Herpes Zoster Ophthalmicus

Just a brief presentation about Herpes Zoster Ophthalmicus

1. Herpes Zoster Ophthalmicus (HZO) Presented by SEA Bunseng, First Year Resident Khmer Soviet Friendship Hospital

2. Outline What is Herpes Zoster Ophthalmicus (HZO)? Anatomy of CN V Pathophysiology Risk of Ocular Involvement Clinical Manifestation Management

3. I. What is Herpes Zoster Opthalmiscus (HZO)? known as shingles/Zoster, is a viral disease characterized by a painful skin rash in one or more dermatome distributions of the fifth cranial nerve, shared by the eye and orbit.

4. II. Anatomy of CN V

5. III. Pathophysiology Following Primary infection of VZV Dorsal Root of Sensory neural Ganglion Dormant Activated VZV VZV specific cell mediated immunity faded Central Nervous System Dermatologic involvement Optical system Auditory System

6. IV. Risk of Ocular Involvement Hutchinson Sign Age AIDS

7. V. Clinical Manifestation Acute Shingle A Prodromal Phase Skin Lesions Disseminated Zoster

8. V. Clinical Manifestation A. Vesicles B. Confluent crusting C. Haemorrhagic rash with involvement of both the ophthalmic and maxillary nerve D. Residual Scarring

9. V. Clinical Manifestation Acute Eye Diseases Conjunctivitis (follicular and/or papillary) Episcleritis, Scleritis Keratitis (Acute Epithelial, Nummular, Stromal, Disciform) Anterior Uveitis with Sectoral iris ischeamia and atrophy IOP elevated Retinitis, choroiditis Neurological Complication

10. V. Clinical Manifestation A. Dendritic epithelial lesions with tapered ends B. Nummular keratitis C. Stromal Keratitis

11. V. Clinical Manifestation Chronic Eye Diseases Neurotrophic keratitis 50% cases Scleritis patchy slceral atrophy Mucous plaque keratitis 5%, between 3rd and 6th month Lipid degeneration in eye with persistent severe nummular or disci form keratitis Lipid-filled granulomata under tarsal conjunctiva together with subconjunctival scarring Eyelid scarring result in ptosis, cicatrices entropion and occasionally ectropion

12. V. Clinical Manifestation A. Scleral atrophy B. Mucous Plaque Keratitis C. Lipid filled granuloma Cicatricial entropion Cicatricial ectropion

13. V. Clinical Manifestation Postherpetic Neuralgia Pain persist > 1 month after rash healed 75% of patient over 70 Yrs Pain (Constant or intermittent), worse at night and aggravated by minor stimuli, touch and heat.

14. VI. Management Acute Shingles Oral Aciclovir 800mg 5t/day for 7-10 days, start within 72 hours of onset Intravenous aciclovir 5-10mg/kg t.i.d is indicated for encephalits Other Oral antiviral agents Valaciclovir 1g tid, famiciclovir 500mg tid and brivudine 125mg qd Systemic steroids (prednisone 40-60 mg daily) Symptomatic Remember it’s contagious to get ChickenPox

15. VI. Management Ocular Involvement 1. Conjunctival involvement : Cool compress and erythromycin ointment b.i.d 2. SPK : lubrication with preservative-free artificial tears q1-2h and ointment q.h.s 3. Corneal or conjunctival pseudodentrites : lubrication with preservative-free artificial tears q1-2h, topical antivirals (e.g ganciclovir 0.15% or vidarabine 3% ointment) tid or aid 4. Immune stromal keratitis: topical steroid (prednisonelone acetate 1%) tapering over months to years using weaker steroids and less than daily dosing 5. Uveitis (with or without immune stromal keratitis): Topical Steroid (prednisolone acetate 1%) and cycloplegic (scopolamine o.25% bid) Treat increased IOP with aggressive aqueous suppression; avoid prostaglandin analogues

16. VI. Management Ocular Involvement 6. Neurotrophic Keratitis: treat mild epithelial defects with erythromycin ointment 4-8 times/days. if corneal ulceration occurs, smears and cultures to rule out infection. If sterile, no response to ointment, consider a bandage contact lens, tarsorrhaphy, amniotic membrane graft or conjunctival flap. 7. Retinitis, choroiditis, optic neuritis or cranial nerve palsy: Acyclovr 5-10 mg/kg i.v q8h for 1 week and prenisolone 60mg p.o for 3 days, then taper over 1 week. Management of Acute retinal necrosis may require intraocular antivirales. 8. Increased IOP: maybe steroid response or secondary to inflammation. if uveitis, increase frequency of steroid for a few days and use topical aqueous suppressants eg. timolol 0.5% bid, brimonidine 0.2% tid or dorzolamide 2% tie. Oral carbonic anhydrase inhibitors if IOP > 30mmhg. If IOP still increased but inflammation controlled, substitue fluorometholone 0.25%, rimexolone 1% or loteprednol 0.5% drops for prednisolone acetate and taper dose

17. References Section 8, External Disease and Cornea. (2012-2013). The American Association of Ophthalmology. page: 119-122 Kenski, J. Jack. MD, (2011). Clinical Ophthalmology: A Systemic Approach, 7 th Edition. Elsevier Saunders, UK. page: 248-253 Ehlers, Justis, P.; Shah, Chirag, P. (2008). Will’s Eye Manual, The Office and Emergency Room Diagnosis and Treatment of Eye Diseases, 5 th Edition. Lippincott Williams & Wilkins http://emedicine.medscape.com/article/1132465-overview http://eyewiki.aao.org/Herpes_Zoster_Ophthalmicus