Ocular Herpes Ocular Herpes HSV 1 and HZOHSV 1 and HZO

Treatment and PreventionTreatment and Prevention

Herpes Zoster Herpes Zoster OphthalmicusOphthalmicus

Dermatomal disease occurring Dermatomal disease occurring along ophthalmic division of along ophthalmic division of trigeminal nervetrigeminal nerve

Nasociliary branch most Nasociliary branch most indicative of ocular involvementindicative of ocular involvement

Hutchenson’s signHutchenson’s sign

HZOHZO Incidence increasing Incidence increasing

Vaccine availableVaccine available

Ocular involvement variedOcular involvement varied

Oral, topical, dermatological therapyOral, topical, dermatological therapy

Incidence of ShinglesIncidence of Shingles

Lifetime risk is 15-20% and peaks in Lifetime risk is 15-20% and peaks in 77thth decade decade10-20% of shingles is HZO10-20% of shingles is HZO10X greater risk in whites and slight 10X greater risk in whites and slight increase in femalesincrease in females10X greater risk with HIV10X greater risk with HIV

ZostavaxZostavax

Vaccine approved for those over 50 Vaccine approved for those over 50

Reduces the incidence and severity of Reduces the incidence and severity of Zoster and PHNZoster and PHN

Insurance covers those over 50 (CDC Insurance covers those over 50 (CDC guideline) -- $200-300 if out of pocket guideline) -- $200-300 if out of pocket

ZostavaxZostavax

Given after all lesions have Given after all lesions have healed for those with recent healed for those with recent outbreakoutbreak

Will cause chickenpox in those Will cause chickenpox in those who have never had itwho have never had it

Avoid in patients with Neomycin Avoid in patients with Neomycin allergy, on systemic steroids and allergy, on systemic steroids and the immuno-compromisedthe immuno-compromised

Avoid pneumovax for 4 wksAvoid pneumovax for 4 wks

Initial symptoms of Initial symptoms of HZOHZO

Prodromal dermatological painProdromal dermatological pain ItchItch Redness and swellingRedness and swelling Vesicles and ulcerationVesicles and ulceration Watch for abdominal distress Watch for abdominal distress

HZOHZO

Skin lesions shed virus for 1-2 Skin lesions shed virus for 1-2 weeks after first symptoms weeks after first symptoms appearappear

Avoid contact with pregnant Avoid contact with pregnant women and the immuno-women and the immuno-compromisedcompromised

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 is Acyclovir 800mg 5x/day for 10 days is standard and usually well covered by standard 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

XereseXerese

Acyclovir and Hydrocortisone Acyclovir and Hydrocortisone cream 5%/1%cream 5%/1%

Dermatological formulation Dermatological formulation Single use packetsSingle use packets On-line discount vouchers On-line discount vouchers

availableavailable

Blepharitis/Blepharitis/ConjunctivitisConjunctivitis Lid margin ulcers seen in 60-80% of Lid margin ulcers seen in 60-80% of

cases – use antibiotic/steroid ungcases – use antibiotic/steroid ung Conjunctival vesicles appear in Conjunctival vesicles appear in

50%, episcleritis also common50%, episcleritis also common Treat with topical steroidTreat with topical steroid Hypoasthesia-25% with profound Hypoasthesia-25% with profound

loss of sensation go on to develop loss of sensation go on to develop neurotrophic keratitisneurotrophic keratitis

Corneal epithelial Corneal epithelial lesionslesions Seen in 40% of patientsSeen in 40% of patients

SPK common and can lead to infiltrative SPK common and can lead to infiltrative keratitis—can resemble HSV keratitis—can resemble HSV keratitis(pseudodendrites), but no end keratitis(pseudodendrites), but no end bulbs and not ulcerative bulbs and not ulcerative

Treat with steroid and antibiotic coverTreat with steroid and antibiotic cover

Filamentary keratitis and mucus Filamentary keratitis and mucus plaques plaques

Mucus plaquesMucus plaques

Mucomyst (Rx) 10-20% Mucomyst (Rx) 10-20% acetylcystine nebulizer sol.acetylcystine 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 weck-cell sponge, forceps or spatulaspatula

Stromal keratitisStromal keratitis

Associated with uveitis Associated with uveitis Anterior - nummularAnterior - nummularDeep – disciformDeep – disciformKeratouveitis/endothelitisKeratouveitis/endothelitisMarginal ulceration – vascularization Marginal ulceration – vascularization and scarring at/near limbusand scarring at/near limbusTreat with steroids and cycloplegicsTreat with steroids and cycloplegics

Necrotizing keratitisNecrotizing keratitis

Common with hypoasthesiaCommon with hypoasthesia Use copious NPATs, patching, Use copious NPATs, patching,

BCL, autologous serumBCL, autologous serum Neurotrophic ulcers with stromal Neurotrophic ulcers with stromal

thinning may require tarsorraphy, thinning may require tarsorraphy, conjunctival flap, PKP—80% conjunctival flap, PKP—80% successsuccess

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 May require dosing q1-2d for

monthsmonths

Secondary GlaucomaSecondary Glaucoma

Develops from trabecular Develops from trabecular inflammation and swelling—blocks inflammation and swelling—blocks outflowoutflow

Use both Combigan and strong Use both Combigan and strong steroid such as Pred 1% or Durezolsteroid such as Pred 1% or Durezol

Depending on IOP, consider Depending on IOP, consider Diamox short termDiamox short term

Post. Post. Uveitis/Retinitis/Optic 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 systemic Needs IV acyclovir and systemic steroidssteroids

Dilate and watch for retinal signs Dilate and watch for retinal signs

Post-Herpetic Post-Herpetic NeuralgiaNeuralgia

Can range from mild short-term itch Can range from mild short-term itch to long-lasting debilitating painto long-lasting debilitating pain

Most common and effective oral Most common and effective oral treatment - Gabapentin (Neurontin-treatment - Gabapentin (Neurontin-an off-label use of anti-seizure an off-label use of anti-seizure med.) and tramadol or hydrocodonemed.) and tramadol or hydrocodone

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 Post-herpetic neuralgia – possible eventual hand-off to primary care eventual hand-off to primary care providerprovider

Herpes Simplex Herpes 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 Most common corneal blindness in

USUS

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, immune UV, stress, fever, surgery, immune

compromise, menses, topical compromise, menses, topical steroids and PA’s (endogenous steroids and PA’s (endogenous prostaglandins)prostaglandins)

HSV 1HSV 1

Primary inoculation through direct Primary inoculation through direct contact of skin or mm innervated contact of skin or mm innervated by trigeminal ganglion by trigeminal ganglion

Usually subclinical, but can see Usually subclinical, but can see +PAN, typically unilateral +PAN, typically unilateral b’conjunctivitis, SPK and skin b’conjunctivitis, SPK and skin vesiculationvesiculation

Secondary HSV Secondary HSV KeratitisKeratitis

Can involve all layersCan involve all layers 4 classifications: 4 classifications:

Infectious epithelial keratitisInfectious epithelial keratitis

Neurotrophic keratopathyNeurotrophic keratopathy

Stromal keratitisStromal keratitis

EndotheliitisEndotheliitis

Epithelial HSV keratitisEpithelial HSV keratitis

Corneal vesicles, dendritic and Corneal vesicles, dendritic and geographic ulcers or raised lesionsgeographic ulcers or raised lesions

Dendritic ulcer most common, heaped Dendritic ulcer most common, heaped borders and end bulbs contain RB borders and end bulbs contain RB staining virusstaining virus

Geographic - in immunocompromised Geographic - in immunocompromised or with topical steroid useor with topical steroid use

Marginal ulcer with infiltrate vs staphMarginal ulcer with infiltrate vs staph

Neurotrophic Neurotrophic keratopathykeratopathy

Non infectious and non inflammatoryNon infectious and non inflammatory Reduced innervation and tear prod.Reduced innervation and tear prod. Non-healing epithelial defect with Non-healing epithelial defect with

smooth borderssmooth borders Later stromal ulceration, Later stromal ulceration,

opacification and possible opacification and possible perforationperforation

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/o Interstitial)- infiltration with or w/o

neovascularization - epith. intact. neovascularization - epith. intact.

EndotheliitisEndotheliitis

Late onset immune response Late onset immune response months to years after episode of months to years after episode of keratitiskeratitis– KP’s, pain, injection, low grade iritis, KP’s, pain, injection, low grade iritis,

and possible epithelial edemaand possible epithelial edema– Disciform KP - central/paracentral Disciform KP - central/paracentral

edemaedema– Diffuse KP and edemaDiffuse KP and edema– Linear KP - mostly peripheral edemaLinear KP - mostly peripheral edema

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, Orals best for immune compromise,

in stromal and neurotrophic in stromal and neurotrophic keratitis, endotheliitis, uveitis, keratitis, endotheliitis, uveitis, children or rarely Zirgan resistant children or rarely Zirgan resistant strainsstrains

Red. risk of epith. to stromal prog.Red. risk of epith. to stromal prog.

Topicals for HSV Topicals 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 One drop 5x/day until epithelial ulcer heals, then tid for 1 wk.ulcer heals, then tid for 1 wk.

75% of ulcers healed in 1 wk.75% of ulcers healed in 1 wk. CycloplegiaCycloplegia

Epithelial DebridementEpithelial Debridement

Additive to topical /oral therapyAdditive to topical /oral therapy For dendritic/geographic ulcersFor dendritic/geographic ulcers Removal of loose epithelium at edge Removal of loose epithelium at edge

of ulcer removes active virusof ulcer removes active virus Decreases chances of stromal Decreases chances of stromal

diseasedisease Use cotton swab, Weck cell sponge Use cotton swab, Weck cell sponge

spear, spatula or blade spear, spatula or blade

Topical steroidsTopical steroids

Can be initiated at q1-4hr for Can be initiated at q1-4hr for stromal disease and indolent stromal disease and indolent ulcers (w/ BCL and NPAT) after ulcers (w/ BCL and NPAT) after several days of antiviral therapyseveral days of antiviral therapy

Continue antivirals and Continue antivirals and cycloplegiccycloplegic

Taper steroids very slowlyTaper steroids very slowly

Stromal meltStromal melt

If stroma starts to progressively thin, If stroma starts to progressively thin, be slow to decrease steroids for fear be slow to decrease steroids for fear of rebound inflammation and further of rebound inflammation and further meltmelt

Cyanoacrylate glue used for small Cyanoacrylate 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

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 Wait 6-12 months after last

episodeepisode Topical steroids used pre-sx to Topical steroids used pre-sx to

minimize inflammationminimize inflammation PKP does not reduce recurrence PKP does not reduce recurrence

raterate

Secondary glaucomaSecondary glaucoma

Treat mild elevation of IOP with topical Treat 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 mechanical Rise in IOP due to mechanical

blockage of TM from inflammatory blockage of TM from inflammatory swellingswelling

Steroids can help by reducing inflam.Steroids can help by reducing inflam.

Recurrent HSVRecurrent HSV

Long term preventative therapy initiated Long term preventative therapy initiated

after 2-3 recurrences in 1 year or in those after 2-3 recurrences in 1 year or in those

with stromal disease. Reduces recurrences with stromal disease. Reduces recurrences

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

QuestionsQuestions