Herpetic Corneal Disease
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CORNEAS ON THE COASTSPOTLIGHT ON HERPETIC CORNEAL DISEASE
Dr Doug Parker PhD FRANZCOCornea, Cataract & Refractive Specialist
Gosford & Wyong Eye SurgeryEye Associates, Macquarie St, Sydney
Central Coast Optometrist Conference, 2 March 2014
Outline
Herpetic corneal disease HSV v VZV Diagnosis Treatment Prophylaxis
MCQs Acknowledgements
Professor John Dart, Moorfields Eye Hospital, London www.aao.org/medialibrary
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
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
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
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 Necrotising keratitis
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 “disciform keratitis” Pseudoguttae and Descemet’s membrane folds
Keratouveitis Immune-mediated Synechiae, cataracts
and glaucoma
Herpes Simplex Keratitis
Diagnosis Clinical Lab tests (no use in stromal keratitis)
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
Triggers for recurrence of HSK
Ophthalmic Systemic
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
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!
Herpes Simplex Keratitis
Treatment Stromal disease
Mainstay is topical steroids Shorten duration of disciform and non-necrotising stromal 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 stromal keratitis
by 50% (HEDS-APT) Aciclovir 400 mg bd Can also use Valaciclovir 500 mg bd, or Famciclovir 250 mg bd
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
Herpes Zoster Ophthalmicus Acute keratitis
May occur up to 1 month after rash starts Punctate keratitis 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 Disciform keratitis (as seen in HSK) Interstitial keratitis with lipid exudation
Long-term complications Profound loss of corneal sensation
neurotrophic ulcer Smoldering stromal keratitis (haze, scarring,
reduced vision) Neuralgia (PHN)
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
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
MCQ #1
Which of the following is a sensitive sign of previous herpetic keratitis?A. Prominent corneal nervesB. Descemet’s membrane foldsC. Reduced corneal sensationD. Corneal vascularisation
MCQ #2
Herpes simplex keratitis and herpes zoster ophthalmicus have the following in common, except:A. They are both caused by a double-
stranded DNA virusB. There is a role for topical antiviral
treatment in both casesC. Both can lead to neurotrophic ulcerationD. There is a role for topical steroid in
certain cases of both conditions
MCQ #3
Which of the following would be the best first step in managing a dendritic corneal ulcer in the absence of any stromal inflammation?A. Commence a topical antiviral agent
aloneB. Commence a topical antiviral agent
and a topical steroidC. Commence lubricants and review in 1
weekD. Commence a topical steroid alone
MCQ #1
Which of the following is a sensitive sign of previous herpetic keratitis?A. Prominent corneal nervesB. Descemet’s membrane foldsC. Reduced corneal sensationD. Corneal vascularisation
MCQ #2
Herpes simplex keratitis and herpes zoster ophthalmicus have the following in common, except:A. They are both caused by a double-
stranded DNA virusB. There is a role for topical antiviral
treatment in both casesC. Both can lead to neurotrophic ulcerationD. There is a role for topical steroid in
certain cases of both conditions
MCQ #3
Which of the following would be the best first step in managing a dendritic corneal ulcer in the absence of any stromal inflammation?A. Commence a topical antiviral agent
aloneB. Commence a topical antiviral agent
and a topical steroidC. Commence lubricants and review in 1
weekD. Commence a topical steroid alone
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