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Version 7, 15.02.10
Condition
Aetiology
Herpes Zoster Ophthalmicus (HZO)
Varicella zoster virus (VZV, a member of the herpes virus family)
Previous systemic infection (varicella, i.e. chickenpox)
Virus lies dormant (sometimes for decades) in dorsal root and cranial nerve
sensory ganglia
Reactivation leads to zoster (shingles)
Herpes zoster affects 20-30% of the population at some point in their
lifetime; 10-20% of these will develop HZO through involvement of the
ophthalmic division of the trigeminal nerve
Predisposing
- Age: mainly in the sixth or seventh decade, but can occur at any age
factors
- AIDS, immunosuppression
Symptoms
- Pain and altered sensation of the forehead on one side
- General malaise
Signs
Skin features
- Unilateral painful, red, vesicular rash, progressing to crusting after 2-3
weeks; resolution often involves scarring
- Periorbital oedema (may close the eyelids and spread to opposite side)
- Lymphadenopathy (swollen regional lymph glands)
- Lesion at the side of the tip of the nose (Hutchinson’s sign) indicates twice
the usual incidence of ocular complications, but these may also occur in one
in three patients without the sign
Ocular lesions (variable in scope and severity, chronic or recurring)
- Mucopurulent conjunctivitis, associated with vesicles on the lid margin;
usually resolves within 1 week
- Scleritis: less common; usually develops after 1 week
- Episcleritis: occurs in around one third of cases
- Keratitis
- Punctate epithelial – early sign, within 2 days (50% of cases)
- Pseudodendrites – fine, multiple stellate lesions (around 4-6 days)
- Nummular – fine granular deposits under Bowman’s layer
- Disciform – 3 weeks after the rash (occurs in 5% of cases)
- Reduced corneal sensation
- Endothelial changes and KP
- Anterior uveitis
- Posterior segment: retinitis, 2 glaucoma, optic neuritis, optic atrophy
- Neurological complications: cranial nerve palsies, optic neuritis,
encephalitis
- Post-herpetic neuralgia: chronic and severe in about 7% patients
Differential
Ocular lesions: Herpes simplex keratitis
diagnosis
Cutaneous lesions: Cellulitis, contact dermatitis
Management by Optometrist
NonRest and general supportive measures (reassurance, support at home, good
pharmacological
diet, plenty of fluids)
Advise avoidance of contact with elderly, pregnant or neonatal individuals,
also those not previously exposed to VZV (who are non-immune) or
immunodeficient patients
Pharmacological
Topical lubricants for relief of ocular symptoms
Pain relief: aspirin paracetamol or ibuprofen (check history for
contraindications)
Management
A3: first aid measures and urgent referral to ophthalmologist if cornea
Version 7, 15.02.10
category
involved. Untreated disciform keratitis can lead to scarring. Neurotrophic
ulceration can lead to perforation
Skin lesions: emergency referral to GP for systemic anti-viral treatment
Possible management by Ophthalmologist
Systemic anti-virals e.g. aciclovir, famciclovir, valaciclovir
Topical steroids
Systemic NSAIDs for scleritis
Surgery, e.g. tarsorrhaphy
Treat ocular complications
NB Some countries (e.g. USA, Germany) have a policy of vaccinating
children against vaccinia. There is evidence that this is protective not only
against vaccinia but also against herpes zoster (Civen R et al: Paed Infect
Dis J 2009; 28(11): 954-9). Some countries (e.g. USA) offer herpes zoster
vaccination for adults over 60
Evidence base
Early treatment with aciclovir (within 72 hours after rash onset) reduces the
percentage of eye disorders in ophthalmic zoster patients from 50% to 2030%. This early treatment also lessens acute pain.
Opstelten W, Zaal M: Managing ophthalmic herpes zoster in primary
care. BMJ 2005; 331: 147–51
Centre for Evidence-based Medicine Level of Evidence = 2b