Long-term outcomes of penetrating keratoplasty for corneal complications of herpes zoster ophthalmicus.

BACKGROUND/AIM: To review the long-term outcomes of penetrating keratoplasty (PKP) for corneal complications of herpes zoster ophthalmicus (HZO). METHODS: We reviewed the medical records of 53 eyes of 53 patients who underwent PKP due to corneal complications of HZO at the Kellogg Eye Center. RESULTS: The mean age of patients at the time of PKP was 68.0±16.4 years, with a follow-up of 4.0±3.8 years and quiescent period of 6.5±5.3 years from active HZO to PKP. Preoperatively, 25 (47.2%) eyes were completely anaesthetic, while 16 (30.2%) had deep corneal neovascularisation in four quadrants. Comorbid ocular disease, including cataract, glaucoma and macular disease, was present in 25 (47.2%) eyes. Twenty patients (37.8%) received acyclovir for the entire postoperative period. There were no recurrences of zoster keratitis in any eye. The most common complications were difficulty healing the ocular surface (12/53, 22.6%) and glaucoma (14/53, 26.4%). Thirty per cent of the eyes required one or more additional postoperative procedures, most commonly tarsorrhaphy (10/53, 18.9%) and amniotic membrane graft (6/53, 11.3%). At 1, 2-4 and ≥5 years, 94%, 82% and 70% grafts remained clear, respectively. Visual acuity improved at 1 year postoperatively (p<0.0001), but this improvement was not sustained. There was no significant benefit of long-term acyclovir on visual acuity (p=0.2132) or graft survival (p=0.241). CONCLUSIONS: Even in eyes with significant preoperative risk factors, PKP for the corneal complications of HZO can achieve favourable tectonic and visual results. Although most grafts remained clear, long-term visual potential may be limited by comorbid ocular diseases. Prophylactic postoperative oral acyclovir did not improve outcomes.

Treatment of Progressive Herpes Zoster-Induced Vasculopathy with Surgical Revascularization: Effects on Cerebral Hemodynamics.

BACKGROUND: Herpes zoster ophthalmicus (HZO) is caused by reactivation of the herpes simplex virus in the trigeminal nerve. HZO-initiated cerebral vasculopathy is well characterized; however, there are no documented cases that report the efficacy of surgical revascularization for improving cerebral hemodynamics following progressive HZO-induced vasculopathy. We present a case in which quantitative anatomic and hemodynamic imaging were performed longitudinally before and after surgical revascularization in a patient with HZO and vasculopathic changes. CASE DESCRIPTION: A 57-year-old female with history of right-sided HZO presented with left-sided hemiparesis and dysarthria and multiple acute infarcts. Angiography performed serially over a 2-month duration revealed progressive middle cerebral artery stenosis, development of new moyamoya-like lenticulostriate collaterals, and evidence of fibromuscular dysplasia in cervical portions of the internal carotid artery. Hemodynamic imaging revealed right hemisphere decreased blood flow and cerebrovascular reserve capacity. In addition to medical therapy, right-sided surgical revascularization was performed with the intent to reestablish blood flow. Follow-up imaging 13 months post revascularization demonstrated improved blood flow and vascular reserve capacity in the operative hemisphere, which paralleled symptom resolution. CONCLUSIONS: HZO can lead to progressive, symptomatic intracranial stenoses. This report suggests that surgical revascularization techniques can improve cerebral hemodynamics and symptomatology in patients with aggressive disease when medical management is unsuccessful; similar procedures could be considered in managing HZO patients with advanced or progressive vasculopathy.

Rate of Retinal Detachment after Early Prophylactic Vitrectomy for Acute Retinal Necrosis.

PURPOSE: To compare the rate of retinal detachment after acute retinal necrosis in eyes that underwent early vitrectomy versus no early vitrectomy. METHODS: Charts of patients (61 eyes) who presented to Texas Retina Associates between January 1, 2006 and December 30, 2014 for acute retinal necrosis were reviewed. Charts with incomplete documentation or follow-up less than 6 months were excluded. Twenty-nine remaining eyes were divided into two groups: early vitrectomy and no early vitrectomy. Primary outcome measure was rate of retinal detachment. RESULTS: Out of 29 eyes, 12 underwent early vitrectomy within 30 days of diagnosis and 17 either underwent vitrectomy after 30 days or did not undergo prophylactic vitrectomy at all. Three out of 12 eyes (25%) developed retinal detachment in the early vitrectomy group versus 10 out of 17 eyes (59%) in the no early vitrectomy group (p = 0.076). CONCLUSIONS: Early vitrectomy within 30 days may prevent retinal detachment after acute retinal necrosis.

Reactivation of Herpes Zoster Keratitis With Corneal Perforation After Zoster Vaccination.

PURPOSE: We present a case of reactivated herpes zoster keratouveitis of 6 years duration with corneal perforation requiring penetrating keratoplasty shortly after inoculation with herpes zoster vaccine (Zostavax, Merck, Quebec, Canada). METHODS: Retrospective case report. RESULTS: A 67-year-old woman with a 5-year history of recurrent unilateral herpes zoster keratouveitis in her right eye presented with another recurrence 2 weeks after Zostavax vaccination. Three months later, she developed descemetocele and 2 months afterward, corneal perforation, which was managed by penetrating keratoplasty. Immunohistopathological examination disclosed positive staining for varicella zoster virus in most of the keratocytes adjacent to the descemetocele and perforation, most vividly in the deeper two-thirds of the stroma where the keratocytes were most dense, but not in corneal epithelium or endothelium. Electron microscopic examination showed universally severely degenerated corneal keratocytes in the corneal stroma adjacent to the perforation with variable numbers of herpes virus capsids present in half of these cells. Only a rare normal-appearing keratocyte was identified in the more peripheral corneal stroma. CONCLUSIONS: We present a case of reactivation of herpes keratouveitis shortly after vaccination with Zostavax in a patient with previous herpes zoster ophthalmicus. We demonstrate, for the first time, ultrastructural evidence consistent with inactive virus capsids in diffusely degenerated keratocytes in the extracted corneal tissue.

Outcomes of cataract surgery in eyes with previous herpes zoster ophthalmicus.

PURPOSE: To report the outcomes of cataract surgery in eyes with previous herpes zoster ophthalmicus (HZO). SETTING: Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA. DESIGN: Retrospective case series. METHODS: Eyes with a history of HZO that had phacoemulsification and intraocular lens implantation were reviewed. The information analyzed included the ophthalmologic history, visual acuity, preoperative and postoperative adjunct treatments, and complications. Analysis of the mean corrected distance visual acuity (CDVA) at 1 month, 1 year, and the last follow-up was performed. RESULTS: Twenty-four eyes were evaluated. The mean CDVA improved from 20/112 (0.75 logMAR ± 0.63 [SD]) preoperatively to 20/53 (0.42 ± 0.56 logMAR) 1 month postoperatively (P = .007) and 20/44 (0.34 ± 0.55 logMAR) at 1 year (P = .052) but decreased to 20/71 (0.55 ± 0.72 logMAR) by last follow-up (P = .605 versus preoperative CDVA). Eleven patients (45.8%) had recurrent keratouveitis after the first episode, 5 before cataract surgery and 6 after cataract surgery. Three had penetrating keratoplasty for worsening corneal opacification. Two patients had tractional retinal detachment from chronic uveitis and required vitrectomy and retinal repair. CONCLUSIONS: Visual recovery after cataract surgery in HZO might be compromised by chronic factors such as ocular surface disease and keratouveitis. Despite long quiescent waiting periods before surgery and aggressive preoperative and postoperative maintenance therapy, visual improvement might be hindered by the inherent pathology associated with HZO. Nevertheless, with careful patient selection, reasonable visual improvement can be achieved. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Boston keratoprosthesis type 1 for herpes simplex and herpes zoster keratopathy.

PURPOSE: The aim of this study was to evaluate and compare the outcomes of Boston keratoprosthesis type 1 (Kpro-1) in eyes with herpes simplex virus (HSV) and herpes zoster virus (HZV) keratopathy. METHODS: A retrospective review was performed of the medical records of every patient treated with a Boston Kpro-1 at the University of Iowa Hospitals and Clinics between January 1, 2008 and July 1, 2012. Eyes with visual loss due to HSV or HZV keratopathy were included in the statistical analysis. The main outcome measures were graft retention, postoperative complications, and visual outcome. RESULTS: Nine eyes met the inclusion criteria, including 5 eyes in the HSV group and 4 eyes in the HZV group. The graft retention rate was 100% in the HSV group after a mean follow-up of 48.4 months, compared with 25% in the HZV group after 50.5 months (P = 0.048). There were 3 cases of microbial keratitis, including 2 eyes that also developed endophthalmitis, in the HZV group, compared with no cases in the HSV group (P = 0.048). There was significantly better best-corrected visual acuity at the most recent examination in the HSV group than in the HZV group (P = 0.019). All 5 HSV eyes had improved best-corrected visual acuity compared with preoperative acuity, whereas only 1 HZV eye experienced a similar result (P = 0.048). CONCLUSIONS: Kpro-1 is associated with an excellent prognosis for graft retention, acceptably low prevalence of sight-threatening complications, and highly satisfactory visual improvement in eyes with HSV keratopathy, but not in eyes with HZV keratopathy.

Long-term results of keratoplasty in patients with herpes zoster ophthalmicus.

PURPOSE: To report the long-term results of keratoplasty in patients with herpes zoster ophthalmicus (HZO). METHODS: All 14 patients underwent keratoplasty for a corneal scar or a perforated corneal ulcer due to HZO at the Wills Eye Institute from January 1999 to August 2011. RESULTS: We performed 9 penetrating keratoplasties and 1 deep anterior lamellar keratoplasty for corneal scarring, and 4 tectonic penetrating keratoplasties for perforated corneal ulceration due to HZO. Eight of the 14 eyes had a temporary tarsorrhaphy concurrent with graft. Postoperative follow-up time ranged from 12 to 132 months (mean 64 ± 38). Postoperatively, the most common complications were dense superficial punctate keratopathy and severe dry eye because of neuropathic keratopathy in 8 eyes, graft rejection in 5 eyes, and secondary glaucoma in 4 eyes. All grafts were clear, and best spectacle-corrected visual acuity was 20/40 or better in 6 eyes (42.8%) and 20/100 or better in 9 eyes at their final evaluation (64.2%). CONCLUSIONS: Although the sample size is small, we demonstrate that very good visual results in long-term follow-up can be achieved when keratoplasty is performed in patients with herpes zoster virus keratopathy. We believe that longer quiescent waiting period between active herpes zoster ocular involvement and keratoplasty may promote better visual results.

The successful use of Boston ocular surface prosthesis in the treatment of persistent corneal epithelial defect after herpes zoster ophthalmicus.

PURPOSE: To describe the use of the Boston ocular surface prosthesis (BOSP) to successfully treat a persistent corneal epithelial defect (PCED) after herpes zoster ophthalmicus that was minimally responsive to conventional therapies. METHODS: A case report. RESULTS: A 44-year-old man who developed a PCED in the right eye after herpes zoster ophthalmicus was treated with conventional therapies, including topical difluprednate opthalmic emulsion, 0.05% cyclosporine ophthalmic emulsion, topical autologous plasma, and oral doxycycline. Silicone plugs were inserted in the right upper and lower puncta. An 18-mm therapeutic hydrogel contact lens was placed in the right eye. After 4 weeks of this treatment, double layer amniotic membrane transplantation and temporary lateral tarsoraphy were performed. Ten days after the procedure, the amniotic membrane had dissolved and the tarsorrhaphy was opened. Because only partial healing of the corneal epithelial defect was observed, the patient was fit with the BOSP that he wore all waking hours. A soft contact lens was worn overnight after the BOSP was removed. Rapid reepithelization was observed within the week after starting the BOSP. The epithelial defect completely healed after 3 weeks, and the uncorrected visual acuity in the right eye improved to 20/50. CONCLUSIONS: The BOSP should be considered as an important treatment option for management of PCEDs in eyes with altered corneal sensitivity.

[Penetrating keratoplasty in corneal infections with herpes simplex virus and varicella zoster virus]. / Perforierende Keratoplastik bei Hornhautinfektionen durch Herpes-simplex-Virus und Varizella-zoster-Virus.

Penetrating keratoplasties due to herpetic corneal scars are more often performed compared to persisting Varicella zoster virus infections, which are quite seldom. Penetrating keratoplasties in herpetic corneas are risk keratoplasties due to the vascularisation and the risk of recurrent virus replication. The prognosis in these corneal transplantations has been improved in recent years due to better postoperative medical treatment with virustatics and systemic immunosuppression. Indications for and treatment following penetrating keratoplasty in herpetic eyes are the topics of this review.

Type I Boston keratoprosthesis with cataract extraction and intraocular lens placement for visual rehabilitation of herpes zoster ophthalmicus: the "KPro Triple".

INTRODUCTION: Management of corneal scarring following herpes zoster ophthalmicus (HZO) is challenging due to the dense corneal anesthesia that results from viral damage to the subepithelial nerve plexus. These patients have significant risk of graft failure following traditional corneal transplantation. We present a case of a 74-year-old white woman with counting fingers vision from HZO-associated corneal scarring and mature cataract where visual rehabilitation was accomplished with a Type I Boston keratoprosthesis (KPro) and concurrent extracapsular cataract extraction and posterior chamber intraocular lens placement (the "KPro Triple"). One month following surgery, the patient's uncorrected visual acuity improved to 20/25; this level of vision has been maintained for 7 months at present. SURGICAL TECHNIQUE (SEE VIDEO): The keratoprosthesis is assembled by creating a sandwich composed of the KPro front plate, the donor cornea, and the KPro backplate that is secured with a locking ring. The host cornea is then trephined and posterior synechiae lysed to allow access to the mature cataract. The cataract is manually expressed and a posterior chamber intraocular lens implanted. The assembled keratoprosthesis is then sutured into position with 9.0 nylon. A bandage contact lens is placed. COMMENT: In patients with severe neurotrophic keratopathy, traditional penetrating keratoplasty is fraught with problems, including poor epithelial healing and corneal ulceration. The Boston KPro can provide rapid visual rehabilitation, despite corneal anaesthesia in these patients, and is currently our treatment of choice as a primary procedure for HZO patients who need corneal transplantation.

Boston keratoprosthesis treatment of herpes zoster neurotrophic keratopathy.

TOPIC: The successful use of the Boston keratoprosthesis in a severely inflamed ulcer in herpes zoster neurotrophic keratopathy. CLINICAL RELEVANCE: Approximately 10% to 20% of patients with herpes zoster will develop herpes zoster ophthalmicus (HZO). Antiviral medication forms the foundation of pharmacologic treatment for acute herpes zoster, but management of HZO is supplemented with topical and systemic antimicrobials and corticosteroid agents as well as surgical interventions. However, HZO is associated with poor healing, as evidenced by a high occurrence of ulceration, superinfection, and surgical failure. METHODS: A 95-year-old man was referred for corneal edema in the right eye. There was a history of acute herpes zoster in the right eye 10 months previously. Slit-lamp examination revealed lagophthalmos, ectropion, total corneal anesthesia, and marked inferior corneal edema. Despite surgical repair of all lid abnormalities and aggressive lubrication and management of rosacea blepharitis, the corneal surface remained unhealthy. Four months later, the patient presented with an inflamed hypopyon ulcer, culture positive for abundant Pseudomonas and Candida albicans. The ulcer progressed to descemetocele in the face of aggressive antimicrobial therapy, vision was light perception (LP), and perforation became imminent. A Boston keratoprosthesis was used to replace the severely damaged cornea, and extracapsular cataract extraction of a mature cataract was also performed. RESULTS: One week after surgery, the inflammation was almost entirely resolved, and cultures of the host button were negative for any organisms. Vision gradually increased from LP to 20/60 over the ensuing 4 months. CONCLUSION: The Boston keratoprosthesis procedure successfully salvaged and restored vision in this high-risk herpes zoster eye in which standard keratoplasty would almost certainly have failed.

Multifocal posterior necrotizing retinitis.

PURPOSE: To describe the clinical features of an acute, inflammatory, and progressive retinal necrosis that affects primarily the posterior pole. DESIGN: Retrospective, interventional case series. METHODS: Twenty-seven eyes of 24 patients diagnosed with and treated for acute retinal necrosis (ARN) were categorized into two groups according to the predominant location of retinitis at presentation: either in the peripheral retina or in the posterior pole. Clinical features, disease progression, visual outcomes, and complications of these two groups were compared. RESULTS: Fifteen eyes demonstrated the known peripheral retinitis pattern, and 12 eyes exhibited a pattern of retinitis that affected mainly the posterior pole. Eyes with peripheral retinitis showed focal, well-demarcated areas of retinal necrosis in the periphery with rapid circumferential progression and rare involvement of the posterior pole. All eyes with posterior pole retinitis had multifocal deep lesions posterior to the vortex veins at presentation, and half of these eyes had lesions in the macula. These lesions progressed to patches of confluent retinitis in both the periphery and the posterior pole. There was no significant difference between the two groups in the incidence of anterior chamber and vitreous cells, vascular sheathing, retinal hemorrhages, or optic disk edema. Patients with posterior retinitis involvement seemed to have a worse visual outcome during the first two years after diagnosis. The Cox proportional hazards model suggested a higher incidence of retinal detachment in patients with posterior retinitis (P = .07). CONCLUSIONS: The authors report a pattern of herpetic retinitis that affects predominantly the posterior pole and may have a worse visual prognosis and a higher rate of retinal detachment.

Herpes simplex virus type 2 as a cause of acute retinal necrosis syndrome in young patients.

PURPOSE: To determine the causative virus in acute retinal necrosis (ARN) syndrome in a series of patients by calculation of modified Witmer coefficients. DESIGN: Noncomparative case series. PARTICIPANTS: Ten patients with ARN syndrome from four medical centers. METHODS: Aqueous samples, vitreous samples, or both were collected prospectively during surgery from patients with a clinical diagnosis of ARN syndrome. Serologic measures of intraocular and serum antibodies to potentially causative viruses were measured by enzyme-linked immunosorbent assay. MAIN OUTCOME MEASURES: Modified Witmer coefficients (immunoglobulin G and immunoglobulin A) for herpes simplex virus types 1 (HSV-1) and 2 (HSV-2), varicella zoster virus (VZV), and cytomegalovirus (CMV), as well as adenovirus type 2, were calculated from aqueous or vitreous samples, or both. RESULTS: Intraocular antibody measurements were strongly suggestive of a single diagnosis in 9 of 10 patients tested. Modified Witmer coefficients demonstrated intraocular antibody production to HSV in five patients and antibodies to VZV in four patients, and the measurement was inconclusive in one patient. No patients were positive for adenovirus or CMV. Strain-specific antibody titers demonstrated that all HSV-positive patients were reactive only to HSV-2. Herpes simplex virus type 2 was found predominantly in younger patients with ARN syndrome (mean age, 21.2 +/- 10 years; range, 17-39 years), whereas VZV was more commonly seen in older patients (mean age, 40.8 +/- 12.2 years; range, 29-58 years; P = 0.033). Immunoglobulin A testing confirmed immunoglobulin G testing in all patients examined. CONCLUSIONS: Although VZV is thought to be the most common cause of ARN syndrome, HSV-2 is an important cause of ARN syndrome, particularly in younger patients. Because infection with HSV-2 has important medical ramifications, these results suggest that determination of a causal agent should be considered in some cases of ARN syndrome.

Penetrating keratoplasty for varicella-zoster virus keratopathy.

PURPOSE: To examine and report the results of penetrating keratoplasty performed in patients with varicella-zoster virus keratopathy. METHODS: The authors retrospectively reviewed the records of 15 patients who had penetrating keratoplasty for varicella-zoster virus keratopathy from January 1989 through December 1998 on the Cornea Service at Wills Eye Hospital. RESULTS: Twelve patients had a preoperative diagnosis of herpes zoster ophthalmicus, and three, of varicella. Four eyes had lateral tarsorrhaphies performed in conjunction with penetrating keratoplasty. Three eyes had endothelial rejection episodes that responded well to treatment with topical steroids. One eye had a regraft 1 month after primary failure, and this second graft also failed because of recurrent neurotrophic keratopathy. Three eyes that had repeated penetrating keratoplasty for graft failure had clear grafts at the last examination. At an average follow-up time of 50 months, 13 (86.7%) grafts remained clear, and the best corrected visual acuity was 20/100 or better in eight (53.3%) eyes. Five patients had decreased visual acuity because of retinal diseases. CONCLUSION: Although varicella-zoster virus keratopathy is an uncommon indication for penetrating keratoplasty, effective visual rehabilitation can be achieved in these patients. Careful postoperative management, frequent lubrication, and lateral tarsorrhaphies to protect the corneal surface are major factors in the successful outcome of these cases.

Detection of varicella-zoster virus genome in the vitreous humor from two patients with acute retinal necrosis; lacking or having a PstI cleavage site.

Using polymerase chain reaction, we detected the varicella-zoster virus genome in the vitreous humor of two patients with clinically diagnosed acute retinal necrosis. One of the two cases was thought to be caused by infection with a varicella-zoster virus lacking a PstI cleavage site. We could not find any clinical differences between the two substrains. The presence of a PstI cleavage site on the varicella-zoster virus genome might not be associated with the occurrence of acute retinal necrosis.

Detection of varicella zoster virus DNA and viral antigen in human eyes after herpes zoster ophthalmicus.

OBJECTIVE: The purpose of the study was to identify varicella zoster virus (VZV) DNA and viral antigen in human eyes at various intervals after clinical onset of herpes zoster ophthalmicus (HZO). DESIGN: A retrospective case series. PARTICIPANTS: There were 9 eyes and 4 corneal buttons surgically obtained from 13 patients with HZO at the University Eye Hospital of Erlangen-Nürnberg between 1984 and 1994. Specimens were examined at different timepoints after clinical onset of HZO (range, 1 day-19 years; median, 36 months). METHODS: Histopathologic evaluation was performed on formalin-fixed and paraffin-embedded tissue by routine histology, immunohistochemistry (5-B-7 murine monoclonal antibody to VZV; peroxidase-antiperoxidase method), and DNA-in situ hybridization (35S deoxyadenosine triphosphate-labeled HindIII fragments [A and C] of VZV). RESULTS: Typical histopathologic changes associated with HZO were identified: vascularization of the corneal stroma (11 of 13), granulomatous reaction to Descemet's membrane (8 of 13), fusiform-shaped ciliary scarring (5 of 9), optic neuritis (4 of 9), and perineuritis (8 of 9) and perivasculitis (8 of 9) of the long posterior ciliary nerves and arteries. VZV antigen was detected in two patients with acute infection 1 and 7 days after onset of HZO, respectively. VZV-DNA was identified in seven patients up to 10 years after onset of HZO in corneal epithelial cells (2 of 13), corneal stroma (5 of 13), inflammatory infiltrate of the anterior chamber (1 of 9), episclera (2 of 9), posterior ciliary nerves (1 of 9) and arteries (5 of 9), optic nerve (5 of 9), and adjacent leptomeninges (2 of 9). CONCLUSION: Persistence of viral genomes, most likely accompanied by gene expression or slow viral replication, appears to be responsible for the often smoldering panophthalmitis and the chronic recurrent keratouveitis in patients with HZO. Localization of viral DNA in vascular structures suggests a role for vasculitis in the pathogenesis of some ocular findings associated with HZO.

Detection of varicella-zoster virus DNA in keratectomy specimens by use of the polymerase chain reaction.

OBJECTIVE: To study the correlation of clinical findings, histopathologic features, and detection of varicella-zoster virus (VZV) DNA in keratectomy specimens. MATERIALS AND METHODS: Fourteen corneal buttons from patients with a confirmed history of herpes zoster ophthalmicus were examined by use of light microscopy and the polymerase chain reaction. The polymerase chain reaction techniques included gel electrophoresis and hybridization for the detection of VZV DNA. RESULTS: Seven (50%) of the 14 specimens were positive for VZV DNA. The positive findings in the specimens correlated with the clinical findings of uveitis (3/3) and the histopathologic features of chronic stromal keratitis (4/4). Patients with stromal scarring, granulomatous keratitis, and neurotrophic ulcers had negative findings. The largest interval between the initial appearance and detection of viral DNA was 51 years. CONCLUSIONS: The results suggest that VZV DNA is not detectable in the cornea in every patient and at every stage of zoster keratitis. This may be due to the low number of VZV particles present in the cornea or the lack of viral DNA in the keratocytes. It remains unclear whether the VZV-related keratopathy is caused by an immunologic response to a viral antigen, the viable virus itself, or both.

[Varicella zoster virus infections of the retina in patients with and without immune suppression]. / Varicella-zoster-Virus-Infektionen der Netzhaut bei Patienten mit und ohne Immunsuppression.

BACKGROUND: Infections of the retina with the varicella-zoster virus can lead to severe visual impairment. Patients with immunodeficiency are particularly predisposed to viral infections, and the alterations of the immune system may lead to a modified clinical picture. PATIENTS: Two cases of infections of the retina with the varicella-zoster virus in an immunocompromised and an immunocompetent patient are presented. The first otherwise healthy patient showed the typical clinical picture of the "acute retinal necrosis syndrome" with orbital pain and decrease of vision. He had inflammatory infiltration of the vitreous and the anterior chamber, retinal vasculitis, optic disc edema and whitening of the peripheral retina with full thickness retinal necrosis. The second patient with AIDS presented with a history of sudden painless loss of vision in one eye. He had a swollen optic disc, inflammatory infiltrates in the choroid and virtually no cellular infiltration of the vitreous or the anterior chamber. The diagnosis of varicella-zoster virus infection of the retina was confirmed in both patients by polymerase chain-reaction of aqueous and vitreous humor, by determination of intraocular antibody titers and immunohistochemistry on retinal biopsy material, respectively. In both patients no inflammation in the fellow eye developed under therapy with aciclovir. The first patient regained full vision after vitrectomy with membrane dissection. CONCLUSIONS: Varicella-zoster virus infections of the retina can present with different clinical pictures in immunocompromised and immunocompetent patients. Early diagnosis and adequate medical and surgical therapy can significantly improve visual prognosis.

[Tarsoconjunctival advancement--a surgical procedure in cicatricial entropion with marginal tarsus deformation]. / Verschiebung der Lidblätter--ein operatives Verfahren bei Narbenentropium mit lidkantennaher Tarsusdeformation.

BACKGROUND: After severe chemical and thermal burns, and in chronic inflammatory conditions of the conjunctiva frequently scarring of the tarsal plate with distortion of the eyelid margin and keratinization of the tarsal conjunctiva could be found. This condition is accompanied with chronic inflammation and malposition of the eyelids resulting in entropion and trichiasis. PATIENTS AND METHODS: A surgical procedure is introduced separating the scarred and shortened tarsal plate from the cutis-muscle sheet. After excision of tarsal scar tissue and of the marginal metaplastic tarsus a new eyelid margin is formed by tarso-conjunctival advancement, correcting trichiasis and cicatricial entropion. During the time from August 1984 to December 1991 this surgical procedure was conducted on 16 patients, correcting 18 upper and 4 lower eyelids. 11 patients suffered from severe chemical and thermal burns, 2 patients from Stevens-Johnson-syndrome, 2 patients from ocular pemphigoid and 1 patient from herpes zoster infection. RESULTS: All patients were examined at least once in the first 6 postoperative months, 11 patients are still under continuing outpatient review. The mean follow-up time is 27 months, the minimum follow-up period is 7 months. In 7 patients the surgical procedure prepared conditions for a successful keratoplasty and in 5 other cases the keratopathy healed. In 4 cases a recurrence of the entropion occurred (18% recurrence rate). CONCLUSIONS: The presented surgical procedure is a promising alternative to more complicated procedures for correcting cicatricial entropion with keratinization of the marginal tarsus.