Differential Diagnosis - Pacific University

5/29/2012
Diagnosis is primarily made based
on clinical features of the corneal
lesion **
Epithelial scrapings with Giemsa
stain:
• Show multinucleated giant cells
• Which are coalesced infected
corneal epithelial cells and
intranuclear viral inclusions 7
viral DNA can be detected in the:
• Corneal epithelium
• Conjunctiva
• Skin
• Anterior chamber tap
Negative cytology results do not
exclude HSV infection
Classic case of a multinucleated herpes simplex virus-infected cell 17
Enzyme-linked virus inducible system
(ELVIS)
• Very specific for detecting herpes virus
• Results in 24hrs!
ELVIS test result is negative
• Cell culture for confirmation is recommended
Cultures obtained within several days of onset, prior to
antiviral therapy give a sensitivity of up to 70%
Enzyme immunoassay (EIA) tests can be
performed in the office
• HerpChek
The Captia test (Trinity Biotech) is a
blood test to detect antibodies to the HSV
• Unlike other tests it can differentiate between
HSV -1 and HSV-2
Combined CORTICOSTEROID and antiviral therapy –
• Viroptic or Zirgan and Pred acetate 1%
• Acyclovir 3% ophthalmic ointment is available in Europe but not in the US
• Cycloplegia and topical lubricants are used to ease patient discomfort
Dosing
• Viroptic (trifluridine 1%) dosing – q2h up to a maximum 9x/day for 7-14 days, then QID for
1-2 days after complete epitheliazation (not to exceed 21 days due to toxicity)
• Zirgan (ganciclovir 0.15%)- q3h up to 5x/day typically 7-10 days–then taper to 1-3x/day
for 7 days
• Pred acetate 1% q1-2h initially then tapered
One common recommendation is:
• Equal frequency of topical antiviral with a corticosteroid
Conducted by the National Eye Institute
Herpetic Eye Disease Study (HEDS) I – 1996
• Focused on stromal keratitis treatment
• Anti-viral alone
• Anti-viral + corticosteroid
• Anti-viral + corticosteroid + acyclovir
Herpetic Eye Disease Study (HEDS) II- 1998
• Focused on epithelial disease
• Looked at early treatment with acyclovir if it prevented progression to stromal
disease
• Patients with previous HSV disease not active within 30 days, if longterm
low dose treatment with acyclovir prevented recurrence
Focused on stromal keratitis (3 groups)
• Anti-viral alone
• Anti-viral + corticosteroid
• Anti-viral + corticosteroid + acyclovir
Results
1. Duration of inflammation and risk of progression were
significantly reduced in patient’s receiving prednisolone
2. The rate of epithelial HSV recurrence was not increased
3. The addition of oral acyclovir to topical corticosteroid and
topical antivirals provided no additional benefit**
• The role of external factors in triggering recurrence
Coursebook Page 17 of 139
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