Dr Doug Parker gave a presentation on herpetic corneal disease. He discussed how herpes simplex virus (HSV) and varicella zoster virus (VZV) can infect the cornea and cause disease. HSV typically causes epithelial dendritic ulcers or stromal keratitis, while VZV causes herpes zoster ophthalmicus. Treatment involves antiviral medications, with steroids also used for stromal inflammation. Reduced corneal sensation is a sign of previous herpetic disease and risks neurotrophic ulcers.
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. Outline
Herpetic corneal disease
HSV vVZV
Diagnosis
Treatment
Prophylaxis
MCQs
Acknowledgements
Professor John Dart, Moorfields Eye Hospital, London
www.aao.org/medialibrary
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. 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. 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. 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
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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