Treatment of ocular herpes

Among the therapeutic factors for herpetic eye diseases, specific virusostatic drugs should be highlighted. These include 5-iodine-2-deoxyuridine (IDU, or kerecid), used in a 0.1% solution in the form of eye drops. The drug is a metabolite and has high antiviral activity. Its mechanism of action is to influence the cell's deoxyribonucleic acid, which prevents the formation of a viral infectious agent. A solution of 5-iodine-2-deoxyuridine in polyvinyl alcohol is called hernlex. Both drugs (kerecid, herplex) are successfully prescribed in the form of drops for herpetic keratitis, but mainly in cases of superficial localization of the process. At first, 5-iodine-2-deoxyuridine was prescribed without hindrance and for a long time, but then they came to the conclusion that it is inappropriate to use it for more than 10 days. The drug may have a toxic effect on the epithelium of the cornea and conjunctiva, causing follicular allergic conjunctivitis and punctate keratitis.

A good virusostatic drug, especially for deep keratitis (disciform type), occurring without damage to the corneal epithelium, is oxolin. In solution, oxolin turned out to be unstable, so it is used mainly in the form of 0.25% ointment. The toxicity of oxolin is low, but when prescribing it to patients, one should warn about the irritating effect of the drug (it has a dionin-like irritant effect, causing a burning sensation, conjunctival hyperemia and even chemosis). However, this seemingly undesirable property of the drug contains a positive factor. Against the background of treatment with oxolin, due to its irritating effects, the resorption of inflammatory infiltrates in the cornea is accelerated.

Antiviral drugs are of great importance in the treatment of herpetic keratitis: tebrofen, florenal in the form of 0.25-0.5% ointment. In some cases, the use of florenal ointment causes a slight burning sensation in the eye, which the patient should also be warned about.

A new era in the therapeutic effect on herpesvirus processes was opened by interferons and interferonogens. Leukocyte interferon is used according to the same scheme as for viral conjunctivitis. For deep forms of keratitis, interferon can be used in the form of subconjunctival injections of 0.3-0.5 ml. A course of treatment usually prescribes 15-20 injections. The effectiveness of the treatment of viral keratitis increases with a combination of interferon and kerecide.

Among interferonogens, pyrogenal has proven itself especially well and is widely used in practice. It is prescribed in drops, intramuscularly and under the conjunctiva of the eyeball. The latter methods of administration are preferable for deep keratitis and iridocyclitis. The drug has a fibrinolytic effect and slows down the cicatricial process. Pyrogenal is administered intramuscularly every other day at 25 MPD, then the dose is increased by 25-50 MPD (the maximum single dose for an adult is 1000 MPD). In the following days, it is prescribed in a dose that causes an increase in body temperature to 37.5-38 °C. Treatment is continued until the increase in body temperature ceases, after which the dose is successively increased by 25-50 MPD. The course of treatment is 10-30 intramuscular injections of pyrogenal. The intervals between courses are 2-3 months. Pyrogenal is administered subconjunctivally at 25-30-50 MPD several times a day. A combination of subconjunctival injections of pyrogenal with gamma globulin at 0.2 ml daily or every other day should be positively evaluated. Up to 20 injections of both drugs are prescribed for a course of treatment.

The category of new biosynthetic interferonogens includes poly-A: U, poly-G: C in a dose of 50-100 mcg under the conjunctiva (0.3-0.5 ml of the drug). The course of treatment consists of 5 to 20 injections of interferonogen.

Antiviral treatment gives the best results if it is carried out along with the use of desensitizing drugs. These include diphenhydramine, calcium preparations, including locally in the form of drops. Naturally, the most active antiallergic agents are corticosteroids (0.5% hydrocortisone suspension, 0.5% cortisone emulsion, 0.1% prednisolone solution, 0.1% dexamethasone solution). However, their use in viral infection of the cornea should be treated with extreme caution. By reducing the inflammatory reaction, these drugs inhibit the formation of antibodies and the production of endogenous interferon, thereby slowing down the epithelialization and scarring of the cornea affected by the herpes simplex virus. It has been proven that when treating herpetic keratitis in an experiment with prednisolone, the virus remains in the tissue longer than without treatment.

In medical practice, against the background of intensive cortisone therapy, when the drug was administered under the conjunctiva, there were cases of descemetocele and corneal perforation. Corticosteroids should be prescribed only in drops for keratitis that occurs without intensive disintegration of corneal tissue, preferably against the background of treatment with gamma globulin in drops or under the conjunctiva, since it increases antiviral immunity. In ididocyclitis, corticosteroids can also be administered under the conjunctiva, monitoring intraocular pressure. In patients receiving steroids for a long time, pneumococcus may join the herpes virus, as evidenced by the appearance of a yellow tint in the corneal infiltrate. In this case, it is advisable to prescribe a 20% solution of sodium sulfacyl, 1% tetracycline or 1% erythromycin ointments. A more favorable course of herpes infection is undoubtedly facilitated by the administration of vitamins A and B, aloe extract, and novocaine blockade.

The method of autohemotherapy in the form of blood instillation or subconjunctival administration in order to increase the antibody titer in the diseased eye is available to all ophthalmologists. Such therapy can be carried out 2-3 weeks after the onset of the disease, when the titer of antiviral antibodies in the patient's body increases.

Treatment of the same profile is the use of gamma globulin. Gamma globulin can be prescribed as intramuscular injections of 0.5-3 ml 3 times with a break of 4-5 days, as subconjunctival injections of 0.2-0.5 ml every other day and as drops. The drip method of treatment is naturally preferable for superficial keratitis, and the introduction of gamma globulin under the conjunctiva or intramuscularly is more appropriate for deep localization of the infectious process in the cornea, iris and ciliary body.

In the treatment of herpetic eye diseases, in order to more actively introduce medicinal substances and use the neurotrophic effect of direct current, it is useful to use medicinal electrophoresis through a bath, closed eyelids or endonasally. Adrenaline, aloe, atropine, vitamin B1, heparin, hydrocortisone, lidase, novocaine, calcium chloride can be introduced by electrophoresis. The choice of drugs for their electrophoretic introduction should be strictly justified. In particular, aloe extract should be prescribed during regression of the herpetic process, in order to resolve corneal opacities. Aloe, B vitamins and novocaine are indicated to improve the trophism of the diseased tissue, accelerate corneal epithelialization. Heparin is introduced to activate the reverse development of the herpetic process, since, according to experimental data, it inhibits the growth of the virus in tissue culture. Hydrocortisone, like lidase, promotes the resorption of infiltrates, more gentle tissue scarring, and a reduction in neovascularization.

Patients with herpes of the eye are prescribed diadynamic currents, microwave, ultrasound therapy and phonophoresis of medicinal substances, in particular interferon, dexamethasone. Magnetotherapy is carried out. O. V. Rzhechitskaya and L. S. Lutsker (1979) suggest using an alternating magnetic field (AMF) of a sinusoidal shape in a continuous mode. The number of sessions is from 5 to 20. It has been proven that an alternating magnetic field increases the permeability of the cornea, and this allows for more active introduction of various medicinal substances into the eye. This method is called magnetoelectrophoresis. In cases of severe herpetic keratitis, magnetoelectrophoresis can be used, in particular, to introduce 5-iodine, -2-deoxyuridine.

The possibilities of cryotherapy of keratitis should be specially discussed. It is performed under instillation anesthesia with 1% dicaine solution, every other day. Up to 10 procedures are prescribed for a course of treatment. The exposure of tissue freezing is 7 sec. The cryo-tip is removed during the defrosting period. Some ophthalmologists are attracted by the operation of trepanoneurotomy. The method prevents the formation of persistent and gross opacities of the cornea. In case of perforation of the cornea, persistent ulcers, frequently recurring keratitis, keratoplasty is indicated. Unfortunately, this measure does not contribute to the prevention of keratitis relapses. Relapses occur more often in the area of the border ring of the transplant. The successes of recent years in the problem of corneal transplantation based on microsurgical techniques, the development of seamless methods of fixing the transplant using bioglue (gamma globulin) or a soft hydrogel contact lens have made keratoplasty surgery the main method in the complex treatment of herpetic lesions of the cornea, occurring with tissue decay.

Sometimes in practical work there is a need for surgical intervention on the eyeball that has suffered a herpes infection in the past. In this case, after an outbreak of inflammation, 3-4 months should fall out. Before the intervention, it is advisable to use interferon in combination with any interferonogen (a course of pyrogenal injections). In recent years, laser argon coagulation has been used for herpetic corneal ulcers, creating a temperature of up to 70 ° C in the radiation exposure zone. Laser coagulation promotes more gentle scarring and has a virus-static effect. Experimental studies have proven that in terms of therapeutic effectiveness, it is superior to IDU and cryotherapy, reducing the patient's treatment time by 2-3 times. Laser coagulation also justifies itself in cases of drug-resistant forms of ophthalmic herpes.

It should be noted that even after successful treatment of severe herpetic keratitis, a decrease in corneal sensitivity (in particular, in the intact eye) is observed for many years, as well as weakness of the epithelial cover of the diseased cornea, and sometimes its rejection. Treatment of such conditions, called postherpetic epitheliopathies, is currently poorly developed. Vitamins of groups A and B, cryoinflation, electrophoresis of novocaine, lysozyme in drops, the use of dexamethasone drops in microdoses (0.001%), and laser coagulation are indicated. Antiviral drugs are inappropriate to prescribe in these cases.

Complex treatment of patients with ophthalmic herpes gives positive results in 95% of cases. However, every ophthalmologist knows that stopping the herpetic process does not mean a complete cure with a guarantee of the absence of possible relapses of ophthalmic herpes.

Prevention of relapses of the disease, issues of prevention occupy an important place in the problem of herpetic eye disease. Despite clinical recovery, the presence of latent herpes infection in the body dictates the need to exclude adverse effects of the external environment. It is necessary to avoid hypothermia. Colds, eye injuries, physical and mental overexertion are extremely dangerous - all factors that contribute to a decrease in the body's resistance, a decrease in antiviral immunity. In case of frequent, sometimes annual, relapses of herpes of the eye, mainly keratitis and iritis, the use of an antiherpetic polyvaccine is indicated. Treatment should not be started in the acute period of the process. After the disappearance of all clinical signs of inflammation, it is necessary to wait 1 month and only then begin the vaccination course. This is due to the fact that even when vaccination is carried out in the cold, i.e. inter-relapse period, an exacerbation of the process is possible, which requires interruption of vaccination and the appointment of desensitizing and antiviral treatment.

The method of anti-relapse therapy consists of intradermal injection (on the inner surface of the forearm) of 0.1-0.2 ml of polyvaccine with the formation of a papule with a "lemon peel". 5 injections are given with an interval of 2 days between them. The first course of vaccination should be carried out in a hospital, and the next one, after 3-6 months (during the first year) can be carried out on an outpatient basis. Then the courses are carried out only on an outpatient basis once every 6 months. The use of herpes polyvaccine does not exclude local prevention of ophthalmic herpes. A preventive measure for the next possible relapse of keratitis is the instillation of interferonogens (pyrogenal at the rate of 1000 MPD, i.e. 1 ml per 10 ml of distilled water, or Poludan at the rate of 200 mcg per 5 ml of distilled water). An important role in the fight against various clinical manifestations of eye pathology caused by the herpes simplex virus belongs to the dispensary service (all patients suffering from frequent relapses should be under dispensary observation).

It is no less important to know another herpetic infection of the eye and its appendages, called shingles (herpes zoster). The disease belongs to the category of cutaneous, occurring with pronounced neuralgic pain syndrome, which is explained by the tropism of the virus to the nervous tissue and skin. In recent years, it has been established that there are two types of neurodermotropic filterable virus, which determines the clinical picture of shingles and the clinical picture of a childhood disease - chickenpox. The cases of infection of children with chickenpox from patients with shingles have become clear. The incubation of shingles lasts 2 weeks, the disease occurs more often in the fall or spring, leaves behind a strong immunity, practically without recurrence. The factors that provoke shingles include infectious diseases, trauma, intoxication, exposure to chemical, food, medicinal agents, especially. with an allergic predisposition to them. The disease is preceded by lethargy, apathy, headache, and an increase in body temperature. Following this, in a certain area, depending on which intervertebral ganglion and the nerve trunk extending from it are affected (most often the III or VII nerves), hyperemia of the skin appears, its swelling with the formation of papules and vesicles. Vesicles usually do not open. They can be filled with pus, blood. Later, crusts appear in place of the vesicles, falling off by the end of the 3rd week. In places of papules and vesicles, dents (pockmarks) remain, similar to those that sometimes occur in children who have had chickenpox. The skin in places where the lichen elements are located is excessively pigmented or, conversely, depigmented. The process is accompanied by severe neuralgic pain, combined with pronounced hypoesthesia or analgesia of the rut in the affected area. Herpes is characterized by the location of rashes only on one side of the body without moving to the other.

The same applies to the defeat of the ophthalmic nerve, which occurs in 10% of cases of herpes zoster in other localizations. The process develops in the branching zone of the ophthalmic nerve (skin of the upper eyelid, forehead, temple and scalp to the midline). In 50% of cases, i.e. almost every second patient, with ophthalmic localization of herpes zoster, the eye becomes ill. Herpetic conjunctivitis, keratitis, iridocyclitis may occur. This is due to the fact that certain branches of the nasociliary nerve (namely the long ciliary nerves), formed as a result of branching of the ophthalmic nerve trunk, perform the function of sensory and trophic innervation.cornea, iris and ciliary body, penetrating into the optic nerve through the sclera into the periochoroidal space. When these branches are involved in the inflammatory process, a clinical picture of herpetic keratitis occurs, sometimes iridocyclitis, which has features characteristic of keratitis and iridocyclitis in infection with the herpes simplex virus.

In order to predict the spread of shingles to the eye tissue, it is necessary to closely monitor the condition of the skin in the area of the inner corner of the eyelids and under the inner commissure of the eyelids. The fact is that the sensitive innervation of these skin areas is carried out by the subblock nerve, which, like the long ciliary nerves, departs from the nasociliary trunk. The appearance of hyperemia of the skin, its infiltration in the indicated areas, the rash of herpetic elements here indicate the involvement of the subblock nerve in the process, after which the long ciliary nerves are usually affected with the appearance of pathological changes on the eyeball.

Timely measures in the form of increased antiviral and desensitizing therapy, local application of exogenous interferon and interferonogens can prevent the development of a viral infection in the eye. In case of orbital localization of shingles, the ophthalmologist should coordinate the appointment of general treatment with a neurologist and dermatologist. To relieve pain, a 50% solution of analgin is usually prescribed intramuscularly, 1-2 ml. The use of broad-spectrum antibiotics, vitamin B1, 1 ml of a 6% solution intramuscularly every other day, which should be alternated with vitamin B12, 200 mcg, is indicated. Skin areas affected by herpes are lubricated with brilliant green, Castellani liquid, sometimes a 2% solution of tannin, 1% solution of silver nitrate. Irrigation of the herpes zone with an interferon solution is useful.

Treatment of keratitis, iridocyclitis corresponds to the treatment prescribed for eye damage by the herpes simplex virus. In the process of curing a patient with shingles, it is necessary to remember the need to isolate children from him, since, as stated above, the shingles virus and the chickenpox virus are almost identical in many characteristics.