When HIV Immunodeficiency and Heterochromia Confuse the Issue: Recurrent Zoster Uveitis Mistaken for Fuchs’ Uveitis


Purpose: We report a case with iris heterochromia misdiagnosed as Fuchs’ uveitis which finally turned out to be a unilateral zoster uveitis in an HIV-positive patient.

Case Report: A 45-year old patient was seen for a recurrent right anterior uveitis treated with prednisolone 1% drops BID. The iris of the right eye was hypochromic and atrophic and several small granulomatous keratic precipitates (KPs) were present. After discontinuation of corticosteroid drops, severe uveitis developed with mutton-fat KPs, and laser flare photometry (LFP) increased from 20 to 50.3 ph/ms. He had presented with right zoster ophthalmicus two years earlier and HIV-serology revealed to be positive.

Conclusion: Iris heterochromia is not a good disease-defining criterion for Fuch’s uveitis even when typical KPs are present and can lead to misdiagnosis. More reliable criteria including stellate KPs, low LFP values, absence of synechiae, vitreitis, and disc hyperfluorescence, all absent in this case, should be sought to confirm or exclude the diagnosis.


Herpes Zoster Uveitis, Heterochromia, HIV

1. Fuchs E. Ueber komplikationen der heterochromie. Z Augenheilkd 1906;15:191–212.

2. Herbort CP, Khairallah M. Editorial: fuchs uveitis: from Imperial Vienna to global appraisal. Int Ophthalmol 2010;30:449–452.

3. Higuchi M, Ohno S, Matsuda H. Clinical characteristics of Fuchs’ heterochromic iridocyclitis. Rinsho Ganka 1982;36:1275–1280.

4. Bouchenaki N, Herbort CP. Fuchs’ uveitis: failure to associate vitritis and disc hyperfluorescence with the disease is the major factor for misdiagnosis and diagnostic delay. Middle East Afr J Ophthalmol 2009;16:239–244.

5. Guex-Crosier Y, Pittet N, Herbort CP. Evaluation of laser flare photometry in the appraisal and management of intraocular inflammation in uveitis. Ophthalmology 1994;101:728–735.

6. Bouchenaki N, Herbort CP. Fluorescein angiographic findings and clinical features in Fuchs’ uveitis. Int Ophthalmol 2010;30:511–519.

7. Tugal-Tutkun I, Güney-Tefekli E, Kamaci-Duman F, Corum I. A cross-sectional and longitudinal study of Fuchs’ uveitis syndrome in Turkish patients. Am J Ophthalmol 2009;148:510–515.

8. Hedayatfar A, Chee SP. Posner Schlossman syndrome associated with cytomegalovirus infection: a case series from a non-endemic area. Int Ophthalmol 2014;34:1123– 1129.

9. Shantha JG, Crozier I, Varkey JD, et al. Long-term management of panuveitis and iris heterochromia in an Ebola survivor. Ophthalmology 2016;123:2626–2628.

10. Wensing B, Relvas LM, Caspers LE, Vidovic Valentincic N, Stunf S, Groot-Mijnes JDF, et al. Comparison of Rubella virus and Herpes virus-associated anterior uveitis. Ophthalmology 2011;118:1905–1910.

11. Nanditha NGA, St-Jean M, Tafessu H, Guillemi SA, Hull MW, Lu M, et al. Missed opportunities for earlier diagnosis of HIV in British Columbia, Canada: e retrospective cohort study. PLoS ONE 2019;14:e0214012.

12. Van den Bogaart L, Ranzani A, Oreni L, Giacomelli A, Corbellino M, Rusconi S, et al. Overlooked cases of HIV infection: an Italian tale of missed diagnostic opportunities. Eur J Intern Med 2020;73:30–35.

13. Mwanza JC, Kayembe DL. Uveitis in HIV-infected patients. Eur J Opthalmol 2001;11:53–56.

14. Biswas J, Sudharshan S. Anterior segment manifestations of human immunodeficiency virus/acquired immune deficiency syndrome. Indian J Ophthalmol 2008;56:363– 375.

15. Martinez E, Gatell J, Moran Y, Aznar E, Buira E, Guelar A, et al. High incidence of herpes zoster in patients with AIDS soon after therapy with protease inhibitors. Clin Infect Dis 1998;27:1510–1513.