Ocular Herpes


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Ocular Herpes

  1. 1. Ocular HerpesOcular Herpes HSV 1 and HZOHSV 1 and HZO Treatment and PreventionTreatment and Prevention
  2. 2. Herpes ZosterHerpes Zoster OphthalmicusOphthalmicus  Dermatomal disease occurring alongDermatomal disease occurring along ophthalmic division of trigeminal nerveophthalmic division of trigeminal nerve  Nasociliary branch most indicative ofNasociliary branch most indicative of ocular involvementocular involvement  Hutchenson’s signHutchenson’s sign
  3. 3. HZOHZO  Incidence increasingIncidence increasing  Vaccine availableVaccine available  Ocular involvement variedOcular involvement varied  Oral, topical, dermatological therapyOral, topical, dermatological therapy
  4. 4. Incidence of ShinglesIncidence of Shingles Lifetime risk is 15-20% and peaks in 7Lifetime risk is 15-20% and peaks in 7thth decadedecade 10-20% of shingles is HZO10-20% of shingles is HZO 10X greater risk in whites and slight10X greater risk in whites and slight increase in femalesincrease in females 10X greater risk with HIV10X greater risk with HIV
  5. 5. ZostavaxZostavax  Vaccine approved for those over 50Vaccine approved for those over 50  Reduces the incidence and severity ofReduces the incidence and severity of Zoster and PHNZoster and PHN  Insurance covers those over 50 (CDCInsurance covers those over 50 (CDC guideline) -- $200-300 if out of pocketguideline) -- $200-300 if out of pocket
  6. 6. ZostavaxZostavax  Given after all lesions have healed forGiven after all lesions have healed for those with recent outbreakthose with recent outbreak  Will cause chickenpox in those whoWill cause chickenpox in those who have never had ithave never had it  Avoid in patients with NeomycinAvoid in patients with Neomycin allergy, on systemic steroids and theallergy, on systemic steroids and the immuno-compromisedimmuno-compromised  Avoid pneumovax for 4 wksAvoid pneumovax for 4 wks
  7. 7. Initial symptoms of HZOInitial symptoms of HZO  Prodromal dermatological painProdromal dermatological pain  ItchItch  Redness and swellingRedness and swelling  Vesicles and ulcerationVesicles and ulceration  Watch for abdominal distressWatch for abdominal distress
  8. 8. HZOHZO  Skin lesions shed virus for 1-2 weeksSkin lesions shed virus for 1-2 weeks after first symptoms appearafter first symptoms appear  Avoid contact with pregnant womenAvoid contact with pregnant women and the immuno-compromisedand the immuno-compromised
  9. 9. HZO treatmentHZO treatment  Oral therapy best if within 72 hrs of onsetOral therapy best if within 72 hrs of onset  Acyclovir 800mg 5x/day for 10 days isAcyclovir 800mg 5x/day for 10 days is standard and usually well covered bystandard and usually well covered by insuranceinsurance  Valaciclovir (Valtrex) 1000mg tid for 10 daysValaciclovir (Valtrex) 1000mg tid for 10 days  Famvir 500mg tid for 10 daysFamvir 500mg tid for 10 days
  10. 10. XereseXerese  Acyclovir and Hydrocortisone creamAcyclovir and Hydrocortisone cream 5%/1%5%/1%  Dermatological formulationDermatological formulation  Single use packetsSingle use packets  On-line discount vouchers availableOn-line discount vouchers available
  11. 11. Blepharitis/ConjunctivitisBlepharitis/Conjunctivitis  Lid margin ulcers seen in 60-80% ofLid margin ulcers seen in 60-80% of cases – use antibiotic/steroid ungcases – use antibiotic/steroid ung  Conjunctival vesicles appear in 50%,Conjunctival vesicles appear in 50%, episcleritis also commonepiscleritis also common  Treat with topical steroidTreat with topical steroid  Hypoasthesia-25% with profound lossHypoasthesia-25% with profound loss of sensation go on to developof sensation go on to develop neurotrophic keratitisneurotrophic keratitis
  12. 12. Corneal epithelialCorneal epithelial lesionslesions  Seen in 40% of patientsSeen in 40% of patients  SPK common and can lead to infiltrativeSPK common and can lead to infiltrative keratitis—can resemble HSVkeratitis—can resemble HSV keratitis(pseudodendrites), but no end bulbskeratitis(pseudodendrites), but no end bulbs and not ulcerativeand not ulcerative  Treat with steroid and antibiotic coverTreat with steroid and antibiotic cover  Filamentary keratitis and mucus plaquesFilamentary keratitis and mucus plaques
  13. 13. Mucus plaquesMucus plaques  Mucomyst (Rx) 10-20% acetylcystineMucomyst (Rx) 10-20% acetylcystine nebulizer sol.nebulizer sol.  10% for ophthalmic—warn of smell10% for ophthalmic—warn of smell  2-4 gtts/day loosen plaques2-4 gtts/day loosen plaques  Steroids qidSteroids qid  Can also remove with cotton swab,Can also remove with cotton swab, weck-cell sponge, forceps or spatulaweck-cell sponge, forceps or spatula
  14. 14. Stromal keratitisStromal keratitis Associated with uveitisAssociated with uveitis Anterior - nummularAnterior - nummular Deep – disciformDeep – disciform Keratouveitis/endothelitisKeratouveitis/endothelitis Marginal ulceration – vascularizationMarginal ulceration – vascularization and scarring at/near limbusand scarring at/near limbus Treat with steroids and cycloplegicsTreat with steroids and cycloplegics
  15. 15. Necrotizing keratitisNecrotizing keratitis  Common with hypoasthesiaCommon with hypoasthesia  Use copious NPATs, patching, BCL,Use copious NPATs, patching, BCL, autologous serumautologous serum  Neurotrophic ulcers with stromalNeurotrophic ulcers with stromal thinning may require tarsorraphy,thinning may require tarsorraphy, conjunctival flap, PKP—80% successconjunctival flap, PKP—80% success
  16. 16. Anterior UveitisAnterior Uveitis  Steroids/cycloplegicsSteroids/cycloplegics  Can be smoldering or recurrentCan be smoldering or recurrent  Taper steroids very slowlyTaper steroids very slowly  May require dosing q1-2d for monthsMay require dosing q1-2d for months
  17. 17. Secondary GlaucomaSecondary Glaucoma  Develops from trabecular inflammationDevelops from trabecular inflammation and swelling—blocks outflowand swelling—blocks outflow  Use both Combigan and strong steroidUse both Combigan and strong steroid such as Pred 1% or Durezolsuch as Pred 1% or Durezol  Depending on IOP, consider DiamoxDepending on IOP, consider Diamox short termshort term
  18. 18. Post. Uveitis/Retinitis/OpticPost. Uveitis/Retinitis/Optic NeuritisNeuritis  Most commonly seen in the immuno-Most commonly seen in the immuno- compromisedcompromised  Sometimes concommitant EOM palsy,Sometimes concommitant EOM palsy, cerebral vasculitiscerebral vasculitis  Needs IV acyclovir and systemicNeeds IV acyclovir and systemic steroidssteroids Dilate and watch for retinal signsDilate and watch for retinal signs
  19. 19. Post-Herpetic NeuralgiaPost-Herpetic Neuralgia Can range from mild short-term itch toCan range from mild short-term itch to long-lasting debilitating painlong-lasting debilitating pain Most common and effective oralMost common and effective oral treatment - Gabapentin (Neurontin-treatment - Gabapentin (Neurontin- an off-label use of anti-seizure med.)an off-label use of anti-seizure med.) and tramadol or hydrocodoneand tramadol or hydrocodone
  20. 20. HZO Long Term SequelaeHZO Long Term Sequelae  Recurrent or smoldering uveitisRecurrent or smoldering uveitis  Dry eye, lid and corneal scarring,Dry eye, lid and corneal scarring, neurotrophic keratitisneurotrophic keratitis  Post-herpetic neuralgia – possible eventualPost-herpetic neuralgia – possible eventual hand-off to primary care providerhand-off to primary care provider
  21. 21. Herpes SimplexHerpes Simplex  25% seropositive for HSV by age 425% seropositive for HSV by age 4  100% by age 60100% by age 60  400,000 in US have had ocular HSV400,000 in US have had ocular HSV  10,000/month have HSV keratitis10,000/month have HSV keratitis  Most common corneal blindness in USMost common corneal blindness in US
  22. 22. HSV KeratitisHSV Keratitis  Incidence 15/1000Incidence 15/1000  Slightly more common in malesSlightly more common in males  Mean age of onset is late 50’s to 60’sMean age of onset is late 50’s to 60’s  UV, stress, fever, surgery, immuneUV, stress, fever, surgery, immune compromise, menses, topical steroidscompromise, menses, topical steroids and PA’s (endogenousand PA’s (endogenous prostaglandins)prostaglandins)
  23. 23. HSV 1HSV 1  Primary inoculation through directPrimary inoculation through direct contact of skin or mm innervated bycontact of skin or mm innervated by trigeminal gangliontrigeminal ganglion  Usually subclinical, but can see +PAN,Usually subclinical, but can see +PAN, typically unilateral b’conjunctivitis, SPKtypically unilateral b’conjunctivitis, SPK and skin vesiculationand skin vesiculation
  24. 24. Secondary HSV KeratitisSecondary HSV Keratitis  Can involve all layersCan involve all layers  4 classifications:4 classifications: Infectious epithelial keratitisInfectious epithelial keratitis Neurotrophic keratopathyNeurotrophic keratopathy Stromal keratitisStromal keratitis EndotheliitisEndotheliitis
  25. 25. Epithelial HSV keratitisEpithelial HSV keratitis  Corneal vesicles, dendritic andCorneal vesicles, dendritic and geographic ulcers or raised lesionsgeographic ulcers or raised lesions  Dendritic ulcer most common, heapedDendritic ulcer most common, heaped borders and end bulbs contain RBborders and end bulbs contain RB staining virusstaining virus  Geographic - in immunocompromisedGeographic - in immunocompromised or with topical steroid useor with topical steroid use  Marginal ulcer with infiltrate vs staphMarginal ulcer with infiltrate vs staph
  26. 26. NeurotrophicNeurotrophic keratopathykeratopathy  Non infectious and non inflammatoryNon infectious and non inflammatory  Reduced innervation and tear prod.Reduced innervation and tear prod.  Non-healing epithelial defect withNon-healing epithelial defect with smooth borderssmooth borders  Later stromal ulceration, opacificationLater stromal ulceration, opacification and possible perforationand possible perforation
  27. 27. Stromal KeratitisStromal Keratitis Necrotizing- invasion of virus, necrosis,Necrotizing- invasion of virus, necrosis, infiltration and epithelial defect usuallyinfiltration and epithelial defect usually from use of steroids w/o antiviralfrom use of steroids w/o antiviral Non-necrotizing- (AKA Immune orNon-necrotizing- (AKA Immune or Interstitial)- infiltration with or w/oInterstitial)- infiltration with or w/o neovascularization - epith. intact.neovascularization - epith. intact.
  28. 28. EndotheliitisEndotheliitis  Late onset immune response monthsLate onset immune response months to years after episode of keratitisto years after episode of keratitis – KP’s, pain, injection, low grade iritis, andKP’s, pain, injection, low grade iritis, and possible epithelial edemapossible epithelial edema – Disciform KP - central/paracentral edemaDisciform KP - central/paracentral edema – Diffuse KP and edemaDiffuse KP and edema – Linear KP - mostly peripheral edemaLinear KP - mostly peripheral edema
  29. 29. Orals for HSV keratitisOrals for HSV keratitis  Acyclovir 400 mg 5x/dayAcyclovir 400 mg 5x/day  Valaciclovir 500mg tidValaciclovir 500mg tid  Famciclovir 1000mg tidFamciclovir 1000mg tid  Orals best for immune compromise, inOrals best for immune compromise, in stromal and neurotrophic keratitis,stromal and neurotrophic keratitis, endotheliitis, uveitis, children or rarelyendotheliitis, uveitis, children or rarely Zirgan resistant strainsZirgan resistant strains  Red. risk of epith. to stromal prog.Red. risk of epith. to stromal prog.
  30. 30. Topicals for HSVTopicals for HSV keratitiskeratitis  Zirgan (ganciclovir 0.15% ophth.Zirgan (ganciclovir 0.15% ophth. gel)5gm tube. Very non-toxicgel)5gm tube. Very non-toxic  One drop 5x/day until epithelial ulcerOne drop 5x/day until epithelial ulcer heals, then tid for 1 wk.heals, then tid for 1 wk.  75% of ulcers healed in 1 wk.75% of ulcers healed in 1 wk.  CycloplegiaCycloplegia
  31. 31. Epithelial DebridementEpithelial Debridement  Additive to topical /oral therapyAdditive to topical /oral therapy  For dendritic/geographic ulcersFor dendritic/geographic ulcers  Removal of loose epithelium at edgeRemoval of loose epithelium at edge of ulcer removes active virusof ulcer removes active virus  Decreases chances of stromal diseaseDecreases chances of stromal disease  Use cotton swab, Weck cell spongeUse cotton swab, Weck cell sponge spear, spatula or bladespear, spatula or blade
  32. 32. Topical steroidsTopical steroids  Can be initiated at q1-4hr for stromalCan be initiated at q1-4hr for stromal disease and indolent ulcers (w/ BCLdisease and indolent ulcers (w/ BCL and NPAT) after several days ofand NPAT) after several days of antiviral therapyantiviral therapy  Continue antivirals and cycloplegicContinue antivirals and cycloplegic  Taper steroids very slowlyTaper steroids very slowly
  33. 33. Stromal meltStromal melt  If stroma starts to progressively thin,If stroma starts to progressively thin, be slow to decrease steroids for fearbe slow to decrease steroids for fear of rebound inflammation and furtherof rebound inflammation and further meltmelt  Cyanoacrylate glue used for smallCyanoacrylate glue used for small peripheral perforations to reform ACperipheral perforations to reform AC  Some go to lateral tarsorrhaphy,Some go to lateral tarsorrhaphy, conjunctival flap or PKPconjunctival flap or PKP
  34. 34. PKP in HSV keratitisPKP in HSV keratitis  Best for those with less neovasc.Best for those with less neovasc.  Wait 6-12 months after last episodeWait 6-12 months after last episode  Topical steroids used pre-sx toTopical steroids used pre-sx to minimize inflammationminimize inflammation  PKP does not reduce recurrence ratePKP does not reduce recurrence rate
  35. 35. Secondary glaucomaSecondary glaucoma  Treat mild elevation of IOP with topicalTreat mild elevation of IOP with topical beta-blockers and/or brimonidinebeta-blockers and/or brimonidine  Higher pressures may require oral CAIHigher pressures may require oral CAI  Rise in IOP due to mechanicalRise in IOP due to mechanical blockage of TM from inflammatoryblockage of TM from inflammatory swellingswelling  Steroids can help by reducing inflam.Steroids can help by reducing inflam.
  36. 36. Recurrent HSVRecurrent HSV Long term preventative therapy initiatedLong term preventative therapy initiated after 2-3 recurrences in 1 year or in thoseafter 2-3 recurrences in 1 year or in those with stromal disease. Reduceswith stromal disease. Reduces recurrencesrecurrences by 40-50%.by 40-50%. Acyclovir 400-800 mg/dayAcyclovir 400-800 mg/day Valaciclovir 500 mg/dayValaciclovir 500 mg/day Famciclovir 1000 mg/dayFamciclovir 1000 mg/day
  37. 37. QuestionsQuestions