Medline ® Abstracts for References 25-28

Studies in the basic and clinical sciences have yielded new information about the biology, infection, latency, and recurrence of the varicella-zoster virus. Contrast is made with the herpes simplex virus. The host-viral relationship is an extremely dynamic one with clinical disease being determined primarily by the host cellular immune system. The complications of herpes zoster ophthalmicus are related to multiple mechanisms including viral growth, vascular and neural damage, and the host-immune response to infection. There are several laboratory tests available for confirming the diagnosis or determining the immune status. Systemic acyclovir administered early in the course alleviates many of the symptoms of herpes zoster ophthalmicus. Acute and postherpetic neuralgia remain significant and enigmatic problems; an update of therapeutic options is offered. The role of corticosteroids in herpes zoster ophthalmicus is scrutinized along with the potential and uncertainties of a varicella-zoster virus vaccine.

OBJECTIVE: To determine the frequency of complications and adverse outcomes due to herpes zoster ophthalmicus before and after the introduction of oral antiviral medications in a community-based setting.

METHODS: We identified all Olmsted County, Minnesota, residents diagnosed with acute herpes zoster ophthalmicus from 1976 through 1998. The frequencies of complications within 6 months of disease onset were compared between untreated patients vs those treated with antivirals.

MAIN OUTCOME MEASURES: Defined complications were ocular sequelae due to herpes zoster ophthalmicus. Adverse outcomes included visual acuity of 20/200 or worse, trichiasis, or eyelid malposition requiring surgical treatment.

RESULTS: A total of 202 patients had been treated with antivirals, and 121 had not. Neurotrophic keratitis was the only complication that was less likely in the treated group (3.3% vs 0%; P =.02). The probability of an adverse outcome at 5 and 10 years was 8.9% among untreated patients and 2.1% among treated patients (P =.009). Among patients whohad been treated, the mean time from symptom onset to initiation of therapy was 4.8 days in those who developed stromal keratitis, corneal edema, scleritis, uveitis, or glaucoma compared with 3.8 days in those who did not (P =.006).

CONCLUSIONS: Neurotrophic keratitis was less frequent among patients who received antiviral therapy. However, among treated patients, development of a serious inflammatory complication was associated with a delay in therapy. Most important, adverse outcomes were less probable in the treated group. These data may support the early and routine use of systemic antiviral therapy for acute herpes zoster ophthalmicus.

Systemic acyclovir (ACV), a new potent anti-herpes drug, was shown to reduce effectively the morbidity in the acute phase of herpes zoster ophthalmicus (AHZO). Using high dose oral ACV (5 X 800 mg/day) our aim in this study was: (1) to compare disease profiles in the ACV-treated group and in a group of zoster patients having had no ACV, analysed retrospectively; (2) to establish if high-dose ACV was able to prevent severe long term complications of AHZO; and (3) to determine the present role of corticosteroids in AHZO. From 1984 to 1988, 48 patients with AHZO of less than 3 days' duration were included. All patients received at least 7 days of oral ACV (5 X 800 mg/d) associated with topical ACV. Steroids were not given unless severe uveitis occurred. Follow-up was 2 years in 43 patients and 1 year in all 48 patients. Main conclusions from our study are: 1. Ocular involvement occurred in 67% of ACV-treated cases, a rate comparable to our retrospective group (59%) and to the literature (71%). However the rate of severe long term complications was minimal (4%) when compared to our non-treated retrospective group (21%). 2. Steroid treatment was not necessary in any of the ACV-treated patients. 3. ACV was well tolerated and did not have to be discontinued in any of the patients. High dose ACV and avoidance of steroids seems to eliminate the severe complications of AHZO.