Transcript Disciform Keratitis - University of Louisville Ophthalmology

Grand Rounds Conference
Reema Syed, MBBS
University of Louisville
Department of Ophthalmology and Visual Sciences
August 7, 2015
Subjective
CC: Pain and redness, left eye x 2 weeks
HPI: 23 year old female with progressively
worsening symptoms for 2 weeks. She was
recently treated at an urgent care center with
“antibiotic eye drops”
History
POH, PMH: unremarkable
Eye Meds: “antibiotic drop” OS QID
Systemic Meds: None
Allergies: NKDA
Objective
BCVA:
Pupils:
IOP:
EOM:
CVF:
OD
OS
20/20
20/200
5 to 3 mm OU, no rAPD
13
16
Full
Full
Full
Full
Objective
SLE:
Unremarkable OD
OS
External/Lids
Normal
Conjunctiva/Sclera
Cornea
2+ injection
small epithelial defect; stromal
edema; KPs; neovascularization
0.5+cell, trace flare
Normal
Clear
Poorly visualized
Anterior Chamber
Iris
Lens
Posterior segment
Anterior segment OS
Corneal stromal edema in a circular form, infero-central epithelial
defect 2x2 mm, inferior neovascularization from limbus to edge of
ulcer
Anterior segment OS
KPs underlying zone of edema
Impression

23 year old female with herpetic disciform keratitis OS
Differential diagnosis
 Bacterial keratitis
 Neurotrophic ulcer
Plan




Acyclovir 400 mg PO 5 times daily
Vigamox QID OS
Cyclopentolate 1% BID OS
Pred Forte 1% OS QID
Follow-up


Patient lost to follow-up
Stopped using all medicines in few weeks when she felt
better
Herpes Keratitis

Herpes viruses:








HSV 1
HSV 2
VZV
CMV
EBV
HHV 8
HHV 6
HHV 7
Pathophysiology

Primary infection:
 Skin and mucosal surfaces innervated by
CN V
 Frequently, non-specific URI
 Vesicular blepharitis, follicular
conjunctivitis, rarely epithelial keratitis

Latent infection:
 Infected skin and mucosal lesions
sensory nerve axons
sensory nerve
ganglia
Pathophysiology

Recurrent disease:
HSV-1
Occurrence
May reactivate frequently
Incidence drops with age
Typically unilateral, usually same site as 1o infection but can occur
along any of the 3 branches of CN V
Causes of
reactivation
Role of environmental and physiological factors controversial
Bilateral recurrent ocular disease in atopic dermatitis
Pain upon
reactivation
Mild-moderate
Sensory loss with repeated recurrence
Kinchington PR et al. Herpes simplex virus and varicella zoster virus, the house guests who never leave.
Herpesviridae. 2012 Jun 12;3(1):5
HSV Epithelial Keratitis



Punctate keratitis
Dendritic ulcer
Geographic ulcer
HSV Epithelial Keratitis

Management:

Self-limited disease, treatment shortens clinical course, reduces
herpetic neuropathy and sub-epithelial scarring

Topical Trifluridine 1% x8/day – epithelial toxicity with
extended use

Oral Acyclovir 400 mg x5/day or Valacyclovir 500 mg TID –
same efficacy as topical antivirals, no ocular toxicity, lower cost
Stromal Keratitis

Most common cause of infectious corneal blindness in the US

Form of recurrent herpetic external disease associated with the
greatest morbidity

Pathogenesis unknown


Cell-mediated immunity to corneal antigens up-reglated by HSV
Bystander effect of proinflammatory cytokines secreted by infected
corneal cells
Stromal Keratitis

Non-necrotizing/Interstitial:


Necrotizing:


unifocal or multifocal stromal haze without epithelial ulceration
Rare; severe, rapidly progressive, stromal inflammation with epithelial
ulceration; may result in perforation
Stromal vascularization, scarring
Endotheliitis

Pathogenesis uncertain but may be due to inflammatory reaction to
live virus in the endothelium

Corneal stromal and epithelial edema, KPs underlying zone of
edema, mild iritis

Disciform (most common), diffuse or linear endotheliitis

Associated trabeculitis and IOP
Management of Stromal Keratitis and
Endotheliitis



Slow taper of topical steroids is the mainstay
Topical Trifluridine QID or Acyclovir 400 mg x5/day
Long-term prophylaxis for recurrent disease (ACV 400 mg BID)
The Herpetic Eye Disease Study

Topical steroids significantly decreased stromal inflammation
and shortened duration of stromal keratitis

No benefit to addition of oral Acyclovir to topical Trifluridine
and Prednisolone in non-necrotizing stromal keratitis

Acyclovir does not prevent stromal keratitis or iritis in patients
with epithelial keratitis

Acyclovir prophylaxis minimizes recurrent disease in patients
with stromal keratitis
• Barron BA et al. Herpetic Eye Disease Stud. A controlled trial of oral acyclovir for herpes simplex stromal keratitisOphthalmology. 1994 Dec;101(12):1871-82.
• Wilhelmus KR et al. Herpetic Eye Disease Study. A controlled trial of topical corticosteroids for herpes simplex stromal keratitis. Ophthalmology. 1994
Dec;101(12):1883-95
• Retrospective study of 87 penetrating keratoplasties in herpetic
keratitis at 3 centers in Germany
• Analyzed the effectiveness of combined systemic acyclovir and
immunosuppressive therapy with cyclosporine A or
mycophenolate mofetil
• Graft survival rates and functional outcomes in these high risk
keratoplasties, when treated with systemic immunosuppression
were comparable with results of normal-risk keratoplasties
References
•
BSCS. External Disease and Cornea
•
Barron BA et al. Herpetic Eye Disease Stud. A controlled trial of oral acyclovir for
herpes simplex stromal keratitisOphthalmology. 1994 Dec;101(12):1871-82.
•
Wilhelmus KR et al. Herpetic Eye Disease Study. A controlled trial of topical
corticosteroids for herpes simplex stromal keratitis. Ophthalmology. 1994
Dec;101(12):1883-95
•
Kinchington PR et al. Herpes simplex virus and varicella zoster virus, the house guests
who never leave. Herpesviridae. 2012 Jun 12;3(1):5
Thank You