Herpes zoster ophthalmicus


  • 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

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:
    • 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
      Herpes zoster ophthalmicus.jpg

Differential Diagnosis

Conjunctivitis Types

Varicella zoster virus

HIV associated conditions


  • Clinical


  • 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


  • Immunocompetent patient: Oral antiviral.
  • Immunocompromised patient: ”IV acyclovir and hospitalization is recommended. Neuroimaging is advised in patients with vision loss.”[3]

See Also


  1. 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.
  2. Wills Eye Manual, 6th edition
  3. 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/