Transcript Grand Rounds - University of Louisville Ophthalmology

Grand Rounds Conference
Jinghua Chen, MD, PhD
University of Louisville
Department of Ophthalmology and Visual Sciences
November 7, 2014
History
CC:
Evaluate OS orbital cellulitis
HPI:

59 year old male presented with OS swelling and pain for one week. One
week ago patient developed a “bump”on his left forehead. He punctured it
with a needle. Next day there was drainage with soft tissue swelling and pain.

Four days ago patient came to ED and was diagnosed with preseptal cellulitis
and received IV Rocephin and vancomycin (x1). Patient was discharged
home on po clindamycin.

Two days ago patient returned with worsening symptoms and was admitted.
He was given IV Rocephin and vancomycin. His symptoms continued to
worsen.
Past Medical History
POH: None
PMH: NIDDM, HTN, CHF
Allergy: NKDA
FH: DM
Exam
BCVA:
OD
20/20
OS
20/20
Pupils:
42
42
No APD
IOP:
EOM:
17
12
Full OU
Anterior Segment & DFE
SLE:
OD
OS
L/L
WNL
rash, scar, redness,
swollen and ptosis
C/S
 K
 AC
 I/L
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL



Vit
DFE:
8/16/2014
CT Without Contrast
Increased soft tissue swelling and edema of left
orbit. No abscess. No retroorbital extension.
Assessment/Differential Diagnosis
Assessment: 59 year old male presented with left
forehead and eyelid swelling, vesicle/rash in a V1
dermal distribution for one week.
DDx:
1) Herpes Zoster Ophthalmicus
2) Herpes Simplex Virus Infection
3) Bacterial Infection
Epidemiology of HZO
Incidence rates of herpes zoster (HZ) in
Duration of herpes zoster (HZ)-related pain
Olmsted County, MN, adults from 1996 to 2001, among Olmsted County, MN, adults (≥22
in 2-y increments.
years) with HZ, stratified by age.
Olmsted Medical Center, Rochester, MN 1996-2001
Frequency of HZ Ocular
Complications
recurrent keratitis
recurrent uveitis
diplopia
cataract
decreased vision
corneal ulceration
ptosis
corneal scarring
scleritis
increased IOP
severe eye pain
conjunctivitis
iritis, uveitis
keratitis
0
10
20
30
40
50
60
70
80
90
%
Olmsted County, Minnesota: 7370 patients with confirmed HZ with eye involvement
between January 1, 1980 and December 31, 2007.
HZ Antiviral and Pain
Management



Oral antiviral agents include acyclovir, valacyclovir, and
famciclovir.
Tricyclic antidepressants, antiseizure drugs, opioids, and
topical analgesics all offer some pain relief
Topical corticosteroids and cycloplegics for severe
keratitis or uveitis
Treatment of herpes zoster related corneal neovascularisation
and lipid keratopathy by photodynamic therapy
Clinical and Experimental Optometry
Volume 97, Issue 3, pages 274-277, 22 SEP 2013 DOI: 10.1111/cxo.12110
http://onlinelibrary.wiley.com/doi/10.1111/cxo.12110/full#cxo12110-fig-0002
Management
PO acyclovir 800mg 5 times per day x 7 days.
 Erythromycin 0.5% ointment topical to skin lesion twice
per day.
 Discontinued IV antibiotics after blood culture turned out
negative.

8/16
8/18
Herpes Zoster Recurrences

Recurrence rate at 8 years was 6.2% from 96
days to 10 years. (8 persons with >1
recurrence)
zoster-associated pain of 30 days or longer
 immunocompromised individuals
 women
 >50 yo

Yawn BP, Wollan PC, Kurland MJ, et al. Herpes zoster recurrences more frequent than previously reported. Mayo Clin Proc. 2011
Feb;86(2):88-93.
Immunization



FDA approved the use of Zostavax (Merck
& Co., Inc.) in 2011 for adults aged ≥60
years. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6333a3.htm
48% reduction in HZ incidence; 59%
reduction in post herpetic neuralgia.
Zoster vaccination should be offered in
people who have had a HZ episode to
prevent potential recurrences.
References
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Yawn BP, Saddier P, Wollan PC, et al. A population-based study of the incidence and complication rates of herpes zoster
before zoster vaccine introduction. Mayo Clin Proc. 2007 Nov;82(11):1341-9.
Yawn BP, Wollan PC, St Sauver JL, et al. Herpes zoster eye complications: rates and trends. Mayo Clin Proc. 2013
Jun;88(6):562-70.
Pavan-Langston D. Herpes zoster antivirals and pain management. Ophthalmology. 2008 Feb;115(2 Suppl):S13-20.
Goh YW, McGhee CNj, Patel DV, et al. Treatment of herpes zoster related corneal neovascularisation and lipid
keratopathy by photodynamic therapy. Clin Exp Optom. 2014 May;97(3):274-7.
Shaikh S and Ta CN. Evalutaion and Management of Herpes Zoster Ophthalmicus Am Fam
Physician. 2002 Nov 1;66(9):1723-1730.
Ghaznawi N, Virdi A, Dayan A, et al. Herpes Zoster Ophthalmicus: Comparison of Disease in Patients 60 Years and
Older Versus Younger than 60 Years. Ophthalmology. 2011 Nov;118(11):2242-50.
Yawn BP, Wollan PC, Kurland MJ, et al. Herpes zoster recurrences more frequent than previously reported. Mayo Clin Proc.
2011 Feb;86(2):88-93.
Hales CM, Harpaz R, Ortega-Sanchez I, et al. Update on recommendations for use of herpes zoster vaccine. MMWR Morb
Mortal Wkly Rep. 2014 Aug 22;63(33):729-31.
Schmader KE, Levin MJ, Gnann JW Jr, et al. Efficacy, immunogenicity, safety, and tolerability of zoster vaccine in subjects 50 to
59 years of age. Presented at the 48th Annual Meeting of the Infectious Diseases Society of America, Vancouver, Canada, October
21--24, 2010. Available at http://idsa.confex.com/idsa/2010/webprogram/Paper3363.html. Accessed November 1, 2011.