RISK FACTORS : Family members/close contact with HSV, History of varicella infection
GENERAL MEASURES :
β’ Warm compresses to skin lesions
β’ Gentle debridement of corneal epithelial lesions
SURGICAL MEASURES Occasionally, debridement of involved epithelium
DRUG(S) OF CHOICE
. Skin and eyelid lesions:
. Prophylactic topical antibiotic ointment, such as bacitracin or erythromycin bid for 1-2 weeks
. Trifl uorothymidine (Viroptic) 1% drops or vidarabine 3% ointment 5 times per day if eyelid margin involved
. Zoster - acyclovir 800 mg po 5 times per day for 10 days or famciclovir 500 mg po tid for 7 days; useful if
started within 7 days of onset and active lesions are present
. Severe or persistent zoster - hospitalize; acyclovir 5-10 mg/kg IV q 8 hours for 5-10 days
. For postherpetic neuralgia in herpes zoster:
- Consider prednisone 60 mg po for 3-7 days and taper off over the next 1-2 weeks
- Cimetidine 400 mg po bid during prednisone treatment
- Consider antidepressant such as amitriptyline 25 mg po tid
. Corneal disease:
. HSV epithelial disease:
- Trifl uorothymidine 1% drops 9 times per day or vidarabine 3% ointment 5 times per day; taper over 10-21 days based on response
- Cycloplegia with scopolamine 0.25% or cyclopentolate 1% drops tid
. Stromal keratitis or uveitis (without epithelial disease):
- Cycloplegia with scopolamine 0.25% or cyclopentolate 1% drops tid
- Topical steroid such as prednisolone acetate 1% drops qid
- Trifluorothymidine 1% drops qid for prophylaxis while on topical steroids
. Optic neuritis, chorioretinitis, or cranial nerve involvement with zoster:
. Acyclovir 5-10 mg/kg IV q 8 hours for 1 week
. Prednisone 60 mg po for 3-7 days and taper over the next 1-2 weeks
. Secondary glaucoma
. Aqueous humor suppressant such as timolol 0.5% drops bid or methazolamide 50 mg po bid or tid
. Neurotrophic ulcer or persistent epithelial disease:
. Consider reducing or discontinuing topical antivirals to avoid toxicity
. Preservative-free lubricant ointment
. Erythromycin 3% ophthalmic ointment q hs or bid
. Consider patching or tarsorrhaphy
Contraindications:
β’ Topical steroids are contraindicated with active corneal epithelial disease
β’ Acyclovir is contraindicated in pregnancy
β’ Prednisone should not be used in immunocompromised patients
Precautions:
β’ Topical antiviral agents are toxic and may cause an allergic reaction; substitution with another agent may be
tried
β’ Topical steroids can raise intraocular pressure
β’ Acyclovir dosage should be reduced in renal insufficiency
ALTERNATIVE DRUGS
β’ Idoxuridine 0.5% ointment or 0.1% drops 5 times per day is more toxic than the other antivirals, but may be
substituted if allergic reaction develops to others
β’ Topical acyclovir ointment to skin lesions - effectiveness uncertain
β’ Medroxyprogesterone 1% drops in place of other steroids if corneal thinning
β’ Capsaicin 0.025% cream tid to 6 times per day for months to years for post-herpetic neuralgia
β’ Non-steroidal anti-infl ammatory agents po for scleritis associated with zoster
β’ Amitriptyline may also be helpful for postherpetic neuralgia
β’ Oral acyclovir 2 gm/day in divided doses x 10 days may be used in patients intolerant of topical antivirals
β’ Oral valacyclovir 500-1000mg bid has been used as an alternative to acyclovir
PATIENT MONITORING :
. Size of epithelial defect
. Vision
. Corneal opacity
. Anterior chamber infl ammation
. Intraocular pressure
PREVENTION/AVOIDANCE
. Avoid close contact with patients with active lesions
. Herpes zoster virus can be spread to individuals who have not had chicken pox
. Avoid known precipitating factors for recurrent HSV
. Topical steroids alone do not reactivate the virus, but may exacerbate spontaneous recurrences
. Very slow taper of topical steroids over many months for corneal epithelial disease
. Antiviral prophylaxis while on topical steroids
. Varicella vaccination prior to infection
. Oral acyclovir 400 mg bid reduces recurrence rate of HSV keratitis by 50%
POSSIBLE COMPLICATIONS
. Corneal neovascularization and scarring resulting in poor vision
. Neurotrophic ulcer with perforation
. Secondary bacterial or fungal infection
. Secondary glaucoma from uveitis or steroid treatment
. Necrotizing interstitial keratitis
. Corneal transplant may be required
. Post-herpetic neuralgia with zoster
. Vision loss from optic neuritis or chorioretinitis
. Systemic involvement
EXPECTED COURSE/PROGNOSIS
. Neonatal primary HSV often disseminated with high mortality rate, 37% have vision worse than 20/200
. Primary HSV in children and adults often asymptomatic; overt disease usually self-limited
. Recurrent ocular HSV:
. Skin lesions in clusters last for 5-7 days
. HSV epithelial disease - without treatment, 40% resolve without sequelae; with treatment, 90-95% resolve without complication
. HSV stromal keratitis usually resolves in weeks to months with some scarring; neovascularization increases risk for severe scarring
. Ocular varicella - may produce a keratitis; usually selflimited, but with occasional complications
. Herpes zoster ophthalmicus
. Dermatitis 8-14 days acute phase with subsequent scarring possible
. Conjunctivitis, episcleritis and scleritis may occur
. Two-thirds of patients develop keratitis and decreased corneal sensation
. Uveitis occurs in about 40%
. Neurotrophic keratitis occurs in one-half; most recover sensation in 2-3 months
. Secondary glaucoma occurs in 10%
. Post-herpetic neuralgia in 20-40%; usually longer lasting in older patients
. Recurrence common for HSV and HZO