Clinical profile and ophthalmologic manifestations of Herpes Zoster Ophthalmicus / Perfil clínico e achados oftalmológicos no Herpes Zoster Oftálmico

ABSTRACT Objective: Herpes Zoster Ophthalmicus (HZO) is caused by varicella-zoster virus (VZV) and commonly affects elderly or immunocompromised patients. It has the potential to generate severe complications such as corneal ulcers, uveitis, retinal necrosis and post herpetic neuralgia. This study aimed to evaluate patients at the acute onset of the disease and describe their clinical profile and ophthalmologic findings. Methods: A cross-sectional study was performed from March 2014 to October 2015. All consecutive patients with the diagnosis of acute HZO (at a vesicle, pustule or crust stage) were enrolled and submitted to an ophthalmologic exam that included ectoscopy, best corrected visual acuity, corneal sensitivity test, slit-lamp examination, Goldmann applanation tonometry and funduscopic examination. Results: Nineteen patients were included. The mean age was 71 years old, ranging from 52 to 88. Ten patients had high blood pressure (52.6%) and nine (47.3%) had diabetes. Visual acuity lowered in comparison to the fellow eye in eleven patients (57%), ranging from one to six lines of vision, due mostly to epithelial keratitis and ocular discharge. Intraocular pressure (IOP) did not varied in most cases compared to the fellow eye. Hutchinson's sign (HS) was present in seven (36%) patients. The correlation between HS and anterior chamber reaction as well as decreased corneal sensitivity was statistically significant with Fisher's test of 0.009 and 0.029 respectively (p<0.05). Conclusion: The clinical profile of our patients was elderly patients with a higher rate of diabetes. Correlation between Hutchinson's sign and anterior chamber reaction as well as decrease in corneal sensitivity was significant. High intraocular pressure or posterior segment complications were not found in any cases.

RESUMO Objetivos: Herpes Zoster Oftálmico (HZO) é uma doença causada pelo vírus varicella-zoster que comumente afeta idosos ou doentes imunossuprimidos, com potencial para gerar graves comorbidades oculares, incluindo úlceras corneanas, uveíte, necrose retiniana e neuralgia pós-herpética. O objetivo deste estudo foi avaliar estes pacientes na forma aguda da doença e descrever seu perfil clínico e achados oftalmológicos. Métodos: Um estudo transversal foi realizado entre março de 2014 e outubro de 2015. Todos os pacientes consecutivos com o diagnóstico de HZO (na forma vesicular, pustulosa ou crostosa) foram incluídos e submetidos ao exame oftalmológico que incluiu ectoscopia, melhor acuidade visual corrigida, teste de sensibilidade corneana, biomicroscopia, tonometria de aplanação de Goldmann e fundoscopia. Resultados: Dezenove pacientes foram incluídos. A idade média foi de 71 anos. Dez (52,6%) pacientes relataram hipertensão arterial sistêmica e nove (47,3%) diabetes mellitus. A acuidade visual do olho acometido se encontrou abaixo do olho contra lateral em 57% dos casos, variando entre uma a seis linhas de visão. A pressão intraocular não variou na maioria dos casos em comparação com o olho contralateral. O sinal de Hutchinson estava presente em sete (36%) pacientes. A correlação entre este sinal e a presença tanto de reação de câmara anterior quanto de hipoestesia corneana foi positiva estatisticamente, com teste exato de Fisher de 0,009 e 0,029 respectivamente (p<0,05). Conclusão: Idosos com uma prevalência elevada de diabetes mellitus representaram o perfil clínico dos pacientes deste estudo. A correlação entre o sinal de Hutchinson e reação de câmara anterior, bem como daquele com hipoestesia corneana foi estatisticamente significativa. Não foi identificado nenhum caso de hipertensão ocular ou complicações de segmento posterior.

Herpes zoster ophthalmicus and varicella zoster virus vasculopathy / Herpes zoster ophthalmicus e vasculopatia por vírus varicella zoster

ABSTRACT Herpes zoster (HZ) corresponds to the reactivation of varicella zoster virus (VZV). Among adults, the ophthalmic division of the trigeminal nerve is one of the most common sites of involvement. Vasculopathy caused by HZ is associated with significant morbidity and mortality, affecting structures such as the brain, which can lead to stroke. In this review, we analyzed the epidemiological and clinical aspects of the vascular involvement of VZV, focusing on the peculiarities of its association with ocular HZ. A review of the available literature indicated that ocular involvement of HZ was a risk factor for vasculopathy after adjusting for age, sex, body mass index, smoking, indicators of metabolic syndrome, and vascular and heart diseases. Considering the severity of this complication, vascular disease mediated by VZV requires early diagnosis and aggressive treatment. Finally, the anti-HZ vaccine has been recommended as a prophylactic measure in the elderly, but it should be used with caution in immunocompromised individuals.

RESUMO Herpes zoster (HZ) corresponde à reativação do vírus varicela zoster (VVZ) e, entre os adultos, o envolvimento da divisão oftálmica do nervo trigêmeo é um dos locais mais comuns A vasculopatia associada ao HZ é uma complicação dotada de grande morbimortalidade e afeta diferentes estruturas, favorecendo, inclusive o acidente vascular cerebral. Nesta revisão analisamos aspectos epidemiológicos e clínicos da vasculopatia mediada pelo VZV, bem como as peculiaridades relacionadas com o HZ ocular. De acordo com dados disponíveis na literatura, o acometimento ocular pelo HZ mostrou ser um fator de risco para vasculopatia após se ajustar para idade, sexo, índice de massa corporal, tabagismo, indicadores da síndrome metabólica, doença vascular e cardiopatias. Em face da gravidade dessa complicação, a doença vascular mediada pelo VZV requer diagnóstico precoce e tratamento agressivo. A vacina anti-HZ tem sido recomendada profilaticamente em idosos, mas deve ser usada com cautela em indivíduos imunocomprometidos.

Optic neuritis complicating herpes zoster ophthalmicus in an immunocompetent patient / Zoster optic neuritis in immunocompentent

A 58-year-old woman presented with rash over the left side of the face and intense acute uveitis. Following careful review of the symptoms and dilated fundus examination unilateral optic neuritis was discovered. The rash was typical of varicella zoster dermatitis. Patients presenting with herpes zoster ophthalmicus should always undergo dilated fundus examination, as there is a potential risk of unexpected posterior segment inflammation. Early diagnosis and prompt treatment can avoid visual sequelae.

Paciente de 58 anos de idade apresentando erupção cutânea no lado esquerdo da face e intensa uveíte unilateral. Após cuidadosa revisão dos sintomas e exame de fundo do olho foi detectada neurite óptica. O rash era típico de dermatite por varicella zoster. Pacientes apresentando quadro de herpes zoster oftálmico devem ser submetidos ao exame de fundo do olho devido ao risco de inesperada inflamação do segmento posterior. Diagnóstico precoce e tratamento imediato podem evitar danos visuais.

A rare case of orbital apex syndrome with herpes zoster ophthalmicus in a human immunodeficiency virus-positive patient.

We report a rare instance of favorable outcome in orbital apex syndrome secondary to herpes zoster ophthalmicus (HZO) in a human immunodeficiency virus (HIV)-positive patient. The patient complained of pain and decrease in vision in one eye (20/640) for 2 weeks accompanied with swelling, inability to open eye, and rashes around the periocular area and forehead. The presence of complete ophthalmoplegia, ptosis, relative afferent pupillary defect, and anterior uveitis with decreased corneal sensation prompted a diagnosis of HZO with orbital apex syndrome. The enzyme-linked immunosorbent assay test and a low CD4 count confirmed HIV. Highly active antiretroviral therapy (HAART), systemic acyclovir, and systemic steroids were started. Visual acuity and uveitis improved within 10 days. By the end of the fourth week, ocular motility also recovered and the final visual acuity was 20/25. We highlight the role of HAART, used in conjunction with systemic steroid and acyclovir therapy, in improving the outcome.

Análise de 29 casos de esclerite. Experiência de um serviço de Reumato-Oftalmologia / Analysis of 29 cases of scleritis. Experience of a Rheumato-Ophthalmology Service

Esclerites são doenças que podem ter como causa uma doença reumatológica, infecciosa ou tumoral ou, ainda, ser uma entidade restrita apenas ao olho. Objetivo: Relatar a experiência de dois anos de um ambulatório conjunto de Reumato-Oftalmologia no diagnóstico e acompanhamento de pacientes com esclerite por três anos. Métodos: Esta é uma análise de 29 casos de esclerite. Todos os casos foram avaliados pelo serviço de Oftalmologia e pelo de Reumatologia. Resultados: Dos 29 casos identificados, foi possível identificar uma doença subjacente em 55,17 por cento dos casos. Observamos doenças reumáticas em 34,4 por cento e infecciosas 20,6 por cento dos casos. As esclerites idiopáticas não se distinguiram das reumáticas quanto às características clínicas embora um maior número de casos com a forma necrosante tenha sido visto nas reumáticas (sem significância estatística). Esclerites com doença reumática subjacente foram tratadas mais vezes com corticóides orais e imunossupressores. Conclusões: A cooperação entre reumatologistas e oftalmologistas se mostrou útil na identificação etiológica de pacientes com esclerite.

Scleritis are entities that may have rheumatic diseases, infections or tumors as etiologic factors or may be a disease restricted only to the eye. Purpose: To share a three year experience of a rheumato-ophthalmologic ambulatory in the diagnosis and treatment of patients with scleritis. Methods: This was a study of 29 cases. All of them were analyzed by the Ophthalmology and Rheumatology Services. Results: From the 29 cases, an underlying disease was found in 55.17 percent. Rheumatic diseases were present in 34.4 percent; infectious in 20.6 percent. Idiophatic forms of scleritis did not differ from the rheumatic ones although a higher number of necrotizing cases were seen in the later group (with no statistical significance). Scleritis due to rheumatic diseases was treated more frequently with oral corticosteroids and immunosuppressive drugs. Conclusions: Patients with scleritis have a high rate of infectious and rheumatic diseases. Cooperation of rheumatologists and ophthalmologists was useful for the etiologic identification of patients with scleritis.

A Case of Optic Neuritis Complicating Herpes Zoster Ophthalmicus in a Child

Here we report a case of optic neuritis in the setting of herpes zoster ophthalmicus (HZO) in a child. A six-year-old girl presented with HZO in the right eye. During the hospitalization, her visual acuity decreased. Fluorescein angiography (FAG) and optical coherence tomography revealed optic neuritis in the affected eye. Visual acuity improved with one month of treatment with acyclovir and steroids. FAG analysis showed no evidence of leakage at the optic disc. At one year post treatment, the patient's fundus exam and vision were normal. Therapy with antivirals and steroids may be effective in patients with childhood HZO optic neuritis

Herpes Zoster ophthalmicus and HIV seropositivity in South-south Nigeria

Herpes zoster is a painful vesiculobullous dermatitis which occurs as a result of previously established varicella zoster virus infection. It is a well established fact that Herpes zoster ophthalmicus is a well known marker of human immune deficiency virus infection even in Africans. The aim of this study is to determine if indeed the herpes zoster condition is a marker for the immune deficiency condition called AIDS in our locality and whether the positivity is related to age or not. A total of 20 consecutive patients that presented between 2003 and 2006 with herpes zoster ophthalmicus were examined retrospectively as to their Human Immune deficiency virus (HIV) status. Their presentation; clinical findings and clinical course are also analyzed. Of the 20 patients examined; there was a male preponderance of 4:3 with most patients above 40 years (35.4between 41-50 years) and half of them were married. Out of the twelve (n=12; 60) patients whose serum was tested for human immunodeficiency virus; eight (n=8; 40) were negative; while four (n=4; 20) were positive for the virus .Eight were not tested. Using 40 years of age as the cutoff; those above 40 years (12 in number); two (n=2; 25) were seropositive while 9 were negative (75). For those below 40 years (8 in number); two (n=2; 25) were positive while six were negative (75).Upon treatment with antivirals (Zovirax ) in the majority of cases there was complete resolution in 8 (57) of the patients with most of the sequelae occurring in those of them who are seropositive.Correlation of impaired immune status with Herpes zoster affectation was found to be more obvious in the younger than 40 years group.Treatment with antivirals gave good resolution in most cases. Blinding complications were found more in those who were seropositive

Síndrome do ápice orbitário causada por herpes zóster oftálmico: relato de caso e revisão da literatura / Herpes zoster ophthalmicus and orbital apex syndrome: case report and literature review

OHerpes Zoster Oftálmico (HZO) decorre da infecção pelo vírus da varicela-zoster que permanece latente no gânglio de Gasser até que seja reativado e comprometa a divisão oftálmica do nervo trigêmeo. HZO freqüentemente causa manifestações oftalmológicas como lesões vesiculares palpebrais, ceratoconjuntivite, esclerite, uveíte, paralisia oculomotora, miosite orbitária e neurite óptica. Raramente o acometimento do ápice da órbita pode ser a manifestação inicial desta grave afecção. Este trabalho relata um caso de síndrome do ápice orbitário associado à meningite, causado por HZO e que foi tratado com corticosteróide e aciclovir sistêmicos.

Herpes Zoster ophthalmicus (HZO) is caused by a varicella-zoster virus infection which remains latent in the ganglion of Gasser until it is reactivated and compromise the ophthalmic division of the trigeminal nerve. HZO commonly causes neuro-ophthalmic complications such as vesicular lesions in the eyelids, keratoconjunctivitis, sclertis, uveitis, ocular palsy, orbital miositis and optic neuritis. HZO rarely presents as an orbital apex syndrome. This paper describes a patient with of orbital apex syndrome associate and meningitis caused by HZO which was treated with systemic steroids and acyclovir.

Encefalitis por virus varicela zoster: a propósito de un caso / Encephalitis by varicella zoster virus: a propos of a case

Se trata de una paciente blanca, femenina, de 79 años, que en el curso de un herpes zoster oftálmico comienza con manifestaciones clínicas neurológicas, que se interpretaron inicialmente como reacciones adversas al tratamiento oral con aciclovir; siendo el sistema nervioso central la localización extracutánea más frecuente de este herpes virus; y la forma más común de afectación neurológica en esta infección es una encefalitis, se pensó en esta entidad a pesar de su atipicidad no reportada en la bibliografía consultada, lo que motivó a realizar una revisión exhaustiva de este tema. La paciente evolucionó satisfactoriamente con desaparición de los síntomas y signos clínicos.

It deals with a 79-years-old, white, female patient, beginning with neurological clinical manifestations in the course of ophthalmologic zoster herpes. Initially they were interpreted as adverse reactions of the acyclovir treatment. Being the central nervous centre the most frequent extra-cutaneous location of this herpes virus, and encephalitis the most common neurologic affection in this infection, we thought about this entity despite of its atypicity, which was not found in the consulted bibliography. It motivated us to make an exhaustive review of this theme. The evolution of the patient was positive, disappearing the clinic signs and symptoms.

A Case of Herpes Zoster with Abducens Palsy

Only a few reports have focused on ocular motor paralysis in herpes zoster ophthalmicus. We report a case of ocular motor paralysis resulting from herpes zoster. The patient, an 80-yr-old woman, presented with grouped vesicles, papules, and crusting in the left temporal area and scalp, with diplopia, impaired gaze, and severe pain. Her cerebrospinal fluid analysis was positive for varicellar zoster virus IgM. Magnetic resonance imaging was performed to rule out other diseases causing diplopia; there were no specific findings other than old infarctions in the pons and basal ganglia. Therefore, she was diagnosed of abducens nerve palsy caused by herpes zoster ophthalmicus. After 5 days of systemic antiviral therapy, the skin lesions improved markedly, and the paralysis was cleared 7 weeks later without extra treatment.

A Case of Complete Ophthalmoplegia in Herpes Zoster Ophthalmicus

PURPOSE: To report a case with complete ophthalmoplegia after herpes zoster ophthalmicus. METHODS: A 70-year-old male patient visited a clinic because of vesicular eruptions over the left side of his face with severe pain. Drooping and severe swelling of the left eyelid were present, along with keratitis and uveitis. While the lid swelling and uveitis were improving, external ophthalmoplegia and exophthalmos were discovered. Intramuscular injections of dexamethasone 5 mg were given for 10 days, followed by oral administration of prednisolone at a dosage of 15 mg for two weeks and 10 mg for two weeks. RESULTS: The patient was fully recovered from the complete ophthalmoplegia and exophthalmos six months after the onset of the cutaneous lesion. CONCLUSIONS: Complete ophthalmoplegia is a rare ophthalmic complication of herpes zoster infection. Therefore, an evaluation of extraocular muscle and lid function should be performed during the examination of herpes zoster patients in order to screen for ophthalmoplegia.

Herpes zóster trigeminal. Tratamiento del herpes zóster oftálmico en fase eruptiva por bloqueo del ganglio de Gasser / Trigeminal herpes zoster. Treatment of ophthalmic herpes zoster in eruptive phase with blockage of Gasserian ganglion

La gravedad del herpes zoster oftálmico combinada con un manejo pobre y/o tardío puede conducir a lesiones oftálmicas crónicas, síndrome de neuralgia postherpética y cicatrices en la piel tan severas que semejan quemaduras de tercer grado. Marsh describe tres etapas de compromiso ocular: 1) lesiones oftálmicas agudas que se desarrollan dentro de las primeras tres semanas de la etapa eruptiva; pueden volverse crónicas y el dolor persistir como síndrome de neuralgia postherpética. 2) lesiones oftálmicas crónicas que pueden persistir por más de 10 años. 3) lesiones oftálmicas recurrentes que pueden reaparecer hasta seis años después del ataque agudo. Ciento cuarenta pacientes con diagnóstico de herpes zoster oftálmico en etapa eruptiva, con evolución de 4 a 18 días y con diversos tipos de lesiones oftálmicas de consecuencias que varían de simples a devastadoras, fueron tratados con bloqueo de ganglio de Gasser inyectando bupivacaína y betametasona para valorar sus efectos sobre tales lesiones. Un día después de haber efectuado el bloqueo del ganglio de Gasser afectado, notamos una disminución importante en la severidad de las lesiones oftálmicas, con cambios notorios en las lesiones de piel con tendencia a su resolución. También obsevamos que ninguno de los pacientes tratados dentro de los primeros siete días del inicio de la etapa eruptiva desarrollaron secuelas oftálmicas, que es uno de los más severos problemas de este padecimiento. Los pacientes bloqueados después de este lapso tuvieron diversos tipos de secuelas oftálmicas. Como conclusión decimos que efectuar este procedimiento tempranamente conduce a una mejoría clínica significativa y cambios dramáticos, en horas, de las lesiones oftálmicas y de la piel, sin que haya secuelas oftálmicas ni se desarrolle síndrome de neuralgia postherpética; además, las cicatrices en la piel fueron benignas.

Granulomatous angiitis of the central nervous system associated with herpes zoster.

Granulomatous angiitis of central nervous system (CNS) is a rare inflammatory disease of blood vessels mostly confined to CNS. We describe a case which presented with right sided hemiplegia with aphasia, after herpes zoster ophthalmicus. CT scan and MRI brain showed a large left sided infarct in the left middle cerebral artery (MCA) territory. MRI angiography revealed narrowing and thinning of left internal carotid artery (ICA) and to a lesser extent, left MCA suggestive of granulomatous vasculitis. Herpes zoster is often associated with major CNS involvement and a vascular etiology was previously postulated. Recent pathological reports suggest that cerebral angiitis secondary to herpes virus infection may be more common than realised.

Piel y ojo / Skin and eye

Piel y ojo comparten un origen común a partir del neuroectodermo (en el ojo, estructurales pricilpalmente esclerocorneanas) (1). La similitud de los epitelios de superficie y de sitios pigmentarios, la contiguidad palpebroconjuntival, la exposición idéntica a microorganismos o alergenos y factores del medio ambiente, los mecanismos de defensa similares, y mecanismos autoinmunes (escleroconjuntiva y úvea), son factores que pueden explicar la patologías comunes, llevando a una sintomatología a la vez dermatológica y oftalmológica; así, enfermedades tales como neurofibromatosis, dermatosis bulosa, vasculitis, Behcet, dermatis atópica y rosácea, son ejemplos de patologías compartidas. El objetivo de esta revisión es definir y explicar cuándo el dermatólogo debe solicitar la evaluación de un oftalmologo

Oclusão de artéria e veia central da retina secundária à presumida vasculite herpética como manifestação inicial da AIDS: relato de caso / Central retinal artery and vein occlusion secondary to presumed herpetic vasculitis as the initial manifestation of the aids: a case report

Objetivo: Apresentar o caso de um homem de 42 anos que teve uma Oclusão de Artéria e Veia Central da Retina por Herpes Zoster como manifestação inicial de AIDS. Uma associação fundoscópia rara, cuja história, achados clínicos, fisiopatologia e diagnósticos diferenciais serão aqui discutidos. Local: Hospital CEMA - São Paulo - Brasil. Método: Relato de caso. Resultados: A associação das alterações fundoscópicas típicas com os dados semiológicos ajudaram na elucidação diagnóstica. Conclusão: A AIDS tem aqui relatada mais uma de suas formas de apresentação. As avaliações fundoscópicas seriadas são importantes no diagnóstico precoce das infecções oportunistas e devem ter um papel adjuvante na terapia anti-retroviral, preservando, assim, a saúde visual destes pacientes.

Presentations of cranial nerve involvement in two patients with Herpes zoster ophthalmicus.

Two cases of Herpes zoster ophthalmicus complicated by motor nerve palsies are being reported. The investigations ruled out other diseases which can affect ocular motor nerves, e.g., diabetes, hypertension, syphilis and malignancy. The cases are being reported because of the rare presentations of Herpes zoster ophthalmicus like isolated internal ophthalmoplegia and VI nerve palsy in Case-1 and absence of iritis with third nerve involvement in Case-2. The probable etiology for occurrence of these uncommon phenomena has been postulated.