ehsanullan selid is about herpetic .pptx

Herpetic corneal disease is the second cause of corneal blindness around the world and early a large proportion of people in different developed country infected to this virus

1. HERPETIC CORNEAL DISEASE Prepared by: Dr. Sayed Ehsanulah Hashemi Under Observation of: Dr. Ibrahim Sharifi & Dr. Sulaiman Shirzad

2. Outline Herpetic corneal di sease HSV v VZV Diagnosis Treatment Prophylaxis

3. Herpetic Corneal Infections HSV-1 (Herpes simplex) Cold sores, keratitis HSV-2 Genital herpes VZV (Varicella zoster) Chicken pox, shingles, HZO All neurotrophic  sensory nerve ganglia Trigeminal

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

8. Triggers for recurrence of HSK Systemic Ophthalmic Contact lens wear Eye injury Corneal grafting Laser eye surgery Cataract surgery Intravitreal injections Topical prostaglandin analogs Stress Systemic infection/fever Sunlight exposure Menstruation Genetic factors

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 use Valaciclovir 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 and VZV 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. Thank you