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All About Herpes Zoster

Course 160 SECO International 2015

March 7 Daryl F. Mann, O.D.

President SouthEast Eye Specialists, PLLC

Chattanooga & Knoxville, TN

Disclosures

•  I have been a paid speaker for Alcon and a consultant for B&L in 2014.

Case Presentation: 224912 2-24-14

•  59 yo WF c/o rash last night & worse today

•  Physical findings: –  VA 20/20 OD/OS –  Ta 10 mm Hg OD/OS –  LASIK flaps OU –  External as shown

•  Dx: HZO –  Placed on Valtrex 1 gm TID

224912 2-27-14

•  Rash is spreading and now has pain

•  Taking Valtrex; also using Zovirax cream

•  VA 20/20 •  IOP 12 mm Hg •  SLEx

–  3 distinct mucous plaques

•  Add Lortab 7.5/500 QID for pain

3-4-14

•  Moderate pain & ache •  VA 20/20 •  IOP 10 mm Hg •  SLEx

–  Trace FL stain; plaques resolved

•  D/C Lortab when no longer needed; start Vitamin E cream

3-12-14

•  Less pain & ache •  VA 20/20 OD •  IOP 14 mm Hg •  SLEx

–  Cornea is clear –  15-20 cell in AC

•  D/C Valtrex and Zovirax cream. Add Durezol BID OD

3-19-14

•  Having more pain and itching

•  Started Lyrica which has helped

•  VA 20/20 OD •  IOP 10 mm Hg •  SLEx

–  AC clear of cell

•  Taper Durezol to QD for 4 days then QOD until return

224912 As Easy As 1, 2, V!

•  8 types of Human Herpes Viruses (HHV) known to affect humans –  HHV-1: Herpes simplex type I (HSVI) –  HHV-2: Herpes simplex type II (HSVII) –  HHV-3: Varicella-zoster virus (VZV) –  HHV-4: Epstein-Barr virus (EBV) –  HHV-5: Cytomegalovirus (CMV) –  HHV-6: Human B-lymphotropic virus (HBLV) –  HHV-7: (HHV-7) –  HHV-8: Kaposi’s sarcoma (KSHV)

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Human Herpes Virus - 3 Varicella Zoster Virus (VZV)

•  Epidemiology •  Risk Factors •  Diagnosis •  Pathogenesis

– Primary Infection – varicella (chickenpox) – Latency stage – Reactivation stage – zoster (shingles)

Human Herpes Virus - 3 Varicella Zoster Virus (VZV)

•  Primary VZV infection –  Varicella (chickenpox) –  Clinical resolution is followed by the establishment of latent infection

within the sensory dorsal root ganglia.

•  Reactivation VZV –  Herpes Zoster (shingles) –  A painful, unilateral vesicular eruption in a restricted dermatomal

distribution –  Herpes zoster ophthalmicus (HZO) occurs when reactivation of the latent

virus involves the nasociliary branch of the 5th cranial nerve

Chickenpox Zoster

VZV Epidemiology

•  99.5% of US adults > age 40 have antibodies to VZV1 •  Zoster incidence rates progressively increase with age •  CDC estimates 32% of persons in the US will

experience zoster during their lifetimes.2

•  Herpes zoster occurs in nearly 1 million persons annually in US3

1Marin M, Meissner HC, Seward JF. Varicella prevention in the US: a review of successes and challenges. Pediatrics. Sep 2008;122(3):e744-51.

2Gnann JW Jr, Whitley RJ. Clinical practice. Herpes Zoster. N Engl J Med 2002;347:340. 3Yawn BP, Saddier P, Wollan PC. A population-based study on the incidence and complication rates of herpes zoster

before zoster vaccine introduction. Mayo Clin Proc 2007;82:1341

Phases of Herpes Zoster

1.  Pre-eruptive (pre-herpetic neuralgia) phase 2.  Acute eruptive phase 3.  Chronic phase (Post-Herpetic Neuralgia)

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Pre-eruptive Phase

•  Sensory phenomena along 1 or more skin dermatomes lasting 1-10 days (average 48 hours)

•  Phenomena usually noted as pain •  Pain may simulate headache, iritis, pleurisy,

cardiac pain, sciatica, appendicitis, abdominal pain •  Other symptoms: malaise, myalgia, headache,

photophobia

• Goh CL, Khoo L. A retrsospective study of the clinical presentation and outcome of herpes zoster in a tertiary dermatology outpatient referral clinic. Int J Dermatol. ˆSep 1997;36(9):667-72.

Acute Eruptive Phase

•  Patchy erythema •  Regional lymphadenopathy •  Grouped herpetiform vesicles •  Unilateral, stopping abruptly at the midline of involved

sensory dermatome •  Vesicular involution, scarring can occur •  Pain, typically severe •  Symptoms tend to resolve in 10-15 days •  Complete healing of lesions may require 1 month

http://www.webmd.com/skin-problems-and-treatments/shingles/ss/slideshow-shingles-pictures

PHN

•  Persistent or recurring pain lasting 30 or more days (9-45% of all cases)1

•  Pain confined to area of dermatomal involvement •  Pain can persists for weeks to years •  Pain worse in elderly2 •  PHN more common after HZO and other upper

body dermatomal involvement

1Pasqualucci A, Pasqualucci V, et al. Prevention of PHN: acyclovir and prednisolone vs epidural local anesthetic and methylprednisolone. Acta Anaesthesiol Scand. Sep 2000;44(8):910-8.

2Kost RG, Straus SE. PHN-pathogenesis, treatment, and prevention. N Engl J Med.Jul 4 1996;335(1):32-42.

Zoster Management

•  Avoid contact with individuals, patients with acute rash are contagious – Especially high risk individuals

•  Goals of therapy: – Shorten clinical course – Relieve pain – Prevent complications – Decrease incidence of PHN

Oral AntiVirals

•  Oral antiviral therapy must be started within 72 hours of symptoms so as to minimize the incidence of post herpetic neuralgia.

•  Acyclovir (Zovirax) –  200 mg & 400 mg –  Zoster: 800 mg 5 X day for 7 days

•  Valacyclovir (Valtrex) –  Pro drug with 3-4x conc; 500 mg & 1 gm –  Zoster: 3 gms per day for 7 days

•  Famciclovir (Famvir) –  125 mg, 250 mg & 500 mg –  Zoster: 1.5 gms per day for 7 day

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Additional Treatment Options

•  Corticosteroids –  Benefit is debatable –  May accelerate resolution

of neuritis but has no effect on PHN1,2

–  40-60 mg QD early for 1 week with rapid taper

•  Anticonvulsants –  Gabapentin (Neurontin) –  Pregabalin (Lyrica)

•  Analgesics –  Oxycodone –  Acetaminophen –  Ibuprofen –  Naproxen

•  Antidepressants, TCAs –  Amitriptyline –  Desipramine

•  Topical analgesics –  Capsaicin

http://www.webmd.com/skin-problems-and-treatments/shingles/ss/slideshow-shingles-pictures

Herpes Zoster Ophthalmicus (HZO) •  HZO represents 10-15% of all cases of HZ1 •  Classic symptoms and lesions of zoster •  Ophthalmic manifestations:

–  Conjunctivitis –  Scleritis –  Episcleritis –  Keratitis –  Uveitis –  Glaucoma –  Ptosis –  Extra ocular muscle palsies

–  Retinitis –  Choroiditis –  Optic neuritis –  Optic atrophy –  Retrobulbar neurtitis –  Exophthalmos –  Lid retraction

1Edgerton G. Herpes zoster ophthalmicus: a review of the literature. Arch Ophthalmol. 1945;34:40-62; 114-53.

HZO Physical Exam

•  Visual acuity •  EOM movements •  Pupil response •  IOP •  Slit lamp exam with & without fluorescein •  DFEx •  Visual fields

Herpes Zoster Ophthalmicus

•  Hutchinson’s sign –  Vessicles at the tip of the

nose in a patient with cutaneous manifestations of herpes zoster – varicella virus reactivation

Herpes Zoster Ophthalmicus

•  Cornea lesions –  Most commonly seen 2nd

week of HZO –  Nummular keratitis:

subepithelial infiltrates –  Mucous plaques –  Dendritic lesions

•  Anterior uveitis –  Trabeculitis with increase IOP

•  Fundus Involvement –  Choroiditis, vasculitis –  ARN, BARN, PORN

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Perform comprehensive evaluation ARN, BARN, PORN

HZO Management

•  Topical – Antiviral therapy – Antiinflammatory therapy – Palliative therapy

•  Systemic – Oral antiviral therapy must be started within 72

hours of symptoms so as to minimize the incidence of post herpetic neuralgia.

HZO Uveitis

•  40% will develop uveitis 1-3 weeks after the onset of the rash1

•  Often associated with iris irregularity •  May persist and be recurrent •  May be associated with elevated IOP •  Treat as any uveitis; continuing oral antiviral

therapy is of disputed value

1Hall AJH. A patient education monograph prepared for the American Uveitis Society. Viewed online at Uveitissociety.org. March 2003.

HZO Glaucoma

•  Treat as typical uveitic glaucoma –  Corticosteroids –  Aqueous suppression –  Avoid prostaglandins and

miotics

•  Glaucoma may be recalcitrant to topical/oral therapy

Cornea

•  May not require any therapy •  Lubricants •  Corticosteroids •  Can develop corneal

hypesthesia leading to ocular surface abnormalities

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Case Presentation: 224912 2-24-14

•  59 yo WF c/o rash last night & worse today

•  Physical findings: –  VA 20/20 OD/OS –  Ta 10 mm Hg OD/OS –  LASIK flaps OU –  External as shown

•  Dx: HZO –  Placed on Valtrex 1 gm TID

224912 2-27-14

•  Rash is spreading and now has pain

•  Taking Valtrex; also using Zovirax cream

•  VA 20/20 •  IOP 12 mm Hg •  SLEx

–  3 distinct mucous plaques

•  Add Lortab 7.5/500 QID for pain

3-4-14

•  Moderate pain & ache •  VA 20/20 •  IOP 10 mm Hg •  SLEx

–  Trace FL stain; plaques resolved

•  D/C Lortab when no longer needed; start Vitamin E cream

3-12-14

•  Less pain & ache •  VA 20/20 OD •  IOP 14 mm Hg •  SLEx

–  Cornea is clear –  15-20 cell in AC

•  D/C Valtrex and Zovirax cream. Add Durezol BID OD

3-19-14

•  Having PHN with pain and itching

•  Started Lyrica which has helped

•  VA 20/20 OD •  IOP 10 mm Hg •  SLEx

–  AC clear of cell

•  Taper Durezol to QD for 4 days then QOD until return

224912 Case Presentation 1-30-14

•  62 yo male reported bump by eye; itching, scalp ache

•  VAcc 2020 •  IOP 18 mm Hg OU •  SLEx unremarkable •  DFEx unremarkable •  Dx’ed HZO and place on

Valtrex 1 gm TID

2-3-14

•  Rash is worse, pain is worse at night

•  Vacc 20/20 OD; 20/25 OS •  SLEx

–  Keratitis

•  IOP 27 mm Hg OS •  Add pred acetate 1% QID

and timolol ½% QD OS

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2-6-14

•  Pain improved •  VAcc 20/20 OS •  SLEx

–  Less staining of epi defects

•  IOP 21 mm Hg •  CPMs

2-27-14

•  No pain; no lesions on scalp •  VAcc 20/20 OS •  Cornea is clear •  IOP 12 mm Hg OS •  D/C all meds

4-3-14 •  No pain •  VAcc 20/20 OS •  IOP 12 mm Hg OS •  Discharged

Zoster Prevention •  Zostavax™

–  50% relative risk reduction for contracting shingles in > 60 age

–  64% reduction age 60-69 –  70% reduction in age 50-59 –  66% reduction in post herpetic neuralgia in those who

contracted shingles despite vaccination –  Initially approved for > age 60; now approve for age 50

and above

Thank You