DESCRIPTION: | SIGNS AND SYMPTOMS: | CAUSES: | DIFFERENTIAL DIAGNOSIS: | LABORATORY: | PATHOLOGICAL FINDINGS: | IMAGING: | TREATMENT | DRUG(S) OF CHOICE | PRECAUTIONS: | ALTERNATIVE DRUGS: | PATIENT MONITORING: | POSSIBLE COMPLICATIONS: | MISCELLANEOUS
DESCRIPTION: TOP : Infections of the eye caused by one of the herpesviruses. Herpes simplex (HSV) types 1 and 2 or varicella-zoster virus. These infections may affect the eyelids and surrounding skin and may also cause conjunctivitis, keratitis, uveitis, as well as retinitis or optic neuritis. These viruses establish latent infections and eye involvement is most often from reactivation of latent viruses. Epstein-Barr virus may cause conjunctivitis or keratitis in infectious mononucleosis. Cytomegalovirus, which is also a herpesvirus, can cause a severe retinitis in immunocompromised patients with AIDS.
System(s) affected: Nervous, Skin/Exocrine
Genetics: No genetic pattern
Incidence/Prevalence in USA:
* HSV - 500,000 cases per year; 1/10,000 infants born with neonatal HSV
* Zoster - 300,000 new cases per year
Predominant age:
* HSV may affect any age
* Zoster usually affects older people
Predominant sex: Male = Female
Varies according to the virus and the ocular structures involved
* Eye pain
* Red eye (usually unilateral)
* Photophobia
* Tearing
* Decreased vision
* Skin/eyelid rash and pain
* Fever (varicella-zoster or infectious mononucleosis)
* Malaise (varicella-zoster or infectious mononucleosis)
* Primary infections:
>> Neonatal HSV, usually HSV-2
>> Primary ocular HSV, usually HSV-1
* Recurrent infections:
>> Reactivation of HSV or herpes zoster virus (HZV) from trigeminal ganglion
* Reactivating factors:
>> Fever
>> Ultraviolet light
>> Cold wind
>> Systemic illness
>> Menstruation
>> Emotional stress
>> Local trauma
>> Immunosuppression
* Family members/close contact with HSV
* History of varicella infection
DIAGNOSIS
* Viral conjunctivitis of other cause
* Bacterial keratoconjunctivitis
* Adult inclusion (chlamydial) conjunctivitis
* Allergic conjunctivitis
* Corneal abrasion
* Recurrent corneal erosion
* Toxic conjunctivitis
* Fungal keratitis
* Iritis/uveitis
* Scleritis
* Laboratory tests are usually not required unless diagnosis in doubt
* Viral culture from cornea, conjunctiva, or skin; fluorescent antibody; polymerase chain reaction (PCR)
* Giemsa stain of corneal or skin lesion scrapings for multinucleated giant cells
Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A
* Vesicular skin rash
* Zoster rash follows dermatome, does not cross midline and involves upper eyelid
* Dendritic keratitis
* HSV dendrites stain with fluorescein
* Large geographic corneal ulcers may occur
* Corneal stromal inflammation, opacity and neovascularization may occur
* Decreased corneal sensation
* Uveitis
* Secondary glaucoma
SPECIAL TESTS:
* Fluorescein staining of the cornea - positive staining with HSV
* Rose bengal staining of cornea - positive with zoster and HSV
* Corneal sensation - usually decreased
* Slit-lamp exam
* Measure intraocular pressure
* Dilated funduscope exam
* Evaluate zoster patients under age 40 for immunodeficiency
DIAGNOSTIC PROCEDURES: TOP : As above
APPROPRIATE HEALTH CARE:
* Outpatient
* Hospitalize if severe systemic spread for IV therapy
* Warm compresses to skin lesions
* Gentle debridement of corneal epithelial lesions
SURGICAL MEASURES: Occasionally, débridement of involved epithelium
ACTIVITY: As tolerated
DIET: Regular
PATIENT EDUCATION: American Academy of Ophthalmology
MEDICATIONS
Skin and eyelid lesions:
* Prophylactic topical antibiotic ointment, such as bacitracin or erythromycin bid for 1-2 weeks
* Trifluorothymidine (Viroptic) 1% drops or vidarabine 3% ointment 5 times per day if eyelid margin involved
* Zoster - acyclovir 800 mg po 5 times per day for 10 days; useful if started within 7 days of onset and active lesions are present
* Severe or persistent zoster - hospitalize; acyclovir 5-10 mg/kg IV q 8 hours for 5-10 days
* For postherpetic neuralgia in herpes zoster:
>> Consider prednisone 60 mg po for 3-7 days and taper off over the next 1-2 weeks
>> Cimetidine 400 mg po bid during prednisone treatment
>> Consider antidepressant such as amitriptyline 25 mg po tid
Corneal disease:
* HSV epithelial disease:
>> Trifluorothymidine 1% drops 9 times per day or vidarabine 3% ointment 5 times per day; taper over 10-21 days based on response
>> Cycloplegia with scopolamine 0.25% or cyclopentolate 1% drops tid
* Stromal keratitis or uveitis (without epithelial disease):
>> Cycloplegia with scopolamine 0.25% or cyclopentolate 1% drops tid
>> Topical steroid such as prednisolone acetate 1% drops qid
>> Trifluorothymidine 1% drops qid for prophylaxis while on topical steroids
Optic neuritis, chorioretinitis, or cranial nerve involvement with zoster:
* Acyclovir 5-10 mg/kg IV q 8 hours for 1 week
* Prednisone 60 mg po for 3-7 days and taper over the next 1-2 weeks
Secondary glaucoma
* Aqueous humor suppressant such as timolol 0.5% drops bid or methazolamide 50 mg po bid or tid
Neurotrophic ulcer or persistent epithelial disease:
* Consider reducing or discontinuing topical antivirals to avoid toxicity
* Preservative-free lubricant ointment
* Erythromycin 3% ophthalmic ointment q hs or bid
* Consider patching or tarsorrhaphy
Contraindications:
* Topical steroids are contraindicated with active corneal epithelial disease
* Acyclovir is contraindicated in pregnancy
* Prednisone should not be used in immunocompromised patients
* Topical antiviral agents are toxic and may cause an allergic reaction; substitution with another agent may be tried
* Topical steroids can raise intraocular pressure
* Acyclovir dosage should be reduced in renal insufficiency
* See manufacturer's literature for additional precautions
Significant possible interactions: See manufacturer's literature
* Idoxuridine 0.5% ointment or 0.1% drops 5 times per day is more toxic than the other antivirals, but may be substituted if allergic reaction develops to others
* Topical acyclovir ointment to skin lesions - effectiveness uncertain
* Medroxyprogesterone 1% drops in place of other steroids if corneal thinning
* Capsaicin 0.025% cream tid to 6 times per day for months to years for post-herpetic neuralgia
* Nonsteroidal anti-inflammatory agents po for scleritis associated with zoster
FOLLOWUP
* Size of epithelial defect
* Vision
* Corneal opacity
* Anterior chamber inflammation
* Intraocular pressure
PREVENTION/AVOIDANCE:
* Avoid close contact with patients with active lesions
* Herpes zoster virus can be spread to individuals who have not had chicken pox
* Avoid known precipitating factors for recurrent HSV
* Topical steroids alone do not reactivate the virus, but may exacerbate spontaneous recurrences
* Very slow taper of topical steroids over many months for corneal epithelial disease
* Antiviral prophylaxis while on topical steroids
* Varicella vaccination prior to infection
* Corneal neovascularization and scarring resulting in poor vision
* Neurotrophic ulcer with perforation
* Secondary bacterial or fungal infection
* Secondary glaucoma from uveitis or steroid treatment
* Necrotizing interstitial keratitis
* Corneal transplant may be required
* Post-herpetic neuralgia with zoster
* Vision loss from optic neuritis or chorioretinitis
* Systemic involvement
EXPECTED COURSE AND PROGNOSIS:
* Neonatal primary HSV often disseminated with high mortality rate, 37% have vision worse than 20/200
* Primary HSV in children and adults often asymptomatic; overt disease usually self-limited
* Recurrent ocular HSV:
>> Skin lesions in clusters last for 5-7 days
>> HSV epithelial disease - without treatment, 40% resolve without sequelae; with treatment, 90-95% resolve without complication
>> HSV stromal keratitis usually resolve in weeks to months with some scarring; neovascularization increases risk for severe scarring
* Ocular varicella - may produce a keratitis; usually self-limited, but with occasional complications
* Herpes zoster ophthalmicus
>> Dermatitis 8-14 days acute phase with subsequent scarring possible
>> Conjunctivitis, episcleritis and scleritis may occur
>> Two-thirds of patients develop keratitis and decreased corneal sensation
>> Uveitis occurs in about 40%
>> Neurotrophic keratitis occurs in one-half; most recover sensation in 2-3 months
>> Secondary glaucoma occurs in 10%
>> Post-herpetic neuralgia in 20-40%; usually longer lasting in older patients
* Recurrence common for HSV and HZO
ASSOCIATED CONDITIONS:
* Immunosuppression
* AIDS
* Malignancy
AGE-RELATED FACTORS:
Pediatric: Neonatal HSV often systemic and life-threatening
Geriatric: Zoster more common in older age groups
Others: Consider immunodeficiency in zoster patients under age 40
PREGNANCY:
* May increase recurrence
* Avoid systemic steroids, acyclovir and other medications contraindicated in pregnancy
* Pregnant women who have not had chicken pox should especially avoid contact with patients with active zoster
SYNONYMS:
* Herpes simplex keratitis
* Herpes zoster ophthalmicus
* Herpetic keratitis or keratouveitis
ICD-9-CM:
* 054.40 herpes simplex (HSV) with ophthalmic complications
* 053.2 herpes zoster (HZV) with ophthalmic complications
SEE ALSO: Conjunctivitis
OTHER NOTES: N/A
ABBREVIATIONS:
* HSV = herpes simplex virus
* HZV = herpes zoster virus
* HZO = herpes zoster ophthalmicus
* VSV = varicella-zoster virus (synonym for HZV)
REFERENCES:
* Albert DM, Jakobiec FA, eds: Principles and Practice of Ophthalmology. Philadelphia, W.B. Saunders Co., 1994
* Cullom RD Jr, Chang B, eds: The Wills Eye Manual - Office and Emergency Room Diagnosis and Treatment of Eye Diseases. 2nd Ed. Philadelphia, J.B. Lippincott Co., 1994
Author(s):
Thomas W. Hejkal, MD, PhD
Copyright - Williams & Wilkins, 1997.