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Time is of the essence when diagnosing, treating herpes
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I recently saw an interesting patient at the request of her primary care physician. Earlier in the week she presented to her physician with a sore, swollen right lower eyelid. The doctor confirmed her suspicion for an internal stye and prescribed hot compresses and an antibiotic ointment.
Unfortunately, 4 days later her symptoms worsened, and she presented to me asking that the stye be drained. After a brief assessment of the lid lesion, I swept back her hair to reveal – yes, you got it – a small patch of vesicular lesions along the scalp line. Her suspected eyelid lesion was, in fact, the first skin eruption in a herpes zoster virus (HZV) infection.
No, this case was not about another clinician’s misdiagnosis or my clinical acumen. We have all been on both sides of the care spectrum and appreciate the advantage of being the second doctor to see a patient. Having the benefit of a tincture of time and seeing what has not worked always makes a second opinion so much easier.
Rather, what this case was truly about was the patient. She received a bone marrow transplant to treat chronic myelocytic leukemia 5 years prior, and I began to think about her immunocompetency as a predisposing factor. Knowing we would be starting antiviral therapy 4 to 5 days after symptom onset made me wonder about an increased risk for post-herpetic neuralgia.
Finally, this case was about the formidable nature of our foe. Herpes viruses are diverse, insidious, opportunistic, increasing in frequency, and – above all – potentially devastating for the eye.
As eye doctors, when we think of herpes, our primary focus is that of herpes simplex virus (HSV) keratitis and HZV with ocular involvement (herpes zoster ophthalmicus, or HZO). This is for good reason. The National Eye Institute estimates that more than 400,000 Americans have been affected by ocular herpes, with almost 50,000 new or recurrent cases occurring annually. The Centers for Disease Control and Prevention estimates the incidence of HZV at one in 250 in the population at large, increasing to one in 100 among those older than 60 years. Fortunately, HZO remains relatively rare, with the Kaiser Pacific Ocular Inflammation Study pegging the incidence at roughly three per 10,000 (Borkar et al.).
However, these numbers do not reflect other members of the herpes family, such as cytomegalovirus and Epstein-Barr virus. The sequelae are far reaching, potentially involving everything from eyelids to retina.
The challenges of managing ocular herpes are threefold. The first challenge lies in the differential diagnosis, as herpes often masquerades quite well and must be considered in everything from blepharoconjunctivitis to uveitis. Needless to say, timely diagnosis is paramount.
The second challenge involves its management. While virulence and clinical presentation drive our therapeutic decisions, other variables such as drug availability, cost, toxicity and compliance influence treatment as well. Oftentimes we treat each case fully aware that topical or oral antivirals, corticosteroids and hypotensive agents might ultimately be necessary.
The final challenge involves prophylaxis – for both initial infection as well as recurrence. Decisions involving long-term viral suppression therapy or primary vaccination are complex and must be weighed on an individual basis.
In this month’s issue of Primary Care Optometry News, we take a timely look at all things herpetic. Our feature article, “Clinicians urge prevention and early, aggressive treatment of herpes”, provides guidance from a panel of respected colleagues, all of whom offer a wealth of experience in diagnosing, treating and preventing herpetic ocular disease. While some of their comments validate existing practice patterns and others shed light on herpetic controversies, all are timely – no doubt an important consideration in a condition where time is of the essence.
- Reference:
- Borkar DS, et al. JAMA Ophthalmol. 2014;132(3):326-31;doi: 10.1001/jamaophthalmol.2013.6277.