Bilateral Limbal Stem Cell Alterations in Patients With Unilateral Herpes Simplex Keratitis and Herpes Zoster Ophthalmicus as Shown by In Vivo Confocal Microscopy.

Purpose: The purpose of this study was to investigate the limbal changes in the palisades of Vogt (POV) in patients with herpes simplex keratitis (HSK) and herpes zoster ophthalmicus (HZO) with the application of in vivo confocal microscopy (IVCM). Methods: We enrolled 35 eyes of 35 consecutive patients with HSK and 4 patients with HZO in this observational study. Thirty-five participants were also recruited from a healthy population as the control group. All subjects were examined by IVCM in addition to routine slit-lamp biomicroscopy. The IVCM images of the corneal basal epithelial cells, corneal nerve, and the corneoscleral limbus were acquired and then were analyzed semiquantitatively. Results: The rate of absent and atypical POV was significantly higher in the affected eyes of patients with HSK than in the contralateral eyes and eyes of controls (88.57% vs. 65.71% vs. 17.14%, P < 0.01). In the HZO group, the rate of absent and atypical POV was 100% in the affected eyes and 50% in the contralateral eyes. When compared to the contralateral unaffected eyes and control eyes, the average density of the central basal epithelial cells and the sub-basal nerve plexus density and the total number of nerves in the central area of the affected eyes were significantly lower in the HSK group (1541 ± 704.4 vs. 2510 ± 746.8 vs. 3650 ± 746.1 cells/mm2, P < 0.0001). Spearman's rank correlation showed that the presence of absent and atypical POV had a significant negative correlation with central corneal basal epithelial cells (rs = -0.44979, P < 0.0001), the density of total nerves (rs = -0.49742, P < 0.0001), and the total nerve numbers (rs = -0.48437, P < 0.0001). A significant positive correlation was established between the presence of absent and atypical POV and HSK severity in affected eyes in the superior, inferior, nasal, and temporal quadrants (rs = 0.68940, rs = 0.78715, rs = 0.65591, and rs = 0.75481, respectively, P < 0.0001) and the contralateral eyes (rs = 0.51636, rs = 0.36207, rs = 0.36990, rs = 0.51241, correspondingly, P < 0.0001). Conclusions: Both eyes of patients with unilateral HSK and HZO demonstrated a profound and significant loss of limbal stem cells, which may explain the fact that HSK and HZO are risk factors for limbal stem cell deficiency (LSCD) in both eyes. The loss of LSCs was strongly correlated with the sub-basal nerve plexus and central basal epithelial cell alterations as shown by IVCM.

Supraorbital Nerve Radiofrequency for Severe Neuralgia Caused by Herpes Zoster Ophthalmicus.

Background: Radiofrequency of the Gasserian ganglion can be used for ophthalmic herpetic neuralgia (OHN), but it is associated with complications. This study aimed to use the supraorbital nerve for computed tomography- (CT-) guided radiofrequency thermocoagulation to treat refractory OHN. Methods: This was a retrospective case series study of patients with simple or combined OHN treated at our hospital between 06/2012 and 06/2018. The numerical rating score (NRS), spontaneous pain, allodynia, gabapentin dosage, paracetamol/oxycodone dosage, patient global impression of change (PGIC) score, Barrow numbness score, postoperative 360-day recurrence rate, and complications were recorded before the operation and at 1, 30, 90, 180, and 360 days after the operation. Results: Compared with baseline, the NRS was decreased, and PGIC was increased at postoperative 1, 30, 90, 180, and 360 days, and the gabapentin and paracetamol oxycodone doses at postoperative 30, 90, 180, and 360 days were decreased (all P < 0.001). Compared with 1 day after the operation, numbness was decreased at 30, 90, 180, and 360 days after the operation (P < 0.001). Compared with baseline, the number of patients with allodynia at each time point after the operation was decreased (P < 0.001), but without a difference for spontaneous pain (P=0.407). No subjects showed drooping eyelid, corneal ulcers, eyeball damage, decreased vision, and other severe complications. Conclusion: CT-guided supraorbital nerve radiofrequency thermocoagulation for the treatment of OHN can effectively relieve pain and reduce the dose of analgesics, without any serious complication. This study suggests that this technique is feasible and applicable to clinical practice.

Herpes zoster ophthalmicus caught in the (Tr)act!

To emphasize the utility of contrast enhanced MRI for identifying the extent of disease in herpes zoster ophthalmicus with intracranial extension to help determine proper management. We present a rare case of herpes zoster ophthalmicus (HZ/HZO) with intracranial extension and MRI demonstration of involvement of the trigeminal nerve, the trigeminal nucleus, and the spinal trigeminal nucleus and tract. Herpes zoster is caused by reactivation of varicella zoster virus. Herpes zoster ophthalmicus with involvement of the ophthalmic division of the trigeminal nerve has been estimated to account for 10-20% of the cases (Yawn et al. in Mayo Clin Proc 88:562-570, 2013). While postherpetic neuralgia is the most common complication, HZ/HZO can rarely manifest in a more sinister manner resulting in multi-dermatomal involvement, disseminated disease, cranial arteritis (Walker in Radiology 107:109-110, 1973), cranial nerve paresis (O.d in Clinical Eye and Vision Care 11:75-80, 1999), hemiplegia (Cavaletti in The Italian Journal of Neurological Sciences 11:297-300, 1990), ocular/dysfunction (Kocaoglu in Türk Oftalmoloji Dergisi 48:42-46, 2018), and intracranial extension (Chen in BMC Infectious Diseases 17:213, 2017; Yawn in Mayo Clin Proc. 88:562-570, 2013). Contrast enhanced MRI (CE-MRI) can be of great benefit to elucidate the extent of disease and intracranial involvement for institution of more aggressive management to prevent further complications.

High resolution vessel wall MRI and vasculopathy related to herpes zoster ophthalmicus.

Varicella zoster virus is a common viral infection with over 50% of patients over the age of 80 years infected with the virus. Following reactivation, some patients succumb to complications of VZV reactivation with neurologic and optic pathway pathology such as VZV vasculopathy resulting in transient ischemic attacks, strokes, aneurysms, as well as optic neuritis. We show that high resolution vessel wall magnetic resonance imaging can aid in the diagnosis of this condition with circumferential wall thickening and enhancement of the infected vessels. Prompt diagnosis is critical as this is a treatable condition that could result in substantial morbidity or mortality if not recognized early.

In vivo confocal microscopy detects bilateral changes of corneal immune cells and nerves in unilateral herpes zoster ophthalmicus.

PURPOSE: To analyze bilateral corneal immune cell and nerve alterations in patients with unilateral herpes zoster ophthalmicus (HZO) by laser in vivo confocal microscopy (IVCM) and their correlation with corneal sensation and clinical findings. MATERIALS AND METHODS: This is a prospective, cross-sectional, controlled, single-center study. Twenty-four eyes of 24 HZO patients and their contralateral clinically unaffected eyes and normal controls (n = 24) were included. Laser IVCM (Heidelberg Retina Tomograph/Rostock Cornea Module), corneal esthesiometry (Cochet-Bonnet) were performed. Changes in corneal dendritiform cell (DC) density and morphology, number and length of subbasal nerve fibers and their correlation to corneal sensation, pain, lesion location, disease duration, and number of episodes were analyzed. RESULTS: HZO-affected and contralateral eyes showed a significant increase in DC influx of the central cornea as compared to controls (147.4 ± 33.9, 120.1 ± 21.2, and 23.0 ± 3.6 cells/mm2; p < 0.0001). In HZO eyes DCs were larger in area (319.4 ± 59.8 µm2; p < 0.001) and number of dendrites (3.5 ± 0.4 n/cell; p = 0.01) as compared to controls (52.2 ± 11.7, and 2.3 ± 0.5). DC density and size showed moderate negative correlation with total nerve length (R = -0.43 and R = -0.57, respectively; all p < 0.001). A higher frequency of nerve beading and activated DCs close to nerve fibers were detected specifically in pain patients. CONCLUSIONS: Chronic unilateral HZO causes significant bilateral increase in corneal DC density and decrease of the corneal subbasal nerves as compared to controls. Negative correlation was observed for DC density and size to nerve parameters, suggesting interplay between the immune and nervous systems. Patients with chronic pain also showed increased nerve beading and activated DCs.

Treatment of Progressive Herpes Zoster-Induced Vasculopathy with Surgical Revascularization: Effects on Cerebral Hemodynamics.

BACKGROUND: Herpes zoster ophthalmicus (HZO) is caused by reactivation of the herpes simplex virus in the trigeminal nerve. HZO-initiated cerebral vasculopathy is well characterized; however, there are no documented cases that report the efficacy of surgical revascularization for improving cerebral hemodynamics following progressive HZO-induced vasculopathy. We present a case in which quantitative anatomic and hemodynamic imaging were performed longitudinally before and after surgical revascularization in a patient with HZO and vasculopathic changes. CASE DESCRIPTION: A 57-year-old female with history of right-sided HZO presented with left-sided hemiparesis and dysarthria and multiple acute infarcts. Angiography performed serially over a 2-month duration revealed progressive middle cerebral artery stenosis, development of new moyamoya-like lenticulostriate collaterals, and evidence of fibromuscular dysplasia in cervical portions of the internal carotid artery. Hemodynamic imaging revealed right hemisphere decreased blood flow and cerebrovascular reserve capacity. In addition to medical therapy, right-sided surgical revascularization was performed with the intent to reestablish blood flow. Follow-up imaging 13 months post revascularization demonstrated improved blood flow and vascular reserve capacity in the operative hemisphere, which paralleled symptom resolution. CONCLUSIONS: HZO can lead to progressive, symptomatic intracranial stenoses. This report suggests that surgical revascularization techniques can improve cerebral hemodynamics and symptomatology in patients with aggressive disease when medical management is unsuccessful; similar procedures could be considered in managing HZO patients with advanced or progressive vasculopathy.

Stroke Associated With Varicella Zoster Vasculopathy: A Clinicoradiological Profile of 3 Patients.

INTRODUCTION: Varicella zoster (VZ) vasculopathy is a rare but well recognized cause of stroke. In the absence of zoster rash and infection in remote past, the disease can pose diagnostic challenge. We report 3 cases of anterior circulation stroke occurring in close temporal relation to VZ. Their clinical, radiologic, and angiographic features are discussed. CASE REPORT: Of the 3 patients, 2 had stroke within a span of 4 to 6 weeks of herpes zoster ophthalmicus while the third patient had zoster of cervical dermatome. Magnetic resonance imaging revealed acute subcortical infarcts in 2, while 1 patient showed acute on chronic infarct in left middle cerebral artery territory. The magnetic resonance angiography was abnormal in 2 patients while it was normal in third. All the patients were treated with acyclovir and antiplatelets with good recovery in 2. CONCLUSIONS: VZ associated vasculopathy may have diverse clinical profile and neuroimaging features. It should be considered as an important and treatable cause of stroke in appropriate clinical settings.

Orbital myositis involving the oblique muscles associated with herpes zoster ophthalmicus.

An 81-year-old woman with right orbital inflammation and acute retinal necrosis following Herpes zoster ophthalmicus was evaluated and treated. CT showed right massive superior and inferior oblique enlargement and moderate enlargement of the remaining extraocular muscles with tendon sparing. The myositis and acute retinal necrosis dramatically improved following prednisone and intravenous acyclovir therapy.

Herpes zoster ophthalmicus and the orbital apex syndrome.

Herpes zoster ophthalmicus (HZO) commonly causes isolated ophthalmoplegic syndromes. Visual loss caused by optic neuritis secondary to HZO can be reversible or irreversible. HZO rarely presents as an orbital apex syndrome, when an association with meningo-encephalitis has been reported. We report a case of orbital apex syndrome secondary to HZO treated with systemic steroids and acyclovir. Our patient suffered no systemic complications and displayed a rapid resolution of optic neuropathy. We discuss this case in the light of previous reports and explore the possible pathogenic mechanisms involved.

Herpes zoster ophthalmicus with delayed contralateral hemiparesis.

A 35-year-old previously healthy woman developed left hemiparesis sixteen weeks after the onset of right herpes zoster ophthalmicus. Cerebral angiography showed complete occlusion of right middle cerebral artery at the origin and segmental narrowing of the right posterior cerebral artery. Computerized tomography (CT) and magnetic resonance imaging (MRI) also revealed a right hemispheric lesion consistent with angiographic findings. Reports from the literature along with the present case suggest that arteritis followed by cerebral infarction is the most probable cause of delayed contralateral hemiparesis.

[Herpes zoster ophthalmicus with contralateral hemiplegia]. / Herpes zoster oftálmico con hemiplejia contralateral.

A 57-year-old patient nonimmunosuppressed who had zoster ophthalmicus associated to contralateral hemiplegia is presented. We noticed on the CT scan an infarction of left caudate nucleus, as well as in the angiography signs of vasculitis. We comment on the clinical and diagnosis features and suggest possible benefit effects of the treatment with acyclovir.

The syndrome of cerebral infarction following herpes zoster ophthalmicus.

Delayed contralateral hemiparesis following herpes zoster (HZ) ophthalmicus is an unusual but distinct clinical entity, presumably caused by HZ-induced arteritis with subsequent cerebral infarction. We report a case showing typical clinical and angiographic findings.

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.

Ophthalmic herpes zoster with contralateral hemiparesis: a case report.

Herpes zoster of the ophthalmic division of the left fifth cranial nerve with contralateral hemiparesis was observed in a 30-year-old man. Left carotid angiography showed segmental constrictions consistent with cerebral arteritis, possibly provoked by direct viral infection along the intracranial part of the ophthalmic nerve. An ischaemic lesion revealed by computed tomographic scan was considered secondary to arteritis and responsible for the hemiparesis. The presence of an immune response within the blood-CSF barrier was suggested by an increase of oligoclonal CSF IgG and IgA.