DIAGNOSIS AND TREATMENT OF HERPES SIMPLEX KERATITIS UPDATE - PowerPoint PPT Presentation

1 / 82
About This Presentation
Title:

DIAGNOSIS AND TREATMENT OF HERPES SIMPLEX KERATITIS UPDATE

Description:

HERPES SIMPLEX KERATITIS UPDATE XVI JORNADAS ... (DISCIFORM) Cell mediated immune response to viral antigens in stroma or endothelium DISCIFORM KERATITIS ... – PowerPoint PPT presentation

Number of Views:844
Avg rating:3.0/5.0
Slides: 83
Provided by: jean72
Category:

less

Transcript and Presenter's Notes

Title: DIAGNOSIS AND TREATMENT OF HERPES SIMPLEX KERATITIS UPDATE


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
(No Transcript)
9
(No Transcript)
10
Vessicles
11
INFECTIOUS EPITHELIAL KERATITIS
  • Corneal vessicles (PEK)
  • Dendrite
  • Geographic (Amoeboid) ulcers
  • Marginal ulcers (Limbal KC)
  • May be associated with conjunctivitis

12
TREATMENTPrimary Herpes Simplex
  • Oral Acyclovir
  • Topical Trifluridine
  • Observation (self-limited)

13
TYPICAL CORNEAL DENDRITE
  • Of first importance in making the clinical
    diagnosis
  • Dendron (Greek- Tree)
  • True ulcer extends through BM

14
(No Transcript)
15
AVOID ROSE BENGAL IF CULTURE
16
DDXDENDRITIC KERATITIS
  • HSV
  • HZV
  • Healing epithelium
  • Thimerosal (Toxicity)
  • SCL

17
(No Transcript)
18
HZV
19
SOFT CONTACT LENS
20
HEALING EPITHELIUM
21
THIMERASOL TOXICITY
22
HEALING EPITHELIUM
23
HSV
24
GEOGRAPHIC (AMOEBOID) ULCER
  • Wide dendrite
  • DDX epithelial defect scalloped border
  • 4-20 of initial lesions
  • /-Associated with previous steroid use

25
(No Transcript)
26
(No Transcript)
27
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

28
INCREASED INFLAMMATION WBC INFILTRATION
29
TREATMENTInfectious Epithelial Keratitis
  • Eliminate virus in short time
  • Decrease potential risk for immune-mediated
    disease
  • Decrease structural damage
  • Clinical, culture, PCR
  • Goal
  • Purpose
  • Diagnosis

30
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

31
(No Transcript)
32
(No Transcript)
33
(No Transcript)
34
TREATMENTInfectious Epithelial Keratitis
  • If slow healing, consider toxicity
  • If epith ulcer persists, consider neurotrophic
  • Avoid steroids

35
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

36
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

37
(No Transcript)
38
(No Transcript)
39
SECTOR IRIS ATROPHY
  • See in both Simplex and Zoster
  • Older patient - probably Zoster
  • If in doubt - treat with Zoster doses

40
STROMAL KERATITIS
  • 2 of initial episodes
  • 20-48 of recurrent HSV
  • Disciform (Immune only)
  • Necrotizing (direct viral invasion)
  • Metaherpetic (post-herpetic trophic ulcer)

41
(No Transcript)
42
IMMUNE (INTERSTITIAL) STROMAL KERATITIS
(DISCIFORM)
  • Cell mediated immune response to viral antigens
    in stroma or endothelium

43
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
  • Descemets folds and KP

44
DISCIFORM KERATITIS
  • Differential diagnosis
  • HSV
  • HZV
  • Vaccinia
  • Mumps
  • Varicella

45
(No Transcript)
46
STROMAL DISEASE
  • Treatment goals
  • Eradicate HSV
  • Limit scarring
  • Limit lipid deposition

47
TREATMENTStromal Keratitis
  • Treatment depends on severity and location of
    inflammation
  • Necrotizing keratitis
  • Interstitial keratitis
  • Immune rings
  • Limbal vasculitis
  • Disciform keratitis

48
TREATMENTDisciform Keratitis
  • Conservative - self limited
  • Oral Acyclovir 400mg 5x/day
  • Topical steroid - rapid taper
  • No topical antiviral (poor penetration)

49
(No Transcript)
50
NECROTIZING STROMAL KERATITIS
  • WBCs (dense infiltrate with overlying defect
  • Blood vessels
  • Thinning
  • Scarring
  • Necrosis and perforation

51
(No Transcript)
52
(No Transcript)
53
(No Transcript)
54
TREATMENTNecrotizing Stromal Keratitis
  • Never studied by HEDS
  • Acyclovir and topical steroids
  • Taper slowly
  • Maintain steroid at lowest dose
  • Recurrence into visual axis
  • Surgery

55
STEROID TAPER
  • Pred Acetate qid gt bid gt qd gt qod
  • 4-6 weeks between steps
  • Look for KP or edema
  • Switch to weaker steroid
  • Ask if redness when miss drop

56
NEUROTROPIC KERATOPATHYPOST HERPETIC
EROSION(Metaherpetic Keratitis)
  • Follows severe epithelial disease
  • Basement membrane damage
  • Non-healing epithelial defect
  • Clinical course

57
(No Transcript)
58
(No Transcript)
59
TREATMENTNeurotrophic Keratopathy
  • Goal
  • Purpose
  • Diagnosis
  • Decrease exposure to toxic substances
  • Increase lubrication
  • Decrease risk 2º infection
  • Decrease risk of stromal melting
  • Rolled borders of epithelium

60
(No Transcript)
61
TREATMENTTrophic Epithelial Defect
  • Protect ocular surface
  • Non preserved lubricants
  • Therapeutic contact lens
  • Gentle debridement
  • Amniotic membrane
  • Tarsorrhaphy

62
(No Transcript)
63
(No Transcript)
64
ENDOTHELIITIS
  • Inflammatory reaction of endothelium
  • Corneal stromal edema without infiltrate
    (disciform, diffuse, linear)
  • KP, Stromal/epithelial edema, iritis
  • Responds to steroids

65
REACTIVATION HSV
  • Hormonal changes
  • Ultraviolet light
  • Surgery of eye
  • Systemic infection
  • Latanoprost

66
REACTIVATION HSV
  • Stress
  • Fever
  • Immunosuppression
  • Trauma (CL wear)
  • 9.6 first year
  • 36 _at_ 5 years
  • 63 within 20 years
  • HEDS 18 recurrence rate

67
RECURRENT HSV
  • Reactivation in latently infected cells
  • Disease pattern affected by
  • Strain of virus (Can block subsequent infection
    by another strain)
  • Genetic constitution of host

68
(No Transcript)
69
PROPHYLAXIS FOR HSV KERATOPLASTY
  • Use oral acyclovir
  • Pre-op 400mg qid for 3 days
  • Post-op 400mg qid for 7 days 400mg bid for
    3months
  • No controlled studies available

70
(No Transcript)
71
(No Transcript)
72
(No Transcript)
73
(No Transcript)
74
TREATMENTStromal Keratitis
  • If corneal perforation
  • Surgical adhesive
  • Lamellar patch graft
  • PKP
  • Use of oral Acyclovir

75
(No Transcript)
76
VALACYCLOVIR(Valtrex)
  • Absorbed rapidly from GI tract
  • Converted into Acyclovir (Prodrug)
  • Plasma levels 3 times higher than same dose with
    Acyclovir
  • Do Not Use with renal disease and HIV
  • Dose 1 Gram qd

77
(No Transcript)
78
FAMCICLOVIR
  • MOA similar to Acyclovir
  • Inhibits HSV DNA synthesis
  • Rapidly absorbed from GI tract
  • Intracellular 1/2 life is 10-20 times
    longer
  • Lactose intolerance

79
FAMCICLOVIR
  • Dose 500mg bid-tid
  • Side effects similar to Acyclovir
  • More expensive cost

80
CIDOFOVIRPENCICLOVIR
  • Variation in chemical structure
  • Inhibit DNA polymerase
  • Less resistance

81
VALTREX ANDFAMVIR
  • Not more effective than Acyclovir
  • Cost issue
  • Compliance issue

82
HEDS STUDY RESULTS
  • Oral antiviral prophylaxis reduces recurrences of
    epithelial and of stromal keratitis
  • Use of topical steroids is of benefit in stromal
    keratitis
  • Use of oral acyclovir may be of help in
    iridocyclitis
  • Prophylactic oral acyclovir helps prevent
    recurrences of herpetic keratitis, particularly
    stromal with a history of recurrence
Write a Comment
User Comments (0)
About PowerShow.com