II. Epidemiology

  1. Varicella Zoster Virus seropositivity: 95% U.S. adults
    1. Lifetime reactivation of VZV as Shingles: 50%
      1. Incidence Herpes Zoster Ophthalmicus: rare

III. Pathophysiology

  1. Initial: Varicella Zoster Virus Infection
  2. Dormancy: VZV lies dormant in Trigeminal NerveGanglion
  3. Reactivation: VZV reactivates in Trigeminal Nerve
  4. Ocular involvement is via the first 2 branches of the Trigeminal Nerve

IV. Predisposing Factors

  1. Immunocompromised Condition (decreased T-Cell Immunity)
    1. Advanced age
    2. Human Immunodeficiency Virus (HIV)
    3. Cancer
    4. Chemotherapy
    5. Radiation Therapy
  2. Acute Herpes Simplex Virus Infection
  3. Reactivating factors
    1. Local Trauma
    2. Fever
    3. Ultraviolet light
    4. Cold wind
    5. Systemic illness
    6. Menstruation
    7. Emotional stress

V. Symptoms

  1. Prodrome (precedes rash by several days)
    1. Lancinating pain lateral to affected eye
    2. Fever
    3. Malaise
    4. Headache
    5. Neck stiffness
  2. Dermatitis (see below)
    1. Ocular involvement may precede rash
  3. Eye Pain
  4. Lacrimation
  5. Visual changes
  6. Unilateral Red Eye

VI. Signs

  1. Hutchinson's Sign (1864)
    1. Nasociliary branch of V2 involvement (tip of nose)
    2. Heralds VZV ocular involvement (2 fold risk)
    3. Ocular effects occur despite no sign in 33% of cases
  2. Herpes Zoster type dermatitis
    1. Vesicular erythematous rash
    2. Follows first Trigeminal Nerve division
      1. Forehead
      2. Eyelid (Blepharitis)
      3. Cornea
    3. Crusts develop after the sixth day of the rash
  3. Lymphadenopathy
  4. Ocular exam
    1. Corneal staining
      1. Fluorescein staining: HSV
      2. Rose bengal staining: HSV and VZV
    2. Slit-lamp exam
    3. Intraocular Pressure
    4. Dilated Funduscopic Exam
  5. Ocular changes (changes develop within 3 weeks of rash)
    1. Iritis or Iridocyclitis
    2. Corneal Dysesthesia (or decreased sensation)
    3. Punctate epithelial Keratitis
      1. Appear as soon as 1-2 days after rash
      2. May proceed to dendrite formation
    4. Dentritiform Keratopathy on Fluorescein exam
      1. Branching with "hyphae-like" patterns
    5. Decreased Visual Acuity
    6. Conjunctivitis (Staphylococcus aureus superinfects)
    7. Acute Retinal necrosis

VII. Differential Diagnosis

VIII. Labs

  1. Viral Culture from Cornea, Conjunctiva, or skin
  2. Giemsa stain from Cornea or skin scrapings
  3. Immunocompromised evaluation for age under 40 years

IX. Complication

  1. Stromal Keratitis
    1. Anterior stromal Keratitis (nummular Keratitis)
      1. Occurs during week 2 in 25% of cases
      2. Fine granular Corneal infiltrates deep to dendrites
    2. Deep stromal Keratitis
      1. Uncommon, develops after anterior stromal Keratitis
      2. Develops 3-4 months after onset
      3. Involves central Cornea
  2. Neurotrophic Keratitis
    1. Pathophysiology
      1. Decreased Corneal sensation
      2. Decreased Lacrimation
      3. Corneal thinning
    2. Results
      1. High risk of Traumatic Injury or perforation
      2. Risk of Bacterial superinfection
  3. Episcleritis or Scleritis
  4. Iritis
  5. Anterior Uveitis (common and usually mild)
    1. May be complicated by Glaucoma or Cataracts
  6. Ischemic Papillitis
  7. Orbital Vasculitis
  8. Ocular motor palsy
  9. Retinitis
    1. Acute Retinal necrosis
    2. Progressive outer Retinal necrosis
      1. Severe retinitis in immunocompromised patients
  10. Visual Loss
  11. Postherpetic Neuralgia (occurs in 7% of cases)

X. Management: Acute

  1. Ophthalmology Consultation
  2. Antiviral agents
    1. General
      1. Reduces ocular complications (Keratitis, Uveitis)
      2. Best prognosis when started early (within 72 hours)
      3. Efficacious if used as late as 7 days after onset
    2. Acyclovir oral or intravenous
      1. Dose: 800 mg PO five times daily for 7-10 days
      2. Intravenous dose for immunocompromised patients
    3. Valacyclovir (Valtrex)
      1. Dose: 1000 mg PO tid for 7-14 days
    4. Famciclovir (Famvir)
      1. Dose: 500 mg PO tid for 7 days
    5. Valacyclovir
  3. Anti-staphylococcal antibiotics
    1. Augmentin
    2. Zithromax
  4. Prednisone
    1. Use only per Ophthalmology Consultation (risk of Corneal perforation)
  5. Inpatient admission criteria
    1. Severe symptoms or multiple dermatomes involved
    2. Immunocompromised condition
    3. Significant facial Bacterial superinfection

XI. Management: General Measures

  1. Ocular Lubricants (e.g. Artificial Tears)
  2. Warm, moist compresses to affected eye
  3. Never use ocular topical anesthetics for home

XII. Management: Acute and Postherpetic Neuralgia

  1. Oral Narcotic Analgesics
  2. Capsaicin to involved skin only
  3. Amitriptyline (Elavil)

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window

Ontology: Herpes Zoster Ophthalmicus (C0019364)

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