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112 Cards in this Set

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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 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
treatment of disciform HSV keratitis
what is disciform HSV keratitis accompanied by
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
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
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