June 2018

COVER FEATURE

Neuro-ophthalmology for the anterior segment surgeon
Neuro-ophthalmic manifestations of varicella zoster virus


by Ellen Stodola EyeWorld Senior Staff Writer/Digital Editor


Herpes zoster ophthalmicus is an issue that patients may present with, but anterior segment surgeons may not be as familiar with the neuro-ophthalmic manifestations of the varicella zoster virus.
Source: Karl Brasse, MD



Experts discuss what to look for in terms of neuro-ophthalmic signs of VZV and how to treat it

While anterior segment surgeons may have patients presenting with herpes zoster ophthalmicus, some may not be as used to dealing with the neuro-ophthalmic manifestations of the varicella zoster virus (VZV). Karl Golnik, MD, Cincinnati Eye Institute, Cincinnati, and Sachin Kedar, MD, University of Nebraska Medical Center, Omaha, shared some of the neuro-ophthalmic manifestations of VZV, as well as what they would recommend in terms of medications and how to deal with these patients.

Neuro-ophthalmic manifestations of VZV

Dr. Kedar said that zoster patients with neuro-ophthalmological complications might present to an ophthalmologist with sudden vision loss from optic nerve involvement, double vision from orbital or cranial nerve involvement, or post-zoster herpetic neuralgia, a debilitating pain syndrome. Patients may also have a cerebral vasculitis, or inflammation of the small blood vessels in the brain, that can manifest with headache, confusion, and visual complaints.
Dr. Golnik has published papers recently on different cranial nerve problems, specifically optic neuropathy and double vision presumed to be due to herpes. Usually when he sees these patients, the rash on their face is evident, and they may present with either loss of vision in one eye or double vision.

If neuro-ophthalmic complications occur, isthere a temporal relationship with intraocular or corneal involvement?

According to Dr. Golnik there is not a temporal relationship with intraocular or corneal involvement when neuro-ophthalmic complications of VZV occur. “Not as far as we know,” he said. “Many patients we see don’t have the usual herpes zoster ophthalmicus.”
When a patient comes in with optic neuropathy, sometimes there is swelling of the optic nerve in back of the eye and sometimes there isn’t, he said. These patients don’t necessarily have anything going on in the cornea or front of the eye, but they could possibly have anterior or retrobulbar optic neuropathy.
“In a majority of patients, both in my personal experience and reported literature, the timeline is variable,” Dr. Kedar said. While some patients report a recent history of herpes zoster ophthalmicus, others present with neuro-ophthalmic complications weeks or months after the original event.

Would you recommend patients with these complications for hospital admission?

Some of the complications may require hospital admission, Dr. Kedar said, especially those with neurological complaints such as altered cognition, severe headaches, neck pain, and other similar symptoms. All patients with acute vision loss or double vision after herpes zoster ophthalmicus should have urgent imaging and possibly a lumbar puncture, he added. Patients with clear evidence of neurological herpes zoster will need intravenous antiviral medications.
“I am a neurologist, so I err on the side of caution and I generally get them into the hospital to facilitate diagnostic studies and start intravenous antivirals when indicated,” he said.
Dr. Golnik agreed that some patients may need to be admitted to the hospital, while others do not. He usually does not admit a patient to the hospital if the symptoms are isolated to optic neuropathy or double vision.
He added that it’s possible to have varicella zoster in the brain and have meningitis and other neurologic symptoms. If they have other systemic neurologic symptoms, patients get admitted to the hospital and have MRIs and lumbar punctures to prove herpes zoster in the spinal fluid, he said.

Preferred medications

Oral antiviral medications are usually sufficient in most patients with isolated neuro-ophthalmological problems, Dr. Kedar said. However, patients who have neurological signs or symptoms, abnormal MRI brain or abnormal CSF studies suggesting central nervous system varicella zoster infection should be treated with intravenous antiviral medications, he added.
Dr. Golnik said there is no real scientific data on using a combination of medications. He noted that particularly for patients presenting with double vision, there is a high likelihood for recovery of single binocular vision with oral antivirals, and he added that it’s hard to show that intravenous antivirals can guarantee better outcomes. “Since these patients are virtually always treated with antivirals, we don’t know what happens if they are not,” he said. It is possible spontaneous improvement in double vision would occur as well.

How patients with neuro-ophthalmic outcomes of VZV generally do

Dr. Golnik said that in terms of outcomes for patients with neuro-ophthalmic manifestations of VZV, you have to separate the patients into those with optic nerve vision loss and those with double vision.
From a double vision standpoint, he said that the vast majority of patients have good recovery of function and resolution of double vision. He found that more than 90% of patients had recovery of single binocular vision.
Meanwhile, for those with optic nerve vision loss, Dr. Golnik said that there are fewer cases, and results tend to be extremely variable. “I tell patients their vision could improve back to normal or not at all,” he said. Some patients are left legally blind in one eye and some patients recover to better than 20/30 vision.
“In my experience, these people do very well as long as they do not have a significant neurological complication,” Dr. Kedar said. Antiviral treatment improves vision in about half of patients; however the degree of improvement is variable, he said. Patients with isolated double vision from cranial nerve or orbital involvement do very well with about 90% reporting single vision by 6–12 months.

Long-term antiviral prophylaxis

Dr. Golnik said that he doesn’t know of any evidence to support the use of long-term antiviral prophylaxis in these patients.
Dr. Kedar said that the only literature for long-term antiviral prophylaxis is for patients with acute retinal necrosis where they do 6 months of prophylactic treatment or in patients who are immunocompromised. He said that usually for a patient with zoster and neuro-ophthalmic complications, he will keep them on antiviral treatment for 3–6 months, although there is no evidence to support it.
“Prevention is better than cure,” Dr. Kedar said. Since herpes zoster is a disease of the elderly and immunosuppressed, he highly recommends that anyone above the age of 50 receives the shingles vaccine.

Editors’ note: Drs. Golnik and Kedar have no financial interests related to their comments.

Contact information

Golnik
: karl.golnik@uc.edu
Kedar: sachin.kedar@unmc.edu

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