eMedicine Specialties > Emergency Medicine > Infectious Diseases
Herpes Zoster Ophthalmicus
Updated: Sep 18, 2008
Introduction
Background
Varicella-zoster virus (VZV) causes 2 distinct syndromes. The primary infection (chickenpox) is a contagious and usually benign febrile illness. Following this infection, virus particles remain in the dorsal root or other sensory ganglion where they may lay dormant for years to decades. As a result of aging, immunosuppressive illness, new stress, or medical treatments, the virus-specific cell-mediated immune responses may decline. Such conditions allow a reactivation of latent VZV and result in a localized cutaneous rash erupting in a single dermatome called herpes zoster (HZ), or shingles. Patients with HZ involving the first division of the trigeminal nerve have a disease process termed herpes zoster ophthalmicus (HZO). HZO was described long ago by Hippocrates, but its relation to VZV was not elucidated until the advent of modern medical tools such as the immunohistochemical assays.
Pathophysiology
When liberated from the trigeminal ganglion, the reactivated VZV (human herpesvirus type 3) travels down the first division (ophthalmic) of the trigeminal nerve to the nasociliary nerve. This branch then divides to innervate the surface of the globe and the skin on the nose down to its tip. This process typically takes 3-4 days for the virus particles to reach the nerve endings. As the virus travels, it leads to perineural and intraneural inflammation, which may damage the eye itself and/or other surrounding structures.
Frequency
United States
More than 90% of adults in the United States have serologic evidence of VZV infection and therefore are at risk for HZ.1 The reported annual incidence of HZ varies from 1.5-3.4 cases per 1000 individuals.2 The key risk factor for the development of HZ is waning of the cell-mediated immune system associated with the normal aging process. However, the incidence of shingles among individuals older than 75 years exceeds 10 cases per 1000 individual-years. This may be due to the fact that immunity wanes as adults age. The lifetime risk of HZ is currently estimated to be 10-20%.2,3
The other well-defined risk factor for HZ is acquired inhibition of the cell-mediated immune response, such as those patients on immunosuppressive drugs and those with the human immunodeficiency virus (HIV). In fact, the relative risk of HZ is at least 15 times greater in those with HIV infections than in those without. The recurrence rate of HZ in AIDS patients has been reported to be as high as 25% compared to less than 4% in immunocompetent individuals. HIV-positive patients who develop HZ are more likely to progress on to AIDS than those who do not. These statistics also apply to children who are infected with HIV in utero.
HZO represents 10-25% of all cases of herpes zoster. The risk of ophthalmic complications in patients with HZ does not seem to correlate with age, gender, or severity of the skin rash.
Mortality/Morbidity
One of the most common complications of herpes zoster in any location is postherpetic neuralgia; neuropathic pain which can persist along the affected dermatome for weeks or even years after the resolution of the rash. Specific complications of herpes zoster ophthalmicus are centered around the destruction of the ocular structures manifesting as various ocular diseases that can lead to permanent loss of sight. Commonly affected structures include the following:
- Eyelids, conjunctiva, episclera, and sclera: Periorbital and conjunctival edema (1 wk); secondary Staphylococcus aureus infection (1-2 wk); focal scleral atrophy (late); scarring that leads to incomplete eyelid closure and thus corneal exposure and desiccation (latent)
- Cornea: Punctate epithelial keratitis (swollen epithelium, 1-2 d); dendritic keratitis (tree branchlike epithelial defects, 4-6 d); stromal keratitis (fine infiltrates beneath the surface, 1-2 wk); deep stromal keratitis (lipid infiltrates and corneal neovascularization, 1 month to years); neurotrophic keratopathy (erosions, persistent defects, corneal ulcers, months to years)
- Anterior chamber: Uveitis (inflammation and iris scarring leading to glaucoma and cataract, 2 weeks to years)
Race
No race suffers from HZO more than any other race.
Sex
One study has shown a higher prevalence in women than in men.4
Age
The incidence of HZ increases dramatically with age.4
Clinical
History
- The prodromal phase of herpes zoster ophthalmicus usually includes an influenzalike illness with fatigue, malaise, and low-grade fever that may last up to 1 week prior to the development of unilateral rash over the forehead, upper eyelid, and nose (the first division of trigeminal nerve dermatome or V1).
- About 60% of patients have varying degrees of dermatomal pain prior to rash eruption. Subsequently, erythematous macules appear that progress to form clusters of papules and vesicles (clear vesicles on red base, 3-5 d). These lesions then evolve into pustules, which soon lyse and crust over (5-7 d).
Physical
- Ocular manifestations of HZ can vary in time of onset, and patients may have only ophthalmic symptoms without the typical skin rash. One prognostic indicator is the Hutchinson sign, the appearance of typical HZ lesions at the tip, side, or root of the nose. This is the area of skin innervated by the anterior ethmoidal branch of the nasociliary nerve. Because the nasociliary nerve also innervates the cornea such skin lesions may herald ocular involvement. The prognostic value of the Hutchinson sign has been validated in one study.5
- Visual acuity can be considered to be a vital sign of the ophthalmologic examination, and the eye examination should begin here.
- Systematically examine the most superficial/external structures first and look for eyelid, conjunctival, and scleral swelling.
- Check for extraocular motor integrity and visual field deficits.
- Perform a funduscopic examination (dilated if possible), and try to elicit photophobia to ascertain the possible presence of iritis. Decreased corneal sensitivity can be seen when testing with a cotton fiber.
- Corneal epithelial lesions may be visible after fluorescein application.
- A slit lamp examination should be used to look for cells/flares in the anterior chamber and the presence of stromal infiltrates.
- After topical anesthesia of the eye, measure the intraocular pressures (normal pressure is below 12-15 cm H2 O).
Causes
See Pathophysiology.
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 |
| Next Page » |
References
Straus SE, Ostrove JM, Inchauspé G, Felser JM, Freifeld A, Croen KD, et al. NIH conference. Varicella-zoster virus infections. Biology, natural history, treatment, and prevention. Ann Intern Med. Feb 1988;108(2):221-37. [Medline].
Ragozzino MW, Melton LJ, Kurland LT, et al. Population-based study of herpes zoster and its sequelae. Medicine (Baltimore). Sep 1982;61(5):310-6. [Medline].
Donahue JG, Choo PW, Manson JE, Platt R. The incidence of herpes zoster. Arch Intern Med. Aug 7-21 1995;155(15):1605-9. [Medline].
Insinga RP, Itzler RF, Pellissier JM, Saddier P, Nikas AA. The incidence of herpes zoster in a United States administrative database. J Gen Intern Med. Aug 2005;20(8):748-53. [Medline].
Zaal MJ, Volker-Dieben HJ, D'Amaro J. Prognostic value of Hutchinson's sign in acute herpes zoster ophthalmicus. Graefes Arch Clin Exp Ophthalmol. Mar 2003;241(3):187-91. [Medline].
Cobo LM, Foulks GN, Liesegang T, et al. Oral acyclovir in the treatment of acute herpes zoster ophthalmicus. Ophthalmology. Jun 1986;93(6):763-70. [Medline].
Severson EA, Baratz KH, Hodge DO, Burke JP. Herpes zoster ophthalmicus in olmsted county, Minnesota: have systemic antivirals made a difference?. Arch Ophthalmol. Mar 2003;121(3):386-90. [Medline].
Tyring S, Engst R, Corriveau C, Robillard N, Trottier S, Van Slycken S, et al. Famciclovir for ophthalmic zoster: a randomised aciclovir controlled study. Br J Ophthalmol. May 2001;85(5):576-81. [Medline].
Colin J, Prisant O, Cochener B, et al. Comparison of the efficacy and safety of valaciclovir and acyclovir for the treatment of herpes zoster ophthalmicus. Ophthalmology. Aug 2000;107(8):1507-11. [Medline].
Whitley RJ, Weiss H, Gnann JW, et al. Acyclovir with and without prednisone for the treatment of herpes zoster. A randomized, placebo-controlled trial. The National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group. Ann Intern Med. Sep 1 1996;125(5):376-83. [Medline].
Wood MJ, Johnson RW, McKendrick MW, et al. A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster. N Engl J Med. Mar 31 1994;330(13):896-900. [Medline].
Shaikh S, Ta CN. Evaluation and management of herpes zoster ophthalmicus. Am Fam Physician. Nov 1 2002;66(9):1723-30. [Medline].
Shafran SD, Tyring SK, Ashton R, et al. Once, twice, or three times daily famciclovir compared with aciclovir for the oral treatment of herpes zoster in immunocompetent adults: a randomized, multicenter, double-blind clinical trial. J Clin Virol. Apr 2004;29(4):248-53. [Medline].
Vazquez M. Varicella zoster virus infections in children after the introduction of live attenuated varicella vaccine. Curr Opin Pediatr. Feb 2004;16(1):80-4. [Medline].
Oxman MN, Levin MJ, Johnson GR, Schmader KE, Straus SE, Gelb LD, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. Jun 2 2005;352(22):2271-84. [Medline].
Buchbinder SP, Katz MH, Hessol NA, et al. Herpes zoster and human immunodeficiency virus infection. J Infect Dis. Nov 1992;166(5):1153-6. [Medline].
Gnann JW, Whitley RJ. Clinical practice. Herpes zoster. N Engl J Med. Aug 1 2002;347(5):340-6. [Medline].
Gross G, Schofer H, Wassilew S, et al. Herpes zoster guideline of the German Dermatology Society (DDG). J Clin Virol. Apr 2003;26(3):277-89; discussion 291-3. [Medline].
Harding SP, Lipton JR, Wells JC, Campbell JA. Relief of acute pain in herpes zoster ophthalmicus by stellate ganglion block. Br Med J (Clin Res Ed). May 31 1986;292(6533):1428. [Medline].
Hutchinson J. Clinical report on herpes zoster frontalis ophthalmicus. Ophth Hosp Rep. 1864;3(72):865-6, 5:191.
Kattah JC, Kennerdell JS. Orbital apex syndrome secondary to herpes zoster ophthalmicus. Am J Ophthalmol. Mar 1978;85(3):378-82. [Medline].
Liang MG, Heidelberg KA, Jacobson RM, McEvoy MT. Herpes zoster after varicella immunization. J Am Acad Dermatol. May 1998;38(5 Pt 1):761-3. [Medline].
Liesegang TJ. Herpes zoster virus infection. Curr Opin Ophthalmol. Dec 2004;15(6):531-6. [Medline].
Mosby's. Drug Consult (Online reference). 2005.
Opstelten W, van Wijck AJ, Stolker RJ. Interventions to prevent postherpetic neuralgia: cutaneous and percutaneous techniques. Pain. Feb 2004;107(3):202-6. [Medline].
Vafai A, Berger M. Zoster in patients infected with HIV: a review. Am J Med Sci. Jun 2001;321(6):372-80. [Medline].
Zaal MJ, Volker-Dieben HJ, Wienesen M, et al. Longitudinal analysis of varicella-zoster virus DNA on the ocular surface associated with herpes zoster ophthalmicus. Am J Ophthalmol. Jan 2001;131(1):25-9. [Medline].
Further Reading
Keywords
herpes zoster ophthalmicus, eye infection, herpes zoster, varicella-zoster virus, varicella zoster virus, VZV, HZO, herpes virus, chickenpox, shingles, human herpesvirus type 3
