You are in: eMedicine Specialties > Ophthalmology > INFECTIOUS DISEASE Herpes ZosterArticle Last Updated: Jan 27, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Manolette R Roque, MD, MBA, DPBO, FPAO, President and CEO, Chief of Service, Ocular Immunology and Uveitis, Consulting Staff, Cornea and Refractive Surgery, Eye Republic Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines Co; Consulting Staff, CME Liaison, Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center Manolette R Roque, MD, MBA, DPBO, FPAO, is a member of the following medical societies: American Academy of Ophthalmic Executives, American Society of Cataract and Refractive Surgery, American Society of Ophthalmic Administrators, American Uveitis Society, International Ocular Inflammation Society, Philippine Medical Association, Philippine Ocular Inflammation Society, and Philippine Society of Cataract and Refractive Surgery Coauthor(s): Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, EYE REPUBLIC Ophthalmology Clinic; C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution Editors: Kilbourn Gordon III, MD, FACEP, Urgent Care Physician, Primary Medical, Huntington Walk-In and Greenwich Convenient Medical Center; Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles; R Christopher Walton, MD, Professor, Director of Uveitis and Ocular Inflammatory Diseases Service, Assistant Department of Ophthalmology, Assistant Dean for Graduate Medical Education and Continuing Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital; Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri; Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences Author and Editor Disclosure Synonyms and related keywords: herpes zoster ophthalmicus, varicella-zoster virus, VZV, HZO, varicella, chickenpox, shingles, postherpetic neuralgia, herpes zoster oticus, Ramsay Hunt Syndrome, dermatomal zoster, zona, Hutchinson sign INTRODUCTIONSection 2 of 11
  BackgroundVaricella-zoster virus (VZV) is a member of the Herpesviridae family. It is the etiologic agent of varicella (chickenpox), the primary infection, and herpes zoster, the reactivation. Herpes zoster ophthalmicus involves the tissues innervated by the ophthalmic division of the trigeminal nerve and accounts for 10-25% of all cases of shingles. The sequelae of herpes zoster ophthalmicus can be devastating and include chronic ocular inflammation, visual loss, and debilitating pain. Herpes zoster oticus involves the inner, middle, and external ear. Herpes zoster oticus presents as excruciating otalgia with an associated cutaneous vesicular eruption (external canal and pinna). When associated facial paralysis is present, the disease is called Ramsay Hunt syndrome. PathophysiologyAfter primary infection, VZV enters the dorsal root ganglia (trigeminal = herpes zoster ophthalmicus, geniculate = herpes zoster oticus), where it remains latent for the lifetime of the individual. The frequency of dermatologic involvement in herpes zoster is similar to the centripetal distribution of the initial varicella lesions. This pattern may suggest that the latency arises from contiguous spread of the virus during varicella from infected skin cells to sensory nerve endings with subsequent ascent to the ganglia. It also may suggest that the ganglia are infected hematogenously during the viremic phase of varicella and that the frequency of the dermatome involvement in herpes zoster reflects the ganglia most often exposed to reactivating stimuli. In immunocompetent patients, specific antibodies (immunoglobulins G, M, and A) appear more rapidly and reach higher titers during reactivation (herpes zoster) than during the primary infection. The appearance of the cutaneous rash due to herpes zoster coincides with a profound VZV-specific T-cell proliferation. Interferon-alpha production appears with the resolution of herpes zoster. The patient has a long-lasting, enhanced, cell-mediated immunity response to VZV. FrequencyUnited StatesRegarding primary infection, more than 90% of the population is infected by adolescence, and approximately 100% are infected by 60 years of age. Herpes zoster affects about 10-20% of the population. The rate is approximately 131 per 100,000 person-years in white individuals. According to Pavan-Langston's review, 1 million consultations for herpes zoster occur per year; and approximately 250,000 of the patients thus examined develop herpes zoster ophthalmicus. A subset of 50% of these patients develops complications of herpes zoster ophthalmicus. Ramsay Hunt syndrome is the cause of as many as 12% of all cases of facial paralysis. Mortality/Morbidity
RaceIn 1995, Schmader et al reported that the lifetime incidence of herpes zoster in whites is twice that of African Americans. SexNo known sex predilection exists. Age
CLINICALSection 3 of 11
HistoryPatients with herpes zoster often report a history of chickenpox. Herpes zoster results in a prodrome (fever, malaise, headache, and dysesthesia) that occurs 1-4 days before the development of the cutaneous lesions. In some cases, a present state of immunocompromise may be noted.
Physical
CausesKnown risk factors for developing herpes zoster relate to the status of cell-mediated immunity to VZV.
DIFFERENTIALSSection 4 of 11
Bell Palsy Burns, Chemical Conjunctivitis, Viral Corneal Erosion, Recurrent Entropion Episcleritis Exophthalmos Glaucoma, Uveitic Headache, Migraine Herpes Simplex HIV Horner Syndrome Keratitis, Herpes Simplex Keratopathy, Neurotrophic Molluscum Contagiosum Ocular Manifestations of HIV Scleritis Trigeminal Neuralgia Uveitis, Evaluation and Treatment
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| Drug Name | Acyclovir (Zovirax) |
|---|---|
| Description | Synthetic purine nucleoside analogue with in vitro and in vivo inhibitory activity against herpes simplex virus types 1 (HSV-1), 2 (HSV-2), and VZV. |
| Adult Dose | Acute treatment: 800 mg q4h PO 5 times/d for 7 d Chronic suppressive therapy for recurrent disease: 400 mg bid up to 12 mo, followed by reevaluation |
| Pediatric Dose | Suggested dose is 10-20 mg/kg/dose qid for 5 d; not to exceed 800 mg |
| Contraindications | Documented hypersensitivity |
| Interactions | Concomitant probenecid or zidovudine prolongs half-life and increases CNS toxicity of acyclovir |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Dosage adjustment recommended in renal impairment; coadministration with potentially nephrotoxic agents may increase risk of renal dysfunction and/or risk of reversible CNS symptoms |
| Drug Name | Famciclovir (Famvir) |
|---|---|
| Description | Orally administered prodrug of antiviral agent penciclovir. Indicated to treat acute herpes zoster or suppression of genital herpes. Initiate as soon as herpes zoster is diagnosed. |
| Adult Dose | 500 mg q8h for 7 d |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity |
| Interactions | Coadministration of probenecid or cimetidine may increase toxicity; coadministration increases bioavailability of digoxin; interactions with drugs metabolized by aldehyde oxidase (6-deoxy penciclovir to penciclovir) can occur; no clinically significant alterations in penciclovir pharmacokinetics observed after single-dose administration of famciclovir 500 mg after pretreatment with multiple doses of allopurinol, cimetidine, theophylline, or zidovudine; no clinically significant effects on penciclovir pharmacokinetics observed after multiple-dose (tid) administration of famciclovir 500 mg with multiple doses of digoxin; steady-state pharmacokinetics of digoxin not altered by concomitant administration of multiple doses of famciclovir 500 mg tid; no clinically significant effects on pharmacokinetics of zidovudine or zidovudine glucuronide observed after a single oral dose of famciclovir 500 mg |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Efficacy has not been established for initial episode genital herpes infection, ophthalmic zoster, disseminated zoster, or in immunocompromised patients with herpes zoster; adjust dose when creatinine clearance <60 mL/min |
| Drug Name | Valacyclovir (Valtrex) |
|---|---|
| Description | Hydrochloride salt of L-valyl ester of antiviral drug acyclovir. Rapidly converted to acyclovir. Indicated to treat acute herpes zoster (shingles) and for suppression of genital herpes. |
| Adult Dose | 1 g tid for 7 d; initiate therapy at earliest sign or symptoms; most effective when started within 48 h of onset of zoster rash |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity |
| Interactions | Probenecid, zidovudine, or cimetidine coadministration prolongs half-life and may increase CNS toxicity |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (sometimes resulting in death) has occurred in advanced HIV disease, allogeneic bone marrow transplant, and renal transplant recipients in clinical trials of Valtrex at doses of 8 g qd; caution in renal failure and coadministration of nephrotoxic drugs; associated with onset of hemolytic uremic syndrome |
| Drug Name | Vidarabine (Vira-A 3%) |
|---|---|
| Description | Antiviral drug for topical treatment of epithelial keratitis caused by HSV. Purine nucleoside obtained from fermentation cultures of Streptomyces antibioticus. Antiviral mechanism not established. Appears to interfere with early steps of viral DNA synthesis. Antiviral activity against viruses in vitro: HSV types 1 and 2, vaccinia, VZV, rhabdovirus, and oncornavirus. |
| Adult Dose | Apply 0.5-inch ribbon into lower conjunctival sac(s) 5 times/d q3h After 5-7 d, corneal epithelialization should begin; approximately 3 wk of treatment may be required for complete reepithelialization If no signs of improvement after a week or if incomplete reepithelialization occurs by 3 wk, consider other forms of topical therapy |
| Pediatric Dose | Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Viral resistance to vidarabine possible but not reported; diagnosis of keratoconjunctivitis due to HSV should be clinically established before therapy; warn patients that Vidarabine (like other ophthalmic ointments) may cause visual blurring; adverse effects (eg, lacrimation, foreign body sensation, conjunctival injection, burning, irritation, superficial punctate keratitis, pain, photophobia, punctal occlusion, and sensitivity) reported |
| Drug Name | Ganciclovir (Vitrasert, Cytovene) |
|---|---|
| Description | Synthetic guanine derivative active against CMV. Acyclic nucleoside analog of 2'-deoxyguanosine that inhibits replication of herpes viruses in vitro and in vivo. Ganciclovir-triphosphate levels as much as 100-fold greater in CMV-infected cells than in uninfected cells, possibly because of preferential phosphorylation. If CMV retinitis progresses during maintenance treatment with either dosage form, administer reinduction regimen. |
| Adult Dose | Prevention of CMV disease in patients with advanced HIV infection and normal renal function: 1000 mg PO tid with food |
| Pediatric Dose | Safety and efficacy in pediatric population have not been established; oral ganciclovir has not been studied in children <13 years <3 years: Not established >3 years: Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | Concomitant administration with cytotoxic drugs (eg, dapsone, vinblastine, Adriamycin, pentamidine, flucytosine, vincristine, amphotericin B, trimethoprim/sulfamethoxazole combinations, other nucleoside analogs) may result in additive toxicity in bone marrow, spermatogonia, and germinal layers of skin and GI mucosa (coadminister only if potential benefits outweigh risks); coadministration with imipenem-cilastatin may cause generalized seizures (use only if potential benefits outweigh risks); serum creatinine level may increase after concurrent use of ganciclovir and cyclosporine or amphotericin B; probenecid reduces renal clearance of ganciclovir; bioavailability may increase when didanosine is administered with or 2 h before ganciclovir; bioavailability may decrease with zidovudine; may increase bioavailability of zidovudine |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Clinical toxicity includes granulocytopenia, anemia and thrombocytopenia; because oral form associated with increased rate of CMV retinitis progression, as compared with IV form, use only when benefits outweigh risks (advanced HIV disease); half-life and plasma/serum concentrations may be increased due to reduced renal clearance; doses > 6 mg/kg IV and rapid infusion may increase toxicity; initially reconstituted IV solutions have a high pH (ie, 11); phlebitis or pain may occur at infusion site despite further dilution in IV fluids; administer with adequate hydration; photosensitization (photoallergy or phototoxicity) may occur |
These drugs are naturally produced proteins with antiviral, antitumor, and immunomodulatory actions. Alpha, beta, and gamma interferons may be given topically, systemically, or intralesionally.
| Drug Name | Interferon alfa-2a and alfa-2b (Roferon, Intron A) |
|---|---|
| Description | Protein product manufactured by recombinant DNA technology. Mechanism of antitumor activity not clearly understood; however, direct antiproliferative effects against malignant cells and modulation of host immune response may play important roles. |
| Adult Dose | 2 million U/m2 SC 3 times/wk for 30 d |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity |
| Interactions | Theophylline may increase toxicity; cimetidine may increase antitumor effects; zidovudine and vinblastine may increase toxicity |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Caution in brain metastases, severe hepatic or renal insufficiencies, seizure disorders, multiple sclerosis, or compromised CNS |
Blood and blood products are used to improve the clinical and immunologic aspects of a disease. They may decrease autoantibody production, and increase solubilization and removal of immune complexes.
| Drug Name | Immune globulins intravenous (IVIG, Gammagard, Gamimune) |
|---|---|
| Description | Following features may be relevant to efficacy: neutralization of circulating myelin antibodies with anti-idiotypic antibodies; down-regulation of proinflammatory cytokines, including IFN-gamma; blockade of Fc receptors on macrophages; suppression of inducer T and B cells and augmentation of suppressor T cells; blockade of complement cascade; promotion of remyelination; and 10% increase in CSF IgG level |
| Adult Dose | 2 g/kg IV over 2-5 d |
| Pediatric Dose | Administer as in adults |
| Contraindications | Documented hypersensitivity; IgA deficiency; anti-IgE/IgG antibodies |
| Interactions | None reported |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Consider checking serum IgA level first and using IgA depleted IVIG (G-Gard-SD), if indicated; IVIG may increase serum viscosity and thromboembolic events Reported adverse effects: migraine, 10% increased risk of aseptic meningitis; increased risk of urticaria, pruritus or petechiae 2-5 d after infusion that may last <1 mo; increased risk of renal tubular necrosis in older patients, diabetic patients, volume-depleted patients, and in patients with preexisting kidney disease IVIG can elevate antiviral or antibacterial antibody titers for 1 mo, increase ESR 6-fold for 2-3 wk, cause apparent hyponatremia |
Vaccines provide active immunity against viral infections.
| Drug Name | Varicella virus vaccine (Varivax) |
|---|---|
| Description | Attenuated varicella virus vaccine offering active immunity to disease caused by VZV. May administer concomitantly with MMR vaccine. Limited data suggest that coadministration with DTP and Pedvax HIB may be safe. |
| Adult Dose | 2 doses of 0.5 mL separated by 4-8 wk |
| Pediatric Dose | 12 months to 12 years: 0.5 mL |
| Contraindications | Documented hypersensitivity; blood dyscrasias, leukemia, lymphomas, other malignant neoplasms affecting bone marrow or lymphatic systems; immunosuppressive therapy; primary and acquired immunodeficiency states; untreated tuberculosis; IV injection |
| Interactions | Salicylates may increase risk of Reye syndrome after vaccination; immunosuppressant drugs may inhibit development of active immunity |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Caution in renal insufficiency; discontinue therapy before performing any surgical procedures; impaired liver function |
These agents help to relieve acute pain, decrease vertigo, and limit the development of PHN.
| Drug Name | Prednisone (Deltasone) |
|---|---|
| Description | Inactive and must be metabolized to active metabolite prednisone. Conversion may be impaired in liver disease. |
| Adult Dose | 5-60 mg/d PO qd or divided bid/qid; taper over 2 wk, as symptoms resolve |
| Pediatric Dose | 4-5 mg/m2/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid; taper over 2 wk, as symptoms resolve |
| Contraindications | Documented hypersensitivity; viral infection, peptic ulcer disease, hepatic dysfunction, connective tissue infections, and fungal or tubercular skin infections; GI disease. |
| Interactions | Corticosteroids may decrease I-131 uptake and produce false-negative results on nitroblue tetrazolium test for systemic bacterial infection; coadministration with estrogens may decrease clearance; concurrent digoxin may cause digitalis toxicity due to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics. |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Because complications of treatment with corticosteroids depend on dose and duration, weigh risks and benefits for dose, duration, and daily vs intermittent therapy; use lowest possible dose to control condition; psychic derangements may appear (eg, euphoria, insomnia, mood swings, personality changes, severe depression, frank psychotic manifestations); existing emotional instability or psychotic tendencies may be aggravated; avascular or aseptic necrosis of femoral head associated with long-term corticosteroid treatment (also in high-dose, short-term therapy); adverse effect more likely with predisposing illness (eg, rheumatoid arthritis or systemic lupus erythematosus); enhanced effect in hypothyroidism and in cirrhosis; aspirin and NSAIDs should be used cautiously with corticosteroids in hypoprothrombinemia; in patients receiving therapy and unusual stress, increase dose of rapidly acting corticosteroids before, during, and after stressful situation; restrict use in active tuberculosis to cases of fulminating disseminated tuberculosis in which corticosteroid is used to manage the disease in conjunction with appropriate antituberculous regimen; if corticosteroids indicated in latent tuberculosis or tuberculin reactivity, close observation is necessary, as disease reactivation may occur (during prolonged corticosteroid therapy, patients should receive chemoprophylaxis); may mask signs of infection, and new infections may appear during use; possible decreased resistance and inability to localize infection; if corticosteroids must be used in bacterial infections, give appropriate anti-infective therapy; patients exposed to certain infections (eg, measles, chickenpox) should seek medical advice; may activate latent amebiasis; rule out amebiasis before giving corticosteroids to a patient who has spent time in the tropics or who has unexplained diarrhea. |
Pain control is essential to providing quality patient care. Analgesics ensure patient comfort and have sedating properties that are beneficial for patients who have sustained trauma or have painful lesions. Various narcotic agents are available individually or in combination with acetaminophen, aspirin, or NSAIDs.
| Drug Name | Oxycodone and aspirin (Percodan) |
|---|---|
| Description | Indicated for relief of moderate to severe pain. Percodan 5/325 mg; Percodan Demi 2.5/325 mg. |
| Adult Dose | Moderate to severe pain: 1 tab (5/325 mg) PO q6h prn; 1-2 tabs (2.5/325 mg) q6h prn. |
| Pediatric Dose | Not FDA approved Unapproved use: 6-12 years: one-fourth Demi tab PO q6h prn moderate to severe pain >12 years: one-half Demi tab PO q6h prn moderate to severe pain |
| Contraindications | Documented hypersensitivity; severe respiratory depression; liver and/or kidney disease |
| Interactions | Increases effects of anticoagulants; cimetidine increases respiratory and CNS depression; in combination, CNS depressants increase risk of CNS depression; phenytoin may decrease concentration; rifampin may decrease concentration |
| Pregnancy | D - Unsafe in pregnancy |
| Precautions | Serious reactions include seizures, respiratory depression; opioids, carisoprodol, and butalbital may be habit forming (dependency, abuse); avoid exceeding acetaminophen 4 g/d in combination products (neutropenia and hemolytic anemia); alcohol, sedatives, and tranquilizers may enhance drowsiness and/or sedation; common reactions are weakness, lightheadedness, nausea, vomiting, constipation, physical dependence, sedation, somnolence, dizziness, euphoria, dry mouth, hypotension, urinary retention, and respiratory depression |
| Drug Name | Oxycodone and acetaminophen (Percocet, Tylox) |
|---|---|
| Description | Percocet 2.5/325, Percocet 5/325 Percocet 7.5/500, Percocet 10/650. Generic oxycodone/acetaminophen 5 mg/325 mg. |
| Adult Dose | Moderate pain: 1-2 tabs PO q4-6h prn; not to exceed 8 g/d acetaminophen, 4 g/d in alcoholism |
| Pediatric Dose | Not applicable |
| Contraindications | Documented hypersensitivity |
| Interactions | Increases effects of anticoagulants; cimetidine increases respiratory and CNS depression; in combination, CMS depressants increase risk of CNS depression; phenytoin may decrease concentration; rifampin may decrease concentration |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Caution is advised in elderly patients and patients with impaired liver function, acute abdomen, prostatic hypertrophy, GI ileus, and/or obstruction; opiate abuse is warning sign; serious adverse reactions include seizures, respiratory depression, and hepatotoxicity; opioids, carisoprodol, and butalbital may be habit-forming (dependency, abuse); avoid exceeding acetaminophen 4 g/d in combination products; alcohol, sedatives, and tranquilizers may enhance drowsiness and/or sedation; common adverse reactions are dizziness, sedation, nausea, vomiting, constipation, dysphoria, confusion, rash, pruritus, physical dependence, urinary retention, and seizures |
| Drug Name | Hydrocodone and acetaminophen (Lortab) |
|---|---|
| Description | Lortab 2.5/500 mg, 5/500 mg, 7.5/500 mg, or 10/500 mg. Generic hydrocodone/acetaminophen 5/500 mg; Trade and generic elixir: 7.5/500 mg hydrocodone/acetaminophen per 15 mL |
| Adult Dose | 1-2 tabs 2.5/500 mg and 5/500 mg PO q4-6h prn moderate pain; not to exceed 8 tabs/d 1 tab 7.5/500 and 10/500 PO q4-6h prn; not to exceed 5 tabs/d Elixir 15 mL PO q4-6h prn; not to exceed 6 doses/d |
| Pediatric Dose | Not approved by the FDA |
| Contraindications | Documented hypersensitivity; patients with depressed respiratory function |
| Interactions | Chronic alcohol use increases risk of hepatotoxicity; combination with anticholinergics and/or antidiarrheals increases risk of severe constipation; combination with CNS depressants increases risk of CNS depression; combination with isoniazid increases risk of hepatotoxicity; combination use with MAOIs increases risk of severe hypertension; combination with tricyclic antidepressants increases concentration of both drugs |
| Pregnancy | D - Unsafe in pregnancy |
| Precautions | Caution advised in elderly patients and patients with head injury, increased ICP, impaired renal function, G-6-PD deficiency, impaired liver function, impaired pulmonary function, chronic alcohol abuse, and/or bowel obstruction; serious adverse reactions are pancytopenia, thrombocytopenia, hepatotoxicity, respiratory depression, convulsions, severe hypotension, dependency and abuse, and/or paralytic ileus; common adverse reactions are lightheadedness, sedation, dizziness, constipation, nausea, vomiting, hypotension, urinary retention, and/or miosis |
These drugs are used for pain relief, especially in cases of PHN.
| Drug Name | Amitriptyline (Elavil) |
|---|---|
| Description | Generic/trade: tablets 10, 25, 50, 75, 100, and 150 mg. |
| Adult Dose | Chronic pain: 0.5-2 mg/kg PO qhs; start with 0.1 mg/kg PO qhs, titrate slowly over 2-3 wk; not to exceed 150 mg/d Depression: 5-100 mg PO qd; start with 50-75 mg PO qd; not to exceed 300 mg/d Elderly patients: consider divided dose of 10 mg PO tid |
| Pediatric Dose | Not approved in children <12 years Chronic pain: 0.5-2 mg/kg PO qhs; start with 0.1 mg/kg PO qhs, titrate slowly over 2-3 wk Depression (9-12 y): 1-3 mg/kg PO daily divided tid; not to exceed 200 mg/d |
| Contraindications | Documented hypersensitivity; patients recovering from acute myocardial infarction; use of MAOIs within 14 d (use with MAOIs contraindicated because additive/synergistic effects may precipitate a hypertensive crisis) |
| Interactions | Use of adrenergic agents warrants BP monitoring; antagonistic effects, and/or decreased hypertensive efficacy (clonidine, guanethidine, guanadrel, methyldopa) may occur; caution with concomitant barbiturates because of additive/synergistic effects, increased risk of CNS/respiratory depression; avoid combination with cimetidine because of hepatic metabolism inhibition with increased amitriptyline levels/toxicity; use with protease inhibitors inhibits hepatic metabolism, increasing amitriptyline levels/toxicity (amprenavir, indinavir, ritonavir, saquinavir); combination with sympathomimetics increases risk of hypertension, arrhythmia, tachycardia (eg, amphetamine, dextroamphetamine, methylphenidate); with warfarin use, anticoagulant effects may increase because of inhibited hepatic metabolism |
| Pregnancy | D - Unsafe in pregnancy |
| Precautions | Caution in patients with urinary retention, seizure history, glaucoma, coronary artery disease, thyroid disease, impaired liver function, and/or suicide risk; serious adverse reactions include seizures, myocardial infarction, stroke, agranulocytosis, and/or thrombocytopenia; common adverse reactions include dry mouth, drowsiness, dizziness, constipation, urinary retention, tachycardia, blurred vision, increased appetite, confusion, and/or disorientation; gradually taper dose when discontinuing cyclic antidepressants to avoid withdrawal symptoms after prolonged use |
These drugs promote hydration of the cornea and conjunctiva.
| Drug Name | Artificial tears (Tears Naturale, Hypo Tears, Lacri-Lube) |
|---|---|
| Description | Ophthalmic lubricants. Contain equivalent of 0.9% NaCl; used to maintain ocular tonicity. Stabilize and thicken precorneal tear film and prolong its breakup time, which occurs with dry-eye states. |
| Adult Dose | 1-2 gtt tid/qid prn |
| Pediatric Dose | Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | A - Safe in pregnancy |
| Precautions | Hyperemia, photophobia, stickiness of eyelashes, ocular discomfort, or irritation may occur |
| Media file 1: Dendritic keratitis. Image courtesy of C. Stephen Foster, MD, Massachusetts Eye Research and Surgery Institute, Harvard Medical School. | |
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| Media file 2: Dendritic keratitis. Image courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic. | |
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| Media file 3: Epithelial defect and melting secondary to varicella-zoster virus infection. Image courtesy of C. Stephen Foster, MD, Massachusetts Eye Research and Surgery Institute, Harvard Medical School. | |
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| Media file 4: Slit-beam study shows the excavation of a corneal ulcer secondary to herpes zoster. Image courtesy of C. Stephen Foster, MD, Massachusetts Eye Research and Surgery Institute, Harvard Medical School. | |
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| Media file 5: Corneal ulcer stained with fluorescein. Image courtesy of C. Stephen Foster, MD, Massachusetts Eye Research and Surgery Institute, Harvard Medical School. | |
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| Media file 6: Corneal ulcer. Image courtesy of C. Stephen Foster, MD, Massachusetts Eye Research and Surgery Institute, Harvard Medical School. | |
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| Media file 7: Corneal ulcer. Image courtesy of C. Stephen Foster, MD, Massachusetts Eye Research and Surgery Institute, Harvard Medical School. | |
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| Media file 8: Corneal scar from a previous episode of herpes zoster keratitis. Image courtesy of C. Stephen Foster, MD, Massachusetts Eye Research and Surgery Institute, Harvard Medical School. | |
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| Media file 9: Sclerokeratouveitis secondary to infection with the varicella-zoster virus. Image courtesy of C. Stephen Foster, MD, Massachusetts Eye Research and Surgery Institute, Harvard Medical School. | |
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| Media file 10: Vesicles in a dermatomal pattern in acute herpes zoster infection. Image courtesy of C. Stephen Foster, MD, Massachusetts Eye Research and Surgery Institute, Harvard Medical School. | |
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| Media file 11: Hutchinson sign. Image courtesy of C. Stephen Foster, MD, Massachusetts Eye Research and Surgery Institute, Harvard Medical School. | |
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| Media file 12: Herpes zoster ophthalmicus. Note the brow tape and sutures on the left lower lid. This patient has neurotrophic lids, for which corneal care is required. Image courtesy of C. Stephen Foster, MD, Massachusetts Eye Research and Surgery Institute, Harvard Medical School. | |
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| Media file 13: Herpes zoster ophthalmicus with Hutchinson sign. Image courtesy of C. Stephen Foster, MD, Massachusetts Eye Research and Surgery Institute, Harvard Medical School. | |
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| Media file 14: Herpes zoster, day 4. Image courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic. | |
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| Media file 15: Herpes zoster, day 8. Image courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic. | |
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| Media file 16: Herpes zoster oticus, day 6. Image courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic. | |
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| Media file 17: Herpes zoster, day 14. Image courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic. | |
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| Media file 18: Lamellar keratoplasty for a corneal perforation with iris prolapse in a patient with herpes zoster ophthalmicus. Image courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic. | |
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| Media file 19: Same patient as in Image 18; 12 months later, note opacified cornea obstructing the visual axis. Image courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic. | |
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