Herpes zoster ophthalmicus is reactivation of a varicella-zoster virus infection (shingles) involving the eye. Symptoms and signs, which might be extreme, include dermatomal forehead rash and uncomfortable swelling of all the tissues of the anterior and, hardly ever, posterior structures of the eye. Medical diagnosis is based upon the particular look of the anterior structures of the eye plus zoster dermatitis of the first branch of the trigeminal nerve (V1). Treatment is with oral antivirals, mydriatics, and topical corticosteroids.
Herpes zoster of the forehead involves the globe in three fourths of cases when the nasociliary nerve is affected (as indicated by a lesion on the tip of the nose) and in one third of cases not involving the suggestion of the nose. Overall, the globe is involved in half of patients.
Symptoms of Herpes Zoster Ophthalmicus
A prodrome of tingling of the forehead might occur. During intense illness, in addition to the painful forehead rash, signs and signs may include severe ocular discomfort; marked eyelid edema; conjunctival, episcleral, and circumcorneal conjunctival hyperemia; corneal edema; and photophobia.
Complications
Keratitis and/or uveitis might be extreme and followed by scarring. Late sequelae — glaucoma, cataract, persistent or frequent uveitis, corneal scarring, corneal neovascularization, and hypesthesia — are common and might threaten vision. Postherpetic neuralgia may establish late. Patients may establish episcleritis (without increased danger of visual loss) and/or retinitis (with danger of severe visual loss).
Diagnosis
- Zoster rash on the forehead or eyelid plus eye findings
Medical diagnosis is based upon a common acute herpes zoster rash on the forehead, eyelid, or both or on a characteristic history plus indications of previous zoster rash (eg, atrophic hypopigmented scars). Vesicular or bullous sores in this distribution that do not yet involve the eye recommend considerable danger and needs to trigger an ophthalmologic assessment to identify whether the eye is involved. Culture and immunologic or PCR research studies of skin at initial evaluation or serial serologic tests are done just when lesions are atypical and the diagnosis unpredictable.
Treatment for Herpes Zoster Ophthalmicus
- Oral antivirals (eg, acyclovir, famciclovir, valacyclovir).
- Often topical corticosteroids.
Early treatment with acyclovir 800 mg po 5 times/day or famciclovir 500 mg or valacyclovir 1 g po tid for 7 days decreases ocular complications. Patients with uveitis or keratitis need topical corticosteroids (eg, prednisolone acetate 1% instilled q 1 h for uveitis or qid for keratitis at first, lengthening the period as symptoms reduce). The student should be dilated with atropine 1% or scopolamine 0.25% 1 drop tid. Intraocular pressure needs to be monitored and treated if it increases substantially above regular values.
Use of a quick course of high-dose oral corticosteroids to prevent postherpetic neuralgia in clients > 60 yr who are in great general health stays controversial.
General treatment
Skin rash treatment ought to prevent bacterial superinfection. With careful assessment, inflammation in all layers of the eye needs to be dismissed and treated with antivirals and steroids if indicated. When a skin rash is the only scientific indication, follow-up care must be directed to eliminating any ocular manifestations that may develop.
Medical therapy
Oral acyclovir 800 mg PO 5 times daily for 7 to 10 days is the primary treatment. Alternatively, a service provider could utilize famciclovir 500 mg PO tid or valacyclovir 1000mg PO tid if the systemic condition warrants or if the patient is unable to tolerate food by mouth, then acyclovir 5-10 mg/kg iv q8 for five days may be made use of.
Topical steroids (e.g., prednisolone acetate 1%) ought to be utilized for interstitial keratitis and uveitis. For episodes of scleritis, retinitis, choroiditis, and optic neuritis, systemic steroids by mouth or intravenous administration should be highly considered.
For increased intraocular pressure typically found in herpes trabeculitis, topical steroids need to be administered as well as liquid suppressants (e.g., timolol, brimonidine, dorzolamide, acetazolamide).
Pain ought to be treated with narcotics if required. Neuropathic pain reacts well to amitriptyline 25 mg PO qhs and can reduce the incidence of postherpetic neuralgia. Capsaicin cream used to the rash may reduce pain as well. Pregabalin 150mg/ day in divided doses might relieve pain due to acute herpetic neuralgia.
Medical follow up
Depending on the ocular findings and severity, the patient ought to be monitored every 1 to 7 days during the acute episode. Keeping an eye on every 3-12 months afterward might be useful to monitor for delayed sequelae such as ocular hypertension, cataract, and cornea scarring. If there is any issue of future worsenings, viral prophylaxis ought to be thought about with acyclovir 400 mg PO bid.
Surgery
Cornea hair transplant is sometimes needed for lesions that cause serious cornea thinning and loss of structural stability of the eye. Scars that are aesthetically significant and refractory to medical therapy and/or tough contact lenses may require hair transplant. Vitrectomy/Retina detachment surgery might be performed, particularly in cases of acute retinal necrosis (ARN). Glaucoma filtering surgery is often carried out if there are troubles with preserving maximum intraocular pressure. If the intraocular inflammation and/or steroid treatment causes a cataract, then cataract surgery might be carried out when the disease process is quiescent.
Surgical follow-up
Depending on the type of surgery performed, the patient should be carefully kept track of for severe inflammation typically related to herpes after surgeries. Viral prophylaxis with antiviral therapy and steroids must be strongly thought about.
Prevention for Herpes Zoster Ophthalmicus
A new recombinant herpes zoster vaccine is advised for healthy adults ≥ 50 yr, regardless of whether they have actually had herpes zoster or been given the older, live-attenuated vaccine. This recombinant vaccine considerably decreases the opportunity of getting herpes zoster; effectiveness is 97% for people aged 50 to 59, 97% for those aged 60 to 69, and 91% for those > 69.
Bottom line
- The eye is affected in about half of cases of V1 varicella-zoster infection reactivation.
- Keratitis and/or uveitis can be severe and trigger morbidity.
- Look of the typical herpes zoster rash is typically diagnostic.
- Treatment is with oral antivirals and usually topical corticosteroids and pupillary dilation.
Other Names of the Disease
- Herpes Zoster Virus Ophthalmicus;
- Ophthalmic Herpes Zoster;
- Varicella-Zoster Virus Ophthalmicus.
