Overview
Also known as ophthalmic shingles, herpes zoster ophthalmicus (HZO) is characterised by the reactivation of a latent varicella zoster infection in the trigeminal nerve. The ophthalmic branch of the trigeminal is usually affected. It is a sight-threatening condition that requires urgent ophthalmological review.
Risk Factors
- Increasing age
- Female sex
- Immunosuppressive states e.g. HIV/corticosteroid use/immunosuppressive drug use/chemotherapy/malignancy
Presentation
The main presenting complaint is a vesicular rash around the eye. The rash may affect the eye itself. Patients usually have a red eye and some other features are as follows:
- Classically, Hutchinson’s sign may be present:
- This is a rash on the tip or side of the nose – this suggests the nasociliary branch of the trigeminal nerve is involved and this nerve supplies the globe
- Vesicular lesions usually affecting a single dermatome
- Eye watering
- Decreased visual acuity
- Forehead tenderness
- Photophobia
Differential Diagnoses
Ramsay Hunt Syndrome (Herpes zoster oticus)
- Auricular pain often presents first
- Vesicles are present on the skin around the ear
- Lower motor neurone facial nerve palsy present – the forehead is affected as well
Bell’s Palsy
- Lower motor neurone facial nerve palsy present – the forehead is affected as well
- Patients may have postauricular pain preceding the paralysis
Investigations
- The diagnosis is usually clinical, although swabs and PCR can be considered if there is diagnostic doubt.
- If patients have atypical presentations or severe disease e.g. the rash extends beyond one dermatome, they should be investigated for immunodeficiency
Management
- 1st-line: oral antiviral treatment for 7-10 days, ideally within 72 hours:
- Options are: aciclovir, valaciclovir, famciclovir
- If severe/patient immunocompromised: IV antivirals
- If the eye is involved: immediate (within 24 hours) ophthalmology referral
- They may initiate corticosteroid eyedrops. These can only be started under ophthalmic supervision.
Patient Advice
- Patients aged 70-79 are eligible for a shingles vaccination if they have not received it.
Complications
- Eye pain
- Anterior uveitis
- Keratitis
- Neuropathic ulcerations
- Scarring of the eyelid
- Optic neuritis
- Cranial nerve palsies
- Retinitis
- Impaired vision
- Postherpetic neuralgia
Prognosis
- The prognosis for younger and healthy patients is excellent
- Pregnant women, the elderly, and immunocompromised patients have the highest risk of serious complications
