Eyeworld

MARCH 2021 | EYEWORLD | 95 C Relevant disclosures Cohen: None de Luise: None Contact Cohen: Elisabeth.Cohen@nyulangone.org de Luise: vdeluisemd@gmail.com Management of HZO-related IOP rise and glaucoma People with HZO can have problems with sec- ondary glaucoma caused by a variety of mecha- nisms, Dr. Cohen said. "If one has iritis or inflammation inside the eye, that is often associated with very high pres- sure and can result in rapid onset of glaucoma, visual field loss, and optic nerve damage," she said. Additionally, steroids used to treat topical inflammation can cause elevated pressure and risk for glaucoma. Anyone on topical steroids should be monitored closely for glaucoma, she added. The mechanisms of IOP rise and glaucoma in HZO include trabeculitis, synechial scarring in the angle, use of topical corticosteroids be- yond 3 weeks, and mechanical blockage of the trabecular meshwork by inflammatory cells, Dr. de Luise said. "Management should be initiated with aqueous suppressant medications," he said. "Topical corticosteroids should also be em- ployed, always with careful and frequent fol- low-up." He added that concerns about cortico- steroid-induced IOP are valid but are tempered by the fact that topical corticosteroids are essen- tial for inflammatory glaucoma management. Additionally, Dr. de Luise said that topi- cal prostaglandins have long been debated in inflammatory glaucoma management. "While there have been rare case reports of topical prostaglandins inducing CME in cases of inflammatory glaucoma, their use should still be considered in these cases," he said. "If medica- tion strategies fail, filtration surgery or tube/ shunt is recommended." Dr. Cohen said that she strongly recom- mends vaccination with Shingrix for persons age 50 years and older, per the FDA approval. Should ophthalmologists manage post-herpetic neuralgia in HZO? According to Dr. de Luise, post-herpetic neuralgia (PHN) is defined as pain that persists after the first 4 weeks of the cutaneous eruption or pain that presents after the first 4 weeks of the cutaneous eruption. PHN can be a difficult and at times prolonged and intractable sequela of HZO. It is gener- ally best if the ophthalmologist refers patients with PHN to a neurologist, neuro-ophthalmologist, or pain management anesthesiologist, he said. "Ophthalmologists can consider initiating therapy for milder cases of PHN, with strategies such as the tricyclic antidepressant amitriptyline, which also has some pain-relieving properties, or 5% lido- caine patches to the affected skin area," Dr. de Luise said. "The calcium channel alpha 2 delta ligand oral agents gabapentin and pregabalin are both FDA labeled for PHN." If PHN persists, it is strongly recommended to enlist neurologists and/or pain management specialty anesthesiologists for further strategies, which can include opioids and stellate ganglion block, Dr. de Luise said. Dr. Cohen agreed that it's helpful to work with a pain management group and/or a neurologist if this issue occurs, as they may be more comfortable prescribing the necessary medications. Post-herpetic neuralgia is the most common and serious complication of zoster. It occurs more fre- quently in older patients, she said, and can have a terrible impact on quality of life. Additionally, Dr. Cohen said that zoster is a risk factor for new onset of depression and is also a common cause of sui- cide due to pain in people age 70 and above. "If you can't control the post-herpetic neuralgia using a reasonable dosage of neuropathic pain medicines or anti-depressants, it's important to work with neurologists and pain management specialists to enhance quality of life for patients and minimize use of narcotic pain medicines as much as possible," she said. She again stressed that she strongly recommends vaccination with Shingrix for persons age 50 years and older, per the FDA approval.

• Blank Page
• Blank Page (1)