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Prevalence of Ocular Manifestations and Visual Outcomes in Patients with Herpes Zoster Ophthalmicus

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Prevalence of Ocular Manifestations and Visual Outcomes in Patients with Herpes Zoster Ophthalmicus CLINICAL SCIENCE Prevalence of Ocular Manifestations and Visual Outcomes in Patients With Herpes Zoster Ophthalmicus Simon K. H. Szeto, MRCS,*† Tommy C. Y. Chan, FRCS,*† Raymond L. M. Wong, MRCS,*† Alex L. K. Ng, MRCS,‡ Emmy Y. M. Li, FRCS,*† and Vishal Jhanji, MD*† associated with increased health care utilization, impact on Purpose: To investigate the prevalence of ocular manifestations and daily social and physical functioning, and work place pro- visual outcomes in patients with herpes zoster ophthalmicus (HZO). ductivity.2 Zoster vaccine has been shown to reduce the 3 Methods: Consecutive cases diagnosed with HZO who attended 2 incidence of herpes zoster by 50%. According to the Centers for Disease Control and Prevention, routine vaccination is hospitals between July 1, 2011, and June 30, 2015, were retrospec- $ tively reviewed. Patient demographics, clinical presentations, and recommended to all immunocompetent individuals aged 60 management were reviewed. The logistic regression model was used years. Herpes zoster ophthalmicus (HZO) is caused by to estimate the odds ratio of visual loss with ocular manifestations. reactivation of latent varicella zoster virus. It presents as painful vesicular rashes along the skin supplied by the Results: A total of 259 patients were included. Of these, 110 (42.5%) ophthalmic branch of the trigeminal nerve. It is believed that patients were ,60 years old and 149 patients (57.5%) were $60 years viral reactivation occurs as a result of declining cell-mediated old. None of the patients had received zoster vaccination before immunity, which can be associated with aging, impaired presentation. Ocular manifestations were present in 170 (65.6%) immunity, trauma, and psychological stress.4 HZO is associ- patients with no difference between both age groups (P = 0.101). ated with ocular and systemic morbidities including keratitis, Conjunctivitis was the most common ocular manifestation, followed uveitis, glaucoma, stroke, and depression secondary to by anterior uveitis and keratitis. After resolution of HZO, 58.7% of postherpetic neuralgia.5–8 patients had a visual acuity of 6/12 or worse. Epithelial keratitis and This study aims to investigate the prevalence of ocular stromal keratitis were independent risk factors for visual loss after manifestations and visual outcomes in patients with HZO at 2 resolution of HZO (P = 0.003 and P = 0.004, respectively). The hospitals in Hong Kong. corresponding odds ratio was 6.59 [95% confidence interval (CI): 1.87–23.19] and 7.55 (95% CI: 1.88–30.30), respectively. The number of ocular manifestations was also associated with an increased risk of visual loss with an odds ratio of 1.49 (95% CI: 1.01–2.20; P = 0.043). MATERIALS AND METHODS Conclusions: A substantial proportion of patients with HZO were This is a retrospective study of patients diagnosed with ,60 years old in this study. The absence of zoster vaccination across HZO at Hong Kong Eye Hospital and Queen Elizabeth the study cohort was noteworthy. Keratitis was the main reason for Hospital, the largest tertiary care ophthalmic hospital and poor visual outcome in these patients. largest general hospital in Hong Kong, respectively, between July 1, 2011, and June 30, 2015. Patients with incomplete Key Words: herpes zoster ophthalmicus, ocular manifestations, follow-up until resolution of HZO were excluded. The study visual outcome, postherpetic neuralgia was conducted in accordance with the tenets of the Declara- (Cornea 2017;36:338–342) tion of Helsinki. The study protocol was approved by the Institutional Review Board of Kowloon Central Cluster, Hospital Authority, Hong Kong. erpes zoster affects approximately 30% of the population Patient demographics, medical history, clinical presen- Hin the United States.1 The burden of herpes zoster makes tations, treatment, and outcomes were reviewed and analyzed. it a sizeable public health problem including expenses All patients were referred from physicians or private oph- thalmologists for management of acute HZO. All patients were followed up and monitored for possible development or Received for publication July 17, 2016; revision received August 19, 2016; progression of HZO-related ocular complications. For the accepted August 24, 2016. Published online ahead of print October 12, purpose of this study, HZO was defined as the presence of 2016. From the *Hong Kong Eye Hospital, Kowloon, Hong Kong, China; typical vesicular rashes affecting the dermatome supplied by †Department of Ophthalmology and Visual Sciences, Chinese University the ophthalmic branch of the trigeminal nerve. Postherpetic of Hong Kong, Hong Kong, China; and ‡Department of Ophthalmology, neuralgia was defined as any symptom of pain or the use of The University of Hong Kong, Hong Kong, China. pain medications documented in medical records at least 3 The authors have no funding or conflicts of interest to disclose. Reprints: Tommy C. Y. Chan, FRCS, Hong Kong Eye Hospital, Kowloon, months after the onset of HZO. A search in the shared Hong Kong, China (e-mail: [email protected]). database by ophthalmologist, physicians, and psychiatrists Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. was performed to identify patients who had postherpetic 338 | www.corneajrnl.com Cornea Volume 36, Number 3, March 2017 Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Cornea Volume 36, Number 3, March 2017 Herpes Zoster Ophthalmicus neuralgia or stroke. The patients were divided into 2 groups based on the age at onset of HZO (,60 and $60 years). Statistical analyses were performed using IBM/SPSS software version 21 (IBM/SPSS Inc, Chicago, IL). Group means were compared with the Mann–Whitney U test. Cat- egorical parameters were evaluated using the x2 test or Fisher exact test. Visual acuity was quantified as logarithm of the minimum angle of resolution for analysis. A multivariate logistic regression model with visual loss as the dependent variable was constructed. Visual loss was defined as reduction in the best-corrected visual acuity by $1 line after resolution of HZO or completion of antiviral medications and topical corticosteroids, compared with the best-corrected visual acuity at the time of presentation. The univariate logistic regression model was also used to estimate the odds ratio of visual loss and postherpetic neuralgia with the number of ocular manifestations. P , 0.05 was considered statistically significant. A false discovery rate, which measures the percentage of false discovery due to random errors, was evaluated for multiple statistical tests by the threshold of P ,0.05. It is estimated by the below formula ðnumber of testsÞ · ðhighest P value obtained less than 0:05Þ · 100%: ðnumber of significant discoveriesÞ FIGURE 1. Distribution of HZO and its associated ocular manifestation among different age groups. The number of patients with or without ocular involvement for each age RESULTS group is indicated in each bar graph. The percentage of pa- A total of 259 patients (259 eyes) with HZO were tients with ocular involvement for each age group is shown on included. Thirty-three cases were excluded during the study the top of each bar graph. There was no significant difference period. The mean age was 62.7 6 17.5 years (range: 22–96 in the likelihood of ocular involvement among different age years). The mean follow-up duration was 9.3 6 10.2 months groups (P = 0.135). (range: 6 months–4 years). One hundred ten (42.5%) patients were ,60 years old, and 149 (57.5%) patients were $60 discovery rate of #0.9%. None of the cases had posterior years old. Male to female ratio was 1.07. The right-to-left uveitis or acute retinal necrosis. ratio was 1.19. Only 2 (0.8%) patients had a history of HZO. Oral antiviral medications (acyclovir or famciclovir) Fourteen patients (5.4%) had concomitant involvement of the were prescribed either by primary physicians or by ophthalmol- dermatome supplied by the maxillary branch of the trigeminal ogists in 250 (96.5%) patients within 72 hours of onset of nerve. The average duration from onset of symptoms to symptoms. None of our patients had received zoster vaccination examination by an ophthalmologist was 4.0 6 2.3 days before. The treatment profile of HZO is shown in Table 2. No (range: 0–14 days). Ninety-two (35.5%) patients had hyper- difference was observed between both age groups (P $ 0.14). tension, 34 (13.1%) had diabetes mellitus, 14 (5.4%) had The average duration of HZO, defined as the time between previous stroke, and 7 (2.7%) had underlying drug-induced onset of rashes and resolution of zoster disease or stopping of immunodeficiency. Hypertension, diabetes mellitus, and antiviral medications and topical steroids, was 28.3 6 28.2 a history of stroke were more common in patients aged days (range: 14–227 days) with no intergroup difference (P = $60 years (P , 0.006). None of the patients tested positive 0.645). None of the patients required acute surgical intervention for human immunodeficiency virus. due to HZO-related ocular involvement. Ocular manifestations were present in 170 (65.6%) The best-corrected visual acuity was 6/12 or worse in patients. There was no significant difference by age in decades 42.7% of the patients at the time of presentation and in 58.7% in terms of ocular involvement (P = 0.135) (Fig. 1). The of the patients after disease resolution. Visual loss was noted distribution of HZO-associated ocular manifestations is sum- in 12.4% of patients. Visual loss was not associated with sex marized in Table 1. The commonest ocular manifestation was (P = 0.867) and immune status (P = 1). The relationship conjunctivitis followed by anterior uveitis and keratitis. There between visual loss and different HZO-related ocular mani- was a significant difference in prevalence of conjunctivitis festations is shown in Table 3.
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