Download rajiv gandhi university of health sciences, karnataka

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA
BANGALORE
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECT
FOR DISSERTATION
1.NAME OF THE CANDIDATE
AND ADDRESS
(IN BLOCK LETTERS)
Dr. ABHIJITH KUMAR
ROOM NO. 207,
POST GRADUATE AND INTERNS
HOSTEL FOR MEN,
OLD EXHIBITION BUILDING,
MMC & RI
MYSORE.
APARTMENTS
2.NAME OF THE INSTITUTION
MYSORE MEDICAL COLLEGE AND
RESEARCH INSTITUTE.
3.COURSE OF THE STUDY
AND SUBJECT
M.S OPHTHALMOLOGY
AND SUBJ
4.DATE OF COMMENCEMENT
OF THE COURSE
03-05-2010
5.TITLE OF THE TOPIC
CLINICAL STUDY OF OCULAR
MANIFESTATIONS IN ZOSTER
OPHTHALMICUS
6. BRIEF RESUME OF THE INTENDED WORK
6.1 NEED FOR THE STUDY
Herpes Zoster Ophthalmicus is the clinical entity caused by reactivation of the latent
Varicella Zoster virus from trigeminal ganglia and involving ophthalmic division of the
trigeminal nerve. Herpes Zoster accounts for 10-25% of all Herpes Zoster cases.
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While Herpes Zoster Ophthalmicus does not necessarily affect the structures of the
eye, many of the acute and long term complications associated with the disease are the result
of direct viral toxicity to the eye or the ensuing inflammatory response within the eye. It is
thought that approximately 50% of those diagnosed with Herpes Zoster Ophthalmicus will
develop complications. Herpes Zoster Ophthalmicus can affect any of the ocular and adnexal
tissues. Most of the patients with Herpes Zoster Ophthalmicus present with a periorbital
vesicular rash distributed according to the affected dermatome. A minority of the patients
may also develop conjunctivitis, keratitis, uveitis, and ocular cranial nerve palsies. Permanent
sequale of ophthalmic zoster infection may include chronic ocular inflammation, loss of
vision, and debilitating pain. The study is intended to know the extent of ocular involvement
in herpes zoster ophthalmicus.
6.2 REVIEW OF LITERATURE
In Harding SP, Lipton JR, Wells JC study Seventy-one patients presenting with acute
herpes zoster ophthalmicus were followed up for six months for a prospective analysis of the
natural history of the disease. Acute and chronic ocular complications, nasociliary nerve
involvement, age, sex, rash, and pain were assessed, and the results are presented. Acute pain
was measured by a visual analogue scale. Postherpetic neuralgia (PHN) was more likely in
patients over 80 and in those who scored their pain highly at presentation. Duration of rash
was longer in patients who developed PHN. No other associations between the parameters
studied were found. Nasociliary nerve involvement was associated with subsequent ocular
disease. Ophthalmic involvement has been considered the most important and potentially
serious of all sites for herpes zoster. It is reported as occurring in 33 to 50% of cases and has
the highest incidence of postherpetic neuralgia (PHN). As a result it is the site that most often
requires treatment, and this is usually prolonged. A number of retrospective studies have
looked at the natural history of herpes zoster. Demoragas and Kierland reviewed 916 cases,
of which 149 (16-3%) were trigeminal. Burgoon et al. reviewed 206 cases, of which 36
(17.5%) were ophthalmic. Both reported a higher incidence of complications in trigeminal
involvement than elsewhere1.
Thomas Catron, H. Gene Hern showed that Herpes zoster is a common diagnosis in
the emergency department (ED). Caused by the reactivation of the varicella zoster virus
(VZV), zoster usually presents as a painful dermatomal rash. In addition to skin or mucosal
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involvement, VZV reactivation commonly affects the ophthalmic division of the trigeminal
nerve and subsequently the eye. This manifestation is termed herpes zoster ophthalmicus
(HZO). Occasionally HZO presents as an isolated ophthalmologic process that is difficult to
distinguish from other more benign causes of a red eye2.
Min-Kyung Shin, Chun-Pill Choi, Mu-Hyoung Lee showed that Herpes Zoster
usually affects sensory neurons. It may also affect motor neurons in rare cases. Herpes zoster
ophthalmicus has caused extraocular muscle palsies of the third, fourth, and sixth cranial
nerves in 7 to 31% of patients. The third nerve appears to be the most commonly affected,
and the fourth nerve, the least. In herpes zoster ophthalmicus, extraocular muscle palsies
usually appear 2 to 4 weeks after a rash, but sometimes occurs simultaneously with a rash or
more than 4 weeks later. The extraocular muscle palsies associated with herpes zoster
ophthalmicus is a transient, self-limited condition, usually seen in the elderly. Such cases
have not often been reported, although extraocular muscle palsies caused by herpes zoster
ophthalmicus appears frequently3.
Wim Opstelten, Michel J W Zaal observed that Herpes zoster (shingles) is a
commonly encountered disorder in general practice. Ophthalmic herpes zoster represents 1020% of all zoster cases. In other words, one out of every 100 individuals will develop
ophthalmic zoster during his or her lifetime. The disease is potentially serious and may result
in severe and lasting pain, particularly in elderly patients. Moreover, without antiviral
treatment, about half of all patients will develop various eye disorders. Conjunctivitis, for
example, is seen in nearly all of ophthalmic zoster patients with ocular involvement. More
severe disorders include keratitis, uveitis, and optic neuritis of the affected eye. If these latter
disorders are not diagnosed and treated adequately the patient’s sight may become
permanently affected. The cornea may lose optical quality because of clouding and surface
irregularities. Moreover, a decreased corneal sensitivity combined with inadequate blinking
may lead to severe problems with dry eyes with subsequent corneal complications
(neurotrophic ulceration and exposure keratopathy, secondary bacterial infection). The risk of
corneal ulceration is particularly enhanced in patients with a substantial loss of corneal
sensitivity. The risk of ophthalmic complications is not related to age or severity of the skin
rash4.
Boateng Wiafe observed that Risk factors for Herpes Zoster Ophthalmicus are
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decreasing immuno-competence, increasing age. Immune suppression may be due to the
human immunovirus (HIV) infection, malignancy, systemic lupus erythematosus, and the use
of immunosuppressive agents. HIV positive patients have a 15-25 times greater prevalence of
zoster compared to the general population. In the immunocompromised patient, the dermatitis
and ocular inflammatory disease are more prolonged and it is more difficult to prevent
complications. Herpes zoster ophthalmicus may be the initial clinical manifestation of HIV
infection. The highest rise in prevalence, due to age, is in the fifth decade of life5.
Saad Shaikh, And Christopher N. TA observed that Antiviral medications such as
acyclovir, valacyclovir, and famciclovir remain the mainstay of therapy and are most
effective in preventing ocular involvement when begun within 72 hours after the onset of the
rash. Timely diagnosis and management of herpes zoster ophthalmicus, with referral to an
ophthalmologist when ophthalmic involvement is present, are critical in limiting visual
morbidity.Patients with herpes zoster ophthalmicus are treated with oral acyclovir (800 mg,
five times daily) for seven to 10 days. Studies report alleviation of pain with oral acyclovir
during the initial stages of the disease, especially if the drug is taken within the first three
days of symptoms, and it may have a favorable effect on postherpetic neuralgia. Valacyclovir
(Valtrex) has higher bioavailability and has been shown to be equally safe and effective for
the treatment of herpes zoster at a dosage of 1,000 mg three times daily for seven or 14 days.
Famciclovir (Famvir), 500 mg orally three times a day for seven days, may also be used.
Acute pain control is achieved by local care and oral analgesics6.
Larry W. Womack, MD, Thomas J. Liesegang studied 86 patients with herpes zoster
ophthalmicus seen at the Mayo Clinic, Rochester, Minn, from 1975 to 1980, 61 had some
form of ocular involvement. Corneal disease was seen in 47, uveitis in 37, postherpetic
neuralgia in 15, scleritis in three, and ocular motor palsies in three. No case of optic nerve or
retinal involvement was found. Of serious concern were four patients with neurologic
complications, including two with contralateral hemiplegia and two with segmental cerebral
arteritis. Because the neurologic complications occur several months after the episode of
herpes zoster ophthalmicus, the association is often overlooked and the opportunity to treat
with corticosteroids for systemic effect is missed7.
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6.3 OBJECTIVES OF THE STUDY

To study the ocular involvement in Herpes Zoster Ophthalmicus.
7. MATERIALS AND METHODS
7.1 SOURCE OF DATA:
1. Outpatients and inpatients of department of Ophthalmology, K.R. Hospital, Mysore.
2. Outpatients and inpatients of various other departments of K.R. Hospital referred to the
department of Ophthalmology , K.R. Hospital, Mysore.
7.2 METHODS OF COLLECTION OF DATA

SAMPLE SIZE: 100 patients

SAMPLING METHOD: Simple Random Sampling

INCLUSION CRITERIA:
Patients coming with Herpes Zoster Ophthalmicus to the OPD at K.R. Hospital.

EXCLUSION CRITERIA:
Patients having other pre-existing ocular diseases.

STATISTICAL METHOD USED:
CHI-SQUARE TEST
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONAL INTERVENTION
TO BE CONDUCTED ON PATIENTS OR ANY OTHER HUMAN BEINGS
OR ANIMALS? IF SO, DESCRIBE BRIEFLY
YES
1. ELISA to detect HIV 1 and 2 antibodies.
2. RBS
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7.4 HAS ETHICAL CLEARANCE OBTAINED FROM YOUR INSTITUTION?
YES (Copy enclosed)
7.5 DURATION OF STUDY: 18 months
8. LIST OF REFERENCES
8.1 JOURNAL REFERENCES
1)Harding SP, Lipton JR, Wells JC. Natural history of herpes zoster ophthalmicus: predictors
of postherpetic neuralgia and ocular involvement. Br J Ophthalmol 1987;71:353-58.
2) Thomas Catron, H. Gene Hern. Herpes Zoster Ophthalmicus. West JEM 2008;9:174-76.
3) Min-Kyung Shin, Chun-Pill Choi, Mu-Hyoung Lee. A Case of Herpes Zoster with
Abducens Palsy. J Korean Med Sci 2007;22:905-07.
4) Wim Opstelten, Michel J W Zaal. Managing ophthalmic herpes zoster in primary care.
BMJ 2005;331:147–51.
5) Boateng Wiafe. Herpes Zoster Ophthalmicus in HIV/AIDS. Community Eye Health
2003;16:35-6.
6) Saad Shaikh, Christopher N. TA. Evaluation and Management of Herpes Zoster
Ophthalmicus. Am Fam Physician 2002;66:1723-30.
7) Larry W. Womack, MD, Thomas J. Liesegang. Complications of Herpes Zoster
Ophthalmicus. Arch Ophthalmol 1983;101:42-5.
8.2 TEXT BOOK REFERENCES
1.Deborah Pavan-Langston. Viral Disease of the Ocular Anterior Segment: Basic Science and
Clinical Disease. In, C.Stephen Foster, Dimitri T Azar, Claes H Dohlman(ed). Smolin and
Thoft’s The Cornea Scientific Foundations and Clinical Practice, 4th Edition. Philadelphia,
Lippincott Williams and Wilkins, 2004;340-357
2.W.Barrylee, Thomas J Liesegang. Herpes zoster keratitis. In, Krachmar, Mannis,
Holland(ed). Cornea- Fundamentals, Diagnosis and Management, 2nd Edition. Philadelphia,
Elsevier Mosby, 2005;1075-92
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