Anti-glaucoma agents-induced pseudodendritic keratitis presumed to be herpetic simplex keratitis: a clinical case series.

Anti-glaucoma agents-induced corneal toxicity may be misdiagnosed as herpetic simplex keratitis (HSK). In our study, nineteen glaucoma patients were presumed to have HSK before referral. Corneal lesions were classified into (I) linear pseudodendritic lesions formed by elevated opacified cells, (II) linear pseudodendritic lesions formed by grouped superficial punctate keratitis (SPK), (III) satellite full-thickness epithelial defects, (IV) satellite lesions formed by elevated opacified cells, and (V) geographic lesions formed by grouped SPK. We observed thirty-one events, with 15 in the lower and 16 in the central corneas. There were 21 (67.7%) type II, five (16.1%) type V, two (6.5%) of each for types III and IV, and one (3.2%) type I events. Among linear lesions (types I and II), 17 (77.3%) had horizontal and 5 (22.7%) had curvilinear orientations. Exposure duration to the last-added anti-glaucoma agent was three days to 14.5 years. About half of the events (16/31, 51.6%) used prostaglandin analogues, and 30/31 (96.8%) applied benzalkonium chloride (BAK)-containing agents. All lesions resolved within two months after decreasing offending medications or enhancing protection of ocular surface. In conclusion, anti-glaucoma agents-induced pseudodendritic keratitis presents majorly in central-lower cornea as horizontally linear lesions, and BAK-containing agents are observed in the most events.

[Diagnostics and management of herpes zoster ophthalmicus]. / Diagnostik und Management des Herpes zoster ophthalmicus.

Herpes zoster (HZ, shingles) represents the secondary manifestation of an infection with varicellazoster virus (VZV). A reactivation of dormant VZV in the ophthalmic branch of the fifth cranial nerve leads to ophthalmic HZ (HZO). The predominantly older and immune compromised patients often present with eye involvement (approximately 50%) as well as characteristic skin changes. Clinical manifestations include the cornea and conjunctiva but anterior uveitis and (rarely) acute retinal necrosis may also occur. Associated sensory symptoms that range from paresthesia to severe pain may severely affect the quality of life. Particularly in immunocompromised and/or elderly patients, HZO is associated with complicated courses. Systemic antiviral treatment and an adequate pain medication are the mainstay of the recommended management. The present article provides an overview of the contents of the current consensus-based European guidelines on the management of HZ with a specific focus on HZO.

Detection of herpes simplex-1 and -2 and varicella zoster virus by quantitative real-time polymerase chain reaction in corneas from patients with bacterial keratitis.

OBJECTIVE:: Bacterial keratitis occurs worldwide, and despite recent developments, it remains a potentially blinding condition. This study assesses the presence of herpes simplex virus (HSV-1 and -2) and varicella zoster virus (VZV) by quantitative real-time polymerase chain reaction (qPCR) in corneal scrapings from patients with bacterial keratitis. METHODS:: A total of 65 patients with clinical diagnoses of infectious corneal ulcers prospectively underwent clinical eye examinations. Corneal scrapings were investigated by Gram staining, Giemsa staining, culture, and qPCR (the study group). Risk factors and epidemiological data were recorded. The control group comprising 25 eyes with typical herpes dendritic keratitis was also analyzed by qPCR. RESULTS:: From the study group (n=65), nine patients (13.8%) had negative smears, cultures, and qPCR findings. Fifty-six (86.2%) patients had positive cultures: 51 for bacteria, 4 for fungi, and 1 for amoebae. Of the patients who had positive bacterial cultures, qPCR identified 10 patients who were also positive for virus: one for VZV and nine for HSV-1. Of the 25 patients in the control group, 21 tested positive for HSV-1 by qPCR analysis. CONCLUSIONS:: Herpes may be present in patients with bacterial corneal ulcers, and qPCR may be useful in its detection.

Detection of herpes simplex-1 and -2 and varicella zoster virus by quantitative real-time polymerase chain reaction in corneas from patients with bacterial keratitis / Detecção de vírus herpes simplex tipo 1 e 2 e varicella zoster por reação em cadeia de polimerase em tempo real em córneas de pacientes com ceratites bacterianas

ABSTRACT Objective: Bacterial keratitis occurs worldwide, and despite recent developments, it remains a potentially blinding condition. This study assesses the presence of herpes simplex virus (HSV-1 and -2) and varicella zoster virus (VZV) by quantitative real-time polymerase chain reaction (qPCR) in corneal scrapings from patients with bacterial keratitis. Methods: A total of 65 patients with clinical diagnoses of infectious corneal ulcers prospectively underwent clinical eye examinations. Corneal scrapings were investigated by Gram staining, Giemsa staining, culture, and qPCR (the study group). Risk factors and epidemiological data were recorded. The control group comprising 25 eyes with typical herpes dendritic keratitis was also analyzed by qPCR. Results: From the study group (n=65), nine patients (13.8%) had negative smears, cultures, and qPCR findings. Fifty-six (86.2%) patients had positive cultures: 51 for bacteria, 4 for fungi, and 1 for amoebae. Of the patients who had positive bacterial cultures, qPCR identified 10 patients who were also positive for virus: one for VZV and nine for HSV-1. Of the 25 patients in the control group, 21 tested positive for HSV-1 by qPCR analysis. Conclusions: Herpes may be present in patients with bacterial corneal ulcers, and qPCR may be useful in its detection.

RESUMO Objetivo: Ceratites bacterianas ocorrem mundialmente e apesar dos novos desenvolvimentos permanece como uma condição que pode levar à cegueira. Avaliar a presença de herpes simples (-1 e -2) e vírus varicella zoster (VZV) por reação em cadeia quantitativa de polimerase em tempo real (qPCR) em raspados corneanos de pacientes com ceratite bacteriana. Métodos: Sessenta e cinco pacientes com ceratite infecciosa foram submetidos a raspados corneanos estudados para gram, Giemsa, cultura e qPCR (grupo de estudo). Foram avaliados fatores de risco e epidemiológicos. O grupo controle foi composto por 25 casos de úlcera dendrítica típica por herpes analisados por qPCR. Resultados: Do grupo de estudo (n=65), nove pacientes (13,8%) apresentaram cultura, qPCR e raspado negativos. Cinquenta e seis (86,2%) pacientes apresentaram cultura positiva, 51 para bacteria, 4 para fungo e 1 para ameba. A qPCR identificou 10 pacientes do grupo de cultura positiva para bactéria que também foram positivos para vírus, um VZV e 9 para HSV-1. Dos 25 pacientes que compunham o grupo controle, 21 apresentaram qPCR positivo para HSV-1. Conclusão: Herpes pode estar presente em pacientes com úlceras de córnea bacterianas e a qPCR pode ser útil na sua detecção.

Herpes Simplex Virus Disease of the Anterior Segment in Children.

PURPOSE: To analyze the clinical presentation, characteristics, treatment, recurrences, and final outcomes and complications of herpes simplex virus (HSV) disease of the anterior segment in patients aged 17 years or younger. METHODS: This is an observational and retrospective study with review of the medical records of all the children diagnosed with herpes simplex infection of the anterior segment at an ophthalmologic referral center, from 2002 to 2012. The diagnosis was made on the basis of the history and examination of patients and in specific cases by viral culture and the polymerase chain reaction. Main outcome measurements included final visual acuity, bilateral disease, and recurrence. Recurrent disease was analyzed with Kaplan-Meier curves. RESULTS: A total of 103 patients were included with a median age at presentation of 9 years. Of them, 6 had bilateral and simultaneous disease. The median follow-up time was 18 months (range, 18 days-12 years). The most common clinical manifestations were epithelial dendritic keratitis in 42 eyes (38.5%) and interstitial keratitis in 39 eyes (35.7%), with 15 patients presenting multiple forms of HSV disease. The median final visual acuity in the group of patients was 20/40. Recurrent disease was evident in 42 (38.5%) of the eyes, with a median recurrence time of 15 months (95% confidence interval, 8.1-26.2 months). CONCLUSIONS: In this study, epithelial dendritic and interstitial keratitis were the most frequent forms of disease in the pediatric population with HSV of the anterior segment. A high rate of recurrent disease was present.

In vivo confocal microscopic features of corneal pseudodendritic lesions in tyrosinemia type II.

PURPOSE: To report the clinical and in vivo confocal microscopic (IVCM) findings of corneal deposits in a patient with tyrosinemia type II. METHODS: The pretreatment and 1-month posttreatment slit-lamp examination and IVCM findings of a patient with tyrosinemia type II are described. RESULTS: A 12-year-old girl diagnosed with tyrosinemia type II was evaluated for photophobia and bilateral ocular discomfort of 1-year duration. The patient had been placed on topical acyclovir treatment with the diagnosis of recurrent bilateral herpetic keratitis during the previous 12 months. Slit-lamp examination revealed bilateral dendritiform epithelial lesions in the central cornea, which stained poorly with fluorescein. IVCM highlighted multiple hyperreflective linear crystalline deposits at the level of superficial epithelium. One month after discontinuation of acyclovir treatment and initiation of a protein-restricted diet therapy, improvement in the patient's symptoms and regression of corneal epithelial lesions was noted. Reduction in the extent of corneal deposits was also confirmed with IVCM. CONCLUSIONS: Corneal involvement, secondary to hereditary tyrosinemia type II, is characterized by pseudodendritic epithelial lesions on slit-lamp examination and hyperreflective linear deposits in the superficial epithelium using IVCM. These lesions may regress expeditiously with a low-protein diet. IVCM may be a useful tool in the differential diagnosis of this disorder by highlighting the crystalline structures in the superficial epithelial layers and also in evaluating the response to the treatment in patients with tyrosinemia type II.

["Herpetic keratitis". Various expressions require different therapeutic approaches]. / "Herpeskeratitis". Unterschiedliche Ausprägungsformen erfordern unterschiedliche Therapieansätze.

Herpes simplex virus (HSV) is a common cause of keratitis. "Herpetic keratitis" is a chameleon, which is well treatable today if the various types of clinical expression of this disease are known to the ophthalmologist and treatment is adjusted accordingly. Types of expression include 1. epithelial keratitis (dendritica/geographica), 2. stromal keratitis (necrotizing vs. non-necrotizing = "interstitial keratitis"), 3. endotheliitis (=disciform keratitis), 4. neurotrophic keratopathy (=so-called metaherpetic keratitis) and 5. (vascularized) corneal scars. A concomitant ocular hypertension should be treated predominantly non-surgically (no prostaglandin analogues). Topical artificial tears (if necessary with acyclovir ointment at night) in the quiet interval are recommended to limit the tendency towards recurrences. After keratoplasty and in cases of severe recurrences of herpetic keratitis, systemic acyclovir application (2×400 mg/day) for at least 1 year is indispensable! Overall, HSV has lost its "terror" today, even after keratoplasty, given adequate management.

Late varicella-zoster virus dendriform keratitis in patients with histories of herpes zoster ophthalmicus.

PURPOSE: To describe the characteristics and course of late varicella-zoster virus (VZV) dendriform keratitis in patients with histories of herpes zoster ophthalmicus (HZO); to describe responses of corneal lesions to antiviral treatment; and to investigate risk factors for recurrence. DESIGN: Retrospective case series. METHODS: Included were patients known to have 1 or more episodes of dendriform lesions beginning at least 2 weeks after HZO in 2 academic practices. Epithelial lesions were evaluated for the presence of VZV DNA by a polymerase chain reaction assay. Demographic, medical, and ophthalmic data were collected for each episode. Responses to treatment with antiviral medications were evaluated. Cumulative risk of recurrence was determined using Kaplan-Meier analysis; potential risk factors for recurrence (age, systemic disease, lesion characteristics, corticosteroids) were evaluated using univariate Cox proportional hazard models. RESULTS: We identified 20 patients (14 women; median age, 65 years) who met inclusion criteria. Dendriform lesions were pleomorphic with thickened, opaque epithelium. Seven patients had systemic diseases characterized by altered immune function. VZV DNA was identified in 15 of 16 cases tested, and all lesions responded to antiviral therapy. The 1-year incidence of first recurrence was 95.8 lesions per 100 person-years of follow-up. Patients had multiple recurrences, but risk of recurrence appeared to decrease over time. No statistically significant risk factors for recurrence were identified. CONCLUSIONS: Late dendriform lesions associated with HZO are foci of productive VZV infection. Lesions can be treated effectively with topical or systemic antiviral agents. Patients can have multiple recurrences of dendriform lesions despite treatment.

A painful red eye.

A man, 75 years of age, presents with a red, painful, watery right eye of 1 week duration. He describes photophobia but says his vision is not reduced or blurry. He was seen at another clinic after 2 days of symptoms and was prescribed topical chloramphenicol antibiotic eye drops. Despite using the eye drops for 5 days, there has been no improvement in his symptoms. The man has no significant ocular past history.