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Herpes zoster (HZ, shingles) represents the secondary manifestation of an infection with varicellazoster virus (VZV). A reactivation of dormant VZV in the ophthalmic branch of the fifth cranial nerve leads to ophthalmic HZ (HZO). The predominantly older and immune compromised patients often present with eye involvement (approximately 50%) as well as characteristic skin changes. Clinical manifestations include the cornea and conjunctiva but anterior uveitis and (rarely) acute retinal necrosis may also occur. Associated sensory symptoms that range from paresthesia to severe pain may severely affect the quality of life. Particularly in immunocompromised and/or elderly patients, HZO is associated with complicated courses. Systemic antiviral treatment and an adequate pain medication are the mainstay of the recommended management. The present article provides an overview of the contents of the current consensus-based European guidelines on the management of HZ with a specific focus on HZO.

Herpes simplex virus (HSV) is a common cause of keratitis. "Herpetic keratitis" is a chameleon, which is well treatable today if the various types of clinical expression of this disease are known to the ophthalmologist and treatment is adjusted accordingly. Types of expression include 1. epithelial keratitis (dendritica/geographica), 2. stromal keratitis (necrotizing vs. non-necrotizing = "interstitial keratitis"), 3. endotheliitis (=disciform keratitis), 4. neurotrophic keratopathy (=so-called metaherpetic keratitis) and 5. (vascularized) corneal scars. A concomitant ocular hypertension should be treated predominantly non-surgically (no prostaglandin analogues). Topical artificial tears (if necessary with acyclovir ointment at night) in the quiet interval are recommended to limit the tendency towards recurrences. After keratoplasty and in cases of severe recurrences of herpetic keratitis, systemic acyclovir application (2×400 mg/day) for at least 1 year is indispensable! Overall, HSV has lost its "terror" today, even after keratoplasty, given adequate management.

Background: Viral infections of Herpes origin are the most commonly encountered ones in man. The most important member of this family is the Herpes simplex virus (HSV), two varieties of which are known to exist: HSV-1 affects predominantly the upper half of the body, whereas HSV-2 is associated mainly with diseases of the urogenital tract. In the immunocompetent host, viral replication is usually confined to cutaneous and mucocutaneous sites, invasion of subcutaneous tissues being impeded by an early onset of non-specific defence mechanisms. These are rapidly complemented by the specific, mainly cellular, immune response., Patients: Epithelial dendritic keratitis is the first symptomatic clinical finding, and after several recurrences, the corneal stroma may become involved. This condition of herpetic stromal keratitis (HSK), which, in contrast to the epithelial one, is believed to be directed by a predominantly immunopathological process, is one of the leading causes of infectious blindness in developed countries., Results: The mechanisms underlying HSK, and the establishment of viral latency and reactivation are poorly understood. But on the basis of studies with mice as well as clinical immunohistological observations, evidence is now accumulating in support of a cell-mediated mechanism being responsible for corneal destruction., Conclusion: Our present knowledge of the pathogenesis of herpetic keratitis is incomplete. The different pathophysiological aspects reflecting our current understanding, such as that of a virally induced autoimmune disease, form the basis of accepted clinical treatment concepts.

A 50 year old patient with non-diagnosed HIV-infection at onset of his illness developed impairment of vision and temporary double vision combined with severe hemianopsia. With normal fundus and suspicious Herpes simplex iritis therapy with Acyclovir was started. Primarily the patient showed a good response to the therapy and loss of vision could be prevented. After 4 weeks CMV-retinitis developed. In spite of Gancyclovir therapy manifestation of total loss of vision after 6 weeks. Autopsy demonstrated signs of simultaneous a CMV-infection of the retina and a herpes simplex-infection of the optic nerve combined with a Non-Hodgkin-Lymphoma of the optic tract.

Acute retinal necrosis (ARN) is characterized by unilateral or bilateral severe vaso-occlusive retinitis. In a large number of cases the patients become blind in the affected eyes as a direct result of the acute inflammation or the subsequent retinal detachment. The etiology is poorly understood; herpesvirus-induced vasculitis is presumed and has been demonstrated by some authors. However, the author's own investigations in seven patients show that even vitreous biopsy reveals a herpetic origin only in a minority of cases. Intravenous treatment with acyclovir and steroids prevented progression of the retinitis but did not reduce the risk of retinal detachment.

Between December 1973 and October 1974 scrapings of the corneal epithelium of 52 patients were examined by immunofluorescence. 41 of these corneal scrapings were suitable for examination. In 31 of 38 cases with the clinical diagnosis of a herpes simplex keratitis virus-specific antigen was found by means of immunofluorescence. The procedure takes only a few hours, and shows with 81,5% correct diagnoses a high reliability; scrapings of patients without herpetic affection never revealed a positive result. In 3 of 4 cases of deep herpetic keratitis, in which the herpetic etiology could only be supposed clinically, the diagnosis was proved by immunofluorescence.

Isolated herpes simplex affecting the lid margin can be distinguished from herpes simplex involving the entire eyelid by characteristic features. The typical intermarginal form of herpes-simplex-blepharitis presents itself as an erosion of about 3 mm in length which may be well discerned in detail after fluorescein staining. The skin adjecent to the lesion may also exhibit superficial ulceration, possibly being covered by crusts. The affected portion of the lid shows localized and moderate swelling as well as pain upon pressure. Injection of the bulbar conjunctiva will characteristically be noted mainly in the area opposing the lid lesion. The regional lymph nodes are enlarged, and possibly tender upon palpation. Local medication with anti-viral ophthalmic ointment is effective within a few days.

In 25 patients with primary and 24 patients with recurrent herpetic corneal disease the cell-mediated immunity to Herpes simplex virus antigen (type I) was measured using a leukocyte migration inhibition assay. After a period of one to 24 months 25 of the patients were tested again. The diagnostic possibilities offered by this method, especially in respect of control of immune-stimulating therapy, and its pitfalls are discussed.

Over a period of 4 months the authors observed 240 outpatients with 302 "red eyes." Oculogenital strains of Chlamydia trachomatis were diagnosed in 12.5% of these cases. Bacterial monoinfections were found in 13.9%, coinfections in 63.9%. The remaining 9.7% included Candida sp. (4%) and Herpes I (1.4%) infections, while 4.3% remained unidentified. Allergic conjunctivitis and "dry eye" syndromes were not considered separately in this study. Specific antibiotic therapy improved the clinical condition due to "saprophytic" bacterial coinfections, indicating the pathogenic importance of this type of infection.

Herpesviruses are the most common causes of infection-related loss of vision or blindness in our part of the world. A better understanding of the underlying pathophysiology, together with major pharmaceutical advances have led to medical and surgical therapy which enables us to preserve or restore useful vision in most patients.

Morphologic changes in rabbit cornea accompanying herpes simplex keratitis especially under the treatment of ethyldeoxyuridine (EDU) are summarized in regard to clinical aspects, light microscopy and electron microscopy. Untreated eyes show virus-dependent characteristic changes of the cell structure: peripheral migration of the cell chromatin, swelling of the nucleus, and disappearance of the nucleolus are persistent. In the nucleus as well as in the cytoplasm mature and immature virus particles are visible which demonstrate the normal virus-replication course. In the EDU treated cornea these particular changes are observed only in the primary stage. After prolonged treatment in the nucleus of the infected cells there are only immature virus particles with optically empty center. This can be evaluated as a sign of inhibition of the normal replication. No virus formation was detected in the cytoplasm. After 7 day treatment of EDU, the corneal epithelium is almost of normal structural appearance. Accordingly, the present results on the rabbit seem to correlate well with the reported therapeutic antiherpetic studies in the human cornea.

From Dimmer's original description of 4 cases of keratitis, it would seem that what is now known as a keratitis nummularis (Dimmer), is not one specific corneal disease but a heterogeneous group of diseases. Salzmann demonstrated in certain cases a clear relationship between it and herpetic keratitis and its corneal complications. Later authors have not convincingly differentiated KND from herpetic keratitis, as no tests have been performed to determine corneal sensitivity. Pillat, who did use the criterion of normality of corneal sensitivity for the diagnosis of KND, was unable to differentiate KND adequately from the sequelae of adenovirus keratitis. Nummular keratitis (Dimmer) does not play a diagnostic part in ophthalmology, as we are not dealing with a nosological entity.

The ophthalmologist differs between three forms of manifestation of the herpetic infection: 1. The superficial keratitis with involvement of the epithelium, known as keratitis punctata, stellata or dendritica. 2. The deep for: the keratitis disciformis. This is a delaged hypersensitivity against the herpes virus or its products of metabolism. 3. The metaherpetic keratopathy develops on the basis of a disturbed metabolism after relapsing, mainly deep herpetic keratitis. Therapy differs according to the forms of manifestation. The prevention of relapses is a problem. The frequency of relapses of the corneal herpes is considerably less and the intervals between the relapses are in general considerably longer than in dermatological herpes affections. Therefore, the influence on the recidivity by the drug Lupidon can be appreciated by a long-term study over several years only.

There are two serological types of herpes simplex virus, HSV-1 and HSV-2. The types can be differentiated by different methods. After a primary infection HSV reaches the sensory ganglions by the way of peripheral nervous tracts. The virus remains for life in the ganglion as virus genome. After activation and return movement a new infection can appear. A lot of various diseases are caused by primary infection, reactivation or reinfection. The diagnosis in herpes virus diseases includes the detection of virus or viral antigens and the demonstration of specific antibodies against HSV. Effective antiviral drugs are available for chemotherapy of HSV-infection. Acyclovir is a beneficial drug without toxic secondary effects. The prevalence of HSV-antibodies in the population is very high.

Aqueous humor from 33 herpes patients, 4 zoster patients, and 14 patients with etiologically unclear anterior uveitis was cultured for the presence of herpes viruses. Nine taps from 8 herpes patients with corneal endothelial disease and/or anterior uveitis yielded herpes simplex virus. In the case of one patient two taps were positive at 14 days' interval. Control cultures from the surface of conjunctiva and cornea were consistently virus-negative. Analysis of the virus-positive cases displayed three remarkable features: 1. Secondary glaucoma was uniformly present. This in itself is an indication for culturable herpes simplex virus in the aqueous. 2. Three clinical pictures could be differentiated biomicroscopically: focal iritis, peripheral endotheliitis, and prolonged disciform keratitis. 3. In a proportion of cases, tissue damage resulting from associated immune reactions seems to be more important for the functional outcome than tissue damage by viral cytolysis itself. After having tried several antiviral substances (trifluorothymidine topically, adeninearabinoside-monophosphate intravenously, human leukocyte interferon intramuscularly and intracamerally) we presently favour a topical combination therapy consisting of trifluorothymidine and steroids. This must be complemented by cycloplegics and--in cases of high intraocular pressure--by acetazolamide.

Acanthamoeba keratitis has become a difficult diagnostic and management problem in contact lens patients over the last few years. A young female contact lens wearer presented with a long history of painful central corneal ulcer. The suspected diagnosis of Acanthamoeba keratitis could only be confirmed by histology and electron microscopy following penetrating keratoplasty. Special stains of scrapings and culture of material on special media failed to establish the diagnosis. This rare (or underdiagnosed?) infection must be considered in the differential diagnosis of keratitis following contact lens wear.