Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
112 Cards in this Set
- Front
- Back
|
overview of herpes simplex virus
|
ds DNA virus; HSV-1 and HSV-2 (80/20) rule; most common cause of corneal opacification
|
|
|
when does the first infection usually occur for herpes simplex virus
|
6 months and 5 years; 80% of adults have antibodies but only 25% manifest
|
|
|
1st exposure infects what with herpes simplex virus
|
the peripheral end organ then travels to ganglia where it may become latent
|
|
|
relapses and immunocompromised
|
common with steroids, UV exposure, stress, fatigue, irradiation, fever, etc
|
|
|
time course of disease
|
once the patient begins to mainfest sgns of infection the entire disease course can run 3-4 weeks or longer
|
|
|
what are the ocular and neurologic manifestations that herpes simplex virus include
|
blepharitis; cnalicular obstruction/canaliculitis; conjunctivitis; keratitis; uveitis; retinitis; encephalitis
|
|
|
s/s of herpes simplex virus blepharitis
|
vesicular lesions later become pusturlar lesion
|
|
|
course of s/s for herpes simplex virus blepharitis
|
pustules eventually break and ulcerate
|
|
|
how long for herpes simplex virus blepharitis to resolve
|
within a week without scarring
|
|
|
what is the first manifestation of eye involvement for herpes simplex virus
|
HSV blepharitis but patients don't always seek care bcs self-limiting not always perceived by patient as eye problem
|
|
|
s/s of HSV conjunctivitis
|
follicular conjunctivitis; moderate to severe injection, hyperemia, chemosis of conjunctiva (with or without PEK); may have pseudomembrane formation; may precede corneal infection or occur in isolation of it
|
|
|
if have recurrent case of follicualr conjunctivitis should look for
|
HSV
|
|
|
HSV Uveitis s/s
|
presents as cells and flare in anterior chamber with or without hypopyon, KP's, etc.; cells and flare are present long after the active infectious process occurs
|
|
|
HSV Retinitis s/s
|
acute retinal necrosis syndrome; bilateral and visually devastating
|
|
|
what does HSV retinitis occur in association with
|
HSV encephalitis
|
|
|
HSV encephalitis
|
neurologic complications are possible with HSV. MRI is diagnostic
|
|
|
what is the spectrum of HSV keratitis disease
|
epithelial disease; stromal disease; neurotrophic keratopathy; endothelitis
|
|
|
what is the more common way that HSV epithilial keratitis will present itself
|
PEK (punctate epithelial keratitis); so use caution whenever you have a follicular conjunctivitis with PEK - rule out HSV before treating for non specific conjunctivitis
|
|
|
what are all the ways that epithilial HSV keratitis will present
|
PEK, small bulbous epithelial lesions, a dendritic ulcer, or a geographical ulcer
|
|
|
Many cases of epithelial involvement show dendrite formation explain
|
dendrite formation is an area of the cornea which is devoid of epithelium and therefore stains with fluorescein
|
|
|
what happens in the area surrounding the dendrite when you stain with fluorescein
|
percolation of fluorescein
|
|
|
explain how the dendrite looks when stained
|
the edges of the terminal ends (end bulbs) of the dendrite contain actively replicating virus in epithelial cells and stain vividly with rose bengal
|
|
|
when the epithelial HSV keratitis ulceration is large what is it called
|
geographical ulcer (it may or may not have dendritic edges)
|
|
|
geographic vs. dendritic ulcers
|
the geographic ulcer responds more slowly than dendritic ulcers to antiviral agents
|
|
|
c/o patient with epitheilial HSV keratitis
|
redness, pain, photphobia, tearing, FBS, reduced VA, hypoesthesia may be presenting symptoms
|
|
|
HSV keratitis stromal inflamation otherwise known as
|
immune stromal keratitis or interstitial keratitis
|
|
|
HSV keratitis superficial stromal scarring s/s
|
faint superficial scars that have developed under an epithelial ulcer, especially if it is chroic and treatment has been delayed or inadequate
|
|
|
treatment for HSV Keratitis superficial stromal scarring
|
treatment is directed at healing the epithelium
|
|
|
HSV necrotizing stromal keratitis s/s
|
lesions appears white, necrotic, and heavily infiltrated. May extend deep into the stroma, resulting in marked corneal thinning or perforation
|
|
|
what is HSV necrotizing stromal keratitis due to
|
this is an immune reaction
|
|
|
treatment for HSV necrotizing stromal keratitis
|
viroptic 1% with corticosteroids to reduce the immune response and minimize eventual stromal scarring
|
|
|
HSV disciform edema keratitis s/s
|
occurs centrally as a disc or corneal edema similar to that caused by Fuchs dystrophy or hydrops.
|
|
|
what is HSV disciform edema keratitis associated with
|
KP's
|
|
|
treatment of disciform HSV keratitis
|
steroids
|
|
|
what is disciform HSV keratitis accompanied by
|
iritis
|
|
|
etiology of disciform HSV keratitis
|
may be a toxic reaction caused by the presence of antigen antibody complexes
|
|
|
what is the effect of oral acyclovir in treating HSV stromal keratitis in patients receinvingconcomitant topical corticosteroids and trifluridine
|
No significant beneficial effect of oral acyclovir in treating HSV stromal keratitis in patients recieving corticosteroids and trifluridine
|
|
|
individuals with prior HSV epithelial keratitis and certain ethnic groups may have what?
|
higher rate of recurrent epithelial keratitis during the acute treatment of HSV stromal keratouveitis
|
|
|
statistics about recurrent HSV stromal keratitis and acyclovir
|
Oral acyclovir given to patients with HSV epithelial keratitis provides no benefit in preventing HSV stromal keratitis or iritis during the subsequent year. Stromal keratitis or uveitis patients were more likely to develop it again
|
|
|
when will acyclovir be beneficial to patients for ocular or orofacial HSV disease
|
after the resolution of ocular HSV disease, 12 months of treatment with acyclovir reduces the rate of recurrent ocular and orofacial HSV disease
|
|
|
long term oral acyclovir treatment and epithelial and stromal HSV
|
long term oral acyclovir treatment reduces epithelial and stromal HSV especially stromal HSV
|
|
|
does having epithelial keratitis predict you will have epithelial keratitis / does stromal keratitis predict you will have it again.
|
epithelial keratitis does not predict epithelial keratitis but stromal keratitis increases the probability of future stromal keratitis
|
|
|
how much to treat a HSV ocular patients
|
$299
|
|
|
because such a high cost what question do you need to ask yourself
|
which patient need prophylaxis most
|
|
|
Drug used for HSV keratitis treatment and percentage
|
viroptic 1%
|
|
|
HSV keratitis; how often do you use antiviral
|
q2h up to 9 times a day during acute infection, tapering as condtion responds; continue QID for 3-5 days after complete re-epithelialzation occurs
|
|
|
HSV keratitis; what is the limit of use for the antibiotic
|
21 days; due to the keratotoxicity of the viroptic drops
|
|
|
describe the surgical treatment for HSV keratitis
|
mechanical debridement of the dendritic lesion (under anesthetic). Follow with viroptic drops in office until epithelium heals q2h to tapper program
|
|
|
how often does the dr need to f/u with patient who has epithelial HSV
|
daily until re-epithelialization
|
|
|
HSV conjunctivitis without keratitis
|
If no corneal involvement is seen but HSV is confirmed use viroptic 1% QID prophylacticaly along with supportive therapy
|
|
|
what is supportive therapy for HSV conjunctivitis
|
artifical tears, cool compresses, vasoconstrictors, and NSAIDS if symptoms are severe
|
|
|
what are the two antiviral agents
|
viroptic 1% and vidarabine (antoher anti-viral agent ointment which may offer some addtional comfort
|
|
|
what is the f/u for pt with HSV conjunctivitis
|
every 2-3 days to check for involvement of cornea
|
|
|
if cornea gets involved with HSV conjunctiva during f/u what is treatment
|
increase viroptic to q2h and follow daily until resolution
|
|
|
HSV blepharitis treatment lid lesion alone
|
optional; topical antibiotic ung on lid lesion to minimize secondary bacterial infection
|
|
|
HSV blepharitis treatment for lid lesions close to margin and conjunctivitis
|
viroptic 1% QID to cover cornea prophylactically
|
|
|
HSV blepharitis severe complecated cases
|
oral acyclovir
|
|
|
follow up for HSV blepharitis
|
depends on degree of suspicion of corneal involvement (every 3-4 days for low risk and every 1-2-3 days for higher risk)
|
|
|
acyclovir and HSV blepharitis
|
acyclovir may be used orally, topically(3% ointment) or intravenously as a supplement to viroptic or other topical therapy or in patients who are intolerant to viroptic
|
|
|
what can be used in conjucntion with viroptic in HSV blepharitis
|
vidarabine ointment especially in overnight coverage.
|
|
|
If patient is not responsive to first line therapy what can the dr use for HSV blepharitis
|
other anti-viral agents; herplex, stoxil
|
|
|
can steroids be used
|
yes but be very careful.
|
|
|
when can steroids be used
|
for immunologic herpetic reactions only
|
|
|
when don't you use steroids for HSV
|
do not use for active epithelial infectious disease
|
|
|
what are examples of when you use corticosteroids for HSV
|
disciform corneal edema that is affecting VA; uveitis persisting after active infection; necrotizing stromal inflammation without epithelial without epithelial staining
|
|
|
what is the treatment for the examples of when you use corticosteroids for HSV
|
use steroids and viroptic 1% in equal dosing frequency
|
|
|
when are corticosteroids contraindicated with HSV
|
on patients with immunologic herpes simplex disease without prophylactic coverage with viroptic
|
|
|
what is the concern with using steroids
|
since steroids depress the immune system reactivation of epithelial disease may occur under these conditions (even if the active epithelial process was not evident at the time of initiating treatment with steroids
|
|
|
What is the rule of thumb when it comes to ocular HSV treatment
|
any epithelial involvement gets viroptic and no steroids. Any stromal (and no epithelial) gets steroids but must cover with viroptic prophylactically to prevent reinfection of epithelium
|
|
|
HSV and oral agents
|
oral agents are given prophylactically to those patients most at risk for recurrences
|
|
|
what are the surgical treatments for corneal scarring
|
conjuctival flaps, lamellar keratoplasty, penetrating keratoplasty, PKP(preferred for severe corneal scarring)
|
|
|
Herpes Zoster Virus primary infection
|
vesicular rash over face, trunk, and extremities
|
|
|
HZV is called what when it effects tip of nose, eye
|
Herpes Zoster Ophthalmicus; V1 is affected; called Hutchinson's sign
|
|
|
what is the spectrum of HZV anterior segment
|
Blepharitis, Conjunctivitis, Keratitis, neurotrophic keratitis, scleritis/episcleritis, POST-HERPETIC NEURALGIA, uveitis
|
|
|
HZV spectrum posterior segment and beyond
|
retinitis, choroiditis, optic neuritis, cranial nerve palsy, may contribute to glaucoma (secondary to uveitis or to the use ot steroids to treat other manifestations)
|
|
|
what is HZV prodrome
|
pts can tell virus about to act up. They get pain, itching, paresthesias along future site of skin eruption, may have flu like symptoms
|
|
|
explain prodrome paresthesias
|
diminshed sensation despite exquisite tenderness
|
|
|
How far in advance will the HZV paitent have prodrome
|
2-3 days
|
|
|
what is the dermatological presentation of HZV
|
well circumscribed, erythematous, maculopapular skin eruptions following dermatomes
|
|
|
in HZV when do the painful vesicles develop
|
within 12 - 24 hours
|
|
|
How long do the painful vesicles last in HZV
|
7-10 days
|
|
|
which HZV is hardest to treat
|
uveitis
|
|
|
what does hutchinson's sign indicate
|
that the eye would be involved
|
|
|
what other dermatomes can HZV follow
|
V2, V3
|
|
|
what does HZV Blepharitis refer to
|
the dermatologic manifestations of this disease
|
|
|
s/s of HZV conjunctivitis
|
follicular; appears similar to other follicular infections; conjunctival chemosis; hyperemia may be profound; not impressive part of illness
|
|
|
s/s of Herpes Zoster Keratitis
|
may present as pseudo-dentrites(have a stuck on appearance instead of excavation)
|
|
|
what is the difference between HSV and HZV end bulbs on the dendrites
|
the dendrites in HZV don't stain as well with rose bengal or fluroscein; may also get plaques, PEK (most commonly)
|
|
|
why does neurotrophic keratitis a sequela to HZV
|
it is a result of damage to the corneal nerves
|
|
|
what are the corneal nerves critical for?
|
the integrity of the corneal epithelium; w/o innervation the epithelium may be sloughed off
|
|
|
treatment of neurotrophic keratitis
|
aggressive lubricant therapy; may require surgical intervention
|
|
|
post-herpetic neuralgia (PHN) definition
|
pain that persits beyond the course of active infection (sometimes 3 months after symptoms first appear)
|
|
|
what is the most serious manifestation of HZV
|
post herpatic neuralgia
|
|
|
the incidence of post herpetic neuralgic increases with what
|
it increases with increasing age of the patient;
|
|
|
why does the pain occur in post herpetic neuralgia
|
the pain occurs because of scarring of the nerve endings as a result of the skin eruptions
|
|
|
can phn be minimized
|
yes with proper treatment early in disease course
|
|
|
which drugs are used to treat Herpes Zoster Virus
|
Acyclovir, Famvir, Valtrex, Antibiotic ung, steroids, supportive therapy
|
|
|
HZV dose of acyclovir
|
800 mg 5 times per day for 7-10 days
|
|
|
when is acyclovier most effective
|
if skin lesions are less than 72 hours old
|
|
|
HZV dose of Famvir
|
500 mg TID x 7 days
|
|
|
HZV dose of Valtrex
|
1 gram TID x 7 days
|
|
|
HSV dose of acyclovir
|
400 mg 5 times per day for 10 days (if herpes is in active state); 400 mg BID for prohylaxis
|
|
|
HSV dose of Famvir
|
125-500 mg BID x 5 days (active); 250 BID for prophylaxis
|
|
|
HSV dose of Valtrex
|
1 g BID x 10 days (active); 500mg - 1g QD for prophylaxis
|
|
|
which drugs are off label for HSV and HZV
|
Acyclovir, Famvir, Valtrex
|
|
|
why do you use antibiotic ung for HZV
|
for prophylactic protection of skin lesions to prevent secondary bacterial infection; for conjunctivitis and keratitis to prevent secondary bacterial infection
|
|
|
what type of compresses do you use on the skin
|
cool - tepid compresses to skin areas avoid hot
|
|
|
why topical steroids
|
if intraocular inflammation is present even if the cornea is compromised as long as antibiotics are on board to prevent secondary superinfection
|
|
|
HSV supportive therapy includes what
|
artificial tears, vasoconstritors, topical NSAIDS; do not underestimate the value of supportive therapy
|
|
|
if post herpetic neuralgia is present what do you prescibe
|
oral steroids and analgesics; tricyclic antidepressants
|
|
|
if the patient is immunocompromised what does the dr need to do
|
hospitalize with IV acyclovir to prevent the occurence of retinal necrosis
|
|
|
is viroptic effective for HZV
|
NO
|
