eMedicine Specialties > Emergency Medicine > Infectious Diseases

Herpes Zoster Ophthalmicus: Differential Diagnoses & Workup

Author: Maria M Diaz, MD, Staff Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center
Coauthor(s): Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn
Contributor Information and Disclosures

Updated: Sep 18, 2008

Differential Diagnoses

Conjunctivitis
Scleritis
Corneal Abrasion
Stroke, Hemorrhagic
Corneal Ulceration and Ulcerative Keratitis
Stroke, Ischemic
Glaucoma, Acute Angle-Closure
Subarachnoid Hemorrhage
Headache, Cluster
Toxoplasmosis
Headache, Migraine
Trigeminal Neuralgia
Iritis and Uveitis
Meningitis
Neoplasms, Brain

Other Problems to Be Considered

Bacterial keratoconjunctivitis
Adult inclusion (chlamydial) conjunctivitis
Allergic conjunctivitis
Recurrent corneal erosion
Toxic conjunctivitis
Fungal keratitis
Retinal necrosis
Connective tissue disease
Optic neuritis
Oculomotor palsy
Space-occupying lesion in the brain (tumors, toxoplasmosis, abscesses)
Multiple sclerosis

Workup

Laboratory Studies

  • The herpes zoster (HZ) rash is distinctive enough that a clinical diagnosis is usually accurate. Nevertheless, the typical dermatomal rash may be absent or the location can be more diffuse, especially in the immunocompromised patients. Occasionally, only ocular signs and symptoms may be present, making the diagnosis difficult.
  • Classically, a Tzanck smear and Wright stain can be performed to demonstrate herpes virus infections (cells are scraped from the base of cutaneous lesions and smeared on a glass slide for microscopy), but such tests do not distinguish VZV from other herpes viruses. Viral culture is also a possibility, yet the virus is relatively difficult to recover from the scrapes. A direct immunofluorescence assay can be used and is more sensitive than viral culture. Like culture, the direct immunofluorescence assay can differentiate herpes simplex virus infections from VZV infections. The assay also has a lower cost and a more rapid turnaround time. Polymerase chain reaction techniques can be useful in detecting the virus DNA from the lesions.

Imaging Studies

  • No imaging studies aid in the diagnosis of HZO.

Other Tests

  • Because HZ may occur in HIV-infected individuals who are otherwise asymptomatic, serologic testing for the retrovirus may be appropriate in patients without apparent risk factors for HZ (nonimmunosuppressed individuals younger than 50 years).

More on Herpes Zoster Ophthalmicus

Overview: Herpes Zoster Ophthalmicus
Differential Diagnoses & Workup: Herpes Zoster Ophthalmicus
Treatment & Medication: Herpes Zoster Ophthalmicus
Follow-up: Herpes Zoster Ophthalmicus
References
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References

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Further Reading

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Keywords

herpes zoster ophthalmicus, eye infection, herpes zoster, varicella-zoster virus, varicella zoster virus, VZV, HZO, herpes virus, chickenpox, shingles, human herpesvirus type 3

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Contributor Information and Disclosures

Author

Maria M Diaz, MD, Staff Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center
Maria M Diaz, MD is a member of the following medical societies: Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn
Mark A Silverberg, MD, FACEP, MMB is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Robin R Hemphill, MD, MPH, Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University
Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Douglas Lavenburg, MD, Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems
Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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