD 20/63, OS 20/20
 IOP: OD 38 mmHg, OS 17 mmHg
 OD: non-granulomatous central KPs, iris pigment
defect, anterior chamber cells 1+, posterior subcapsular
cataract, the iridocorneal angle open with pigment
 OS: regular
 Fundus:
 OD/OS: regular with physiologic excavation of the
optic nerve
April 2010: First Presentation
 non-granulomatous central KPs
First Presentation - Diagnostics
 negative anterior chamber fluid analysis (PCR) for
 CMV
 Epstein-Barr virus
 herpes simplex virus
 varicella zoster virus
 all other tests negative: serology for syphilis,
borreliosis and Bartonella, Quantiferon test, ANA,
ANCA, chest CT
Diagnosis
 CMV- indduced anterior uveitis
 based on:
 Clinical findings with classical Posner-Schlossman
Syndrome behaviour of intraocular pressure
 Missing response to acyclovir
Treatment
 topical antiglaucomatosa
 prednisolone eye drops (3x/day)
 systemic valganciclovir
 3 weeks: 900 mg b.i.d.
 followed by 450 mg b.i.d.
Follow up – After 1-6 Months
Mai-October 2010




no recurrence since the start of valganciclovir therapy
VA: OD 20/1000
IOP: OD 16-17 mmHg
only two old KPs, no cells, posterior subcapsular
cataract
 therapy:
 reduction of topical therapy
 systemic valganciclovir 450 mg b.i.d
 clear corneal phacoemulsification 11/2010
Follow up – After 7 Months
October 2011
 OD: 20/20
 no recurrence
 termination of valganciclovir therapy
Follow up – After 11 Months
March 2012
 recurrence with IOP of 40 mmHg,
 anterior chamber cells 1+
 therapy
 valganciclovir (450 mg 2x/day
 topical rimexolone (4x/day)
 topical ganciclovir (5x/day)
 acetacolamide (2x125 mg/day)
Follow-up – After 1-2 Years
April 2012 – April 2013
 IOP 14-17 mmHg
 no recurrence
 reduction of topical therapy
 termination of oral therapy in 04-2013
Follow-up – After 28 Months
August 2013
 recurrence with IOP of 60 mmHg
 acetacolamide 2x250 mg/day
 start therapy with leflunomide 20mg/d
 topical therapy with
 antiglaucomatosa,
 prednisolone 3x/day
 ganciclovir 3x/day
Follow-up – After 29 Months
September 2013
 twice recurrences with IOP of 60 mmHg
 stop of leflunomide (headache, nausea)
 topical therapy with
antiglaucomatosa
prednisolone 3x/day
ganciclovir 3x/day
Follow-up – After 30- 42 Months
October 2013-October 2014
 no recurrences
 reduction of topical therapy
Final Ocular Investigation – After 42 Months
October 2014
 VA: 0.7
 anterior chamber no cells
 optic disc: physiological excavation
 no topical treatment besides arteficial
tears
Final Diagnosis
 Possner-Schlossman Syndrome (PSS)
 Differential diagnosis
 Herpetic anterior uveitis (HSV, VZV)
 Fuchs` uveitis
Problems
 rare disease
 often misdiagnosed
 negative AC tap (PCR) does not exclude PSS
 unclear treatment regimen when AC tap is
negative
 recurrences after termination of systemic
valganciclovir therapy often reported
Conclusion – CMV anterior Uveitis
 Clinical signs can mimic other viral uveitis disorders
 When AC tap is negative but the clinical signs are
suggestive for PSS, systemic acyclovir ineffective: systemic
valganciclovir is recommended
 In case of recurrences, oral valganciclovir therapy with
additional topical ganciclovir can be repeated
 In long-lasting undiagnosed PSS treated only with aciclovir,
the response to valgancilovir seems limited