Herpes zoster ophthalmicus

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)
• Consider immunocompromise in patients <40yrs

Clinical Features

• Prodrome of HA, malaise, photophobia, fever
• Unilateral pain or hypesthesia in V1 distribution
• Hyperemic conjunctivitis, episcleritis, lid droop

Differential Diagnosis

Conjunctivitis Types

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

Varicella zoster virus

• Varicella (Chickenpox)
• Herpes zoster (Shingles)
  • Herpes zoster ophthalmicus
  • Herpes zoster oticus (Ramsay Hunt syndrome)

HIV associated conditions

• HIV neurologic complications
  • Toxoplasmosis
  • Cryptococcosis
  • AIDS Dementia
  • Seizures in patients with HIV-AIDS
  • Primary CNS lymphoma
• HIV pulmonary complications
  • Pneumocystis jirovecii pneumonia (PCP)
  • Tuberculosis (TB)
  • CMV pneumonia
• Ophthalmologic complications
  • CMV Retinitis
  • Herpes Zoster Ophthalmicus
• Other
  • AIDS fever of unknown origin
  • Immune reconstitution inflammatory syndrome
  • HIV diarrhea
  • Esophageal candidiasis
  • Kaposi's sarcoma
  • Pruritic papular eruption of HIV
  • Hairy oral leukoplakia
• HAART medication side effects
  • HAART-induced lactic acidosis
  • Neuropyschiatric effects
  • Hepatic toxicity
  • Renal toxicity
  • Steven-Johnson's
  • Cytopenias
  • GI symptoms
  • Endocrine abnormalities

Evaluation

• Zoster in distribution of V1
• Slit-lamp exam:
  • 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

Management

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

See Also

• Herpes zoster oticus