Background & Aims
Herpes ophthalmicus is the most common cranial dermatome of herpes zoster and is involved in up to 20% of cases of herpes zoster (1,2). Post-herpetic neuralgia (PHN) is common and is often refractory despite multimodal neuropathic pain treatments. Involvement of the eye is a significant risk factor for the development of PHN (3). Recurrent uveitis following herpes zoster infection is a well-established complication (1). PHN rarely resolves if patients have had pain for more than 6 months (4). PHN tends to cause long-term quality of life impairment (4).
We present a patient who suffered from more severe PHN pain in a right V1 distribution in July 2020 with recurrent uveitis, whose symptoms were not effectively controlled with gabapentin, pregabalin, nortriptyline, duloxetine, oxcarbazepine, or lamotrigine (5). After 18 months of refractory PHN, the patient had significant pain relief and improvement in her uveitis following treatment with medical grade cannabidiols (CBD).
Methods
We conducted a chart review on a patient who is being followed in the Burrard Pain Clinic. We also obtained all available records from her ophthalmologist. Serial assessments were performed with the patients and additional interviews were conducted to ensure a thorough history was available. A 0-10 numeric rating scales was used to assess pain levels and a screening assessment was performed with Generalized Anxiety Disorder 7-item score (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) questionnaires for anxiety and depression. The patient also wrote a narrative to highlight her perspective on her overall experience with this therapy.
Results
When assessed in September 2021, her PHN was a constant burning pain was rated at 8/10, with significant allodynia. In addition, she described a 10/10 stabbing pain during her 7 flairs of uveitis, which could last for up to a week and occurred nearly every month. She screened negative for comorbid conditions of depression (GAD-7=3/21) and anxiety (PHQ-9=7/27).
She began treatment with CBD 20 mg daily in March 2022, which was increased to 40 mg in July. Her PHN pain improved to 1/10 in August 2022. She had 2 recurrences of uveitis in August 2022 and October 2022, with each event resolving symptomatically in 3-5 days. Her 0.5% prednisolone eye drops were increased to a q2H frequency. Her CBD was titrated up to 200 mg daily following these events and her prednisolone drops were reduced to once daily in February 2023. She was able to return to part time work in May 2022 and full-time work in February 2023. She had no further flairs and was titrated off all CBD in August 2023.
Conclusions
We describe a patient with complications of Herpes Zoster Ophthalmicus: PHN with recurrent uveitis. This patient had debilitating pain, which interfered with her daily activities and ability to work. CBD was used as a third line agent, as is currently recommended by the Canadian guidelines for neuropathic pain (5), where this patient was treated by an experienced pain specialist with training in clinical pharmacology (MO). After initiating treatment with CBD, the patient had resolution of her post-herpetic pain, and a dramatic reduction in frequency, duration, and severity of her uveitis flairs without symptomatic keratitis. She tolerated CBD without any side effects, in keeping with its well-established safety profile (6). Spontaneous remission of uveitis and PHN is possible but the temporal correlation with CBD use (4,7), suggests a possible causative role of CBD in the resolution of these two syndromes. Overall, the use of CBD for PHN and uveitis warrants further investigation.
References
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Presenting Author
May C Ong
Poster Authors
Topics
- Treatment/Management: Cannabinoids and Cannabis