Herpes zoster ophthalmicus

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.[1].

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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.

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.[2].

Risk factors

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• 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.[3].

Diagnosis

• HZO is primarily a clinical diagnosis based on history and classic findings on physical and slit-lamp examination.[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.[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.

Herpes zoster ophthalmicus Resources
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