Herpes zoster ophthalmicus

a case presentation of herpes zoster ophthalmicus

1. Herpes Zoster Ophthalmicus - Dr Pravda Chaturvedi

2. Name- Vineet Raj, Age- 28 years, Male Resident- Indore Visited eye OPD on 12th Feb 2018. He was referred from dermatology dept as a diagnosed case of HZO, for ophthalmology opinion.

3. Chief Complaints: pain, redness and rashes on left side of fore head, temple, lids, face and side of the nose.

4. History: The rash and pain appeared over left side of the face one day before. On examination: VA: RE 6/6, LE 6/9 Vesicopapular rash on left side of forehead, temple, left upper eyelid, lower lid, along lid margin, ala of the nose. Bilateral Ocular Motility normal Pupillary reactions normal

5. RIGHT EYE LEFT EYE Conjunctiva- Normal Cornea- Clear, Sensation normal Anterior chamber-Normal Pupil-RRR Iris-NCP Lens-Clear Fundus -Normal Conjunctiva-Hyperemia, mucoid discharge + nt Cornea-Clear, Sensation normal Anterior chamber-Normal Pupil-RRR Iris-NCP Lens-Clear Fundus -Normal

6. Treatment Prescribed Tab Valciclovir 1gm TDS*7 days Tab PCM 500mg BD*7 days Oint Calamine for local application Eye oint aciclovir 3% 5 times in LE*7 days Eye drop CMC 0.5% QID LE Tab Amitrptylin 75 mg OD Adv to take precautions as the patient might be infectious to family members.

7. Herpes Zoster Virus Core of linear ds DNA genome, Icosahedral protein capsid , Protein tegument, Envelope of viral glycoproteins .

8. The production of viral progeny destroys the infected cell. HSV types 1 and 2 and VZV establish latent infections in dorsal root ganglia such as the trigeminal ganglion.

9. Primary VZV infection occurs upon direct contact with VZV skin lesions or respiratory secretions via airborne droplets. VZV latency occurs in neural ganglia. (T3-L3,CN V) reactivates in approximately 20% of infected individuals. Of all cases with zoster, 15% involve the ophthalmic division of CN V Zoster (shingles) represents endogenous reactivation of latent virus in people with a waxing level of immunity to infection.

10. VARICELLA ZOSTER VIRUS Chicken pox ─› dorsal root ganglia ─› reactivation ─› shingles

11. Age- sixth to ninth decades Majority patients are healthy, with no specific predisposing factors. More common in patients on immunosuppressive therapy systemic malignancy a debilitating disease, or HIV infection after major surgery trauma radiation

12. CLINICAL PRESENTATION Fever, malaise, warmth, redness, increased sensation in the affected dermatome. The rash of begin as macules ―› papules ―› vesicles ―› pustules

13. dermatitis may result in large scabs that resolve slowly and leave significant scarring

14. Inflammation of almost any ocular tissue can occur and recur in HZO. Eyelid- vesicular eruption, secondary bacterial infection, eyelid scarring, marginal notching, loss of cilia, trichiasis , cicatricial entropion or ectropion . Scarring and occlusion of the lacrimal puncta Conjunctiva- Follicular conjunctivitis

15. Sclera- Episcleritis , Scleritis Cornea- punctate and dendritic keratitis Decreased corneal sensation Nummular corneal infiltrates Interstitial keratitis Disciform keratitis Corneal vascularisation Lipid keratopathy Corneal opacity

16. Ant Chamber- trabeculitis , Raised IOP Iris- Iritis Choroid- Focal choroiditis . Retina- occlusive retinal vasculitis , RD

17. Optic Nerve- Papillitis , Retrobulbar Neuritis Orbit- Eyelid ptosis , orbital oedema , proptosis , Cranial Nerve- CN III most commonly involved

18. Structure Acute Chronic Eyelid Rash and vesicles Scarring, loss of lashes Conjunctiva Conjunctivitis Cornea Corneal ulcers scarring, loss of sensation Uvea Uveitis iris damage, glaucoma Retina Retinitis CME Optic nerve Optic neuritis Glaucoma Orbit Partial or complete paralysis of eye movements

19. Diagnosis Usually clinical Typical presentation involving one dermatome. Involvement of more than one dermatome shows severe immunosuppresion

20. Laboratory Inv viral culture, PCR. Serologic testing D/d Herpes simplex Drug reaction Contact dermatitis Insect bite

21. HSV VZV Dermatomal distribution incomplete complete Pain moderate severe Skin scarring no common PHN no common Iris atophy patchy sectoral B/L involvement uncommon no Recurrent epithelial common rare keratitis Corneal hypoesthesis sectoral /diffuse may be severe Dendrite central ulceration, no central ulcer, morphology terminal bulbs dendritiform mucous plaque

22. Management Oral anti viral agents- famciclovir 500 mg 3 times per day, valacyclovir 1 g 3 times per day, acyclovir 800 mg 5 times per day reduces viral shedding from vesicular skin lesions reduces the chance of systemic dissemination of the virus, decreases the incidence and severity of the most common ocular complications .

23. may reduce the duration if not the incidence of postherpetic neuralgia if begun within 72 hours of the onset of symptoms. Intravenous acyclovir therapy is indicated in patients at risk for disseminated zoster due to immunosuppression . It is supported by iv fluids and bed rest. Vaccination against varicella is recommended for anyone older than 12 months of age without a history of chickenpox or with a negative serology.

24. Prednisone 30 mg orally twice daily on days 1 - 7; then 15 mg twice daily on days 8 - 14; then 7.5 mg twice daily on days 15 – 21 This will reduce severity of the acute signs and symptoms but not the incidence or severity of PHN.

25. Corneal ulcers require topical anti viral and tear substitutes. Stromal involvement require lubrication or topical corticosteroids. If HZO results in decreased corneal sensation, then surgery may be required to protect this surface by tarsorrhaphy .

26. HZO uveitis - corticosteroid and cycloplegic eye drops. Severe inflammation unresponsive to eye drops resulting in optic nerve inflammation or eye movement problems may require corticosteroid pills. If Glaucoma develops, then additional eye drops or even surgery may be required to control the pressure.

27. Lotions containing calamine (e.g., Caladryl ) may be used on open lesions to reduce pain and pruritus . Topically administered lidocaine ( Xylocaine ) and nerve blocks have also been reported to be effective in reducing pain.

28. Post herpetic neuralgia Neuralgic pain persists for more than a month beyond healing and lasts for more than six months. Insect crawling or burning sensation in trigeminal dermatome. Pain can be severe enough to result in sleep disturbance, anorexia and depression.

29. Elderly individuals, immuno -compromised are more likely to be affected. Pathology involves ischemic vasculitis of the nerves resulting in fibrotic scar involving large fibers. Cold compressions are advised.

30. Tricyclic antidepressants Amitriptyline 10 to 25 mg PO HS Increase dosage by 25 mg every 2 to 4 weeks until response is adequate, or to maximum dosage of 150 mg per day.

31. Nortriptyline 10 to 25 mg PO HS; increase dosage by 25 mg every 2 to 4 weeks until response is adequate, or to maximum dosage of 125 mg per day. Imipramine 25 mg PO HS; increase dosage by 25 mg every 2 to 4 weeks until response is adequate, or to maximum dosage of 150 mg per day.

32. Anticonvulsants Carbamazepine ( Tegretol ) 100 mg PO HS; increase dosage by 100 mg every 3 days until dosage is 200 mg three times daily, response is adequate or blood drug level is 6 to12 μg per mL (25.4 to 50.8 μmol per L). Gabapentin ( Neurontin ) 100 to 300 mg PO HS; increase dosage by 100 to 300 mg every 3 days until dosage is 300 to 900 mg three times daily or response is adequate.

33. Capsaicin 0.025 percent skin cream depletes substance P. Its a tachykinin that transmits pain impulse and prevents reaccumulation .

34. Prognosis Most patients with HZO have a single attack and do not go on to get further attacks. Visual outcome is generally good, with vision loss usually due to corneal problems rather than uveitis . Some patients, however, may develop chronic disease, including uveitis that requires long-term therapy and may persist for years.

35. Message A common and treatable viral infection. Patient education/counseling . Post herpetic neuralgia is extremely painful condition. Can transmit chicken pox.