Herpes zoster ophthalmicus

Background

• Occurs when VZV 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)
• Consider immunocompromise in pts <40yrs

Clinical Features

1. Prodrome of HA, malaise fever
2. Unilateral pain or hypesthesia in V1 distribution
3. Hyperemic conjunctivitis, episcleritis, lid droop

Diagnosis

1. Zoster in distribution of V1
2. Slit-lamp exam:
   1. Pseudodendrite (poorly staining mucous plaque w/ no epithelial erosion
      1. In contrast to HSV which has true dendrite w/ epithelial erosion and staining
   2. Cell and flare

Differential Diagnosis

Conjunctivitis Types

• Viral conjunctivitis
  • Epidemic keratoconjunctivitis
  • Herpes zoster ophthalmicus
  • Herpes simplex keratitis
• Bacterial conjunctivitis
  • Gonorrheal conjunctivitis
  • Chlamydia conjunctivitis
• Allergic conjunctivitis
• Caustic keratoconjunctivitis

Treatment

1. Cool compresses/lubrication drops
2. Topical antibiotics to skin to prevent secondary infection
3. Acyclovir indicated for rash <1wk duration
   1. Treatment - acyclovir IV 10 mg/kg q8hrs x7-10 days
   2. OR famiciclovir PO 500 mg q8hrs x14 days
   3. OR valacyclovir PO 1g q8hrs
4. Prevention of reactivation
   1. Acyclovir PO 500 mg 5x per day
5. Ophtho consultation regarding steroid use

Source

• UpToDate
• Tintinalli

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