Herpes simplex virus dermatitis in patients using latanoprost

Ocular Surface Disease and Anti-Glaucoma Medications: Various features, Diagnosis, and Management Guidelines

PURPOSE

Assessment of ocular surface in patients using anti-glaucoma medications (AGM) is rarely a priority for clinicians since glaucoma management targets intraocular pressure and preserves vision. This review summarizes the various adverse effects of topical AGM on the ocular surface and highlights the importance of ocular surface assessment in these patients.

METHODS

A literature search of articles (English only) on the subject matter was conducted focusing on recent articles published in the past 5 years.

RESULTS

The use of multiple anti-glaucoma medications in glaucoma patients increases patients' exposure to the drug and the preservatives present in these medications. Long-term use of these medications has deleterious effects on the conjunctiva, cornea, eyelids, and periocular tissues like trichiasis, entropion, symblepharon, forniceal shortening, punctate keratopathy, non-healing epithelial defects, and pannus. Treatment requires drug withdrawal or substitution by oral or topical non-preserved and less toxic preparations of AGMs. The ocular surface and symptoms can improve if the condition is diagnosed early and after drug withdrawal in over 90% of eyes. However, stopping or changing AGMs can often present with its own unique set of challenges in intra-ocular pressure control which may often need glaucoma surgery in close to 20% of eyes for IOP control.

CONCLUSION

Topical antiglaucoma medications (with their preservatives) can induce severe ocular surface and periorbital changes. Early identification and withdrawal of the offending drug/preservative can help to reverse the changes except in eyes with extensive cicatrization.

Overview and update on cytomegalovirus-associated anterior uveitis and glaucoma

Cytomegalovirus anterior uveitis is the most common ocular inflammatory disease caused by cytomegalovirus infection. It mainly occurs in middle-aged males with competent immunologic function, and the incidence is higher in Asia. The clinical manifestations vary from Posner-Schlossman syndrome and corneal endotheliitis to Fuchs uveitis syndrome, and are often accompanied by intraocular hypertension. Secondary glaucoma is a potentially blinding ocular complication with a pathogenesis that includes complicated immunological factors, intraocular inflammation, different types of angle abnormalities, and the administration of steroids, which may result in physical discomfort and visual impairment. Diagnostic tests, such as the polymerase chain reaction, optical coherence tomography, ocular microscopy, and confocal microscopy, might help in identifying anterior uveitis caused by other viruses. Combinations of antiviral medications and anti-inflammatory agents are effective treatments. If pharmacological therapy cannot reduce intraocular pressure or slow the progression of glaucomatous optic neuropathy, surgical intervention is required as a last resort.

Impact of the use of anti-glaucoma medications on the risk of herpetic keratitis recurrence

PURPOSE

Numerous case reports have associated anti-glaucoma medications with recurrence of herpes simplex virus (HSV) and herpes zoster virus (HZV) keratitis. The aim of our study was to determine whether different anti-glaucoma agents are associated with recurrence of herpetic keratitis.

METHODS

This was a retrospective cohort study using health databases from a Canadian province from January 2001 to December 2012. A new cohort of users on topical prostaglandins (PGs), beta blockers (BBs), alpha-2 agonists (AAs) and carbonic anhydrase inhibitors (CAIs) was created. The date of the third anti-glaucoma drug dispensation within 90 days was deemed the index date of the case. Herpetic keratitis events, as defined by an ICD-9/10 code for HSV or HZV keratitis, or the dispensation of an anti-viral medication by either an ophthalmologist or an optometrist, were examined prior to and following the index date. Risk ratios (RRs) were computed to compare the risk of HSV/HZV keratitis among the PG, BB, AA, and CAI groups individually and collectively while adjusting for age and sex.

RESULTS

Among 19,986 users of glaucoma medications identified, there were 684 cases of HSV/HZV keratitis. There was no increased risk of HSV/HZV keratitis recurrence for any of the four glaucoma medications classes individually or collectively when adjusted for age and sex. There was also no increased risk for redeveloping either HSV keratitis only or HZV keratitis only amongst all anti-glaucoma users.

CONCLUSION

There is no association between the use of topical ocular hypotensive therapies and HSV/HZV keratitis recurrence. Further studies are needed to confirm these findings.

[Latanoprost in hypotensive therapy of glaucoma]

The review presents an analysis of therapeutic effectiveness, safety and pharmacokinetics of latanoprost - the reference representative of the prostaglandin group, summarizes the experience of its clinical use in glaucoma as monotherapy and in combination with antihypertensive drugs of other pharmacological groups, its possible effect on the inflammatory process in the anterior segment of the eye, as well as its probable participation in the development of macular edema. The article also gives a recount of relevant local and systemic adverse events.

Reactivation of herpes simplex viral keratitis following the botulinum toxin injection

We describe a case of 55-year-old male farmer presented with recurrent corneal abrasions with a spastic entropion in the left eye. Superior cornea showed typical nummular opacities suggestive resolved herpetic eye diseases. On further enquiry, he had similar episodes in the past. Contralateral eye was essentially normal. Following the botulinum toxin injection for the management of spastic entropion, subject developed reactivation of herpetic necrotizing stromal keratitis. Diagnostic corneal scrapings were negative for herpes simplex virus-1 antigen by immunofluorescence assay and for DNA by molecular techniques. The case was successfully managed with topical steroids and antiviral medications.

Allergic Contact Dermatitis Caused by Latanoprost Ophthalmic Solution

PURPOSE

Latanoprost is a prostaglandin F2 alfa analog that lowers intraocular pressure by increasing uveoscleral outflow. Herein we describe two cases of allergic contact dermatitis (ACD) to latanoprost.

METHODS

A 69-year-old man with open-angle glaucoma developed erythematous erosive swelling of bilateral eyelids after 4 months of latanoprost therapy. An 84-year-old man with open-angle glaucoma had pruritic erythematous plaques on the bilateral lower eyelids after latanoprost therapy for 4 months.

RESULTS

In both cases, latanoprost was discontinued and the condition gradually resolved in 1 month. The eyelid lesions recurred in days upon latanoprost rechallenge, but subsided after cessation of rechallenge.

CONCLUSIONS

ACD should be suspected if patients on latanoprost therapy have pruritus, erythema, swelling, or erosions on the eyelids even when the symptoms appear after several months of therapy, especially in the elderly.

A review of the use of latanoprost for glaucoma since its launch

INTRODUCTION

Prostaglandins are increasingly used as first choice treatment for glaucoma because they are highly effective, lack relevant systemic side effects and require just once-daily administration. Latanoprost is an ester prodrug analog of prostaglandin F2α, which reduces intraocular pressure (IOP) by increasing uveoscleral outflow. Latanoprost 0.005% has received European and US approval as the first-line drug for reducing IOP in patients with open-angle glaucoma or ocular hypertension. Following the recent patent expiry for Xalatan®, a number of latanoprost generics have entered the glaucoma market.

AREAS COVERED

This review, achieved through PubMed and Medline research methods, describes the composition, pharmacokinetics, mode of action, efficacy, side effects and safety profile of latanoprost.

EXPERT OPINION

Latanoprost was the first prostaglandin analog introduced in glaucoma management and it dramatically changed the market of the disease thanks to its efficacy and safety. Conjunctival hyperemia, which is commonly found after latanoprost use, is associated with a minor efficacy and duration of trabeculectomy; yet, from the ophthalmologist's perspective, this side effect seems largely counterbalanced by the high efficacy and safety of this compound. It is always advisable to consider the pro-inflammatory mode of action of latanoprost because this may have negative effects in particular patients (i.e., those with uveitis and cystoid macular edema) for whom caution and close follow-up is necessary.

The management of glaucoma and intraocular hypertension: current approaches and recent advances

In the last decade, numerous novel ocular hypotensive agents have been introduced for the control of intraocular pressure (IOP). Clinicians now have more options than ever in the selection of medical therapy for the treatment of glaucoma and ocular hypertension. When selecting an ocular hypotensive medication for their patients, clinicians should consider not only the IOP-lowering efficacy of an agent, but also the ability of the drug to allow patients to achieve target levels of IOP that are low enough to stop the progression of glaucomatous damage. Other considerations should include how well the drug controls diurnal IOP, the likelihood of serious adverse events, the versatility of the medication for use as an adjunctive agent, as well as other potential attributes (ie, neuroprotection).

Effects of common topical antiglaucoma medications on the ocular surface, eyelids and periorbital tissue

Glaucoma affects millions of people around the world. With the baby boom generation aging, the number of people affected by primary open-angle glaucoma in the US is expected to reach 3.3 million by 2020, and about half may not know they have the disease. The treatment of most forms of glaucoma includes the use of topical agents that enhance aqueous humour outflow, reduce aqueous production, or both. Topical intraocular pressure-lowering drugs must penetrate across the tissues of the eye to reach their therapeutic targets. Often, these tissues show the first signs and symptoms of drug toxicity and adverse effects. These include eyelid dermatitis, malpositions, lacrimal system scarring, ocular discomfort upon instillation, tear film instability, conjunctival inflammation, subconjunctival fibrosis, conjunctival epithelium changes, and corneal surface and endothelial impairment. For these reasons, ophthalmologists should evaluate the risks and benefits of ophthalmic medications before initiating therapy, identify the minimum dosages necessary to achieve a therapeutic benefit, and monitor patients for local and systemic adverse effects. Adverse events may be reduced by changing to a different class of topical medication, using corticosteroids, lubricating the eyes frequently, and reducing exposure to preservatives. This in turn can lead to higher levels of adherence to antiglaucoma therapy, improved outcomes and a reduction in the costs associated with long-term glaucoma complications. This article reviews the ocular adverse effects associated with the various classes of topical antiglaucoma drugs, with a particular focus on the ocular surface, eyelids and periorbital tissue.

Bimatoprost in the treatment of eyelash hypotrichosis

Eyelashes hypotrichosis is a condition indicated by an inadequate amount of eyelashes. Hypertrichosis of eyelashes, characterized by excessive eyelash growth, is a regular phenomenon associated with ophthalmic prostaglandin and prostamide analogs. Recently, the US Food and Drug Administration approved Latisse((R)) (bimatoprost 0.03% solution), identical to the ophthalmic solution for glaucoma treatment, for increasing eyelash length, thickness and darkness in patients with hypotrichosis of the eyelashes. When prostaglandin and prostamide analogs interact with the prostanoid receptors in the hair follicle, this most likely stimulates the resting follicles (telogen phase) to growing follicles (anagen phase). Prostaglandin and prostamide analogs may also prolong the anagen phase of eyelashes, leading to an increase of eyelash length. Although bimatoprost is effective in promoting increased growth of healthy eyelashes and adnexal hairs, its effectiveness in patients with eyelash alopecia areata is debatable and its protective effect is not yet studied in patients with eyelash loss secondary to radiation or chemotherapy. Bimatoprost is generally safe when applied to the base of the eyelashes at the lid margin with minimum side effects. However, other ocular or systemic side effects associated with ophthalmic prostaglandin and prostamide analogs may occur when instilled on the surface of the eye, and patients must be informed and monitored.

Herpes Simplex Keratitis After Cataract Surgery

PURPOSE

Herpetic keratitis is a rare complication of cataract surgery. We describe 3 cases of herpes simplex keratitis after cataract surgery in eyes with no clinical history of this disease.

METHODS

Three patients underwent uneventful phacoemulsification of cataract with intraocular lens implantation. All were treated postoperatively with topical steroids. On subsequent development of corneal dendritic epithelial lesions in the operated eyes, the corticosteroids were replaced by treatment with topical acyclovir.

RESULTS

The first postoperative day was uneventful. Corneal dendritic epithelial lesions were observed 1-5 weeks postoperatively and healed without sequelae after topical acyclovir treatment.

CONCLUSIONS

In view of the surgical trauma along with the topical corticosteroid treatment commonly prescribed after cataract surgery, physicians should be aware of the possible development of herpetic epithelial keratitis even in patients with no clinical history of this disease.

Corneal ulceration associated with naturally occurring canine herpesvirus-1 infection in two adult dogs

CASE DESCRIPTION

An 8-year-old Labrador Retriever with diabetes mellitus in which bilateral phacoemulsification had been performed 3 weeks earlier was evaluated for acute onset of blepharospasm, and a 7-year-old Miniature Schnauzer with chronic immune-mediated thrombocytopenia was reevaluated for keratoconjunctivitis sicca that had been diagnosed 4 weeks earlier.

CLINICAL FINDINGS

Dendritic corneal ulcerations were detected in both dogs. Canine herpesvirus-1 (CHV-1) was isolated from corneal swab specimens obtained during the initial evaluation of each dog and during recheck examinations performed until the ulcerations were healed. Canine herpesvirus-1 serum neutralization titers were detected in both dogs. Results of virus isolation from oropharyngeal and genital swab specimens were negative for both dogs. The isolated viruses were identified as CHV-1 via immunofluorescence, transmission electron microscopy, PCR assay, and gene sequencing. Negative controls for PCR assay and virus isolation included conjunctival swab specimens from 50 dogs without extraocular disease and corneal swab specimens from 50 dogs with corneal ulcers, respectively.

TREATMENT AND OUTCOME

Lesions resolved in both dogs after topical administration of idoxuridine or trifluridine and discontinuation of topically administered immunosuppressive medications.

CLINICAL RELEVANCE

To the authors' knowledge, this is the first report of corneal ulcerations associated with naturally occurring CHV-1 infection and may represent local ocular recrudescence of latent CHV-1 infection. The viruses isolated were identified as CHV-1, and the morphology, antigenicity, and genotype were similar to those for CHV-1 isolates obtained from a puppy that died from systemic CHV-1 infection.

Evolving Paradigms in the Medical Treatment of Glaucoma

In the last 5 years, numerous novel ocular hypotensive agents have been introduced for the control of intraocular pressure (IOP). Clinicians now have more options than ever in medical therapy for the treatment of glaucoma and ocular hypertension. When selecting an ocular hypotensive medication for their patients, clinicians should consider not only the IOP-lowering efficacy of an agent but also the ability of the drug to achieve target levels of IOP that are low enough to stop the progression of glaucomatous damage. Other considerations should include how well the drug controls diurnal IOP, the likelihood of serious adverse events, the versatility of the medication for use as an adjunctive agent, as well as other potential attributes (e.g., neuroprotection).

Association between Ocular Herpes Simplex Virus and Topical Ocular Hypotensive Therapy

PURPOSE

To evaluate whether use of particular topical hypotensive therapies is associated with ocular herpes simplex virus (OHSV).

MATERIALS AND METHODS

This population-based, retrospective, cohort study used claims records from the Protocare Sciences managed care database (United States). Data were extracted from September 1, 1996 through June 30, 2002. An OHSV event was either a medical claim from the utilization database coded with an International Classification of Diseases Ninth Revision (ICD-9) code for OHSV (ICD-9 = 054.4, 054.40-054.44, 054.49) or a pharmacy claim for vidarabine or trifluridine ophthalmic solution.

RESULTS

A total of 93,869 eligible glaucoma patients, 21 different ocular hypotensive agents, and 192,840 agent-utilizing patient combinations were identified. In all, 411 patients had an OHSV event; 272 of 411 patients had at least 1 ocular hypotensive agent dispensed prior to the OHSV event but not preceding the event by less than 7 days. Of these, 219 had only 1 ocular hypotensive agent dispensed on the last fill date prior to the OHSV event, yielding an overall OHSV event rate of 0.11%. There was no significant association between OHSV event rates and agent use for either the set of 21 agents (P = 0.260; chi2) or when 14 products having < 5% usage were combined (P = 0.058). Prevalence rates were estimated as 161 per 100,000 population for 2000 to 2001 and 165 per 100,000 for 1999 to 2001.

CONCLUSIONS

Ocular herpes simplex virus is extremely rare in patients treated with ocular hypotensive therapies, and its prevalence is similar to that found in the general population. The current analysis revealed no association between the use of particular topical ocular hypotensive therapies and OHSV.

[The latest in herpes simplex keratitis therapy]

Herpetic keratitis is characterized by spontaneous recurrences and a risk of vision loss, the latter being more serious when relapses are frequent and severe. Two clinical forms are commonly distinguished: epithelial keratitis, usually quickly resolved with topical antivirals, and stromal keratitis, which has a slower progression, even when both steroids and antivirals are used. Great strides have been made during the last 20 Years in the therapy of herpes keratitis, which is now considered and treated as a chronic disease. Randomized controlled studies definitively showed the decrease in spontaneous herpetic ocular events in patients treated with long-term oral acyclovir. The effectiveness of preventive treatment has also been shown during high-risk periods, especially ocular surgery, in patients with a history of herpes keratitis. However, the optimal duration and dosage of antiviral prevention have yet to be defined. We can also hope that in the future novel antiviral strategies such as vaccination will reduce the place of herpes keratitis as an indication for corneal graft.

Latanoprost : an update of its use in glaucoma and ocular hypertension

Latanoprost (Xalatan) is an ester analogue of prostaglandin F2alpha that reduces intraocular pressure (IOP) by increasing uveoscleral outflow. The IOP-lowering efficacy of latanoprost 0.005% lasts for up to 24 hours after a single topical dose, which allows for a once-daily dosage regimen. In patients with ocular hypertension or open-angle glaucoma, a single drop of latanoprost 0.005% solution (about 1.5 microg) administered topically once daily reduced diurnal IOP by 22 to 39% over 1 to 12 months' treatment in well-controlled trials; efficacy was maintained during treatment periods of up to 2 years. At this dosage, latanoprost was significantly more effective than timolol 0.5% twice daily in 3 of 4 large, double-blind, randomised studies, was generally as effective as bimatoprost or travoprost, and was significantly more effective than dorzolamide, brimonidine or unoprostone. Furthermore, in patients whose IOP was poorly controlled with timolol, switching to latanoprost monotherapy was at least as effective at lowering IOP as adding dorzolamide or pilocarpine to the regimen. Latanoprost has also shown significant additive effects when used in combination with one or more other glaucoma medications. The fixed combination of latanoprost plus timolol was significantly more effective than either of its individual components in two double-blind randomised studies and more effective than the fixed combination of dorzolamide and timolol in a 3-month, evaluator-masked study. Data in patients with angle-closure glaucoma are limited, but in patients with elevated IOP after undergoing iridotomy, latanoprost 0.005% once daily was significantly more effective than timolol 0.5% twice daily at reducing IOP over 12 weeks of treatment in a large double-blind, randomised study. Latanoprost is generally well tolerated and, unlike timolol, induces minimal systemic adverse events. In well-controlled, 6-month trials, the most commonly occurring drug-related ocular events in latanoprost recipients were mild to moderate conjunctival hyperaemia (3 to 15%) and iris colour change (2 to 9%); these seldom required patient withdrawal although the latter may be permanent. Latanoprost 0.005% as a single daily drop has shown good IOP-lowering efficacy in patients with open-angle glaucoma or ocular hypertension and does not produce the cardiopulmonary adverse effects associated with beta-blockers. Thus, latanoprost is a valuable addition to the first-line treatment options for patients with open-angle glaucoma or ocular hypertension. In addition, adjunctive treatment with latanoprost in patients who are refractory to beta-blocker therapy is a viable, second-line treatment option. Although preliminary findings are promising, wider clinical experience is required to define the place of latanoprost in the treatment of angle-closure glaucoma.

New onset of herpes simplex virus epithelial keratitis after penetrating keratoplasty

PURPOSE

To report a series of patients with no previous history of herpes simplex virus (HSV) infection who had new onset of herpetic keratitis after penetrating keratoplasty (PK).

DESIGN

Noncontrolled, retrospective case series.

METHODS

We included in the study the patients who had new onset of herpetic keratitis after penetrating keratoplasty for corneal diseases unrelated to HSV infection who were seen at the Cornea Service at Wills Eye Hospital (Philadelphia, Pennsylvania) from January 1996 to December 2002. The diagnosis of HSV epithelial keratitis was based on clinical characteristics of either a classic herpetic dendrite, a geographic ulcer, or a nonhealing epithelial defect that responded only to antiviral therapy.

RESULTS

Fourteen patients were included in the study. Eight of these (57%) had presented with a geographic ulcer whereas six patients (43%) had a classic dendrite. The most common primary corneal disease that led to PK was pseudophakic bullous keratopathy (36%), followed by keratoconus (29%), Fuchs dystrophy (21%), and corneal scar unrelated to HSV (14%).

CONCLUSIONS

The ophthalmologist should be aware of the possibility of herpetic keratitis in eyes after PK, even in patients with no previous history of HSV infection.

The effects of Xalatan on the recovery of ocular herpes simplex virus type 1 (HSV-1) in the induced reactivation and spontaneous shedding rabbit models

PURPOSE

Xalatan treatment has been reported both clinically and experimentally to promote recurrences of herpetic keratitis. Our goal was to determine the effects of topical Xalatan and its components on the recovery of ocular herpes simplex virus type 1 (HSV-1) in the Induced Reactivation (IR) and Spontaneous Shedding (SS) HSV-1/NZW rabbit latency models using virological outcome measures.

METHODS

HSV-1 latently-infected rabbits in both the IR and SS studies were divided into different topical treatment groups to evaluate commercial Xalatan, its preservatives, and vehicle against appropriate negative and positive controls. In the IR Studies, 91 rabbits received intra-stromal injections of water in both eyes to promote ocular shedding of latent HSV-1. All eyes were then treated and cultured for 10 days. In the SS Studies, 65 rabbits were treated and cultured in both eyes for 30 days.

RESULTS

Dexamethasone, a positive control, promoted extensive ocular shedding of HSV-1 in both the IR and SS Models. In general, neither Xalatan nor its components demonstrated any adverse effects, but some experimental variation was noted. All groups demonstrated comparable recovery of latent HSV-1 from respective trigeminal ganglia.

CONCLUSIONS

Our experimental studies support the world wide clinical epidemiological experience that commercial Xalatan does not appear to promote HSV-1 ocular shedding.

Putative side effects of prostaglandin analogs

Anecdotal case reports describe the occurrence of cystoid macular edema, iritis, herpes simplex keratitis, periocular skin darkening, and headaches in patients treated with prostaglandin analogs for glaucoma. The purpose of this article is to critically analyze these anecdotal case reports in light of a few well-controlled, randomized clinical studies to determine whether conclusions can be made about a causal relationship between the use of prostaglandin analogs and the occurrence of these side effects. None of these putative side effects has been proven to be causally related to latanoprost therapy using valid scientific methodology. These possible side effects occur rarely. Cystoid macular edema, iritis, and herpes simplex keratitis occur in eyes with risk factors. To scientifically establish a causal relationship between drug therapy and rare side effects, repeated rechallenging with masked controls is required. With rare exception, such methodology has not been used with any of these putative side effects. Nevertheless, even without firm establishment of a causal relationship, caution is advised with the use of prostaglandin analogs in eyes with risk factors for cystoid macular edema, iritis, and herpes simplex keratitis until properly designed, large, controlled studies provide more definitive information.