Herpes Zoster Ophthalmicus (HZO)

Presented by SEA Bunseng, First Year ResidentKhmer Soviet Friendship Hospital

Outline

I. What is Herpes Zoster Ophthalmicus (HZO)?

II. Anatomy of CN V

III.Pathophysiology

IV. Risk of Ocular Involvement

V. Clinical Manifestation

VI. Management

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.

II. Anatomy of CN V

III. PathophysiologyFollowing 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

IV. Risk of Ocular Involvement

✤ Hutchinson Sign

✤ Age

✤ AIDS

V. Clinical Manifestation

A. Acute Shingle

✴ A Prodromal Phase

✴ Skin Lesions

✴ Disseminated Zoster

V. Clinical Manifestation

A. Vesicles B. Confluent crusting

C. Haemorrhagic rash with involvement of both the ophthalmic and maxillary nerve

D. Residual Scarring

V. Clinical Manifestation B.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

V. Clinical Manifestation

A. Dendritic epithelial lesions with tapered ends

B. Nummular keratitis

C. Stromal Keratitis

V. Clinical Manifestation C. 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

V. Clinical Manifestation

A. Scleral atrophy B. Mucous Plaque Keratitis C. Lipid filled granuloma

Cicatricial entropion Cicatricial ectropion

V. Clinical Manifestation

D. 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.

VI. Management

A. 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

VI. Management

B. 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

VI. Management

B. 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

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, 7th 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, 5th Edition. Lippincott Williams & Wilkins

✴http://emedicine.medscape.com/article/1132465-overview ✴http://eyewiki.aao.org/Herpes_Zoster_Ophthalmicus