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EW FEATURE 32 Neuro-ophthalmology for the anterior segment surgeon • June 2018 AT A GLANCE • Optic neuropathy and double vision are two neuro-ophthalmic compli- cations that may be seen in patients with VZV. • Patients with isolated optic neuropa- thy or double vision generally do not have to be admitted to the hospital, but this should be determined on a case-by-case basis. Patients with other neurological complications may need additional testing and/or admission to the hospital. • Oral antivirals are generally used for these patients and can offer good recovery for many. Intravenous anti- virals may need to be used in some cases. The shingles vaccine should be recommended for all individu- als older than 50 years to prevent herpes zoster ophthalmicus and its complications. by Ellen Stodola EyeWorld Senior Staff Writer/Digital Editor Dr. Golnik agreed that some patients may need to be admitted to the hospital, while others do not. He usually does not admit a patient to the hospital if the symptoms are isolated to optic neuropathy or double vision. He added that it's possible to have varicella zoster in the brain and have meningitis and other neurologic symptoms. If they have other systemic neurologic symp- toms, patients get admitted to the hospital and have MRIs and lumbar punctures to prove herpes zoster in the spinal fluid, he said. altered cognition, severe head- aches, neck pain, and other similar symptoms. All patients with acute vision loss or double vision after herpes zoster ophthalmicus should have urgent imaging and possibly a lumbar puncture, he added. Patients with clear evidence of neurological herpes zoster will need intravenous antiviral medications. "I am a neurologist, so I err on the side of caution and I gener- ally get them into the hospital to facilitate diagnostic studies and start intravenous antivirals when indicat- ed," he said. double vision from orbital or cranial nerve involvement, or post-zoster herpetic neuralgia, a debilitating pain syndrome. Patients may also have a cerebral vasculitis, or inflam- mation of the small blood vessels in the brain, that can manifest with headache, confusion, and visual complaints. Dr. Golnik has published papers recently on different cranial nerve problems, specifically optic neurop- athy and double vision presumed to be due to herpes. Usually when he sees these patients, the rash on their face is evident, and they may present with either loss of vision in one eye or double vision. If neuro-ophthalmic complications occur, is there a temporal relationship with intraocular or corneal involvement? According to Dr. Golnik there is not a temporal relationship with intra- ocular or corneal involvement when neuro-ophthalmic complications of VZV occur. "Not as far as we know," he said. "Many patients we see don't have the usual herpes zoster oph- thalmicus." When a patient comes in with optic neuropathy, sometimes there is swelling of the optic nerve in back of the eye and sometimes there isn't, he said. These patients don't necessarily have anything going on in the cornea or front of the eye, but they could possibly have anterior or retrobulbar optic neuropathy. "In a majority of patients, both in my personal experience and reported literature, the timeline is variable," Dr. Kedar said. While some patients report a recent histo- ry of herpes zoster ophthalmicus, others present with neuro-ophthal- mic complications weeks or months after the original event. Would you recommend patients with these complications for hospital admission? Some of the complications may require hospital admission, Dr. Kedar said, especially those with neurological complaints such as Experts discuss what to look for in terms of neuro-ophthalmic signs of VZV and how to treat it W hile anterior segment surgeons may have patients presenting with herpes zoster ophthalmicus, some may not be as used to dealing with the neuro-ophthalmic manifesta- tions of the varicella zoster virus (VZV). Karl Golnik, MD, Cincin- nati Eye Institute, Cincinnati, and Sachin Kedar, MD, University of Nebraska Medical Center, Omaha, shared some of the neuro-ophthal- mic manifestations of VZV, as well as what they would recommend in terms of medications and how to deal with these patients. Neuro-ophthalmic manifestations of VZV Dr. Kedar said that zoster patients with neuro-ophthalmological complications might present to an ophthalmologist with sudden vision loss from optic nerve involvement, Neuro-ophthalmic manifestations of varicella zoster virus Herpes zoster ophthalmicus is an issue that patients may present with, but anterior segment surgeons may not be as familiar with the neuro-ophthalmic manifestations of the varicella zoster virus. Source: Karl Brasse, MD continued on page 34

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