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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 volume 38, pages 61–67 (2024)Cite this article

Subjects

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.

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Fig. 1: Proposed management algorithm for suspected HSV/VZV AU.

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Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author upon reasonable request.

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Funding

HNS’s work is supported by the NIH Intramural Research Program (IRP). The funding organisation had no role in the design or conduct of this research. RA has received NMRC Clinician Scientist Award from National Medical Research Council, Singapore, but the funding organisation has no role in the design or conduct of this research.

Author information

Author notes

  1. These authors contributed equally: Zheng Xian Thng, Ikhwanuliman Putera.

  2. These authors jointly supervised this work: Rupesh Agrawal, Vishali Gupta.

Authors and Affiliations

  1. National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore

    Zheng Xian Thng & Rupesh Agrawal

  2. Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia—Cipto Mangunkusumo Kirana Eye Hospital, Jakarta, Indonesia

    Ikhwanuliman Putera & Rina La Distia Nora

  3. Department of Immunology, Erasmus University Medical Center, Rotterdam, The Netherlands

    Ikhwanuliman Putera & Rina La Distia Nora

  4. Department of Ophthalmology, Erasmus University Medical Center, Rotterdam, The Netherlands

    Ikhwanuliman Putera

  5. National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital, London, UK

    Ilaria Testi, Mark Westcott, Andrew D. Dick, Carlos Pavesio & Rupesh Agrawal

  6. Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore

    Kevin Chan & Rupesh Agrawal

  7. Singapore National Eye Centre, Singapore, Singapore

    Soon-Phaik Chee

  8. Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

    Soon-Phaik Chee

  9. University of Bristol, Bristol, UK

    Andrew D. Dick & Carlos Pavesio

  10. UCL Institute of Ophthalmology, London, UK

    Andrew D. Dick

  11. Department of Ophthalmology, Massachusetts Eye and Ear/Harvard Medical School, and Schepens Eye Research Institute, Boston, MA, USA

    John H. Kempen

  12. Sight for Souls, Fort Myers, FL, USA

    John H. Kempen

  13. Department of Ophthalmology, Addis Ababa University, Addis Ababa, Ethiopia

    John H. Kempen

  14. MyungSung Christian Medical Center (MCM) Eye Unit, MCM General Hospital, and MyungSung Medical School, Addis Ababa, Ethiopia

    John H. Kempen

  15. Department of Ophthalmology, IHU FOReSIGHT, Sorbonne-APHP, 47-83 bd de l’Hopital, 75013, Paris, France

    Bahram Bodaghi

  16. Wilmer Eye Institute, Department of Ophthalmology, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Jennifer E. Thorne & Douglas A. Jabs

  17. Center for Clinical Trials and Evidence Synthesis, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Jennifer E. Thorne & Douglas A. Jabs

  18. Institute of Specific Prophylaxis and Tropical Medicine, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria

    Talin Barisani-Asenbauer

  19. Department of Ophthalmology, Leiden University, Leiden, The Netherlands

    Marc D. de Smet

  20. MIOS sa, Lausanne, Switzerland

    Marc D. de Smet

  21. Flinders University College of Medicine and Public Health, Adelaide, SA, Australia

    Justine R. Smith

  22. Queensland Eye Institute, Brisbane, QLD, Australia

    Justine R. Smith

  23. Department of Ophthalmology, Save Sight Institute, The University of Sydney, Sydney, NSW, Australia

    Peter McCluskey

  24. Department of Ophthalmology, Utrecht University Medical Center, Utrecht, The Netherlands

    Joke H. de Boer

  25. National Eye Institute, National Institutes of Health, Bethesda, MD, USA

    H. Nida Sen

  26. Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

    Debra A. Goldstein

  27. Department of Ophthalmology, Fattouma Bourguiba University Hospital, Monastir, Tunisia

    Moncef Khairallah

  28. Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA

    Janet L. Davis

  29. Oregon Health and Science University, Portland, OR, USA

    James T. Rosenbaum

  30. Legacy Devers Eye Institute, Portland, OR, USA

    James T. Rosenbaum

  31. School of Biological Sciences, University of Manchester, Manchester, UK

    Nicholas P. Jones

  32. Byers Eye Institute, Stanford Medical School, Stanford, CA, USA

    Quan Dong Nguyen

  33. Duke NUS Medical School, Singapore, Singapore

    Rupesh Agrawal

  34. Singapore Eye Research Institute, Singapore, Singapore

    Rupesh Agrawal

  35. Advanced Eye Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

    Vishali Gupta

Authors
  1. Zheng Xian Thng
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  2. Ikhwanuliman Putera
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  3. Ilaria Testi
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  4. Kevin Chan
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  5. Mark Westcott
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  6. Soon-Phaik Chee
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  7. Andrew D. Dick
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  8. John H. Kempen
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  9. Bahram Bodaghi
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  10. Jennifer E. Thorne
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  11. Talin Barisani-Asenbauer
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  12. Marc D. de Smet
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  13. Justine R. Smith
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  14. Peter McCluskey
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  15. Rina La Distia Nora
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  16. Douglas A. Jabs
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  17. Joke H. de Boer
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  18. H. Nida Sen
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  19. Debra A. Goldstein
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  21. Janet L. Davis
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  24. Quan Dong Nguyen
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  26. Rupesh Agrawal
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  27. Vishali Gupta
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Consortia

on behalf of TITAN consensus guidelines group

  • Zheng Xian Thng
  • , Ikhwanuliman Putera
  • , Rupesh Agrawal
  • , Ilaria Testi
  • , Mark Westcott
  • , Soon-Phaik Chee
  • , Andrew D. Dick
  • , John H. Kempen
  • , Manfred Zierhut
  • , 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 Boer
  • , H. Nida Sen
  • , Debra A. Goldstein
  • , Moncef Khairallah
  • , Janet L. Davis
  • , Quan Dong Nguyen
  • , Carlos Pavesio
  • , Vishali Gupta
  • , 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
  • , James T. Rosenbaum
  • , 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
  • , Nicholas P. Jones
  • , 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

Contributions

All authors contributed to the intellectual development of this paper. RA and VG conceived and planned the study. ZXT and IP wrote the first draft of the paper. ZXT, IP, IT, and KC performed the literature review. ZXT, IP, IT, KC, MW, SPC, ADD, JHK, BB, JET, TBA, MDdS, JRS, PM, RLDN, DAJ, JHdB, HNS, DAG, MK, JLD, JTR, NPJ, QDN, CP, RA, and VG contributed to interpreting the results and provided critical feedback to the paper. The final version of the paper has been seen and approved by all authors.

Corresponding authors

Correspondence to Rupesh Agrawal or Vishali Gupta.

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Thng, Z.X., Putera, I., Testi, I. et al. 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 38, 61–67 (2024). https://doi.org/10.1038/s41433-023-02630-9

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  • DOI: https://doi.org/10.1038/s41433-023-02630-9

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