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)
  • 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
  • Neonatal HSV
• HHV-2: Herpes Simplex Virus-2
  • Neonatal HSV
• 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

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
  • 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

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

• 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 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.”

See Also

• Herpes zoster oticus