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Purpose : To describe unusual fundus findings in typical varicella zoster (VZV) kerato-uveitis. Methods : Observational, retrospective case study of five patients diagnosed with VZV kerato-uveitis. Results : Four out of five cases had a history of typical herpes zoster ophthalmicus skin rash over the forehead. All five patients had stromal keratitis, granulomatous keratic precipitates, and mild-moderate anterior chamber reaction, and two cases had typical VZV-iris atrophic changes. All cases demonstrated clear vitreous and multiple hypopigmented choroidal lesions (MHCL) with indistinct borders only in the affected eyes. Imaging studies failed to demonstrate evidence of active or resolved choroiditis. MHCL remained status quo in all including two cases who had recurrences of kerato-uveitis. Conclusion : We describe previously unreported novel fundus finding, MHCL in typical VZV-kerato-uveitis cases. We presume MHCL are due to loss of melanin from choroidal melanocytes secondary to the VZV infection and propose a term "choroidal vitiligo" to describe these novel fundus findings.

Purpose: To investigate the prevalence of ocular manifestations and visual outcomes in patients with herpes zoster ophthalmicus (HZO)., Methods: Consecutive cases diagnosed with HZO who attended 2 hospitals between July 1, 2011, and June 30, 2015, were retrospectively reviewed. Patient demographics, clinical presentations, and management were reviewed. The logistic regression model was used to estimate the odds ratio of visual loss with ocular manifestations., Results: A total of 259 patients were included. Of these, 110 (42.5%) patients were <60 years old and 149 patients (57.5%) were ≥60 years old. None of the patients had received zoster vaccination before presentation. Ocular manifestations were present in 170 (65.6%) patients with no difference between both age groups (P = 0.101). Conjunctivitis was the most common ocular manifestation, followed by anterior uveitis and keratitis. After resolution of HZO, 58.7% of patients had a visual acuity of 6/12 or worse. Epithelial keratitis and stromal keratitis were independent risk factors for visual loss after resolution of HZO (P = 0.003 and P = 0.004, respectively). The corresponding odds ratio was 6.59 [95% confidence interval (CI): 1.87-23.19] and 7.55 (95% CI: 1.88-30.30), respectively. The number of ocular manifestations was also associated with an increased risk of visual loss with an odds ratio of 1.49 (95% CI: 1.01-2.20; P = 0.043)., Conclusions: A substantial proportion of patients with HZO were <60 years old in this study. The absence of zoster vaccination across the study cohort was noteworthy. Keratitis was the main reason for poor visual outcome in these patients.

Importance: With the increased use of data from electronic medical records for research, it is important to validate International Classification of Diseases, Ninth Revision (ICD-9) codes for their respective diagnoses., Objective: To assess the accuracy of using ICD-9 codes to identify ocular inflammatory diseases., Design, Setting, and Participants: Retrospective secondary database analysis. The setting was Kaiser Permanente Hawaii, an integrated managed care consortium that serves approximately 15% of the general Hawaiian population. Participants were patients with ICD-9 diagnosis codes that might be associated with a diagnosis of ocular inflammation seen at Kaiser Permanente Hawaii between January 1, 2006, and December 31, 2007. The data collection and analysis took place from January 2011 to August 2015., Main Outcomes and Measures: The main outcome was the positive predictive value (PPV) of ICD-9 codes for identifying specific types of ocular inflammatory disease. The PPVs were calculated by determining the ratio of the confirmed cases found by medical record review to the total number of cases identified by ICD-9 code., Results: Of the 873 patients identified by a comprehensive list of ICD-9 codes for ocular inflammatory diseases, 224 cases were confirmed as uveitis after medical record review. Using a set of uveitis-specific codes and eliminating patients with a history of ocular surgery, the overall PPV for uveitis was 61% (95% CI, 56%-66%). The PPVs for individual uveitis codes ranged from 0% to 100%, and 11 uveitis codes had a PPV exceeding 80%. Herpes zoster ophthalmicus and scleritis/episcleritis ICD-9 codes had PPVs of 91% (95% CI, 86%-95%) and 60% (95% CI, 54%-66%), respectively., Conclusions and Relevance: Our results suggest that using ICD-9 codes alone to capture uveitis and scleritis/episcleritis diagnoses is not sufficient in the Kaiser Permanente Hawaii healthcare system, although there were specific uveitis codes with high PPVs. However, the electronic medical record can reliably be used to identify herpes zoster ophthalmicus cases. Medical record review, as was done in this study, is recommended to elucidate diagnoses for uveitis and scleritis/episcleritis.

Purpose: The purposes of this study are to develop and validate new diagnostic criteria for acute retinal necrosis (ARN) based on the ocular findings, clinical course, and virologic testing of intraocular fluids., Subjects and Methods: The Japanese ARN Study Group, comprising 8 uveitis specialists and 1 statistician, was formed to develop new diagnostic criteria for ARN. The criteria used a combination of clinical features consistent with ARN including 6 early-stage ocular findings ([1a] anterior chamber cells or mutton-fat keratic precipitates; [1b] yellow-white lesion(s) in the peripheral retina [granular or patchy in the early stage, then gradually merging]; [1c] retinal arteritis; [1d] hyperemia of the optic disc; [1e] inflammatory vitreous opacities; and [1f] elevated intraocular pressure), 5 clinical courses ([2a] rapid expansion of the retinal lesion(s) circumferentially, [2b] development of retinal breaks or retinal detachment, [2c] retinal vascular occlusion, [2d] optic atrophy, and [2e] response to antiviral agents), and the results of virologic testing of intraocular fluids by means of either polymerase chain reaction or the Goldmann-Witmer coefficient for herpes simplex virus or varicella zoster virus. Various combinations of findings were analyzed to maximize the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The criteria were then used to retrospectively analyze patients who had been diagnosed as having ARN or control uveitis. Patients were followed at 1 of 7 tertiary uveitis clinics between 2009 and 2011., Results: Analysis of the data allowed delineation of 2 levels of diagnosis: "virus-confirmed ARN" (defined as the presence of both early-stage ocular findings 1a and 1b, the presence of any 1 of the 5 clinical courses, and a positive virologic test result) and "virus-unconfirmed ARN" (defined as the presence of 4 of 6 early-stage ocular findings including 1a and 1b, presence of any 2 of the 5 clinical courses, and a negative virologic test result, or when virologic testing had not been performed). The new diagnostic criteria were applied to 45 patients with ARN and 409 patients with control uveitis, resulting in a sensitivity of 0.89, a specificity of 1.00, a PPV of 1.00, and an NPV of 0.99., Conclusions: New diagnostic criteria for ARN were developed and found to achieve high statistical values.

Purpose: The aim of this study was to describe clinical manifestations of herpetic ocular infection caused by herpes simplex virus (HSV), varicella zoster virus (VZV), and cytomegalovirus (CMV) in a referral center in Northern Italy., Methods: This retrospective study included 241 patients with herpetic ocular infection referred to the tertiary-care Ocular Immunology and Uveitis Service, at the San Raffaele Scientific Institute in Milan, from January 2006 to August 2013. The main clinical parameters evaluated were etiology, clinical features, ocular complications, and recurrences of the infection., Results: Two hundred forty-one patients (144 female and 97 male) were followed for a mean time of 24.9 ± 18.2 months (range, 12-72). One hundred eighty-nine (78.4%) patients had HSV, 45 (18.7%) had VZV, and 7 (2.9%) had CMV infection. In the HSV and VZV groups, the most frequent manifestation was keratitis (41.3% and 31.1%, respectively), followed by anterior uveitis (33.3% and 28.9%, respectively). The most common CMV presentation was retinitis (71.4%). The main complications observed were glaucoma (38.1% in HSV group, 40% in the VZV group, and 28.6% in the CMV group) and cataract (27.5% in HSV group, 26.7% in VZV group, and 28.6% in CMV group), whereas retinal detachment frequently occurred in patients with retinitis (50%, 42.9%, and 40% among HSV, VZV, and CMV patients, respectively). Recurrences were observed in 65.1%, 51.1%, and 28.6% of patients with HSV, VZV, and CMV, respectively., Conclusions: Manifestations of herpetic ocular disease in our patients are comparable with other published series. However, the rate of ocular complications and recurrences during follow-up were higher compared with other series.

Purpose: To provide population-based data on the risk, types, and outcomes of eye involvement in herpes zoster (HZ)., Methods: A cohort study based on review of the medical records of patients in whom HZ was diagnosed between January 1, 1980, and December 31, 2007, was performed. Herpes zoster was confirmed by the presence of the typical rash and symptoms or by laboratory testing, and eye involvement was confirmed by ophthalmologists' evaluation. Information was collected on all eye diagnoses and on HZ eye-related visits, treatments, procedures, and outcomes., Results: Of the 2035 individuals with HZ in any dermatome, 184 (9.0%) had eye involvement. The mean age of the 184 was 62.6 years, and 5 cases occurred in patients younger than 21. Overall, 6.5% (12) were immunosuppressed at the time of the eye complications. The rate of increase in HZ eye involvement was 23% by decade from 1980 to 2007. Common eye complications were keratitis (n=144, 76.2%), uveitis/iritis (n=88, 46.6%), and conjunctivitis (n=67, 35.4%). Recurrent keratitis and recurrent iritis/uveitis occurred in 6.9% (13) and 7.4% (14), respectively. Outcomes included 6 patients (3.3%) with new vision decrements to 20/200 or worse. Two individuals had successful corneal transplants. Another 6 individuals (3.3%) had lid ptosis that affected vision, including 1 elderly woman with permanent unilateral tarsorrhaphy. Severe HZ eye pain was reported to be directly responsible for 1 unsuccessful suicide attempt. Acute retinal necrosis did not develop in any individual. A mean of 10.8 eye visits per patient with HZ and eye involvement was reported to continue for a mean of 308 days., Conclusion: Eye complications are common and result in considerable health care use and permanent vision decrement in about 6.6% (6) of individuals with HZ eye involvement. Most health care use and long-term adverse outcomes occurred in patients in whom prevention of HZ with the zoster vaccine would be possible., (Copyright © 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background: Ocular complications of herpes zoster ophthalmicus (HZO) may lead to substantial visual disability, severe post-herpetic neuralgia and rarely fatal cerebral complications., Aim: To identify the pattern of ocular manifestation in herpes zoster ophthalmicus., Materials and Methods: A cross-sectional descriptive study was under taken including the clinically diagnosed cases of HZO. All of them underwent a complete ophthalmological evaluation., Results: Sixty-eight cases of HZO were examined, of which 37 (54.4 %) were male and 31 (45.6%) female. The mean age was 48.7 ± 18.5 years. Most of the patients (64.7 %) were above the age of 40 years. 77.94 % of the patients had some form of ocular involvement. Pain (77.9 %) was the commonest ocular complaint. In young patients less than 35 years, HIV was the most common risk factor (19.3 %).Visual status was good in the majority (73.5 %) of patients at presentation. Lid and adnexal findings (45.8 %) were most common ocular involvement followed by conjunctivitis (41.1 %). Corneal complication was seen in 38.2 % of cases, uveitis in 19.1 % and post-herpetic neuralgia (PHN) and secondary glaucoma each in 5.8 %., Conclusion: Eyelid and ocular adnexal involvement is most commonly found in patients with herpes zoster ophthalmicus followed by corneal complication and uveitis. There needs to be awareness of ocular involvement, which can be sight threatening, among the HZO patients and other medical departments and an increased emphasis on regular ophthalmic examination., (© NEPjOPH.)

Introduction: Herpes zoster ophthalmicus (HZO) is characterized by a typical vesicular eruption affecting the distribution of the ophthalmic division of the trigeminal nerve which can be of varying severity. The correlation of eruption severity and ocular involvement and subsequent visual loss is still to be established. In this prospective longitudinal study we evaluated the correlation of eruption severity with ocular complications, visual outcome and postherpetic neuralgia., Methods: Patients with HZO underwent detailed ophthalmological and dermatological examination at presentation and follow-up on 1(st) , 2(nd) and 4(th) week and 3(rd) and 6(th) month. Eruption severity was graded as mild, moderate and severe based on the number of vesicles. The correlation of eruption severity and distribution with ocular complications, visual outcome and postherpetic neuralgia was statistically evaluated., Results: Severe eruption was seen in 14(28%), moderate eruption in 21(42%) and mild eruption in 15(30%). Severe eruption was significantly associated with increased incidence and severity of ocular involvement (p = 0.04 and p = 0.04 respectively), occurrence of uveitis (p = 0.004), reduced visual outcome (p = 0.002) and the occurrence of PHN (p = 0.05). Lacrimal nerve involvement was also associated with increased incidence (p = 0.03) and severity (p = 0.02) of ocular complications and visual loss (p = 0.01)., Conclusion: Increasing eruption severity is a good predictor of occurrence of ocular complications and subsequent visual loss in HZO. Presence of a severe eruption is an indication for early ophthalmic intervention. Nasociliary nerve and lacrimal nerve involvement are also good predictors of ocular complications.

Purpose of Review: The virology, pathophysiology, and treatment of the varicella zoster virus (VZV) have been investigated for many years now. Infection with VZV has different ramifications for people of different ages and immune status. The various aspects of VZV disease make it difficult to treat. Selected aspects of VZV disease that pertain to ocular disease are presented., Recent Findings: The risk factors for VZV disease in the different age spectrums and with concomitant immunodeficiencies have been further clarified. Studies suggest that the VZV may persist for prolonged periods on the cornea after herpes zoster ophthalmicus (HZO). Herpes Simplex Virus (HSV) or VZV may cause many cases of idiopathic uveitis with sectoral iris atrophy. The different patterns of retinal disease caused by VZV may relate to the immune status. Systemic antiviral medications for herpes zoster should be instituted within 72 hours of the rash but could be used later. Systemic antivirals combined with systemic corticosteroids improve the early quality of life in HZ patients. Postherpetic neuralgia is not prevented by early systemic antivirals or corticosteroids. Present systemic antivirals are all effective, but Famvir offers the best dosing schedule. The VZV vaccine is effective but there are some issues that suggest the need for a different vaccination regimen., Summary: Further research must be performed on the clinical and therapeutic aspects of the VZV disease. Although both the vaccine and systemic antivirals have brought tremendous improvements, the disease persists. Therapy lessens but does not eliminate many of the complications. The disease may manifest in unpredictable patterns in this era of vaccination.

Our understanding of the spectrum of diseases caused by VZV continues to evolve with new and atypical presentations. Newer diagnostic studies are implicating VZV as the cause of a host of inflammatory conditions, some of which present sine herpete. Finally, the continued development of antiviral drugs and vaccines will allow safer and more effective treatment of VZV and its complications.

The purpose of this study was to describe the clinical characteristics and course of peripheral ulcerative keratitis (PUK) secondary to herpes varicella-zoster virus in patients with the acquired immunodeficiency syndrome (AIDS). Three AIDS patients with ocular herpes zoster infection (mean age at onset, 33.0 years; range, 30-42) developed PUK. The three patients had skin involvement, and two of them had bilateral keratouveitis. All were treated with high-dose oral acyclovir (4 g/day) with or without topical antiviral therapy. Two of the patients responded well to oral acyclovir, but one of them stopped the treatment, and bilateral progressive outer retinal necrosis and lethal encephalitis developed. The third patient had a recurrent episode of inflammation with PUK, extensive stromal scarring, and deep neovascularization. AIDS patients with herpes varicella-zoster virus infection may have severe and protracted corneal manifestations, including PUK. The correct diagnosis and aggressive early long-term systemic antiviral treatment must be instituted to control inflammation, ulcer progression, and complications.