Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Herpes Simplex Virus Iridocyclitis Abstract: Iridocyclitis occurs in 4% of ocular herpes simplex infections usually between the ages of 41-46. 9-10 This case highlights successful management of this rare occurrence in a 77 year old Caucasian male. I. Case History a. Patient demographics i. 77 year old white male b. Chief Complaint i. Presented with eye pain c. History of Present Illness (HPI) i. Location: left eye ii. Onset: the morning prior iii. Relief: no help with Tylenol iv. Duration: 1 day v. Frequency: constant vi. Severity: moderate vii. Associated symptoms: photophobia, redness, tearing, pressure d. Ocular history: established patient i. Uveitis in the left eye 3 years prior (likely related to colitis) ii. Glaucoma suspect based on asymmetric cupping and intraocular pressure greater in the right eye iii. Dry eye syndrome iv. Pseudophakia both eyes e. Medical history/Medications i. Hypertension x 4 years, diverticulosis x 2 years, ulcerative colitis x 10 years, anemia x 9 years and gout x 1 year ii. Dextran, dicyclomine HCL, lisinopril, sulfalsalazine f. Other: nonsmoker, blood pressure: 132/66 II. Pertinent findings a. Clinical i. Best corrected visual acuities: 20/20 OD, OS ii. Pupils: equal, reactive to light OD, OS, negative APD iii. VF: FTFC, OD, OS iv. Motility: FROM OU, no diplopia v. IOP: 18 mmHg OD, 10mmHg OS at 1:31pm vi. SLE 1. Right eye findings unremarkable 2. Left eye findings: a. Conjunctiva: 2+ injection with prominent leading vessels towards the limbus b. Cornea: 2+ inferior punctate epithelial keratopathy and fine keratic precipitates in the lower half (consistent with von Arlt’s triangle) seen on reexamination c. Anterior chamber: deep with 3+ cell and flare d. Iris: prominent, engorged iris vasculature with areas of hemorrhage at 3, 9 and 12 o’clock vii. Gonioscopy left eye only 1. Regular, open to ciliary body in all quadrants (40 RD) with temporal peripheral anterior synechiae viii. DFE 1. Lens: PCIOL, centered OU 2. Vitreous: clear OU 3. C/D: 0.5 OD, 0.25 OS with pink distinct borders OU 4. A/V: 2/3 OU 5. Macula: flat/intact OU 6. Periphery: no holes, tears, or detachments OU 7. Posterior pole: unremarkable OU b. Laboratory Studies: i. Negative: ANA, RPR, HLA-B27, ACE ii. Positive: HSV IgG type 1 and 2 c. Others: i. No carotid bruit ii. Small oral ulcer on left side mouth (noticed at the end of the initial examination) III. Differential diagnosis (beginning with the initial leading diagnosis) a. Primary i. Vascular 1. Ocular ischemic syndrome unilateral, 77 yrs old decreased vision, ocular pain, iris vasculitis, but no mid-peripheral hemorrhages, no after images or history of amarosis fugax 4-6 a. Possible etiologies i. Carotid diseaseno carotid bruit, need carotid doppler ii. Ophthalmic artery diseaseless common b. Other i. Infectious Anterior Uveitis4-6 1. Herpes simplex and herpes zoster ophthalmicus patient exhibited fine keratic precipitates, iris hemorrhaging, cell/flare, no corneal involvement 2. Syphilis patient has no previous history 3. Lyme Diseaseno tick bite or skin rash, negative RPR 4. Tuberculosisno phlyctenular keratitis, no post. uveitis, PPD not tested 5. Multiple Sclerosisno clinical signs or symptoms of MS 6. Sarcoidosis- negative ACE, mostly in AA, women, between 20-40 yrs 7. Vogt-Koyanagi-Haradapatient denied symptoms such as tinnitus, hearing loss or dysacusia IV. Diagnosis and Discussion a. Unique features of case engorged iris vasculature with iris hemorrhaging, leading conjunctival vessels, lack of epithelial defect, normal intraocular pressure and 20/20 vision and von Arlt’s triangle i. Leading to initial diagnosis OIS (prior to dilated fundus examination) ii. No retinal findings on DFE led to reevaluation of signs/symptoms, case history review and consultation with ophthalmology iii. Small cold sore on left side of mouth noted at this point reexamination of ocular findingsvon Arlt’s triangle noted b. Final Diagnosis i. Herpes simplex virus iridocyclitis based on patients case history, clinical findings, small oral cold sore (seen at the end of the exam), and inconclusive signs and symptoms of ocular ischemic syndrome c. Criteria for diagnosis i. Case history review and examination of patient as a whole ii. Symptomsphotophobia, reduced visual acuity, ocular pain, redness 1. Mostly unilateral, only 8-19% bilateral 13, 17 iii. Signs keratic precipitates (von Arlt’s triangle), iris atrophy, iris hemorrhage, anterior/ vitreous cells, iris transillumination defects, posterior iris synechiae, increased intraocular pressure, unexplained corneal scarring 3-6, 12, 14, 18 iv. Lab HSV IgG 1, 2; polymerase chain reaction (PCR) test of aqueous humor may be tested3-6, 11, 14 d. General information on Herpes Virus Family i. 8 recognized human herpes viruses: herpes simplex virus type (HSV) 1, HSV 2, varicella-zoster virus, cytomegalovirus, Epstein–Barr virus, human herpes virus 6, 7, and 85,8 ii. 60-90% of people are affected by one of the viruses in the herpes family7, 13 iii. By the age of 5, 60% of a all children have been infected with HSV type 13 iv. Herpes simplex virus cuboidal capsule surrounding linear double stranded DNA virus genome that commonly affects humans7, 5 v. Primary HSV-1 infection most commonly in the mucocutaneous distribution of the trigeminal nerve5, 14 vi. Primary infection of any of the 3 branches of cranial nerve V (ophthalmic, maxillary, mandibular) leads to latent infection in the trigeminal ganglion5 vii. Inter-neuronal spread of HSV patients develop subsequent ocular disease without ever having had primary ocular HSV infection5 viii. Recurrent ocular HSV infection a reactivation of the virus in the trigeminal ganglion, producing a lytic infection in ocular tissue5 ix. Increased recurrence in cold weather months with flu-like viral respiratory infections, menstruation, sunlight and emotional stress7, 13 e. Epidemiology and pathogenesis of ocular HSV i. Herpetic corneal disease500,000 cases of blindness in US 8-10 ii. One leading cause of anterior uveitis 9-17% 8, 11 iii. Average age41-46 years9-10 iv. Average diagnosis time 3.4 years10 v. No sexual predilection 1, 9 vi. Can effect every layer of ocular tissue blepharitis, conjunctivitis, scleritis, episcleritis, keratitis, anterior uveitis, vitritis and retinitis 3, 5-9 vii. Statistical breakdown of ocular presence 9-10 1. lid or conjunctiva make up 54 % 2. superficial cornea 63% 3. deeper cornea 6% 4. uveitis in 4% viii. Most common manifestion of herpetic uveitisiridocyclitis rather than posterior uveitis, panuveitis or retinitis 3, 9 ix. Uveitis in herpetic disease more commonly associated with keratitis 3, 8, 18 x. Anterior uveitis presenting in the elder populationmostly idiopathic (31.2%) with herpes simplex/zoster and HLA-B27 positive as the next two most common causes 2, 16 V. Treatment and Management a. Initial treatment i. Began use of Pred Forte every hour in the left eye and oral Valtrex 500 mg three times a day1, 11 b. First follow-up: 7 days after initial visit i. Vision: 20/20 OD, OS ii. SLE: smaller KP’s than previous visit, 2-3 + cell and flare in anterior chamber, engorged iris vasculature iii. IOP: 22 mmHg OD, 12mmHg OS at 2:19 PM iv. Continued same treatment but reduced Pred Forte to every 2 hours in the left eye, added artificial tears 4 times a day both eyes, Alphagan P 2 times a day in the right eye c. Second follow-up: 14 days after initial visit i. Vision: 20/20 OD, OS ii. SLE: resolved KP’s, 1+ cell in anterior chamber, mildly irritated iris vasculature between 4 and 7 o’clock on iris iii. IOP: 19mm Hg OD, 9mm Hg OS at 2:05 PM iv. Continued with same regimen but decreased Pred Forte to every 6 hours left eye d. Third follow-up:1 month after initial presentation i. Vision: 20/20 OD, OS ii. SLE: clear cornea, quiet anterior chamber, no ciliary flush iii. IOP: 13 mmHg OD, 12 mmHg at 1:31 PM iv. Start slow taper of Pred Forte over 6 weeks; continue Valtrex 500mg three times a day; continue artificial tears four times a day, other follow-ups scheduled e. Possible complications microbial infections secondary to corneal compromise, secondary glaucoma (one of the most significant causes of visual loss), cataracts and other rare ocular complications (retinal detachment, epiretinal membrane, endophthalmitis, corneal perforation 3, 5, 14 f. Recurrence rate i. After one episode of ocular HSV rate of reoccurrence increases to 10% at 1 year, 23% at 2 years, and 50% at 10 years 11, 12 ii. Larger time intervals between previous episodeslinked to a larger time interval in future ocular episodes 3 VI. Conclusion and clinical pearls a. Things do not always seem as they appear, as illustrated in this ocular herpes simplex iridocyclitis case. b. When you think you know the diagnosis, it is easy to make the patient’s signs and symptoms fit that particular ocular condition, while excluding other possibilities. c. If the findings do not match the initial diagnosis, continue to reevaluate the signs, symptoms and list of differentials. d. It is important to remember to keep an objective mind when looking at all signs, look at the patient as a whole and continue case history throughout the examination. e. Before you know it, the answer may be staring right at you. VII. References 1. Barron B. A Controlled Trial of Oral Accylovir for the Prevention of Stromal Keratitis or Iritis in Patients with Herpes Simples Virus Epithelial Keratitis-The herpetic Eye Disease Study Group. Am Journal of Ophthalmology 1997; 115:703-712. 2. Chatzistefaunou K, Markomichelakis N. Characteristics if Uveitis Presenting for the First Time in the Elderly. Ophthalmology 1998; 105: 347-352. 3. Green, L. Herpes Simplex Ocular Inflammatory Disease. Int Ophthalmology Clinics 2006; 46:27-37. 4. Kaiser PK, Friedman NJ. The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology. Saunders an imprint of Elsevier. 2nd ed 2004. 5. Kanski J. Clinical Ophthalmology: A Systematic Approach. Butterworth-Heinemann and. 6th ed 2007. 6. Kunimotoe DY, Friedberg MA. The Wills Eye Manual. Lippincott Williams and Wilkins. 4th ed 2004. 7. Khan B. Clinical Manifestations and Treatment Modalities in Herpes Simplex Virus of the Ocular Anterior Segment. Int Ophthalmology 2004; 44:103-133. 8. Liesegang T. Classification of Herpes Simplex Virus Keratitis and Anterior Uveitis. Cornea 1999; 18(2): 127-143. 9. Liesegang T, Melton J. Epidemiology of Ocular Herpes Simplex: Incidence in Rochester, Minn, 1501982. Arch of Ophthalmology 1989; 107: 1155-1159. 10. Liesegang T. Herpes Simplex Virus Epidemiology and Ocular Importance. Cornea 2001; 20:1-13. 11. Miserocchi E, Modorati G. Efficacy of Valacyclovir vs. Acyclovir for the Prevention of Recurrent Herpes Simplex Virus Eye Disease: A Pilot Study. Am Journal of Ophthalmology. 2007; 144; 547-551. 12. Microchip E, Wahid NK, Visual Outcome in Herpes Simplex Virus and Varicella Zoster Virus Uveitis. Ophthalmology 2002; 109:1532-1537 13. Pepose J, Keadle T, Ocualar Herpes Simplex: Changing Epidemiology, Emerging Disease Patterns, and the Potential of Vaccine Prevention and Therapy. Am. Journal of Ophthalmology 2006; 141:547-557. 14. Rapuano C, Luchs J, Kim T. Anterior Segment: The Requisites in Ophthalmology. Mosby. 1st ed 2000. 15. Santos, C. Herpes Simplex Uveitis. Boletin Medical Association of Puerto Rico 2004; 96: 71-83. 16. Suhler E, Lloyd M. Incidence and Prevalence of Uveitis in Veterans Affairs Medical Centers of the Pacific Northwest. Am Journal of Ophthalmology 2008; 146: 890-890 17. Souza PM, Holland EJ, Huang AJ, Bilateral Herpetic Keratoconjunctivitis. American Academy of Ophthalmology 2003; 110:493-496 18. Van der Lelij A, Ooijman F. Anterior Uveitis with Sectoral Iris Atrophy in the Absence of Keratitis. Ophthalmology 2000; 107:1164-1170 19. Wilhelmus, KR, Falcon, MG, Jones, B.R. Herpes Iridocyclitis. Int Ophthalmology 1981; 4: 143-150. 20. Whitley RJ, Roizman B. Herpes Simplex virus infections. Lancet 2001: 357:1513-1518.