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Herpes Ophthalmicus
Aka: Herpes Ophthalmicus, Zoster Ophthalmicus, Herpes Zoster Ophthalmicus, Ophthalmic Herpes Zoster, Hutchinson's Sign- See Also
- 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%
- Varicella Zoster Virus seropositivity: 95% U.S. adults
- 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
- 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
- Immunocompromised Condition (decreased T-Cell Immunity)
- Symptoms
- Prodrome (precedes rash by several days)
- Dermatitis (see below)
- Ocular involvement may precede rash
- Eye Pain
- Lacrimation
- Visual changes
- Unilateral Red Eye
- 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
- Hutchinson's Sign (1864)
- 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
- Herpes Keratitis
- Labs
- Viral Culture from Cornea, Conjunctiva, or skin
- Giemsa stain from Cornea or skin scrapings
- Immunocompromised evaluation for age under 40 years
- 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
- Visual Loss
- Postherpetic Neuralgia (occurs in 7% of cases)
- Management: Acute
- Ophthalmology Consultation
- Antiviral agents
- General
- 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
- Valacyclovir
- Anti-staphylococcal antibiotics
- Prednisone
- Use only per Ophthalmology Consultation (risk of Corneal perforation)
- Inpatient admission criteria
- Management: General Measures
- Ocular Lubricants (e.g. Artificial Tears)
- Warm, moist compresses to affected eye
- Never use ocular Topical Anesthetics for home
- Management: Acute and Postherpetic Neuralgia
- Oral Narcotic Analgesics
- Capsaicin to involved skin only
- Amitriptyline (Elavil)
- 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]