Optic chiasm, optic nerve, and retinal involvement secondary to varicella-zoster virus

Immunocompromised patients are known to be at risk for varicella-zoster virus reactivation, often in atypical manners. We describe a 30-year-old man with simultaneous involvement of the retina, optic chiasm, and optic nerve with varicella-zoster virus who had a bitemporal visual field defect.

Morphology of epithelial keratitis in herpes zoster ophthalmicus. A non-contact photomicrographic in vivo study in the human cornea

PURPOSE

To investigate the in vivo morphology of epithelial changes in acute herpes zoster keratitis.

METHODS

10 patients with acute disease. In 7, systemic acyclovir treatment was started at presentation, in 2 < or = 24 hours before, 1 was not treated. The corneae were examined with the slit lamp, followed intermittently for 3-30 days, and photographed at intervals ranging between 1 to 7 days.

RESULTS

All but one patient had epithelial changes at presentation; all developed new ones. The smallest discernible entities were abnormal cells of about 10-15 microm in diameter, singular or grouped. Larger foci measured about 100-200 microm. 2 patients showed pseudodendrites at presentation, and further 3/9 observed > or = 2 weeks developed them. Some lesions showed white surface plaques. No ulcerations were observed. Healing occurred < or = 10-22 days after the onset of symptoms.

CONCLUSIONS

The study seemed to have followed the natural course of the disease. The rapidly changing morphology in the absence of ulcerative features indicated successive damage counteracted by reparative forces.

Penetrating keratoplasty for varicella-zoster virus keratopathy

PURPOSE

To examine and report the results of penetrating keratoplasty performed in patients with varicella-zoster virus keratopathy.

METHODS

The authors retrospectively reviewed the records of 15 patients who had penetrating keratoplasty for varicella-zoster virus keratopathy from January 1989 through December 1998 on the Cornea Service at Wills Eye Hospital.

RESULTS

Twelve patients had a preoperative diagnosis of herpes zoster ophthalmicus, and three, of varicella. Four eyes had lateral tarsorrhaphies performed in conjunction with penetrating keratoplasty. Three eyes had endothelial rejection episodes that responded well to treatment with topical steroids. One eye had a regraft 1 month after primary failure, and this second graft also failed because of recurrent neurotrophic keratopathy. Three eyes that had repeated penetrating keratoplasty for graft failure had clear grafts at the last examination. At an average follow-up time of 50 months, 13 (86.7%) grafts remained clear, and the best corrected visual acuity was 20/100 or better in eight (53.3%) eyes. Five patients had decreased visual acuity because of retinal diseases.

CONCLUSION

Although varicella-zoster virus keratopathy is an uncommon indication for penetrating keratoplasty, effective visual rehabilitation can be achieved in these patients. Careful postoperative management, frequent lubrication, and lateral tarsorrhaphies to protect the corneal surface are major factors in the successful outcome of these cases.

Stroke after zoster ophthalmicus in a 12-year-old girl with protein C deficiency

A 12-year-old girl who had zoster ophthalmicus 10 months earlier presented with hemiparesis and corresponding basal ganglionic infarction related to middle cerebral artery branch thrombosis ipsilateral to the zoster. Hematologic evaluation disclosed protein C deficiency. This represents the first zoster-associated stroke reported in childhood associated with protein C deficiency, with extension of the latency period between zoster and infarction, previously reported to be 6 months.

Recurrent varicella-zoster virus retinitis in a patient treated with systemic corticosteroids

A case of recurrent unilateral varicella-zoster virus (VZV) retinitis is reported. The retinitis was characterized by arteriolitis and retinal necrosis with secondary chorioretinal atrophy localized in the periphery of the supratemporal quadrant of the retina. Polymerase chain reaction analysis of aqueous humor demonstrated VZV DNA in both the initial and recurrent episode. The Goldmann-Witmer coefficient for VZV IgG was elevated. The initial VZV retinitis was successfully treated with acyclovir and corticosteroids. Three years later, high-dose corticosteroids alone were used to treat idiopathic facial nerve palsy. One month after concluding corticosteroids therapy, the VZV retinitis recurred in the same eye, suggesting that administration of the high-dose corticosteroids caused VZV reactivation and induced recurrence of VZV retinitis.

Herpes zoster ophthalmicus and HIV infection in Nigeria

Eight patients, 3 men and 5 women, aged between 24 and 40 years who had herpes zoster ophthalmicus (HZO) were seen in the Eye Department of the University of Nigeria Teaching Hospital, Enugu between 1994 and 1997. One of the patients was already on treatment for active pulmonary tuberculosis at the time he was first seen. All had skin eruptions at different stages of development in the area of distribution of the first trigeminal nerve on the affected side of the face and head. Ocular examination revealed impaired vision in the affected eye (between 6/12 and hand movement) in all the patients. All had lid oedema while 5 had ptosis (3 partial and 2 complete). Various degrees of conjunctival injection were observed in all patients while 6 of them had corneal anaesthesia and keratitis. Uveal inflammation, present in all the patients varied from mild iritis in 4 individuals to severe iridocyclitis in the remaining 4. Pupils reacted to light sluggishly in 2 patients while they were dilated and fixed in 3 others. None had any associated abnormalities in the posterior segment. Six of the patients consented and were screened for human immunodeficiency virus (HIV) infection. Of these, 4, including the patient with pulmonary tuberculosis, tested seropositive while 2 were seronegative. All 8 were treated with topical acyclovir. This was combined with oral acyclovir in one of the patients. Follow-up period was between 2 and 52 weeks. During this period skin eruptions and anterior segment signs improved in 5 patients while remaining stable in 3 others; post-herpetic neuralgia persisted on the affected side in 4 patients. Patients who were HIV seropositive did not recover as quickly or to the same extent as the seronegative ones. It is concluded that HZO infection may indicate underlying HIV infection in young Africans as has been found in whites.

Chronic varicella-zoster virus epithelial keratitis in patients with acquired immunodeficiency syndrome

OBJECTIVE

To characterize further a chronic epithelial keratitis caused by varicella-zoster virus infection in patients with acquired immunodeficiency syndrome (AIDS).

METHODS

Patients with AIDS and chronic epithelial keratitis associated with varicella-zoster virus from 3 institutions were identified. Patient records were reviewed retrospectively for the following data: medical and demographic characteristics, techniques of diagnosis, physical findings, course, response to treatment, and outcome.

RESULTS

Sixteen patients were studied. CD4+ T-lymphocyte cell counts were available in 11 patients, with a median of 0.034 x 10(9)/L (range, 0-0.094 x 10(9)/L). Two patients had no history of a zosteriform rash. In the remaining patients, the interval between rash and keratitis ranged from 0 days to 6 years. In all cases, the keratitis was chronic and characterized by gray, elevated, dendriform epithelial lesions that stained variably with fluorescein and rose bengal. The peripheral and midperipheral cornea was most commonly affected, and, in 13 of the 16 patients, the lesions crossed the limbus. Pain was a prominent feature, occurring in 12 of 16 patients. In 9 of 12 patients tested, varicella-zoster virus was identified by culture, direct fluorescent antibody testing, polymerase chain reaction testing, or a combination of these studies, with direct fluorescent antibody testing (6 of 8 positive results) and polymerase chain reaction testing (3 of 3 positive results) appearing to be the most sensitive. Response to antiviral medication was variable.

CONCLUSIONS

In patients with AIDS, varicella-zoster virus may cause a chronic infection of the corneal epithelium. The keratitis is characterized by dendriform lesions, prolonged course, and frequently by extreme pain. It can occur without an associated dermatitis.

Detection of varicella zoster virus DNA and viral antigen in human eyes after herpes zoster ophthalmicus

OBJECTIVE

The purpose of the study was to identify varicella zoster virus (VZV) DNA and viral antigen in human eyes at various intervals after clinical onset of herpes zoster ophthalmicus (HZO).

DESIGN

A retrospective case series.

PARTICIPANTS

There were 9 eyes and 4 corneal buttons surgically obtained from 13 patients with HZO at the University Eye Hospital of Erlangen-Nürnberg between 1984 and 1994. Specimens were examined at different timepoints after clinical onset of HZO (range, 1 day-19 years; median, 36 months).

METHODS

Histopathologic evaluation was performed on formalin-fixed and paraffin-embedded tissue by routine histology, immunohistochemistry (5-B-7 murine monoclonal antibody to VZV; peroxidase-antiperoxidase method), and DNA-in situ hybridization (35S deoxyadenosine triphosphate-labeled HindIII fragments [A and C] of VZV).

RESULTS

Typical histopathologic changes associated with HZO were identified: vascularization of the corneal stroma (11 of 13), granulomatous reaction to Descemet's membrane (8 of 13), fusiform-shaped ciliary scarring (5 of 9), optic neuritis (4 of 9), and perineuritis (8 of 9) and perivasculitis (8 of 9) of the long posterior ciliary nerves and arteries. VZV antigen was detected in two patients with acute infection 1 and 7 days after onset of HZO, respectively. VZV-DNA was identified in seven patients up to 10 years after onset of HZO in corneal epithelial cells (2 of 13), corneal stroma (5 of 13), inflammatory infiltrate of the anterior chamber (1 of 9), episclera (2 of 9), posterior ciliary nerves (1 of 9) and arteries (5 of 9), optic nerve (5 of 9), and adjacent leptomeninges (2 of 9).

CONCLUSION

Persistence of viral genomes, most likely accompanied by gene expression or slow viral replication, appears to be responsible for the often smoldering panophthalmitis and the chronic recurrent keratouveitis in patients with HZO. Localization of viral DNA in vascular structures suggests a role for vasculitis in the pathogenesis of some ocular findings associated with HZO.

Optic neuritis heralding varicella zoster virus retinitis in a patient with acquired immunodeficiency syndrome

We report on a 29-year-old severely compromised acquired immunodeficiency syndrome patient who developed retrobulbar optic neuritis 5 weeks after an episode of cutaneous herpes zoster infection. During the optic neuritis, varicella zoster virus could be demonstrated in the cerebrospinal fluid. The neuritis responded well to treatment with foscarnet, but, 3 weeks into therapy, varicella zoster retinitis developed. Additional treatment with intravenous acyclovir stopped progression of the retinitis and resulted in healing of the retinal lesions. This case suggests that retrobulbar optic neuritis can be regarded as a prodrome of imminent acute retinal necrosis. Early recognition and prompt therapy with combined antivirals may prevent the development of this devastating ocular complication of varicella zoster infection.

The progressive outer retinal necrosis syndrome: successful treatment with combination antiviral therapy

BACKGROUND AND OBJECTIVE

To assess a two-drug combination of antiviral therapy for the progressive outer retinal necrosis syndrome (PORN), given the current poor outcome with acyclovir alone.

PATIENTS AND METHODS

A retrospective review was performed on six consecutive patients who were diagnosed with PORN and were treated with various combinations of intravenous or oral plus intravenous antiviral therapy. The relative efficacies of these modalities were compared.

RESULTS

Six eyes of six patients showed active retinitis at the time of presentation. Three patients had unilateral retinitis, and the remaining patients had necrotic, end-stage disease in their fellow eye. All the patients were treated with combination therapy, consisting of either ganciclovir and acyclovir (three patients), foscarnet and ganciclovir (two patients), or foscarnet and acyclovir (one patient). Standard induction doses were employed. During the combination therapy, all six eyes showed resolution of the retinitis, manifested by complete fading of the original retinal lesions and an absence of new lesion formation. At the final follow-up, the areas of prior active retinitis had resolved and remained quiescent. A mild recurrence developed in one eye when ganciclovir and foscarnet were both tapered to a single daily dose. This recurrence promptly resolved with reinduction (twice daily) dosing. Two patients maintained a visual acuity of 20/50 or better in their involved eye for the duration of follow-up (38 and 27 weeks, respectively). One patient maintained a visual acuity of 20/40 for 14 weeks. The remaining three patients had macula-off retinal detachments despite resolution of active retinitis. In addition, for the duration of follow-up, one of the three patients with unilateral disease had retinitis in the uninvolved eye; all three uninvolved fellow eyes maintained a visual acuity of 20/20. One patient had progressive optic atrophy.

CONCLUSIONS

Prolonged combination antiviral therapy for PORN may successfully arrest the progression of retinitis, maintain remission, and prevent involvement of the fellow eye. Furthermore, if aggressive therapy is begun early, good vision may be preserved.

Herpes zoster ophthalmicus in patients with human immunodeficiency virus infection

PURPOSE

To investigate the ocular complications of herpes zoster ophthalmicus in patients with human immunodeficiency virus (HIV) infection.

METHODS

This was a retrospective cohort study of 48 HIV-infected patients (48 eyes) treated at San Francisco General Hospital for herpes zoster ophthalmicus from December 1985 through March 1994.

RESULTS

All patients were initially treated with either intravenous or oral acyclovir. The median CD4 lymphocyte count at diagnosis was 48 per mm3 (range, 2 to 490 per mm3). Fifteen patients (31%) had mild or no ocular involvement. Seventeen patients (35%) had stromal keratitis, mostly mild, and two (4)% developed chronic infectious pseudodendritic keratitis. Twenty-four study patients (50%) had iritis, but only three (6%) had elevations in intraocular pressure. Two patients (4%) developed postherpetic neuralgia, and two others (4%) had zoster-associated central nervous system disease. Only two patients (4%) developed necrotizing retinitis, both in the form of the progressive outer retinal necrosis syndrome.

CONCLUSIONS

Excluding the patients with retinitis and central nervous system disease, the rate of sight-threatening complications in our series was lower than expected. Almost one third of study patients had no ocular complications or only mild surface epithelial disease. Although the relatively low incidence of sight-threatening disease in our study population may have been a consequence of aggressive management with acyclovir, chronic infectious pseudodendritic keratitis, retinitis, and central nervous system disease, complications of ophthalmic zoster whose pathogenesis is largely a consequence of active viral replication, were particularly devastating and difficult to manage.

Intravitreal ganciclovir treatment in progressive outer retinal necrosis

PURPOSE

To report two patients with progressive outer retinal necrosis, which is presumed to be caused by the varicella-zoster virus in patients with acquired immunodeficiency syndrome (AIDS).

METHOD

Case report.

RESULTS

The patients were treated with intravenous foscarnet, 60 mg per kg of body weight three times per week, without response. Remission of retinal necrosis occurred with the commencement of intravitreal ganciclovir treatment, 400 mg two times per week. Laser photocoagulation was performed in both cases. Neither patient developed retinal detachment.

CONCLUSIONS

Intravitreal ganciclovir treatment combined with systemic antiviral agent therapy in patients with progressive outer retinal necrosis may delay progress of the disease. Early photocoagulation may prevent the development of retinal detachment if retinal necrosis is controlled.

Herpes zoster ophthalmicus and the immunocompromised host: a case report and review

BACKGROUND

Herpes zoster is the secondary form of varicella zoster virus disease, caused by the reactivation of the dormant virus in the sensory ganglia. It manifests as a unilateral cutaneous dermatitis with a prodromal fever and malaise. Herpes zoster ophthalmicus occurs when the ophthalmic division of the trigeminal nerve becomes afflicted.

CASE REPORTS

This case represents a middle-aged female with breast carcinoma. Cancer radiotherapy and chemotherapy created an immunosuppressed state, which allowed the development of herpes zoster ophthalmicus. Most patients who manifest zoster are immunocompetent. However, with the increased incidence of immunodeficient states (e.g., chemotherapy, organ transplantation and acquired immunodeficiency syndrome), clinicians are faced with a greater number of cases of zoster. In the immunodeficient population, especially, dissemination of the zoster and potentially damaging complications can occur.

CONCLUSIONS

In the light of these facts, clinicians must be well versed in all aspects of herpes zoster disease, including the clinical and laboratory diagnosis, as well as the incidence and presentation of herpes zoster. Current treatments, such as the use of famciclovir, acyclovir, valcyclovir, and prednisone, must also be understood.

Varicella-zoster virus is strongly associated with atypical necrotizing herpetic retinopathies

Aqueous humor samples from nine patients with atypical necrotizing retinopathies of suspected viral origin, six with acute retinal necrosis syndrome (ARN), and 17 with active cytomegalovirus (CMV) retinitis underwent amplification for viral DNA of herpes simplex virus type 1 (HSV-1), varicella-zoster virus (VZV), and human CMV. VZV DNA was detected in seven of the nine aqueous humor samples from patients with atypical necrotizing retinopathies of suspected viral origin and in four of the six samples from individuals with ARN; of the two other samples from patients with ARNS, no viral DNA was found in one, and both CMV DNA and HSV-1 DNA, but not VZV DNA, were detected in one (this patient presented with bilateral ARNS 2 months after being successfully treated for CMV retinitis). Thus, VZV is likely to be the main pathogen of atypical necrotizing herpetic retinopathies. DNA amplification may be used to establish an early, sensitive, and reliable diagnosis of any form of necrotizing retinopathy in 80% of cases, irrespective of viral etiology.

Repair of retinal detachments due to herpes varicella-zoster virus retinitis in patients with acquired immune deficiency syndrome

PURPOSE

The authors characterize surgical techniques and report results for repair of retinal detachments due to varicella-zoster retinitis in patients with acquired immune deficiency syndrome (AIDS).

BACKGROUND

Varicella-zoster virus (VZV) retinitis is a distinctly aggressive infection in patients with AIDS. Retinal detachments occur in the majority of such patients, and contribute to their poor visual prognosis.

METHODS

A case series of five eyes in four patients with AIDS and retinal detachments due to VZV retinitis is presented, highlighting surgical technique and results. Pars plana vitrectomy, silicone oil tamponade, and endolaser photocoagulation were used in all cases.

RESULTS

Apparent contraction of the necrotic retina was observed, requiring large relaxing retinectomies to achieve retinal attachment in three of the five eyes. Follow up after surgery was 4, 6, 15, 29, and 30 months. Four eyes maintained ambulatory vision and the retinas remained attached.

CONCLUSION

Vitrectomy with silicone oil tamponade may be used to preserve ambulatory vision in carefully selected patients with AIDS and retinal detachments due to VZV retinitis. Relaxing retinectomy is a useful technique to achieve and maintain retinal attachment.

Optic neuropathy preceding acute retinal necrosis in acquired immunodeficiency syndrome

OBJECTIVE

To describe the clinical course of varicella-zoster optic neuropathy preceding acute retinal necrosis in patients with acquired immunodeficiency syndrome.

DESIGN

Case series.

SETTING

Two tertiary care centers in San Diego, Calif, and London, England.

PATIENTS

Three human immunodeficiency virus-positive men with previous cutaneous zoster infection, optic neuropathy, and necrotizing retinitis.

RESULTS

All patients had an episode of zoster dermatitis treated with acyclovir. Visual loss consistent with an optic neuropathy ensued, followed by typical herpetic retinitis. The cause of visual loss was not suspected to be varicella-zoster until after the retinitis occurred. Despite aggressive medical treatment, 4 of 6 eyes progressed to retinal detachment.

CONCLUSIONS

Varicella-zoster may cause an optic neuropathy in patients with acquired immunodeficiency syndrome, especially in those with previous shingles. A high index of suspicion is necessary to establish the diagnosis and begin early antizoster treatment.

Varicella-zoster virus retrobulbar optic neuritis in a patient with human immunodeficiency virus

PURPOSE

To determine the cause of bilateral retrobulbar optic neuritis followed by progressive outer retinal necrosis in a patient with human immunodeficiency virus (HIV).

METHODS

Extensive ophthalmologic, neurologic, infectious disease, rheumatologic, and radiologic examinations were performed.

RESULTS

Cerebrospinal fluid samples taken after the onset of bilateral retrobulbar optic neuritis and before the development of clinical progressive outer retinal necrosis disclosed varicella-zoster virus from polymerase chain reaction and viral culture.

CONCLUSION

Ophthalmologists and neurologists should consider varicella-zoster virus optic neuritis as a potential precursor of progressive outer retinal necrosis and as a cause of retrobulbar optic neuritis in patients infected with HIV.

Herpes zoster peripheral ulcerative keratitis in patients with the acquired immunodeficiency syndrome

The purpose of this study was to describe the clinical characteristics and course of peripheral ulcerative keratitis (PUK) secondary to herpes varicella-zoster virus in patients with the acquired immunodeficiency syndrome (AIDS). Three AIDS patients with ocular herpes zoster infection (mean age at onset, 33.0 years; range, 30-42) developed PUK. The three patients had skin involvement, and two of them had bilateral keratouveitis. All were treated with high-dose oral acyclovir (4 g/day) with or without topical antiviral therapy. Two of the patients responded well to oral acyclovir, but one of them stopped the treatment, and bilateral progressive outer retinal necrosis and lethal encephalitis developed. The third patient had a recurrent episode of inflammation with PUK, extensive stromal scarring, and deep neovascularization. AIDS patients with herpes varicella-zoster virus infection may have severe and protracted corneal manifestations, including PUK. The correct diagnosis and aggressive early long-term systemic antiviral treatment must be instituted to control inflammation, ulcer progression, and complications.

Fluorescein angiography in the progressive outer retinal necrosis syndrome

PURPOSE

Progressive outer retinal necrosis syndrome is a devastating retinopathy seen primarily in patients with acquired immune deficiency syndrome. To provide additional details of the pathogenesis of this disease, the authors describe the evolution of clinical and fluorescein angiographic changes during the course of progressive outer retinal necrosis syndrome.

METHODS

The authors performed serial clinical examinations, fundus photography, and fluorescein angiography in a patient with acquired immune deficiency syndrome with progressive outer retinal necrosis syndrome. Clinical and fluorescein angiographic findings were correlated to provide detailed sequential analysis of the pathologic changes occurring during the course of this disorder.

RESULTS

The angiographic changes seen during the various stages of the disease consisted of zonal microvascular alterations, retinal pigment epithelium (RPE) destruction, and choroidal leakage. Retinal damage was correlated closely with regions of choroidal leakage and was clinically evident as outer retinal whitening. Disease reactivation occurred as a prominent brush-fire border of intense leakage involving the retina, RPE, and choroid. Extensive damage to the retinal vasculature and RPE was noted in the wake of clinical infection.

CONCLUSIONS

The angiographic findings in our patient demonstrate that the progressive outer retinal necrosis syndrome is a retinochoroiditis that involves the full thickness of retina as well as the RPE and choroid. The inflammatory changes seen throughout the course of this disease correlate with the histopathologic patterns reported to date.

Multiple recurrent branch retinal artery occlusions associated with varicella zoster virus

PURPOSE

The authors describe an immunocompetent patient who developed multiple recurrent branch retinal artery occlusions (BRAOs) associated with the varicella zoster virus (VZV).

METHODS

A 69-year-old woman with mild bilateral vitritis developed superior and inferior BRAOs in her right eye with decreased visual acuity to 20/40, and a peripheral BRAO inferotemporally in her left eye. One month later, the inferotemporal BRAO progressed proximally in her left eye with a decrease of visual acuity to 20/40. After an extensive negative systemic evaluation, she underwent a diagnostic pars plana vitrectomy of her right eye.

RESULTS

Vitreous fluid was positive for VZV DNA by polymerase chain reaction (PCR). The patient was treated with intravenous acyclovir and systemic oral steroids. After remaining disease free for 3 months, the patient had two recurrences: 1) a mild vitritis and 2) development of a new superior temporal artery occlusion in the left eye. Both recurrences were treated with oral acyclovir and systemic steroids. The patient remained recurrence free for 12 months on a maintenance dose of oral acyclovir, and for 4 additional months without acyclovir.

CONCLUSIONS

Varicella zoster virus can be associated with the syndrome of multiple recurrent BRAOs. The diagnosis of VZV-associated BRAO can be established by PCR of intraocular fluid.