Morning Report: 7/12/2012

Thanks to Dr. Meister for today’s Morning Report!

Morning Report: Zoster Ophthalmicus

Epidemiology:1-3 /1000 cases per year, 10-25% of shingles infections, lifetime risk of shingles is 10-20%, usually starts in 5^th decade of life, immune compromised are more at risk

Presentation:

Usually flu like illness, fatigue. Fever, malaise, can last up to one week prior to development of rash

Erythemetous macules- 3-5 days to vesicles, crust over in 5-7 days

Eye pain, conjunctivitis, tearing, decreased vision, skin/eyelid rash

Hutchinson’s sign- may be harbinger of worsening ocular involvement as nasociliary branch also innervates cornea

Anatomy:

The Ophthalmic Nerve, or first division of the trigeminal, is a sensory nerve. It supplies branches to the cornea, ciliary body, and iris; to the lacrimal gland and conjunctiva; to the part of the mucous membrane of the nasal cavity; and to the skin of the eyelids, eyebrow, forehead, and nose. It passes forward along the lateral wall of the cavernous sinus, below the oculomotor and trochlear nerves; just before entering the orbit, through the superior orbital fissure, it divides into three branches: lacrimal, frontal, and nasociliary

Physical exam:

Visual acuity

PHOTOPHOBIA?
Eyelid, conjunctival, scleral swelling
Check for extra-ocular motor integrity, visual field defects

Cotton swab for corneal sensitivity: test for decreased sensitivity- numbness

Fluorescin stain

Fundoscopic exam: looking for anterior uveitis
Intra-ocular pressure

Complications:

Secondary staph infection

Focal scleral atrophy

Punctate epithelial keratitis

Dendritic keratitits- 4-6 days

Stromal keratititis- fine infiltrates beneath surface of corneal epithelium

Deep stromal keratitis- lipid infiltrates and corneal neovasculariztion- 1 month to years

Uveitis- can lead to scaring/cataracts/gluacoma

Neurotrophic keratopathy: erosions, persistent defects, corneal ulcers months to years

Treatment:

Acyclovir/famicyclovir/valycyclovir (TID) 7-10 days, best if given within 72 hours of symptom onset, no clear benefit after, but still gonna give it – reduces complications and duration of pain ACUTELY, but not post herpetic neuralgia

Steroids: reduce duration of pain and increase healing rate, but does not reduce post herpetic neuralgia

What are you gonna treat their eyes with? Depends on the presentation- DON’T GIVE TOPICAL STEROID WITHOUT OPHTHO CONSULTATION- to be avoided if epithelial involvement- a/w spontaneous recurrence of keratitis and exacerbation of symptoms

Blepharitis/conjunctivitis – Palliative, with cool compresses and topical lubrication; topical antibiotics for secondary infections
Stromal keratitis – Topical steroids
Neurotrophic keratitis – Neurotrophic keratopathy is a degenerative corneal disease induced by an impairment of trigeminal nerve. Impairment of loss of corneal sensory innervation is responsible for corneal epithelial defects, ulcer, and perforation. Topical lubrication; topical antibiotics for secondary infections; tissue adhesives and protective contact lenses to prevent corneal perforation
Uveitis – Topical steroids; oral steroids; oral acyclovir; cycloplegics
Scleritis/episcleritis – Topical nonsteroidal anti-inflammatory agents and/or steroids- scleritis usually more painful and may lead to vision loss

Acute retinal necrosis/progressive outer retinal necrosis – Intravenous acyclovir (1500 mg per m² per day divided into 3 doses) for 7-10 days, followed by oral acyclovir (800 mg orally 5 times daily) for 14 weeks; laser/surgical intervention

Consider calamine for rash

Hospital admission should be considered for patients with any of the following: