Herpes zoster ophthalmicus occurs when the varicella-zoster virus is reactivated in the ophthalmic division of the trigeminal nerve. Herpes zoster ophthalmicus represents up to one fourth of all cases of herpes zoster. Most patients with herpes zoster ophthalmicus experience a rash distributed according to the affected area. A minority of patients may develop conjunctivitis, keratitis, uveitis, and ocular cranial-nerve palsies. Permanent sequelae of ophthalmic zoster infection may include chronic ocular inflammation, loss of vision, and debilitating pain. Antiviral medications such as acyclovir, valacyclovir, and famciclovir remain the primary therapy and are most effective in preventing ocular involvement when begun within 72 hours after the onset of the rash. Timely diagnosis and management of herpes zoster ophthalmicus, with referral to an ophthalmologist are critical in limiting visual loss.
Herpes zoster is a common infection caused by the human herpesvirus 3, the same virus that causes chickenpox. It is a member of the same family as herpes simplex virus, Epstein-Barr virus, and cytomegalovirus. Reactivation of the latent virus in neurosensory ganglia produces the characteristic signs of herpes zoster, commonly known as shingles. Normal aging, poor nutrition, and immunocompromised status correlate with outbreaks of herpes zoster, and certain factors such as physical or emotional stress and fatigue may precipitate an episode.
Herpes zoster ophthalmicus represents approximately 10 to 25 percent of all cases of herpes zoster. Although herpes zoster ophthalmicus most often produces a classic dermatomal rash, a minority of patients may have only ophthalmic findings, limited mainly to the cornea. Direct ocular involvement is not specifically correlated with age, gender, or severity of disease. Serious sequelae include chronic ocular inflammation, vision loss, and disabling pain.
Symptoms of Herpes Zoster Ophthalmicus
The prodromal phase of herpes zoster ophthalmicus includes an influenza-like illness with fatigue, malaise, and low-grade fever that lasts up to one week before the rash over the forehead appears. About 60 percent of patients have varying degrees of dermatomal pain in the distribution of the ophthalmic nerve. Subsequently, symptoms appear and rapidly progress over several days to papules and vesicles containing clear serous fluid and, later, pustules. These lesions rupture and typically crust over, requiring several weeks to heal completely.
People with poor immune systems, particularly those with human immunodeficiency virus infection, have a much higher risk of developing herpes zoster ophthalmicus than the normal population. These patients may have a generalized vesicular rash and become severely ill one to two weeks after disease onset. In addition, such patients develop more serious visual sequelae.
Viral transmission from patients with herpes zoster can occur, but it is less frequent than transmission from patients with chickenpox. Virus can be transmitted through direct contact with secretions from vesicles and secretion-contaminated articles.