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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