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Ocular Shingles (Shingles affecting the eye)

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globe anatomy
anatomy of the eye (click on image to enlarge)

What is ocular shingles?

Ocular shingles (herpes zoster ophthalmicus) is an inflammation of the eye and surrounding skin caused by an infection of a virus in the Herpes group called the Varicella Zoster virus (the Chicken Pox virus). The name, shingles, comes from a Latin word meaning belt or girdle, as shingles usually presents as a rash along the path of a nerve in a band-like pattern.

Zoster
Shingles

What causes shingles?

Shingles is caused by the Chicken Pox virus that reactivates after years of “hibernation” in the nerve cells. When you contract Chicken Pox, the virus takes refuge inside nerve cells and remains there for life after the rash goes away. This is a common behavior of all viruses in the Herpes group. Years later, when the immune system “forgets” the virus, it re-emerges as shingles.

Why is shingles becoming more common?

Currently, it is estimated that half of all people will develop shingles during their lifetime. The reason appears to relate to the use of the Chicken Pox vaccine. Prior to vaccination, adults would be routinely exposed to the Chicken Pox virus as they were intermittently exposed to children with active Chicken Pox. This frequent exposure to the virus by adults used to keep the immune system primed to keep the virus contained inside the nerve cells. Now that children no longer contract Chicken Pox, adults no longer receive the benefit of immune priming. Over time the immune system forgets the virus and allows the escape of the virus from the nerve.

What are the symptoms of ocular shingles?

The symptoms of shingles depend on the location of the nerves that harbor the virus. If the chest wall is affected, the eyes are spared. If the trigeminal nerve is affected, the forehead develops a rash. If the rash reaches the tip of the nose, the eye is often affected. The rash starts with redness and tiny blisters that crust and scar over time. Pain may occur before the rash appears and is described as burning, sharp, jabbing or tingling. Pain may be severe. It is the persistence of pain that may be disabling.

Aside from the possibility of long-term pain, other problems may relate to shingles. There appears to be an increased risk (4.5x) of stroke after shingles. There may also be an increased risk of cancer, inflammation of blood vessels (temporal arteritis), heart attack, and depression.

Ocular shingles is when shingles affects the eye. It may cause inflammation of the front window of the eye (the cornea) with scarring. Glaucoma may occur and require life-long treatment to prevent blindness. Intraocular inflammation may affect the front of the eye (iritis) or deep inside the eye threatening loss of vision. The inflammation may persist or return intermittently into the future.

What treatment is available?

Antiviral and anti-inflammatory medications may help treat shingles. The systemic treatment of shingles is managed by an internal medicine doctor (and sometimes by an infectious disease specialist). Treatment may hasten the recovery from shingles, but does not eliminate the late complications of infection.

Ocular complications of shingles are treated by ophthalmologists. Apart from anti-viral pills, eyes drops can help prevent loss of vision. After the initial inflammation is controlled, regular exams are important to diagnose problems that may occur in the future.

What can be done to prevent shingles?

An ounce of prevention is worth a pound of cure. The chance of shingles can be reduced by the use of a vaccine. This vaccine reduces the risk, but does not eliminate the chance of getting shingles. If shingles does occur after vaccination, it us usually not as severe compared to those without the vaccine. Not surprisingly, the effect of the vaccine wears off over a period of five to ten years. Research suggests that booster shots may help extend the effect of the vaccine; however, the cost of the vaccine appears to hinder formal recommendations for repeat vaccination. The newest vaccine, Shingrix, became available in 2018 and offers the best protection.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright © 2018-2022 Designs Unlimited of Florida. All Rights Reserved.

Treatment of Uveitis

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globe anatomy
anatomy of the eye (click on image to enlarge)

How is Uveitis treated?

The key to treating uveitis is to identify the underlying cause. However, the specific cause may not always be found. Therefore, it is helpful to place a given case of uveitis into various classifications in order to treat most effectively. In some cases there is an infection that requires treatment with antibiotics. In other cases there is an underlying inflammation in the body outside the eye that is not associated with infection. In such cases the treatment of the systemic condition is required to settle the eye. Finally, there are inflammatory conditions not associated with infection that only affect the eyes. In these cases treatment may be directed to the eye alone. Such treatment often starts with eye drops.

What infections cause uveitis?

A large variety of organisms may infect the eye: bacteria, viruses, fungi, worms, insect larvae, protozoa, and other parasites. Some infect the eye alone. Others infectious agents affect other parts of the body as well. Infectious agents may enter the eye from a cut or opening into the eye from an eye injury. This is called endophthalmitis. Urgent antibiotic treatment is required as the risk of permanent loss of vision is high.

In other types of infection, the organism enters the eye through the blood stream. An infectious agent may enter the body through a cut in the skin, through the gastro-intestinal tract, the uro-genital tract or through the lungs. Once it is in the body the organism may enter the blood vessels and travel to the eye. For example, toxoplasmosis is a parasite found in contaminated food that enters the gastro-intestinal tract. It then spreads to the eye through the blood stream and infects the retina.

Because a large variety of infectious agents may enter the eye, the patient must inform the doctor of possible exposure to infection and carefully complete a uveitis questionnaire. Sometimes, a medical specialist in infectious disease is consulted.

What systemic inflammatory conditions can affect the eye?

Many autoimmune conditions cause inflammation without infection. The immune system abnormally identifies the body as being “foreign.” The resultant inflammation may affect various organs of the body. For example, rheumatoid arthritis in an autoimmune condition that affect the joints and sometimes causes inflammation of the sclera (the white outer coat of the eye).

In order to identify an autoimmune disease, the doctor will ask many questions about inflammation outside the eye (uveitis questionnaire) and order appropriate tests.

What are inflammatory conditions that affect the eye alone?

Sometimes, the immune system attacks the eye without affecting other organs in the body. The underlying trigger or cause of inflammation cannot usually be found. These conditions are placed into categories that help plan treatment strategies. For example, anterior uveitis (inflammation of the front of the eye) is initially treated with anti-inflammatory eye drops. On the other hand, Birdshot Chorioretinitis (BSCR) is an inflammation of the back part of the eye that usually requires long-term systemic treatment (pills or injections in the skin). There are many different ocular inflammatory conditions, which are identified by tests ordered by the doctor.

What medications are used for uveitis?

The type of treatment depends on the cause and category of inflammation. Antibiotics are used if an infection is suspected. The doctor prescribes antibiotics by pill or IV (intravenous) if the infection affects organs outside the eye. The doctor prescribes eye drops, pills, and/or injections if the infection affects only the eye.

The eye doctor may consult a rheumatologist to help monitor treatment with a systemic anti-inflammatory medication (pills and/or injections) if an inflammation affects organs outside the eye. Sometimes, an inflammation only affecting the eye requires the use of systemic medication, too. The ophthalmologist may also use eye drops and painless eye injections to control the inflammation.

Anti-inflammatory eye drops include steroid eye drops and non-steroid eye drops. They may be used separately or together depending on the type of inflammation. Steroid eye drops may cause the intra-ocular pressure to rise and must be monitored. Non-steroid eye drops may irritate the cornea (the front window of the eye). Dilating drops are often used to minimize pain from inflammation and help prevent harmful scar tissue from damaging the iris (the brown or blue part on the front of the eye).

Steroid injections may be given next to the eye (subtenon’s injection) or into the eye (intravitreal injection). Anesthetics help prevent pain with injection. Steroid implant injections (Ozurdex and Iluvien) offer longer duration of effect. Steroid injections may be especially useful in the treatment of macular edema (swelling of the retina) in patients with uveitis.

Steroid pills are often used at the beginning of treatment to control severe inflammation. Prednisone is the most common medication used to treat uveitis. It is usually used at high starting doses and then is slowly tapered down to an acceptable dose for long-term use or is completely discontinued. Prednisone has unacceptable side effects if used in high doses for many months to years.

Non-steroidal anti-inflammatory drugs (NSAIDS) given as pills may provide steroid-free treatment for some cases of uveitis. Some are available over-the-counter. Others are available by prescription. They may adversely affect the stomach and kidney.

Immune system suppressants help to quell uveits. Methotrexate, azathioprine, mycophenolate mofetil, cyclosporin are often used safely and effectively. Routine blood tests help detect side effect before permanent damage occurs. Although there was concern of an increased risk of skin cancer and lymphoma due to immune suppression, the SITE extension study showed that cancer risk is not increased. Very strong medications are used in very severe inflammation that threatens life or blindness (cyclophosphamide and chlorambucil). Pregnancy is avoided while on immune suppressants.

Biologic medications are new and very effective in the treatment of uveitis. Humira is given at home as an injection under the skin every two weeks. Long-term effects are being studied.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright © 2017-2022 Designs Unlimited of Florida. All rights reserved.

HLA B-27 and the Eye

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globe anatomy
anatomy of the eye (click on image to enlarge)

What is HLA-B27?

HLA-B27 is the name of an inherited marker found on white blood cells. It is found to be present with blood testing in one to ten percent of the population (higher in Scandinavians and some Native American groups). HLA is an abbreviation for Human Leukocyte Antigen. HLA-B27 is important to identify as it may be associated with medical problems such as inflammation of the eye, arthritis, psoriasis, and bowel inflammation, which may require medical treatment. There is an estimated risk of one-in-four that a person with HLA-B27 will develop eye or joint inflammation. Low vitamin D levels may play a role in causing the inflammation.

How does it affect the eye?

People who inherit HLA-B27 may develop iritis at some time during their lives. Iritis (also called anterior uveitis) means inflammation of the iris (the colored part of the eye). This inflammation is an irritation without infection. The inflammation is due to the natural immune system in the body mistakenly attacking the eye (similar to the way the immune system attacks the joints in rheumatoid arthritis). Symptoms include deep aching eye pain, redness, tearing, and light sensitivity. Other conditions of the eye may cause similar symptoms, so it is important to see an eye doctor promptly to make the correct diagnosis. Symptoms may be mild or severe. Treatment with drops (steroid and non-steroid), shots, and/or pills is important to prevent complications such as decreased vision, glaucoma, cataract, scarring, deformity, and blindness.

In 15-20% of patients with ocular inflammation associated with HLA-B27, the posterior structures of the eye may be involved.  This inflammation is called intermediate uveitis.  Symptoms include floaters and blurred vision.  Although eye drops may be helpful, steroid injections and systemic medications may be needed.  It is important to know if there is joint inflammation when deciding how to treat eye inflammation, because Humira is preferred over other medications if immunosuppressive therapy is needed.  Humira (and other TNF-apha inhibitors) are effective for both eye and joint inflammation.  Whereas, methotrexate and mycophenolate are good for eye inflammation, but less effective against joint inflammation associated with HLA B27.

How can it affect other parts of the body?

HLA-B27 is associated with ankylosing spondylitis, reactive arthritis, inflammatory bowel disease, and psoriasis. Ankylosing spondylitis is an arthritis that involves the spine, and it usually causes back pain and stiffness. Reactive arthritis usually involves large joints like the knees, ankles, feet, and wrists. It may follow an episode of infection of the intestines, bladder, or genitals. Inflammatory bowel disease may involve the small intestine (Crohn’s disease) or the large intestine (ulcerative colitis). Psoriasis is a skin condition causing raised red areas of the skin with scaling. Rarely, patients with HLA-B27 will suffer from scarring of the lungs (apical pulmonary fibrosis) or inflammation of the large blood vessels (aortitis).

Who should I see for evaluation of HLA-B27?

If you test positive for HLA-B27, you should inform all of your doctors so they may be alert for associated medical problems. You may be referred to an ophthalmologist if you have eye symptoms. A rheumatologist may evaluate joint symptoms with examination and X-rays. A gastroenterologist evaluates stomach problems. Recognizing symptoms and reporting to the doctor in a timely fashion may prevent severe and permanent complications.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright © 2017-2022 Designs Unlimited of Florida. All Rights Reserved.

Anterior Uveitis (Iritis)

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globe anatomy
anatomy of the eye (click on image to enlarge)

What is iritis?

Iritis (pronounced, “eye-RYE-tis”) is a general term used to describe inflammation in the front of the eye. Specifically, it means inflammation of the iris. The iris is the name given to the layer of tissue in the eye that gives it a brown or blue color and serves to protect the eye from excessive light. Iritis is also called anterior uveitis.

What causes iritis?

Iritis may be caused by systemic inflammatory disease, trauma, infection, or sometimes for unknown reasons. Infection by a virus, bacterium, fungus, or other parasite rarely causes iritis. Infections may be limited to the eye or may involve other organs as well. More commonly, iritis is caused by inflammation without infection. For example, sarcoidosis, arthritis, lupus, and inflammatory bowel disease may cause iritis. The most common type of arthritis that causes iritis is ankylosing spondylitis, a condition that causes low back stiffness in the morning. Iritis also commonly follows an injury to the eye. In some cases, no underlying cause of iritis can be found.

What are the symptoms of iritis?

The eye may be painful, red, tearing, and light sensitive. Tiny floating spots which move or “float” may be seen. Symptoms may be mild, or they may be severe and disabling. Iritis may cause glaucoma, cataract, or scarring of the iris producing a distorted pupil (the part of the eye that is normally round and black). Blurred vision is common, and blindness may occur if iritis is not treated.

 How is iritis managed?

When the doctor diagnoses iritis, laboratory tests may be ordered to help determine its cause. A questionnaire may be reviewed. Occasionally, a surgical biopsy is needed. If infection is found, antibiotics are prescribed. Dilating drops are used to limit pain and scarring of the iris. To limit the damage from inflammation, iritis is treated with anti-inflammatory medication in the form of eye drops (steroid and non-steroid), injections, or prednisone pills. The eye drops must be used very frequently to break an acute attack of iritis. Sometimes, non-steroid pills (e.g. methotrexate) or biologics (e.g. Humira) maybe needed. Aggressive treatment is recommended to prevent complications and permanent injury to the eye. Surgery may be required to treat complications of iritis such as glaucoma and cataract. Iritis is a serious eye problem and may result in loss of vision or blindness. However, by seeing your eye doctor promptly and taking the medications exactly as recommended, permanent damage from iritis can be minimized. In some cases, iritis can return in either eye at a future date. Therefore, if you become aware of the return of symptoms of iritis in the future, contact your doctor without delay.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright © 2016-2022 Designs Unlimited of Florida. All Rights Reserved.

Uveitis

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globe anatomy
anatomy of the eye (click on image to enlarge)

What is uveitis?

Uveitis (pronounced, “you-vee-EYE-tis”) is a general term used to describe inflammation inside the eye. The uvea is the name given to the layer of tissue in the eye that has a brown color (melanin pigment) and blood vessels, which serve to provide blood supply and protect the eye from excessive light. The uvea can be divided into separate parts, which perform different functions in the eye: the iris, the ciliary body, the pars plana, and the choroid. The part of the uvea in the front of the eye is called the iris (the round, blue or brown part of the eye that you can see in the mirror). Behind the iris is the ciliary body, which produces the fluid that fills the eye. The pars plana serves as the boundary between the ciliary body and the choroid. The back part of the uvea that lies under the retina (the “film” in the eye that “takes the picture”) is called the choroid. Therefore, in any one patient uveitis is usually given a more specific name depending on where most of the inflammation is located in the eye. For example, inflammation of the iris is called iritis. When inflammation is mainly in the central vitreous gel of the eye, it is called intermediate uveitis.

What causes uveitis?

Uveitis may be caused by infection, injury from trauma, disease in the body outside the eye, or sometimes for unknown reasons. Infection by a virus, bacteria, fungus, or other parasite may cause uveitis. Infections may be limited to the eye or may involve other organs as well. In other cases uveitis is caused by inflammation without infection. For example, arthritis, multiple sclerosis, lupus, and inflammatory bowel disease may cause uveitis. Uveitis commonly occurs following an injury to the eye. In some cases, no underlying cause can be found to be the cause of uveitis. Very rarely, cancer may cause uveitis. Tobacco may be an aggravating factor and should be discontinued.

What are the symptoms of uveitis?

Various symptoms may be experienced depending on where is uvea is most inflamed. Symptoms may be mild or they may be severe and disabling. The eye may be painful, red, tearing, and light sensitive. Tiny floating spots which move or “float” may be seen. Sometimes blind spots, blurred vision, distortion, or loss of side vision occurs.

How is uveitis managed?

To effectively treat uveitis it is important to find the underlying cause whenever possible. Take some time to carefully review and report to your doctor any unusual or unexplained symptoms (see uveitis questionnaire) such as rashes, inflamed tattoos, back and joint problems. Tell your doctor if you have been exposed to TB (tuberculosis), traveled abroad, spent time in rural settings, or may be exposed to animals or infections. Heredity may also play a role. You should tell your doctor about any family members with inflammatory disorders anywhere in the body. Also, review and report your ancestry (for example, Asian, Mediterranean, or American Indian ancestry). When the doctor diagnoses uveitis, laboratory tests may be ordered to help determine its cause. Occasionally, a surgical biopsy is needed for diagnosis.   If infection is found, antibiotics are prescribed. To limit the damage from inflammation, uveitis is treated with anti-inflammatory medication in the form of eye drops (steroid and non-steroid), eye injections, and/or systemic therapy (pills or injections into the skin). When systemic therapy is used, the eye doctor frequently coordinates medical care with the expert assistance of a rheumatologist. Rarely, surgery is required to treat uveitis. In some cases, uveitis may be long-lasting. In these cases, years of therapy are needed to preserve vision. Uveitis is a serious eye problem and may result in loss of vision or blindness. However, by seeing your eye doctor and taking the medications exactly as recommended, damage to your vision can be minimized.

In some cases, uveitis can return at a future date. Therefore, if you become aware of symptoms of uveitis in the future, do not hesitate to contact your doctor.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright © 2016-2023 Designs Unlimited of Florida. All Rights Reserved.

Ocular Toxoplasmosis

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anatomy of the eye (click on image to enlarge)

What is ocular toxoplasmosis?

Ocular toxoplasmosis is an inflammation of the eye caused by an infection of the retina by a parasite called Toxoplasma gondii. The retina is a thin layer of delicate nerve tissue that lines the inside wall of the eye like the film in a camera. In the eye, light is focused onto the retina, which “takes the picture” of objects you look at and sends the image to the brain.

What causes ocular toxoplasmosis?

Toxoplasma gondii infects humans and animals throughout the world. Twenty to fifty percent of adults in the United States test positive for exposure, but few people experience symptoms. The most common presentation resembles mononucleosis with symptoms of fever, fatigue, and swollen lymph glands. Because the toxoplasma organism can become inactive and form a protective microscopic cyst within human cells, it can cause relapses of infection and spread to new areas of the body months to years after the initial infection. If the parasite spreads through the blood stream to the eye, ocular toxoplasmosis may threaten blindness.

How is toxoplasmosis contracted?

The most common ways to contract infection are as follows: 1.) Hand-to-mouth transmission of the toxoplasma organism in cat feces e.g. cleaning the litter box. 2.) Eating undercooked meat, chicken, or eggs from infected animals. 3.) Eating unwashed fruits and vegetables that are contaminated by animal feces. 4.) Hand-to-mouth transmission from handling infected raw meat or animal products. 5.) Transmission from infected mother to child through the placenta during pregnancy. 6.) Rarely, Toxoplasma infection may acquired through contaminated drinking water or dust in the air.

Toxoplasma gondii completes its life cycle by producing millions of oocysts (eggs) in the intestines of the cat. These infectious eggs leave the cat in the feces and may lie dormant in the ground for up to two years. These eggs may infect an animal that may eat from the ground or a human who eats unwashed, contaminated fruits and vegetables from the ground. Once inside a human or animal, the eggs “hatch”, multiply, and spread throughout the body. When the immune system attacks the parasite, it becomes dormant and “hibernates” inside cells throughout the body. In months or years in the future, it may become active to cause infection again.

What are the symptoms of ocular toxoplasmosis?

If toxoplasma reaches the eye, early symptoms include seeing new tiny floating spots (floaters), pain, redness, tearing, light sensitivity, and blurred vision. Late symptoms include permanent blind spots in the vision and, rarely, blindness. These symptoms are not specific for ocular toxoplasmosis, but they are especially important to recognize in people with known toxoplasma scars in the retina. If such symptoms are promptly reported to the doctor, treatment may minimize permanent damage to the eye.

What treatment is available?

Sulfa antibiotics (Septra or Bactrim) are frequently used for several weeks to treat active infection. In some cases of toxoplasmosis, another antibiotic called clindamycin is used. This medicine may rarely cause a severe bloody diarrhea, which should be reported to the doctor immediately for effective treatment. Prednisone pills and similar eyedrops may be used to decrease inflammation. Rarely, antibiotics may be injected into the eye.  Often, the pupil of the eye is dilated with eyedrops during the active infection to prevent scarring and to relieve pain.

It is not uncommon for untreated ocular toxoplasmosis to result in loss of vision. It is rare to experience serious side effects from medication used to treat toxoplasmosis. Armed with the knowledge to report side effects promptly to the doctor, you can minimize the chance of suffering from any permanent ill-effects from treatment.

Finally, notify your doctor if you had a toxoplasma infection in the past as it may be important to avoid intraocular steroid injections to prevent a return of infection.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright © 2014-2022 Designs Unlimited of Florida.  All Rights Reserved.