Stromal Keratitis in the Zoster Eye Disease Study: Lessons Learned.

To report an unusual case of a late-stage reactivation of immune stromal keratitis associated with herpes zoster ophthalmicus (HZO), occurring without any apparent predisposing factors, more than 4 years after an acute zoster dermatomal rash. Significant corneal hypoesthesia and a central band keratopathy developed within 6 months of the late-stage reactivation. The clinical case management, issues associated with management, and management options are discussed, including the use of standardized, regulatory approved, antibacterial medical honey. An 83-year-old woman presented for routine review with a reactivation of right anterior stromal keratitis and mild anterior uveitis, occurring more than 4 years after an acute HZO dermatomal rash and an associated initial episode of anterior stromal keratitis. Corneal sensation became markedly impaired, and over the subsequent 6 months, a right central band keratopathy developed despite oral antiviral and topical steroid therapy. Visual acuity with pinhole was reduced to 20/100 in the affected eye and moderate irritation and epiphora were experienced. The patient declined the surgical intervention options of chelation, lamellar keratectomy, and phototherapeutic keratectomy to treat the band keratopathy. Longer-term management has involved preservative-free artificial tears, eyelid hygiene, standardized antibacterial medical honey, topical nonpreserved steroid, and UV-protective wraparound sunglasses. The clinical condition has improved over 14 months with this ocular surface management regimen, and visual acuity of 20/30 is currently achieved in a comfortable eye. The chronic and recurrent nature of HZO can be associated with significant corneal morbidity, even many years after the initial zoster episode. Long-term review and management of patients with a history of herpes zoster stromal keratitis are indicated following the initial corneal involvement. Standardized antibacterial medical honey can be considered in the management of the chronic ocular surface disease associated with HZO and warrants further evaluation in clinical trials.

Objective: To evaluate the demographic characteristics, systemic comorbidities, and ocular manifestations of herpes zoster ophthalmicus (HZO) patients in a tertiary referral center, and to analyze associations between Hutchinson's sign and ocular involvement. Material and Methods: In this retrospective descriptive study, the medical records of patients diagnosed with HZO between January 2022-March 2025 were reviewed. Data on demographics, systemic diseases, ocular findings, and treatments were collected. Best-corrected visual acuity, intraocular pressure, and both anterior and posterior segment involvement were comprehensively assessed. The relationship between Hutchinson's sign and ocular complications was statistically analyzed. Results: A total of 115 patients (115 eyes) were included, with a mean age of 57.9±20.3 years; 53.9% were female. Systemic comorbidities were present in 64.3%, with hypertension (40.9%), immunosuppression (28.7%), and diabetes (27.0%) being the most common. Unilateral involvement was predominant (87.8%), while bilateral disease was observed in 12.2%. Ocular findings included vesicular eyelid lesions (87.0%), blepharoconjunctivitis (73.9%), periorbital edema (68.7%), ptosis (55.7%), and corneal involvement (51.3%), with pseudodendritic (23.5%) and stromal keratitis (14.8%) being the most common corneal pathologies. Anterior uveitis was detected in 13%. Hutchinson's sign was significantly associated with iris involvement (p=0.023), anterior uveitis (p=0.020), disciform keratitis (p=0.002), and skin involvement (p=0.007). Conclusion: HZO remains a significant cause of ocular morbidity, especially in older adults and those with systemic comorbidities. Hutchinson's sign is a critical predictor of severe ocular involvement. Early diagnosis and antiviral therapy are essential for preventing vision-threatening complications.

Herpes zoster ophthalmicus (HZO) is a clinical manifestation of the reactivation of latent varicella zoster virus (VZV) infection in the trigeminal ganglia that affects the nerve's ophthalmic division.1 Timely diagnosis and treatment are critical in reducing visual morbidity. HZO can result in a variety of long-term and recurrent complications, which can be sight-threatening.1 Herein, we report a very rare case of ulcerated keloid on HZO scar that developed in an immunocompetent young woman. A 26-year-old white female presented with a blurred vision. She had a history of herpes zoster ophtalmicus involving the right side of the forehead 4 months earlier. The infection was insufficiently treated with oral valacyclovir as the patient only received the drug for 3 days. Clinical examination revealed a keloid scar in the forehead with a sharp vertical demarcation line, associated with a palpebral retraction and eyelid necrosis (Figure 1). Dermatological examination was otherwise normal, with no further keloid scars. The extraocular motility was full. Her visual acuity was limited to hand motion on the right eye and 20/20 in the left eye. Anterior segment examination found an ulcerative stromal keratitis and corneal hypoesthesia. The posterior segment was unremarkable. She had a negative HIV test. She underwent superior eyelid reconstruction with intralesional injections of corticosteroids for her keloid scar with a favorable outcome. Keloid is a benign connective tissue tumor that develops as a result of a complex aberrant wound-healing response.2 It can result in disfiguration, restriction of movement, infection, and ulceration as seen in our patient.2 The mechanisms underlying the development of keloids are not well known. Both hereditary and environmental factors play a role in keloid formation. Given the absence of family history and the unique anatomical site of the keloid in our case, the familial predisposition may not apply. Indeed, old scars in other parts of her body showed no signs of keloid even in high-risk areas like the chest. The term Wolf's isotopic phenomenon refers to the development of new skin disease at the site of a previously cured one.3 In most cases, the preceding disease is HZ.4 The most frequent isotopic responses that develop on the site of HZ are granulomatous and lichenoid reactions and infiltrations of hematologic diseases.5 Keloid formation is an extremely rare but well-documented isotopic response of HZ. It was initially reported by Requena et al.5 who investigated cutaneous reactions at sites of HZ scars in 16 patients. Among them, only one patient developed keloid. In another study, among 246 HIV-positive patients, 23 patients had keloid development as a complication of HZ.6 Only one case of keloid formation in HZ ophthalmicus has been described, it occurred in an African woman following the use of traditional herbs to the herpetic rash.7 A wide range of latency durations between infection and cutaneous reaction, spanning from days to years, was described.3 The pathogenesis of these skin reactions is not totally understood. Viral and immunological etiologies were proposed. Viral infection may alter local skin immunity which would favor hyperreactivity, leading to inflammatory processes, or local immunosuppression, leading to tumor infiltrations or infections.3 We report here the first case of ulcerated keloid after HZO in an immunocompetent woman. We hypothesize that keloid formation, in our patient, can be explained by Wolf isotopic phenomenon. Herpes zoster (HZ) lesions were also deep and poorly treated, which could have played a role. Rym Maamouri and Anissa Zaouak wrote the manuscript with support from Refka Frioui. Amri Ali analyzed the data. Monia Cheour supervised the project. All authors have read and approved the final manuscript. None declared. The authors certify that they have obtained all appropriate patient consent forms, in which the patients gave their consent for imagesand other clinical information to be included in the journal.

To report a case of herpes zoster ophthalmicus (HZO) reactivation after recombinant zoster vaccination. A 78-year-old woman, with a history of HZO 20 years ago, was referred for progressive corneal thinning in her left eye that started 1 week after her second dose of recombinant zoster vaccination. At presentation, visual acuity was counting fingers. Corneal sensation was markedly decreased. Slit lamp examination revealed a temporal paracentral epithelial defect 1.5 × 2.0 mm in size with 40% thinning and surrounding stromal inflammation suggestive of stromal keratitis with ulceration. The patient was started on oral valacyclovir, topical erythromycin ointment, and hourly topical lubrication. A bandage contact lens was placed and was replaced 1 week later with self-retained cryopreserved amniotic membrane ring. The ring was removed in the following week when the thinned area was epithelialized with no further evidence of stromal lysis. HZO reactivation after recombinant zoster vaccination is uncommon but possible. Ophthalmologists should remain aware of potential risks of zoster vaccination and take special precautions in patients with HZO history.

Topical steroids as first-line treatment for phimosis are well established, but both the accurate diagnosis of pathological phimosis and the regimen of use of steroid ointment are not widely known, as judged by a review of referrals to a specialist clinic. This study aims to determine the proportion of patients with an accurate diagnosis of phimosis and appropriate use of steroid treatment prior to specialist referral for phimosis. Retrospective data were collected for 781 boys with a mean age of 11.8 ± 0.22 years, including the reason for general practitioner referral, previous use of topical steroids, and specialist management. Six hundred patients were referred with a diagnosis of phimosis; 181 were referred with an alternative diagnosis. Only 218 boys had pre-referral steroid treatment. Conservative therapy was used for 614 patients, of whom 489 received topical steroid ointment. Circumcision or dorsal slit procedures were required for failed medical management in 95. Most boys with phimosis are cured with the use of an appropriate topical steroid; however, very few have steroid ointment as part of their care prior to referral.

Ulcerative Keratitis in Gastrointestinal Stromal Tumor Patients Treated with Perifosine

The Zoster Eye Disease Study (ZEDS) is a multicenter randomized clinical trial (RCT) funded by the National Eye Institute aiming to determine the efficacy of suppressive valacyclovir treatment in herpes zoster ophthalmicus (HZO) that enrolled fewer participants than planned (527/780, 67.6%). Understanding reasons for nonparticipation of likely eligible prescreened patients provides insights into patient populations that are not represented by ZEDS and barriers in clinical trials. In this retrospective cohort study, HZO adults likely eligible for ZEDS with a history of a typical rash and a medical record within the past year of an episode of epithelial or stromal keratitis or iritis were prescreened at activated Participating Clinical Centers from 2017 to 2022 using a standard prescreening log. De-identified data including demographic information, reasons for exclusion because of ineligibility, and patient refusal were retrospectively entered into REDCap and analyzed. Prescreening logs with reasons for nonconsent (1244/1706, 72.9%) were included in the data set. Patients were excluded from the study (915/1244, 73.6%) because they did not meet all inclusion criteria (619/915, 67.7%) or met an exclusion criterion (296/915, 32.3%). Among the 12 exclusion criteria for the ZEDS study, immunocompromise (76/296, 25.7%) and renal insufficiency (50/296, 16.9%) were most frequently reported. Patient refusal to participate (327/1,244, 26.3%) was common. The most common reasons for ineligibility were immunocompromise and renal insufficiency. There may be benefits to long-term antiviral use in these populations not captured in ZEDS. A quarter (26.3%) of prescreened patients refused participation, showing the substantial impact of patient preferences on trial participation.

Herpes Zoster Ophthalmicus: Comparison of Disease in Patients 60 Years and Older Versus Younger than 60 Years

To describe the treatment of chronic stromal Acanthamoeba keratitis (AK) with oral voriconazole monotherapy. All cases of chronic stromal AK recalcitrant to traditional therapy subsequently treated with systemic voriconazole seen at the University of Illinois Eye and Ear Infirmary between June 2003 and July 2009 were reviewed for clinical presentation, clinical course, and outcome. Three eyes of 2 patients were identified with culture-confirmed chronic stromal AK unresponsive to traditional antiacanthamoebal therapies, requiring topical corticosteroids to maintain corneal clarity. Oral voriconazole 200 mg twice daily achieved a rapid but transient reduction of inflammation and elimination of corticosteroid dependency but, in both patients, recrudesced approximately 6 weeks after its discontinuation. Subsequent repeated and/or extended use of oral voriconazole alone resulted in complete resolution ranging from 7 to 11 months off all medications with final best-corrected visual acuity ranging from 20/20 to 20/25. Recalcitrant chronic Acanthamoeba stromal keratitis was successfully treated with extended systemic voriconazole administration with good preservation of vision. The clinical resolution of chronic stromal keratitis in our 2 cases suggests that voriconazole may have a larger role in the treatment of AK.

Past, present, and prospects in microsporidial keratoconjunctivitis- A review

Optic neuritis (ON) secondary to herpes zoster ophthalmicus (HZO) is a rare complication. Here, we report a case of a young female with no prior comorbidities who developed ON secondary to HZO. She had a 4-day history of acute onset of pain in the right eye along with skin manifestations. Ophthalmic examination revealed keratic precipitates, multiple dendritic lesions with stromal keratitis, and fundus examination showed temporal disc pallor. Magnetic resonance imaging of the brain showed intraconal, intracanalicular part of the right optic nerve sheath complex thickening with surrounding fat stranding and homogenous enhancement on post-contrast administration. The patient was treated with intravenous steroids and antivirals and showed gradual improvement in vision.

To evaluate the clinical features of pediatric non-infectious uveitis (NIU) patients treated with adalimumab (ADA) and the efficacy of ADA in patients unresponsive to conventional immunosuppressive therapy. The records of 91 NIU patients aged ≤16 years who received ADA therapy were evaluated retrospectively. The patients' demographic and clinical characteristics and treatment approaches were recorded. The efficacy of ADA in patients treated for at least 1 year after failure of conventional immunosuppressive treatment was evaluated by comparing the best corrected visual acuity (BCVA), severity of intraocular inflammation, uveitis flare-ups, topical and systemic corticosteroid (CS) use, and central macular thickness (CMT) values before and after ADA treatment. The study included 103 eyes of 53 patients, of whom 29 (54.7%) were female. The mean age at presentation was 8.2±3.4 (range: 3-16) years. The mean follow-up period was 41.6±28.2 (range: 18-120) months. Twenty-six patients (49.0%) had anterior uveitis, 22 (41.5%) had intermediate uveitis, and 5 (9.4%) had panuveitis. The mean duration of ADA treatment was 23.0±13.7 (range: 12-60) months. Uveitis flare-ups developed in only 13 patients (24.5%) while on ADA treatment. When pre- and post-treatment periods were compared, the mean number of uveitis flare-ups, intraocular inflammation severity, mean dose of topical and systemic CS, and mean CMT values were significantly lower in the post-treatment period (p<0.05). The mean BCVA was significantly improved after 6 and 12 months of ADA treatment compared to the pre-treatment visual acuity (p<0.05). ADA effectively controlled intraocular inflammation, reducing the need for systemic and topical CS and improving visual outcomes in pediatric NIU.

What's new in atopic dermatitis?

To evaluate the relative efficacy of topical steroids in preventing radiation dermatitis (RD). Multiple databases including Medline, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), China Biological Medicine (SinoMed), and Wanfang Database were searched for randomized controlled trials (RCTs) of RD prevention in patients with cancer from inception to November 26, 2021, followed by an update on June 1, 2021. Six RCTs evaluating the efficacy of topical steroids in preventing RD in a total of 661 patients with cancer were included. RD incidence was lower with topical steroids compared with placebo at week 3 (relative risk [RR]=0.68, 95% confidence interval [CI]: 0.31-1.50) and at radiation therapy (RT) completion (RR=0.97, 95% CI: 0.93-1.00). Topical steroids demonstrated a less risk of developing dermatitis of Radiation Therapy Oncology Group (RTOG) grades 2 and 3 at the completion of RT (RR=0.66, 95% CI: 0.55-0.80 and RR=0.54, 95% CI: 0.38-0.77, respectively). However, topical steroids did not reduce RTOG grades 1 and 2 dermatitis at week 3(RR=0.73, 95% CI: 0.45-1.14 and RR=0.66, 95% CI: 0.27-1.60, respectively). Notably, the use of topical steroids did not decrease RD incidence when patients received combined chemotherapy (RR=0.60, 95% CI: 0.42-0.86), and an obvious reduction in the incidence of RD at RT completion was found when patients used the topical steroids twice-daily (RR=0.66, 95% CI: 0.47-0.93, P=0.02). Topical steroids reduced RD incidence in patients receiving RT. Thus, twice-daily topical steroids may be recommended for patients at the beginning of RT.

PurposeOral lichen planus (OLP) is an intractable chronic inflammatory disease associated with dyskeratosis. This study aimed to investigate the clinical features of OLP at the initial diagnosis and classified it using the clinical visual examination type classification. Furthermore, we evaluated whether the clinical characteristics and effectiveness of symptomatic treatment differ between the typical reticular type and other types of OLP. MethodsWe evaluated the age, sex, chief complaints, clinical morphological forms, lesion sites, cytological and histopathological findings, therapeutic strategies, and therapeutic responsiveness of 132 patients with OLP. ResultsOf 132 patients, there were 42 men and 90 women (mean age, 66.4 ± 13.0 years). The buccal mucosa was the most affected site (n = 95). The reticular form was the most common clinical morphological form (n = 124). Biopsy was performed in 48 patients. The erosive form was the most common among the biopsied lesions. Regarding therapeutic strategies, topical steroids were prescribed to 85 patients, 47 of whom experienced symptomatic relief and 38 showed no changes in symptoms. The rates of symptomatic relief following topical steroid use were 70.4% and 15.9% for the reticular and erosive forms, respectively. In patients with erosive and plaque-like forms, symptomatic relief with topical steroid use was difficult to achieve, whereas in those with other forms, a moderate response was observed. ConclusionTopical steroids are often ineffective in patients with erosive or mixed forms, and these clinical morphological forms are associated with a higher risk of malignant transformation than the other forms. Therefore, early histological examination is important.