Herpes Zoster Ophthalmicus


Herpes Zoster Ophthalmicus


The ophthalmic zoster is a late and localised eruption reached a group of nerves located around the eye.



The buttons ophthalmic zoster affecting the region of the eye and the cornea.




The most common presentation for ocular HSV and HZV infection is pain, blurred vision, redness, tearing, and light sensitivity in one eye. HZV is also often accompanied by a shingles rash (small "vesicles," or blisters) on the forehead on the side that is affected and sometimes the tip of the nose.

Source : Medicinenet 



Although herpes zoster can occur at any age, it is mainly a disease of adults >60 years of age.

Source : Up to date 

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.

Source : MSD Manuals



Varicella-zoster virus (VZV) infection causes two clinically distinct forms of disease. Primary infection with VZV results in varicella, also known as chickenpox, characterized by vesicular lesions in different stages of development on the face, trunk, and extremities. Herpes zoster, also known as shingles, results from reactivation of endogenous latent VZV infection within the sensory ganglia.

Source : Uptodate



Most HSV eye infections that are limited to the outer layer of the cornea resolve within a couple of weeks with antiviral therapy, leaving little or no permanent damage. HSV infections of the deeper tissue layers may have a higher complication rate due to inflammation.

With HZV and shingles, the keratitis may also resolve over a couple of weeks with antiviral therapy. However, it is not uncommon for a painful burning sensation to linger in the area of the skin rash for months or even years. This is referred to as postherpetic neuralgia and sometimes responds to neurologic medications aimed at suppressing signals from the pain nerves.

Both types of herpes eye infections can leave residual corneal scarring that can blur the vision. In some cases, this can be corrected with surgery. Damage to the corneal nerves can also lead to chronic numbness of the cornea, causing dry eye and, in advanced cases, predisposing to dry-eye related corneal erosions or ulcers. In these cases lubricating drops, punctal plugs, and sometimes eyelid surgery may help protect the cornea.

Unfortunately, both HSV and HZV ophthalmicus can recur with unpredictable frequency in either eye. Frequent recurrences should warrant a general medical check-up to rule out any underlying condition that may be weakening the immune system. However, in many cases it is the virulence of the particular virus strain that determines its activity level. 

Source : Medicinenet




Most of the time the diagnosis can be made based on the symptoms and the signs alone.

Herpes keratitis typically produces a distinct erosion of the outer layer of the cornea. This tiny erosion is called a "dendrite" and has a tree-branching pattern that can be seen by the examiner using an eye drop containing a yellow dye and a blue light. Under a slit-lamp microscope the eye doctor can look for further clues to distinguish between an HSV and an HZV keratitis, but in either case, the initial antiviral treatment is the same.

Close examination of the other eye tissues (including the skin, conjunctiva, anterior chamber, iris, retina, and more) also offers additional clues to make the diagnosis as well as helps tailor treatment. In questionable cases, a culture can be obtained to confirm the diagnosis.

Source : Medicinenet



Episodes of herpes zoster are generally self-limited and resolve without intervention; they tend to be more benign and mild in children than in adults. An enormous number and variety of therapeutic approaches have been proposed over the years, most of which are probably ineffective.[69] Some effective therapies for herpes zoster do exist, however, and these can reduce the extent and duration of symptoms, and possibly the risk of chronic sequelae (eg, postherpetic neuralgia [PHN]) as well.

Therapeutic choices generally depend on the host’s immune state and on the presentation of zoster. Conservative therapy includes nonsteroidal anti-inflammatory drugs (NSAIDs); wet dressings with 5% aluminium acetate (Burow solution), applied for 30-60 minutes 4-6 times daily; and lotions (such as calamine).

Treatment is of greatest benefit in those patient populations at risk for prolonged or severe symptoms, specifically, immunocompromised people and persons older than 50 years. The benefit of treating younger and healthier populations is unclear.


Uncomplicated zoster does not require inpatient care. Hospital admission should be considered for patients with any of the following:

  • Severe symptoms
  • Immunosuppression
  • Atypical presentations (eg, myelitis)
  • Involvement of more than 2 dermatomes
  • Significant facial bacterial superinfection
  • Disseminated herpes zoster
  • Ophthalmic involvement
  • Meningoencephalopathic involvement

Patients with disseminated disease or severe immunosuppression or who are unresponsive to therapy should be transferred to a higher level of care. If consultation is required but not available at the initial facility, patients should be transferred to a tertiary care medical center.


Medications used include steroids, analgesics, anticonvulsants, and antiviral agents. Surgical care is not generally indicated for the treatment of herpes zoster, though it may be required to treat certain complications (eg, necrotizing fasciitis). Rhizotomy (surgical separation of pain fibers) may be considered in cases of extreme, intractable pain.


Source : Emedicine



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