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Herpes and the Eye

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by

Kevin Hong

on 2 November 2012

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Transcript of Herpes and the Eye

Acyclovir
Acute disease - 400 mg PO 5 times/day for 10d
Maintenance – 400 mg BID (QD may be sufficient)

Famciclovir
Acute disease: 250 mg PO tid for 10 d
Maintenance: 250 mg PO bid

Valacyclovir
Acute disease: 1000 mg PO bid for 10 days
Maintenance: 500 mg or 1000 mg PO qd the herpes virus created by kevin hong headache malaise symptoms fever mid-line
respecting
lesions herpes boy herpes zoster background herpes simplex virus herpes zoster virus Simplex is typically self limiting, but drug therapy can hasten recovery
Use steroids on HSV-stromal infection only if NO epithelial involvement is seen
Treat HZO within 72 hours of onset of symptoms for best results treatment protocols A series of reports sponsored by the National Eye Institute, dating back to May 1989.
Over 700 patients with various HSV disease states were studied herpetic eye disease study herpes simplex DS-DNA virus
Can remain dormant and become reactivated (25%)
Transmitted via close/sexual contact
HSV-1 = oral herpes
HSV-2 = genital herpes DS-DNA virus
Often remains dormant in sensory nerves forever (Trigeminal for HZO)
Transmitted via close contact or airborne particles Direct contact Airborne particles Viral infection of the eyelids
Typically more likely in children than in adults Blepharitis small vesicles
along lid base Small vesicles or pustules with inflamed, erythematous base along the lid margin and/or periocular skin. conjunctivitis Viral conjunctivitis is much more common than bacterial.

Signs: Follicular conjunctival reaction, preauricular adenopathy, keratitis last 2-4 weeks "started in one eye, and then moved to the other" patients typically experience itching, foreign body sensation, tearing, redness, and photophobia Keratitis Typically starts as a unilateral red eye with variable ocular discomfort. "the great masquerader" signs include photophobia, epiphora, variable visual involvement, dendritic lesions dendritic
lesions While this is the typical appearance of HSV-Keratitis, the earliest signs will appear as punctate keratopathy BE CAREFUL! cotton wisp test Neurotrophic keratitis Due to repeat HSV disease
Corneal innervation
Decreased tear formation Signs and symptoms:
Stromal scarring
Neovascularization
Necrosis/Perforation lymph node anatomy Hutchinson's
Sign HZO Complications Keratitis
Uveitis
Edema
Secondary bactieral infections Scleral atrophy
Scarring
Exposure keratopathy
Acute retinal necrosis ocular signs/symptoms Drug Therapy Trifluridine 1% drops, 9 times a day (q2h), then TID one week after resolution

Zirgan opthalmic gel (0.15%) 5 times a day, then TID for one week after resolution

Vidarabine 3% ointment, 5 times a day 40-60mg Prednisone daily for 10 days


Oral acyclovir 800mg q4h 7-10 days
Famciclovir 500mg 3x/day for 7 days
Valacyclovir 1000mg 3x/day for 7 days Use caution with probenecid, a drug used commonly with gout patients. It decreases antiviral metabolism and increases clearance time. Herpes Simplex Herpes Zoster Topical Drugs Steroids Antivirals Oral Drugs History Group of viruses established in 1973
Current state of herpesvirale
3 families
3 sub-families
17 genera
90 species
8 human varieties of herpes virus Viral Structure lipid bilayer viral protein & mRNA protective protein cage interface w/ cell membrane receptors Viral Entry
Within one week of infection, the vesicles may ulcerate or harden into crusts. Branches of the Trigeminal thank you for watching. remember to be sensitive when telling patients they have herpes. Herpes Zoster Hutchinson's sign will be apparent since HZO has affected the nasociliary nerve of the ophthalmic branch. Oral acyclovir did not alter the duration or success rates in treating stromal keratitis.

Oral acyclovir did not prevent the development of stromal keratitis in patients with epithelial disease.

Oral acyclovir did decrease the recurrence rate of any type of ocular herpes simplex disease. Post Herpetic Neuralgia Anti-depressants -TCAs work well with these patients
Heat/Cold packs
Capsaicin (topical)
Oral NSAIDS/opioids
TENS Unit
Relaxation techniques No cure available. Treatment for symptoms is available for pain management. Conclusions Note the follicles and watery (as opposed to mucousy) discharge HEDS I HSV-Stromal Keratitis: Topical corticosteroids +topical trifluridine
HSV- Stromal Keratitis: Topical corticosteroids + topical trifluridine + oral acyclovir
HSV-Iridocyclitis: Topical corticosteroids + topical trifluridine + oral acyclovir* HEDS II HSV-Epithelial Keratitis: Early treatment with acyclovir for stromal and iridocyclitis prevention
Prophylactic low dose acyclovir for prevention of recurrence
External triggers for HSV recurrence Rare, but more common in immunodeficient individuals 50-75% chance of ocular involvement *only 50 patients enrolled. Acyclovir MAY be helpful in iridocyclitis, but further research is needed 10% at 1 year
23% at 2 years
36% at 5 years
over 60% at 20 years Recurrence Rates Epithelial keratitis: 9.4 times more likely
Stromal keratitis: 8.4 times more likely
Blepharoconjunctivitis: 34.5 times more likely Overall Recurrence Without Prophylactics
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