Common Eye Dermatitis: HZV and HSV Infections: Adult • Redness of periocular skin can be allergic Patients (if associated with prominent itching) or bacterial (if associated with open sores/wounds) Julie D. Meier, MD Assistant Professor of • Both HZV and HSV can have devastating ocular sequelae if not treated promptly OSU Eye and Ear Institute

General Categories of Herpes Zoster Eye Infections Ophthalmicus

• Symptoms: Skin rash and , may be • Dermatitis of Lids (HZV, HSV) preceded by headache, fever, eye pain or • of Lids (pre- vs post-septal) • • Signs: Vesicular skin rash involving CN V • distribution; Involvement of tip of nose can predict higher rate of ocular involvement •

1 Herpes Zoster Herpes Simplex Virus Ophthalmicus • Symptoms: • Work-up 9 Duration of rash; Immunocompromised? 9 , pain, light sensitivity, skin rash 9 Complete ocular exam, including slit 9 Fever, flu-like symptoms lamp, IOP, and dilated exam • Signs: • Can have conjunctival or corneal involvement, elevated IOP, anterior 9 Skin rash: Clear vesicles on chamber inflammation, , or erythematous base that progress to even involvement of and optic crusting nerve.

Herpes Zoster Herpes Simplex Virus Ophthalmicus • Work-up: • Treatment: 9 Previous episodes? 9 If present within 3 days of rash’s 9 Previous nasal, oral or genital sores? appearance: oral Acyclovir/ Valacyclovir 9 Recurrences can be triggered by fever, stress, trauma, UV exposure 9 Bacitracin ointment to skin lesions 9 External exam: More suggestive of HSV 9 Warm compresses if lesions centered around eye and no involvement of forehead/scalp 9 TOPICAL ANTIVIRALS (e.g. Viroptic) HAVE NO ROLE 9 Slit Lamp Exam, IOP check, dilated exam

2 Herpes Simplex Virus Preseptal Cellulitis

• Treatment: • Signs: 9 Bacitracin ointment to 9 Eye is quiet, no pain or restriction of eye skin lesions movement 9 Any lid margin, 9 May be a history of recent trauma or conjunctival, or corneal (stye) or recent infection such involvement needs topical antivirals (e.g. as Viroptic) and close care with • Organisms: ophthalmologist 9 Usually S. aureus or strep species

Cellulitis Preseptal Cellulitis Preseptal vs Postseptal • Work-up: • Orbital septum: membrane separating lids 9 Sinus congestion or discharge? Trauma? from orbital contents 9 Full eye exam, especially checking motility • Symptoms: and any evidence of proptosis • Treatment: 9 Both: Tenderness of lids, swelling, redness 9 If afebrile, Augmentin PO X 10 days 9 Follow every 1-2 days until definite 9 : Pain on eye movement, improvement fever, double vision, eye itself is also red, decreased vision 9 If febrile, or no improvement after a few days, hospitalize for IV

3 Orbital Cellulitis Blepharitis • Signs: 9 Pain on eye movement or restriction, • Inflammation of anterior decreased vision, proptosis, eye itself or posterior lid margins red • Symptoms: Itching, • Organisms: burning, crusting 9 Staph and strep species, bacteroides, • Signs: Crusts to lashes, gram negative rods mucous discharge, 9 Mucomycosis must be considered in all swollen lids, may have diabetic or immunocompromised corneal infiltrates patients

Orbital Cellulitis Blepharitis • Work-up: • If woman, ask about eye make-up hygiene. 9 Trauma, diabetes/immunocompromised, systemic symptoms? 9 Should be throwing away every 3-4 months, removing each night, washing 9 Complete eye exam (motility, proptosis, hands before application and not abnormality) sharing products’ 9 CT scan of orbits 9 Poor make-up related hygiene can lead 9 CBC, blood cultures to blepharitis, conjunctivitis and even corneal infection • Treatment: Hospitalize for IV antibiotics and close follow-up 9 Products contaminated after first use

4 Blepharitis Bacterial

• Treatment: conjunctivitis 9 Warm compresses for 10-15 minutes • Etiology (acute presentation) twice daily, followed by lid scrubs with baby shampoo 9 Gonococcus 9 Lubrication with artificial tears 3-4 times 9 Staph species daily 9 Strep pneumonia 9 If moderate to severe, can add ophthalmic ointment at 9 Hemophilus influenzae (kids) bedtime

Bacterial Gonococcal vs other conjunctivitis (acute) bacterial agents

• Signs: 9 Purulent discharge of varying degree 9 Chemosis (swelling of the ) • Symptoms: 9 Redness, foreign body sensation

5 Bacterial Treatment Conjunctivitis • Gonococcal 9 If only conjunctiva involved, one dose of • If hyperacute presentation wiith copious ceftriaxone IM amounts of purulent drainage, concern is mainly for gonococcal infection 9 If corneal involvement, patient needs hospitalization and ceftriaxone IV Q12- 9 Immediate referral to ophthalmology for 24 hours exam as there is a risk for corneal perforation 9 Treat for possible coinfection with chalmydia with doxycycline or azithromycin and treat sexual partners 9 Follow daily until definite improvement

Bacterial Viral Conjunctivitis Conjunctivitis • Work-up: • Symptoms: 9 Conjunctival swab for culture and 9 Itching, burning, foreign body sensation, sensitivities and Gram stain history of recent URI or sick contact 9 Complete eye exam, excluding any 9 Usually starts in one eye and involves corneal involvement second eye a few days later • Treatment: (other than gonococcal) • Etiologies: 9 Topical fluoroquinolone drops QID 9 Usually adenovirus, unless specific evidence of HSV or HZV involvement 9 Follow-up every 1-2 days until otherwise improvement

6 Viral Conjunctivitis Infectious Keratitis • Signs: 9 Watery mucous • Infection within the discharge • Can be bacterial or viral, more commonly, 9 Red, swollen lids and less commonly fungal or parasitic 9 Inferior conjunctival follicles • Particularly dangerous in settings of contact wearers or with recent trauma 9 Tender, palpable preauricular node

Viral Conjunctivitis Infectious Keratitis • Work-up: • Symptoms: 9 History and eye exam only (no cultures 9 Red eye needed unless has become chronic) 9 Mild to severe pain • Treatment: 9 Decreased vision 9 Artificial tears and cool compresses 9 , discharge • Signs: 9 Strict handwashing 9 Injection 9 Contagious for 10-12 days from day of onset: may need to restrict school and 9 Focal white opacity in cornea or area that work stains with fluorescein

7 Infectious Keratitis Infectious Keratitis • Etiology: • Work-up: 9 Staph, strep species 9 History: contact lens wear and care regimen, recent trauma, previous eye 9 Pseudomonas (particularly in contact lens wearers) diseases or surgery 9 HSV/HZV 9 If associated skin lesions, may be more concerned for herpetic infection 9 Fungal (especially after trauma with vegetable matter) 9 Full eye exam, including likely culture of infiltrate 9 Acanthomeoba (especially in contact lens wearers with poor lens hygiene or 9 Immediate referral for contact lens recent swimming) wearers

Infectious Keratitis Infectious Keratitis • Treatment: 9 Topical cycloplegic drops (e.g. scopolamine) for comfort 9 Topical antibiotics of varying frequency depending on: • Whether the patient is a contact lens wearer • Size of infiltrate and proximity to visual axis 9 Daily follow-up

8 Infectious Keratitis Summary: • Primary Care Physician will be the first provider • HZV related corneal changes to see a wide range of eye problems 9 Intensive lubrication, but no topical • Among those that require immediate referral to antivirals ophthalmology include: • HSV Corneal Ulcers (Dendrites) 9 HSV/HZV infection 9 Topical Viroptic 1 drop nine times daily 9 Red eye with restricted eye movements (orbital cellulitis) 9 Close follow-up to monitor for toxicity to cornea and improvement in dendrite 9 Conjunctivitis with abrupt onset of copious discharge (gonococcal) 9 Red, painful eye in a contact lens wearer

Infectious Keratitis • : Neonatal 9 Not getting better with antibiotics, feathery borders Conjunctivitis 9 Need Intensive topical antifungals • Acanthomoeba: 9 Pain out of proportion to exam in a contact lens wearer David L. Rogers, M.D. 9 Long term treatment with multiple agents, Nationwide Children’s Hospital may even need corneal transplant for medical failures

9 Neonatal Bacterial Infections Conjunctivitis Ophthalmia Neonatorum • Usually Acquired from infected mother during • Purulent ocular passage through birth drainage canal. • Chemical irritation or a pathogenic organism • Chlamydia ophthalmia is the most common • Diagnosis made clinically and cause confirmed with lab testing

Chemical Chlamydial Ophthalmia Conjunctivitis Conjunctivitis • Occurs in 2-4% of births • Causes 30-50% of conjunctivitis in neonates. • Generally from silver • Prevalence of maternal chlamydial nitrate prophylaxis infection is 2-20% • 30-50% of neonates born to infected mother will develop conjunctivitis • 5-20% will develop pneumonia

10 Chlamydial Ophthalmia Other bacterial causes:

• May range form mild conjunctivitis with • Streptococcus pneumoniae and minimal mucopurulent discharge to severe nontypeable Haemophilus influenzae cause edema with copious drainage and 15% of cases. pseudomembrane formation. • Follicles are not present in the conjunctiva as they are in older children and adults.

Gonorrheal Ophthalmia Viral Conjunctivitis

• Conjunctivitis due to • Major viral causes are Neisseria gonorrhoeae HSV1 and HSZ2 • Incidence in the US is 2 to • HSV 3/10,000 births. can be isolated or with disseminated or CNS • Severe eyelid edema, infection. chemosis and profuse purulent exudate. • Can be mistaken for bacterial or chemical • If untreated, corneal conjunctivitis ulcerations and blindness may occur. • Presence of dendritic keratitis is pathognomonic.

11 Diagnosis

• Conjunctival material is Gram stained, • Because of overlap in presentation and onset, cultured for gonorrhea and tested for causes are difficult to distinguish clinically. chlamydia. • Conjunctivae are injected, and discharge (watery • Viral culture is obtained only if viral or purulent) is present. infection is suspected by skin lesions or maternal infection.

Timing can be a Clue Treatment - General Tips

• Chemical: usually appears within 6 to 8 h after instillation of silver nitrate and disappears spontaneously within 48 to 96 h • Neonates with conjunctivitis and maternal gonococcal infection or with gram-negative • Chlamydial ophthalmia usually occurs 5 to 14 intracellular diplococci should be treated with days after birth. ceftriaxone before results of confirmatory tests. • Gonorrheal ophthalmia: acute purulent • Corticosteroid-containing ointments may conjunctivitis, 2 to 5 days after birth or earlier seriously exacerbate eye infections due to C. with premature rupture of membranes. trachomatis and HSV and should be avoided. • If caused by other bacteria: variable onset, ranging from 4 days to several weeks.

12 Treatment Treatment Chlamydial Ophthalmia Other Bacteria

• Systemic therapy is treatment of choice • Conjunctivitis due to other bacteria usually due to risk of nasopharyngeal infection and responds to topical ointments containing chlamydial pneumonia. polymyxin plus bacitracin or erythromycin. • Erythromycin 12.5 mg/kg po q 6 h for 2 wk is recommended. Efficacy of Tx is 80%. • Second treatment course may be needed.

Treatment Treatment Gonorrheal Ophthalmia Herpetic Keratoconjunctivitis • Hospitalized to observe for possible • Treated with systemic acyclovir 20 mg/kg q systemic gonococcal infection. 8 h for 14 to 21 days • Give a single dose of ceftriaxone 25 to 50 • Add topical 1% trifluridine ophthalmic mg/kg IM to a maximum dose of 125 mg. drops or ointment with a maximum of 9 • Frequent saline irrigation of the eye doses/24 h. prevents secretions from adhering. • Systemic therapy is important, because • Topical antimicrobial ointments used alone dissemination to the CNS and other organs are ineffective. can occur.

13 Prevention Take Home Message

• 1% silver nitrate drops or 0.5% erythromycin • Neonatal ophthalmic ointments or drops instilled into each Conjunctivitis can eye after delivery effectively prevents gonorrheal cause permanent ophthalmia. impairment of vision. • These agents do not prevent chlamydial • Refer to an ophthalmia; povidone iodine 2.5% drops may be ophthalmologist for effective against chlamydia and is effective “eye” specific therapy against gonococci but is not available in the US.

Prevention

• Neonates of mothers with untreated gonorrhea should receive a single injection of ceftriaxone 50 mg/kg IM or IV, up to 125 mg. • Both mother and neonate should be screened for chlamydia infection.

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