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ORIGINAL ARTICLE
Year : 2019  |  Volume : 12  |  Issue : 3  |  Page : 250-255  

Ocular involvements, its complications, visual outcome, and treatment response of herpes zoster ophthalmicus: Review of 35 patients from Andaman and Nicobar Island


1 Department of Ophthalmology, MS Ophthalmology, Andaman and Nicobar Islands Institution of Medical Science, Port Blair, Andaman and Nicobar, India
2 Department of Dermatology, Andaman and Nicobar Islands Institution of Medical Science, Port Blair, Andaman and Nicobar, India

Date of Submission02-Jun-2018
Date of Acceptance12-Nov-2018
Date of Web Publication15-May-2019

Correspondence Address:
Sujit Das
Department of Ophthalmology, Andaman and Nicobar Islands Institution of Medical Science, Port Blair - 744 104, Andaman and Nicobar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_87_18

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  Abstract 


Aim: The aim of this study is to evaluate the ocular involvements, its complications, visual outcome, and treatment response of herpes zoster ophthalmicus (HZO). Design: This was an observational and retrospective study. Methods: All clinically diagnosed cases were included in the study. All were subjected to corneal staining, corneal sensation, best-corrected visual acuity (BCVA), intraocular pressure, and fundus examination. All were treated with oral acyclovir (800 mg) 1 tablet 5 times a day for 5 days along with tablet pregabalin (150 mg twice/day) and neurobion forte (1 tablet/day). Acyclovir eye ointment was given 5 times a day for 14 days with antibiotic and cycloplegic drops. Mean follow-up was 12 months. Results: Mean age of presentation was 51–55 years (40%) with male predominance (88.6%). Unilateral eye involvement was 32 (91.4%) and bilateral was three (8.6%). Blepharitis was (80%) the most common ocular involvement followed by punctuate keratitis (77.1). Ocular complications were neurotrophic keratopathy (5.7%), corneal opacity (5.7%), and postherpetic neuralgia (62.9%). Mean BCVA was 20/20 in 33 eyes (94.3%). The sensitivity of acyclovir was found 100%. Conclusion: Rapid diagnosis and early institution of antiviral therapy are necessary to prevent ocular morbidity. History of chickenpox, low immunity, and environmental factors (hot climate, humidity, and rainfall,) greatly influences the occurrence of HZO. The overall visual outcome is good with early institution of antiviral therapy.

Keywords: Herpes zoster, herpes zoster ophthalmicus, herpetic eye disease, keratitis, keratouveitis, varicella zoster virus-uveitis


How to cite this article:
Das S, Pradeep B, Mandal C. Ocular involvements, its complications, visual outcome, and treatment response of herpes zoster ophthalmicus: Review of 35 patients from Andaman and Nicobar Island. Med J DY Patil Vidyapeeth 2019;12:250-5

How to cite this URL:
Das S, Pradeep B, Mandal C. Ocular involvements, its complications, visual outcome, and treatment response of herpes zoster ophthalmicus: Review of 35 patients from Andaman and Nicobar Island. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2019 Dec 15];12:250-5. Available from: http://www.mjdrdypv.org/text.asp?2019/12/3/250/258214




  Introduction Top


Herpes zoster ophthalmicus (HZO) is reactivation of the varicella zoster virus (VZV), mainly involving the ophthalmic division of trigeminal nerve with classical vesicular eruptions. HZO is the second most common clinical manifestation of VZV.[1] The incidence and severity of HZO increase with advancing age.[2] VZV-specific cell-mediated immunity keeps VZV latent in the trigeminal ganglion and is boosted by periodic re-exposure to VZV. HZO occurs when there is involvement of ophthalmic division of the fifth cranial nerve.[3] Ocular involvement occurs in approximately 50% of herpes zoster patients.[4] HZO is often associated with significant ocular morbidity and may lead to significant visual impairment in the absence of prompt and adequate treatment. There is a long list of complications from HZO, but the most frequent and debilitating complication of HZO is postherpetic neuralgia (PHN) that persists or develops after the rash has resolved. The main risk factors for ocular involvement are advancing age, low immunity, and history of chickenpox. The presence of vesicular rash over the tip of the nose (Hutchinson's sign) indicates the risk of involvement of ciliary nerve and thereby involvement of the retina and optic nerve. Many cases of herpes zoster, HZO, and PHN can be prevented by the zoster vaccine.[5],[6]


  Methods and Materials Top


All patients who were clinically diagnosed to have HZO, based on history, clinical features, and slit lamp findings over a period of 2 years from June 2016 to June 2018 were included in the study. All patients were subjected to corneal staining, corneal sensation, best-corrected visual acuity (BCVA), intraocular pressure, papillary reaction, and fundus examination. HZO was treated as per the standard treatment protocol followed in the institution and the response to the treatment was analyzed over 2 years. All were treated with oral acyclovir (800 mg) 1 tablet 5 times a day for 7 days along with tablet pregabalin (150 mg) 1 tablet twice daily and tablet neurobion forte once a day. Acyclovir eye ointment 5 times a day for 14 days with antibiotic (moxifloxacin - 1 drop 4 times/day) and cycloplegic (homatropine-2% - 1 drop thrice daily) was prescribed. Those presented with optic neuritis and Bell's palsy was treated with injection dexamethasone 2cc intravenous stat followed by oral prednisolone 1 mg/kg/bt with rapid tapering dose. In all cases, sugar, complete blood count, and serological test for HIV and syphilis were done. All of them were followed after 7 days, 14 days, 30 days, 3 months, 6 months, 12 months, and 24 months.


  Results Top


Out of the total 35 patients with 38 eyes, male was predominated (n = 31, 88.6%) and female was 4 (11.4%) [Table 1]. Maximum age group affected was between 51-55 years [Table 2]. Unilateral eye [Figure 1] involvement was seen in 32 cases (91.4%) and bilateral [Figure 2] eye involvement was seen in three cases (8.6%) [Table 3]. Initial VA was 6/6 in 20 cases (57.14%), 6/12 in 8 cases (22.85%), 6/24 in 5 cases (14.28%), and 6/60 in 2 cases (5.71%) [Table 4]. History of chickenpox was found in 24 cases (68.57%) and most of them were above 50 years. No history of severe head trauma was there. One patient was on chronic corticosteroid therapy for rheumatoid arthritis. HIV was found in only two cases (2.85%) of below 40 years of age and diabetes was found in 21 cases (60%). There was no leukemia [Table 5]. Corneal (punctuate keratitis) and conjunctival involvement (keratoconjunctivitis) [Figure 3] and [Figure 4] was found in 27 cases (71.14%), blepharitis [Figure 5] in 28 (80%), iritis (isolated anterior uveitis [AU]) [Figure 6] in 3 (8.57%), and keratouveitis in 5 (14.28%). Bell's palsy [Figure 7] was present in one case (2.85%) and 5 cases presented with subconjunctival hemorrhage [Figure 8]. Scleritis was present [Figure 9] in one case (2.85%) and one case was presented with optic neuritis (2.85%) [Figure 10]. There was no retinal and orbital involvement. Corneal hypoesthesia was present in 16 cases (45.71%) and neurotrophic ulcer [Figure 11] was developed in two cases (2.85%). PHN [Figure 12] was found in 21 cases (60%). During 1-year follow-up, corneal leucomatous opacity was developed in two cases (2.85%) [Figure 13] and [Table 6]. Intraocular pressure elevation was seen in five cases (14.28%) but responded well with treatment [Table 7]. No secondary glaucoma and pseudodendritic keratitis were observed in the follow-up period. On follow-up, VA was good maintaining BCVA 20/20 in 33 cases (94.28%) [Table 8].
Table 1: Percentage of gender affected

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Table 2: Age group commonly affected

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Figure 1: Classical vesicular rash involving trigeminal distribution of ophthalmic nerve with classical Hutchinson's sign (unilateral)

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Figure 2: Herpes zoster ophthalmicus with bilateral eye involvement

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Table 3: Percentage of eye involvements

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Table 4: BCVA LogMAR at presentation

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Table 5: Comorbidities

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Figure 3: Herpes zoster ophthalmicus and keratoconjunctivitis

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Figure 4: Herpes zoster ophthalmicus with corneal staining positive (Keratitis)

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Figure 5: Herpes zoster ophthalmicus with blepharitis

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Figure 6: Herpes zoster ophthalmicus with keratouveitis

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Figure 7: Herpes zoster ophthalmicus with Bell's palsy

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Figure 8: Herpes zoster ophthalmicus presented with subconjunctival hemorrhage

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Figure 9: Herpes zoster ophthalmicus presented with scleritis

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Figure 10: Herpes zoster ophthalmicus presented with optic neuritis

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Figure 11: Herpes zoster ophthalmicus developed neurotropic ulcer

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Figure 12: Herpes zoster ophthalmicus developed postherpetic neuralgia

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Figure 13: Postherpes zoster ophthalmicus corneal opacity

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Table 6: Ocular involvement

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Table 7: Initial rise of intraocular pressure elevation

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Table 8: BCVA LogMAR after 12 months

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  Discussion Top


Herpes zoster, commonly known as shingles, is caused by reactivation of latent VZV present in the sensory ganglia after chickenpox infection. Any sensory ganglion may be involved, but the dermatomes most commonly affected, in order of frequency, are trigeminal, thoracic, cranial, cervical, lumbar, and sacral.[7] HZO involves the dermatome innervated by the ophthalmic division of the trigeminal nerve and accounts for 20% of all cases of herpes zoster.[7] Herpes zoster eye complications are well known and should be treated as early as possible to prevent ocular morbidity. Corneal involvement occurs approximately in 34% of cases.[8] Corneal involvement may occur concurrently with the disease or may present later on. One such example is keratouveitis which has a typical onset of 7 days after HZO.[9] The estimation of HZO ranges between 320 and 410 per 100,000 population per year.[10] A recent study from the Pacific region estimates that the overall incidence of HZO is 30.9 per 100,000 population per year.[10] Previous studies also showed that the incidence of HZO increases significantly with age, which is similar to our study.[1],[2],[3],[10] A recent case series reports that HZO affects similarly individuals aged younger than or older than 60 years, with the most common decade of onset between age 50 and 59 years.[10],[11] Increased age has been associated with a decrease in cell-mediated immunity, which is a crucial factor to prevent reactivation of the latent VZV.[2],[10]

Ghaznawi et al. showed that younger individuals who are on immunosuppressive treatment and/or suffering from cancer or HIV infections are prone for HZO because of decreased cell-mediated immunity and present only in 11.1% of cases.[11],[12] Our study is also similar to that study in this respect.

The results of our study, consistent with data from a previous report, showed significant difference in HZO incidence between men and women and between specific age groups.[10],[11],[12]

Blepharitis was the most common ocular manifestation of HZO in our series, occurring in 80% of eyes, followed by punctate keratitis (71.4%) of eyes. However, in a study including 73 immunocompetent patients from the Netherlands during 6-month follow-up, AU was reported in 43.8% of eyes at initial examination, followed by stromal keratitis in 30.1% of eyes.[13] In a recent study from the Pacific Islanders, a lower rate of AU was recorded (6% of cases); however, keratitis was recorded in 28.3% of cases.[9],[10],[13] In the current study, isolated AU, isolated keratitis, and keratouveitis were more likely to be concomitant to HZO eruption. In addition, we found that all were more likely to occur in patients ≥50 years old. However, Ghaznawi et al.[2] found that neurotrophic keratopathy affected 19.6% of all patients and was more frequent in older patients. Similarly, Liesegang[8] reported a 25% prevalence of neurotrophic keratitis. In our study, neurotrophic keratopathy was found in 2.85% cases.

Optic neuritis is a very rare squeal of HZO[14] that may occur simultaneously to the acute vesicular rash or, more frequently, as a postherpetic complication, up to 10 weeks after disease onset.[15] In our study, optic neuritis was recorded only in one patient. Good recovery of HZO optic neuritis with systemic acyclovir and steroid has also been reported.[14]

The overall visual outcome was relatively good in our series, with 94.28% of eyes having a final BCVA 20/20. Causes of low vision are optic disc atrophy, neurotrophic keratopathy, and corneal opacity. Zaal et al.[11] reported a final VA >20/25 in 90.4% of cases at 6 months follow-up. As well, Gupta et al.[10] reported a final BCVA of 20/40 or better in 90% of immune competent subjects younger than 40 years old. In a prospective study, 56.3% of the patients had a VA of 6/6 or better.[13]

In this study, PHN was found in 22 cases (62.9%) higher than those of previous studies.[16] A higher incidence (17.8%) of PHN also was reported by Ghaznawi et al.[2] in an American series of 112 patients aged >60 years of age. As well as, in a Pacific region study, PHN was recorded in 20.9% of the patients[10] with 64.3% of patients was older than 65 years. The main risk factor for PHN is advancing age. Other risk factors are the severity of acute zoster pain and rash, ocular involvement, and late presentation.[15],[16]


  Conclusion Top


Rapid diagnosis and early institution of antiviral therapy are necessary to prevent ocular morbidity and blindness. The sensitivity of acyclovir was found 100%. The key predisposing factors are males, especially above 50 years of age. History of chickenpox, low immunity, and environmental factors such as hot climate, humidity, and rainfall greatly influence the occurrence of HZO. The overall visual outcome is good, maintaining VA of 20/20 in 33 cases (94.28%) in our study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Liesegang TJ. Herpes zoster ophthalmicus natural history, risk factors, clinical presentation, and morbidity. Ophthalmology 2008;115:S3-12.  Back to cited text no. 1
    
2.
Ghaznawi N, Virdi A, Dayan A, Hammersmith KM, Rapuano CJ, Laibson PR, et al. Herpes zoster ophthalmicus: Comparison of disease in patients 60 years and older versus younger than 60 years. Ophthalmology 2011;118:2242-50.  Back to cited text no. 2
    
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Mullooly JP, Riedlinger K, Chun C, Weinmann S, Houston H. Incidence of herpes zoster, 1997-2002. Epidemiol Infect 2005;133:245-53.  Back to cited text no. 3
    
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Rostad SW, Olson K, McDougall J, Shaw CM, Alvord EC Jr. Transsynaptic spread of varicella zoster virus through the visual system: A mechanism of viral dissemination in the central nervous system. Hum Pathol 1989;20:174-9.  Back to cited text no. 4
    
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Dworkin RH, Schmader KE. Treatment and prevention of postherpetic neuralgia. Clin Infect Dis 2003;36:877-82.  Back to cited text no. 5
    
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Yawn BP, Wollan PC, St Sauver JL, Butterfield LC. Herpes zoster eye complications: Rates and trends. Mayo Clin Proc 2013;88:562-70.  Back to cited text no. 6
    
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Aithal S, Kuruvila S, Ganguly S. Zosteriform herpes simplex and herpes zoster: A clinical clue. Indian Dermatol Online J 2013;4:369.  Back to cited text no. 7
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8.
Liesegang TJ. Corneal complications from herpes zoster ophthalmicus. Ophthalmology 1985;92:316-24.  Back to cited text no. 8
    
9.
Wang TJ, Hu CC, Lin HC. Increased risk of anterior uveitis following herpes zoster: A nationwide population-based study. Arch Ophthalmol 2012;130:451-5.  Back to cited text no. 9
    
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Borkar DS, Tham VM, Esterberg E, Ray KJ, Vinoya AC, Parker JV, et al. Incidence of herpes zoster ophthalmicus: Results from the Pacific ocular inflammation study. Ophthalmology 2013;120:451-6.  Back to cited text no. 10
    
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Gupta N, Sachdev R, Sinha R, Titiyal JS, Tandon R. Herpes zoster ophthalmicus: Disease spectrum in young adults. Middle East Afr J Ophthalmol 2011;18:178-82.  Back to cited text no. 11
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12.
Zaal MJ, Völker-Dieben HJ, D'Amaro J. Visual prognosis in immunocompetent patients with herpes zoster ophthalmicus. Acta Ophthalmol Scand 2003;81:216-20.  Back to cited text no. 12
    
13.
Nithyanandam S, Stephen J, Joseph M, Dabir S. Factors affecting visual outcome in herpes zoster ophthalmicus: A prospective study. Clin Exp Ophthalmol 2010;38:845-50.  Back to cited text no. 13
    
14.
de Mello Vitor B, Foureaux EC, Porto FB. Herpes zoster optic neuritis. Int Ophthalmol 2011;31:233-6.  Back to cited text no. 14
    
15.
Cebrián-Cuenca AM, Díez-Domingo J, San-Martín-Rodríguez M, Puig-Barberá J, Navarro-Pérez J, Herpes Zoster Research Group of the Valencian Community. et al. Epidemiology and cost of herpes zoster and postherpetic neuralgia among patients treated in primary care centres in the Valencian community of Spain. BMC Infect Dis 2011;11:302.  Back to cited text no. 15
    
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Opstelten W, Mauritz JW, de Wit NJ, van Wijck AJ, Stalman WA, van Essen GA, et al. Herpes zoster and postherpetic neuralgia: Incidence and risk indicators using a general practice research database. Fam Pract 2002;19:471-5.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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