Viral Diseases and Look–A- Likes (2 hours)
Matthew J. Garston, O.D.
I. Pearls in Diagnosis of Herpetic disease
A. Herpes Simplex
1) Lashes
2) Conjunctiva-follicles
a. Differential of follicular conjunctivitis
3) Cornea --Rose Bengal vs. Fluorescein
a. Epithelium
b. Stroma
4) Healing response
5) Previous history
6) Anterior chamber reaction
7) Fellow eye-- usually uninvolved
8) Herpes Simplex dermatitis- natural history
9) Other areas of involvement
B. Treatment choices --antiviral drugs-( note Tx trend is toward oral meds)
1) Topical –drops
a) Viroptic -dose (FDA-standard)
every 2h x 9 till healing then q4h x 7 days (this can vary)
2) Topical – gel
a) Zirgan –dose 5xd until healed then 3xd x 7 days
3) Oral
a) Acyclovir-dose 400 mg x 5d for 7 days—least expensive
b) Valtrex --dose 1 gram bid x 10 days
c) Famvir -- dose 250 mg bid x 10 days
4) Debridement + oral antivral
5) Use of topical steroids
a) ? in epithelial disease
b) in stromal disease
c) for secondary iritis
C. Recurrence rates
20% in 2 years
40% in 5 years
67% in 7 years
Reference; Leisegang TJ, Herpes Simplex Virus
Epidemiology & Ocular Importance
Cornea: 2001; (20) 1-13
D.. Treatment options to prevent recurrences
II. Herpes Simplex Cases; Cornea Conjunctiva, & Skin
A. Case 1 -steroid-antibiotic enhanced dendrite
MG Age 21 M
Hx: Tx with steroid antibiotic x 2 weeks –not better
CC: “Left eye still tears and is irritated. Wants second opinion”
B. Case 2 - recurring corneal epithelial disease
NW Age 43
F
Hx: several episodes of H.S. epithelial disease with 2ndary iritis
CC: “My eye problem has returned”
C. Case 3 - Returning epithelial & stromal disease
DS
Age 32
F
Hx: iritis and herpes simplex
CC: “My eye is light sensitive and I need to have steroid drops”
D. Case 4 - Herpetic Dermatitis
AL
Age 32
F
Hx: HSV under eyelid - cornea clear -also genital herpes
CC; Wants us to fill Rx from another health plan
E. Case 5 Eyelid HSV lesion that shortly involved cornea
KF
Age 47
M
Hx: Repeated attacks of HSV
CC: “Redness around left eyelid for 5 days. It began as a blister
and now lid is very swollen.”
F. Case 6 – Trauma triggers HSV keratitis
EB Age 53
F
Hx: Ammonia splashed into her right eye 2 days ago. She still has same
area that did not heal after 2 more days. Sent to eye clinic for evaluation.
CC: slight pain and redness.
G. Case 7 - HSV 3 weeks after given HZV vaccine to prevent HZV
RP
Age 61
M
Hx: as above, but red left eye x 2weeks
CC: Blurred VA and redness not responding to antibiotic Tx
H. Case 8- Painless HSV
JM
Age 25
M
Hx: Punctal stenosis OS
CC: VA decreased, no pain
I. Case 9 Stromal herpes without epithelial involvement
BN
Age 27
M
Hx: Cold sore on lip about 1 week ago
CC: Eye red, lid tender and swollen, VA blurred
E-mycin helped at first but now getting worse.
J. Case 10 – recurring stromal Herpes Simplex
RA Age 86
M
Hx: Repeat episodes of HSV now on Famvir 500 mg 1 x day
to prevent reoccurances
CC: Blurred VA and discomfort
K. Case 11 –Herpes Simplex Conjunctivitis
CB
Age 54
F
Hx; unremarkable
CC: 2 weeks of redness OS that is getting worse with antibiotic Tx
III. Herpes Zoster (HZV)
A. Pearls in diagnosis of Herpes Zoster (shingles)
1) Statistics on corneal involvement
- eye involved in about ½ of cases
within 2-3 days of rash.
2) Corneal staining of Zoster lesion v. Simplex lesion
3) Facial and body locations for skin lesions
4) Herpes Zoster and age
B. Associated body signs
Ache, flu, face or body pain
C) Treatment for pain and lesion
1) oral antivrals-- best if within 2-3 days of onset of Sxs
D. Treatment to prevent recurrences
IV. Herpes Zoster Cases
A. Case 12- Herpes Zoster Corneal findings
KA
Age 36 M
Hx: left sided facial pain started about 4-5 days ago
2 days later he developed a rash.
CC: My left eye feels “scratchy”
Treatment pearls: Steroids are used only if there is significant
underlying corneal edema. Lubrication alone may be the best Tx.
as it was in this case.
V. Look A-Like cases
A. Case 13 - Early Acanthamoeba Keratitis
AK
Age 22
M
Hx: daily disposable contact lens wearer. Used tap water with lenses.
CC: “My right eye is red and I am in terrible pain.”
B. Case 14 - recurrent corneal erosion from Map Dot Fingerprint Dystrophy
AB
Age 37
F
Hx: frequently rubs eyes
CC: eye pain left eye started yesterday afternoon after eye rubbing
C. Case 15 - Classic Epidemic Keratoconjunctivitis (EKC) Case
(Follicles and early puntate lesions can resemble early HSV)
RG
Age 35
M (optometrist)
Hx: shook hands with a patient who had a red eye
CC: Scratchy feeling and VA blurring in right eye
VI. Summary