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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) Version 12, Page 1 of 3 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) Version 12, Page 2 of 3 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) Version 12, Page 3 of 3 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