Herpes Eye Infections
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- Eye infection (blepharitis, conjunctivitis, keratitis, stromal keratitis, uveitis, retinitis, glaucoma, or optic neuritis) caused by herpes simplex virus (HSV) types 1 or 2 or varicella-zoster virus (VZV, also known as human herpes virus type 3 [HHV3])
- HSV: can affect many parts of the eye but most often affects the cornea (herpes keratoconjunctivitis); HSV1 > HSV2; can be further divided into primary and recurrent
- VZV: When VZV is reactivated and affects the ophthalmic division of the 5th cranial nerve, this is known as herpes zoster ophthalmicus (HZO), a type of shingles.
- System(s) affected: eye, skin, central nervous system (CNS) (neonatal)
- Predominant age: HSV—mean age of onset 37.4 years but can occur at any age, including primary infection in newborns; VZV usually advancing age (>50 years)
- Predominant sex: HSV—male = female; HZO—female > male
- HSV keratitis: In the United States, approximated at 18.2 per 100,000 person-years. Incidence is 1.5 million per year worldwide (1).
- VZV: 1 million new cases of shingles per year in the United States; 25–40% develop ophthalmic complications. Temporary keratitis is most common.
Etiology and Pathophysiology
- HSV and VZV are Herpesviridae dsDNA viruses.
- HSV: primary infection from direct contact with infected person via saliva, genital contact, or birth canal exposure (neonates)
- Primary infection may lead to severe disease in neonates, including eye, skin, CNS, and disseminated disease.
- Recurrent infection is more common overall cause of herpetic eye infections.
- VZV: Primary infection from direct contact with infected person may cause varicella (“chickenpox”) and/or lead to a latent state within trigeminal ganglia.
- Reactivation of the virus may affect any dermatome (resulting in herpes zoster or “shingles”), including the ophthalmic branch (HZO).
- HSV: personal history of HSV or close contact with HSV-infected person
- General risk factors for reactivation: stress, trauma, fever, UV light exposure, other viral infections
- Risk factors for HSV keratitis: UV laser eye treatment, some topical ocular medications such as prostaglandin analogues and primary/secondary immunosuppression
Consider primary/secondary immunodeficiency disorders in all zoster patients <40 years of age (e.g., AIDS, malignancy).
- Contact precautions with active lesions (HSV and VZV)
- VZV can be spread to those who have not had chickenpox and are not immunized.
- Varicella recombinant zoster vaccine (Shingrix) (VZV only): 2 doses 2 to 6 months apart recommended by the CDC for all persons age 50 years and older; preferred over older vaccine (Zostavax), which can still be used for persons age >60 years unable to take Shingrix (4)
- Do not give varicella vaccine during an acute infection.
- Acyclovir can be used prophylactically to prevent recurrence of ocular HSV.
- HSV immunization currently being researched (1)
Zoster vaccination is contraindicated if HIV-positive or other immunocompromised state, pregnancy, or in active untreated tuberculosis (TB).
- Pregnant women without history of chickenpox should avoid contact with persons with active zoster.
- Pregnancy increases risk of recurrence of HSV/VZV.
- Shingrix and Zostavax vaccinations are both contraindicated during pregnancy.
Commonly Associated Conditions
Primary and secondary immunocompromised states