Herpes Zoster Ophthalmicus After COVID-19 Vaccination: Chance Occurrence or More?

ABSTRACT

As the understanding of COVID-19 infection becomes better, it is being recognized as a complex multisystem pathology rather than just affecting the lungs. Several ocular findings have been documented by researchers in individuals infected with COVID-19, and ocular symptoms may even be the first presenting feature of COVID-19 infection in 2.26% individuals. Several countries have started vaccination with inactivated or live vaccines to combat this pandemic, and varied side effects have been reported after vaccination. Few cases of herpes zoster have previously been reported in elderly patients with comorbidities after receiving COVID-19 vaccines. In this article, the authors described 2 interesting cases of herpes zoster ophthalmicus (HZO) after receiving a live COVID-19 vaccine. The first case was a 35-year-old immunocompetent man who developed HZO 3 days postvaccine. The second case was a 40-year-old immunocompetent man who developed HZO 28 days postvaccine. To the best of our knowledge, no literature to date has described HZO after live vaccine.

Conjunctivitis: a systematic review of diagnosis and treatment

IMPORTANCE

Conjunctivitis is a common problem.

OBJECTIVE

To examine the diagnosis, management, and treatment of conjunctivitis, including various antibiotics and alternatives to antibiotic use in infectious conjunctivitis and use of antihistamines and mast cell stabilizers in allergic conjunctivitis.

EVIDENCE REVIEW

A search of the literature published through March 2013, using PubMed, the ISI Web of Knowledge database, and the Cochrane Library was performed. Eligible articles were selected after review of titles, abstracts, and references.

FINDINGS

Viral conjunctivitis is the most common overall cause of infectious conjunctivitis and usually does not require treatment; the signs and symptoms at presentation are variable. Bacterial conjunctivitis is the second most common cause of infectious conjunctivitis, with most uncomplicated cases resolving in 1 to 2 weeks. Mattering and adherence of the eyelids on waking, lack of itching, and absence of a history of conjunctivitis are the strongest factors associated with bacterial conjunctivitis. Topical antibiotics decrease the duration of bacterial conjunctivitis and allow earlier return to school or work. Conjunctivitis secondary to sexually transmitted diseases such as chlamydia and gonorrhea requires systemic treatment in addition to topical antibiotic therapy. Allergic conjunctivitis is encountered in up to 40% of the population, but only a small proportion of these individuals seek medical help; itching is the most consistent sign in allergic conjunctivitis, and treatment consists of topical antihistamines and mast cell inhibitors.

CONCLUSIONS AND RELEVANCE

The majority of cases in bacterial conjunctivitis are self-limiting and no treatment is necessary in uncomplicated cases. However, conjunctivitis caused by gonorrhea or chlamydia and conjunctivitis in contact lens wearers should be treated with antibiotics. Treatment for viral conjunctivitis is supportive. Treatment with antihistamines and mast cell stabilizers alleviates the symptoms of allergic conjunctivitis.

Herpes gladiatorum with ocular involvement in a mixed martial arts fighter

We report a case of herpes gladiatorum (HG) in a professional mixed martial arts (MMA) fighter. The eruption appeared following a sparring session with a new partner and progressed to involve the left eye. Fever and facial rash prompted the patient to go to the hospital where he was treated with antiviral therapy. The considerable increase in popularity of MMA may lead to a greater prevalence of HG as well as other cutaneous infections contracted through skin-to-skin contact.

Pathogenesis of conjunctivitis caused by Newcastle disease viruses in specific-pathogen-free chickens

The pathogenesis of conjunctivitis caused by Newcastle disease viruses (NDVs) was investigated in 3-week-old specific-pathogen-free chickens. The chickens were inoculated intramuscularly, by eye drop or intranasally, with 10(7) plaque forming units of viscerotropic velogenic Newcastle disease virus (VVNDV), mesogenic NDV or lentogenic NDV. Macroscopically, lower palpebral conjunctivae appeared red with oedematous swelling in chickens inoculated with VVNDV. Histologically, mild lesions were focal hyperplasia of the conjunctival epithelial cells with cellular infiltration in the lamina propria of the conjunctivae in the chickens inoculated with VVNDV. Moderate lesions were vascular necrosis with congestion and haemorrhages, hyperplasia of conjunctival epithelial cells, and oedema and cellular infiltration in the lamina propria of the conjunctivae. Fibrin thrombi were observed in the capillaries of the lamina propria. In marked lesions, the whole conjunctiva was affected with more severe and extensive lesions. The mesogenic and lentogenic NDV strains induced no gross conjunctival lesions, but induced mild conjunctivitis without vascular necrosis.

Delayed epithelial ingrowth caused by viral conjunctivitis after LASIK

To report a patient who presented with epithelial ingrowth caused by viral keratoconjunctivitis 3 months after LASIK surgery. A 41-year-old man presented with decreased visual acuity in the right eye, which had developed about 3 weeks before. He had undergone LASIK surgery 3 months prior without complications. Two months after the surgery, he was treated for viral conjunctivitis. During the treatment period, filamentary keratitis developed, and a therapeutic bandage contact lens was applied for 2 weeks. Upon presentation, examination revealed a corrected visual acuity of 20/100 and irregular epithelial sheets under the edematous flap. The flap was lifted, and the in-grown epithelium was removed. The flap was repositioned with double continuous 10-0 nylon sutures. Post-operatively, the patient developed a mild diffuse lamellar keratitis that resolved rapidly with topical corticosteroid treatment. At 2 months, the corrected visual acuity was 20/20 without interface opacities. As the patient showed no complications prior to viral conjunctivitis, we suspect that the viral infection caused edema of the corneal flap, which caused epithelial ingrowth under the flap. Patients who have viral conjunctivitis after LASIK surgery should be examined carefully and managed with consideration of flap complications.

Management strategies for acute infective conjunctivitis in primary care: a systematic review

A systematic review of the literature on all aspects of the management of acute infective conjunctivitis is undertaken. Acute infective conjunctivitis is a common presentation in primary healthcare. It is usually a mild condition and serious complications are rare. Clinical signs are a poor discriminator of bacterial and viral causes. Studies of treatment show that there is a high rate of clinical cure without any treatment (65% within 2-5 days). Treatment with topical antibiotics improves the rate of clinical recovery and this is more marked in the first 2-5 days after presentation (number needed to treat [NNT] = 6), but less by 6-10 days (NNT = 13). Studies comparing treatment with different antibiotics do not demonstrate that any one antibiotic is superior; the choice of antibiotic should be based on consideration of cost and bacterial resistance. The present practice of prescribing antibiotics to most cases is not necessary.

Ocular vaccinia following exposure to a smallpox vaccinee

PURPOSE

To describe the presentation and management of the first identified case of ocular vaccinia infection associated with the current smallpox vaccination program.

DESIGN

Case report.

METHODS

Vaccinia virus was isolated by cell culture of a conjunctival swab. Direct staining with fluorescein isothiocyanate-labeled vaccinia antibody and polymerase chain reaction testing confirmed the diagnosis.

RESULTS

In February 2003, a 26-year-old woman developed right preseptal cellulitis and blepharoconjunctivitis following contact with a vaccinated member of the military. The preseptal cellulitis resolved with antibacterial therapy, and the conjunctival infection was treated successfully with a 14-day course of topical trifluridine and a single dose of intravenous vaccinia immune globulin.

CONCLUSIONS

To facilitate rapid diagnosis and appropriate treatment, clinicians must maintain a high index of suspicion for ocular smallpox vaccine-associated adverse reactions in vaccine recipients and their close contacts.

Comparison of the efficacy and safety of valaciclovir and acyclovir for the treatment of herpes zoster ophthalmicus

OBJECTIVE

To compare the efficacy and safety of valaciclovir and acyclovir in immunocompetent patients with herpes zoster ophthalmicus.

DESIGN

A multicenter, randomized, double-masked study.

PARTICIPANTS

One hundred ten immunocompetent patients with herpes zoster ophthalmicus diagnosed within 72 hours of skin eruption were treated; 56 were allocated to the valaciclovir group and 54 to the acyclovir group.

METHODS

Patients randomized to the valaciclovir group received two 500-mg tablets of valaciclovir three times daily and one tablet of placebo twice daily. Patients in the acyclovir group received one 800-mg tablet of acyclovir five times daily and one tablet of placebo three times daily for 7 days.

MAIN OUTCOME MEASURES

Main outcome measures included the frequency, severity, and duration of ocular complications, patient reports of zoster-associated pain, and the outcome of skin lesions. Tolerance was also assessed on the incidence and types of adverse effects and changes in laboratory parameters. The analysis was mainly descriptive and performed on an intent-to-treat basis.

RESULTS

Ocular complications of herpes zoster ophthalmicus were similar in the valaciclovir and acyclovir treatment groups. The main complications were conjunctivitis (54% and 52%, respectively), superficial keratitis (39% and 48%, respectively for punctate keratitis; 11% in each group for dendritic keratitis), stromal keratitis (13% in each group), and uveitis (13% and 17%, respectively). The long-term outcomes of these ocular complications were favorable and similar in both treatment groups. Pain duration and severity and outcome of skin lesions were similar between groups. Most patients reported prodromal pain. After 1 month, 25% of patients in the valaciclovir group and 31% in the acyclovir group still reported pain. The percentage of patients experiencing postherpetic neuralgia decreased during follow-up. The tolerance to acyclovir and valaciclovir was comparable and considered good. The most frequent adverse events were vomiting and edema of the eyelids or face (3%-5%). Three serious adverse events not linked to the study drugs occurred.

CONCLUSIONS

Valaciclovir is as effective as acyclovir in preventing ocular complications of herpes zoster ophthalmicus, including conjunctivitis, superficial and stromal keratitis, and pain. Tolerability of the two drugs is similar, but the dosing schedule of valaciclovir is simpler.

Acute follicular conjunctivitis caused by adenovirus type 34

PURPOSE

Adenovirus type 34 belongs to adenovirus subgenus B. The prototype virus of adenovirus 34 was isolated from a renal transplant recipient. However, no case of acute conjunctivitis caused by adenovirus 34 has been reported. Recently, we encountered two cases of acute follicular conjunctivitis in which adenovirus 34 was isolated.

METHODS

The clinical isolates were identified by the standard neutralization test. The sequences of seven hypervariable regions in the hexon protein of these cases were compared with those of several prototype strains of adenovirus subgenus B.

RESULTS

The cases were middle-aged, 34 and 41 years old, and male, and they exhibited moderate conjunctivitis with upper respiratory tract symptoms. Isolates from cell culture were identified as adenovirus 34 by NT. The mean homology rate (percentage of total number of coincident amino acids in the total length of amino acids in seven hypervariable regions) between clinical isolates and the adenovirus 34 prototype was 96.5%; in contrast, those between clinical isolates and the prototypes of adenovirus 11, adenovirus 14, and adenovirus 35 were 55.6%, 66.7%, and 57.9%, respectively. The results of conventional serotyping by neutralization test were confirmed by these values.

CONCLUSIONS

These results indicate that adenovirus 34 may induce acute conjunctivitis in immunocompetent subjects and that special attention should be paid to adenovirus 34 as a causative agent for adenoviral conjunctivitis.

Persistence of herpes simplex virus type 1 DNA in chronic conjunctival and eyelid lesions of mice

Herpes simplex virus type 1 (HSV-1) causes chronic blepharitis and conjunctivitis as well as keratitis in humans. The pathogenesis of these inflammatory ocular and dermal lesions is not well understood. We have examined the persistence of HSV-1 DNA and its relationship to inflammatory lesions in the conjunctiva and eyelid skin of mice which were inoculated with HSV-1 by the corneal route. Viral DNA was detected by in situ PCR in the conjunctiva and eyelid tissue of infected mice at 5, 11, 23, and 37 days postinfection (p.i.). This DNA was localized in the epithelial cells of the conjunctiva and hair follicles and in the epidermal cells of the eyelid skin. Viral proteins were not detected in the conjunctiva or the eyelid skin after 5 days p.i., even though histopathological lesions were found at 23 and 37 days p.i. in both tissues. The DNA-containing cells were adjacent to sites of inflammation in the chronic lesions in both the conjunctiva and the eyelid skin. A similar temporal and spatial relationship between HSV-1 DNA and inflammatory lesions has been previously reported for the cornea. Our data suggest that the lesions in the cornea, conjunctiva, and eyelid skin progress similarly. Further studies are required to determine whether the long-term presence of HSV-1 is involved in the mechanism by which these chronic inflammatory lesions develop. The presence of HSV-1 DNA in these extraocular tissues for extended periods may constitute persistent viral infection of nonneuronal cells.

Common ocular infections. A prescriber's guide

While most ocular infections are benign, others can be associated with devastating visual consequences. Most patients present with either ocular discharge, visual symptoms or a red or painful eye. The primary care physician is usually the first to evaluate these patients. We have separated ocular infections into 3 groups. Infections affecting the cornea and conjunctiva often present with eye pain and a red eye; noninfectious aetiologies can have a similar presentation. Infections inside the eye (endophthalmitis) often have devastating consequences. They usually occur following penetrating ocular trauma or after intraocular surgery. Prompt referral to an ophthalmologist is crucial. Infections in the soft tissue surrounding the eye (ocular adnexa and orbit) can involve the eye indirectly and can spread from the orbit into the brain. The purpose of this article is to review ocular infections and current opinion regarding treatment. A general guideline should be that the approach to treatment be governed by the severity of symptoms and the magnitude of possible consequences. Mild external infections can be typically treated empirically. Severe conjunctivitis, and any corneal infection, require aggressive management, often including cultures and broad spectrum antibiotics; cultures are often used to guide treatment. Devastating vision loss can occur, even with aggressive management. Preseptal cellulitis in adults and older children can be managed conservatively with oral antibiotics if the orbit and optic nerve are not involved and the patient is otherwise healthy. Orbital or optic nerve involvement, on the other hand, demands orbital imaging and more aggressive intervention. Patients who have had recent surgery are at risk for developing endophthalmitis. Complaints of pain or a red eye must be taken very seriously. These patients must be considered to have an intraocular infection until it can be ruled out, and should be aggressively managed by a physician trained in eye diseases and surgery.

Adenovirus pneumonia with severe sequelae in an immunocompetent adult

Notable complications from adenovirus pneumonia in healthy adults are rare. We report a well-documented case of adenovirus type 3 infection in a previously well adult woman that resulted in severe pulmonary complications as well as self-limited ocular, hepatic, and gastrointestinal abnormalities.

Cowpox virus

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Causes of conjunctivitis and keratoconjunctivitis in Karachi, Pakistan

The causes of conjunctivitis and keratoconjunctivitis in 388 patients who attended eye casualty departments in Karachi, Pakistan, during a 5 month period were investigated. Most of these infections were diagnosed as adenovirus (291, 75%) or bacterial (71, 18.3%). Of the remainder, 9 cases (2.3%) were caused by herpes simplex virus and 7 (1.8%) by Chalmydia trachomatis. There was no evidence of typical active trachoma in this urban population. Bacteria or Candida albicans were also grown from 44 of the adenovirus cases (15%). Many of the bacteria grown from eyes in this study were resistant to antibiotics, probably because of inadequate and/or inappropriate self-medication with antibiotics in this community.

Intermediate human adenovirus type 22/H10,19,37 as a new etiological agent of conjunctivitis

Eight strains of a new intermediate adenovirus were isolated in the course of an investigation of conjunctivitis in Hiroshima City, Japan. The strain was first isolated in July 1986. All eight strains were isolated from conjunctival swab samples from patients with conjunctivitis, mainly epidemic keratoconjunctivitis. The virus was typed as adenovirus type 22 in neutralization tests and was related closely to types 10, 19, and 37 in hemagglutination inhibition tests. The DNA cleavage patterns of the eight strains with nine restriction endonucleases were the same with one exception but different from those of the above serologically related species. We conclude that the intermediate adenovirus is a new etiological agent of conjunctivitis, mainly epidemic keratoconjunctivitis.

Per-nasal swabbing as an aid to the diagnosis of chlamydial and adenovirus conjunctivitis

Two hundred and thirty four patients (adults and babies) with conjunctivitis were investigated by taking eye swabs and in addition by taking per-nasal swabs. Chlamydia trachomatis was isolated from 20 patients and adenovirus from 14 patients. Per-nasal swabbing led to a 53% increase in chlamydia diagnosis and a 27% increase in the diagnosis of adenovirus infection. It is suggested that per-nasal swabbing has an important role to play in detecting chlamydial conjunctivitis which itself may be an indicator for high morbidity in patients and their contacts.

Diagnosis and management of conjunctival papillomas

Lumps and bumps have been seen on the ocular surface or adnexa of many of our patients. Most of these are readily identified; however, we may occasionally see an unusual "growth" and wonder about its pathological significance. The topic of epithelial neoplastic growths with special emphasis on the subclass of papillomas is reviewed. The question of histopathological significance is raised in a case of epibulbar conjunctival growths. The differential diagnosis, which leads to the definitive diagnosis of viral conjunctival papillomas, is discussed. The management of viral conjunctival papillomas is reviewed.

Concurrent adenoviral and herpetic ocular infections

We report two cases of a previously unrecognized clinical entity: concurrent adenoviral and herpetic ocular infection. The first case was recognized clinically by the presence of herpetic keratitis and findings attributable to epidemic keratoconjunctivitis (EKC) including lid swelling, pseudomembranous and follicular conjunctivitis, subconjunctival hemorrhages, preauricular lymphadenopathy, and corneal infiltrates. Only Herpes simplex virus was recovered by culture. In the second case of apparent EKC (again initially only Herpes simplex was isolated) after maintaining virus cultures long enough to isolate adenovirus, the diagnosis of concurrent infection was established when the second virus was isolated.

Herpes zoster ophthalmicus

The incidence and severity of herpes zoster ophthalmicus have increased because of the growing number of immunocompromised patients. Uveitis and keratitis are the most common inflammatory complications. Corneal exposure from scarring and contraction of the upper lid may require reconstructive plastic surgery. Preliminary studies of oral acyclovir, specifically targeted at preventing ocular complications, are encouraging.

Severity of experimentally reactivated herpetic eye disease is related to the neurovirulence of the latent virus

The authors examined the eye diseases produced during acute and experimentally reactivated infections of rabbits intranasally inoculated with high and low neurovirulent strains of herpes simplex virus, type-1 (HSV-1). Experimental reactivation of latent trigeminal ganglionic infection was accomplished by an injection of cyclophosphamide followed by one injection of dexamethasone the next day. Neither drug, when given as a single injection, reactivated latent HSV-1 infection. During acute and reactivated phases of high neurovirulent HSV-1 strain infection, many rabbits developed very severe conjunctivitis and keratitis. Some rabbits developed hemorrhagic corneal lesions, and a few became blind. Only a few rabbits with acute and reactivated low neurovirulent virus strain infections developed mild conjunctivitis. The high neurovirulent strain was recovered from tear film more frequently than the low neurovirulent strain during reactivated infections. By use of 3H-labelled DNA prepared from purified virus to probe trigeminal ganglionic tissues in situ, both strains of virus were found to establish ganglionic latency to about the same degree. Reactivation correlated with an increase in the amount of HSV-1 RNA per ganglionic neuron and a change in subcellular location. These studies indicate that the relative neurovirulence of the infecting strain determines the ease with which it can be reactivated from latency and the severity of the reactivated ocular disease produced.

Viral particles in the conjunctiva of a patient with the acquired immune deficiency syndrome

Conjunctival biopsy from a 39-year-old man with the acquired immune deficiency syndrome revealed the presence of herpes virus particles by electron microscopy. The finding of herpes virus particles in the conjunctiva may be of prognostic significance in documenting the presence of systemic viral infection.

Cat-scratch disease. An overview based on a study of 1,200 patients

This study by one individual of 1,200 patients with cat-scratch disease provides a heretofore unavailable realistic evaluation of a common infectious disease. All patients had lymphadenopathy, a prerequisite for diagnosis. Suppuration occurred in 11.8% of patients. Cat contact was established for 99.1%, and the cat was immature in the vast majority. An inoculation site, the most neglected feature in the study of the patients, was detected in 92.6%. The results of a skin test, considered as specific as the standard tuberculin test and to be safe but not standardized, was positive in 99%. The 12 patients with negative skin tests probably were tested too early in the course of the disease to have developed reactivity. Skin tests of 578 family members of patients, who served as controls, gave positive results in 18.5%. Of 60 patients with unusual manifestations, 48 had the oculoglandular syndrome of Parinaud. Other manifestations included erythema nodosum, encephalopathy, osteolytic lesions, thrombocytopenic purpura, and erythema marginatum. Most patients in this series had received antibiotics of many types during the course of the disease. None appeared beneficial. The disease is benign in character in a majority of patients. Surgical removal of involved lymph nodes or biopsy of lymph nodes or inoculation sites is not necessary for diagnosis or management. A survey of hospitals in the United States discharging more than 750 pediatric patients annually indicates that cat-scratch disease is a problem in all sections of the country.