Herpetic Corneal Disease

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Herpetic Corneal Disease- Herpes Simplex Keratitis and Herpes Zoster Ophthalmicus

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Herpetic Corneal Disease

  1. 1. CORNEAS ON THE COAST SPOTLIGHT ON HERPETIC CORNEAL DISEASE Dr Doug Parker PhD FRANZCO Cornea, Cataract & Refractive Specialist Gosford&Wyong Eye Surgery Eye Associates, Macquarie St, Sydney CentralCoast Optometrist Conference, 2 March 2014
  2. 2. Outline  Herpetic corneal disease  HSV vVZV  Diagnosis  Treatment  Prophylaxis  MCQs  Acknowledgements  Professor John Dart, Moorfields Eye Hospital, London  www.aao.org/medialibrary
  3. 3. Herpetic Corneal Infections  HSV-1 (Herpes simplex)  Cold sores, keratitis  HSV-2  Genital herpes  VZV (Varicella zoster)  Chicken pox, shingles, HZO  All neurotrophic sensory nerve ganglia  Trigeminal
  4. 4. Herpes Simplex Keratitis  Primary HSV infection by direct contact  May get a blepharoconjunctivitis (follicular)  Latency  Utilises cellular enzymes for replication  host cell death  Loss of ganglion cells  reduced corneal sensation  Basic forms:  Epithelial  Stromal  Endothelial
  5. 5. Herpes Simplex Keratitis  Challenges:  Making the diagnosis  Recognising recurrences and judging activity  Treatment and prophylaxis  Epithelial keratitis  Actively replicating virus  Dendritic ulcer  may leave a ghost dendrite  Geographic ulcer  Marginal keratitis  Metaherpetic (trophic) ulcer
  6. 6. Herpes Simplex Keratitis  Stromal and endothelial keratitis  Immune-mediated response to non-replicating virus (severe forms may be live)  Focal, multifocal or diffuse stromal opacities  May be associated oedema and AC reaction  With new vessels  “interstitial keratitis”  May leak lipid  Necrotisingkeratitis  Due to live particles (multiple recurrences, HSV-2)  Must be distinguished from microbial keratitis  May cause melting and perforation  Associated uveitis and trabeculitis glaucoma  Localised endothelial dysfunction  “disciformkeratitis”  Pseudoguttae and Descemet’s membrane folds  Keratouveitis  Immune-mediated  Synechiae, cataracts and glaucoma
  7. 7. Herpes Simplex Keratitis  Diagnosis  Clinical  Lab tests (no use in stromalkeratitis)  Culture, PCR, serology  Differential: AK, RCES, healed ED in OSD, HZ  Long-term complications  Recurrence  inflammation and scarring  Reduced sensation  A sensitive sign of previous HSK  Poor tear production, decreased growth factors  Leads to persistent epithelial defects and neurotrophic ulcers
  8. 8. Triggers for recurrence of HSK Ophthalmic Systemic  Contact lens wear  Eye injury  Corneal grafting  Laser eye surgery  Cataract surgery  Intravitreal injections  Topical prostaglandin analogs  Stress  Systemic infection/fever  Sunlight exposure  Menstruation  Genetic factors
  9. 9. Herpes Simplex Keratitis  Treatment  Herpetic Eye Disease Study (HEDS)  Epithelial disease  Debridement (also use for PCR or culture)  Monotherapy with topical antiviral (Aciclovir, Ganciclovir,Trifluridine)  No added benefit of oral antiviral but may be useful in kids or allergic patients  Normal dendrites heal in 1-3 weeks  If not  think toxicity, resistance or wrong diagnosis!
  10. 10. Herpes Simplex Keratitis  Treatment  Stromal disease  Mainstay is topical steroids  Shorten duration of disciform and non-necrotisingstromal disease  Dosing based on severity of inflammation  Taper to prevent rebound  Always under antiviral cover  Simultaneous oral antiviral prophylaxis reduces risk of HSV reactivation at ganglion level  Prophylaxis  Topical antivirals are toxic with prolonged use  Systemic aciclovir reduces recurrence of stromalkeratitis by 50% (HEDS-APT)  Aciclovir 400 mg bd  Can also useValaciclovir 500 mg bd, or Famciclovir 250 mg bd
  11. 11. Herpes Zoster Ophthalmicus (HZO)  Varicella-zoster virus (VZV)  Primary infection is chicken pox  Becomes latent in multiple ganglia  Reactivates as shingles  HZO in 10-20% cases  Exact triggers unknown but decreased cellular immunity is common  Diagnosis:  Fever, malaise, chills  Pain or tingling in dermatome  Maculopapular rash  vesicles  crusting  May have eyelid oedema  Hutchinson’s sign indicates involvement of nasociliary nerve (and eye)  Can affect any part of the eye
  12. 12. Herpes Zoster Ophthalmicus  Acute keratitis  May occur up to 1 month after rash starts  Punctatekeratitis and pseudodendrites (lack terminal bulbs)  Does not respond to topical antivirals  Nummular keratitis (coin-shaped lesions) are an immune-mediated stromal reaction to antigen  Recurrent keratitis  Mucous plaques  Disciformkeratitis (as seen in HSK)  Interstitial keratitis with lipid exudation  Long-term complications  Profound loss of corneal sensation neurotrophic ulcer  Smoldering stromalkeratitis (haze, scarring, reduced vision)  Neuralgia (PHN)
  13. 13. Herpes Zoster Ophthalmicus  Treatment  Topical antivirals have no role  Oral antivirals begun early can reduce severity of disease and long-term complications (e.g neuralgia)  Aciclovir 800 mg 5 times per day, or Famvir 500 mg tds  Topical steroids may be necessary for stromal inflammation, but difficult to wean  Need to support the neurotrophic cornea  Lubricants, punctal occlusion, bandage contact lenses, tarsorrhaphy, conjunctival flaps all have a role  Nerve growth factor  Zostavax
  14. 14. Herpetic corneal disease  Key points  HSV andVZV cause distinctive clinical pictures  Each layer of the cornea may be affected with different manifestations  Never start topical steroid in suspected herpes simplex keratitis without antiviral cover  Reduced corneal sensation can be a useful sign of previous disease  Protect the neurotrophic cornea
  15. 15. MCQ #1  Which of the following is a sensitive sign of previous herpetic keratitis? A. Prominent corneal nerves B. Descemet’s membrane folds C. Reduced corneal sensation D. Corneal vascularisation
  16. 16. MCQ #2  Herpes simplex keratitis and herpes zoster ophthalmicus have the following in common, except: A. They are both caused by a double-stranded DNA virus B. There is a role for topical antiviral treatment in both cases C. Both can lead to neurotrophic ulceration D. There is a role for topical steroid in certain cases of both conditions
  17. 17. MCQ #3  Which of the following would be the best first step in managing a dendritic corneal ulcer in the absence of any stromal inflammation? A. Commence a topical antiviral agent alone B. Commence a topical antiviral agent and a topical steroid C. Commence lubricants and review in 1 week D. Commence a topical steroid alone
  18. 18. MCQ #1  Which of the following is a sensitive sign of previous herpetic keratitis? A. Prominent corneal nerves B. Descemet’s membrane folds C. Reduced corneal sensation D. Corneal vascularisation
  19. 19. MCQ #2  Herpes simplex keratitis and herpes zoster ophthalmicus have the following in common, except: A. They are both caused by a double-stranded DNA virus B. There is a role for topical antiviral treatment in both cases C. Both can lead to neurotrophic ulceration D. There is a role for topical steroid in certain cases of both conditions
  20. 20. MCQ #3  Which of the following would be the best first step in managing a dendritic corneal ulcer in the absence of any stromal inflammation? A. Commence a topical antiviral agent alone B. Commence a topical antiviral agent and a topical steroid C. Commence lubricants and review in 1 week D. Commence a topical steroid alone

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