After the primary infection, latency is established in the sensory ganglion. VZV-specific T cell–mediated immunity maintains VZV in the latent state. Viral reactivation results when immunity declines due to age, illness, or immunosuppression. Herpes zoster of the forehead involves the globe in three fourths of cases when the nasociliary nerve is affected (as indicated by a lesion on the tip of the nose) and in one third of cases not involving the tip of the nose. Overall, the globe is involved in half of patients. Varicella zoster virus is highly contagious and transmission may occur by direct contact with an ulcerated skin lesion or airborne aerosols.
Symptoms and Signs of Herpes Zoster Ophthalmicus
A prodrome of pain or tingling of the forehead may occur. During acute disease, in addition to the painful forehead rash, symptoms and signs may include severe ocular pain; marked eyelid edema; conjunctival, episcleral, and circumcorneal conjunctival hyperemia; corneal edema; and photophobia.
Keratitis Herpes Simplex Keratitis Herpes simplex keratitis is corneal infection with herpes simplex virus. It may involve the iris. Symptoms and signs include foreign body sensation, lacrimation, photophobia, and conjunctival... read more and/or uveitis Overview of Uveitis Uveitis is defined as inflammation of the uveal tract—the iris, ciliary body, and choroid. However, the retina and fluid within the anterior chamber and vitreous are often involved as well.... read more may be severe and followed by scarring. Late sequelae—glaucoma, cataract, chronic or recurrent uveitis, corneal scarring, corneal neovascularization, and hypesthesia—are common and may threaten vision. Postherpetic neuralgia Postherpetic neuralgia Herpes zoster is infection that results when varicella-zoster virus reactivates from its latent state in a posterior dorsal root ganglion. Symptoms usually begin with pain along the affected... read more may develop later. Drugs for neuropathic pain (eg, gabapentin or tricyclic antidepressants) can help. Patients may develop episcleritis Episcleritis Episcleritis is self-limiting, recurring, usually idiopathic inflammation of the episcleral tissue that does not threaten vision. Symptoms are a localized area of hyperemia of the globe, irritation... read more (without increased risk of visual loss) and/or retinitis (with risk of severe visual loss).
Diagnosis of Herpes Zoster Ophthalmicus
Zoster rash on the forehead or eyelid plus eye findings
Diagnosis is based on either a typical acute herpes zoster rash on the forehead, eyelid, and tip of the nose, or on the characteristic pain plus signs of previous zoster rash (eg, atrophic hypopigmented scars). Both skin findings are unilateral (ie, do not cross the midline). Vesicular or bullous lesions in this distribution that do not yet obviously involve the eye should still prompt an ophthalmologic consultation to determine whether the eye is involved. Culture and immunologic or polymerase chain reaction studies of skin at initial evaluation or serial serologic tests are done only when lesions are atypical and the diagnosis uncertain.
Treatment of Herpes Zoster Ophthalmicus
Oral antivirals (eg, acyclovir, famciclovir, valacyclovir)
Sometimes topical corticosteroids
Early treatment with acyclovir 800 mg orally 5 times/day or famciclovir 500 mg or valacyclovir 1 g orally 3 times/day for 7 days reduces ocular complications. Patients with uveitis or keratitis require topical corticosteroids (eg, prednisolone acetate 1%, 1 drop instilled every 1 hour for uveitis or 4 times/day for keratitis initially, lengthening the interval as signs and symptoms lessen). The pupil should be dilated with atropine 1% or scopolamine 0.25% 1 drop 3 times/day. Intraocular pressure must be monitored and treated if it rises significantly above normal values.
Use of a brief course of high-dose oral corticosteroids to prevent postherpetic neuralgia in patients > 60 years who are in good general health remains controversial.
Prevention of Herpes Zoster Ophthalmicus
Recombinant herpes zoster vaccine Herpes Zoster Vaccine Chickenpox (varicella) and shingles ( herpes zoster) are caused by the varicella-zoster virus; chickenpox is the acute invasive phase of the virus, and shingles represents reactivation of the... read more is recommended for immunocompetent adults ≥ 50 years, regardless of whether they have had herpes zoster or been given the older, live-attenuated vaccine. This recombinant vaccine decreases the chance of getting herpes zoster by 97% for adults 50 to 69 years and 91% for adults ≥ 70 years.
The eye is affected in about half of cases of V1 varicella-zoster virus reactivation.
Keratitis and/or uveitis can be severe and cause morbidity.
Appearance of the typical herpes zoster rash is usually diagnostic.
Treatment is with oral antivirals and usually topical corticosteroids and pupillary dilation.
Give the recombinant herpes zoster vaccine to all immunocompetent adults ≥ 50 years.