Treatment of herpes of the eyes

Among the therapeutic factors for herpetic diseases of the eye should be identified specific virosostatic drugs. These include 5-iodo-2-deoxyuridine (IMU, or kerecid), used in a 0.1% solution in the form of eye drops. The drug is a metabolite, has a high antiviral activity. The mechanism of its action is the effect on the deoxyribonucleic acid of the cell, which prevents the formation of a viral infectious beginning. A solution of 5-iodo-2-deoxyuridine in polyvinyl alcohol is called a hernlex. Both drugs (kerecid, herplex) are successfully administered in the form of drops in herpetic keratitis, mainly in cases of surface localization of the process. At first, 5-iodine-2-deoxyuridine was unobstructed for a long time, but then they came to the conviction that it would be inappropriate to apply it for more than 10 days. The drug may have a toxic effect on the epithelium of the cornea and conjunctiva, causing the phenomenon of follicular allergic conjunctivitis, spot keratitis.

A good virosostatic drug, especially with deep keratitis (such as a dysformiform), proceeding without disturbing the integrity of the corneal epithelium, is oxolin. In solution, oxoline was unstable, so it is used mainly in the form of 0.25% ointment. The toxicity of oxoline is low, but. Appointing him sick, you should warn about the irritant effect of the drug (he has a dionine-like irritant effect, causing a burning sensation, congestion hyperemia and even the phenomenon of chemosis). However, this seemingly undesirable property of the drug contains a positive factor. Against the background of treatment with oxoline due to its irritating effects, the resorption of inflammatory infiltrates in the cornea is accelerated.

Great value in the treatment of herpetic keratitis have antiviral drugs: tebrofen, florenal in the form of 0.25-0.5% ointment. In some cases, the use of ointment florenal causes in the eye a feeling of slight burning, which should also warn the patient.

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

Interferonogens is especially well proven pyrogenal, widely used in practice. It is prescribed in drops, intramuscularly and under the conjunctiva of the eyeball. The latter methods of administration are preferred for deep keratites and iridocyclites. The drug has a fibrinolytic effect that slows the scar process. Pyrogenal is used intramuscularly every day for 25 MFA, then the dose is increased by 25-50 MTD (the maximum single dose for an adult is 1000 MTD). In the following days, he was prescribed in a dose that caused an increase in body temperature to 37.5-38 ° C. The treatment is continued until the body temperature rises and the dose is subsequently increased by 25-50 MPD. The course of treatment is 10-30 intramuscular injections of pyrogenal. Intervals between courses 2-3 months. Pyrogenal under the conjunctiva is prescribed for 25-30-50 MTD several times in the subsection. It should be positively evaluated by combining injection of pyrogenal with a conjunctiva with gamma globulin of 0.2 ml daily or every other day. The course of treatment prescribed up to 20 injections of both.

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

Antiviral treatment gives the best results if the background of the use of desensitizing drugs is carried out. They 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 appointment in viral infection of the cornea should be treated with extreme caution. By reducing the inflammatory response, these drugs inhibit the formation of antibodies and the production of endogenous interferon, thereby slowing the epithelization and scarring of the corneal shepatized herpes simplex virus. It is proved that in the treatment of herpetic keratitis in the experiment with prednisolone, the virus in the tissue lasts longer than without treatment.

In medical practice, against the background of intensive cortisone therapy, when the drug was injected under the conjunctiva, there were cases of descemetocele and perforation of the cornea. Corticosteroids should be prescribed only in drops with keratitis, which proceeds without intensive disintegration of the corneal tissue, better against gamma-globulin treatment in drops or conjunctiva, as it increases antiviral immunity. With ididotsiklitah corticosteroids can also be administered under the conjunctiva, controlling intraocular pressure. In patients who receive steroids for a long time, the pneumococcus can join the herpes virus, as evidenced by the appearance of a yellow shade in the infiltrate of the cornea. In this case, it is advisable to administer 20% sodium sulfacyl solution, 1% tetracycline or 1% erythromycin ointment. The more favorable course of herpetic infection is undoubtedly facilitated by the appointment of vitamins of groups A and B, the extract of aloe, and the carrying out of the Novocaine blockade.

Available for all ophthalmologists is the method of autohemotherapy in the form of blood instillation or its subconjunctival injection with the aim of increasing the antibody titer in the patient with an eye. Such therapy can be carried out 2-3 weeks after the onset of the disease, when the titer of antiviral antibodies in the body of the sick person will increase.

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

In the therapeutic complex of herpetic diseases of the eye for the purpose of more active administration of medicinal substances and the use of a neurotrophic action of direct current, it is useful to use medicinal electrophoresis through a bath, closed eyelids or endonasal. By electrophoresis, adrenaline, aloe, atropine, vitamin B1, heparin, hydrocortisone, lidazum, novocaine, calcium chloride can be administered. The choice of preparations for their electrophoretic administration should be strictly justified. In particular, the aloe extract should be prescribed in case of regression of the herpetic process, with the aim of resolving corneal opacities. Aloe, B group vitamins and novocaine are indicated to improve the trophism of diseased tissue, to accelerate the epithelialization of the cornea. Heparin is administered in order to activate the reverse development of the herpetic process, because, according to experimental data, it inhibits the growth of the virus in tissue culture. Hydrocortisone, like lidase, promotes resorption of infiltrates, a more tender scar tissue, a decrease in neovascularization.

Heropic eyes appoint diadynamic currents, microwave, ultrasound therapy and phonophoresis of medicinal substances, in particular interferon, dexamethasone. Carry out magnetotherapy. OV Rzhechitskaya and LS Lutsker (1979) suggest the use of a variable magnetic field (PMP) of a sinusoidal form in a continuous mode. The number of sessions is from 5 to 20. It is proved that the alternating magnetic field increases the permeability of the cornea, and this allows more active introduction into the eye of various medicinal substances. This method was called magnetoelectrophoresis. In cases of severe herpetic keratitis by magnetoelectrophoresis, it is possible in particular to introduce 5-iodine, -2-deoxyuridine.

Particular attention should be paid to the possibilities of cryotherapy of keratitis. It is carried out under instillation anesthesia with a 1% solution of dicaine, every other day. For the treatment course, up to 10 procedures are prescribed. The exposure to the freezing of the fabric is 7 s. The kioonachonnik cleaned during the thawing period. Some ophthalmologists are attracted by trepanoneurotomy surgery. The method prevents formation of persistent and gross opacities of the cornea. At a perforation of a cornea, persistent ulcers, often recurring keratitis is shown keratoplasty. Unfortunately, this measure does not help prevent the recurrence of keratitis. Relapses occur more often in the area of the border graft ring. Advances in recent years in the problem of corneal transplantation based on microsurgical techniques, the development of seamless methods of attaching the transplant with bioclea (gamma globulin) or soft hydrogel contact lens, have made the keratoplasty operation the main method in the complex treatment of herpetic corneal lesions that occur with tissue disintegration.

Sometimes, in practical work, there is a need for surgical intervention on the eyeball that has undergone a herpetic infection in the past. In this case, after an outbreak of inflammation, it should fall out 3-4 months. Before intervention it is advisable to use interferon in combination with any interferonogen (a course of pyrogenal injections). In recent years, with the herpetic ulcer of the cornea, laser argon coagulation began to be produced, creating a temperature of up to 70 ° C in the zone of radiation exposure. Laser coagulation promotes more gentle scarring and has a viral effect. Experimental studies have shown that it is superior in therapeutic effectiveness to IMU and cryotherapy, reducing the treatment time of the patient by 2-3 times. Laser coagulation also justifies itself in cases of drug-resistant forms of ophthalmoherpes.

It should be noted that even after successful treatment with severe herpetic keratitis, for many years, the sensitivity of the cornea (in particular, on the intact eye) has decreased, the weakness of the epithelial cover of the cornea that has recovered, and sometimes its rejection. The treatment of such conditions, called postherpetic epitheliopathy, is still little developed. Vitamins A and B are shown, cryooblation, Novocain electrophoresis, lysozyme in drops, the use of drops of dexamethasone in microdoses (0.001%), laser coagulation. Antiviral drugs in these cases are not advisable.

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

Prevention of recurrence of the disease, prevention issues occupy an important place in the problem of herpetic eye disease. Despite the clinical recovery, the presence of a latent herpetic infection in the body dictates the need to exclude the adverse effects of the external environment. It is necessary to avoid hypothermia of the body. Catarrhal diseases, eye injuries, physical and mental overstrain are extremely dangerous - all factors that contribute to reducing the body's resistance, reducing the antiviral immunity. With frequent, sometimes annual, recurrences of herpes of the eye, mainly keratitis and iritis, the use of antiherpetic polivaccine is indicated. Do not start treatment in an acute period of the process. After the disappearance of all clinical signs of inflammation, one should wait 1 month and only then proceed to the course of vaccination. This is due to the fact that even during vaccination in a cold, i.e., inter-recurrent period, the process may worsen, which requires the interruption of vaccination and the administration of desensitizing and antiviral treatment.

The method of anti-relapse therapy consists in the intra-cutaneous injection (on the inner surface of the forearm) of 0.1-0.2 ml of a polivaccine with the formation of a papule with a "lemon crust". Do 5 injections with an interval between them in 2 days. The first course of vaccination should be carried out in a hospital, and the next, after 3-6 months (during the first year) can be performed on an outpatient basis. Further courses are conducted only on an outpatient basis once every 6 months. The use of herpetic polivaccine does not exclude the local prophylaxis of ophthalmoherpes. Prophylactic measure of the next possible relapse of keratitis is instillation of interferonogens (pyrogenal at the rate of 1000 MTD, ie 1 ml per 10 ml of distilled water, or half-way at the rate of 200 μg per 5 ml of distilled water). An important role in the fight against various clinical manifestations of the pathology of the eye caused by the herpes simplex virus belongs to the dispensary service (all patients suffering from frequent relapses should be under clinical supervision).

No less important is the knowledge of another herpetic infection of the eye and its appendages, called the herpes zoster (herpes zoster). The disease belongs to the category of skin, proceeding with a pronounced neuralgic pain syndrome, which is explained by the virus's tropism to the nervous tissue and skin. In recent years, it has been established that there are two types of neurodermotropic filtering virus, which causes a clinical picture of the herpes zoster and the clinical picture of childhood disease - chicken pox. Became understandable cases of infection of children with chicken pox from patients with shingles. Incubation of shingles lasts 2 weeks, the disease occurs more often in autumn or spring, leaves behind a persistent immunity, practically not recurring. To factors provoking herpes zoster, include infectious diseases, trauma, intoxication, exposure to chemical, food, medicament agents, especially. At an allergic predisposition to them. The disease is preceded by lethargy, apathy, headache, fever. After this, in a certain zone, depending on which intervertebral ganglion and the nerve stem leaving it (the third or the seventh nerves most often), there is skin hyperemia, its swelling with the formation of papules and vesicles. Vesicles usually do not open. They can be filled with pus, blood. In the future, on the place of the vesicles appear crusts, falling off by the end of the third week. In the places of papules and vesicles there are dents (pockmarks) like those that are sometimes observed in children who have suffered varicella. The skin in the locations of elements depriving is excessively pigmented or, conversely, depigmented. The process is accompanied by severe neuralgic pains, combined with pronounced hypostasis or analgesia of the rut at the site of the lesion. Herpes is characterized by the location of the rashes only on one side of the body without changing to another.

This also applies to the defeat of the orbital nerve, which happens in 10% of cases of shingles of other localizations. The process develops in the zone of branching of the orbital nerve (skin of the upper eyelid, forehead, temple and the scalp to the middle line). In 50% of cases, that is, practically in every second patient, the eye becomes ill with ophthalmic localization of the herpes zoster. There may be herpetic conjunctivitis, keratitis, iridocyclitis. This is due to the fact that certain branches of the nasolacaryngeal nerve (namely, long ciliary nerves) formed as a result of branching of the orbital nerve trunk. Function as a sensitive and trophic innervationhorny, iris and ciliary body, penetrating into the circumference of the optic nerve through the sclera into the perochoroidal space. When these branches are involved in the inflammatory process, a clinical picture of herpetic keratitis, sometimes of iridocyclitis, has features characteristic of keratitis and iridocyclitis when infected with herpes simplex virus.

To anticipate the spread of shingles on the eye tissue, we must closely monitor the skin in the inner corner of the eyelids and under the internal adhesion of the eyelids. Del "is that the sensitive innervation of these cutaneous areas is due to the sub-block nerve, which, like the long ciliary nerves, departs from the nososnichnogo trunk. The appearance of skin hyperemia, its infiltration in these areas, the precipitation of herpetic elements here testify to the involvement of the sub-block nerve, which is then usually affected in the long ciliary nerves with the appearance of pathological changes on the eyeball.

Adopted in time measures in the form of enhanced antiviral and desensitizing therapy, topical application of exogenous interferon and interferonogen can prevent the development of viral infection in the eye. With ophthalmic localization of the herpes zoster, the appointment of a general treatment ophthalmologist should be coordinated with a neurologist and dermatologist. To remove the pain syndrome, usually appoint an intramuscular 50% solution of analgin in 1-2 ml. The use of broad-spectrum antibiotics, vitamin B1 in 1 ml of a 6% solution intramuscularly every other day, should be alternated with vitamin B12 at 200 μg. Skin areas affected by herpes are smeared with brilliant green, Castellani liquid, sometimes with 2% tannin solution, 1% silver nitrate solution. It is useful to irrigate the herpes zone with a solution of interferon.

The treatment of keratitis, iridocyclitis corresponds to the treatment prescribed for the defeat of the eye with the herpes simplex virus. In the process of curative treatment of a patient with shingles, one should remember the need to isolate children from it, since, as mentioned above, the herpes zoster virus and varicella zoster virus are almost identical in many characteristics.