The Infectious Uveitis Treatment Algorithm Network (TITAN) Report 1-global current practice patterns for the management of Herpes Simplex Virus and Varicella Zoster Virus anterior uveitis

Zheng Xian Thng; Ikhwanuliman Putera; Ilaria Testi; Kevin Chan; Mark Westcott; Soon-Phaik Chee; Andrew D Dick; John H Kempen; Bahram Bodaghi; Jennifer E Thorne; Talin Barisani-Asenbauer; Marc D de Smet; Justine R Smith; Peter McCluskey; Rina La Distia Nora; Douglas A Jabs; Joke H de Boer; H Nida Sen; Debra A Goldstein; Moncef Khairallah; Janet L Davis; James T Rosenbaum; Nicholas P Jones; Quan Dong Nguyen; Carlos Pavesio; Rupesh Agrawal; Vishali Gupta; TITAN consensus guidelines group

doi:10.1038/s41433-023-02630-9

The Infectious Uveitis Treatment Algorithm Network (TITAN) Report 1-global current practice patterns for the management of Herpes Simplex Virus and Varicella Zoster Virus anterior uveitis

Eye (Lond). 2024 Jan;38(1):61-67. doi: 10.1038/s41433-023-02630-9. Epub 2023 Jul 7.

Authors

Zheng Xian Thng^#¹, Ikhwanuliman Putera^#^{2

3

4}, Ilaria Testi⁵, Kevin Chan⁶, Mark Westcott⁵, Soon-Phaik Chee^{7

8}, Andrew D Dick^{5

9

10}, John H Kempen^{11

12

13

14}, Bahram Bodaghi¹⁵, Jennifer E Thorne^{16

17}, Talin Barisani-Asenbauer¹⁸, Marc D de Smet^{19

20}, Justine R Smith^{21

22}, Peter McCluskey²³, Rina La Distia Nora^{2

3}, Douglas A Jabs^{16

17}, Joke H de Boer²⁴, H Nida Sen²⁵, Debra A Goldstein²⁶, Moncef Khairallah²⁷, Janet L Davis²⁸, James T Rosenbaum^{29

30}, Nicholas P Jones³¹, Quan Dong Nguyen³², Carlos Pavesio^{5

9}, Rupesh Agrawal^{33

34

35

36

37}, Vishali Gupta³⁸; TITAN consensus guidelines group

Collaborators

TITAN consensus guidelines group:
Manfred Zierhut, Joke Boer, Alan Palestine, Alastair K Denniston, Alessandro Invernizzi, Amer Radgonde, Amitabh Kumar, Andre Curi, Aniruddha Agarwal, Anita Chan Sook Yee, Annabelle A Okada, Ariel Schlaen, Arnd Heiligenhaus, Avinash Gurbaxani, S Bala Murugan, Cecilia S Lee, Dipankar Das, Edoardo Baglivo, Ester Carreño, J Fernando Arevalo, Francesco Pichi, Harvey Uy, Hassan A Al-Dhibi, Justus G Garweg, Jyotirmay Biswas, Kalpana Babu Murthy, Laure Caspers, Luca Cimino, Lyndell L Lim, Maite Sainz de la Maza, Mamta Agarwal, Manabu Mochizucki, Manisha Agarwal, Marion R Munk, Massimo Accorinti, Mudit Tyagi, Nisha Acharya, Padmamalini Mahendradas, Parthopratim Dutta Majumder, Philip I Murray, Phoebe Lin, Piergiorgio Neri, Reema Bansal, Russell W Read, Salil Mehta, Samir S Shoughy Shawki, Shahana Mazumdar, Shishir Narain, Sofia Androudi, Somasheila Murthy, S R Rathinam, Stephen Teoh Charn Beng, Sudharshan Sridharan, Sumita Phatak, Christoph Tappeiner, Timothy Y Y Lai, Yew Sen Yuen, Yun Feng

Affiliations

¹ National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore.
² Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Kirana Eye Hospital, Jakarta, Indonesia.
³ Department of Immunology, Erasmus University Medical Center, Rotterdam, The Netherlands.
⁴ Department of Ophthalmology, Erasmus University Medical Center, Rotterdam, The Netherlands.
⁵ National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital, London, UK.
⁶ Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
⁷ Singapore National Eye Centre, Singapore, Singapore.
⁸ Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
⁹ University of Bristol, Bristol, UK.
¹⁰ UCL Institute of Ophthalmology, London, UK.
¹¹ Department of Ophthalmology, Massachusetts Eye and Ear/Harvard Medical School, and Schepens Eye Research Institute, Boston, MA, USA.
¹² Sight for Souls, Fort Myers, FL, USA.
¹³ Department of Ophthalmology, Addis Ababa University, Addis Ababa, Ethiopia.
¹⁴ MyungSung Christian Medical Center (MCM) Eye Unit, MCM General Hospital, and MyungSung Medical School, Addis Ababa, Ethiopia.
¹⁵ Department of Ophthalmology, IHU FOReSIGHT, Sorbonne-APHP, 47-83 bd de l'Hopital, 75013, Paris, France.
¹⁶ Wilmer Eye Institute, Department of Ophthalmology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
¹⁷ Center for Clinical Trials and Evidence Synthesis, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
¹⁸ Institute of Specific Prophylaxis and Tropical Medicine, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria.
¹⁹ Department of Ophthalmology, Leiden University, Leiden, The Netherlands.
²⁰ MIOS sa, Lausanne, Switzerland.
²¹ Flinders University College of Medicine and Public Health, Adelaide, SA, Australia.
²² Queensland Eye Institute, Brisbane, QLD, Australia.
²³ Department of Ophthalmology, Save Sight Institute, The University of Sydney, Sydney, NSW, Australia.
²⁴ Department of Ophthalmology, Utrecht University Medical Center, Utrecht, The Netherlands.
²⁵ National Eye Institute, National Institutes of Health, Bethesda, MD, USA.
²⁶ Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
²⁷ Department of Ophthalmology, Fattouma Bourguiba University Hospital, Monastir, Tunisia.
²⁸ Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.
²⁹ Oregon Health and Science University, Portland, OR, USA.
³⁰ Legacy Devers Eye Institute, Portland, OR, USA.
³¹ School of Biological Sciences, University of Manchester, Manchester, UK.
³² Byers Eye Institute, Stanford Medical School, Stanford, CA, USA.
³³ National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore. rupesh_agrawal@ttsh.com.sg.
³⁴ National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital, London, UK. rupesh_agrawal@ttsh.com.sg.
³⁵ Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore. rupesh_agrawal@ttsh.com.sg.
³⁶ Duke NUS Medical School, Singapore, Singapore. rupesh_agrawal@ttsh.com.sg.
³⁷ Singapore Eye Research Institute, Singapore, Singapore. rupesh_agrawal@ttsh.com.sg.
³⁸ Advanced Eye Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. vishalisara@yahoo.co.in.

^# Contributed equally.

PMID: 37419957
PMCID: PMC10764303 (available on 2025-01-01)
DOI: 10.1038/s41433-023-02630-9

Abstract

Aims: To present current expert practice patterns and to formulate a consensus for the management of HSV and VZV AU by uveitis specialists worldwide.

Methods: A two-round online modified Delphi survey with masking of the study team was conducted. Responses were collected from 76 international uveitis experts from 21 countries. Current practices in the diagnosis and treatment of HSV and VZV AU were identified. A working group (The Infectious Uveitis Treatment Algorithm Network [TITAN]) developed data into consensus guidelines. Consensus is defined as a particular response towards a specific question meeting ≥75% of agreement or IQR ≤ 1 when a Likert scale is used.

Results: Unilaterality, increased intraocular pressure (IOP), decreased corneal sensation and diffuse or sectoral iris atrophy are quite specific for HSV or VZV AU from consensus opinion. Sectoral iris atrophy is characteristic of HSV AU. Treatment initiation is highly variable, but most experts preferred valacyclovir owing to simpler dosing. Topical corticosteroids and beta-blockers should be used if necessary. Resolution of inflammation and normalisation of IOP are clinical endpoints.

Conclusions: Consensus was reached on several aspects of diagnosis, choice of initial treatment, and treatment endpoints for HSV and VZV AU. Treatment duration and management of recurrences varied between experts.

MeSH terms

Atrophy
Herpes Simplex* / diagnosis
Herpes Simplex* / drug therapy
Herpes Zoster Ophthalmicus* / diagnosis
Herpes Zoster Ophthalmicus* / drug therapy
Herpes Zoster*
Herpesvirus 3, Human
Humans
Simplexvirus
Uveitis*
Uveitis, Anterior* / diagnosis
Uveitis, Anterior* / drug therapy