Herpes zoster ophthalmicus: Difference between revisions

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==Background==
==Background==
*Herpes zoster (HZV) ophthalmicus
*Occurs when [[varicella zoster virus]] is reactivated in the ophthalmic division (V1) of trigeminal nerve
*Occurs when the varicella-zoster virus is reactivated in the ophthalmic division of the trigeminal nerve
*50% of cases associated with ocular involvement
*10-25% of all zoster cases
**Highly suggested by vesicles at tip of nose (Hutchinson's sign)
*Most cases involve skin only, but serious ocular involvement can occur (if involves nasociliary branch)
**Nasociliary branch of V1 innervates both the lateral/tip of nose as well as the cornea
**Hutchinson’s sign = pustules at tip of the nose
*Consider immunocompromise in patients <40yrs
***Mild specificity for ocular involvement
***NOT sensitive for ocular involvement


==Diagnosis==
{{Herpes viruses}}
#Rash in distribution
{{Conjunctivitis DDX}}
#If corneal invovement
##Corneal dedrite  on fluorescein stain
###Appear branching or ‘‘medusa-like’’ pattern with tapered ends
####In contrast to HSV dendrites, which have terminal bulbs


==Treatment==
==Clinical Features==
#No corneal involvement
[[File:Herpes zoster ophthalmicus2.jpg|thumb|Herpes zoster ophthalmicus]]
##Topical antibiotics may prevent secondary infection
*Prodrome of [[headache]], malaise, photophobia, [[fever]]
##Cool compresses/lubrication drops
*Unilateral [[eye pain|pain]] or hypesthesia in V1 distribution
##Ophtho followup (within 24hrs if any ocular involvement)
*Hyperemic [[conjunctivitis]], [[episcleritis]], lid droop
#Corneal involvement
*Vesicular [[rash]] in V1 distribution
##Artificial tears (preservative-free) Q1-2 hrs
*[[Slit-lamp exam]]:
##Ocular lubricant ointment QHS
**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>
##Consult ophtho regarding
**Pseudodendrite (poorly staining mucous plaque with no epithelial erosion)
###Systemic or topical antiviral agents
***In contrast to [[HSV]] which has true dendrite with epithelial erosion and staining
###Topical steroids (caution; only in consultation)
**Cell and flare


==Source==
==Differential Diagnosis==
{{VZV types}}
{{HIV associated conditions}}
{{Unilateral red eye DDX}}
{{Bilateral Red Eyes}}
 
==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<ref>Wills Eye Manual, 6th edition</ref> '''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.”<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==
*[[Herpes zoster oticus]]
 
==References==
<references/>


[[Category:ID]]
[[Category:ID]]
[[Category:Ophtho]]
[[Category:Ophthalmology]]

Latest revision as of 17:13, 4 February 2026

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

Conjunctivitis Types

Clinical Features

Herpes zoster ophthalmicus
  • 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:
    • Initial finding of punctate epithelial keratitis that then evolves into pseudodendrite[1]
    • 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

Varicella zoster virus

HIV associated conditions

Unilateral red eye

^Emergent diagnoses
^^Critical diagnoses


Bilateral red eyes

Evaluation

  • Clinical

Management

  • Cool compresses/lubrication drops
  • Topical antibiotics to skin to prevent secondary infection
  • Antiviral therapy indicated for rash <1wk duration
  • Prevention of reactivation
  • 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

  1. ↑ Li, J. Y. (2018). Herpes zoster ophthalmicus. Current Opinion in Ophthalmology, 29(4), 328–333. doi:10.1097/icu.0000000000000491
  2. ↑ 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.
  3. ↑ Wills Eye Manual, 6th edition
  4. ↑ 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/
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