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Herpes Zoster Ophthalmicus

(Herpes Zoster Virus Ophthalmicus; Ophthalmic Herpes Zoster; Varicella-Zoster Virus Ophthalmicus)

By

Melvin I. Roat

, MD, FACS, Sidney Kimmel Medical College at Thomas Jefferson University

Last full review/revision Aug 2022| Content last modified Sep 2022
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Herpes zoster ophthalmicus is a reactivated latent varicella-zoster virus (VZV) infection (shingles Herpes Zoster 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 Herpes Zoster ) involving the eye. Symptoms and signs, which may be severe, include unilateral dermatomal forehead rash and painful inflammation of all the tissues of the anterior and, rarely, posterior structures of the eye. Diagnosis is based on the characteristic appearance of the anterior structures of the eye plus ipsilateral zoster dermatitis of the first branch of the trigeminal nerve (V1). Treatment is with oral antivirals, mydriatics, and topical corticosteroids.

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.

Complications

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.

Key Points

  • 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.

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