herpetic corneal disease

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


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


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


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


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!


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

herpetic corneal disease

Education