전안부 컨퍼런스 2011. 10. 7 Pf. 김만수/ R3. 염혜리

C.C) Dec.VA(OS) onset) 내원 2~3개월 전 P/Hx) DM/HBP(-/-) 2009.8.31 손 O 용(M/48) C.C) Dec.VA(OS) onset) 내원 2~3개월 전 P/Hx) DM/HBP(-/-) Ocular trauma/op Hx.(-/-) 6년 전부터 3~4회 좌안 각막염 반복 수 개월 전부터 좌안 시력저하 발생 Local clinic 에서 헤르페스 각막염이라 듣고 Virgan, O-OF 점안 치료

VA OD 1.0 OS 0.02(N-C) IOP OD 14 mmHg OS 17 mmHg at 12:40PM Conj. OD not injected OS not injected Cornea OD clear OS oval type stromal opacity at center, KP(-), epidefect(-) AC deep & cell(-)/ OU Pupil round & nl sized, LR(+/+) /OU Lens OD mild cortical opacity OS mild cortical opacity

oval type stromal opacity at center, KP(-), epidefect(-) Pachy 576/601 um

Plan) R/O Herpetic keratitis (OS) O-GC x5 O-LON x4 Stromal type Plan) O-GC x5 O-LON x4 H-TRI 3T #1 PO for 15 days Vacrax 3T #3 PO

2009/09/17 VA 0.25 Cornea reduced stromal opacity in half /OS 2009/10/8 VA 0.25 Conj. not injected Cornea stromal scar /OS Pachy OD 587/OS 511 Plan) O-GC x2 O-LON x2 for 2 wks -> x1 for 2 wks Valcrax 3T #3 for 1 mo

2010/1/7 VA 0.63 Conj. not injected Cornea scar (healing state) /OS Pachy OS 561 Plan) O-GC x2 O-LON x1 cut Valcrax 3T #3 for 1 mo

C.C) known herpes keratitis(OS) onset)내원 1년전 P/Hx) DM/HBP(-/-) 2010.7.29 김 O 은 (M/69) C.C) known herpes keratitis(OS) onset)내원 1년전 P/Hx) DM/HBP(-/-) Ocular trauma/op Hx.(-/+) 2010.2.22 Phaco+PCL(OS) at 파티마병원 2010.5 Herpes keratitis(OS) 로 치료 2010.7. Laser keratectomy(OS) x2 gls(-) eyedrop(+): O-GAF x4, O-LON x4, virgan q4hrs po(+): steroid 40mg, acyclovir 800mg

VA OD 0. 1(0.125) -중학교 때 열병 앓은 후 우안시력 저하 OS FC 50cm (N-C) IOP OD 12 mmHg OS 13 mmHg at 14:20 Conj. OD not injected OS sl. injected Cornea OD disciform scar at central lesion OS mod edematous c DM folding, central epidefect, inf. NV(+) AC deep & cell(-)/ OU Pupil round & nl sized, LR(+/+) /OU Lens OD mild nucleosclerosis OS PCL in situ

Pachy OD/OS 584/644 Cell count OD/OS 911/error

Imp) Neurotrophic ulcer(OS) PED(OS) Plan) O-FM x1 oral acyclovir 인공눈물약 추후 좌안 각막이식 고려

operation 2010.8.15 PPKP(OS) by Pf. 김만수 Trephine Donor 7.25 mm Recipient 7.00 mm

2011.7.25 VA 0.04/0.25

Review 2011.10.7 R3. 염혜리

Epidemiology The only natural reservoir; Human HSV1 & HSV2 Close personal contact for the spread of HSV Major portals of entry; mucous membrane & skin Primary infection Typically between 3 & 9days from contact to infection Asymptomatic; most common Clinical manifesatation; only 6%

Pathogenesis Primary infection Latency Reactivation ‘Mucocutaneous inoculation’ (주로 perioral region, rather than the eye) Latency ‘Entry’  ‘viral replication within an end organ’  ‘retrograde transport to various ganglia’ (trigeminal, cervical, sympathetic ggl, brain stem) ‘Latent virus in ganglia or end organ (cornea)’ Reactivation ‘Replication in ggl.’  ‘viral spread to more extensive end organs’

Ocular herpes Primary ocular herpes Congenital herpes Recurrent ocular herpes Infectious epithelial keratitis Neurotrophic ulcer Necrotizing storomal keratitis Immune stromal keratitis Endotheliitis Iridocyclitis

Primary ocular herpes Infected nearly 60% of population by 5 years Clinical manifestation; only 6% Confined to the epithelium Lack of previous immunologic stimulus Typical periocular & eyelid skin vesicles Dendritic lesion Formation of microcysts; negative fluorescein staining Eroding the overlying epithelium to form microdendritic lesions Follicular conjunctivitis Preauricular adenopathy Treatment; oral acyclovir 400mg 5 times daily

Congenital(neonatal) herpes Rare Infection route In conjunction with genital herpes in the mother; HSV2(80%) Oral, breast feeding, nosocomial, etc. Clinical manifestation Periocular skin lesions Conjunctivitis Epithelial & stromal keratitis Cataract Empiric treatment & amblyopia therapy

Recurrent ocular herpes Recurrence rate 36% at 5yrs, 63% at 20yrs after a primary episode 70~80% within 10yrs after a second episode Blepharitis Focal vesicular lesion with surrounding erythema Heals without a scar Unless secondarily infected DDx. with staphyloccocci, seborrhea, MGD Tend to involve the entire lid Do not cause vesicles

Typically a unilateral disease!!! Bilateral Conjunctivitis Follicular conjunctivitis & dendritic ulcer Self limiting Treatment; topical acyclovir Typically a unilateral disease!!! Bilateral Only 3% 40% associated with atopy More common in younger patients

Recurrent herpes keratitis Infectious epithelial keratitis 100% Reactivation of live virus Symptoms Photophobia, pain, watery discharge Clinical manifestation Dendritic ulcer branching, linear lesion with terminal bulbs Swollen epithelial borders; contain live virus Geographic ulcer

Recurrent herpes keratitis Infectious epithelial keratitis DDx. with dendritic ulcer HSV dendritic epitheliopathy Healing epithelium after the infection or Toxic effect of antiviral medication Not ulcerated; no fluoroscein staining Varicella-zoster pseudodendrites Raised, no fluoroscein staining No terminal bulbs

Recurrent herpes keratitis Infectious epithelial keratitis Marginal ulcer; unique clinical features Dendritic ulcer Anterior stromal infiltrate underlying the ulcer Adjacent limbal injection, often neovascularization Uncommon More difficult to treat than a central dendritic ulcer

Recurrent herpes keratitis Infectious epithelial keratitis Sequelae Complete resolution Dendritic epitheliopathy Stromal scarring; ghost figures or footprints With corneal thinning & decreased vision Stromal disease; 25%

Recurrent herpes keratitis Infectious epithelial keratitis Medical treatment Physical debridement with a sterile cotton-tipped applicator Topical antiviral agents Trifluridine 1% q2hrs while awake or Vidarabine 3% 5times a day For 10~14days(after 5~7days, tapered to half doses) Prophylactic antibiotics when treating large geographic ulcers No steroid!!! except marginal ulcer Prophylaxis oral dose; 400mg twice a day If the lesion persists after 14 days DDx. with dendritic epitheliopathy True ulcer → vidarabine as an alternative agent

Neurotrophic keratopathy Neither immune nor infectous!! Impaired corneal innervation with decreased tear secretion Clinical manifestation Oval epithelial defect with heaped-up smooth borders Medical treatment Discontinuation of all unnecessary topical agents ; especially antivirals Artificial tears for promoting epithelial healing Prophylactic antibiotics, if necessary Gentle debridement Boggy, rolled epithelium at the border T-lens with antibiotics Tape tasorrhapy Steroid if accompanying inflammation

Recurrent herpes keratitis Necrotizing stromal keratitis Rare Direct viral invasion of the corneal stroma Clinical manifestation Necrosis, ulceration & dense infiltration Overlying epithelial defect May lead to thinning & perforation May resemble bacterial keratitis Often refractory to treatment

Recurrent herpes keratitis Immune stromal keratitis Immunologic reaction (& live virus) 20%~48% of patients with ocular HSV Clinical manifestation Punctate stromal opacities; AAC immune complexes Sromal haze & edema; focal, multifocal, or diffuse Immune ring; AAC precipitate Neovascularization; sectoral Almost always intact overlying epithelium

Punctate opacities Stromal Haze Stromal Edema

Recurrent herpes keratitis Immune stromal keratitis Medical treatment Mild inflammation with no prior steroid use; no steroid Topical steroid indication Mod. to severe inflammation Symptomatic with photophobia & discomfort Longer than 10wks(with tapering) Oral steroid indication(adding) Severe inflammation Topical antiviral coverage if possible Equal frequency until the steroids are reduced to a dose equivalent to O-LON x1

Recurrent herpes keratitis Endotheliitis Keratic precipitates; 100% under stromal edema Corneal stromal edema without stromal infiltrate Iritis Immunologic; type IV hypersensitivity KP & iritis Respond to steroid Live virus 3 categories Disciform Diffuse Linear

Disciform endotheliitis Most common type Clinical manifestation Round or disc-shaped stromal edema Typically have a definite demarcation between involved & uninvolved cornea ground glass appearance Central or paracentral Elevated IOP Inflammatory cells blocking aqueous outflow Primary trabeculitis Look for ghost scars or footprints!!!

Disciform endotheliitis Self limited; many cases Severe cases can lead to permanent edema, scarring & NV - if untreated Treatment Mild inflammation with no prior steroid use; no steroid Topical steroid indication Mod. to severe inflammation Symptomatic with photophobia & discomfort Longer than 10wks(with tapering) Oral steroid indication(adding) Severe inflammation

Diffuse endotheliitis Rare Clinical manifestation Typically scattered KP over the entire cornea Overlying diffuse stromal edema If severe, retrocorneal palque with hypopyon

Diffuse endotheliitis Treatment Mild inflammation with no prior steroid use; no steroid Topical steroid indication Mod. to severe inflammation Symptomatic with photophobia & discomfort Longer than 10wks(with tapering) Topical antiviral coverage if possible Equal frequency until the steroids are reduced to a dose equivalent to O-LON x1 Oral steroid & antiviral indication(adding) Severe inflammation

Linear endotheliitis Major complaint; pain!!! Clinical manifestation Bilateral; 50% Lines of KP progressing centrally from the limbus ; similar with allograft rejection Peripheral stromal & epithelial edema between the KP & the limbus Corneal decompenstation is common Treatment Aggressive treatment with topical & systemic antivirals & steroid

Iridocyclitis Can occur without prior history of a keratitis!!! Clinical manifestation Fine KP & AC reaction Segmental iris atrophy; ischemic necrosis of the iris stroma Anterior chamber pigment dispersion Most commonly accompanies Immune stromal keratitis Endotheliitis Trabeculitis may occur; acute elevation of IOP Look for ghost scars or footprints!!! Treatment Add oral acyclovir 200mg 5 times a day