DEPARTMENT OF OPHTHALMOLOGYDEPARTMENT OF OPHTHALMOLOGY

SINDH GOVT. QATAR HOSPITALSINDH GOVT. QATAR HOSPITAL

DR MARIAM KASHIFDR MARIAM KASHIFPOST GRADUATE STUDENT(MCPS)POST GRADUATE STUDENT(MCPS)

DR JAMEEL AHMED BURNEYDR JAMEEL AHMED BURNEYSUPERVISOR/HEAD OF DEPARTMENTSUPERVISOR/HEAD OF DEPARTMENT

CaseCase

A 35 year old man presented with A 35 year old man presented with FeverFever - 4days- 4daysBurning sensation on forehead Burning sensation on forehead

and around left eyeand around left eye - 2 days- 2 daysVesicular eruptionsVesicular eruptions - 1 day- 1 dayDischarge (LE)Discharge (LE) - 1 day- 1 dayDV (LE)DV (LE) - 1 day- 1 day

HistoryHistory

Low grade fever 4 days back associated Low grade fever 4 days back associated with headache, tiredness and malaise.with headache, tiredness and malaise.

Pain and Burning sensation on left side of Pain and Burning sensation on left side of forehead and around left eye.forehead and around left eye.

1 day back eruption of groups of vesicles 1 day back eruption of groups of vesicles on left side of forehead, left upper eyelid on left side of forehead, left upper eyelid and nose associated with itching and pain.and nose associated with itching and pain.

Redness and mucopurulent discharge Redness and mucopurulent discharge from left eye along with decreased vision.from left eye along with decreased vision.

Past HistoryPast History

No long term illness, decreased appetite No long term illness, decreased appetite or weight loss.or weight loss.

No drug history or known drug allergies.No drug history or known drug allergies. H/O chicken pox at the age of 10yrs.H/O chicken pox at the age of 10yrs.

Family and Social HistoryFamily and Social History

Unmarried, lives with parents and two Unmarried, lives with parents and two siblings; all healthy.siblings; all healthy.

No addictions.No addictions. Works in garment factory.Works in garment factory. Belongs to middle class family.Belongs to middle class family.

Medical ExamMedical Exam

Well oriented young man, in pain and Well oriented young man, in pain and concerned about his condition.concerned about his condition.

Vitals: Blood pressure 120/70mmhg, pulse Vitals: Blood pressure 120/70mmhg, pulse 80/min,temp 98 degree.80/min,temp 98 degree.

CV: regular without murmur or gallop.CV: regular without murmur or gallop. Chest: clear.Chest: clear. Abdomen: no significant finding.Abdomen: no significant finding.

Ocular ExamOcular Exam

Visual Acuity 6/6 RE 6/12 LEVisual Acuity 6/6 RE 6/12 LE External Inspection :erythamatous skin, groups External Inspection :erythamatous skin, groups

of flesh colored vesicles on left side of forehead, of flesh colored vesicles on left side of forehead, left upper eyelid, along lid margin, side and tip of left upper eyelid, along lid margin, side and tip of the nose. (Hutchinson's Sign)the nose. (Hutchinson's Sign)

Bilateral Ocular Motility normalBilateral Ocular Motility normal Pupillary reactions normalPupillary reactions normal

Slit Lamp ExaminationSlit Lamp ExaminationRIGHT EYERIGHT EYE LEFT EYELEFT EYE

ConjunctivaConjunctiva NormalNormal HyperemiaHyperemia

CorneaCornea ClearClear

Sensation Sensation normalnormal

Ulcer Ulcer (Dendritic in (Dendritic in patternpattern

Fluorescine +ve)Fluorescine +ve)

Sensation reducedSensation reduced

Anterior Anterior chamberchamber

NormalNormal NormalNormal

LensLens ClearClear ClearClear

FundusFundus NormalNormal NormalNormal

Differential Diagnosis Differential Diagnosis

OCULAROCULAR SKIN SKINHerpes simplex keratitisHerpes simplex keratitis Drug allergy Drug allergy

Herpes zoster ophthalmicusHerpes zoster ophthalmicus Contact dermatitis Contact dermatitis

Insect biteInsect bite

DiagnosisDiagnosis

HERPES ZOSTER OPHTHALMICUSHERPES ZOSTER OPHTHALMICUS HistoryHistory Vesicles (Hutchinson’s Sign)Vesicles (Hutchinson’s Sign) Dendritic ulcerDendritic ulcer

Varicella zoster virusVaricella zoster virus

Double stranded DNA virusDouble stranded DNA virus AlphaherpesvirinaeAlphaherpesvirinae

OverviewOverview

VARICELLA ZOSTER VIRUSVARICELLA ZOSTER VIRUSChicken poxChicken pox dorsal root ganglia dorsal root ganglia reactivation reactivation shingles shingles

single single dermatomedermatome

Risk FactorsRisk Factors

90% susceptible after primary infection90% susceptible after primary infection Old ageOld age ImmunosupressionImmunosupression MalignancyMalignancy Severe illnessSevere illness

Herpes Zoster OphthalmicusHerpes Zoster Ophthalmicus

Involvement of first Division (Ophthalmic) Involvement of first Division (Ophthalmic) of Trigeminal nerveof Trigeminal nerve

SymptomsSymptoms

Prodromal (fever ,fatigue ,malaise, headache)Prodromal (fever ,fatigue ,malaise, headache) Burning pain (forehead ,eyelid ,nose)Burning pain (forehead ,eyelid ,nose) VesiclesVesicles Red EyeRed Eye Watering/DischargeWatering/Discharge PhotophobiaPhotophobia Decreased visionDecreased vision

Signs (Ex.Ocular)Signs (Ex.Ocular)

Hutchinson’s SignHutchinson’s Sign

( vesicles on forehead, upper eyelid, side & ( vesicles on forehead, upper eyelid, side & tip of nose)tip of nose)

Hutchinson's signHutchinson's sign

Signs (ocular)Signs (ocular) ConjunctivitisConjunctivitis

(Hyperemia, discharge)(Hyperemia, discharge)

Signs (ocular)Signs (ocular) KeratitisKeratitis Dendritic corneal ulcer ( Fine branching pattern)Dendritic corneal ulcer ( Fine branching pattern)

Dendritic ulcerDendritic ulcer

Signs (ocular)Signs (ocular)

StainingStaining

Fluorescein

Rose Bengal

Signs (ocular)Signs (ocular)

Corneal epithelial defects and ulcersCorneal epithelial defects and ulcers

Signs (ocular) Signs (ocular)

Anterior Uveitis (affects a third of patients) Anterior Uveitis (affects a third of patients) Red eyeRed eye Cells, flareCells, flare Posterior synachiaePosterior synachiae Keratic precipetates (KPs)Keratic precipetates (KPs)

Posterior Synachiae

Anterior UveitisAnterior Uveitis

KPs

Signs (ocular)Signs (ocular)

EpiscleritisEpiscleritis ScleritisScleritis Stromal keratitisStromal keratitis Disciform keratitisDisciform keratitis

ComplicationsComplications Post herpetic neuralgiaPost herpetic neuralgia : pain that remains for more than 1 : pain that remains for more than 1

month after rash has healedmonth after rash has healed75% cases (esp. over 70yrs)75% cases (esp. over 70yrs)aggravated by minor stimuli (touch ,heat) aggravated by minor stimuli (touch ,heat)

Cranial nerve palsies Cranial nerve palsies Third (most common)Third (most common)Fourth & sixthFourth & sixth

Optic neuritisOptic neuritis EncephlitisEncephlitis Rare Rare Cranial arteritisCranial arteritis Guillain-Barre syndromeGuillain-Barre syndrome

Ocular complicationsOcular complications

Eyelid scarringEyelid scarring Raised IOP (steroid induced)Raised IOP (steroid induced) Neurotrophic keratitisNeurotrophic keratitis Chronic scleritisChronic scleritis Lipid degeneration (cornea)Lipid degeneration (cornea)

TreatmentTreatmentSystemic :Within 72hrs

Acyclovir 800mg 5 times daily

Famciclovir 500mg TID

Local:Local: Acyclovir skin ointment (rash)Acyclovir skin ointment (rash) Topical AcyclovirTopical Acyclovir Topical antibiotics (Chloramphenicol)Topical antibiotics (Chloramphenicol) Topical steroids (uveitis)Topical steroids (uveitis)

TreatmentTreatment

Treatment of ComplicationsTreatment of Complications

Post herpetic neuralgiaPost herpetic neuralgia Cold compressCold compress Local CAPSAICIN oint (QID) / Local CAPSAICIN oint (QID) /

LIDOCAINE ointLIDOCAINE oint Pain killers Pain killers Oral Tricyclic antidepressantsOral Tricyclic antidepressants

No Post herpetic neuralgiaNo Post herpetic neuralgia

Message Message

A common and treatable viral infection.A common and treatable viral infection. Patient education/Counseling. Patient education/Counseling. Post herpetic neuralgia is extremely Post herpetic neuralgia is extremely

painful condition.painful condition. Can transmit chicken pox.Can transmit chicken pox.