Morning Report

Morning Report: 7/12/2012

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Thanks to Dr. Meister for today’s Morning Report!

Morning Report: Zoster Ophthalmicus

Epidemiology:1-3 /1000 cases per year, 10-25% of shingles infections, lifetime risk of shingles is 10-20%, usually starts in 5th decade of life, immune compromised are more at risk

 

Presentation:

Usually flu like illness, fatigue. Fever, malaise, can last up to one week prior to development of rash

Erythemetous macules- 3-5 days to vesicles, crust over in 5-7 days

Eye pain, conjunctivitis, tearing, decreased vision, skin/eyelid rash

Hutchinson’s sign- may be harbinger of worsening ocular involvement as nasociliary branch also innervates cornea

 

Anatomy:

The Ophthalmic Nerve, or first division of the trigeminal, is a sensory nerve. It supplies branches to the cornea, ciliary body, and iris; to the lacrimal gland and conjunctiva; to the part of the mucous membrane of the nasal cavity; and to the skin of the eyelids, eyebrow, forehead, and nose. It passes forward along the lateral wall of the cavernous sinus, below the oculomotor and trochlear nerves; just before entering the orbit, through the superior orbital fissure, it divides into three branches: lacrimal, frontal, and nasociliary

 

Physical exam:

Visual acuity

PHOTOPHOBIA?
Eyelid, conjunctival, scleral swelling
Check for extra-ocular motor integrity, visual field defects

Cotton swab for corneal sensitivity:  test for decreased sensitivity- numbness

Fluorescin stain

Fundoscopic exam:  looking for anterior uveitis
Intra-ocular pressure

 

Complications:

Secondary staph infection

Focal scleral atrophy

Punctate epithelial keratitis

Dendritic keratitits- 4-6 days

Stromal keratititis- fine infiltrates beneath surface of corneal epithelium

Deep stromal keratitis- lipid infiltrates and corneal neovasculariztion- 1 month to years

Uveitis- can lead to scaring/cataracts/gluacoma

Neurotrophic keratopathy: erosions, persistent defects, corneal ulcers months to years

 

Treatment:

Acyclovir/famicyclovir/valycyclovir (TID)   7-10 days, best if given within 72 hours of symptom onset, no clear benefit after, but still gonna give it –  reduces complications and duration of pain ACUTELY, but not post herpetic neuralgia

Steroids:  reduce duration of pain and increase healing rate, but does not reduce post herpetic neuralgia

What are you gonna treat their eyes with?  Depends on the presentation- DON’T GIVE TOPICAL STEROID WITHOUT OPHTHO CONSULTATION- to be avoided if epithelial involvement- a/w spontaneous recurrence of keratitis and exacerbation of symptoms

  • Blepharitis/conjunctivitis – Palliative, with cool compresses and topical lubrication; topical antibiotics for secondary infections
  • Stromal keratitis – Topical steroids
  • Neurotrophic keratitis – Neurotrophic keratopathy is a degenerative corneal disease induced by an impairment of trigeminal nerve. Impairment of loss of corneal sensory innervation is responsible for corneal epithelial defects, ulcer, and perforation. Topical lubrication; topical antibiotics for secondary infections; tissue adhesives and protective contact lenses to prevent corneal perforation
  • Uveitis – Topical steroids; oral steroids; oral acyclovir; cycloplegics
  • Scleritis/episcleritis – Topical nonsteroidal anti-inflammatory agents and/or steroids- scleritis usually more painful and may lead to vision loss

Acute retinal necrosis/progressive outer retinal necrosis – Intravenous acyclovir (1500 mg per m2 per day divided into 3 doses) for 7-10 days, followed by oral acyclovir (800 mg orally 5 times daily) for 14 weeks; laser/surgical intervention

Consider calamine for rash

Hospital admission should be considered for patients with any of the following:

  • Severe symptoms
  • Immunosuppression
  • Involvement of more than 2 dermatomes
  • Significant facial bacterial superinfection
  • Retinal involvement

 

That’s all for now. Leave your comments below.

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital
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