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Anterior Segment Disease > 2: Herpes > Flashcards

2: Herpes Flashcards

1
Q

herpes simplex virus (HSV) is the leading cause of _____

A

infectious corneal blindness in all developed countries

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2
Q

HSV is categorized by _____, and further categorized by _____

A

viral strand;

infection- primary or recurrent

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3
Q

primary HSV-1 transmission

A
  • mucosal membranes
  • saliva
  • tears
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4
Q

primary HSV-1 is highly ______;

____% of population get it by age 5, and _____% by age 60

A

contagious;
60;
~100

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5
Q

primary HSV-1 most common patient populations

A

school-aged children** and neonates (rare)

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6
Q

primary HSV-1 has a more severe presentation in _____

A

neonates and immunocompromised

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7
Q

primary HSV-1 symptoms are _____;

symptoms include:

A

RARE (~94% of patients are asymptomatic);

  • flu-like malaise
  • low-grade fever
  • possible concurrent upper respiratory infection
  • oropharynx > ocular
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8
Q

primary HSV-1 ocular clinical signs

A
  • pre-auricular node swelling
  • vesicular rash (eyelids and adnexa)
  • follicular conjunctivitis
  • rare: multiple corneal punctate lesions –> coalesce into epithelial dendrite
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9
Q

primary HSV-1: epithelial vesicles

A
  • contain the live virus

- primary HSV-1 vesicles are limited to the epithelium

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10
Q

after active infection, primary HSV-1 lies latent in the _____

A

trigeminal and dorsal root ganglia

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11
Q

recurrent HSV-1 transmission

A
  • mucosal membranes
  • saliva
  • tears
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12
Q

recurrent HSV-1 has more severe presentation in _____

A

children and immunocompromised

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13
Q

recurrent HSV-1 laterality

A

unilateral&raquo_space; bilateral

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14
Q

ocular involving recurrent HSV-1 is also known as _____

A

Herpes Simplex Keratitis (HSK)

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15
Q

ocular involving recurrent HSV-1 (HSK) symptoms

A
  • pain/ocular discomfort
  • photophobia
  • watering
  • itching
  • decreased vision/blurry vision
  • corneal desensitization (hypoesthesia)
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16
Q

ocular involving recurrent HSV-1 (HSK) signs

A
  • pre-auricular node swelling
  • vesicular rash (eyelids and adnexa)
  • follicular conjunctivitis
  • dendritic keratitis**
  • conjunctival injection
  • superficial macropunctate keratitis (larger punctate areas than classic SPK)
  • other anterior and posterior complications
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17
Q

ocular involving recurrent HSV-1 (HSK): adnexal and eyelid vesicles

A

clear vesicles on an erythematous base that progress to crusting (more itchy than painful)

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18
Q

ocular involving recurrent HSV-1 (HSK): corneal types of HSK

A

HSK-epithelial:

  • dendritic
  • geographic
  • neurotrophic
  • marginal

HSK-stromal:

  • disciform (also is endothelial)
  • immune
  • necrotizing

Endotheliitis

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19
Q

HSK-epithelial: dendritic keratitis

A
  • pathognomonic herpetic finding
  • ulceration of the epithelium with underlying stromal thinning
  • heaped, swollen epithelial cells create boundary and terminal end-bulbs
  • branching/arborized appearance
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20
Q

HSK-epithelial: dendritic keratitis staining

A
  • (+) stain with fluorescein in center

- (+) stain with fluoroscien (mild), rose bengal, lissamine green along boundary

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21
Q

HSK-epithelial: dendritic keratitis left unmanaged

A

unmanaged –> corneal haze, stromal infiltration –> scarring

22
Q

HSK-epithelial: geographic keratitis

A
  • dendritic may progress to geographic

- swollen, scalloped borders

23
Q

HSK-epithelial: neurotrophic keratitis

A
  • sterile ulcer
  • typically in tandem with interstitial (necrotizing) keratitis
  • stromal melt and corneal perforation –> “endophthalmitis”
  • corneal degradation –> desnsitization –> “I got better!”
  • vision threatening
24
Q

HSK-epithelial: marginal/limbal keratitis

A
  • active virus + inflammatory reaction

- peripheral ulcer –> stromal infiltrate –> limbal/corneal neo

25
Q

HSK-stromal: disciform keratitis

A
  • non-necrotizing (does not degrade the corneal tissue), immune response to residual herpetic proteins –> inflammation
  • opaque or “ground glass”, disc shaped stromal and endothelial infiltration with stromal and endothelial edema
  • can occur concomitantly with HSK-epithelial, can occur after HSK-epithelial
26
Q

HSK-stromal: immune, stromal keratitis (SK)

A
  • non-necrotizing stromal keratitis, aka “stromal keratitis”
  • round/lobulated opaque/whitened stromal infiltration (haze and scarring)
  • can occur concomitantly with HSK-epithelial, can occur after HSK-epithelial
27
Q

HSK-stromal: necrotizing, interstitial keratitis (IK)

A
  • less common, more severe
  • white/gray opaque stromal infiltration with necrosis and ulceration, stromal edema, possible abscess, corneal neovascularization
  • may also have concomitant uveitis, hypopyon, trabeculitis (inflammatory increase in IOP)
  • unmanaged IK –> neurotrophic ulcer, corneal perforation
  • high risk of vision loss
28
Q

HSK-endothelial: endotheliitis

A
  • endothelial keratitis
  • typically in tandem with HSK-stromal involvement, especially disciform
  • presents with endothelial folds, endothelial edema, stromal edema, may include keratic precipitates
  • concomitant uveitis, trabeculitis (increased IOP)
  • high risk of vision loss
29
Q

recurrent HSV-1 (HSK) complications

A
  • corneal hypoesthesia (especially with corneal involvement)
  • uveitis: anterior, intermediate, posterior, panuveitis; typically in tandem with SK, IK, or endotheliitis; AC rxn (mild to severe), granulomatous KPs, elevated IOP; iris atrophy, posterior synechiae, secondary angle closure (trabeculitis)
  • scleritis > episcleritis
  • retinitis, acute retinal necrosis (ARN): neonates, immunocompromised, concurrent HIV/AIDS infection; severe, bilateral, rapid progression
  • optic neuritis: optic nerve edema, typically in tandem with retinal necrosis
30
Q

varicella zoster virus (VZV) categorization

A

categorized by infection: primary or recurrent

31
Q

primary VZV

A
  • chicken-pox
  • childhood condition
  • largely declined since introduction of the varicella vaccination in 1995
32
Q

recurrent VZV

A
  • shingles
  • elderly > adult condition
  • can occur at any age, but typically 60-80 years
33
Q

VZV laterality

A

ALWAYS unilateral*

34
Q

after primary infection, VZV lies dormant in ____

A

trigeminal ganglion

35
Q

3 stages of reactivated VZV

A

1) prodrome (pre-eruptive)
2) active virus outbreak (acute eruptive, active HZO)
3) post-herpetic neuralgia (chronic neuropathy)

36
Q

reactivated VZV prodrome symptoms

A

more common:

  • headache
  • fever
  • malaise
  • bodily tingling, burning, pain
  • blurred vision, ocular irritation, photophobia

less common:

  • moodiness
  • depression
  • insomnia

*prodrome symptoms may carry over with the active viral outbreak

37
Q

reactivated VZV outbreak

A
  • aka: shingles
  • erythematous rash –> erupts into crusty, scaly vesicular lesions; follows trigeminal dermatome pattern; ALWAYS respects facial midline*; may involve scalp, face, ear, neck, torso, arms, legs; intensely painful!
  • Hutchinson’s sign: vesicular eruptions on tip of the nose; still respects facial midline; signals nasociliary nerve involvement –> higher risk of ocular involvement
  • ocular complications (HZO)
38
Q

herpes zoster ophthalmicus (HZO)

A
  • 10-20% of all shingles patients
  • VZV reactivation along the ophthalmic branch of the trigeminal nerve; HZO linked to weakening T-cell immunity of elderly and immunocompromised pts
39
Q

herpes zoster ophthalmicus (HZO) symptoms and signs

A
  • blurred vision
  • ocular irritation
  • photophobia
  • redness
  • tearing
  • painful unilateral vesicular rash (look at scalp, forehead, ear, behind ear, adnexa, eyelids, cheek, nose)
  • periorbital edema
  • ptosis (from edema)
  • corneal involvement
40
Q

herpes zoster ophthalmicus (HZO) corneal involvement

A
  • pseudodendrite*
  • superficial punctate keratitis (SPK)
  • disciform stromal keratitis, immune stromal keratitis (SK), necrotizing/interstitial keratitis (IK), endotheliitis
  • neurotrophic ulcer
  • neovascularization, corneal thinning, corneal opacification
41
Q

pseudodendrite

A
  • elevated mucosal plaque, “painted on” appearance
  • not a true epithelial ulcer
  • less vibrant/less complete staining with fluorescein
  • expect minimal to no rose bengal or lissamine green staining
  • no terminal endbulbs; tapered lines
  • may also present with filaments
42
Q

VZV/HZO complications

A
  • uveitis: anterior, intermediate, posterior, panuveitis; AC rxn (mild to severe), granulomatous KPs; iris atrophy, posterior synechiae, trabeculitis –> increased IOP
  • scleritis: anterior and posterior
  • retinitis/choriditis: slight increased predilection to involve choroid over HSV
  • optic neuritis
  • brain and orbit: CVA/ischemic damage; orbital apex syndrome
43
Q

orbital apex syndrome

A
  • paralysis of CN II, III, IV, VI, ophthalmic branch of CN V
  • optic nerve atrophy, permanent visual loss even with restoration of EOM movement and reduction of orbital inflammation with systemic steroids
44
Q

post-herpetic neuralgia (PHN)

A
  • develops if recurrent VZV is unmanaged
  • ~72 hour window to initiate appropriate treatment
  • severely painful nervous condition
  • can last months to years post active infection
  • # 1 cause of suicide in patients with chronic pain >70 years old
45
Q

VZV prevention

A
  • varicella vaccine: “chicken-pox” vaccine, 1995
  • Zostavax: 2006, no longer vaccination of choice for shingles
  • Shingrix: 2017, proven greater efficacy than Zostavax at shingles prevention
  • reduced risk of VZV complications
  • 90% effectivity in prevention of shingles AND PHN ages 50-70
  • 85% for 70+
  • approved for 50+
  • 2 doses separated by 2-6 months
  • not approved for immunocompromised or those receiving chemo/radiation
  • may receive even if had Zostavax vaccine previously
  • may receive if had shingles previously, just not during active infection
46
Q

oral antiviral doses for HSK

A
  • acyclovir: 400 mg 5x/day PO x7-10 days
  • valacyclovir: 500 mg tid PO x7-10 days
  • famciclovir: 250 mg tid PO x7-10 days
47
Q

oral antiviral doses for VZV/HZO

A
  • acyclovir: 800 mg 5x/day PO x7-10 days
  • valacyclovir: 1000 mg tid PO x7-10 days
  • famciclovir: 500 mg tid PO x7-10 days
48
Q

oral antivirals for prophylaxis

A
  • acyclovir: 400 mg bid
  • valacyclovir: 500 mg qd
  • famciclovir: 250 mg bid
49
Q

reasons for prophylaxis tx of herpes

A
  • multiple recurrences of any type of HSV keratitis, especially HSV stromal keratitis
  • recurrent inflammation with scar/vascularization approaching visual axis
  • more than one episode of HSV keratitis with ulceration
  • post-keratoplasty performed for HSV-related scarring/astigmatism
  • postoperatively in patients with a history of HSV ocular disease undergoing any type of ocular surgery or laser procedure
  • in patients with a history of HSV during immunosuppressive treatment
50
Q

intravenous antivirals for herpes

A
  • for immunocompromised or sight threatening disease

- more common for posterior segment complications or patients with concurrent HIV/AIDS, CMV

Anterior Segment Disease (22 decks)

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