 So, hey everybody, I'm Adam Frederick, one of the cornea fellows. If you don't know me already, I'm going to go through this really quickly because it's not that complicated and I think the discussion is going to be the more interesting part. So, this is a patient for those of you who didn't get to see it with numular keratitis and that's more of a descriptive term than a diagnostic term. It's a 22-year-old male. He had a history of shingles on the left side of his face in 2014. He told me that it was initial ocular involvement. I'm not really sure at that time if it was actual globe involvement but it was definitely all around his eye and he had Hutchinson sign on his nose. He was treated systemically with acyclovir. He has no systemic illnesses and interestingly he actually developed a third nerve palsy at this time back in 2014 with this shingles episode that is pretty much completely resolved. So, he went a year off of all medicines and really had nothing happen and last year in August, this is 2015, he had some eye irritation that didn't have pain but just he noticed his vision was kind of funny. He actually works at an optical place and got the doctor there to look at his eye and the doctor essentially said, yeah, you've got probably a shingles flare in your eye and he started them on acyclovir and sent the patient to us at Moran. So, when he presented to us, his right eye has been completely unaffected this entire time. His left eye was about 20, 30 and he had these multiple large areas of corneal involvement. It was a numular keratitis. It was, there was some thinning but no severe thinning and he never really had and has never really had much of an ac or an iridus reaction during this whole entire course. So, these are some pictures of what his eye looked like. This, you can see especially inferiorly those well demarcated, numular lesions and he actually has some stuff superiorly. There's another shot. This is sort of a better illumination shot. So, that's pretty classic from a descriptions standpoint of a numular keratitis, what it looks like. You have that granular central appearance with sort of a ring of I guess lipid deposits or haze around the outside. There is another shot. So, when he saw us, he had not been on any topical steroids. He was on acyclovir 800 milligrams QID PO. We started them on Predforte QID and said come back in two weeks. At his two week follow up he looked pretty inactive and we decreased his acyclovir. He had been on the 800 QID dose for several weeks at this point and we decided to try and taper off of his Predforte topically at that time and said come back in four to six weeks. Came back in four to six weeks. He was again inactive. He was off the prednisone. He was doing fine. His vision was stable and we set him out for three months. He came back in three months and was essentially then stable and we decreased his acyclovir one more time to just 800 milligrams PO daily and he was again not on any steroids. We were going to see him for six months but he came back about a month and a half later and he noticed the same sort of symptoms. Some blurry vision in his left eye. He never really has eye pain because he's got essentially a neurotrophic cornea. He had rare cell in his AC and new area that looked like it had some activity inferiorly with some haze and edema and his vision had decreased. So we bumped his acyclovir back up to 800 PO QID and restarted Predforte QID. Sent him out for about two weeks and he came back and was essentially the same. Vision was the same. We kind of kept going with the same course and that leads him to today where he has tapered off of his Predforte sum. He's only on Predforte BID and he's on acyclovir 800 TID right now. We're kind of left with the situation where it's a young person with no systemic illnesses. He's got this zoster corneal involvement that actually had a flare on acyclovir at 800 daily was not on topical steroids at that time. So some of the questions are with this guy what do we do with his acyclovir? Does he need acyclovir and how much? What about topical preds? What about chronic prednisone or other steroids in a young person? Is that a good idea? Is that a bad idea? What about maybe trying different antivirals or anything else we need to do? And I've already talked with some people about this sum but I'd be interested in anybody's opinion and of course Dr. Dolly Will's opinion. So dramatic interest. Okay thank you. This is a very interesting case and actually I touched on the simplex virus and zoster in my talk yesterday. So for those people who are there, sorry if I'm going to be a little bit redundant but this actually kind of highlights how these two entities need to be kept very separately in terms of your plot process. So let's talk about zoster first because this is what the patient had. Zoster occurred and this patient had classic V1 distribution of zoster. The patient received full dose antiviral treatment at that time. Zoster dosing of acyclovir or one of the associated you know valacyclovir or famvir and then result. Now sequelae from zoster and when I think of the corneal sequela from zoster in this patient I think of it more like an interstitial keratitis. Numbular is basically describing the shape right like a coin shape. This is an interstitial zoster related keratitis. So when you look at each of those lesions what's really important if you go back let's go back to the to the clinical picture you can see uh yeah there's that really nice so when you look at the the appearance let's see is this the laser pointer okay uh especially the nasal lesion had significant vessels coursing right into the lesion and what's this whitish stuff that's in the lesion lipid right it's hoping for one of the residents to say okay okay anyway that's right Dr. Huffman all right okay so yeah so it's lipid it's from the leaky blood vessels from the interstitial keratitis right so now so this is zoster the reason these lesions are occurring are because of the vessels right that are coming in at this point all you need to do is use steroids I don't feel that there's a role for oral antivirals anymore because this is zoster so what I would do in this patient is I would use fml I would not use pred because there's no I write this component there's no intraocular information fml is a very nice strong steroid on the ocular surface so I would switch this patient to fml I would you know depending on the vessels I would titrate I might start a qid and then for a month and I want those vessels to close and then we just slowly decrease the steroid dose until we can get basically closure of these of these vessels and and it prevent any further leakage of the lipid and in terms so that's zoster okay and sometimes these patients need to be you know like maybe one drop of fml every other day something like that just to keep everything quiet in terms of visual rehabilitation for this patient I would definitely not do a transplant because he's neurotrophic I instead would recommend a scleral contact lens that would be a wonderful um optical kind of rehabilitation method in him because remember the scleral lens is going to vault over the cornea so it's not going to create any abrasions or erosions it's actually going to bathe the cornea in fluid all day and uh and he'll see beautifully with that scleral contact lens so he was excited when we already talked to him about this option he said oh great you know this is the name you can see again and and he should be relatively stable so I would um take him off the oral antivirals and then and just you know switch him to fml okay let me just talk quickly about herpes simplex because that's a completely different disease entity that's when I use antivirals pretty chronically in the patients that have recurrences so in herpes simplex virus it's really important to continue that uh that oral antiviral prophylaxis because when they get reactivation if they have steroids on board you know I have that picture of of kind of fire and the cornea if putting steroids on a cornea that has live virus live herpes simplex virus is like pouring gasoline on a fire it's a disaster so in those cases you use the oral prophylaxis just in case they're going to get some reactivation virus okay so uh you just really have to in your mind differentiate these two herpes uh disease entities and then when you think of simplex always think in terms of is there live virus on the eye or not is this an immune condition or not okay thank you hope not yes sir so sometimes science is a funny way of progressing winter's day last winter in uh in England in Liverpool we become a team with my friend Steve of K and I said that I use laser beams to close the vessels on and I have a micro laser that I would develop why can't they close these vessels on the cornea of course the usual discussion you may damage the eye you may cause uh ischemia you may traumatize the iris you couldn't hear it damage the angle based upon that we're sitting there with a social visitor he's a cornea expert and our last things that we're sort of carrying this you say you've got the wrong story sure what came off that is we did some dye stones on the vessels that grow on the cornea and he then started using the old fashioned way that we used to use clothes made from the legs micro needles so he's the last of a few months now he's he's done that he's published some preliminary reports I'm not sure if you're familiar with his work I remember Dua has been doing it for quite a while right using a needle yes a micro needle at using the 540 dial I placed now and cutting down the power to see if you can do that even more accurately than putting a needle in these vessels we've asked him to allow us to use micro needles so we're going to let Steve let's be at his successful work out that the laser beams might put the legs back forward and if you can close these vessels off you can improve the sheesh you should improve the scarring aspects and you could possibly prevent the long vision so this is ongoing work it's playing out the science progressive casual conversation with special needs