Thomas J. Liesegang

Ocular Complications of Wegener's Granulomatosis

140 patients with biopsy-proven Wegeners granulomatosis were examined during a 16-year period at the Mayo Clinic. Forty patients had diverse and explosive ophthalmic involvement, including conjunctivitis, episcleritis, scleritis, corneal ulceration, uveitis, retinal vasculitis, optic neuropathy, orbital mass, orbital cellulitis, and obstruction of the nasolacrimal duct. The multiple ophthalmic and systemic complications in these 40 patients and the importance of establishing the pathologic diagnosis are discussed. Treatment with corticosteroids and immunosuppressive agents has dramatically improved the prognosis, although substantial mortality (four patients died of Wegeners granulomatosis) and ocular morbidity (three eyes were enucleated) are still associated with this disease.

Conjunctival and Corneal Intraepithelial and Invasive Neoplasia

The histopathologic findings and clinical records of 98 patients with conjunctival and corneal intraepithelial neoplasia (CIN) and 22 patients with invasive neoplasia were studied. Pathologic material was evaluated for cell type, degree of dysplasia, margins of excision, and change in pattern with recurrence. Clinical records were reviewed for demographic features, presenting symptoms, clinical appearance, therapy, and subsequent course. Recurrences occurred in 23 patients with CIN and 9 patients with invasive neoplasia. Intraocular or orbital extensions or both occurred in four patients and metastatic disease in two patients. The cell type, clinical appearance, and degree of dysplasia did not correlate with recurrence; involvement of the margins of the initial excision was an important prognostic sign for recurrence.

Oral Acyclovir in the Treatment of Acute Herpes Zoster Ophthalmicus

Seventy-one nonimmunocompromised patients with herpes zoster ophthalmicus, presenting within seven days of onset of characteristic skin eruption, were enrolled in a prospective, longitudinal, randomized, double-masked, placebo-controlled trial with oral acyclovir. In a previous interim report we noted more prompt resolution of dermatomal signs and symptoms with acyclovir treatment. There was also a reduction of viral shedding in acyclovir-treated patients coupled with a trend to greater rate of microdissemination of the virus in placebo-treated patients (Cobo LM, et al. Ophthalmology 1985; 92:1574-83). While further substantiating these findings, we report that a ten-day course of treatment with oral acyclovir (600 mg, five times a day) is well-tolerated and significantly reduces the incidence and severity of the most common complications of herpes zoster ophthalmicus: dendritiform keratopathy, stromal keratitis, and uveitis. While this acyclovir treatment regimen reduces the zoster-related pain during the acute phase of the disease, especially in patients treated within 72 hours of onset of skin lesions, it has no evident effect on either incidence, severity, or duration of post-herpetic neuralgia in the patients studied.

Herpes Zoster Ophthalmicus: Natural History, Risk Factors, Clinical Presentation, and Morbidity

TOPIC The incidence and morbidity of herpes zoster (HZ) and HZ ophthalmicus (HZO), and the potential impact of varicella vaccine on their epidemiology. CLINICAL RELEVANCE Herpes zoster affects 20% to 30% of the population at some point in their lifetime; approximately 10% to 20% of these individuals will have HZO. METHODS The peer-reviewed literature published from 1865 to the present was reviewed. RESULTS Herpes zoster is the second clinical manifestation of varicella-zoster virus (VZV). The incidence and severity of HZ increase with advancing age. Varicella-zoster virus-specific cell-mediated immunity, which keeps latent VZV in check and is boosted by periodic reexposure to VZV, is an important mechanism in preventing VZV reactivation as zoster. Thus, widespread varicella vaccination may change the epidemiology of HZ. Herpes zoster ophthalmicus occurs when HZ presents in the ophthalmic division of the fifth cranial nerve. Ocular involvement occurs in approximately 50% of HZ patients without the use of antiviral therapy. There is a long list of complications from HZ, including those that involve the optic nerve and retina in HZO, but the most frequent and debilitating complication of HZ regardless of dermatomal distribution is postherpetic neuralgia (PHN), a neuropathic pain syndrome that persists or develops after the zoster rash has resolved. The main risk factor for PHN is advancing age; other risk factors include severe acute zoster pain and rash, a painful prodrome, and ocular involvement. Many cases of HZ, HZO, and PHN can be prevented with the zoster vaccine. CONCLUSION Vaccination is key to preventing HZ, HZO, and PHN, but strategies for both varicella and HZ vaccines will need to be evaluated and adjusted periodically as changes in the epidemiology of these VZV diseases become more evident.

Ocular and Systemic Findings in Relapsing Polychondritis

The ocular and systemic findings in 112 Mayo Clinic patients with relapsing polychondritis were reviewed. The incidence of males and females was equal, with median age at diagnosis of 51 years and the median follow-up of 6 years. Most patients had several organ systems involved at the time of the diagnosis. Twenty-one patients had ocular symptoms at the onset, and 57 developed ocular symptoms during their course. Major ocular complications included proptosis, lid edema, episcleritis/scleritis, corneal infiltrates/thinning, iridocyclitis, retinopathy, and optic neuritis. The major system involvement included otorhinolaryngeal, respiratory, arthritic, renal, cardiovascular, dermatologic, and neurologic diseases. Generally, laboratory studies were not helpful in making the diagnosis but were valuable in monitoring the disease. Based on the experience in these cases, the indications for the various therapeutic modalities are offered.

Viscoelastic substances in ophthalmology

The desirable properties of a viscoelastic substance for ophthalmologic applications are intimately tied to its chemical and rheologic properties. This report describes the relevant rheologic properties (e.g., viscosity, viscoelasticity, pseudoplasticity, cohesiveness, and coatability) of the available viscoelastic substances and presents the general principles of their use as well as some specific technical aspects. In addition, the various uses of viscoelastic substances in ophthalmic surgery are outlined. There is no single ideal substance for all circumstances. With a knowledge of the rheologic properties of each substance, the ophthalmologist will be able to choose among the different ones as necessary to suit each clinical situation.

Corneal Complications From Herpes Zoster Ophthalmicus

Abstract Of 94 patients with acute herpes zoster ophthalmicus who were seen during a six-year period, 61 had corneal involvement. The corneal complications in the order of chronological clinical occurrence were punctate epithelial keratitis in 51%, early pseudodendrites in 51%, anterior stromal infiltrates in 41%, sclerokeratitis in 1%, kerato-uveitis/endotheliitis in 34%, serpiginous ulceration in 7%, delayed corneal mucous plaques in 13%, disciform keratitis in 10%, neurotrophic keratitis in 25%, and exposure keratitis in 11 %. Some of the earlier lesions seemed to result from viral infection, whereas later lesions resulted from timbal vasculitis, an immunologic mechanism to soluble viral antigen, a delayed hypersensitivity reaction, or damage to nerves and tissues. An elucidation of the lesions awaits better viral and immunologic detection techniques and further histopathologic study. Modern topical and systemic antiviral therapy, corticosteroids, and surgery have a role in treatment.

Diagnosis and Therapy of Herpes Zoster Ophthalmicus

Studies in the basic and clinical sciences have yielded new information about the biology, infection, latency, and recurrence of the varicella-zoster virus. Contrast is made with the herpes simplex virus. The host-viral relationship is an extremely dynamic one with clinical disease being determined primarily by the host cellular immune system. The complications of herpes zoster ophthalmicus are related to multiple mechanisms including viral growth, vascular and neural damage, and the host-immune response to infection. There are several laboratory tests available for confirming the diagnosis or determining the immune status. Systemic acyclovir administered early in the course alleviates many of the symptoms of herpes zoster ophthalmicus. Acute and postherpetic neuralgia remain significant and enigmatic problems; an update of therapeutic options is offered. The role of corticosteroids in herpes zoster ophthalmicus is scrutinized along with the potential and uncertainties of a varicella-zoster virus vaccine.

Short- and long-term endothelial cell loss associated with cataract extraction and intraocular lens implantation.

A group of 249 patients undergoing cataract extraction with intraocular lens implantation underwent specular microscopic endothelial cell photographs before surgery and eight weeks, one year, and two years after surgery. The intraocular lenses used were the Shearing posterior chamber lens and the transiridectomy clip lens after extracapsular cataract extraction and the Medallion iris suture lens after intracapsular cataract extraction. Thirty-seven patients who underwent cataract extraction without implantation served as controls. Eight weeks after surgery, there was no statistical difference between the groups with intraocular lenses and the groups without them. One year and two years after surgery, endothelial cell loss had occurred in all groups except the group who underwent extracapsular cataract extraction without intraocular lens implantation--a group in which the patients were younger. The long-term endothelial cell loss was greater after intracapsular cataract extraction and was greater in the presence of an implant. There was statistically more endothelial cell loss with the transiridectomy clip lens than with the posterior chamber lens eight weeks and one year after surgery; the patients with posterior chamber lenses had continued to have more endothelial cell loss during the second postoperative year.

Observations on the natural history of herpes zoster ophthalmicus

We have studied certain aspects of the natural history of acute herpes zoster ophthalmicus in placebo-treated patients followed prospectively over one year as part of a therapeutic drug trial. Observations on the incidence of ocular complications relating to the efficacy of oral acyclovir in this disease have been previously published. This report provides supplemental observations on the natural history of frequently observed ocular complications of zoster ophthalmicus: corneal hypesthesia, episcleritis, dendritiform keratopathy, stromal keratitis, anterior uveitis, and post herpetic neuralgia. These ocular complications of zoster typically present within the first two weeks of the diagnosis. This report characterizes the onset of corneal hypesthesia, episcleritis, dendritiform keratopathy, stromal keratitis, and anterior uveitis as well as interrelationships amongst these sequellae of herpes zoster ophthalmicus. Post-herpetic neuralgia occurs in 52% of patients and persists beyond a year in 22% of those affected.