1. 전안부 컨퍼런스
Pf. 김만수/ R3. 염혜리

2. C.C) Dec.VA(OS) onset) 내원 2~3개월 전 P/Hx) DM/HBP(-/-)
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

3. 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

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

5. 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

6. 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

7. 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

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

9. 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

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

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

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

13.
VA 0.04/0.25

14. Review
R3. 염혜리

15. 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%

16. 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’

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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

26. 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%

27. 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

28. 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

29. 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

30. 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

31. Punctate opacities
Stromal Haze
Stromal Edema

32. 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

33. 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

34. 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!!!

35. 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

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

37. 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

38. 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

39. 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