Systemic Antiviral Medications Research Articles

What is known about the diagnosis and treatment of herpes labialis?

Herpes labialis is one of the most common skin infections. In most people it is asymptomatic or mildly symptomatic, but very severe cases do occur. Herpes remains latent and can recur. Herpes labialis is a clinical diagnosis. If in doubt, additional testing can be carried out, usually polymerase chain reaction. There are no treatments that can eliminate the virus. In case of more severe symptoms and frequent recurrences, there may be an indication for treatment. In case of mild complaints, topical zinc sulphate/zinc oxide and analgesics (systemic or topical lidocaine) will suffice. More severe complaints and frequent recurrences can be treated with antiviral creams (Aciclovir) or with systemic antiviral medication (Valaciclovir). In frequent recurrences, prophylactic Valaciclovir can also be given for a period of many months. Treatment should be started as soon as possible and will slightly shorten the duration of the disease.

Acute appendicitis in pediatric patients with Coronavirus Disease 2019 (COVID-19): A case series from a developing country's tertiary hospital

Introductionand importance: A common gastrointestinal presentation of both COVID-19 and multisystem inflammatory syndrome in children (MIS-C) is acute abdominal pain, which sometimes mimics appendicitis. Literature describing children with COVID-19 infection and concurrent acute appendicitis is growing, and understanding these patients’ clinical picture is necessary for their proper treatment. Case presentationWe present a case series of six healthy children before they developed classic symptoms of appendicitis. At the same time, they were also found to have confirmed COVID-19. All patients had fever and right lower abdominal pain. Four of six children having Alvarado score above seven had surgical treatment, while the others only received systemic antibiotic and antiviral medication. Surgical results of two patients revealed perforated appendicitis. No mortality occurred among them. Clinical discussionThere is increasing recognition of gastrointestinal involvement in patients with COVID-19 and MIS-C. There are several postulates to explain appendicitis in COVID-19. First, inflammatory response is exaggerated in SARS-CoV-2 infected patients. Second, obstruction of the appendiceal lumen is caused by mesenteric adenopathy, which in turn, is caused by COVID-19 infection, not fecalith. Third, hyperinflammatory response in MIS-C triggers inflammation in appendix. ConclusionClinicians must recognize that abdominal pain with fever could be the presenting symptoms of COVID-19 with MIS-C. MIS-C, which has severe presentations with gastrointestinal manifestations and high mortality rate, should be considered as a differential diagnosis for a patient with appendicitis-like symptoms and a positive SARS-CoV-2 infection.

Como identificar uma manifestação oral de Herpes-Zoster?

O herpes-zóster é uma infecção viral causada pela reativação do vírus da varicela-zóster, que acomete geralmente a população idosa. O vírus da varicela, quando em estado dormente, se localiza nos gânglios trigeminais e quando reativado pode causar lesões no rosto e vesículas intra bucais. Esta doença pode afetar com maior prevalência pacientes imunossuprimidos e caracteriza-se por erupções maculopapulares distribuídas na região do nervo afetado, causando dores intensas, tremores e até parestesia. O diagnóstico do herpes zoster geralmente é estabelecido por meio do quadro clínico apresentado pelo paciente e o tratamento é voltado aos sintomas e à causa, optando pelo uso de medicações antivirais sistêmicas e tópicas. Este artigo relata o caso de uma paciente, do sexo feminino, leucoderma, sem problemas de saúde e tratamentos imunossupressores prévios, de 56 anos de idade, que deu entrada ao pronto socorro, tendo com queixa principal a dor extra oral em hemiface direita, com evolução rápida de três dias após exodontia.

How Can we Treat Recurrent Herpes Virus Infection Without the Use of Antiviral Drugs?

Statement of the problem: The herpes virus manifests as an eruption of red, painful blisters or sores in the skin, genitals, lips or eyes. In western medicine, the causative symptoms are related to herpes simplex 1, herpes simplex 2, and varicella-zoster viruses, often combined with a weakening of immune function. In Traditional Chinese Medicine (TCM), this entire process is indicative of Fire Toxin and Damp Heat. Purpose: To demonstrate that recurrent herpes virus infections can be treated without the use of antiviral drugs. Methods: Two case reports. The first, from an 8-year-old girl with recurrent periocular lesions on the right eye, with edema formation, small blisters, hyperemia and hyperchromic spots. The symptoms were treated several times with topical and systemic antiviral medication, with the condition showing improvement only shortly. The second case report, from a 60-year-old woman, with a condition of recurrent genital herpes virus type 2, which would not improve with the use of antiviral medication. Both patients were referred to an infectologist with a TCM background, who restructured the patient’s dietary habits, counselling that all hot energy foods should be avoided. Auricular acupuncture sessions with apex ear bloodletting were also performed. Results: A complete improvement of the conditions of both patients was obtained without using any antiviral drugs. Conclusion: It is possible to treat recurrent herpes virus infection without the use of antiviral drugs. To this end, it is important to see the patient as a whole and treat their energy imbalances by withdrawing their Heat process through acupuncture and dietary counselling.

Clinical Evaluation of Intravitreal Injection of Ganciclovir in Refractory Corneal Endotheliitis

ABSTRACTPurpose: To evaluate the efficacy and safety of intravitreal ganciclovir (GCV) injection in refractory endotheliitis.Methods: Retrospectively recruited 25 eyes with endotheliitis, proved by clinical manifestations, positive PCR for viral DNA and responded poor to topical and systemic antiviral medications. All patients received additional continued intravitreal GCV injections.Results: Cytomegalovirus (CMV), varicella zoster virus (VZV), and herpes simplex virus (HSV) DNA were detected in 64.0%, 28.0%, and 8.0% of the eyes, respectively. Within 2 weeks after the last injection, 16/25 eyes recovered corneal clarity; active keratic precipitates (KPs) were eliminated in 21/25 eyes; intraocular pressure (IOP) was controlled in 12/15 eyes with elevated IOP on study entry. Best-corrected visual acuity increased at the last follow-up (p = 0.016). Clinical recurrence occurred in three patients. No complications were detected.Conclusions: CMV endotheliitis was the main type of refractory endotheliitis. Despite its invasive nature, intravitreal GCV injection appears to be an effective method for refractory endotheliitis.

The necessity and optimal time for performing pars plana vitrectomy in acute retinal necrosis patients

BackgroundTo compare the efficacy of pars plana vitrectomy (PPV) at different time points to treat acute retinal necrosis (ARN) and to investigate the necessity of PPV for ARN.MethodsA retrospective review of the treatment options and outcomes of the ARN patients was performed. Thirty ARN patients (34 eyes) were included in this study. The eyes were divided into 3 groups depending on the treatment administered. In the medically treated group, there was no retinal detachment (RD) at the first visit. The routine group patients were treated with systemic antiviral medications, as well as with intravitreal antiviral injections. In the early PPV treatment group, there was no RD at the first visit. The early PPV treatment group patients were treated with systemic antiviral medications and PPV plus silicone oil tamponade and intravitreal injection. In the PPV group, there was RD at the first visit. The PPV group patients were treated with systemic antiviral medications and PPV plus silicone oil tamponade and intravitreal injection.ResultsIn the medically treated group, the mean baseline best corrected visual acuity (BCVA) (logMAR) was 1.38 ± 0.35. The BCVA was 1.21 ± 0.36 at the last visit for the medically treated group. In this group, one eye (12.5%) developed RD after 1 month of treatment. In the early PPV treatment group, the mean BCVA (logMAR) was 1.68 ± 0.26. The BCVA was 1.83 ± 0.21 at the last visit for the early PPV group. In this group, five eyes (29.4%) had recurrent RD before silicone oil removal. In the PPV group, the mean BCVA (logMAR) was 2.0 ± 0.35. The BCVA was 1.72 ± 0.34 at the last visit for the PPV group. In this group, one eye (11.1%) had recurrent RD before silicone oil removal. There were no significant differences among the three groups in the baseline BCVA and the BCVA at the last visit (p>0.05). There were no significant differences between the early PPV group and the PPV group in the recurrent RD rates (p = 0.38).ConclusionsProphylactic PPV showed no difference in recurrent RD rates or better BCVA. Therefore, prophylactic vitrectomy cannot prevent RD nor improve the prognosis of ARN based on our research.

Association Between Medications and Herpes Zoster in Japanese Patients with Rheumatoid Arthritis: A 5-year Prospective Cohort Study.

To investigate the association between medications and herpes zoster (HZ) in patients with rheumatoid arthritis (RA) given biological disease-modifying antirheumatic drugs (bDMARD) or conventional synthetic DMARD in the clinical setting during 5 years using the Registry of Japanese Rheumatoid Arthritis Patients on Biologics for Longterm Safety (REAL) database. We calculated the crude incidence rate (IR) of HZ treated with systemic antiviral medications in 1987 patients from the REAL database. To estimate the association between HZ and medications, a nested case control study was performed with 1:5 case-control pairs matched for age, sex, observation start year, and comorbidity (HZ case group, n = 43; control group, n = 214). We calculated OR and 95% CI of the use of bDMARD, methotrexate (MTX), and corticosteroids for the occurrence of HZ using a conditional logistic regression analysis. The median patient age was 60.0 years, female proportion was 81.5%, and median disease duration was 6.0 years. The crude IR (95% CI) of HZ was 6.66 (4.92-8.83)/1000 person-years. The OR (95% CI) of medication use were 2.28 (1.09-4.76) for tumor necrosis factor inhibitor (TNFi) and 1.13 (1.03-1.23) for oral corticosteroids dosage (per 1 mg prednisolone increment), both of which were significantly elevated. The OR of non-TNFi and MTX usage were not elevated. TNFi use and higher corticosteroids dosage were significantly associated with HZ in Japanese patients with RA in the clinical setting.

Cytomegalovirus Retinitis: A Review.

Cytomegalovirus (CMV) is a ubiquitous DNA herpes virus that causes significant morbidity and mortality in immunocompromised individuals. CMV retinitis is a potentially blinding manifestation of CMV infection that was commonly seen in advanced acquired immunodeficiency syndrome (AIDS) in the era before modern combination antiretroviral therapy era, but is also recognized in patients with immune deficiency from multiple causes. The advent of and advances in antiretroviral therapies for human immunodeficiency virus have decreased the incidence of CMV retinitis by over 90% among AIDS patients, and improved visual outcomes in those affected. The diagnosis is generally a clinical one, and treatment modalities include systemic and intravitreal antiviral medications. Retinal detachment and immune recovery uveitis are sight-threatening complications of CMV retinitis that require specific treatments.

Valacyclovir versus acyclovir for the treatment of herpes zoster ophthalmicus in immunocompetent patients.

Herpes zoster ophthalmicus affects the eye and vision, and is caused by the reactivation of the varicella zoster virus in the distribution of the first division of the trigeminal nerve. An aggressive management of acute herpes zoster ophthalmicus with systemic antiviral medication is generally recommended as the standard first-line treatment for herpes zoster ophthalmicus infections. Both acyclovir and its prodrug valacyclovir are medications that are approved for the systemic treatment of herpes zoster. Although it is known that valacyclovir has an improved bioavailability and steadier plasma concentration, it is currently unclear as to whether this leads to better treatment results and less ocular complications. To assess the effects of valacyclovir versus acyclovir for the systemic antiviral treatment of herpes zoster ophthalmicus in immunocompetent patients. We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register; 2016, Issue 5), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to June 2016), Embase (January 1980 to June 2016), Web of Science Conference Proceedings Citation Index-Science (CPCI-S; January 1990 to June 2016), BIOSIS Previews (January 1969 to June 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP; www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 13 June 2016. We considered all randomised controlled trials (RCTs) in which systemic valacyclovir was compared to systemic acyclovir medication for treatment of herpes zoster ophthalmicus. There were no language restrictions. Two review authors independently selected trials, evaluated the risk of bias in included trials, and extracted and analysed data. We did not conduct a meta-analysis, as only one study was included. We assessed the certainty of the evidence for the selected outcomes using the GRADE approach. One study fulfilled the inclusion criteria. In this multicentre, randomised double-masked study carried out in France, 110 immunocompetent people with herpes zoster ophthalmicus, diagnosed within 72 hours of skin eruption, were treated, with 56 participants allocated to the valacyclovir group and 54 to the acyclovir group. The study was poorly reported and we judged it to be unclear risk of bias for most domains.Persistent ocular lesions after 6 months were observed in 2/56 people in the valacyclovir group compared with 1/54 people in the acyclovir group (risk ratio (RR) 1.93 (95% CI 0.18 to 20.65); very low certainty evidence. Dendritic ulcer appeared in 3/56 patients treated with valacyclovir, while 1/54 suffered in the acyclovir group (RR 2.89; 95% confidence interval (CI) 0.31 to 26.96); very low certainty evidence), uveitis in 7/56 people in the valacyclovir group compared with 9/54 in the acyclovir group (RR 0.96; 95% CI 0.36 to 2.57); very low certainty evidence). Similarly, there was uncertainty as to the comparative effects of these two treatments on post-herpetic pain, and side effects (vomiting, eyelid or facial edema, disseminated zoster). Due to concerns about imprecision (small number of events and large confidence intervals) and study limitations, the certainty of evidence using the GRADE approach was rated as low to very low for the use of valacyclovir compared to acyclovir. This review included data from only one study, which had methodological limitations. As such, our results indicated uncertainty of the relative benefits and harms of valacyclovir over acyclovir in herpes zoster ophthalmicus, despite its widespread use for this condition. Further well-designed and adequately powered trials are needed. These trials should include outcomes important to patients, including compliance.

Complex management of resistant oral herpes simplex virus infection following hematopoietic stem cell transplantation: potential role of topical cidofovir

Herpes simplex virus (HSV) infection commonly occurs during the immunosuppression associated with hematopoietic stem cell transplantation (HSCT). Prophylaxis of recurrent infection and management of clinical infection have relied upon acyclovir and congeners. More recently, resistant HSV infection is seen in HSCT and presents new challenges in management. We present a case of HSV following HSCT that provided effective symptomatic management. Oral symptoms and lesions were repeatedly reduced when topical cidofovir was used, strongly supporting the effect of cidofovir used in a host who could not tolerate systemic antiviral medications. Topical cidofovir can provide effective management of symptomatic oropharyngeal HSV while reducing risk of systemic toxicity and drug interaction and represents an additional approach to management for management in medically compromised patients.

Clinical presentations of Herpes Zoster Ophthalmicus (diagnosis and therapy)

To study and summarize clinical features of HZO (including the rate of complications and their nature) and to determine the relationship between clinical and laboratory data from these patients. The study included 133 patients with ophthalmic and neurological complications of HZO (group 1 (n=28) - retrospective analysis of outpatient records for the period 1995-2005; group 2 (n=95) - a prospective study for the period 2005-2015), who received a course of conservative treatment in either the Botkin City Hospital, branch № 1, or in the ophthalmic department of the Moscow herpes centre (Gerpeticheskiy Tsentr Ltd.). Laboratory tests were performed only in patients from group 2 and included: examination of biological fluids for six types of herpes viruses by polymerase chain reaction, examination of tears and urine for DNA of Chlamydia, Mycoplasma, and Ureaplasma, and serological blood testing for markers of herpes virus infection. Patients from group 1 were prescribed topical antiviral, antibacterial, and anti-inflammatory therapy, in rare cases - acyclovir per os. In group 2, the treatment included systemic antiviral medications and immune correction therapy. Anti-inflammatory therapy consisted of local and systemic non-steroidal agents (NSAIDs). The most common ophthalmic complications of HZO in both groups were stromal keratitis and keratoiridocyclitis, neurological - III and VI cranial nerves palsies. The duration of the disease in the first group ranged from 2 months to 3 years; in the second group, patients were divided into two subgroups: subgroup A with the disease duration of no more than one month (n=81) and subgroup B with the disease duration from 1.5 to 9 months (n=14). Varicella-zoster virus (VZV) DNA was present in tears and/or other biological fluids of patients from group 2 in more than 70% of cases (n=67). Particularly, in 27.4% of cases the virus was isolated in two fluids and in 7.4% of cases - in three fluids. The duration of virus production in tears and other biological fluids (saliva, blood, and urine) ranged from 10 days to 4 months. Topical non-steroidal anti-inflammatory drugs and systemic etiological treatment in case of intraocular inflammation in HZO patients may reduce the risk of severe consequences of VZV reactivation and help avoid recurrences later in life.

The impact of donor age and endothelial cell density on graft survival following penetrating keratoplasty

PurposeTo determine if donor age and preoperative endothelial cell density (ECD) affect corneal endothelial failure following penetrating keratoplasty (PK).MethodsPreoperative and postoperative data for PKs performed in the UK between April...

Postoperative Hemorrhagic Occlusive Retinal Vasculitis: Expanding the Clinical Spectrum and Possible Association with Vancomycin

To describe a syndrome of hemorrhagic occlusive retinal vasculitis (HORV) that developed after seemingly uncomplicated cataract surgery. Retrospective case series. Eleven eyes of 6 patients from 6 different institutions. Cases were identified after discussion among retina specialists. The findings on presentation, clinical course, and outcome of a series of 7 eyes of 4 patients were compared with a previous report of 4 eyes of 2 patients, and data from both series were combined for a comprehensive analysis. Historical data, examination findings, imaging results, systemic evaluation findings, treatment regimens, and visual outcomes. Eleven eyes of 6 patients underwent otherwise uncomplicated cataract surgery, receiving viscoelastic and prophylactic intracameral vancomycin during the procedure. Despite good initial vision on postoperative day 1, between 1 to 14 days after surgery, all eyes demonstrated painless vision loss resulting from HORV. Extensive ocular and systemic evaluations were unrevealing in all patients. All patients were treated with aggressive systemic and topical corticosteroids. Additional treatments included systemic antiviral medication in 4 patients, intravitreal antibiotics in 4 eyes, and pars plana vitrectomy in 4 eyes. Skin testing for vancomycin sensitivity showed negative results in 3 patients and was not performed in the others. Neovascular glaucoma developed in 7 eyes, and all eyes received intravitreal anti-vascular endothelial growth factor (VEGF) injection, panretinal photocoagulation, or both for retinal ischemia. Final visual acuity was less than 20/100 in 8 of 11 eyes. Postoperative HORV is an exceedingly rare and potentially devastating condition that can occur after otherwise uncomplicated cataract surgery. Although the precise cause remains unknown, this disease may represent a delayed immune reaction similar to vancomycin-induced leukocytoclastic vasculitis. Despite treatment with high-dose corticosteroids, antiviral medication, and early vitrectomy in many patients, visual outcomes typically were poor in this series. Early intervention with intravitreal anti-VEGF medication and panretinal photocoagulation may help to prevent additional vision loss resulting from neovascular glaucoma.

Advances in the management of acute retinal necrosis.

Acute retinal necrosis is a viral syndrome characterized by a panuveitis with necrotizing retinitis that may be complicated by retinal detachment, vaso-occlusion, optic neuropathy, and other causes of decreased visual acuity. Polymerase chain reaction testing provides a rapid and sensitive method of identifying the viral etiology of acute retinal necrosis, which is most commonly caused by herpes simplex virus type 1, herpes simplex virus type 2, and varicella zoster virus. Prompt diagnosis and treatment is paramount to prevent further vision loss. We review the management of acute retinal necrosis including systemic, local intravitreal, and combination antiviral medications. We also discuss the appropriate and inappropriate use of corticosteroids, laser retinopexy, surgical therapy, and other adjunctive measures.

Bilateral ischemic maculopathy in acquired immune deficiency syndrome

BackgroundThis brief report aims to report a case of bilateral macular ischemia as a cause of sudden decreased vision in a patient with acquired immune deficiency syndrome (AIDS).FindingsA 26-year-old male with disseminated cryptococcal meningitis, Candida thrush, Pneumocystis jiroveci pneumonia, and positive human immunodeficiency virus (HIV) infection with CD4 count of 4 cells/μl complained of sudden blurred vision in both eyes while on treatment with systemic antiviral, antifungal, and antibiotic medications. Ocular examination revealed HIV retinopathy changes with significant macular ischemia in both eyes, which was confirmed by fluorescein angiography. One dose of intravitreal foscarnet (1.2 mg/0.1 cc) was injected in both eyes. Laboratory work-up of serum and vitreous samples showed negative cytomegalovirus (CMV) titers. At 2 weeks of follow-up, he was started on treatment with atripla, a combination anti-retroviral therapy for AIDS. At 6 weeks of follow-up, there was an improvement in visual acuity and clinical findings.ConclusionsNoninfectious HIV retinopathy in AIDS is common, but bilateral macular ischemia is a rare presentation. It is important to rule out CMV retinitis as it is a major cause of visual morbidity among AIDS patients.

幼儿急性视网膜坏死之病例报告

目的：报告一个5岁女童罹患急性视网膜坏死之少见病例。方法：病例报告。结果：一名5岁女童因多日前突发性右眼红痛及视力模糊而求诊，病患于1岁时曾有疱疹病毒性脑炎之病史。眼科理学检查发现右眼视力为0.1，左眼为1.0。裂隙灯检查发现右眼前房及玻璃体皆有中度炎症反应，视网膜周边则出现坏死性区域。由于其典型之眼底病灶，故诊断为急性视网膜坏死，并开始给予静脉注射Acyclovir及类固醇眼药水治疗。儿科检查和实验室测试，包括免疫测试，都是正常的。十天后改为口服Valaciclovir并加上口服类固醇治疗。药效初期反应良好，三星期后视网膜坏死区域已减少，患眼视力也进步至0.3；口服类固醇逐步减量，原先之病灶于4星期后皆已消失，仅留下视网膜色素层变化，但于治疗7星期后倂发裂孔性视网膜剥离。结论：我们报告一例急性视网膜坏死发生于5岁女童之少见病例，病患经全身性抗病毒药物合倂口服类固醇治疗后一度恢复良好，但于治疗7星期后倂发裂孔性视网膜剥离。 Purpose: To report an uncommon case of acute retinal necrosis in a 5-year-old girl. Methods: Case report. Results: A 5-year-old girl presented with redness, ocular pain and blurred vision present for few days on the right eye. The past medical history revealed herpetic encephalitis at the age of 1. On examination, visual acuity was 6/60 on the right and 6/6 on the left. Slit-lamp examination showed moderate anterior uveitis and vitritis in her right eye. Fundoscopy showed large areas of peripheral circumferential retinal necrosis. Under the diagnosis of acute retinal necrosis due to its typical fundus lesions, treatment with intravenous Acyclovir and topical steroid eyedrops were started immediately. Pediatric examination and laboratory testing, including immunologic tests, were normal. After 10 days, treatment was changed to oral Valaciclovir and Prednisolone. Topical treatment was tapered gradually. The response was well initially, with resolution of retinitis patches and improvement of visual acuity to 6/20 in 3 weeks. Oral steroids were gradually reduced, and original lesions completely disappeared in 4 weeks, leaving only retinal pigment epithelial change. Seven weeks later, vision dropped to counting finger on the right due to rhegmatogeous retinal detachment. Conclusion: We report an uncommon case of acute retinal necrosis in a 5-year-old girl. This patient responded well to systemic antiviral medication and steroid initially but developed rhegmatogeous retinal detachment 7 weeks later.

Perifosine-Related Rapidly Progressive Corneal Ring Infiltrate

To report a case of unilateral rapidly progressing corneal ring infiltration in a patient being treated with the investigational drug perifosine for Waldenström's macroglobulinemia. Interventional case report. A 55-year-old woman who was receiving treatment with perifosine for Waldenström's macroglobulinemia developed a corneal ring infiltrate in her left eye. She was treated with topical antibiotics and systemic antiviral medication, but the ring infiltrate continued to expand, resulting in complete stromal opacification and a total epithelial defect. Repeated microbiologic tests, including corneal biopsy, failed to identify an infectious agent. Weeks after instituting systemic immunosuppressive medications, including corticosteroids and cyclophosphamide, the ocular inflammation gradually resolved with corneal re-epithelialization and severe stromal neovascularization. Patients treated with perifosine should be monitored for ocular adverse events. Perifosine-related corneal infiltration may progress rapidly and, after appropriate microbiologic examination, aggressive anti-inflammatory therapy should be considered.

Multilayer amniotic membrane transplantation for treatment of necrotizing herpes simplex stromal keratitis

To evaluate the efficacy of multilayer amniotic membrane transplantation (AMT) combined with antivirus and corticosteroid drug to treat necrotizing herpes simplex stromal keratitis. Thirteen patients (13 eyes) of necrotizing stromal keratitis were referred to Shandong Eye Institute and Qingdao Eye Hospital between January 2003 and April 2004. The course of disease was 3 - 22 months (mean 15 months). Corneal inflammation persisted and corneal ulcer progressed despite topical and systemic antiviral treatment for over 1 weeks. Multilayer amniotic membrane transplantation was performed after excluding of bacterial and fungal infection by microbiologic studies including smears and cultures of necrotic corneal tissue and confocal microscope. Topical and systemic antiviral medications were given with adjuvant corticosteroid eyedrops postoperatively. We investigated the healing of corneal ulcer and improvement of stromal edema with slit lamp biomicroscope, the integrity of corneal defect with fluorescein staining, the migration of healthy corneal epithelial cells and transformation of amniotic membrane with confocal microscopy. All patients were followed up for 3 - 13 months (mean 10 months). Corneal ulcer healed within 1 - 3 weeks postoperatively with negative fluorescein staining. Corneal stromal edema faded away within 1 month. Superficial amniotic membrane patches dissolved or shed on postoperative day 7 - 10, while the deeper grafts were adhered into the ulcer and fused with the surrounding fibroblasts. One of these grafts remained in situ more than 3 months. Confocal microscope examination indicated flat epithelial progenitor cells on the surface of residual amniotic membrane. Corneal transparence was achieved in 7 eyes, macula in 4 eyes and leucoma in 2 eyes 3 months after the operation. No recurrence of necrotizing stromal keratitis was occurred in 13 patients during the follow-up period. Multilayer AMT combined with antivirus and corticosteroid treatment is an effective method to treat necrotizing herpes simplex stromal keratitis.

Diffuse granulomatous necrotizing scleritis

A 34-year-old man presented with anterior scleral thinning in the right eye (RE) and a painful nodular scleritis in the left eye (LE). Fundus examination showed a healed vasculitis and an inferior epiretinal neovascular membrane in the LE. Topical and systemic oral steroids and antiviral medication were prescribed. One year later, optic disc hyperaemia and swelling and macular oedema became apparent in the LE. Pulsed intravenous steroids were administered for 1 year, when a nasal septum perforation and vitreous haemorrhage in the LE were diagnosed. The eye was enucleated 3.5 years after the initial complaint. Necrotizing granulomatous tissue replacing the sclera and subconjunctival granulomatous tissue were observed. Six months later, oedema and neovascularization of the right optic disc were observed and cyclophosphamide was started, with regression of the clinical signs. No systemic abnormalities have so far become apparent. Posterior scleritis is most often observed in patients with no signs of associated systemic autoimmune disease. The diagnosis in this case is most probably one of Wegener's granulomatosis (WG). In WG, the diagnosis is based on necrotizing granulomas of the respiratory tract, generalized focal necrotizing vasculitis and focal necrotizing glomerulonephritis. Eye involvement with WG has been reported in up to 58% of cases. Evaluation of the scleritis patient should include a detailed medical history, chest X-rays, blood tests, autoantibody serology and analysis of urinary sediment. Cyclophosphamide is the treatment of choice for patients with ocular manifestations of WG, polyarteritis nodosa or rheumatoid arthritis, either alone or in combination with systemic steroids. Visual loss is expected in 85% of individuals with severe necrotizing posterior scleritis.

Herpes zoster virus infection

The virology, pathophysiology, and treatment of the varicella zoster virus (VZV) have been investigated for many years now. Infection with VZV has different ramifications for people of different ages and immune status. The various aspects of VZV disease make it difficult to treat. Selected aspects of VZV disease that pertain to ocular disease are presented. The risk factors for VZV disease in the different age spectrums and with concomitant immunodeficiencies have been further clarified. Studies suggest that the VZV may persist for prolonged periods on the cornea after herpes zoster ophthalmicus (HZO). Herpes Simplex Virus (HSV) or VZV may cause many cases of idiopathic uveitis with sectoral iris atrophy. The different patterns of retinal disease caused by VZV may relate to the immune status. Systemic antiviral medications for herpes zoster should be instituted within 72 hours of the rash but could be used later. Systemic antivirals combined with systemic corticosteroids improve the early quality of life in HZ patients. Postherpetic neuralgia is not prevented by early systemic antivirals or corticosteroids. Present systemic antivirals are all effective, but Famvir offers the best dosing schedule. The VZV vaccine is effective but there are some issues that suggest the need for a different vaccination regimen. Further research must be performed on the clinical and therapeutic aspects of the VZV disease. Although both the vaccine and systemic antivirals have brought tremendous improvements, the disease persists. Therapy lessens but does not eliminate many of the complications. The disease may manifest in unpredictable patterns in this era of vaccination.