Herpes Zoster Ophthalmicus: Disease Overview

Aaruran Nadarajasundaram

Introduction

Herpes Zoster Ophthalmicus (HZO) is a manifestation of shingles involving the ophthalmic division of the trigeminal nerve. It results from the reactivation of the varicella-zoster virus (VZV), which remains dormant in sensory ganglia following primary infection (1). It’s a condition with growing burden as in the United Kingdom, the incidence of herpes zoster is estimated at 1 in 4 will develop herpes zoster during their lifetime, with HZO accounts for approximately 10–20% of all herpes zoster cases (2, 3). Approximately two-thirds of HZO cases occur in individuals over 50 years old (4).

Pathophysiology

Following primary infection, VZV becomes latent in sensory ganglia. Reactivation can occur years later, often due to immunosuppression or aging, leading to viral replication and spread along sensory nerves. In HZO, reactivation involves the ophthalmic division of the trigeminal nerve, particularly the nasociliary branch, which innervates ocular and periocular structures. This leads to the characteristic dermatomal rash and potential ocular complications (1, 5).

Signs and Symptoms

HZO typically presents with a prodrome of headache, malaise, and fever, followed by unilateral pain, tingling, or burning sensations in the affected dermatome. Within days, an erythematous maculopapular rash develops, progressing to vesicles and pustules, and eventually crusting over (6). Ocular involvement may include conjunctivitis, keratitis, uveitis, and, in severe cases, optic neuritis. Hutchinson’s sign—the presence of lesions on the tip of the nose—indicates nasociliary nerve involvement and a higher risk of ocular complications (4, 7).

Investigations and Diagnosis

Diagnosis is primarily clinical, based on the characteristic rash and distribution. In uncertain cases, polymerase chain reaction (PCR) testing of vesicular fluid can detect VZV DNA, providing definitive confirmation (8). Ophthalmic examination is crucial to assess the extent of ocular involvement, including slit-lamp examination to evaluate for keratitis or uveitis (9).

Treatment

Early initiation of antiviral therapy within 72 hours of rash onset is essential to reduce complications for a total of 7 to 10 days (8). Oral antivirals such as aciclovir, valaciclovir, or famciclovir are commonly used. Adjunctive corticosteroids may be considered to reduce inflammation, though their use should be carefully evaluated against potential side effects

(10). Topical treatments, including antiviral eye drops and corticosteroids, may be indicated for ocular involvement. Pain management is also important, with options ranging from analgesics to neuropathic pain agents (4, 6).

Prognosis

The prognosis of HZO varies depending on patient factors, timing of treatment, and disease severity. Early antiviral treatment in immunocompetent individuals typically leads to resolution of lesions (7). However, complications such as postherpetic neuralgia, vision impairment, and, in rare cases, stroke can occur.

References

  1. Liesegang TJ. Herpes zoster ophthalmicus natural history, risk factors, clinical presentation, and morbidity. Ophthalmology. 2008;115(2 Suppl):S3-S12
  2. Gater A, Abetz-Webb L, Carroll S, et al. Burden of herpes zoster in the UK: findings from the zoster quality of life (ZQOL) study. BMC Infect Dis. 2014;14:402
  3. Scott DAR, Liu K, Danesh-Meyer HV, et al. Herpes Zoster Ophthalmicus Recurrence: Risk Factors and Long-Term Clinical Outcomes. Am J Ophthalmol. 2024;268:1-9
  4. College of Optometrists. Herpes zoster ophthalmicus (HZO). Available at: https:// www.college-optometrists.org/clinical-guidance/clinical-management-guidelines/ herpeszosterophthalmicus_hzo
  5. Lin HC, Chien CW, Ho JD. Herpes zoster ophthalmicus and the risk of stroke: a population-based follow-up study. Neurology. 2010;74(10):792-797
  6. Cohen EJ. Herpes zoster ophthalmicus. Ophthalmic Surg. 1987;18(3):174-177
  7. Yawn BP, Wollan PC, St Sauver JL, Butterfield LC. Herpes zoster eye complications: rates and trends. Mayo Clin Proc. 2013;88(6):562-570
  8. Dworkin RH, Johnson RW, Breuer J, et al. Recommendations for the management of herpes zoster. Clin Infect Dis. 2007;44(Suppl 1):S1-S26
  9. EyeWiki. Herpes Zoster Ophthalmicus. Available at: https://eyewiki.org/ Herpes_Zoster_Ophthalmicus
  10. Kahloun R, Attia S, Jelliti B, et al. Ocular involvement and visual outcome of herpes zoster ophthalmicus: review of 45 patients from Tunisia. Int Ophthalmol. 2012;32(4):383-388

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