Herpes simplex virus epidemiology and ocular importance.

PURPOSE: To review the changing epidemiology of herpes simplex disease and correlate it with the epidemiology of ocular herpes simplex disease. METHOD: A review of pertinent reports in the world literature about the epidemiology of herpes simplex and specifically about ocular herpes simplex. RESULTS: In developed countries, many individuals are reaching adolescence and adulthood without prior herpesvirus infection. Herpes simplex genital infection is increasing at a rapid rate in sexually active adolescents and adults, with about one in six adults now infected in the United States. Similar statistics are confirmatory worldwide in developed countries. Active herpes simplex infection is a risk factor for acquisition of human immunodeficiency virus. The Herpetic Eye Disease Study, as well as prior studies from Moorfields Eye Hospital and the Mayo Clinic in Rochester, Minnesota, provides us with the epidemiology of ocular herpes simplex. Recent studies suggest an older age of onset and perhaps overall more severe ocular disease as compared with the older literature. CONCLUSIONS: Herpes simplex is a significant health concern at present with genital infections increasing in epidemic proportions. This is also reflected in a rise in the incidence of neonatal herpes. Herpes simplex virus type 1 (HSV-1) infection is being acquired for the first time in an older age group. A significant and increasing proportion of genital herpes is caused by HSV-1. Serologic studies are no longer as useful in distinguishing orofacial herpes from genital herpes. More acute retinal necrosis syndrome cases are associated with HSV-2. Speculation about the future of ocular herpes is made based on this changing epidemiology.

Use of antimicrobials to prevent postoperative infection in patients with cataracts.

Despite the high frequency of cataract surgery, there are still no definitive studies on antibiotic prophylaxis against endophthalmitis after cataract surgery. Most surgeons follow an empiric approach. The results of several recent studies shed additional light on this complex topic. There is better knowledge of the usual source of the infection and the specific organisms incriminated. This review presents some principles of prophylactic treatment and selected literature that addresses the effectiveness of antisepsis, topical preoperative antibiotics, intracameral antibiotics, subconjunctival antibiotics, systemic antibiotics, and postoperative antibiotics. The worldwide problem of antibiotic resistance should temper our approach. Some organizational statements are reviewed, and personal recommendations are offered. Controversy still abounds.

Varicella-zoster virus eye disease.

PURPOSE: To review the epidemiology, biology, systemic and ocular features, and treatment options for varicella zoster disease, including postherpetic neuralgia. METHODS: Literature search and review of author's experience with patients with varicella and herpes zoster ophthalmicus. RESULTS: In recent years there has been an increase in the knowledge about the biology, latency, and epidemiology of the varicella-zoster virus. The clinical features are correlated with the pathologic changes. The pathophysiologic mechanisms and treatment of postherpetic neuralgia are reviewed. Treatment options with antiviral therapy and corticosteroids are offered. Initial experience with the varicella vaccine is encouraging. CONCLUSIONS: The laboratory and clinical studies have enhanced our knowledge of the varicella-zoster virus and increased our ability to treat this infection and the aftermath. We are still far short of providing adequate therapy for patients who experience the severe forms of the disease.

Perioperative antibiotic prophylaxis in cataract surgery.

PURPOSE: To review the rationale for various methods of perioperative prophylaxis in elective cataract surgery. METHODS: The surgical and ophthalmologic literature is reviewed to determine accepted principles for the use of perioperative prophylactic agents in clean elective surgical procedures. RESULTS: After an assessment of the nonophthalmic surgical literature, specific principles are applied to the use of antimicrobial agents in perioperative prophylaxis of cataract surgery. Current practice patterns and specific techniques of perioperative prophylaxis are scrutinized. The emerging problem of antimicrobial resistance in the world and specifically in ophthalmology is addressed. Recommendations are offered balancing the needs of the individual patient with the best interests of society as a whole. CONCLUSION: Potent therapeutic agents should be reserved for therapy. A method of perioperative prophylaxis is suggested, with a stratified approach indicated in selected circumstances. A clear consensus is probably not possible with divergent views expressed.

Latanoprost and herpes simplex keratitis.

PURPOSE: To report three cases in which herpes simplex keratitis developed after initiation of latanoprost therapy. METHODS: Case report. RESULTS: One patient with a history of herpes simplex keratitis had recurrence of herpes simplex keratitis with latanoprost treatment, resolution when latanoprost was stopped, and another recurrence when rechallenged with latanoprost. A second patient with a history of herpes simplex keratitis had bilateral recurrence with initiation of latanoprost; antiviral therapy could not eradicate herpes simplex keratitis until the latanoprost was discontinued. The third patient with latanoprost-associated herpes simplex keratitis cleared with the discontinuation of latanoprost and start of antiviral therapy; reinstitution of latanoprost with prophylactic antiviral medication kept the cornea clear, but as soon as the antiviral suppression was discontinued, herpes simplex keratitis reappeared. CONCLUSION: Latanoprost, among its diverse pharmacologic effects, may mediate inflammation in the eye. Prostaglandins may be a final common pathway for stimulating recurrence of herpes simplex keratitis. Clinicians should be aware of this possible association.

Classification of herpes simplex virus keratitis and anterior uveitis.

PURPOSE: To review the classification of herpes simplex virus (HSV) keratitis and anterior uveitis using the available clinical, pathologic, and laboratory models of disease. METHODS: The literature was reviewed to establish prior classifications of herpes simplex keratitis and uveitis. The author introduces a classification attempting to encompass all patients with this disease process, taking into account the newer proposed mechanisms of disease. RESULTS: A classification of HSV keratitis and uveitis is introduced based on the literature and the experience of the author in treating patients with this condition. CONCLUSIONS: There are multiple mechanisms of disease after ocular HSV infection, including damage from live virus, from immune and inflammatory mechanisms, and from structural damage in the aftermath of HSV infection (metaherpetic disease). Clinical, pathologic, and etiologic descriptions of these disease manifestations are offered. This may allow better communication between clinicians and authors of research protocols by defining the different aspects of this complex disease process.

Fingertip dermatitis in an ophthalmologist caused by proparacaine.

PURPOSE: To report the late diagnosis of allergic response to proparacaine hydrochloride in an ophthalmologist. METHOD: Case report. In a 49-year-old practicing ophthalmologist, the history, clinical findings of fingertip dermatitis, skin pathology, and skin patch testing are described. RESULTS: Proparacaine, as the initiating agent, took almost 3 years to identify because of the unusual pattern of allergy. We explored numerous treatment options before identifying and removing the offending agent. CONCLUSIONS: Ophthalmologists may be exposed to proparacaine on a daily basis. This unique report heightens the awareness of this rare work-related complication.

Varicella zoster viral disease.

Herpes zoster is cause of considerable morbidity, especially among elderly patients, with a suggestion of a slight increase in incidence among female patients. Substantial research on the biology of the varicella zoster virus has led to advances in our knowledge of the pathophysiology of the disease along with more successful therapy for the acute episodes of herpes zoster. Ophthalmic zoster is more common than zoster in other cranial nerves and is associated with pronounced suffering. This article reviews the epidemiology, biology, and latency of herpes zoster, discusses the pathophysiology of the disease, and describes treatment options with antivirals and corticosteroids. The pathophysiology and treatment options for postherpetic neuralgia are also addressed. The varicella vaccine is now available, and initial results suggest that this may lessen the effect of herpes zoster in the future.

Conjunctival changes associated with glaucoma therapy: implications for the external disease consultant and the treatment of glaucoma.

PURPOSE: Enhance recognition by the external disease specialist of the conjunctival changes associated with glaucoma therapy and the reported association with glaucoma filtration surgery. METHODS: Literature search with emphasis on the cellular and subcellular changes induced by antiglaucoma medications, the definition and diagnosis of drug-induced cicatricial conjunctivitis (DICC), and the implications for future glaucoma therapy or surgery. RESULTS: Significant conjunctival and subconjunctival changes occur associated with the use of antiglaucoma medications that affect the success of glaucoma filtration surgery. The extreme form of change is the DICC, which is clinically and pathologically identical to ocular cicatricial pemphigoid. The autoantigen in the basement membrane probably differs in these two disease processes. CONCLUSIONS: There is a movement toward an earlier approach to glaucoma filtration surgery, in large part based on the literature reviewed here. The external disease specialist needs to be cognizant of these conjunctival changes to best consult on patients receiving antiglaucoma medications.

Tropicamide eyedrops cannot be used for reliable diagnosis of Alzheimer's disease.

OBJECTIVE: To evaluate the mydriatic effect of tropicamide eyedrops as a diagnostic test for Alzheimer's disease. MATERIAL AND METHODS: In a double-blind, placebo-controlled study, we assessed pupillary responses in 22 normal control subjects, 23 patients with probable Alzheimer's disease, 4 patients with isolated memory difficulty, and 6 patients with non-Alzheimer's dementia. Three separate studies were performed, the second and third on a subset of the original group. With use of infrared binocular pupillography, after 5 minutes of dark adaptation, we averaged pupil size during a 1-minute interval for baseline determinations. We then instilled 0.01% tropicamide into one eye. In the first two studies, we averaged pupil size for a 1-minute period at 5-minute intervals for 30 minutes, followed by a pupil light reflex test. In the third study, we measured pupil size every 5 minutes for 45 minutes and omitted the light reflex test. RESULTS: No significant difference was noted in pupil dilatation between normal subjects and patients with Alzheimer's disease and between patients with non-Alzheimer's dementias and the Alzheimer's disease group in all three studies. Furthermore, on reperformance of the test in the same patients, more than 50% changed from a group above or below 13% pupil dilatation (a cutoff reported to distinguish Alzheimer's disease from normal control subjects) to the opposite group. CONCLUSION: Results of this study indicate that pupil measurement after instillation of tropicamide cannot be used as a reliable diagnostic test for Alzheimer's disease. Moreover, test-retest reliability with use of dilute tropicamide eyedrops is questionable.

Contact lens-related microbial keratitis: Part II: Pathophysiology.

The literature is reviewed concerning the pathophysiologic effects of contact-lens wear, the microbiology of contact-lens wear, the change in microflora with contact-lens wear, the contamination of contact lenses and contact-lens products, patient compliance, and corneal interaction with the contact lens. Hypoxia and hypercapnia are the most significant changes in the cornea as a result of contact-lens wear. Changes take place in the conjunctival flora in patients with contact lenses. Compliance of patients and contamination of contact lenses and contact-lens products are significant risk factors. The corneal interaction with the contact lens can overwhelm the protective mechanisms of the cornea, increasing the ability of microbes to adhere to the cornea and progress to microbial keratitis. Some of the factors associated with microbial keratitis are modifiable and should stimulate the contact-lens industry to develop better contact lenses and contact lens products and also permit ophthalmologists to obtain better informed consent from their patients.

Contact lens-related microbial keratitis: Part I: Epidemiology.

PURPOSE: To put into perspective the individual risk and the societal burden of contact lens microbial keratitis. METHODS: I reviewed the available epidemiologic data on contact lens microbial keratitis with emphasis on distinguishing microbial from nonmicrobial keratitis, determining the incidence of the disease, the relative risk with different styles of contact lenses, and the risk factors. RESULTS: Contact lens wear can be classified in multiple different ways (indications for wear, contact lens material, wearing schedule, and replacement schedule). Adverse effects of contact lens wear on the cornea have been documented by several studies. Distinction between aseptic and septic focal infiltrates is discussed. The incidence rates for bacterial microbial keratitis range from approximately two/10,000 per year for rigid contact lens, 2.2-4.1/10,000 per year for daily-wear soft contact lens, to 13.3-20.9/10,000 per year for extended-wear soft contact lenses. The risk with therapeutic contact lenses is much higher: approximately 52/10,000 per year. Comparative studies suggest that the relative risk of microbial keratitis is approximately 1 for rigid gas-permeable lenses (RGPs; the referent), 0.5-2.74 for polymethylmethacrylate (PMMA), 1.0-4.2 for daily-wear soft contact lenses, 2.7-36.8 for extended-wear soft contact lenses, and 13.0-13.3 for disposable soft contact lens wear. The most significant risk factors include overnight wear, smoking, male sex, and socioeconomic status. CONCLUSIONS: There is a significant health concern for the 26 million wearers of contact lenses with some potentially modifiable risk factors. Identification of the risk factors and further studies of the pathogenesis allow contact lens manufacturers to direct research efforts and practitioners to provide better information and informed consent to patients.

Prophylactic antibiotics in cataract operations.

The rationale for prophylactic antibiotics in cataract operations must be continually reevaluated in light of cost-effectiveness and adverse reactions. The principles learned from wound infections associated with general surgical procedures should be applied to the limited knowledge about the rare event of endophthalmitis. Herein the literature on experimental and clinical wound infections in general surgical procedures is reviewed, with analysis of microbial flora, pathophysiology of wound infections, and pharmacokinetics of antibiotics. Experimental and clinical studies on prophylactic antibiotics to prevent endophthalmitis are reviewed, including information on topically applied antibiotics, chemical antisepsis, and administration of subconjunctival, intracameral, and systemic antibiotics. In addition, the benefits, limitations, and risks of the various types of prophylactic antibiotics are discussed. Because of the limited data on prophylactic antibiotics in cataract operations, providing dogmatic statements is difficult. General recommendations are offered based on the currently available literature, and a stratified approach is suggested based on wound construction and number of anterior segment maneuvers.

Complete ophthalmoplegia after zoster ophthalmicus.

Complete ophthalmoplegia following herpes zoster ophthalmicus (HZO) is rare. We report three cases of HZO-associated complete ophthalmoplegia and review thirteen additional cases reported in the English language medical literature over the past 30 years. HZO-associated complete ophthalmoplegia occurs mostly in individuals over the age of 50 years and usually occurs within one to two weeks of the development of cutaneous HZO. The prognosis for recovery is good, with-significant improvement typically seen within 2 months and complete or near resolution within 18 months time.

Plasmacytoma manifesting as recurrent cellulitis and hematic cyst of the orbit.

PURPOSE: To describe a patient with recurrent periorbital cellulitis and orbital blood cyst as the initial manifestation of primary extramedullary plasmacytoma. METHODS: The chart, imaging studies, and histopathologic examination results and literature on the subject were reviewed. RESULTS: Orbital surgery disclosed a hematic cyst along with a solitary plasma cell tumor. CONCLUSIONS: Periorbital cellulitis and pain can be a manifestation of a plasma cell tumor. Bleeding may occur within a necrotic orbital tumor.

Glaucoma: changing concepts and future directions.

Important concepts about glaucoma have evolved during the past few decades. Glaucoma is a family of diseases not defined by a specific intraocular pressure but rather as an optic neuropathy that can occur at any intraocular pressure depending on the optic nerve susceptibility of the individual person. Increased risk factors for idiopathic open-angle glaucoma include advancing age, black race, a family history of glaucoma, and increased intraocular pressure. The primary-care physician is in the prominent position of recognizing patients with increased risk factors or suspicious eye findings who should be referred to an ophthalmologist. Topically applied ophthalmic medications have systemic side effects that must be recognized and monitored by the primary-care physician. In the United States, glaucoma is usually treated with topically applied medications; laser or surgical therapy is done if medical treatment fails. The National Eye Institute is conducting multicenter studies to confirm whether this is still the most appropriate strategy for this common disease.

Pigmented conjunctival and scleral lesions.

OBJECTIVE: The multiple causes of pigmentations of the conjunctiva and sclera are reviewed, and the recommended therapeutic modalities are discussed. DESIGN: Information from personal experience and the recent literature is summarized to determine the optimal diagnostic and treatment approaches for suspicious pigmented conjunctival and scleral lesions. MATERIAL AND METHODS: Clinical descriptions and illustrations are presented to characterize these ocular lesions. RESULTS: Pigmented lesions of the conjunctiva and sclera arise from either melanocytes or nonmelanocytes and have a diverse differential diagnosis. These lesions can be classified into congenital melanosis, conjunctival nevi, acquired melanosis (secondary or primary), and conjunctival melanomas. In secondary acquired melanosis, the increased conjunctival pigmentation is caused by irradiation, hormonal changes, chemical irritation, or chronic inflammatory conjunctival disorders. The biologic behavior of primary acquired melanosis of the conjunctiva is a controversial topic with important implications because it may progress to melanoma. In patients with primary acquired melanosis, a biopsy is recommended in order to grade the disease, offer a prognosis, and direct further treatment. Conjunctival melanomas may arise from primary acquired melanosis, from nevi, or de novo, or they may be metastatic lesions. CONCLUSION: Of the wide spectrum of melanocytic conjunctival lesions, those with malignant potential are melanosis oculi, nevus of Ota, junctional nevus, compound nevus, primary acquired melanosis, and melanomas.