Prevalence of Ocular Manifestations and Visual Outcomes in Patients With Herpes Zoster Ophthalmicus

Risk Factors for the Development of Ocular Complications in Herpes Zoster Ophthalmicus and Zoster Vaccine Utilization in a Large, Urban Health System

PURPOSE

To characterize the epidemiology of herpes zoster (HZ) and herpes zoster ophthalmicus (HZO) in an urban hospital system and determine risk factors associated with developing ocular complications in HZO. To report the frequency of shingles vaccination and HZ reactivation following shingles vaccination in this population.

METHODS

A retrospective cohort study was conducted on patients seen at the University of Illinois Hospital system from January 1, 2010 to December 1, 2021 with HZ and HZO identified by diagnosis code. Charts of HZO patients seen within 1 year of diagnosis were abstracted. Multivariable logistic regression analysis identified factors associated with the development of ocular complications in HZO.

RESULTS

During the study period, 3283 patients had HZ; mean age of onset was 52.3 years, 61.6% were female, and 37% were Black. HZO with ocular involvement was seen in 110 (3.4%) patients. Ocular complications developed in 40 (36.4%) patients; the most common complication was corneal scarring (70%). Age (odds ratio [OR] 1.04, 95%CI 1.0-1.1), female gender (OR 2.86, 95%CI 1.0-8.1), steroids at initial visit (4.46, 95%CI 1.4-14.6), and stromal keratitis (OR 3.45, 95% CI 1.2, 9.8) were associated with developing ocular complications. Of eligible populations, 5333 (1.5%) received shingles vaccination; 43 patients developed reactivation of HZ following vaccination.

CONCLUSIONS

In HZO, age, female gender, steroids at initial visit, and stromal keratitis are strongly associated with developing ocular complications. Shingles vaccination rates were low in this study population. Understanding potential for complications in HZ/HZO and vaccination uptake can help identify at risk populations to prevent disease. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

A systematic literature review of the epidemiology and burden of herpes zoster in selected locales in Asia Pacific

Herpes zoster (HZ) is a painful rash which typically affects older adults. This is of concern in Asia-Pacific given its aging population. As HZ epidemiology and burden are evolving, this systematic literature review aimed to update the current understanding of HZ burden and associated costs for selected Asia-Pacific locales. MEDLINE and Embase were searched for English articles of HZ studies conducted in Australia, China, Hong Kong, Japan, Korea, New Zealand, Singapore, and Taiwan. Eligible outcomes included HZ incidence and prevalence, occurrence of HZ-related complications, healthcare resource utilization, costs, and HZ-associated quality of life outcomes. This paper focused on HZ data in the general adult population (N = 90 articles). Substantial HZ-related disease and economic burden were observed in these locales, consistent with global trends. These findings reinforce the increasing burden of HZ and need for preventive strategies, which may include raising awareness and encouraging timely vaccination.

Clinical Features of Varicella-Zoster Virus-Associated Anterior Uveitis with or without Ophthalmic Herpes Zoster

PURPOSE

This study aimed to investigate the clinical characteristics, diagnostic markers, and treatment outcomes of varicella-zoster virus-associated anterior uveitis (VZV-AU) with and without ophthalmic herpes zoster (herpes zoster ophthalmicus (HZO) and zoster sine herpete (ZSH), respectively).

METHODS

Clinical records of 47 VZV-AU patients (21 ZSH, 26 hZO) were retrospectively reviewed for clinical findings, medication use, and PCR using aqueous humor (AH) results.

RESULTS

There was no significant difference in age, gender, visual acuity (VA), or intraocular pressure (IOP) between the two groups. At the initial visit, small-to-medium white keratic precipitates (KPs) were significantly more observed in ZSH group than in HZO group, although there was no significant difference in the frequencies of other ocular findings between the two groups. Early antiviral medication use was significantly higher in HZO group (96.2%) than in ZSH group (19.1%). PCR was performed in 85.7% of ZSH and 53.8% of HZO patients. VZV-DNA positivity and viral load were similar between groups. Multivariate analysis revealed a positive correlation between white KPs and VZV viral load in AH. Although the ultimate use of antiviral medication was still less in ZSH group (71.4%), there were no significant differences in VA and IOP at the last visit between the two groups.

CONCLUSION

Patients with ZSH had more white KPs and received less early antiviral medication than those with HZO. However, visual outcomes were similar between the two groups. Small-to-medium white KPs were significantly associated with the viral load of VZV in AH, suggesting that they could be an active marker.

Herpes Zoster Ophthalmicus Uveitis: Onset and Complications

PURPOSE

To describe the timing of uveitis onset and frequency of associated complications in individuals with herpes zoster ophthalmicus (HZO).

DESIGN

Retrospective, cohort study.

METHODS

Individuals with acute HZO seen at the Auckland District Health Board from 2006 to 2016 were studied. The primary outcome measures were the proportion who developed uveitis and time to diagnosis of uveitis following the onset of HZO. Secondary outcome measures included complications of HZO uveitis and effects of prompt antiviral (within 72 hours) on outcomes.

RESULTS

A total of 869 patients with HZO were included for analysis, of whom 413 (47.6%) developed uveitis. Median time from onset of rash to diagnosis of uveitis was 10 days (IQR 6-14). Of the 658 individuals examined within the first week following rash onset (days 0 through 7), 17.6% (116/658) were diagnosed with uveitis at that initial presenting examination, with an additional 24.9% (164/658) diagnosed with uveitis at a subsequent visit. Complications were higher in eyes with uveitis, including moderate or severe vision loss, corneal scarring, neurotrophic keratitis, band keratopathy, corneal melt, elevated intraocular pressure, glaucoma, and cataract (all P < .01). Prompt antiviral was associated with a lower rate of moderate vision loss among eyes with uveitis (P = .02).

CONCLUSIONS

Uveitis occurred in approximately half of individuals with HZO and was most frequently diagnosed during the second week following rash onset. Eyes with uveitis were more likely to have other ocular complications and loss of vision.

Herpes Zoster Ophthalmicus Recurrence: Risk Factors and Long-Term Clinical Outcomes

PURPOSE

To examine the frequency of recurrences, risk factors, and long-term clinical outcomes in subjects with herpes zoster ophthalmicus (HZO).

DESIGN

Retrospective cohort study.

METHODS

All subjects with acute HZO seen at a single center from 2006 to 2016 were included in the study. The primary outcome measure was eye disease recurrence. The secondary outcome measure was moderate vision loss (≤20/50).

RESULTS

A total of 869 patients with acute HZO were identified, with a median follow-up time of 6.3 years (interquartile range 3.7-8.9 years). In all, 551 recurrences were observed, and at least 1 recurrence was seen in 200 subjects (23.0%), with uveitis (34.8%) being the most common. The median time to first recurrence was 3.5 months. Predictors of disease recurrence included immunosuppression (P = .026), higher presenting intraocular pressure (P = .001), corneal involvement (P = .001), and uveitis (P < .001) on multivariate analysis. Topical steroids were initiated in the first month of presentation in 437 subjects, and recurrence was observed in 184 (42.1%) of these subjects. Following cessation of topical steroid treatment, recurrence occurred after a median of 1.4 months (90% within 7 months). Moderate vision loss (≤20/50) occurred in 15.5%, 28.6%, 31.4%, 50.0%, and 57.4% of eyes with 0, 1, 2, 3, and 4 or more recurrences.

CONCLUSIONS

Recurrence of HZO eye disease is common, with an increased risk of vision loss with more recurrences. These findings indicate the need for close monitoring for potential recurrences, especially after cessation of topical steroid treatment, and in individuals with identified risk factors for recurrence.

Changing age pattern and diverse outcomes of herpes zoster ophthalmicus: exploring the temporal trend, decrease in incident age and influence of treatment strategies

PURPOSE

Herpes Zoster Ophthalmicus (HZO) is a disease commonly affecting the elderly and immunocompromised. Over the last several years, a trend towards decreasing incident age, albeit with varying clinical features, has been observed. This temporal trend towards the younger age group necessitates a detailed evaluation to determine possible causes of its occurrence in this population.

METHOD

This is a hospital-based retrospective study. 154 datasheets were initially identified. After excluding non-relevant data sheets (88), 56 relevant and complete records were subjected to comprehensive analysis in adherence to the inclusion criteria.

RESULTS

Most commonly affected age group was < 40 years, with the mean age being 38. Conjunctivitis was the most frequent occurrence seen in 82.05%. Keratitis was seen in varying forms as, epithelial (64.44%), stromal (15.3%) & nummular (3.57%). Anterior uveitis in 35.89%, posterior uveitis (retinitis, neuro-retinitis) in 7.69% of cases, posterior segment involvement (rhegmatogenous retinal detachment, optic atrophy) in 8.8%, secondary glaucoma in 28.2%, optic neuritis in 5.3% while orbital apex and cavernous sinus involvement were seen in one case.

CONCLUSION

This study reflects a temporal shift in the incidence of HZO towards the younger age group. The proportion of younger patients with HZO is increasing with some male preponderance. Identifiable factors contributing to potential risk, recurrence, and chronicity of HZO are related to demographics, immune status, dietary, environmental associations, vaccination status, and previous history of recurrences. Reported outcomes can be valuable in understanding the evolving patterns of HZO and improving patient care, public health and vaccination policies.

[Clinical presentation and treatment of herpes zoster and postherpetic neuralgia]

Herpes zoster (HZ) is a common disease caused by reactivation of varicella zoster virus. Diagnosis is usually based on the typical clinical presentation. Standard treatment includes antiviral, topical and analgesic therapies. As a complication, postherpetic neuralgia (PHN) can result from acute HZ infection, particularly in older and/or immunocompromised people. This can seriously impair the quality of life of those affected and requires adequate analgesia. In addition to the genesis, clinical presentation and treatment recommendations for HZ and PHN, this article also deals in particular with the vaccination prophylaxis recommended by the standing vaccination commission of the Robert Koch Institute (STIKO).

Herpes Zoster Ophthalmicus: Presentation, Complications, Treatment, and Prevention

Herpes zoster (HZ) is caused by reactivation of latent infection of varicella zoster virus (VZV) in sensory (cranial, dorsal root) ganglia. Major risk factors for HZ are increasing age and immunosuppression. HZ ophthalmicus (HZO) is a subset of HZ with involvement of the ophthalmic division of the fifth cranial trigeminal nerve. Approximately 4-20% of patients with HZ develop HZO. Approximately 50% of patients with HZO develop ocular disease, among whom up to 25% develop chronic or recurrent disease. Common manifestations of ocular disease include conjunctivitis, keratitis, and uveitis, whereas optic neuropathy and retinitis are uncommon. Due to the potential for vision impairment, ocular involvement requires urgent ophthalmic consultation. Early recognition and timely treatment with antivirals may prevent ocular complications. HZO is preventable by vaccination against HZ. Vaccine efficacy/effectiveness studies have been largely conducted for HZ with few studies assessing HZO. Both the recombinant adjuvanted vaccine (RZV) and live-attenuated vaccine (ZVL) significantly reduce the incidence of HZ and HZO in older adults. RZV is more effective than ZVL. Data on the effectiveness of vaccines for prevention of recurrent disease in patients with HZO are limited; however, vaccination is recommended. Despite recommendations to vaccinate individuals likely to benefit from an HZ vaccine, coverage for adults remains suboptimal. Barriers to vaccination include patient beliefs about HZ or HZ vaccines, and factors related to healthcare providers. In particular, the lack of a recommendation from their primary care physician is often cited by patients as a reason for remaining unvaccinated. By encouraging vaccination against HZ, physicians not only prevent HZ and HZO but also potential vision loss due to HZO.Graphical abstract available for this article.

Herpes zoster ophthalmicus: frequency and risk factors for developing uncommon ocular manifestations

OBJECTIVE

To determine the frequency of herpes zoster ophthalmicus (HZO) and assess risk factors for developing uncommon ocular manifestations of laboratory-verified HZO.

DESIGN

Retrospective cohort study.

METHODS

The frequency of HZO out of all herpes zoster cases was calculated using International Classification of Diseases codes for patients seen at the University of Pittsburgh Medical Center from January 1, 2004 to October 31, 2021. We also collected demographic and clinical data of patients with HZO identified by polymerase chain reaction (PCR) detection of varicella zoster virus from January 1, 2011 to December 31, 2020.

RESULTS

The frequency of HZO from 2004 to 2021 in all ages was 4.2% and ranged from 2.7% to 6.7% annually, with a consistent increase of 2.9% from 2012 to 2021. After the live zoster vaccine became available in 2008, the frequency of HZO decreased by 5.1% from 2008 to 2012 in patients aged 60 and older. Among 50 cases of PCR-verified HZO, 62% represented clinically-common ocular manifestations, mostly comprised of 13 cases of keratitis and 10 cases of anterior uveitis. Fifteen cases of acute retinal necrosis (ARN) represented the majority of uncommon HZO manifestations (38%), which were significantly more likely to occur in immunosuppressed patients (unadjusted odds ratio 4.55, 95% confidence interval 1.29-13.83).

CONCLUSIONS

The overall frequency of HZO from 2004 to 2021 was 4.2% and has increased annually since 2012. Uncommon ocular manifestations of PCR-verified HZO, mostly comprised of ARN, were more likely to occur in immunosuppressed patients.

Herpes Zoster Optic Neuritis: A Catastrophe of a Disease

Isolated herpes zoster optic neuritis is a rare sequelae of herpes zoster ophthalmicus (HZO). It can occur in the acute phase of HZO, or as post-herpetic complications. We report a case of a young patient with poorly controlled diabetes who developed herpes zoster optic neuritis one month after the initial skin manifestation despite completing a two-week course of oral acyclovir 800 mg five times a day. He complained of a five-day history of sudden onset, painless left eye blurring of vision. His vision over the left eye was no light perception with the presence of a left relative afferent pupillary defect. Fundus examination of the left eye revealed a swollen optic disc. Magnetic resonance imaging showed minimal fat streakiness over the left orbit. He was treated with one week of intravenous methylprednisolone 1 g/day, followed by a tapering dose of oral prednisolone (1 mg/kg/day) together with oral acyclovir 800 mg five times a day for another week. His visual acuity remained poor with a slight improvement in vision to hand motion.

Increasing hospitalisation of patients with herpes zoster ophthalmicus-an interdisciplinary retrospective analysis

BACKGROUND

The occurrence of herpes zoster is rising globally. Future trends will be influenced by changes in population demographics and the growing number of patients at risk. Overall this poses a challenge for healthcare systems.

METHODS

In our interdisciplinary, single-centre retrospective analysis, we aimed to assess the burden of the disease within the Department of Dermatology and the Eye Centre from the Medical Centre, University of Freiburg from 2009-2022. We obtained data from 3034 cases coded using the ICD-10 B02.x. Patients were characterised by sex, age, year of treatment, and type of treatment (inpatient vs. outpatient).

RESULTS

Overall we observed a 200% increase in the number of herpes zoster patients over the 13-year period. Upon closer analysis, this was mainly due to a rise in inpatient treatment for herpes zoster ophthalmicus.

CONCLUSIONS

If the incidence of herpes zoster ophthalmicus continues to increase at the current rate the number of hospitalisations of zoster ophthalmicus would double by 2040, assuming guideline-appropriate treatment. Overall, the results show a growing need for inpatient ophthalmological care.

Public health impact of herpes zoster vaccination on older adults in Hong Kong

The growing burden of herpes zoster (HZ) in Hong Kong, due to an aging population with increasing life expectancy, may be reduced by vaccination. This study aimed to estimate public health impact of HZ vaccination in Hong Kong. The ZOster ecoNomic Analysis (ZONA) model was adapted with Hong Kong-specific key model inputs/assumptions, where available. Base case analysis involved adults ≥50 years of age (YOA), exploring three vaccination strategies (no vaccination/recombinant zoster vaccine [RZV]/zoster vaccine live [ZVL]) under private market (5% coverage) and mass vaccination (40% coverage) settings. Scenario and sensitivity analyses were performed. In the base case population (3.13 million), without vaccination, 891,024 HZ (28.4%), 156,097 post-herpetic neuralgia (PHN) (5.0%), and 38,755 (1.2%) HZ ophthalmicus (HZO) were projected over their remaining lifetime. Mass RZV vaccination reduced HZ, PHN, and HZO cases by 204,875 (-23.0%), 31,949 (-20.5%), and 8,471 (-21.9%), respectively, which was 4-5 times that reduced with ZVL. RZV was more efficient than ZVL, with lower number needed to vaccinate to prevent one HZ/PHN/HZO case (RZV: 7/40/148; ZVL: 27/163/709). Among all age cohorts, the greatest reduction in cases was projected for RZV (versus no vaccination/ZVL) in the youngest cohort, 50-59 YOA. Results were robust under scenario and sensitivity analyses. HZ burden in Hong Kong is substantial. Mass RZV vaccination is expected to considerably reduce public health burden of HZ among individuals ≥50 YOA, compared with no vaccination/ZVL. Results may support value assessment and decision-making regarding vaccination strategies for HZ prevention in Hong Kong.

Herpes Zoster Ophthalmicus Clinical Presentation and Risk Factors for Lesion Recovery

Purpose

Herpes zoster ophthalmicus (HZO) causes trouble in patients' daily life and work. In severe cases, it may even lead to a decrease or loss of vision. To understand the demographic information and ocular symptoms of hospitalized patients with HZO, and to find potential factors related to improvement time of skin rash and duration of ocular symptoms at discharge, we design this study.

Patients and Methods

This is a retrospective study. All patients diagnosed with HZO who were hospitalized in the Department of Dermatology of a hospital in Chongqing, China from January 1, 2015 to December 30, 2021 were included in this study. A total of 189 patients were included in this study. Clinical manifestations of the disease during hospitalization, improvement time of ocular skin lesions, and whether ocular skin lesions disappeared completely at discharge were recorded.

Results

The most common ocular symptom was eyelid swelling (92.6%), followed by eye pain (48.7%). The most common ocular sign was conjunctivitis (78.3%), followed by keratitis (15.9%). There were 149 cases without residual ocular symptoms and 40 cases with residual ocular symptoms. There was no statistically significant difference in demographic characteristics between the two groups (P>0.05). Age ≥70 years (B=0.381, -0.061~0.022, P=0.005), use of glucocorticoids (B=0.260, 0.024~0.496, P=0.031), and use of topical antiviral drugs (B=0.380, 0.054~0.705, P=0.023) were factors affecting the time interval from admission to improvement of skin rash. Tearing (HR, OR=4.827, 1.956~11.909, P<0.001) and blood urea nitrogen (OR=0.787, 0.620-1.000, P=0.050) were factors influencing residual ocular symptoms.

Conclusion

This study could help clinicians gain a deeper understanding of the clinical manifestations and partial influencing factors of HZO patients, which may contribute to future clinical work.

Infectious Neuropathies

OBJECTIVE

This article discusses the clinical manifestations and management of infectious peripheral neuropathies.

LATEST DEVELOPMENTS

Several infectious etiologies of peripheral neuropathy are well-recognized and their treatments are firmly established. The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is associated with several central and peripheral nervous system manifestations, including peripheral neuropathies. Additionally, some COVID-19 vaccines have been associated with Guillain-Barré syndrome. These disorders are an active area of surveillance and research. Recent evidence-based guidelines have provided updated recommendations for the diagnosis and treatment of Lyme disease.

ESSENTIAL POINTS

Infectious agents of many types (primarily bacteria and viruses) can affect the peripheral nerves, resulting in various clinical syndromes such as mononeuropathy or mononeuropathy multiplex, distal symmetric polyneuropathy, radiculopathy, inflammatory demyelinating polyradiculoneuropathy, and motor neuronopathy. Knowledge of these infections and the spectrum of peripheral nervous system disorders associated with them is essential because many have curative treatments. Furthermore, understanding the neuropathic presentations of these disorders may assist in diagnosing the underlying infection.

A Case of Herpes Zoster Ophthalmicus in a Recently Transplanted Renal Patient

Herpes Zoster Ophthalmicus (HZO) is a common manifestation of the reactivated Varicella Zoster virus, primarily affecting the eye and trigeminal nerve. This case study presents the clinical course of a 51-year-old male who underwent a renal transplant due to end-stage renal disease, further complicating the management of HZO. The patient's medical history also includes hypertension, type 2 diabetes mellitus, chronic kidney disease (CKD), cerebrovascular accident (CVA), and retinal detachment. Upon examination, the diagnosis of HZO was confirmed based on the presence of a characteristic unilateral vesicular rash in the V1 cranial nerve dermatomal distribution, accompanied by ophthalmic symptoms such as eyelid swelling and visual impairment. Given the patient's immunosuppressive regimen post-transplant, intravenous acyclovir was initiated for antiviral therapy, while supportive care was provided for pain control. Notably, the patient experienced a subsequent decrease in pain intensity and improvement in the vesicular rash. This case highlights the challenges in managing HZO in patients with a history of renal transplant and multiple comorbidities, emphasizing the importance of tailored treatment strategies to optimize patient outcomes. Further research is warranted to better understand the impact of immunosuppression and comorbidities on the course and management of HZO in this population.

Clinical Manifestations and Long-term Outcomes of Endothelial Keratoplasty in Patients with Proven VZV-related Endothelial Decompensation

PURPOSE

To report the clinical manifestations, postoperative complications and long-term outcomes of endothelial keratoplasty in VZV-related endothelial decompensation.

METHODS

In this retrospective study, thirteen eyes undergoing endothelial keratoplasty (EK) for VZV-related endothelial decompensation were compared with controls for Fuchs endothelial dystrophy or pseudophakic bullous keratopathy.

RESULTS

Twelve patients did not have typical dermal pain or blisters. Ten patients had obvious iris abnormalities. Glaucoma was noted in eight patients before surgery. The best spectacle-corrected visual acuity improved from 1.12 ± 0.47 to 0.39 ± 0.43 (p = .002), whereas endothelial cell (EC) loss was 65% ±15% at 12 months that higher than that in the controls (p < .05). Postoperative complications included graft detachment (2/13), recurrence of endotheliitis (3/13), neurotrophic ulcer (1/13) and scleritis (1/13).

CONCLUSIONS

The onset of VZV-related endothelial decompensation is generally insidious. Iris segmental atrophy, glaucoma and pigment KPs are highly suspected to be associated with VZV. EK is a reasonable option to rehabilitate vision.

Ocular effects caused by viral infections and corresponding vaccines: An overview of varicella zoster virus, measles virus, influenza viruses, hepatitis B virus, and SARS-CoV-2

Many viral infections can affect vision and the visual system. Vaccination to prevent diseases is commonplace today, acting by stimulating an immune response without developing the pathology. It involves the production of persisting antibodies against the pathogen and the activation of T cells. Certain diseases have already been eradicated by rigorous vaccination campaigns, while others are hoped to be eliminated soon. Vaccines currently available on the market are largely safe, even if they can rarely cause some adverse effects, such as ocular complications. Analyzing existing literature, we aimed to compare the pathological effects on the eye due to the most common viral infections [in particular varicella zoster virus (VZV), measles virus, influenza viruses, hepatitis B virus, and SARS-CoV-2] with the possible ocular adverse effects of their relative vaccines, in order to establish a risk-benefit relationship from an ophthalmological point of view.

Physical Examination in Human Immunodeficiency Virus Disease

Human immunodeficiency virus (HIV)-associated disease is known for its protean manifestations. However, many of the characteristic findings on physical examination are not associated with HIV infection per se but the numerous opportunistic infections (OIs) that are common in patients with advanced HIV disease. Common findings of acute HIV infection include fever, adenopathy, rash, and oral ulcers. Chronic HIV infection is associated with skin, rheumatologic, and neurologic manifestations. OIs also cause skin, oropharyngeal, ocular, and neurologic manifestations. A skilled clinician can often recognize HIV disease based on the combination of these findings.

Clinical Factors associated with the Early Reduction of Corneal Sensitivity in Herpes Zoster Ophthalmicus

Purpose

Methods

Results

Conclusions

Ocular manifestation and visual outcomes in herpes zoster ophthalmicus: a prospective study from a tertiary hospital of Eastern India

AIM

To estimate the magnitude of different ocular manifestation in clinically established herpes zoster ophthalmicus (HZO) patients and assessment of the visual outcome after two months of initial examination.

METHODS

An observational prospective study was conducted on 42 clinically diagnosed Tzanck smear positive cases HZO to observe the occurrence and frequency of different ocular manifestation and their visual outcome in 10-month period with 2mo follow up. Full ophthalmological examination using slit lamp, non-contact tonometry, applanation tonometry, direct and indirect ophthalmoscope were performed.

RESULTS

Out of 42 patients of HZO, 33 had one or more type of ocular manifestation staring from lid skin involvement to conjunctivitis, keratitis, uveitis, increased intraocular pressure (IOP) and optic neuritis but no retinal manifestation. More number of HZO cases and ocular manifestation were found with advancement of ages. Young HZO patients were more associated with human immunodeficiency virus (HIV) infection and HIV infected people with HZO infection had more ocular manifestation. Male to female ratio was 2:1 among HZO cases but ocular manifestation occurred more among males. Female with advanced age were involved more. Lid involvement (73.81%), conjunctivitis (69.05%), and keratitis (59.52%) were most common ocular manifestation followed by anterior uveitis (30.95%) and episcleritis (11.90%). Ocular hypertension (42.86%) was associated with almost every ocular manifestation. Among the cases of more than 45 years of age, 9.52% patients acquired 6/6 vision compared to 7.14% patients at and below 45 years of age after 8wk of follow up.

CONCLUSION

The visual outcomes are poor in HZO with advanced age group. Visual outcome of the affected eyes is poor than unaffected eyes. The loss of vision is mainly due to keratitis, anterior uveitis, posterior uveitis, and optic neuritis.

Colombian Ocular Infectious Epidemiology Study (COIES): Herpes Zoster Ophthalmicus prevalence and sociodemographic characterization, 2015-2019

OBJECTIVES

This study aimed to estimate the prevalence of Herpes Zoster Ophthalmicus (HZO) and describe the sociodemographic disease distribution by age, sex, and region in Colombia using National Health Registry data between January 1, 2015, to December 31, 2019.

METHODS

We conducted a cross-sectional study using the Integrated Social Protection Information System database from the Colombian Ministry of Health, the unique official database in the country. We used the specific code of the International Classification of Diseases for HZO (B02.3) from 2015-2019 to estimate the prevalence and the demographic status of the disease in Colombia.

RESULTS

The average prevalence was 0.99 in 100,000 inhabitants. Females represented 54.44% of the cases from 2.378 included patients. The distribution by age has a continual increasing distribution from the quinquennial age group of 55 years. The geographic analysis shows a higher disease burden in the Andean region, followed by the Caribbean and Pacific regions.

CONCLUSION

This is the first study that determines the HZO epidemiological characteristic based on a National Health database in our region. We found an age distribution similar to previous studies and bore out that higher altitudes correlate with a higher burden of the disease.

Antiviral Therapy for Varicella Zoster Virus (VZV) and Herpes Simplex Virus (HSV)-Induced Anterior Uveitis: A Systematic Review and Meta-Analysis

Topic: Herpes simplex virus (HSV) and varicella zoster virus (VZV) are the most common ocular pathogens associated with infectious anterior uveitis. Currently, there are a number of antiviral agents administered to treat viral anterior uveitis (VAU). However, there is no consensus or guidelines about the most appropriate approach leading for the best treatment outcomes with fewer ocular complications. Clinical Relevance: To perform a systematic review and meta-analysis of the efficacy of different antiviral therapies in the management of anterior uveitis secondary to HSV and VZV. Methods: We searched PubMed, Web of Science, CINAHL, OVID, and Embase up to January 2020. Randomized trials, non-randomized intervention studies, controlled before and after studies and observational studies assessing the effect of oral and or topical treatments for VAU were considered. Data extraction and analysis with evaluation of the risk of bias in the included trials were performed. Results: Oral acyclovir demonstrated a statistically significant good treatment outcome in the management of VZV anterior uveitis (vs. placebo) (OR 0.26, 95% CI 0.11-0.59), but did not have similar effect in HSV anterior uveitis (OR 0.47, 95% CI 0.15-1.50). In the treatment of VZV anterior uveitis, there was significant superiority of oral acyclovir-7 day course-over topical acyclovir (OR 4.17, 95% CI 1.28-13.52). Whereas, there was no significant superiority of one of the following treatment regimens over the others: topical acyclovir over topical corticosteroids (OR 1.86, 95% CI 0.67-5.17), and oral acyclovir-7 day course-over oral acyclovir-14 day course-(OR 0.21, 95% CI 0.01-4.50) or oral valaciclovir (OR 1.40, 95% CI 0.48-4.07). Conclusion: Treatment of HSV and VZV anterior uveitis is currently based on individual experiences and limited literature, largely due to weak clinical trial evidence in this regard. Our results highlight the existence of a substantial gap in our evidence base. This finding might contribute to future research studies to ascertain the role of different antiviral therapies in the treatment of VAU. Systematic Review Registration: PROSPERO registration number: CRD420202 00404.

Herpes Zoster Ophthalmicus Clinical Presentation and Risk Factors for Loss of Vision

PURPOSE

To determine the rate of moderate and severe vision loss following herpes zoster ophthalmicus (HZO) and to identify associated factors.

DESIGN

Retrospective cohort study.

METHODS

All subjects with acute HZO seen at a single center from 2006 to 2016 were included in the study. The primary outcome measure was the proportion of individuals with moderate and/or severe loss of vision following an acute episode of HZO. Secondary outcome measures included causes and factors associated with permanent loss of vision owing to HZO.

RESULTS

A total of 869 patients with acute HZO were identified with a median follow-up time of 6.3 years (interquartile range 3.7-8.9 years). Ocular involvement of HZO was diagnosed at or within the first month of presentation in 737 individuals (84.8%). The most common sites of ocular involvement were conjunctivitis (76.1%), followed by keratitis (51.2%) and uveitis (47.6%). Moderate vision loss (≤20/50) secondary to HZO occurred in 83 eyes (9.6%) while severe vision loss (≤20/200) occurred in 31 eyes (3.6%). Causes of loss of vision included corneal scarring (94.0%), corneal perforation (4.8%), and secondary glaucoma (1.2%). Severe vision loss was associated with older age (hazard ratio [HR] 1.059, P = .001), immunosuppression (HR 3.125, P = .028), poor presenting visual acuity (HR 2.821, P = .002), and uveitis (HR 4.777, P = .004) on multivariate analysis.

CONCLUSIONS

Among individuals with HZO, approximately 1 in 10 individuals may develop moderate or severe vision loss, primarily owing to corneal scarring. Older age, immunosuppression, and uveitis are associated with severe permanent loss of vision secondary to HZO.

Incidence of acute complications of herpes zoster among immunocompetent adults in England: a matched cohort study using routine health data

BACKGROUND

Herpes zoster can cause rare but serious complications; the frequency of these complications has not been well described.

OBJECTIVES

To quantify the risks of acute non-postherpetic neuralgia (PHN) zoster complications, to inform vaccination policy.

METHODS

We conducted a cohort study among unvaccinated immunocompetent adults with incident zoster, and age-, sex- and practice-matched control adults without zoster, using routinely collected health data from the UK Clinical Practice Research Datalink (years 2001 to 2018). Crude attributable risks of complications were estimated as the difference between Kaplan-Meier-estimated 3-month cumulative incidences in patients with zoster vs. controls. We used Cox models to obtain hazard ratios for our primary outcomes in patients with and without zoster. Primary outcomes were ocular, neurological, cutaneous, visceral and zoster-specific complications. We also assessed whether antivirals during acute zoster protected against the complications.

RESULTS

In total 178 964 incident cases of zoster and 1 799 380 controls were included. The absolute risks of zoster-specific complications within 3 months of zoster diagnosis were 0·37% [95% confidence interval (CI) 0·34-0·39] for Ramsay Hunt syndrome, 0·01% (95% CI 0·0-0·01) for disseminated zoster, 0·04% (95% CI 0·03-0·05) for zoster death and 0·97% (95% CI 0·92-1·00) for zoster hospitalization. For other complications, attributable risks were 0·48% (95% CI 0·44-0·51) for neurological complications, 1·33% (95% CI 1·28-1·39) for ocular complications, 0·29% (95% CI 0·26-0·32) for cutaneous complications and 0·78% (95% CI 0·73-0·84) for visceral complications. Attributable risks were higher among patients > 50 years old. Patients with zoster had raised risks of all primary outcomes relative to controls. Antiviral prescription was associated with reduced risk of neurological complications (hazard ratio 0·61, 95% CI 0·53-0·70).

CONCLUSIONS

Non-PHN complications of zoster were relatively common, which may affect cost-effectiveness calculations for zoster vaccination. Clinicians should be aware that zoster can lead to various complications, besides PHN.

Effectiveness of the Recombinant Zoster Vaccine for Herpes Zoster Ophthalmicus in the United States

PURPOSE

To examine the effectiveness of the recombinant zoster vaccine (RZV) for preventing herpes zoster ophthalmicus (HZO) in the general United States population.

DESIGN

Retrospective, observational cohort study.

PARTICIPANTS

Individuals enrolled in the OptumLabs Data Warehouse (OLDW; OptumLabs, Cambridge, MA) who were age eligible for herpes zoster (HZ) vaccination (≥50 years of age) from 2018 through 2019. The OLDW is a longitudinal, de-identified administrative claims and electronic health record database of patients in the United States with commercial insurance, Medicare Part D, or Medicare Advantage METHODS: Patients were required to have 365 days or more of continuous enrollment to be eligible. Those with a diagnosis code of HZ or an immunocompromising condition within 1 year before study inclusion were excluded. Vaccination with the RZV was ascertained by Current Procedural Terminology codes, and HZO was ascertained by International Classification of Diseases, Tenth Revision, codes. Cox proportional hazards regression models were used to estimate the hazard ratio of HZO associated with RZV, and inverse-probability weighting was used to control for confounding. Vaccine effectiveness was calculated from hazard ratios.

MAIN OUTCOME MEASURES

Incidence of HZO in vaccinated versus unvaccinated person-times and vaccine effectiveness were assessed.

RESULTS

From January 1, 2018, through December 31, 2019, a total of 4 842 579 individuals were included in this study. One hundred seventy-seven thousand two hundred eighty-nine (3.7%) received 2 valid doses of RZV. The incidence rate of HZO was 25.5 cases (95% confidence interval [CI], 17.4-35.8 cases) per 100 000 person-years in the vaccinated group compared with 76.7 cases (95% CI, 74.7-78.7 cases) in the unvaccinated group. The overall adjusted effectiveness of RZV against HZO was 89.1% (95% CI, 82.9%-93.0%).

CONCLUSIONS

The effectiveness of RZV against HZO in individuals 50 years of age and older is high in a clinical setting. However, the low vaccination rate in this study highlights the public health need to increase HZV use. Ophthalmologists can play an important role in recommending vaccination to eligible patients.

Epidemiology of Viral Induced Anterior Uveitis

Purpose: Viral agents are the most common cause of infectious anterior uveitis worldwide. The purpose of this review is to analyze the frequency, gender and racial differences of viral anterior uveitis (VAU) in various populations.Methods: Systematized literature review of epidemiological reports of VAU cited in PubMed, EMBASE and the Cochrane Library database published until June 30th, 2020.Results: A total of 12 clinical studies on epidemiology of definite VAU and 36 clinical studies of presumed VAU were identified. Members of Herpesviridae family represent the most common causes of VAU. Other less frequently reported causes, such as rubella and endemic viruses (HTLV-1, Chikungunya, Dengue, Ebola, Zika virus) were also analyzed.Conclusion: HSV, VZV are prevalent worldwide. CMV is more frequent in Asia, and rubella in the West. However, due to globalization and air travel, HTLV-1, Chikungunya, Dengue and Ebola may become important causes of VAU across the world.

Ethylenediaminetetraacetic Acid Chelation in Herpes Zoster Ophthalmicus Is Associated With a High Rate of Corneal Melt and Perforation

PURPOSE

To examine the rate and risk factors for band keratopathy after herpes zoster ophthalmicus (HZO) and the outcomes of ethylenediaminetetraacetic acid (EDTA) treatment.

METHODS

This is a retrospective review of all subjects with HZO seen at Auckland District Health Board between January 2006 and December 2016.

RESULTS

A total of 869 subjects with HZO were included in the study. Median follow-up was 6.3 years (total 5504.4 patient-years). Band keratopathy developed in 13 subjects (1.5%). On multivariate analysis, older age at onset [hazard ratio (HR), 1.092; P = 0.034], intraocular pressure ≥30 mm Hg at presentation (HR, 5.548; P = 0.013), and number of recurrences (HR, 1.849; P < 0.001) were associated with increased risk for band keratopathy. Corneal melt occurred in 22 subjects (2.5%) during the follow-up period. On multivariate analysis, uveitis (HR, 8.618; P = 0.004) and disodium EDTA chelation (HR, 8.666; P < 0.001) were associated with increased risk for corneal melt. EDTA chelation was performed in 8 subjects. Corneal melt occurred after EDTA chelation in 4 subjects, and corneal perforation occurred in 2 subjects. One subject was eviscerated due to severe endophthalmitis after repeated corneal perforation and another required enucleation for recurrent corneal melt and microbial keratitis.

CONCLUSIONS

Band keratopathy is an uncommon complication of HZO. Treatment with EDTA chelation might be associated with a significant risk for severe complications in these eyes and should be approached with caution.

[S2k guideline for the diagnosis and therapy of zoster and post-zoster neuralgia]

Diese Leitlinie richtet sich an Dermatologen, Ophthalmologen, HNO-Ärzte, Pädiater, Neurologen, Virologen sowie Infektiologen, Anästhesisten und Allgemeinmediziner in Klinik und Praxis und dient zur Information für andere medizinische Fachrichtungen, die an der Behandlung des Zoster beteiligt sind. Darüber hinaus soll die Leitlinie Kostenträgern und politischen Entscheidungsträgern zur Orientierung dienen. Die Leitlinie wurde im formellen Konsensusverfahren (S2k) von Dermatologen, Virologen/Infektiologen, Ophthalmologen, HNO-Ärzten, Neurologen, Pädiatern und Anästhesisten/Schmerzmedizinern erstellt.

Die Leitlinie stellt einen Überblick über die klinische und molekulare Diagnostik sowie den Antigennachweis, die Antikörperkultur und Viruskultur dar. Diagnostisch besondere Situationen und komplizierte Verläufe der Erkrankung finden ebenfalls Berücksichtigung. Die antivirale Therapie des Zoster und der Postzosterneuralgie wird im Allgemeinen und für besondere Situationen dargelegt. Detaillierte Angaben zur Schmerzbehandlung finden Erwähnung und sind in einer Übersicht dargestellt. Ebenso werden die lokaltherapeutischen Maßnahmen thematisiert.

The Spectrum of Microbial Keratitis: An Updated Review

Background:

In microbial keratitis, infection of the cornea can threaten vision through permanent corneal scarring and even perforation resulting in the loss of the eye. A literature review was conducted by Karsten, Watson and Foster (2012) to determine the spectrum of microbial keratitis. Since this publication, there have been over 2600 articles published investigating the causative pathogens of microbial keratitis.

Objective:

To determine the current spectrum of possible pathogens implicated in microbial keratitis relative to the 2012 study.

Methods:

An exhaustive literature review was conducted of all the peer-reviewed articles reporting on microbial pathogens implicated in keratitis. Databases including MEDLINE, EMBASE, Scopus and Web of Science were searched utilising their entire year limits (1950-2019).

Results:

Six-hundred and eighty-eight species representing 271 genera from 145 families were implicated in microbial keratitis. Fungal pathogens, though less frequent than bacteria, demonstrated the greatest diversity with 393 species from 169 genera that were found to cause microbial keratitis. There were 254 species of bacteria from 82 genera, 27 species of amoeba from 11 genera, and 14 species of virus from 9 genera, which were also identified as pathogens of microbial keratitis.

Conclusion:

The spectrum of pathogens implicated in microbial keratitis is extremely diverse. Bacteria were most commonly encountered and in comparison, to the review published in 2012, further 456 pathogens have been identified as causative pathogens of microbial keratitis. Therefore, the current review provides an important update on the potential spectrum of microbes, to assist clinicians in the diagnosis and treatment of microbial keratitis.

Varicella Zoster Virus Induces Differential Cell-Type Specific Responses in Human Corneal Epithelial Cells and Keratocytes

Purpose

While VZV DNA and antigen have been detected in acute and chronic VZV keratitis, it is unclear whether productive infection of corneal cells is ongoing or whether residual, noninfectious VZV antigens elicit inflammation. Herein, we examined VZV-infected primary human corneal epithelial cells (HCECs) and keratocytes (HKs) to elucidate the pathogenesis of VZV keratitis.

Methods

HCECs and HKs were mock- or VZV infected. Seven days later, cells were examined for morphology, proinflammatory cytokine and matrix metalloproteinase (MMP) release, ability to recruit peripheral blood mononuclear cells (PBMCs) and neutrophils, and MMP substrate cleavage.

Results

Both cell types synthesized infectious virus. VZV-infected HCECs proliferated, whereas VZV-infected HKs died. Compared to mock-infected cells, VZV-infected HCECs secreted significantly more IL-6, IL-8, IL-10, and IL-12p70 that were confirmed at the transcript level, and MMP-1 and MMP-9; conditioned supernatant attracted PBMCs and neutrophils and cleaved MMP substrates. In contrast, VZV-infected HKs suppressed cytokine secretion except for IL-8, which attracted neutrophils, and suppressed MMP release and substrate cleavage.

Conclusions

Overall, VZV-infected HCECs recapitulate findings of VZV keratitis with respect to epithelial cell proliferation, pseudodendrite formation and creation of a proinflammatory environment, providing an in vitro model for VZV infection of corneal epithelial cells. Furthermore, the proliferation and persistence of VZV-infected HCECs suggest that these cells may serve as viral reservoirs if immune clearance is incomplete. Finally, the finding that VZV-infected HKs die and suppress most proinflammatory cytokines and MMPs may explain the widespread death of these cells with unchecked viral spread due to ineffective recruitment of PBMCs.