This document discusses ocular herpes, including herpes zoster ophthalmicus (HZO) and herpes simplex virus (HSV). HZO causes a dermatomal rash along the trigeminal nerve and can lead to ocular involvement. Treatment includes oral, topical, or dermatological antivirals. HSV is common and can cause various forms of keratitis through epithelial, stromal, neurotrophic, or endothelial involvement. Management involves antiviral medications, topical steroids, and debridement as needed depending on the type and severity of infection. Long term sequelae can include recurrent uveitis, dry eye, scarring, or neuralgia.

1. Ocular HerpesOcular Herpes
HSV 1 and HZOHSV 1 and HZO
Treatment and PreventionTreatment and Prevention

2. Herpes ZosterHerpes Zoster
OphthalmicusOphthalmicus
 Dermatomal disease occurring alongDermatomal disease occurring along
ophthalmic division of trigeminal nerveophthalmic division of trigeminal nerve
 Nasociliary branch most indicative ofNasociliary branch most indicative of
ocular involvementocular involvement
 Hutchenson’s signHutchenson’s sign

4. HZOHZO
 Incidence increasingIncidence increasing
 Vaccine availableVaccine available
 Ocular involvement variedOcular involvement varied
 Oral, topical, dermatological therapyOral, topical, dermatological therapy

5. Incidence of ShinglesIncidence of Shingles
Lifetime risk is 15-20% and peaks in 7Lifetime risk is 15-20% and peaks in 7thth
decadedecade
10-20% of shingles is HZO10-20% of shingles is HZO
10X greater risk in whites and slight10X greater risk in whites and slight
increase in femalesincrease in females
10X greater risk with HIV10X greater risk with HIV

6. ZostavaxZostavax
 Vaccine approved for those over 50Vaccine approved for those over 50
 Reduces the incidence and severity ofReduces the incidence and severity of
Zoster and PHNZoster and PHN
 Insurance covers those over 50 (CDCInsurance covers those over 50 (CDC
guideline) -- $200-300 if out of pocketguideline) -- $200-300 if out of pocket

7. ZostavaxZostavax
 Given after all lesions have healed forGiven after all lesions have healed for
those with recent outbreakthose with recent outbreak
 Will cause chickenpox in those whoWill cause chickenpox in those who
have never had ithave never had it
 Avoid in patients with NeomycinAvoid in patients with Neomycin
allergy, on systemic steroids and theallergy, on systemic steroids and the
immuno-compromisedimmuno-compromised
 Avoid pneumovax for 4 wksAvoid pneumovax for 4 wks

8. Initial symptoms of HZOInitial symptoms of HZO
 Prodromal dermatological painProdromal dermatological pain
 ItchItch
 Redness and swellingRedness and swelling
 Vesicles and ulcerationVesicles and ulceration
 Watch for abdominal distressWatch for abdominal distress

10. HZOHZO
 Skin lesions shed virus for 1-2 weeksSkin lesions shed virus for 1-2 weeks
after first symptoms appearafter first symptoms appear
 Avoid contact with pregnant womenAvoid contact with pregnant women
and the immuno-compromisedand the immuno-compromised

12. HZO treatmentHZO treatment
 Oral therapy best if within 72 hrs of onsetOral therapy best if within 72 hrs of onset
 Acyclovir 800mg 5x/day for 10 days isAcyclovir 800mg 5x/day for 10 days is
standard and usually well covered bystandard and usually well covered by
insuranceinsurance
 Valaciclovir (Valtrex) 1000mg tid for 10 daysValaciclovir (Valtrex) 1000mg tid for 10 days
 Famvir 500mg tid for 10 daysFamvir 500mg tid for 10 days

13. XereseXerese
 Acyclovir and Hydrocortisone creamAcyclovir and Hydrocortisone cream
5%/1%5%/1%
 Dermatological formulationDermatological formulation
 Single use packetsSingle use packets
 On-line discount vouchers availableOn-line discount vouchers available

15. Blepharitis/ConjunctivitisBlepharitis/Conjunctivitis
 Lid margin ulcers seen in 60-80% ofLid margin ulcers seen in 60-80% of
cases – use antibiotic/steroid ungcases – use antibiotic/steroid ung
 Conjunctival vesicles appear in 50%,Conjunctival vesicles appear in 50%,
episcleritis also commonepiscleritis also common
 Treat with topical steroidTreat with topical steroid
 Hypoasthesia-25% with profound lossHypoasthesia-25% with profound loss
of sensation go on to developof sensation go on to develop
neurotrophic keratitisneurotrophic keratitis

17. Corneal epithelialCorneal epithelial
lesionslesions
 Seen in 40% of patientsSeen in 40% of patients
 SPK common and can lead to infiltrativeSPK common and can lead to infiltrative
keratitis—can resemble HSVkeratitis—can resemble HSV
keratitis(pseudodendrites), but no end bulbskeratitis(pseudodendrites), but no end bulbs
and not ulcerativeand not ulcerative
 Treat with steroid and antibiotic coverTreat with steroid and antibiotic cover
 Filamentary keratitis and mucus plaquesFilamentary keratitis and mucus plaques

20. Mucus plaquesMucus plaques
 Mucomyst (Rx) 10-20% acetylcystineMucomyst (Rx) 10-20% acetylcystine
nebulizer sol.nebulizer sol.
 10% for ophthalmic—warn of smell10% for ophthalmic—warn of smell
 2-4 gtts/day loosen plaques2-4 gtts/day loosen plaques
 Steroids qidSteroids qid
 Can also remove with cotton swab,Can also remove with cotton swab,
weck-cell sponge, forceps or spatulaweck-cell sponge, forceps or spatula

23. Stromal keratitisStromal keratitis
Associated with uveitisAssociated with uveitis
Anterior - nummularAnterior - nummular
Deep – disciformDeep – disciform
Keratouveitis/endothelitisKeratouveitis/endothelitis
Marginal ulceration – vascularizationMarginal ulceration – vascularization
and scarring at/near limbusand scarring at/near limbus
Treat with steroids and cycloplegicsTreat with steroids and cycloplegics

26. Necrotizing keratitisNecrotizing keratitis
 Common with hypoasthesiaCommon with hypoasthesia
 Use copious NPATs, patching, BCL,Use copious NPATs, patching, BCL,
autologous serumautologous serum
 Neurotrophic ulcers with stromalNeurotrophic ulcers with stromal
thinning may require tarsorraphy,thinning may require tarsorraphy,
conjunctival flap, PKP—80% successconjunctival flap, PKP—80% success

28. Anterior UveitisAnterior Uveitis
 Steroids/cycloplegicsSteroids/cycloplegics
 Can be smoldering or recurrentCan be smoldering or recurrent
 Taper steroids very slowlyTaper steroids very slowly
 May require dosing q1-2d for monthsMay require dosing q1-2d for months

33. Secondary GlaucomaSecondary Glaucoma
 Develops from trabecular inflammationDevelops from trabecular inflammation
and swelling—blocks outflowand swelling—blocks outflow
 Use both Combigan and strong steroidUse both Combigan and strong steroid
such as Pred 1% or Durezolsuch as Pred 1% or Durezol
 Depending on IOP, consider DiamoxDepending on IOP, consider Diamox
short termshort term

34. Post. Uveitis/Retinitis/OpticPost. Uveitis/Retinitis/Optic
NeuritisNeuritis
 Most commonly seen in the immuno-Most commonly seen in the immuno-
compromisedcompromised
 Sometimes concommitant EOM palsy,Sometimes concommitant EOM palsy,
cerebral vasculitiscerebral vasculitis
 Needs IV acyclovir and systemicNeeds IV acyclovir and systemic
steroidssteroids
Dilate and watch for retinal signsDilate and watch for retinal signs

37. Post-Herpetic NeuralgiaPost-Herpetic Neuralgia
Can range from mild short-term itch toCan range from mild short-term itch to
long-lasting debilitating painlong-lasting debilitating pain
Most common and effective oralMost common and effective oral
treatment - Gabapentin (Neurontin-treatment - Gabapentin (Neurontin-
an off-label use of anti-seizure med.)an off-label use of anti-seizure med.)
and tramadol or hydrocodoneand tramadol or hydrocodone

38. HZO Long Term SequelaeHZO Long Term Sequelae
 Recurrent or smoldering uveitisRecurrent or smoldering uveitis
 Dry eye, lid and corneal scarring,Dry eye, lid and corneal scarring,
neurotrophic keratitisneurotrophic keratitis
 Post-herpetic neuralgia – possible eventualPost-herpetic neuralgia – possible eventual
hand-off to primary care providerhand-off to primary care provider

39. Herpes SimplexHerpes Simplex
 25% seropositive for HSV by age 425% seropositive for HSV by age 4
 100% by age 60100% by age 60
 400,000 in US have had ocular HSV400,000 in US have had ocular HSV
 10,000/month have HSV keratitis10,000/month have HSV keratitis
 Most common corneal blindness in USMost common corneal blindness in US

40. HSV KeratitisHSV Keratitis
 Incidence 15/1000Incidence 15/1000
 Slightly more common in malesSlightly more common in males
 Mean age of onset is late 50’s to 60’sMean age of onset is late 50’s to 60’s
 UV, stress, fever, surgery, immuneUV, stress, fever, surgery, immune
compromise, menses, topical steroidscompromise, menses, topical steroids
and PA’s (endogenousand PA’s (endogenous
prostaglandins)prostaglandins)

41. HSV 1HSV 1
 Primary inoculation through directPrimary inoculation through direct
contact of skin or mm innervated bycontact of skin or mm innervated by
trigeminal gangliontrigeminal ganglion
 Usually subclinical, but can see +PAN,Usually subclinical, but can see +PAN,
typically unilateral b’conjunctivitis, SPKtypically unilateral b’conjunctivitis, SPK
and skin vesiculationand skin vesiculation

43. Secondary HSV KeratitisSecondary HSV Keratitis
 Can involve all layersCan involve all layers
 4 classifications:4 classifications:
Infectious epithelial keratitisInfectious epithelial keratitis
Neurotrophic keratopathyNeurotrophic keratopathy
Stromal keratitisStromal keratitis
EndotheliitisEndotheliitis

44. Epithelial HSV keratitisEpithelial HSV keratitis
 Corneal vesicles, dendritic andCorneal vesicles, dendritic and
geographic ulcers or raised lesionsgeographic ulcers or raised lesions
 Dendritic ulcer most common, heapedDendritic ulcer most common, heaped
borders and end bulbs contain RBborders and end bulbs contain RB
staining virusstaining virus
 Geographic - in immunocompromisedGeographic - in immunocompromised
or with topical steroid useor with topical steroid use
 Marginal ulcer with infiltrate vs staphMarginal ulcer with infiltrate vs staph

47. NeurotrophicNeurotrophic
keratopathykeratopathy
 Non infectious and non inflammatoryNon infectious and non inflammatory
 Reduced innervation and tear prod.Reduced innervation and tear prod.
 Non-healing epithelial defect withNon-healing epithelial defect with
smooth borderssmooth borders
 Later stromal ulceration, opacificationLater stromal ulceration, opacification
and possible perforationand possible perforation

49. Stromal KeratitisStromal Keratitis
Necrotizing- invasion of virus, necrosis,Necrotizing- invasion of virus, necrosis,
infiltration and epithelial defect usuallyinfiltration and epithelial defect usually
from use of steroids w/o antiviralfrom use of steroids w/o antiviral
Non-necrotizing- (AKA Immune orNon-necrotizing- (AKA Immune or
Interstitial)- infiltration with or w/oInterstitial)- infiltration with or w/o
neovascularization - epith. intact.neovascularization - epith. intact.

51. EndotheliitisEndotheliitis
 Late onset immune response monthsLate onset immune response months
to years after episode of keratitisto years after episode of keratitis
– KP’s, pain, injection, low grade iritis, andKP’s, pain, injection, low grade iritis, and
possible epithelial edemapossible epithelial edema
– Disciform KP - central/paracentral edemaDisciform KP - central/paracentral edema
– Diffuse KP and edemaDiffuse KP and edema
– Linear KP - mostly peripheral edemaLinear KP - mostly peripheral edema

53. Orals for HSV keratitisOrals for HSV keratitis
 Acyclovir 400 mg 5x/dayAcyclovir 400 mg 5x/day
 Valaciclovir 500mg tidValaciclovir 500mg tid
 Famciclovir 1000mg tidFamciclovir 1000mg tid
 Orals best for immune compromise, inOrals best for immune compromise, in
stromal and neurotrophic keratitis,stromal and neurotrophic keratitis,
endotheliitis, uveitis, children or rarelyendotheliitis, uveitis, children or rarely
Zirgan resistant strainsZirgan resistant strains
 Red. risk of epith. to stromal prog.Red. risk of epith. to stromal prog.

54. Topicals for HSVTopicals for HSV
keratitiskeratitis
 Zirgan (ganciclovir 0.15% ophth.Zirgan (ganciclovir 0.15% ophth.
gel)5gm tube. Very non-toxicgel)5gm tube. Very non-toxic
 One drop 5x/day until epithelial ulcerOne drop 5x/day until epithelial ulcer
heals, then tid for 1 wk.heals, then tid for 1 wk.
 75% of ulcers healed in 1 wk.75% of ulcers healed in 1 wk.
 CycloplegiaCycloplegia

55. Epithelial DebridementEpithelial Debridement
 Additive to topical /oral therapyAdditive to topical /oral therapy
 For dendritic/geographic ulcersFor dendritic/geographic ulcers
 Removal of loose epithelium at edgeRemoval of loose epithelium at edge
of ulcer removes active virusof ulcer removes active virus
 Decreases chances of stromal diseaseDecreases chances of stromal disease
 Use cotton swab, Weck cell spongeUse cotton swab, Weck cell sponge
spear, spatula or bladespear, spatula or blade

56. Topical steroidsTopical steroids
 Can be initiated at q1-4hr for stromalCan be initiated at q1-4hr for stromal
disease and indolent ulcers (w/ BCLdisease and indolent ulcers (w/ BCL
and NPAT) after several days ofand NPAT) after several days of
antiviral therapyantiviral therapy
 Continue antivirals and cycloplegicContinue antivirals and cycloplegic
 Taper steroids very slowlyTaper steroids very slowly

57. Stromal meltStromal melt
 If stroma starts to progressively thin,If stroma starts to progressively thin,
be slow to decrease steroids for fearbe slow to decrease steroids for fear
of rebound inflammation and furtherof rebound inflammation and further
meltmelt
 Cyanoacrylate glue used for smallCyanoacrylate glue used for small
peripheral perforations to reform ACperipheral perforations to reform AC
 Some go to lateral tarsorrhaphy,Some go to lateral tarsorrhaphy,
conjunctival flap or PKPconjunctival flap or PKP

58. PKP in HSV keratitisPKP in HSV keratitis
 Best for those with less neovasc.Best for those with less neovasc.
 Wait 6-12 months after last episodeWait 6-12 months after last episode
 Topical steroids used pre-sx toTopical steroids used pre-sx to
minimize inflammationminimize inflammation
 PKP does not reduce recurrence ratePKP does not reduce recurrence rate

59. Secondary glaucomaSecondary glaucoma
 Treat mild elevation of IOP with topicalTreat mild elevation of IOP with topical
beta-blockers and/or brimonidinebeta-blockers and/or brimonidine
 Higher pressures may require oral CAIHigher pressures may require oral CAI
 Rise in IOP due to mechanicalRise in IOP due to mechanical
blockage of TM from inflammatoryblockage of TM from inflammatory
swellingswelling
 Steroids can help by reducing inflam.Steroids can help by reducing inflam.

60. Recurrent HSVRecurrent HSV
Long term preventative therapy initiatedLong term preventative therapy initiated
after 2-3 recurrences in 1 year or in thoseafter 2-3 recurrences in 1 year or in those
with stromal disease. Reduceswith stromal disease. Reduces
recurrencesrecurrences
by 40-50%.by 40-50%.
Acyclovir 400-800 mg/dayAcyclovir 400-800 mg/day
Valaciclovir 500 mg/dayValaciclovir 500 mg/day
Famciclovir 1000 mg/dayFamciclovir 1000 mg/day

61. QuestionsQuestions