Herpes zoster ophthalmicus
|Herpes zoster ophthalmicus|
|Other names||Ophthalmic zoster|
|Herpes zoster ophthalmicus|
|Symptoms||Rash of the forehead, swelling of the eyelid, pain and red eye|
|Complications||Vision loss, chronic pain|
|Causes||Reactivation of varicella zoster virus|
|Risk factors||Poor immune function, psychological stress, older age|
|Diagnostic method||Based on symptoms|
|Prevention||Herpes zoster vaccine|
|Medication||Antiviral pills such as acyclovir, steroid eye drops|
|Frequency||Up to 125,000 per year (US)|
Herpes zoster ophthalmicus (HZO), also known as ophthalmic zoster, is shingles involving the eye. Symptoms generally include a rash of the forehead with swelling of the eyelid. There may also be eye pain, eye redness, and light sensitivity. Before the rash appears tingling may occur in the forehead along with a fever. Complications may include vision loss, increased pressure within the eye, and chronic pain.
The underlying mechanism involves a reactivation of the varicella zoster virus within the ophthalmic nerve (the first division of the trigeminal nerve). Risk factors include poor immune function, psychological stress, and older age. Diagnosis is generally based on symptoms.
Treatment is generally with antiviral pills such as acyclovir. Steroid eye-drops and drops to dilate the pupil may also be used. The herpes zoster vaccine is recommended for prevention in those over the age of 50. Shingles affects up to half a million people in the United States a year of which 10% to 25% involve the eye.
Signs and symptoms
- Viral prodrome
- Preherpetic neuralgia
- Rash, transitioning from papules to vesicles to pustules to scabs. The frontal nerve is more commonly affected than the nasociliary nerve or lacrimal nerve.
- Hutchinson's sign: cutaneous involvement of the tip of the nose, indicating nasociliary nerve involvement. A positive Hutchinson's sign increases the likelihood of ocular complications associated with HZO.
- Disseminated distribution in individuals with immunodeficiency.
- Epithelial: punctate epithelial erosions and pseudodendrites: often have anterior stromal infiltrates. Onset 2 to 3 days after the onset of the rash, resolving within 2–3 weeks. Common.
- Nummular keratitis: have anterior stromal granular deposits. Occurs within 10 days of onset of rash. Uncommon
- Necrotising interstitial keratitis: Characterised by stromal infiltrates, corneal thinning and possibly perforation. Occurs between 3 months and several years after onset of rash. Rare.
- Disciform Keratitis (Disciform Endotheliitis): a disc of corneal oedema, folds in Descemet's membrane, mild inflammation evident within the anterior chamber and fine keratic precipitates. Chronic. Occurs between 3 months and several years after the onset of the rash. Uncommon.
- Neurotrophic: corneal nerve damage causes persistent epithelial defect, thinning and even perforation. Cornea becomes susceptible to bacterial and fungal keratitis. Chronic. Late onset. Uncommon.
- Mucous plaques: linear grey elevations loosely adherent to the underlying diseased epithelium/stroma. Chronic. Onset between 3 months and several years after the onset of the rash.
Anterior uveitis develops in 40–50% of cases with HZO within 2 weeks of onset of the skin rashes. Typical HZO keratitis at least mild iritis, especially if Hutchinson's sign is positive for the presence of vesicles upon the tip of the nose.
Treatment is usually with antivirals such as acyclovir or valacyclovir by mouth. There is uncertainty as to the difference in effect between these two antivirals. Antiviral eye drops have not been found to be useful. These medications work best if started within 3 days of the start of the rash.
- "Herpes Zoster Ophthalmicus - Eye Disorders". Merck Manuals Professional Edition. Retrieved 21 December 2019.
- Shaikh S, Ta CN (November 2002). "Evaluation and management of herpes zoster ophthalmicus". American Family Physician. 66 (9): 1723–30. PMID 12449270.
- "Herpetic Corneal Infections: Herpes Zoster Ophthalmicus". www.aao.org. Retrieved 21 December 2019.
- Khurana AK (2008). Comprehensive Ophthalmology. ISBN 9781905740789.
- Denniston AK, Murray PI (2009-06-11). Oxford Handbook of Ophthalmology. ISBN 9780199552641.
- Schuster AK, Harder BC, Schlichtenbrede FC, Jarczok MN, Tesarz J (November 2016). Cochrane Eyes and Vision Group (ed.). "Valacyclovir versus acyclovir for the treatment of herpes zoster ophthalmicus in immunocompetent patients". The Cochrane Database of Systematic Reviews. 11: CD011503. doi:10.1002/14651858.CD011503.pub2. PMC 6464932. PMID 27841441.
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