Download Herpes Zoster Ophthalmicus (HZO)

CLINICAL MANAGEMENT GUIDELINES
Herpes Zoster Ophthalmicus (HZO)
Aetiology
Predisposing factors
Symptoms
Signs
Varicella zoster virus (VZV), also known as human herpesvirus-3 (HHV3)
 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
 Vaccination: some countries (e.g. USA, Canada, Australia,
Japan, Germany) have a policy of vaccinating children against
varicella. There is evidence that this is protective not only against
chickenpox but also against herpes zoster in later life (Civen R et
al: Paed Infect Dis J 2009;28:954-9). In some countries (e.g.
USA) herpes zoster vaccination is offered to adults over 60.
Public Health England introduced herpes zoster vaccination for
people aged 70 years (routine cohort) and 79 years (catch-up
cohort) in September 2013
Age: mainly sixth or seventh decade, but can occur at any age
Immune compromise: HIV/AIDS, medical immunosuppression
Pain and altered sensation of the forehead on one side
Rash affecting forehead and upper eyelid appears a day to a week later
General malaise, headache, fever
Skin features
 unilateral painful, red, vesicular rash on the forehead and upper
eyelid, 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 nodes)
 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, may be chronic or
recurrent)
 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
o punctate epithelial – early sign, within 2 days (50% of
cases)
o pseudodendrites – fine, multiple stellate lesions (around
4-6 days)
o nummular – fine granular deposits under Bowman’s layer
o disciform – 3 weeks after the rash (occurs in 5% of cases)
o reduced corneal sensation (neurotrophic keratitis)
o endothelial changes and KP
 anterior uveitis
 secondary glaucoma
 posterior segment: retinitis, choroiditis, optic neuritis, optic
atrophy
Herpes Zoster Ophthalmicus (HZO)
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Date of search 07.12.14; Date of revision 20.02.15; Date of publication 28.05.15; Date for review 06.12.16
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Herpes Zoster Ophthalmicus (HZO)

neurological complications: cranial nerve palsies, optic neuritis,
encephalitis
 post-herpetic neuralgia: chronic and severe in about 7% of
patients
Complications can occur months or years after the acute phase
Differential diagnosis Ocular lesions: herpes simplex keratitis
Cutaneous lesions: cellulitis, contact dermatitis, atopic eczema, impetigo
Management by Optometrist
Practitioners should recognise their limitations and where necessary seek further advice or refer
the patient elsewhere
Non pharmacological
Rest and general supportive measures (reassurance, support at home,
good diet, plenty of fluids)
Advise avoidance of contact with elderly or pregnant individuals, also
babies and children not previously exposed to VZV (who are nonimmune) or immunodeficient patients
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Pharmacological
Topical lubricants for relief of ocular symptoms
Pain relief: aspirin, paracetamol or ibuprofen (check history for
contraindications). Stronger analgesics (e.g. opiates) may be indicated
(co-manage with GP)
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Management Category
B3: management to resolution if co-managed with GP and keratitis
limited to epithelium
Maintain low threshold for referral since HZO is associated with chronic
and recurrent complications that may be sight threatening
A3: first aid measures and urgent referral (within one week) to
ophthalmologist if deeper cornea involved
Untreated disciform keratitis can lead to scarring
Neurotrophic ulceration can lead to perforation
A1: for acute skin lesions: emergency referral (same day) to GP for
systemic anti-viral treatment
Early treatment with aciclovir (within 72 hours after rash onset) reduces
the percentage of eye disorders in ophthalmic zoster patients from 50%
to 20-30%. This early treatment also lessens acute pain
Possible management by Ophthalmologist
Systemic anti-virals e.g. aciclovir, famciclovir, valaciclovir
Topical steroids
Immunosuppressive therapy for scleritis
Botulinum toxin-induced ptosis or surgical tarsorrhaphy for neurotrophic
corneal ulceration
Treat other ocular complications
Evidence base
*GRADE: Grading of Recommendations Assessment, Development and
Evaluation (see http://gradeworkinggroup.org/toolbox/index.htm)
Sources of evidence
Gelb LD. Preventing herpes zoster through vaccination. Ophthalmology.
2008;115(2 Suppl):S35-8
Liesegang TJ. Herpes zoster ophthalmicus natural history, risk factors,
Herpes Zoster Ophthalmicus (HZO)
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Date of search 07.12.14; Date of revision 20.02.15; Date of publication 28.05.15; Date for review 06.12.16
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Herpes Zoster Ophthalmicus (HZO)
clinical presentation, and morbidity. Ophthalmology. 2008;115(2
Suppl):S3-12
McDonald EM, de Kock J, Ram FS. Antivirals for management of herpes
zoster including ophthalmicus: a systematic review of high-quality
randomized controlled trials. Antivir Ther. 2012;17(2):255-64
Opstelten W, Zaal M. Managing ophthalmic herpes zoster in primary
care. BMJ 2005;331:147–51
LAY SUMMARY
Herpes Zoster Ophthalmicus (HZO) is a viral infection of the nerve that supplies sensation (touch
and pain) to the eye surface, eyelids, forehead and nose. The virus that affects it (Varicella Zoster
Virus [VZV] also causes chickenpox. Patients who develop HZO, like most people, have usually
been exposed to chickenpox by the age of 16 and though they recover from that infection, the virus
lies dormant in parts of the brain and spinal cord, with its activity suppressed by the body’s immune
system. If, for some reason, that suppression weakens, viruses can become reactivated and travel
down the nerve, reaching the tissues that it supplies and causing inflammation. When the skin is
involved, the condition is known as shingles. Shingles occurs more often and is likely to be more
severe in older people whose immunity to VZV is weakening, and in people whose immune system
is not functioning normally, as for example in HIV/AIDS, or is suppressed by medical treatment.
In HZO the skin of one side of the forehead and scalp is affected, along with the eye on the same
side. Any part of the eye can be involved, but most commonly it is the eye surface, including the
conjunctiva (the white of the eye) and the cornea (the clear window of the eye). The cornea reacts
in various ways; the most serious long-term effects result from damage to the corneal nerves,
causing loss of sensation.
When HZO first appears, patients benefit from anti-viral tablets prescribed as soon as possible,
usually by the GP. Mild cases can be co-managed by the optometrist and the GP but more severe
cases need to be referred to the ophthalmologist.
Public Health England recently introduced shingles vaccination for people aged 70 or 79. This is
given once and provides a good measure of protection against the condition.
Herpes Zoster Ophthalmicus (HZO)
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Date of search 07.12.14; Date of revision 20.02.15; Date of publication 28.05.15; Date for review 06.12.16
© College of Optometrists