Herpes zoster ophthalmicus

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Herpes zoster ophthalmicus
Herpes zoster ophthalmicus
Synonyms	Ophthalmic shingles
Pronounce	N/A
Specialty	N/A
Symptoms	Rash, pain, conjunctivitis, keratitis, uveitis, vision loss
Complications	Postherpetic neuralgia, vision impairment
Onset	Typically after age 50
Duration	2 to 4 weeks
Types	N/A
Causes	Varicella zoster virus
Risks	Immunosuppression, age, stress
Diagnosis	Clinical diagnosis, PCR, serology
Differential diagnosis	Herpes simplex keratitis, bacterial conjunctivitis, uveitis
Prevention	Zoster vaccine
Treatment	Antiviral drugs, corticosteroids, pain management
Medication	Acyclovir, Valacyclovir, Famciclovir
Prognosis	N/A
Frequency	10-20% of herpes zoster cases
Deaths	N/A

Alternate names

HZO; Herpes zoster ophthalmicus (HZO)

Definition

Herpes zoster ophthalmicus occurs due to the reactivation of the latent varicella-zoster virus. It is a variation of herpes zoster that can cause a variety of ocular complications and requires urgent treatment.<ref>Minor M, Payne E. Herpes Zoster Ophthalmicus. [Updated 2021 Jan 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557779/</ref>[1].

File:Day07 shingles or Herpes Zoster Virus attacking forehead and eye.jpg

Epidemiology

• In the United States, herpes zoster affects about 1 per 1000 individuals annually.
• However, in the over 60-years population, the incidence is closer to 1 per 100 individuals.
• The incidence in older adults is lower in those who have received either the live attenuated or inactivated recombinant zoster vaccines.
• Among patients diagnosed with herpes zoster, some epidemiological studies estimate about 8% to 20% are complicated by HZO, with many of those cases resulting in ocular involvement.

File:HerpesZosterOpth.jpg

Cause

• In those with a history of prior infection, the VZV normally lies dormant within a dorsal root ganglion.
• In a healthy individual, immunity acquired from the initial infection allows suppression of the virus.
• However, often in the setting of weakened immunity, the virus may reactivate in the form of herpes zoster, also known as shingles.<ref>Minor M, Payne E. Herpes Zoster Ophthalmicus. [Updated 2021 Jan 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557779/</ref>[2].

Risk factors

File:Herps zoster ophthalmicus.jpg

• The main risk factors for HZO include age over 50-years-old and immunocompromised status (e.g., history of HIV, autoimmune diseases requiring corticosteroids or other immunosuppressants, organ or bone marrow transplant, or chemotherapy treatment).
• Other chronic diseases, acute illnesses, and physical and emotional stressors can also precipitate HZO.

Signs and symptoms

• Patients with HZO typically present with prodromal pain in a unilateral V1 dermatomal distribution, followed by an erythematous vesicular or pustular rash to the same area.
• Pain is neuropathic, and patients may describe the sensation as "burning" or "shooting", sometimes accompanied by paresthesias.
• Additionally, the herpetic rash may be preceded by constitutional symptoms such as fever, fatigue, malaise, and headaches.
• The presence of herpetic lesions around the tip of the nose is known as the Hutchinson sign.
• The presence of Hutchinson sign indicates nasociliary branch involvement of V1, which confers a higher risk for ocular involvement.<ref>Minor M, Payne E. Herpes Zoster Ophthalmicus. [Updated 2021 Jan 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557779/</ref>[3].

Diagnosis

• HZO is primarily a clinical diagnosis based on history and classic findings on physical and slit-lamp examination.<ref>Minor M, Payne E. Herpes Zoster Ophthalmicus. [Updated 2021 Jan 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557779/</ref>[4].
• Additional procedures, such as ocular tonometry and corneal esthesiometry, may be performed for a more thorough evaluation to assess for complications.
• Other diagnostic tests, such as viral cultures, polymerase chain reaction (PCR), and antibody testing, are rarely required to establish a diagnosis of HZO.

Treatment

• Treatment for HZO includes prompt initiation of antiviral agents for all patients, as well as supportive care for symptom management.
• Other adjunct therapies, such as antibiotics, topical or systemic corticosteroids, and corneal epithelial debridement, are considered.<ref>Minor M, Payne E. Herpes Zoster Ophthalmicus. [Updated 2021 Jan 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557779/</ref>[5].
• Supportive care: Artificial tears, cold compresses, and analgesics may be employed.
• Antiviral agents: Ideally, treatment with systemic antiviral agents should begin within 72 hours of disease onset.
• Antibiotics: Topical antibiotics (e.g., erythromycin ophthalmic ointment) are often administered to help prevent secondary bacterial infection.
• Corticosteroids: Both topical and systemic corticosteroids may be used in disease management.
• Topical aqueous suppressants: These agents are commonly used in combination with topical corticosteroids in the treatment of elevated IOP secondary to HZO.
• Debridement: Ophthalmology may consider debridement in cases of epithelial keratitis.

References

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NIH genetic and rare disease info

• NIH info on Herpes zoster ophthalmicus

Herpes zoster ophthalmicus is a rare disease.

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