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2-22: Herpes Zoster Ophthalmicus

Manpreet Singh; Denise Whitfield

Clinical Summary

Reactivation of endogenous latent varicella-zoster virus within the trigeminal ganglion with neuronal spread through the ophthalmic branch results in crops of grouped vesicles on the forehead and periocularly.

Patients typically present with periocular rash and an injected eye, along with a watery discharge. The most common corneal lesion is punctate epithelial keratitis, in which the cornea has a ground-glass appearance because of stromal edema. Pseudodendrites, also very common, form from mucous deposition, are usually peripheral, and stain moderate to poorly with fluorescein. These may be differentiated from the dendrites of HSV in that the pseudodendrites lack the rounded terminal bulbs at the end of the branches and are broader and more plaquelike. Anterior stromal infiltrates may be seen in the 2nd or 3rd week after the acute infection. Follicles (hyperplastic lymphoid tissue that appears as gray or white lobular elevations, particularly in the inferior cul-de-sac) and regional adenopathy may or may not be present. Iritis is seen in approximately 40% of patients.

FIGURE 2.54

Herpes Zoster Ophthalmicus. A vesicular rash in the distribution of the ophthalmic division (V1) of the trigeminal nerve is seen. The presence of the lesion near the tip of the nose (Hutchinson sign) increases the risk of ocular involvement. (Photo contributor: Lawrence B. Stack, MD.)

In a patient with herpes zoster ophthalmic us, there is peri-orbital redness, swelling, and rashes over the forehead, cheek, and nose, confined to the right half of the face.
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Management and Disposition

Treat patients with epithelial defects with topical broad-spectrum antibiotics to prevent secondary infection. Initiate oral antivirals within 72 hours of onset, and treat for 7 to 10 days. Use cycloplegics if an iritis is present. Artificial tears or ointment may be helpful, and narcotic analgesics may be required. Ophthalmologic consultation is indicated.

Pearls

  1. Ocular complications may follow the rash by many months to years. These complications have a highly variable presentation that can mimic almost any ophthalmic condition.

  2. Recurrence is more common in the immunocompromised host.

  3. Perform a careful eye exam with corneal staining. Nearly two-thirds of patients will develop ocular lesions.

  4. Corneal hypesthesia and the appearance of dendrites with fluorescein staining are seen in both herpes zoster ophthalmicus and herpes simplex keratitis.

  5. Patients with skin lesions on the tip of the nose (Hutchinson sign) are at high risk for ocular involvement. However, the eye may be involved without a nasal lesion.

FIGURE 2.55

Herpes Zoster Ophthalmicus. A large circular dendrite is seen in this patient with ocular involvement from herpes zoster virus. (Photo contributor: Alexandra Bingnear, RN.)

In a patient with herpes zoster ophthalmicus, there is a dilated pupil with a large, circular strand within.
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FIGURE 2.56

Herpes Zoster Ophthalmicus. Grouped vesicles on the forehead and eyebrow are seen with conjunctival injection indicating ocular involvement. (Photo contributor: Lawrence E. Heiskell, MD, FACEP, FAAFP.)

In a patient with herpes zoster ophthalmicus, there is a red bulbar conjunctiva along with clusters of raised, red, lesions over the eyebrows and forehead.
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FIGURE 2.57

Herpes Zoster Ophthalmicus. Scabbed over lesions indicating late-stage herpes zoster ...

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