Keratitis_IV - VIRAL INFECTIONS OF CORNEA 24 December 2011...

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Unformatted text preview: VIRAL INFECTIONS OF CORNEA 24 December 2011 Prof Sanjay Shrivastava 1 Copy of lecture taken by Prof Sanjay Shrivastava for Junior Final M.B.B.S students of Gandhi Medical College Bhopal (M.P.) India 24 December 2011 Prof Sanjay Shrivastava 2 Types 24 December 2011 Prof Sanjay Shrivastava 3 Superficial Viral Keratitis 24 December 2011 Prof Sanjay Shrivastava 4 Causes Causes: 1. Herpes Zoster 2. Adenoviruses 3. Chlamydia Trachomatis 4. Inclusion Conjunctivitis 5. Rare causes: Mumps, Measles, Vaccinia, Infectious mononucleosis, Secondary to Molluscum Contagiosum and Warts 24 December 2011 Prof Sanjay Shrivastava 5 Clinical Manifestations 24 December 2011 Prof Sanjay Shrivastava 6 I. Punctate Epithelial Erosion This is most common manifestation of viral superficial infections Minute epithelial defects, staining with Fluorescein Acute manifestation associated with conjunctivitis. There is pain, photophobia and lacrimation Usually characterized by recurrences of fresh erosions occurring in crops after subsidence of initial keratitis 24 December 2011 Prof Sanjay Shrivastava 7 Superficial Punctate Keratitis 24 December 2011 Prof Sanjay Shrivastava 8 Differential Diagnosis Bacterial due to staphylococcal toxins (associated with blepharitis and conjunctivitis) Chemical General febrile illness due to adenovirus may also be associated with this clinical picture 24 December 2011 Prof Sanjay Shrivastava 9 Treatment Lubricating (artificial tear) drops Chloramphenicol eye drops to prevent secondary bacterial infection 24 December 2011 Prof Sanjay Shrivastava 10 II. Punctate Epithelial Keratitis (Superficial Punctate Keratitis) Both eyes are affected Prolonged course for months or years Affects deeper layer, sometimes opacities extends to Bowman’s membrane and superficial stroma (Punctate sub­epithelial keratitis) 24 December 2011 Prof Sanjay Shrivastava 11 Clinical Picture Superficial opacities , grey dots, slightly raised above in the central cornea, they do not take fluorescein stain, but stain with Rose Bengal Combined picture of epithelial and sub­ epithelial lesions may be present, as in epidemic keratoconjunctivitis, pharyngo­ conjunctival fever, herpes, vaccinia etc, it may also occur without known cause as in Thygeson superficial keratitis 24 December 2011 Prof Sanjay Shrivastava 12 Treatment Lubricating (artificial tear) drops Steroids may be used under supervision (required for long time) 24 December 2011 Prof Sanjay Shrivastava 13 Herpes Simplex 24 December 2011 Prof Sanjay Shrivastava 14 Herpes Simplex The herpes simplex virus is essentially human pathogen that can cause asymptomatic infection as well as active disease in variety of organs Two antigenic types are known: a. Herpes Simplex Virus (HSV) – 1 b. Herpes Simplex Virus (HSV) – 2 24 December 2011 Prof Sanjay Shrivastava 15 Antigenic types HSV – 1 usually causes oropharyngeal disease and HSV – 2 usually involves genital areas Typically ocular disease is caused by type 1 rather than type 2. Humans are the only natural reservoir of HSV. Close personal contact is necessary for the spread of virus 24 December 2011 Prof Sanjay Shrivastava 16 HSV infection Primary infection rarely causes clinical manifestations. Recurrent infection is more common from Trigeminal ganglion in most of the cases Factors implicated in the activation of recurrent HSV ocular disease (Reactivation of latent infection) immune system deficiency, sunlight, heat, trauma (including surgery), abnormal body temperature, menstruation, other infectious diseases, emotional stress 24 December 2011 Prof Sanjay Shrivastava 17 Ocular manifestations Blepharitis Conjunctivitis Keratitis Iridocyclitis 24 December 2011 Prof Sanjay Shrivastava 18 Corneal involvement Epithelial Corneal vesicles Dendritic ulcer Geographical ulcer Marginal ulcer II. Neurotrophic Keratopathy I. 24 December 2011 Prof Sanjay Shrivastava 19 Corneal Involvement III IV Stromal Necrotizing stromal keratitis Interstitial immune mediated (Non­necrotizing) Keratitis Endothelial: Disciform, Diffuse and Linear Primary lesion usually seen in children, manifest itself as follicular keratoconjunctivitis In recurrent form only cornea is involved 24 December 2011 Prof Sanjay Shrivastava 20 Corneal Lesions 24 December 2011 Prof Sanjay Shrivastava 21 I. Superficial Punctate Keratitis Superficial Punctate Keratitis – Numerous minute whitish plaques arranged in rows or groups. These lesions desquamate forming erosions which heals rapidly without leaving opacities Symptoms: Pain, irritation, blepharospasm, and photophobia Recurrence of fresh crops 24 December 2011 Prof Sanjay Shrivastava 22 Epithelial Keratitis 24 December 2011 Prof Sanjay Shrivastava 23 Corneal Lesions Desquamation leaves minute shallow clear facets, they are not vascularized, arranged in groups, they have crenated edges. Several lesions may coalesce and epithelial filaments are present Cornea is relatively insensitive 24 December 2011 Prof Sanjay Shrivastava 24 II Dendritic Ulcer Dendritic Ulcer: occurs in severe form of disease. Lesions coalesce and spread in all directions to form large shallow ulcer with crenated edges. Grey striae extending in one or more directions, increasing in length, sending knobbed lateral branches – Dendritic figure form This appearance is seen exclusively in this condition and is pathognomonic 24 December 2011 Prof Sanjay Shrivastava 25 Dendritic Ulcer Surface over infiltration breaks leaving extremely irritating chronic ulcer Lesions persists for weeks or months sending out fresh branches which remains superficial Only 1 or 2 lesions may take fluorescein stain at any given time Fresh spots continue to form and disease has tendency to recur A large confluent ulcer may form 24 December 2011 Prof Sanjay Shrivastava 26 Dendritic Keratitis 24 December 2011 Prof Sanjay Shrivastava 27 Dendritic Keratitis 24 December 2011 Prof Sanjay Shrivastava 28 Dendritic Ulcer In the mean time stroma may be implicated and a disciform keratitis develops due to immunological reaction Iritis usually accompanies severe form of herpetic keratitis In very severe form of disease hypopyon may develop , from which virus may be isolated 24 December 2011 Prof Sanjay Shrivastava 29 Herpes Simplex Keratitis Dendritic Keratitis 24 December 2011 Geographical Keratitis Prof Sanjay Shrivastava 30 Herpes Simplex Keratitis Stromal necrosis leading to Descemetocele 24 December 2011 Prof Sanjay Shrivastava Marginal Keratitis 31 Dendritic Ulcer Diagnosis Immunoflurescence test, Culture of epithelial scrapping or Tissue biopsy 24 December 2011 Prof Sanjay Shrivastava 32 Treatment 1. 2. 3. 4. Topical and Systemic Antivirals Topical and Systemic Steroids Supportive therapy (artificial tears) Cycloplegics 24 December 2011 Prof Sanjay Shrivastava 33 Local Antiviral Drugs 1. 2. 3. 4. Idoxuridine 5% drops used 5 times a day Trifluridine 1% drops used 4 times a day Acyclovir ointment 3% used 5 times a day Vidarabine ointment 3% used 5 times a day ORAL : Acyclovir 400 / 800 mgm tab 24 December 2011 Prof Sanjay Shrivastava 34 Treatment of Epithelial Keratitis Topical antivirals + Antibiotics (antiviral is usually required for 15 days) Lubricating (Artificial tear) eye drops Cycloplegic drops Debridement of edges of Dendritic ulcer with moist cotton tipped applicator Corticosteroids are contraindicated 24 December 2011 Prof Sanjay Shrivastava 35 Treatment of stromal disease (and also of endothelial and iridocyclitis) Treated with topical steroid and antiviral drugs 24 December 2011 Prof Sanjay Shrivastava 36 Indications of systemic Acyclovir 1. 2. 3. 4. 5. 6. 7. Non­responsive immune compromised primary HSV infected case especially with iridocyclitis Significant primary HSV infection Immune compromised patient (Moderate to severe) with HSV infection Infectious epithelial keratitis in adults HSV iridocyclitis Recurrent epithelial infection: Dose: 200 – 400 mgm twice daily for long term (6 months) Operated cases of penetrating Keratoplasty to prevent recurrence (400 mgm bid) 24 December 2011 Prof Sanjay Shrivastava 37 Adjuvant therapy 1. 2. 3. 4. 5. 6. Therapeutic contact lens Collagenase inhibitors Tarsorrhaphy Conjunctival Flap Cyanoacrylate glue in cases of perforated ulcer Lamellar or penetrating keratoplasty 24 December 2011 Prof Sanjay Shrivastava 38 Herpes Zoster Ophthalmicus 24 December 2011 Prof Sanjay Shrivastava 39 HZO Caused by Varicella Zoster virus which belongs to herpes virus group In developed world approximately 95% of the population shows evidence of prior VZV infection Varicella is highly contagious exanthematous illness manifested by prodromal symptoms and diffuse vesicular rash 24 December 2011 Prof Sanjay Shrivastava 40 HZO Following acute infection VZV travels through peripheral nerves axons to dorsal root where it becomes latent Virus is endemic and becomes epidemic during late winter and early spring Varicella manifestations cause significant morbidity and mortality in immuno­ suppressed hosts 24 December 2011 Prof Sanjay Shrivastava 41 HZO Herpes zoster occurs due to reactivation of VZV, upon reactivation virus replicates in the cells of dorsal root ganglion and travel to skin and mucous membrane via axons. Cranial nerve involvement (Trigeminal) occurs in approximately 13 ­20% of cases Presence of vesicles at the side of the nose results from involvement of nasociliary nerve which supplies this area and intra­ocular structures (Hutchinson’s sign) 24 December 2011 Prof Sanjay Shrivastava 42 HZO Ocular involvement is seen in about 50% of cases Corneal involvement occurs in about 2/3rd of patients with ocular disease in acute HZO 24 December 2011 Prof Sanjay Shrivastava 43 Herpes Zoster Ophthalmicus (HZO) PATHOGENESIS After infection during childhood or youth, the virus becomes dormant usually in Gasserian Ganglion. In case of Zoster Ophthalmicus it appears later particularly when cellular immunity is depressed, particularly in elder persons 24 December 2011 Prof Sanjay Shrivastava 44 HZO Virus travels down along one or more branches of ophthalmic division (which is branch of Vth nerve, trigeminal nerve) The area of distribution of branches of ophthalmic division of V th nerve is marked by rows of vesicular eruptions or scars left by vesicles Branches of ophthalmic nerve involved are ­supraorbital, supratrochlear and infratrochlear; frequently nasal branch and sometimes infraorbital branch 24 December 2011 Prof Sanjay Shrivastava 45 HZO Condition is usually unilateral, butit may be bilateral in immuno­compromised cases 24 December 2011 Prof Sanjay Shrivastava 46 Symptoms General: fever, malaise, eruptions along the distribution of involved nerve, preceded by severe neuralgic pain. It sometimes ceases after outbreak of the eruptions, but may persists for months or years Skin of affected area becomes edematous and red Differential diagnosis – erysipelas but distribution along involved nerve branches differentiate 24 December 2011 Prof Sanjay Shrivastava 47 Herpes Zoster Ophthalmicus Clinical photographs showing distribution of rashes 24 December 2011 Prof Sanjay Shrivastava 48 Symptoms Vesicles may suppurate , bleed and may cause small scars (depressed) Eruptive stage lasts for about 6 weeks followed by depressed sensation of affected scarred area Ocular complications arise when eruptive stage is subsiding. The ocular complication are usually overlooked during acute stage due to difficulty in examination of eye. 24 December 2011 Prof Sanjay Shrivastava 49 Symptoms The ocular complications are associated with involvement of nasociliary branch which is characterized by presence of vesicles on the tip of nose 24 December 2011 Prof Sanjay Shrivastava 50 Ocular Manifestations 1. 2. 3. 4. Lid edema Numerous minute white round spots in the epithelium, soon involving the stroma, seen as coarse sub­epithelial punctate keratitis Discoid lesions are termed nummular keratitis (hardly distinguishable from other forms of viral keratitis) Sometimes infiltration involves stroma, as diffuse stromal inflammation, with iridocyclitis 24 December 2011 Prof Sanjay Shrivastava 51 Corneal changes in HZO Punctate epithelial keratitis Pseudodendritic keratitis Anterior stromal keratitis Kerato­uveitis / endothelitis Serpiginous ulceration Sclerokeratitis Corneal mucous plaques Disciform keratitis 24 December 2011 Prof Sanjay Shrivastava 52 Corneal involvement in HZO 24 December 2011 Prof Sanjay Shrivastava 53 Ocular involvement in HZO Skin scarring + keratouveitis 24 December 2011 Scleritis + Keratitis Prof Sanjay Shrivastava 54 Corneal changes in HZO Neurotrophic keratopathy Exposure keratopathy Interstitial keratitis / lipid keratopathy Permanent corneal edema 24 December 2011 Prof Sanjay Shrivastava 55 Ocular Manifestations Cornea is usually anaesthetized Scleritis – leaving grey scarred areas on sclera Iridocyclitis – leaving sectoral iris atrophy Intra­ocular tension low initially, increases later Corneal anaesthesia persists for long 24 December 2011 Prof Sanjay Shrivastava 56 Ocular involvement in HZO Keratitis 24 December 2011 Prof Sanjay Shrivastava Scleritis 57 Ocular involvement in HZO Keratitis Distribution of Skin lesions 24 December 2011 Prof Sanjay Shrivastava 58 Ocular Manifestations There may be associated paralysis of the oculo­motor nerve, abducens and facial nerve which usually passes off in 6 weeks Complications: retinal necrosis (after 5 days to 3 months) and optic neuritis Neurological manifestations: acute neuralgia, post herpetic neuralgia, encephalitis, myelitis/ encephalomyelitis, segmental motor weakness, cranial neuropathies and delayed cerebral vasculitis 24 December 2011 Prof Sanjay Shrivastava 59 Treatment 1. Acyclovir: 800 mgms five times a day for 10 days (it reduces the period of viral shedding , accelerate the time for healing by 50%, decreases the pain and reduces occurrence of fresh lesions. It reduces the chance of post herpetic neuralgia) Systemic Acyclovir should be given early preferably within 4 days of beginning of rashes Alternatively oral Famciclovir, 250 mgms thrice daily for 7 days 24 December 2011 Prof Sanjay Shrivastava 60 Treatment 2. Oral strong analgesics and non­steroidal anti­ inflammatory drugs 3. Maintenance of hygienic condition to prevent secondary infection. Topical antiviral (acyclovir) and antibiotic ointment on skin lesions 4. Topical antibiotic drops and ointment in the eye during acute phase 5. Scleritis is treated with topical steroid and antiviral to reduce ischemia and scarring 24 December 2011 Prof Sanjay Shrivastava 61 Treatment 6. Systemic steroids are indicated in: a. progressive proptosis b. 3rd nerve palsy c. optic neuritis (to take care of occlusive vasculitis) 7. Artificial tears for dryness of ocular surface 8. Neurotrophic ulcer by lateral tarsorrhaphy 9. Penetrating keratoplasty – in cases of dense scarring and lipoidal deposits in central cornea 24 December 2011 Prof Sanjay Shrivastava 62 ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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