Herpes zoster ophthalmicus: Difference between revisions
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**Nasociliary branch of V1 innervates both the lateral/tip of nose as well as the cornea | **Nasociliary branch of V1 innervates both the lateral/tip of nose as well as the cornea | ||
*Consider immunocompromise in patients <40yrs | *Consider immunocompromise in patients <40yrs | ||
{{Herpes viruses}} | |||
==Clinical Features== | ==Clinical Features== | ||
*Prodrome of headache, malaise, photophobia, fever | [[File:Herpes zoster ophthalmicus2.jpg|thumb|Herpes zoster ophthalmicus]] | ||
*Unilateral pain or hypesthesia in V1 distribution | *Prodrome of [[headache]], malaise, photophobia, [[fever]] | ||
*Hyperemic conjunctivitis, episcleritis, lid droop | *Unilateral [[eye pain|pain]] or hypesthesia in V1 distribution | ||
*Hyperemic [[conjunctivitis]], [[episcleritis]], lid droop | |||
*Vesicular [[rash]] in V1 distribution | |||
*[[Slit-lamp exam]]: | |||
**Initial finding of punctate epithelial keratitis that then evolves into pseudodendrite<ref>Li, J. Y. (2018). Herpes zoster ophthalmicus. Current Opinion in Ophthalmology, 29(4), 328–333. doi:10.1097/icu.0000000000000491 </ref> | |||
**Pseudodendrite (poorly staining mucous plaque with no epithelial erosion) | |||
***In contrast to [[HSV]] which has true dendrite with epithelial erosion and staining | |||
**Cell and flare | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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==Evaluation== | ==Evaluation== | ||
* | *Clinical | ||
==Management== | ==Management== | ||
*Cool compresses/lubrication drops | *Cool compresses/lubrication drops | ||
*Topical antibiotics to skin to prevent secondary infection | *Topical [[antibiotics]] to skin to prevent secondary infection | ||
*Antiviral therapy indicated for rash <1wk duration | *Antiviral therapy indicated for rash <1wk duration | ||
**[[Acyclovir]] IV 10mg/kg q8hrs x7-10 days<ref>Wills Eye Manual, 6th edition</ref> '''OR''' | **[[Acyclovir]] IV 10mg/kg q8hrs x7-10 days<ref>Wills Eye Manual, 6th edition</ref> '''OR''' | ||
**[[ | **[[Famciclovir]] 500mg PO q8hrs x14 days '''OR''' | ||
**[[Valacyclovir]] 1g PO q8hrs | **[[Valacyclovir]] 1g PO q8hrs | ||
*Prevention of reactivation | *Prevention of reactivation | ||
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==Disposition== | ==Disposition== | ||
*Immunocompetent patient: Oral antiviral. | |||
*Immunocompromised patient: ”IV acyclovir and hospitalization is recommended. Neuroimaging is advised in patients with vision loss.”<ref>SAEM Clinical Image Series: A Case of a Painful Facial Rash. J Chan, et al. Aliem accessed Dec 16, 2019 available online at https://www.aliem.com/2019/12/saem-clinical-image-series-facial-rash/ </ref> | |||
==See Also== | ==See Also== | ||
Latest revision as of 21:13, 12 July 2023
Background
- Occurs when varicella zoster virus is reactivated in the ophthalmic division (V1) of trigeminal nerve
- 50% of cases associated with ocular involvement
- Highly suggested by vesicles at tip of nose (Hutchinson's sign)
- Nasociliary branch of V1 innervates both the lateral/tip of nose as well as the cornea
- Consider immunocompromise in patients <40yrs
Herpes Virus Types
- HHV-1: Herpes Simplex Virus-1
- HHV-2: Herpes Simplex Virus-2
- Herpes B virus
- Varicella zoster virus
- Varicella (Chickenpox)
- Herpes zoster (Shingles)
- Herpes zoster ophthalmicus
- Herpes zoster oticus (Ramsay Hunt syndrome)
- HHV-6 (Roseola infantum)
- HHV-8 (Kaposi’s sarcoma)
- Epstein-Barr virus
- Cytomegalovirus
Clinical Features
- Prodrome of headache, malaise, photophobia, fever
- Unilateral pain or hypesthesia in V1 distribution
- Hyperemic conjunctivitis, episcleritis, lid droop
- Vesicular rash in V1 distribution
- Slit-lamp exam:
Differential Diagnosis
Conjunctivitis Types
Varicella zoster virus
- Varicella (Chickenpox)
- Herpes zoster (Shingles)
- Herpes zoster ophthalmicus
- Herpes zoster oticus (Ramsay Hunt syndrome)
HIV associated conditions
- HIV neurologic complications
- HIV pulmonary complications
- Ophthalmologic complications
- Other
- HAART medication side effects[2]
- HAART-induced lactic acidosis
- Neuropyschiatric effects
- Hepatic toxicity
- Renal toxicity
- Steven-Johnson's
- Cytopenias
- GI symptoms
- Endocrine abnormalities
Evaluation
- Clinical
Management
- Cool compresses/lubrication drops
- Topical antibiotics to skin to prevent secondary infection
- Antiviral therapy indicated for rash <1wk duration
- Acyclovir IV 10mg/kg q8hrs x7-10 days[3] OR
- Famciclovir 500mg PO q8hrs x14 days OR
- Valacyclovir 1g PO q8hrs
- Prevention of reactivation
- Acyclovir PO 500mg 5x per day
- Ophtho consultation regarding steroid use
Disposition
- Immunocompetent patient: Oral antiviral.
- Immunocompromised patient: ”IV acyclovir and hospitalization is recommended. Neuroimaging is advised in patients with vision loss.”[4]
See Also
References
- ↑ Li, J. Y. (2018). Herpes zoster ophthalmicus. Current Opinion in Ophthalmology, 29(4), 328–333. doi:10.1097/icu.0000000000000491
- ↑ Gutteridge, David L MD, MPH, Egan, Daniel J. MD. The HIV-Infected Adult Patient in The Emergency Department: The Changing Landscape of the Disease. Emergency Medicine Practice: An Evidence-Based Approach to Emergency Medicine. Vol 18, Num 2. Feb 2016.
- ↑ Wills Eye Manual, 6th edition
- ↑ SAEM Clinical Image Series: A Case of a Painful Facial Rash. J Chan, et al. Aliem accessed Dec 16, 2019 available online at https://www.aliem.com/2019/12/saem-clinical-image-series-facial-rash/