Zoster Ophthalmicus

  • Herpes zoster (or shingles) is due to reactivation of endogenous latent VZV within the sensory ganglia.
  • Rash typically starts as erythematous papules that evolve into grouped vesicles and can become more pustular and hemorrhagic by day 4 in a single or multiple dermatome pattern.
  • Lesions tend to crust by days 7-10 and are considered no longer infectious.
  • Herpes zoster ophthalmicus is a potentially serious sight-threatening condition linked to VZV reactivation of trigeminal ganglion.
  • Typically involves the ophthalmic branch of cranial nerve V.
  • 50-72% of patients with ophthalmicus will have direct ocular involvement: conjunctivitis, episcleritis, iritis, keratitis, lid droop.
  • Vesicular lesions on nose are associated with high risk of zoster ophthalmicus – Hutchinson’s Sign.
  • Typically it is a clinical diagnosis but can perform Tzanck smear of vesicle, viral culture, or VZV PCR.
  • Ophthalmology involvement is highly recommended.
  • Antiviral therapy: oral famciclovir or valacyclovir for 7-10 days; if retinitis involvement use acyclvoir 10mg/kg IV q8h (Johns Hopkins Antibiotic Guide)
  • Adjunctive therapies: cool compresses, topical steroids (ex. Loteprednol), systemic steroids used when there’s significant edema and concern for pressure on optic nerve in periorbital region.