Herpes zoster ophthalmicus and acquired immune deficiency syndrome

Acquired immune deficiency syndrome (AIDS) is a recently recognized disease characterized by abnormalities in cell-mediated immunity that predispose affected persons to severe opportunistic infections and unusual malignant neoplasms. We describe four cases of herpes zoster ophthalmicus in four previously healthy homosexual men. Two had signs and symptoms consistent with AIDS, and two had signs and symptoms of a lymphadenopathic syndrome associated with AIDS. We suggest that underlying AIDS be considered in young, healthy persons with herpes zoster ophthalmicus and no known cause of immunosuppression.

The varicella-zoster virus: systemic and ocular features

Although the varicella-zoster virus infections are usually benign skin diseases, they can have serious systemic manifestations and complications. This article reviews the current concepts concerning the anatomy and physiology of the virus and the epidemiology, pathogenesis, pathology, immunology, and laboratory diagnosis of these infections. The information gained in these areas has improved our knowledge of the disease, permitted the detection of susceptible patients, allowed the earlier use of new antiviral treatment, and provided a background for the use of active and passive immunization. The clinical features and consequences of both varicella and herpes zoster are described. The prevention and treatment are underscored, especially with regard to the newer systemic antiviral therapy. Herpes zoster ophthalmicus is specifically detailed because of its frequency and because of serious ocular and systemic implications for both the dermatologist and the ophthalmologist. The nerve innervation of the eye and ocular adnexa as it pertains to herpes zoster ophthalmicus is outlined, and a description is given of the multiple ocular complications for the dermatologist. Data on the role of antiviral agents and of topical and systemic corticosteroids in herpes zoster ophthalmicus are presented. Postherpetic neuralgia, probably the most difficult management problem of herpes zoster ophthalmicus, is addressed from a descriptive, preventive, and treatment view.

The ocular manifestations of herpes zoster, varicella, infectious mononucleosis, and cytomegalovirus disease

Herpes zoster, caused by varicella-zoster (V-Z) virus which also causes varicella (chickenpox), is usually a benign self-limited disease. However, when the ophthalmic division of the trigeminal nerve is affected, the ocular disease (ophthalmic zoster), although also usually mild and self-limited, may have severe complications (corneal scarring, glaucoma, iris atrophy, posterior synechiae, scleritis, motor disturbances, optic neuritis, retinitis, anterior segment necrosis, and phthisis bulbi and servere postherpetic neuralgia). Varicella affects the eye rarely (except for the typical lid lesions), but associated conjunctival and corneal lesions, iridocyclitis, glaucoma, chorioretinitis, and optic nerve lesions have been described. Infectious mononucleosis may involve the eye either by direct involvement or from a remote focus such as the central nervous system. Ocular manifestations of cytomegalovirus disease is usually limited to the choroid and retina unless involvement of the developing embryo occurs prior to the development of the eye.

Herpes zoster virus sclerokeratitis and anterior uveitis in a child following varicella vaccination

PURPOSE

To report a case of herpes zoster virus sclerokeratitis with anterior uveitis following vaccination with live attenuated varicella vaccine (Oka strain).

DESIGN

Case report.

METHODS

The case records of the patient were reviewed retrospectively. Pertinent literature citations were identified using MEDLINE.

RESULTS

A 9-year-old boy presented with herpes zoster ophthalmicus 3 years following vaccination with live attenuated varicella vaccine (Oka strain). Examination of the affected eye revealed a moderate follicular response on the palpebral conjunctiva, decreased corneal sensation, mildly elevated intraocular pressure, diffuse anterior scleritis with marginal keratitis, and a moderately severe anterior uveitis. Amplified DNA from fluid taken from the base of a cutaneous vesicle produced wild-type varicella zoster virus (VZV) DNA, not Oka strain.

CONCLUSIONS

Herpes zoster virus infection needs to be considered in all patients who present with scleritis, keratitis, or anterior uveitis, regardless of their varicella vaccination status.

Aseptic meningitis and optic neuritis preceding varicella-zoster progressive outer retinal necrosis in a patient with AIDS

Varicella-Zoster Virus (VZV) is the second most common ocular pathogen in patients with HIV infection. VZV retinitis is estimated to occur in 0.6% of patients with HIV infection and may occur in one of two clinical syndromes. The first is the acute retinal necrosis syndrome, which also may be seen in immunocompetent hosts. The second clinical syndrome occurs in patients with CD4 cell counts typically < 50 x 10(6)/l and is termed progressive outer retinal necrosis. VZV retinitis has been reported to occur simultaneously with other VZV central nervous system manifestations such as encephalitis and myelitis in HIV-infected patients. In addition, VZV retrobulbar optic neuritis heralding VZV retinitis has recently been described in HIV-infected patients who had suffered a recent episode of dermatomal herpes zoster. Herein we report the case of an HIV-infected individual who presented with VZV meningitis and retrobulbar optic neuritis that preceded the onset of progressive outer retinal necrosis. We also review of the literature of seven additional reported cases of retrobulbar optic neuritis preceding the onset of VZV retinitis.

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.

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.

Progressive outer retinal necrosis in immunocompetent patients treated initially for optic neuropathy with systemic corticosteroids

PURPOSE

To report two cases of progressive outer retinal necrosis occurring in immunocompetent individuals after treatment with corticosteroids for presumed optic neuropathy.

DESIGN

Observational case report.

SETTING

University-based tertiary eye hospital.

METHODS

Retrospective review of existing clinical records.

RESULTS

Two patients were treated empirically with systemic corticosteroids for suspected inflammatory papillopathy. Subsequently, both were diagnosed with necrotizing herpetic retinitis with features of progressive outer retinal necrosis. Anterior chamber paracentesis confirmed varicella-zoster infection. Both patients were human immunodeficiency virus negative; one patient with rheumatoid arthritis was taking etanercept. Both became completely blind in one eye despite intensive treatment with antiviral medication intravenously and intravitreally.

CONCLUSIONS

Progressive outer retinal necrosis is not confined to patients with underlying severe immunodeficiency, such as acquired immune deficiency syndrome. Initial treatment of acute, unexplained vision loss with systemic corticosteroids may lead to catastrophic visual loss in patients with evolving necrotizing herpetic retinopathy.

Successful treatment of progressive outer retinal necrosis syndrome

PURPOSE

Progressive outer retinal necrosis is a destructive retinopathy found in patients with acquired immune deficiency syndrome. Treatment of this disorder has been unsuccessful in reported patient series, with the patients experiencing profound bilateral loss of vision.

METHODS

We treated six patients with combination antiviral therapy, usually with intravenous foscarnet and either ganciclovir or acyclovir.

RESULTS

These six patients retained a visual acuity of 20/100 or better in at least one eye for the remainder of their lives (a period > 4 months for each patient). Retinal detachments developed in four patients, for which vitrectomy and silicone oil tamponade were required.

CONCLUSIONS

A combination of intravenous antiviral therapy and aggressive vitrectomy techniques to repair any associated detachments may allow the preservation of useful visual acuity in patients with progressive outer retinal necrosis. This is the first reported series of successful long-term treatment of patients with this disorder.

Keratitis

Corneal inflammation or keratitis is a significant cause of ocular morbidity around the world. Fortunately, the majority of the cases are successfully managed with medical therapy, but the failure of therapy does occur, leading to devastating consequences of either losing the vision or the eye. This review attempts to provide current information on most, though not all, aspects of keratitis. Corneal inflammation may be ulcerative or nonulcerative and may arise because of infectious or noninfectious causes. The nonulcerative corneal inflammation may be confined to the epithelial layer or to the stroma of the cornea or may affect both. For clarity, this section has been divided into nonulcerative superficial keratitis and nonulcerative stromal keratitis. While the former usually includes hypersensitivity responses to microbial toxins and unknown agents, the latter can be either infectious or noninfectious. In the pathogenesis of ulcerative keratitis, microorganisms such as bacteria, fungi, parasites (Acanthamoeba), or viruses play an important role. Approximately, 12.2% of all corneal transplantations are done for active infectious keratitis. Available world literature pertaining to the incidence of microbial keratitis has been provided special place in this review. On the other hand, noninfectious ulcerative keratitis can be related to a variety of systemic or local causes, predominantly of autoimmune origin.

Herpes zoster ophthalmicus following bone marrow transplantation in children

Varicella zoster virus (VZV) infection is a frequent complication following bone marrow transplantation (BMT). Involvement of the ophthalmic division of the trigeminal nerve, herpes zoster ophthalmicus (HZO), can result in significant and potentially vision-threatening ocular complications. We report the frequency and characteristics of HZO following BMT, including the timing of infection, treatment, ocular complications, and visual outcome. Between 1983 and 1997, 572 patients underwent BMT and seven children developed HZO at a median of 150 days following transplantation. All but one of the children had undergone allogeneic BMT. All of the children were treated with acyclovir after onset of the rash but none had received prophylactic therapy. All seven children developed ocular complications within the first 4 weeks following the onset of the dermatomal rash but none reported any symptoms during this period. Complications included keratitis in six, anterior uveitis in three and scleritis in one. Keratitis was an early complication developing within the first 4 weeks, while anterior uveitis and scleritis occurred later in the course of the disease. The high frequency of ocular complications and lack of symptoms in children with HZO following BMT suggests that early ophthalmologic evaluation is warranted in this group of patients. Prompt diagnosis and treatment of ocular complications is essential in the prevention of acute and long-term ocular sequelae in these children.

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.

Infantile herpes zoster ophthalmicus and acute hemiparesis following intrauterine chickenpox

A 17-month-old boy developed herpes zoster ophthalmicus (HZO) and delayed contralateral hemiparesis following intrauterine varicella exposure. CT demonstrated multiple areas of hypodensity in the left basal ganglia, and angiography showed occlusion of left lenticulostriate arteries. As in most adults with HZO and delayed hemiparesis, this infant had a self-limiting course with excellent recovery.

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.

Herpes zoster ophthalmicus: a medical review

Patients with herpes zoster undergo extensive screening to detect underlying malignant disease which is compromising their immunity. In a retrospective survey of 1000 patients with herpes zoster ophthalmicus 12 patients had malignant disease which was known on presentation. No new cases were detected or discovered on follow-up. Three patients developed a disseminated rash, but none of these had an underlying malignant disease.

Varicella-zoster virus: mechanisms of pathogenicity and corneal disease

As ophthalmologists, many of our patients suffer from the ravages, both ocular and non-ocular, of the varicella-zoster virus. This article is a comprehensive review of the pathogenetic mechanisms of this ubiquitous virus. We review the basic virology, mechanisms of varicella, zoster, latency, reactivation, and the host immune response to the virus. Herpes zoster ophthalmicus is discussed with special attention to the cornea and mechanisms of viral keratitis.

Presumed Reactivation of Herpes Zoster Ophthalmicus Following Laser in situ Keratomileusis

PURPOSE

To report a case of herpes zoster ophthalmicus reactivation following laser in situ keratomileusis (LASIK) for myopia.

METHODS

A 54-year-old healthy male underwent uneventful bilateral LASIK for the correction of myopia and astigmatism (-5.75 -3.00 x 20 degrees right eye, -5.50 -3.00 x 170 degrees left eye). Two months following LASIK, an epithelial dendritic lesion appeared in the lower third of the corneal flap of the left eye with vesiculoulcerative lesions of the lateral side of the tip of the nose.

RESULTS

The patient was treated with topical and oral antiviral agents and had complete recovery of the lesions in 10 days.

CONCLUSIONS

Herpes zoster reactivation may occur following LASIK. Reactivation of herpes zoster in this case could have been coincidental, or secondary to LASIK and the subsequent use of topical corticosteroids following LASIK.

Isolation of the human T-cell leukemia/lymphotropic virus type III from aqueous humor in two patients with perivasculitis of the retinal vessels

The human T-cell leukemia/lymphotropic virus type III (HTLV-III) has been isolated from aqueous humor in two patients with perivasculitis of the peripheral retinal vessels, an AIDS-related ocular manifestation. Both patients had antibodies to HTLV-III and although they presented with herpes zoster ophthalmicus, they did not present other symptoms known to be associated with HTLV-III infection. The isolation of HTLV-III from aqueous humor in these two patients with retinal perivasculitis suggests that the virus itself may play a role in the etiology of this ocular sign. The presence of infectious HTLV-III in the anterior chamber further emphasises the necessity to discard corneas from HTLV-III infected donors.

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.