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DIAGNOSIS AND TREATMENT OF HERPES SIMPLEX KERATITIS UPDATE

DIAGNOSIS AND TREATMENT OF HERPES SIMPLEX KERATITIS UPDATE. XVI JORNADAS DE OFTALMOLOGIA DR. BENJAMIN BOYD AUGUST, 2005. RICHARD L. ABBOTT, M.D. PROFESSOR OF OPHTHALMOLOGY. RICHARD L. UCSF FRANCIS I. PROCTOR FOUNDATION. HUMANS ARE THE . HUMANS ARE THE ONLY NATURAL RESERVOIR OF HSV.

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DIAGNOSIS AND TREATMENT OF HERPES SIMPLEX KERATITIS UPDATE

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  1. DIAGNOSIS AND TREATMENT OF HERPES SIMPLEX KERATITIS UPDATE XVI JORNADAS DE OFTALMOLOGIA DR. BENJAMIN BOYD AUGUST, 2005

  2. RICHARD L. ABBOTT, M.D. PROFESSOR OF OPHTHALMOLOGY RICHARD L. UCSF FRANCIS I. PROCTOR FOUNDATION

  3. HUMANS ARE THE HUMANS ARE THE ONLY NATURAL RESERVOIR OF HSV HSV 1 OROPHARYNX HSV 2 GENITAL AREA

  4. TRIFLURIDINE VIDARABINE IDOXURIDINE

  5. HSV OCULAR DISEASE • Approx. 1/2 million people in U.S. • Approx. 20-45% of world population • Approx. 50,000 active episodes annually • Approx. 20,000 new cases annually • By age 5….60% of population infected • Only 6% develop clinical manifestations

  6. PRIMARY HERPES SIMPLEX • Acquired from environment (oral lesions, saliva) • Not from viral latency • Unilateral vesicular blepharoconjuntivitis • Pruritic vessicles of lids, skin, eyelid margin • Follicular conjunctivitis • Palpable preauricular lymph node • PEK (RARE dendrite)

  7. Look for vessicles

  8. Vessicles

  9. INFECTIOUS EPITHELIAL KERATITIS • Corneal vessicles (PEK) • Dendrite • Geographic (Amoeboid) ulcers • Marginal ulcers (Limbal KC) • May be associated with conjunctivitis

  10. TREATMENTPrimary Herpes Simplex • Oral Acyclovir • Topical Trifluridine • Observation (self-limited)

  11. TYPICAL CORNEAL DENDRITE • Of first importance in making the clinical diagnosis • Dendron (Greek- “Tree”) • True ulcer – extends through BM

  12. AVOID ROSE BENGAL IF CULTURE

  13. DDX:DENDRITIC KERATITIS • HSV • HZV • Healing epithelium • Thimerosal (Toxicity) • SCL

  14. HZV

  15. SOFT CONTACT LENS

  16. HEALING EPITHELIUM

  17. THIMERASOL TOXICITY

  18. HEALING EPITHELIUM

  19. HSV

  20. GEOGRAPHIC (AMOEBOID) ULCER • “Wide” dendrite • DDX epithelial defect – scalloped border • 4-20% of initial lesions • +/-Associated with previous steroid use

  21. LIMBAL (MARGINAL) HSV-I KERATITIS • Atypical presentation • More resistant to Rx • DDX: Staph marginal infiltrate • No epithelial defect • Progress circumferential • Associated with blepharitis • Typical location 2, 4, 8, 10

  22. INCREASED INFLAMMATION WBC INFILTRATION

  23. Goal: Purpose: Diagnosis: Eliminate virus in short time Decrease potential risk for immune-mediated disease Decrease structural damage Clinical, culture, PCR TREATMENTInfectious Epithelial Keratitis

  24. TREATMENTInfectious Epithelial Keratitis • Gentle debridement • Topical antivirals (10-14 days max) • Viroptic 1% q 2h or • Vira A 5X/day • If no response 72 hours – STOP • Resistance rate - 3%

  25. TREATMENTInfectious Epithelial Keratitis • If slow healing, consider toxicity • If epith ulcer persists, consider neurotrophic • Avoid steroids

  26. ACYCLOVIR REGIMEN • 400 mg 5x/day for 10-14 days • Reduce to b.i.d. for 10 days • Very safe • Headaches, GI upset • Watch dose renal disease

  27. HSV IRIDOCYCLITIS • 1-9% of all non-traumatic anterior uveitis • May occur independently • Live virus in aqueous • Average time to resolution: 4 weeks • Treat with topical steroids, cycloplegics, and PO Acyclovir • Watch IOP – Trabeculitis

  28. SECTOR IRIS ATROPHY • See in both Simplex and Zoster • Older patient - probably Zoster • If in doubt - treat with Zoster doses

  29. STROMAL KERATITIS • 2% of initial episodes • 20-48% of recurrent HSV • Disciform (Immune only) • Necrotizing (direct viral invasion) • Metaherpetic (post-herpetic trophic ulcer)

  30. IMMUNE (INTERSTITIAL) STROMAL KERATITIS (DISCIFORM) • Cell mediated immune response to viral antigens in stroma or endothelium

  31. DISCIFORM KERATITIS • +/- Previous HSV epithelial keratitis • Non-necrotizing • Focal, multifocal, or diffuse area of edema • Mild lymphocytic stromal inflammatory infiltrate- chronic and recurrent • Epithelium intact • Descemet’s folds and KP

  32. DISCIFORM KERATITIS • Differential diagnosis • HSV • HZV • Vaccinia • Mumps • Varicella

  33. STROMAL DISEASE • Treatment goals • Eradicate HSV • Limit scarring • Limit lipid deposition

  34. TREATMENTStromal Keratitis • Treatment depends on severity and location of inflammation • Necrotizing keratitis • Interstitial keratitis • Immune rings • Limbal vasculitis • Disciform keratitis

  35. TREATMENTDisciform Keratitis • Conservative - self limited • Oral Acyclovir 400mg 5x/day • Topical steroid - rapid taper • No topical antiviral (poor penetration)

  36. NECROTIZING STROMAL KERATITIS • WBC’s (dense infiltrate with overlying defect • Blood vessels • Thinning • Scarring • Necrosis and perforation

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