II. Epidemiology
-
Varicella Zoster Virus seropositivity: 95% U.S. adults
- Lifetime reactivation of VZV as Shingles: 50%
- Incidence Herpes Zoster Ophthalmicus: rare
- Lifetime reactivation of VZV as Shingles: 50%
III. Pathophysiology
- Initial: Varicella Zoster Virus Infection
- Dormancy: VZV lies dormant in Trigeminal NerveGanglion
- Reactivation: VZV reactivates in Trigeminal Nerve
- Ocular involvement is via the first 2 branches of the Trigeminal Nerve
IV. Predisposing Factors
-
Immunocompromised Condition (decreased T-Cell Immunity)
- Advanced age
- Human Immunodeficiency Virus (HIV)
- Cancer
- Chemotherapy
- Radiation Therapy
- Acute Herpes Simplex Virus Infection
- Reactivating factors
- Local Trauma
- Fever
- Ultraviolet light
- Cold wind
- Systemic illness
- Menstruation
- Emotional stress
V. Symptoms
- Prodrome (precedes rash by several days)
- Dermatitis (see below)
- Ocular involvement may precede rash
- Eye Pain
- Lacrimation
- Visual changes
- Unilateral Red Eye
VI. Signs
- Hutchinson's Sign (1864)
- Nasociliary branch of V2 involvement (tip of nose)
- Heralds VZV ocular involvement (2 fold risk)
- Ocular effects occur despite no sign in 33% of cases
-
Herpes Zoster type dermatitis
- Vesicular erythematous rash
- Follows first Trigeminal Nerve division
- Forehead
- Eyelid (Blepharitis)
- Cornea
- Crusts develop after the sixth day of the rash
- Lymphadenopathy
- Ocular exam
- Corneal staining
- Fluorescein staining: HSV
- Rose bengal staining: HSV and VZV
- Slit-lamp exam
- Intraocular Pressure
- Dilated Funduscopic Exam
- Corneal staining
- Ocular changes (changes develop within 3 weeks of rash)
- Iritis or Iridocyclitis
- Corneal Dysesthesia (or decreased Sensation)
- Punctate epithelial Keratitis
- Appear as soon as 1-2 days after rash
- May proceed to Dendrite formation
- Dentritiform Keratopathy on Fluorescein exam
- Branching with "hyphae-like" patterns
- Decreased Visual Acuity
- Conjunctivitis (Staphylococcus Aureus superinfects)
- Acute Retinal necrosis
VII. Differential Diagnosis
-
Herpes Keratitis
- Herpes Keratitis crosses the midline whereas Herpes Zoster Ophthalmicus does not
- Conjunctivitis
- Corneal Abrasion
- Acute Narrow Angle Glaucoma
- Iritis
- Uveitis
- Scleritis
- Trigeminal Neuralgia
- Migraine Headache
- Meningitis
VIII. Labs
- Viral Culture from Cornea, Conjunctiva, or skin
- Giemsa stain from Cornea or skin scrapings
- Immunocompromised evaluation for age under 40 years
IX. Complication
- Stromal Keratitis
- Neurotrophic Keratitis
- Pathophysiology
- Decreased Corneal Sensation
- Decreased Lacrimation
- Corneal thinning
- Results
- High risk of Traumatic Injury or perforation
- Risk of Bacterial superinfection
- Pathophysiology
- Episcleritis or Scleritis
- Iritis
- Anterior Uveitis (common and usually mild)
- Ischemic Papillitis
- Orbital Vasculitis
- Ocular motor palsy
- Retinitis
- Acute Retinal necrosis
- Progressive outer Retinal necrosis
- Severe retinitis in Immunocompromised patients
- Visual Loss
- Postherpetic Neuralgia (occurs in 7% of cases)
X. Management: Acute
- Urgent Ophthalmology Consultation
-
Antiviral Agents
- General
- Reduces ocular complications (Keratitis, Uveitis)
- Best prognosis when started early (within 72 hours)
- Efficacious if used as late as 7 days after onset
- Recovery rates and outcomes similar between IV and oral Antiviral Agents
- Acyclovir oral or intravenous
- Dose: 800 mg PO five times daily for 7-10 days
- Intravenous dose for Immunocompromised patients
- Valacyclovir (Valtrex)
- Dose: 1000 mg PO tid for 7-14 days
- Famciclovir (Famvir)
- Dose: 500 mg PO tid for 7 days
- General
- Anti-staphylococcal Antibiotics
-
Prednisone
- Use only per Ophthalmology Consultation (risk of Corneal perforation)
- Inpatient admission criteria
- Severe symptoms or multiple Dermatomes involved
- Immunocompromised condition
- Significant facial Bacterial superinfection
XI. Management: General Measures
- Ocular Lubricants (e.g. Artificial Tears)
- Warm, moist compresses to affected eye
- Never use ocular Topical Anesthetics for home
XII. Management: Acute and Postherpetic Neuralgia
- Oral Narcotic Analgesics
- Capsaicin to involved skin only
- Amitriptyline (Elavil)
XIII. References
- Ritterband (1998) Rev Med Virol 8(4): 187-201 [PubMed]
- Karlin (1993) Ann Ophthalmol 25(6):208-15 [PubMed]
- Cobo (1988) Am J Med 85(2A):90-3 [PubMed]
- Pavan-Langston (1995) Neurology 45(12 Suppl 8):S50-1 [PubMed]
- Liesegang (1991) Ophthalmology 98(8):1216-29 [PubMed]
- Liesegang (1999) Cornea 18(5):511-31 [PubMed]
- Marsh (1993) Eye 7(Pt 3): 350-70 [PubMed]
- Shaikh (2002) Am Fam Physician 66(9):1723-32 [PubMed]
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Related Studies
Definition (MSH) | Virus infection of the Gasserian ganglion and its nerve branches characterized by pain and vesicular eruptions with much swelling. Ocular involvement is usually heralded by a vesicle on the tip of the nose. This area is innervated by the nasociliary nerve. |
Concepts | Disease or Syndrome (T047) |
MSH | D006563 |
ICD9 | 053.2 |
ICD10 | B02.3 , B02.30 |
SnomedCT | 154328001, 186526008, 87513003, 186524006 |
English | Herpes Zoster Ophthalmicus, Herpes Zoster, Ocular, Ocular Herpes Zoster, Herpes zoster+ophthalmic comp., Ophthalmic herpes zoster infec, Ophthalmic herpes zoster infection, herpes zoster with ophthalmic complications (diagnosis), herpes zoster with ophthalmic complications, Zoster ocular disease, unspecified, Herpes Zoster Ophthalmicus [Disease/Finding], ophthalmicus herpes zoster, zoster ophthalmic, ocular herpes zoster, zoster ophthalmicus, herpes zoster ophthalmicus, ophthalmic zoster, herpes zoster ophthalmic, ophthalmic herpes zoster, Ophthalmic herpes zoster infection (disorder), Ophthalmic zoster, Ophthalmic herpes zoster, Herpes zoster ophthalmic, Herpes zoster with ophthalmic complications, Herpes zoster ophthalmicus, Zoster ocular disease, Herpes zoster with ophthalmic complication, Zoster ophthalmicus, Herpes zoster ophthalmicus (disorder), Herpes zoster with ophthalmic complication (disorder), herpes; eye (h.zoster) (etiology), herpes; ophthalmicus (h.zoster) (etiology), herpes; zoster, eye (etiology), herpes; zoster, eye (manifestation), zoster; herpes, eye (etiology), zoster; herpes, eye (manifestation) |
Swedish | Ögonherpes |
Czech | herpes zoster ophthalmicus, Herpes zoster ophthalmicus, Oční Herpes zoster, Herpes zoster s očními komplikacemi |
Finnish | Silmänseudun vyöruusu |
Russian | HERPES ZOSTER GLAZA, GLAZA HERPES ZOSTER, HERPES ZOSTER OPHTHALMICUS, HERPES ZOSTER ГЛАЗА, ГЛАЗА HERPES ZOSTER |
German | Zoster ophthalmicus, Herpes zoster der Augen, ophthalmischer Herpes zoster, Herpes zoster mit ophthalmischen Komplikationen, ophthalmischer Zoster, Herpes zoster ophthalmicus, Herpes zoster, okular |
Italian | Herpes Zoster oculare, Herpes zoster oftalmico, Zoster oftalmico, Herpes zoster con complicazioni oftalmiche, Herpes Zoster oftalmico |
Korean | 대상포진 눈병 |
Spanish | herpes zoster oftálmico, enfermedad ocular por zoster, herpes zoster oftálmico (trastorno), herpes zóster oftálmico (trastorno), herpes zóster oftálmico, herpes zoster con complicaciones oftálmicas, zóster oftálmico, Herpes Zóster Oftálmico, Herpes Zóster Ocular, Zóster oftálmico, Herpes zóster con complicaciones oftálmicas, Herpes zóster oftálmico, herpes zóster con complicaciones oftálmicas (trastorno), herpes zóster con complicaciones oftálmicas |
Polish | Półpasiec powieki i gałki ocznej, Półpasiec oczny |
Japanese | 帯状疱疹-眼部, 眼帯状疱疹, ガンタイジョウホウシン, タイジョウホウシンガンガッペイショウヲトモナウモノ, 帯状疱疹、眼合併症を伴うもの, 疱疹-帯状-眼部, 眼部帯状ヘルペス, 眼部帯状疱疹, ヘルペス-帯状-眼部, 帯状ヘルペス-眼部 |
Norwegian | Helvetesild på øyet, Herpes zoster, okulær, Herpes zoster ophthalmicus, Oftalmisk zoster, Herpes zoster-sykdom i øye, Okulær herpes zoster |
Dutch | oftalmische herpes zoster, oftalmische zoster, herpes zoster ophthalmicus, herpes zoster oftalmisch, herpes zoster met oogcomplicaties, herpes; oog (h.zoster), herpes; ophthalmicus (h.zoster), herpes; zoster, oog, zoster; herpes, oog, Oogziekte bij herpes zoster, Herpes zoster ophthalmicus, Herpes zoster, oculaire |
French | Herpès zoster avec complications ophtalmiques, Zona ophtalmique, Zona oculaire |
Hungarian | Ophthalmicus zoster, herpes zoster ophthalmicus, Ophthalmicus herpes zoster, Herpes zoster ophthalmicus szövődményekkel, ophthalmicus herpes zoster |
Portuguese | Zóster oftálmico, Herpes zóster com complicações oftálmicas, Herpes zóster oftálmico, Herpes zóster nos olhos, Herpes Zoster Ocular, Herpes Zoster Oftálmico |
Ontology: Hutchinson's sign (C1444627)
Concepts | Disease or Syndrome (T047) |
SnomedCT | 410500004 |
English | Hutchinson sign, Herpes zoster involving tip of nose, Hutchinson's sign (diagnosis), herpes zoster hutchinson's sign, Hutchinson's sign (disorder), Hutchinson's sign |
Spanish | herpes zoster que compromente la punta de la nariz, signo de Hutchinson (trastorno), signo de Hutchinson |