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Herpes Zoster Ophthalmicus

(Herpes Zoster Virus Ophthalmicus; Ophthalmic Herpes Zoster; Varicella-Zoster Virus Ophthalmicus)

By

Melvin I. Roat

, MD, FACS, Sidney Kimmel Medical College at Thomas Jefferson University

Last full review/revision May 2020| Content last modified May 2020
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Topic Resources

Herpes zoster ophthalmicus is reactivation of a varicella-zoster virus infection (shingles) involving the eye. Symptoms and signs, which may be severe, include dermatomal forehead rash and painful inflammation of all the tissues of the anterior and, rarely, posterior structures of the eye. Diagnosis is based on the characteristic appearance of the anterior structures of the eye plus zoster dermatitis of the first branch of the trigeminal nerve (V1). Treatment is with oral antivirals, mydriatics, and topical corticosteroids.

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.

Symptoms and Signs

A prodrome of tingling of the forehead may occur. During acute disease, in addition to the painful forehead rash, symptoms and signs may include severe ocular pain; marked eyelid edema; conjunctival, episcleral, and circumcorneal conjunctival hyperemia; corneal edema; and photophobia.

Complications

Keratitis and/or uveitis may be severe and followed by scarring. Late sequelae—glaucoma, cataract, chronic or recurrent uveitis, corneal scarring, corneal neovascularization, and hypesthesia—are common and may threaten vision. Postherpetic neuralgia may develop later. Patients may develop episcleritis (without increased risk of visual loss) and/or retinitis (with risk of severe visual loss).

Diagnosis

  • Zoster rash on the forehead or eyelid plus eye findings

Diagnosis is based on a typical acute herpes zoster rash on the forehead, eyelid, or both or on a characteristic history plus signs of previous zoster rash (eg, atrophic hypopigmented scars). Vesicular or bullous lesions in this distribution that do not yet involve the eye suggest significant risk and should prompt an ophthalmologic consultation to determine whether the eye is involved. Culture and immunologic or polymerase chain reaction studies of skin at initial evaluation or serial serologic tests are done only when lesions are atypical and the diagnosis uncertain.

Treatment

  • Oral antivirals (eg, acyclovir, famciclovir, valacyclovir)

  • Sometimes topical corticosteroids

Early treatment with acyclovir 800 mg orally 5 times/day or famciclovir 500 mg or valacyclovir 1 g orally 3 times/day for 7 days reduces ocular complications. Patients with uveitis or keratitis require topical corticosteroids (eg, prednisolone acetate 1% instilled every 1 hour for uveitis or 4 times/day for keratitis initially, lengthening the interval as symptoms lessen). The pupil should be dilated with atropine 1% or scopolamine 0.25% 1 drop 3 times/day. Intraocular pressure must be monitored and treated if it rises significantly above normal values.

Use of a brief course of high-dose oral corticosteroids to prevent postherpetic neuralgia in patients > 60 years who are in good general health remains controversial.

Prevention

Recombinant herpes zoster vaccine is recommended for immunocompetent adults ≥ 50 years, regardless of whether they have had herpes zoster or been given the older, live-attenuated vaccine. This recombinant vaccine decreases the chance of getting herpes zoster by 97% for adults 50 to 69 years and 91% for adults ≥ 70 years.

Key Points

  • The eye is affected in about half of cases of V1 varicella-zoster virus reactivation.

  • Keratitis and/or uveitis can be severe and cause morbidity.

  • Appearance of the typical herpes zoster rash is usually diagnostic.

  • Treatment is with oral antivirals and usually topical corticosteroids and pupillary dilation.

  • Give the recombinant herpes zoster vaccine to all immunocompetent adults ≥ 50 years.

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