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HSV Keratitis and Herpes Zoster
Ophthalmicus
Presenter : Dr.Rasika Thakur
Moderator : Dr. Vishram Sangit
Case presentation
HSV keratitis
Introduction
Pathology and Clinical features
Treatment
Herpes zoster ophthalmicus
I...
Case scenario 1
 Mr X, 24/M
Came to us on 29/12/2011 with c/o redness and
watering of RE since 2 months
BCVA-RE:FC1/2 m...
29/12/2011
2/1/2012
5/1/2012 13/1/2012
27/1/2012 1/3/2012
13/9/2012
26/10/2012
30/11/2012
Case scenario ii
Patient Mr.XYZ, 65/M
C/o redness and watering since 7 days
18/3/2014
Fortified cefazolin half hourly
Ciplox eyedrop half hourly
Atropin eyedrop TDS
21/3/2014
28/3/2014
2/4/2014
Impression -HSV keratitis with bacterial keratitis
21/4/2014
Mixed corneal ulcer
Introduction
Herpes simplex is the leading cause of infectious corneal
blindness*
While not all humans manifest herpes i...
Herpes simplex virus
Life cycle of HSV
Primary HSV infection
Blepharoconjunctivitis
Follicular conjunctivitis
Lid vesicles and conjunctival dendrites
Kaposi’...
Clinical Importance
Human herpesviruses have in common a state called
“latency” where the virus remains dormant in cells ...
Recurrent HSV Infections
Multiple factors are thought to cause recurrence including
fever, sunlight, irradiation, menses,...
Epithelial Keratitis
 Symptoms
FB sensation
photophobia
Redness
Blurred vision
Clinical features
Punctate epithelia...
Epithelial Keratitis
Dendritic ulcer
Geographic ulcer
Marginal keratitis
Metaherpetic (trophic) ulcer
Dendritic ulcer
Classic herpetic lesion
The borders are slightly raised,grayish, and stain with rose
bengal as they cons...
Geographic ulcer
Immunocompromised, on topical steroids, or have
longstanding, untreated ulcers*
Dichotomous branching a...
Marginal keratitis
Located near the limbus
The presence of an epithelial defect and lack of corneal
sensation can aid in...
Treatment
Indications- ulcers larger than 4 mm, marginal ulcers, and
ulcers with underlying stromal inflammation
Topical...
Metaherpetic (trophic) ulcer
Trophic ulcer,if it arises de novo or a metaherpetic ulcer if
it follows a dendrite or geogr...
Treatment
Stop toxic medications
Tear film supplementation
Bandage contact lenses
Amniotic membrane
The cautious use ...
Stromal/Endothelial Keratitis
It is an immune-mediated response to nonreplicating viral
particles
All layers of the corn...
Stromal/Endothelial Keratitis
Endotheliitis
Necrotizing keratitis
Immune stromal keratitis
Keratouveitis
Endotheliitis
Manifests as overlying stromal edema from endothelial
dysfunction
Longstanding stromal edema leads to perm...
Endotheliitis
Localized endotheliitis
Disc-shaped area of
corneal edema so called
disciform keratitis
There is minimal
...
Necrotizing keratitis
Inflammation in the cornea is due to a reaction to live
viral particles in the corneal stroma
Corn...
Necrotizing keratitis
Immune stromal keratitis
Manifests as focal, multifocal, or diffuse stromal opacities
or an immune ring
Stromal edema an...
Keratouveitis
Uveitis is usually granulomatous with large “mutton-fat”
keratic precipitates on the endothelium
It can le...
Treatment
The mainstay of treatment is topical steroids as they
decrease inflammation and therefore scarring
 Oral antiv...
Diagnosis
Diagnostic testing is seldom needed in epithelial HSVK
because of its classic clinical features and is not usef...
Diagnosis
Culture
DNA Testing
 Fluorescent Antibody Testing
Tzanck Smear
 Serum Antibody Testing
HERPETIC EYE DISEASE STUDY (HEDS)
To assess the effect of adding steroids and acyclovir to
conventional therapy with trif...
HEDS
Herpes Stromal Keratitis, Not on Steroids Trial
Compared with the placebo group, patients who received
prednisolone...
HEDS
Herpes Stromal Keratitis, on Steroid Treatment
There was no apparent benefit to adding oral acyclovir to
topical co...
HEDS
Herpes Simplex Virus Iridocyclitis, Receiving Topical
Steroids
The trial was stopped because of slow recruitment, b...
HEDS
Herpes Simplex Virus Epithelial Keratitis Trial
In the treatment of acute HSV epithelial keratitis with
TFT, the ad...
HEDS
Acyclovir Prevention Trial
Oral acyclovir reduced the risk of any form of recurrent
ocular herpes by 41% and stroma...
HEDS
Ocular HSV Recurrence Factor Study
No association was found between psychological or other
forms of stress and HSV ...
Limitations:
Many of the trials had inadequate recruitment or high
dropout rate
Oral acyclovir in the prevention trials ...
Current antivirals
Treatment
Steroids
1% prednisolone acetate or 0.1% dexamethasone is used
Surgery
Penetrating keratoplasty (PKP)
Conju...
FUTURE DIRECTIONS
Heat shock and glycoprotein subunit vaccines have shown
some promise in clinical trials in decreasing t...
Herpes zoster ophthalmicus
Introduction
Recurrent infection of varicella (chickenpox) in the
ophthalmic division of the trigeminal dermatome most
fr...
Epidemiology and clinical Importance
Herpes zoster is a neurocutaneous disease caused by the
human herpes virus 3
Member...
Pathogenesis
In temperate climates,primary infection occurs before the
age of 10, manifests as chickenpox (varicella)
Th...
Pathogenesis
Begins with a prodrome of influenza-like illness -fatigue,
malaise, nausea and mild fever accompanied by
pro...
Clinical manifestations
Clinical manifestations
Eyelids
Periorbital edema, pain, and hyperesthesia of the eyelid
skin
Secondary bacterial infec...
Clinical manifestations
Conjunctiva
papillary, pseudomembranous,
membranous, or follicular reaction
Episclera/Sclera
H...
Clinical manifestations
Cornea
Herpes zoster corneal disease can result in significant
vision loss.
Five basic clinical...
Clinical manifestations
Uveitis-
 Nongranulomatous or granulomatous iridocyclitis
(anterior uveitis) with keratic precip...
Clinical manifestations
Anterior Chamber Angle and Glaucoma
Plugging of the trabecular meshwork due to the
presence of c...
Clinical manifestations
Pupil
Horner’s syndrome
A tonic pupil secondary to herpes zoster ciliary
ganglionitis
Optic Ne...
Clinical manifestations
Vitreous-Vitreous opacities, vitritis, and vitreous
hemorrhage
Retina –
Retinal hemorrhages
Re...
Clinical manifestations
Extraocular Muscles
Ophthalmoplegia 11–31%
Affect cranial nerves three, four, and six
Can also...
Clinical manifestations
Postherpetic Neuralgia
Pain that continues following rash healing
Pain has three phases:
 Acut...
Herpes zoster ophthalmicus in acquired
imune deficiency syndrone (AIDS)
HZO is an important early clinical marker for AID...
Herpes zoster ophthalmicus in acquired
imune deficiency syndrome(AIDS)
Progressive outer retinal necrosis a distinct form...
Diagnosis
The diagnosis of herpes zoster disease is based on clinical
findings
Direct detection of the virus and indirec...
Management
Systemic medication-
Oral acyclovir (800 mg, five times daily) for 7–10 days
Famciclovir (500 mg three times...
Management of Ocular Manifestation
Palliative therapy including Burow’s solution, cool
compresses, mechanical cleansing o...
Management of Ocular Manifestation
Tarsorrhaphy, conjunctival flap, or autologous
conjunctival transplantation
Steroids ...
Management of Ocular Manifestation
Herpes zoster retinitis, optic neuritis, chorioretinitis,
acute retinal necrosis syndr...
Postherpetic Neuralgia treatment
Analgesics
Antidepressants (amitriptyline, desipramine,
clomipramine), carbamazepine, a...
Postherpetic Neuralgia treatment
Amitriptyline for 90 days reduced the incidence of pain at
6 months.
Trial of percutane...
Clinical pattern of Herpes simplex
keratitis: A case series
Dr Vishram Sangit1
Dr Suhas Haldipurkar1
,
Dr Maninder Setia1
...
Purpose
To study the clinicoepidemiological pattern of Herpes
simplex keratitis in a tertiary eye hospital in western
Mah...
Results
41 eyes of 40 patients identified
All diagnoses – clinical
Mean age - 44.4 +/- 18.54 years
M:F – 27:13
Past h...
Clinical form of HSV Keratitis
Treatment protocols
Epithelial disease- Acyclovir ointment 5 times a day for 3
weeks
Stromal disease- Acyclovir ointment...
Treatment outcomes
All cases resolved on medical therapy
Mean duration to resolution for entire group was 34.18
+/- 15.8...
Mean time to resolution in various
forms of HSV keratitis ( days)
Recurrence pattern
Primary clinical form developing
recurrence during treatment
Clinical form of recurrence in HSV
keratit...
Conclusions
Stromal form of HSV keratitis is the commonest presentation in our
series followed by mixed variety
HSV kera...
Thank you
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Herpes simplex keratitis & herpes zoster opthalmicus

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Herpes simplex keratitis & herpes zoster opthalmicus

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  • Vision-re-fc1/2 m,n 36
  • Congestion,geographic ulcer,deep to mid stromal infiltrates
    We diagnosed him as HSV keratits and started him on
    Acivir e/o 5 times,chlorocol e/d ,refresh tears eye drops
  • Pred forte eye drop 8 times a day
  • Infiltrate decreased,vascularization decreased,congestion decreased
    Occa cells
  • No blepharospasm,congestion resolved,scaring started,minimal activity,differential thinning
    Stop acivir and chlorocol
    Vision 6/18p,n8 (-3.50/-6.00*70)
    1/3/3012-resolved keratitis,sec calcareous degeneration
  • c/o blurring with glassed and watering
    Re-activity at the edges seen,nummulae +,started on predforte
  • Mild congestion
  • Resolution of vessels and calcareous deposits
    Cnac eyedrop re—6.25/-4.50*105-6/12
  • BCVA
    RE-6/18,n18
    LE-PL+
    h/o DM 3-4 YRS
  • MEIBOMITIS,CORNEAL ULCER,congestion+,traces of hypopyon,SCRAPING WAS DONE-GRAM positive cocci in pairs were +
  • Hypopyon resolved,congestion decreased
  • REDNESS WATERNING and pain,
    Virson gel e/o 5 times, fortified cefazolin ciplox 2 hrly atropin tid
  • Congestion +infiltration has decresed,hypopyon resolved
    Predforte eye drops 6 times
    HSV keratitis with bacterial keratitis
  • No blepharospasm,congestion decreased,corneal infiltration markedly decreased,thining stable
  • Three subfamilies:
    Alphaherpesviruses - HSV-1, HSV-2, VZV
    Betaherpesviruses - CMV, HHV-6, HHV-7
    Gammaherpesviruses - EBV, HHV-8
  • HSV is a large double-stranded DNA virus that has an icosahedral capsid. This is surrounded by a poorly defined tegument enclosed in a host cell membrane-derived envelope with viral-derived glycoprotein projections
  • Keratitis caused by HSV is the most common cause of cornea-derived blindness in developed nations
  • Transcript of "Herpes simplex keratitis & herpes zoster opthalmicus"

    1. 1. HSV Keratitis and Herpes Zoster Ophthalmicus Presenter : Dr.Rasika Thakur Moderator : Dr. Vishram Sangit
    2. 2. Case presentation HSV keratitis Introduction Pathology and Clinical features Treatment Herpes zoster ophthalmicus Introduction Pathology and Clinical features Treatment Clinical pattern of Herpes simplex keratitis: A case series
    3. 3. Case scenario 1  Mr X, 24/M Came to us on 29/12/2011 with c/o redness and watering of RE since 2 months BCVA-RE:FC1/2 m,N36,LE:6/6,N6 Patient had taken treatment elsewhere ,but found no relief with Eye drop tobramycin Eye drop moxifloxacin and ketorolac Eye ointment neosporin • Recurrent attack of HSV keratitis
    4. 4. 29/12/2011
    5. 5. 2/1/2012
    6. 6. 5/1/2012 13/1/2012
    7. 7. 27/1/2012 1/3/2012
    8. 8. 13/9/2012
    9. 9. 26/10/2012
    10. 10. 30/11/2012
    11. 11. Case scenario ii Patient Mr.XYZ, 65/M C/o redness and watering since 7 days
    12. 12. 18/3/2014 Fortified cefazolin half hourly Ciplox eyedrop half hourly Atropin eyedrop TDS
    13. 13. 21/3/2014
    14. 14. 28/3/2014
    15. 15. 2/4/2014 Impression -HSV keratitis with bacterial keratitis
    16. 16. 21/4/2014
    17. 17. Mixed corneal ulcer
    18. 18. Introduction Herpes simplex is the leading cause of infectious corneal blindness* While not all humans manifest herpes infection, more than 90% carry the latent virus HSV keratitis is Herpes simplex viral infection of the cornea *Liedtke W., Opalka B., Zimmermann C.W., Lignitz E.: Age distribution of latent herpes simplex virus 1 and varicella-zoster virus genome in human nervous tissue. J Neurol Sci 1993; 116:6-11
    19. 19. Herpes simplex virus
    20. 20. Life cycle of HSV
    21. 21. Primary HSV infection Blepharoconjunctivitis Follicular conjunctivitis Lid vesicles and conjunctival dendrites Kaposi’s varicelliform eruption Severe morbidity -multi-system failure or bacterial superinfection Darougar S., Hunter P.A., Viswalingam M., et al: Acute follicular conjunctivitis and keratoconjunctivitis due to herpes simplex virus in London. Br J Ophthalmol 1978; 62:843-849
    22. 22. Clinical Importance Human herpesviruses have in common a state called “latency” where the virus remains dormant in cells and periodically reactivates Herpes simplex viruses 1 and 2 (HSV-1 and HSV-2) have an affinity for the sensory ganglion cells and are therefore called neurotrophic viruses
    23. 23. Recurrent HSV Infections Multiple factors are thought to cause recurrence including fever, sunlight, irradiation, menses, and emotional stress Recurrent disease most commonly causes keratitis HSVK is broadly classified into epithelial and stromal/endothelial keratitis
    24. 24. Epithelial Keratitis  Symptoms FB sensation photophobia Redness Blurred vision Clinical features Punctate epithelial keratitis Classic arborizing dendritic epithelial ulcers with terminal bulbs Geographic epithelial ulcer Ciliary flush & conjunctival injection
    25. 25. Epithelial Keratitis Dendritic ulcer Geographic ulcer Marginal keratitis Metaherpetic (trophic) ulcer
    26. 26. Dendritic ulcer Classic herpetic lesion The borders are slightly raised,grayish, and stain with rose bengal as they consist of infected cells that have undergone acantholysis On resolution, a dendrite-shaped scar, called a ghost dendrite, may remain in the superficial stroma
    27. 27. Geographic ulcer Immunocompromised, on topical steroids, or have longstanding, untreated ulcers* Dichotomous branching and terminal bulbs are seen at the periphery *Wilhelmus K.R., Coster D.J., Donovan H.C., et al: Prognosis indicators of herpetic keratitis. Analysis of a five-year observation period after corneal ulceration. Arch Ophthalmol 1981; 99:1578-
    28. 28. Marginal keratitis Located near the limbus The presence of an epithelial defect and lack of corneal sensation can aid in diagnosis Significant stromal inflammation They are more resistant to treatment and frequently become trophic ulcers* *Thygeson P.: Marginal herpes simplex keratitis simulating marginal catarrhal ulcer. Invest Ophthalmol 1971; 10:1006
    29. 29. Treatment Indications- ulcers larger than 4 mm, marginal ulcers, and ulcers with underlying stromal inflammation Topical antivirals Gentle wiping débridement is a very good adjunct therapy as infected cells are acantholytic and are poorly adherent Wilhelmus K.R.: The treatment of herpes simplex virus epithelial keratitis. Trans Am Ophthalmol Soc 2000; 98:505-532
    30. 30. Metaherpetic (trophic) ulcer Trophic ulcer,if it arises de novo or a metaherpetic ulcer if it follows a dendrite or geographic ulcer Causes- Toxicity from antiviral medications Lack of neural-derived growth factors Poor tear surfacing Low-grade stromal inflammation Neurotrophic ulcers start as roughened epithelium, which then breaks down to produce an epithelial defect with smooth margins
    31. 31. Treatment Stop toxic medications Tear film supplementation Bandage contact lenses Amniotic membrane The cautious use of topical steroids may be necessary if there is significant underlying inflammation
    32. 32. Stromal/Endothelial Keratitis It is an immune-mediated response to nonreplicating viral particles All layers of the cornea are affected and may involve the trabecular meshwork and iris It is classified based on the predominant site and type of involvement
    33. 33. Stromal/Endothelial Keratitis Endotheliitis Necrotizing keratitis Immune stromal keratitis Keratouveitis
    34. 34. Endotheliitis Manifests as overlying stromal edema from endothelial dysfunction Longstanding stromal edema leads to permanent scarring and is the major cause of decreased vision associated with HSVK
    35. 35. Endotheliitis Localized endotheliitis Disc-shaped area of corneal edema so called disciform keratitis There is minimal stromal inflammation and no epithelial involvement Diffuse and linear endotheliitis Accompanied by trabeculitis with a resulting elevated intraocular pressure Pseudo-guttae and Descemet’s folds
    36. 36. Necrotizing keratitis Inflammation in the cornea is due to a reaction to live viral particles in the corneal stroma Corneal melting and perforation Associated with uveitis and trabeculitis that may lead to recalcitrant glaucoma
    37. 37. Necrotizing keratitis
    38. 38. Immune stromal keratitis Manifests as focal, multifocal, or diffuse stromal opacities or an immune ring Stromal edema and a mild anterior chamber reaction It is called interstitial keratitis (IK) if accompanied by vascularization
    39. 39. Keratouveitis Uveitis is usually granulomatous with large “mutton-fat” keratic precipitates on the endothelium It can lead to significant morbidity from synechiae, cataracts, and glaucoma Unilateral uveitis associated with high intraocular pressure is almost always caused by HSV
    40. 40. Treatment The mainstay of treatment is topical steroids as they decrease inflammation and therefore scarring  Oral antivirals Topical antivirals Aggressive topical and systemic antivirals along with steroids are necessary in necrotizing keratitis and focal serous iritis
    41. 41. Diagnosis Diagnostic testing is seldom needed in epithelial HSVK because of its classic clinical features and is not useful in stromal keratitis as there is usually no live virus present
    42. 42. Diagnosis Culture DNA Testing  Fluorescent Antibody Testing Tzanck Smear  Serum Antibody Testing
    43. 43. HERPETIC EYE DISEASE STUDY (HEDS) To assess the effect of adding steroids and acyclovir to conventional therapy with trifluridine (TFT) It was a prospective  Randomized Double-masked Placebo-controlled Multi-center study Divided into six trials: three therapeutic, two preventive, and one cohort
    44. 44. HEDS Herpes Stromal Keratitis, Not on Steroids Trial Compared with the placebo group, patients who received prednisolone phosphate drops had faster resolution and fewer treatment failures Wilhelmus K.R., Gee L., Hauck W.W., et al: Herpetic Eye Disease Study. A controlled trial of topical corticosteroids for herpes simplex stromal keratitis. Ophthalmology 1994; 101:1883- 1895
    45. 45. HEDS Herpes Stromal Keratitis, on Steroid Treatment There was no apparent benefit to adding oral acyclovir to topical corticosteroids and TFT. However, visual acuity improved over 6 months in more patients in the acyclovir group than in the placebo group Barron B.A., Gee L., Hauck W.W., et al: Herpetic Eye Disease Study. A controlled trial of oral acyclovir for herpes simplex stromal keratitis. Ophthalmology 1994; 101:1871-1882
    46. 46. HEDS Herpes Simplex Virus Iridocyclitis, Receiving Topical Steroids The trial was stopped because of slow recruitment, but treatment failures occurred at a higher rate in the placebo group than in the acyclovir group, indicating a potential benefit to adding oral acyclovir to the regimen of a topical steroid and an antiviral A controlled trial of oral acyclovir for iridocyclitis caused by herpes simplex virus. The Herpetic Eye Disease Study Group. Arch Ophthalmol 1996; 114:1065-1072
    47. 47. HEDS Herpes Simplex Virus Epithelial Keratitis Trial In the treatment of acute HSV epithelial keratitis with TFT, the addition of oral acyclovir offered no additional benefit in preventing subsequent stromal keratitis or iritis
    48. 48. HEDS Acyclovir Prevention Trial Oral acyclovir reduced the risk of any form of recurrent ocular herpes by 41% and stromal keratitis by 50%. The risk of multiple recurrences decreased from 9% to 4% Although there was no rebound increase in keratitis after discontinuation of the acyclovir, the protection did not persist once the acyclovir was discontinued Oral acyclovir for herpes simplex virus eye disease: effect on prevention of epithelial keratitis and stromal keratitis. Herpetic Eye Disease Study Group. Arch Ophthalmol 2000; 118:1030-1036
    49. 49. HEDS Ocular HSV Recurrence Factor Study No association was found between psychological or other forms of stress and HSV recurrences Previous episodes of epithelial keratitis were not a predictor for future occurrences while previous, especially multiple, episodes of stromal keratitis markedly increased the probability of subsequent stromal keratitis Oral acyclovir for herpes simplex virus eye disease: effect on prevention of epithelial keratitis and stromal keratitis. Herpetic Eye Disease Study Group. Arch Ophthalmol 2000; 118:1030-1036
    50. 50. Limitations: Many of the trials had inadequate recruitment or high dropout rate Oral acyclovir in the prevention trials was only used for 3 weeks The steroid regimen was standardized and not tailored to inflammation TFT was used in both the study and placebo groups in all the therapeutic trials
    51. 51. Current antivirals
    52. 52. Treatment Steroids 1% prednisolone acetate or 0.1% dexamethasone is used Surgery Penetrating keratoplasty (PKP) Conjunctival flap Amniotic membrane (AMT)
    53. 53. FUTURE DIRECTIONS Heat shock and glycoprotein subunit vaccines have shown some promise in clinical trials in decreasing the number and severity of recurrences of HSVK while newer medications such as topical ganciclovir and cidofovir may prove to be more effective and cause less toxicity compared to current therapy* Although monotherapy with interferon has not been found to be effective, it increases the efficacy of acyclovir and ganciclovir when given in combination** *Colin J., Hoh H.B., Easty D.L., et al: Ganciclovir ophthalmic gel (Virgan; 0.15%) in the treatment of herpes simplex keratitis. Cornea 1997; 16:393-399 **Wilhelmus K.R.: The treatment of herpes simplex virus epithelial keratitis. Trans Am Ophthalmol Soc 2000; 98:505-532
    54. 54. Herpes zoster ophthalmicus
    55. 55. Introduction Recurrent infection of varicella (chickenpox) in the ophthalmic division of the trigeminal dermatome most frequently affecting the nasociliary branch
    56. 56. Epidemiology and clinical Importance Herpes zoster is a neurocutaneous disease caused by the human herpes virus 3 Member of the herpes virus family (Herpesviridae) and exclusively infects human or simian cells The lifetime risk is 20–30%, and 50% of those living until 85 years of age will be affected* Physical trauma and surgery have been correlated with the development of zoster** *Donahue J.G., Choo P.W., Manson J.E., Platt R.: The incidence of herpes zoster. Arch Intern Med 1995; 155:1605-1609 **Evans R.W., Lee A.G.: Herpes zoster ophthalmicus, ophthalmoplegia and trauma. Headache 2004; 44:286-288
    57. 57. Pathogenesis In temperate climates,primary infection occurs before the age of 10, manifests as chickenpox (varicella) The virus then establishes a latent state in the sensory ganglia When there is diminished virus-specific and cell-mediated immunity, the virus may reactivate and spread to the corresponding dermatome along a spinal or cranial nerve to generate the characteristic unilateral vesicular exanthema
    58. 58. Pathogenesis Begins with a prodrome of influenza-like illness -fatigue, malaise, nausea and mild fever accompanied by progressive pain and skin hyperesthesia A diffuse erythematous or maculopapular rash then appears over a single dermatome 3–5 days later These eruptions progress to form clusters of papules and clear vesicles, which then evolve through stages of pustulation and crusting
    59. 59. Clinical manifestations
    60. 60. Clinical manifestations Eyelids Periorbital edema, pain, and hyperesthesia of the eyelid skin Secondary bacterial infection may occur following dermal involvement* Complications- scarring, cicatricial ectropion or entropion, trichiasis, madarosis, poliosis, or even frank loss of eyelid tissue *Weiss R.: Herpes zoster following spinal surgery. Clin Exp Dermatol 1989; 14:56-57
    61. 61. Clinical manifestations Conjunctiva papillary, pseudomembranous, membranous, or follicular reaction Episclera/Sclera HZV episcleritis and scleritis may be either localized or diffuse
    62. 62. Clinical manifestations Cornea Herpes zoster corneal disease can result in significant vision loss. Five basic clinical forms:  Epithelial keratitis (acute or chronic)  Nummular stromal keratitis  Disciform keratitis  Limbal vascular keratitis  Neurotrophic keratitis, with or without corneal perforation
    63. 63. Clinical manifestations Uveitis-  Nongranulomatous or granulomatous iridocyclitis (anterior uveitis) with keratic precipitates and posterior synechiae Lens -Posterior subcapsular cataracts
    64. 64. Clinical manifestations Anterior Chamber Angle and Glaucoma Plugging of the trabecular meshwork due to the presence of cellular debris, iris pigment, or hyphema Pupillary-block glaucoma secondary to posterior synechiae, with resultant iris bombe Peripheral anterior synechiae Chronic open-angle glaucoma-due to damage to the trabecular meshwork Chang S.D., De Luise V.P.: In: Tasman W., Jaeger E.A., ed. Duane’s ophthalmology, Vol, 4. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.ch 20 (CD-ROM)
    65. 65. Clinical manifestations Pupil Horner’s syndrome A tonic pupil secondary to herpes zoster ciliary ganglionitis Optic Nerve Neuroretinitis, retrobulbar neuritis, or an ischemic optic neuropathy Herpes zoster optic neuritis may result from local transmission of the virus within the orbit from the fifth to the second cranial nerve
    66. 66. Clinical manifestations Vitreous-Vitreous opacities, vitritis, and vitreous hemorrhage Retina – Retinal hemorrhages Retinal thrombophlebitis Branch or central retinal artery occlusion Retinal arteritis Necrotizing retinopathy, necrotizing retinitis Exudative or rhegmatogenous retinal detachment  Ischemic perivasculitis
    67. 67. Clinical manifestations Extraocular Muscles Ophthalmoplegia 11–31% Affect cranial nerves three, four, and six Can also manifest as a myositis that may also lead to ophthalmoplegia
    68. 68. Clinical manifestations Postherpetic Neuralgia Pain that continues following rash healing Pain has three phases:  Acute pain occurring within 30 days after rash onset  Subacute herpetic neuralgia that persists beyond the acute phase but resolves before 120 days  Chronic PHN that persists 120 days or more after rash onset
    69. 69. Herpes zoster ophthalmicus in acquired imune deficiency syndrone (AIDS) HZO is an important early clinical marker for AIDS, especially in high-risk younger patients Higher incidence, greater severity, and prolonged course of corneal and uveitic involvement, as well as postherpetic neuralgia Treatment -prolonged treatment course of intravenous acyclovir
    70. 70. Herpes zoster ophthalmicus in acquired imune deficiency syndrome(AIDS) Progressive outer retinal necrosis a distinct form of necrotizing herpetic retinopathy Characterized by multifocal, deep retinal lesions that rapidly progress to confluence with minimal or no intraocular inflammation, an absence of vascular inflammation, and perivenular clearing of retinal opacification
    71. 71. Diagnosis The diagnosis of herpes zoster disease is based on clinical findings Direct detection of the virus and indirect serological detection of specific antibodies Cytologic examination of cutaneous vesicular scrapings reveals multiple eosinophilic intranuclear inclusions (Lipschutz bodies) and multinucleated giant cells (Tzanck preparation) Electron microscopy VZV-DNA can also be directly detected in clinical specimens using real-time PCR
    72. 72. Management Systemic medication- Oral acyclovir (800 mg, five times daily) for 7–10 days Famciclovir (500 mg three times daily for 7 days) Valacyclovir (1000 mg three times daily) Cobo L.M., Foulks G.N., Liesegang T., et al: Oral acyclovir in the treatment of acute herpes zoster ophthalmicus. Ophthalmology 1986; 9
    73. 73. Management of Ocular Manifestation Palliative therapy including Burow’s solution, cool compresses, mechanical cleansing of the involved skin, and topical antibiotic ointment without steroid are helpful in treating skin lesions Débridement may also be helpful Neurotrophic keratitis or the epithelial defects -nonpreserved artificial tears, eye ointments, pressure patching, or therapeutic soft contact lenses
    74. 74. Management of Ocular Manifestation Tarsorrhaphy, conjunctival flap, or autologous conjunctival transplantation Steroids should not be used in cases of exposure or neurotrophic keratitis because of the possibility of keratolysis* Topical cycloplegics Aqueous suppressants and topical corticosteroids should be used to treat HZO glaucoma *Liesegang T.: Corneal complications from herpes zoster ophthalmicus. Ophthalmology 1985; 92:316.
    75. 75. Management of Ocular Manifestation Herpes zoster retinitis, optic neuritis, chorioretinitis, acute retinal necrosis syndrome, and progressive outer retinal necrosis are best treated with a combination of systemic steroids and acyclovir i.v
    76. 76. Postherpetic Neuralgia treatment Analgesics Antidepressants (amitriptyline, desipramine, clomipramine), carbamazepine, and phenytoin Famciclovir and valacyclovir significantly reduce the duration but not incidence Steroids have no effect on PHN
    77. 77. Postherpetic Neuralgia treatment Amitriptyline for 90 days reduced the incidence of pain at 6 months. Trial of percutaneous electrical nerve stimulation (PENS) in 50 patients suggested a decrease in pain incidence at 3 and 6 months when compared with famciclovir
    78. 78. Clinical pattern of Herpes simplex keratitis: A case series Dr Vishram Sangit1 Dr Suhas Haldipurkar1 , Dr Maninder Setia1 , Mr Anirban Paik1 1 Laxmi Eye Institute, Panvel, Maharashtra FP-799; Electronic Poster no. 11
    79. 79. Purpose To study the clinicoepidemiological pattern of Herpes simplex keratitis in a tertiary eye hospital in western Maharashtra
    80. 80. Results 41 eyes of 40 patients identified All diagnoses – clinical Mean age - 44.4 +/- 18.54 years M:F – 27:13 Past history of similar episode- 20 patients History of trauma in 7 patients Only 2 out of 40 patients reported pain as the presenting complaint Redness and blurring of vision was the most common symptom reported by 38 patients Mean duration of symptoms before presentation was 17.67 days ( range 2 to 90 days)
    81. 81. Clinical form of HSV Keratitis
    82. 82. Treatment protocols Epithelial disease- Acyclovir ointment 5 times a day for 3 weeks Stromal disease- Acyclovir ointment 5 times a day with 1% prednisolone acetate in tapering doses Endothelitis- Intensive prednisolone acetate 1% with systemic Acyclovir 400 mg 5 times a day
    83. 83. Treatment outcomes All cases resolved on medical therapy Mean duration to resolution for entire group was 34.18 +/- 15.85 days Clinical form Epithelial Stromal Endothelitis Kerato-uveitis Mixed Duration (days) 18.6 39.06 29.66 35 35.91 Time to resolution in various forms of HSV keratitis
    84. 84. Mean time to resolution in various forms of HSV keratitis ( days)
    85. 85. Recurrence pattern Primary clinical form developing recurrence during treatment Clinical form of recurrence in HSV keratitis (%)
    86. 86. Conclusions Stromal form of HSV keratitis is the commonest presentation in our series followed by mixed variety HSV keratitis affects people in young and productive age group Good response to medical therapy achieved in all forms Resolution of stromal keratitis takes longest while epithelial keratitis takes shortest time Recurrences are common and clinical form of disease in recurrences can be different from the original disease form
    87. 87. Thank you
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