Herpes Eye Infections

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Basics

Description

  • 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: 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)

Epidemiology

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)

Incidence

  • 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 US; 25–40% develop ophthalmic complications. Temporary keratitis is most common.

Prevalence

  • Ocular HSV prevalence estimated at 500,000 in the United States (1)
  • VZV: Prevalence of herpes zoster infection is 20–30%. Ocular involvement in 50% if not treated with antivirals (2); overall lifetime prevalence of HZO: 1%

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).

Risk Factors

  • 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
  • HZO
    • History of varicella infection, advancing age (>50 years), sex (female > male), acute/painful prodrome, trauma, stress, immunosuppression (1),(3)
ALERT
Consider primary/secondary immunodeficiency disorders in all zoster patients <40 years of age (e.g., AIDS, malignancy).

General Prevention

  • Contact precautions with active lesions (HSV and VZV)
  • VZV can be spread to those who have not had chickenpox, are not immunized, or are not immune.
  • 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, although no longer available in the United States (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)
ALERT
Zoster vaccination with live vaccine (Zostavax) is contraindicated if HIV positive or other immunocompromised state, pregnancy, or in active untreated tuberculosis (TB).

Pregnancy Considerations

  • 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

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Basics

Description

  • 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: 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)

Epidemiology

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)

Incidence

  • 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 US; 25–40% develop ophthalmic complications. Temporary keratitis is most common.

Prevalence

  • Ocular HSV prevalence estimated at 500,000 in the United States (1)
  • VZV: Prevalence of herpes zoster infection is 20–30%. Ocular involvement in 50% if not treated with antivirals (2); overall lifetime prevalence of HZO: 1%

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).

Risk Factors

  • 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
  • HZO
    • History of varicella infection, advancing age (>50 years), sex (female > male), acute/painful prodrome, trauma, stress, immunosuppression (1),(3)
ALERT
Consider primary/secondary immunodeficiency disorders in all zoster patients <40 years of age (e.g., AIDS, malignancy).

General Prevention

  • Contact precautions with active lesions (HSV and VZV)
  • VZV can be spread to those who have not had chickenpox, are not immunized, or are not immune.
  • 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, although no longer available in the United States (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)
ALERT
Zoster vaccination with live vaccine (Zostavax) is contraindicated if HIV positive or other immunocompromised state, pregnancy, or in active untreated tuberculosis (TB).

Pregnancy Considerations

  • 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

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